Intubation difficile: Reco UK

Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults

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Kétamine pour le PTSD: Oui!

Efficacy of Intravenous Ketamine for Treatment of Chronic Posttraumatic Stress Disorder. A Randomized Clinical Trial

Feder A. et Al. JAMA Psychiatry. 2014 Jun;71(6):681-8. doi: 10.1001/jamapsychiatry.2014.62

 

Importance  Few pharmacotherapies have demonstrated sufficient efficacy in the treatment of posttraumatic stress disorder (PTSD), a chronic and disabling condition.

Objective  To test the efficacy and safety of a single intravenous subanesthetic dose of ketamine for the treatment of PTSD and associated depressive symptoms in patients with chronic PTSD.

Design, Setting, and Participants  Proof-of-concept, randomized, double-blind, crossover trial comparing ketamine with an active placebo control, midazolam, conducted at a single site (Icahn School of Medicine at Mount Sinai, New York, New York). Forty-one patients with chronic PTSD related to a range of trauma exposures were recruited via advertisements.

Interventions  Intravenous infusion of ketamine hydrochloride (0.5 mg/kg) and midazolam (0.045 mg/kg).

Main Outcomes and Measures  The primary outcome measure was change in PTSD symptom severity, measured using the Impact of Event Scale–Revised. Secondary outcome measures included the Montgomery-Asberg Depression Rating Scale, the Clinical Global Impression–Severity and –Improvement scales, and adverse effect measures, including the Clinician-Administered Dissociative States Scale, the Brief Psychiatric Rating Scale, and the Young Mania Rating Scale.

Results  Ketamine infusion was associated with significant and rapid reduction in PTSD symptom severity, compared with midazolam, when assessed 24 hours after infusion (mean difference in Impact of Event Scale–Revised score, 12.7 [95% CI, 2.5-22.8]; P = .02). Greater reduction of PTSD symptoms following treatment with ketamine was evident in both crossover and first-period analyses, and remained significant after adjusting for baseline and 24-hour depressive symptom severity. Ketamine was also associated with reduction in comorbid depressive symptoms and with improvement in overall clinical presentation. Ketamine was generally well tolerated without clinically significant persistent dissociative symptoms.

 

Conclusions and Relevance  This study provides the first evidence for rapid reduction in symptom severity following ketamine infusion in patients with chronic PTSD. If replicated, these findings may lead to novel approaches to the pharmacologic treatment of patients with this disabling condition.

Médecine militaire et civile

Apports de la médecine de l’avant militaire en situation préhospitalière civile

Derkenne C. et Al. Ann. Fr. Med. Urgence (2015) 5:245-251

L’évolution récente des matériels issus de la médecine de guerre pourrait profiter à la médecine préhospitalièrecivile. Des dispositifs comme les garrots ou les pansements hémostatiques sont encore très peu diffusés en pratique civile, malgré des recommandations fortes et assez anciennes de sociétés savantes civiles. Les dispositifs de lutte contre l’hypothermie en préhospitalier sont, en pratique civile, limités, là où les praticiens militaires disposent de couvertures perfectionnées et beaucoup plus efficaces. Enfin, un modèle de kit de drain thoracique, ergonomique, léger et autorisant l’autotransfusion nous paraît pouvoir avantageusement remplacer les différents moyens disponibles en Smur. Selon des données scientifiques issues essentiellement de la médecine militaire, l’utilisation de ces matériels en médecine préhospitalière civile pourrait être particulièrement utile lors de la prise en charge de traumatisés sévères.

 

ATLS: Encore rebof

Ongoing military evolution of Trauma Life Support

Mercer SJ et Al. Anaesthesia. 2015 Nov;70(11):1332-3

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Encore un avis sur l'apport de l'ATLS et son caractère très basique et probablement non adapté au contexte de la médecine tactique, du moins pour les personnels devant s'y confronter réellement. Des jugements à méditer car l'impact budgétaire d'enseignements tels qu'ATLS, PHTLS, .... n'est pas négligeable.

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We read with interest the editorial by Wiles [1], illustrating that the Advanced Trauma Life Support Course (ATLS) has not evolved in line with current UK trauma management. In the Defence Medical Services (UK-DMS), our own Battlefield Advanced Trauma Life Support Course (BATLS) [2] diverged significantly from ATLS in 2005 to reflect our high-threat working environment and the blast and ballistic mechanisms that predominated. There was also a paradigm shift in the initial assessment and management of casualties to <C> ABC from the traditional ABC [3], where <C> represents the need to control catastrophic haemorrhage on the battlefield first, with soldiers trained to apply limb tourniquets and topical haemostatic dressings.

We have addressed a number of the concerns raised by Wiles [1] in our Military Operational Surgical Training (MOST) Course [4] that has now been running since 2010. This consists of an intensive 5-day programme designed for the whole of the complex trauma team, emphasising team resource management issues [5] and evolving rapidly to incorporate current research and new experience from the deployed environment. Until recently, this course focused on deployments to Afghanistan, but it has recently changed to allow preparation for contingency deployments anywhere in the world.

Activities include multidisciplinary workshops in the Royal College of Surgeons cadaver laboratory, allowing the link between anatomy and surgical techniques as part of the integrated damage-control resuscitation – damage-control surgery sequence [6], focusing on decision-making, communication and teamworking. Workshops also cover topics such as the management of difficult airway in trauma, damage-control resuscitation, near-point testing in resuscitation and anaesthesia with limited resources. There is also the opportunity to discuss ethical issues, paediatrics, critical care, acute pain, pre-hospital and in-transit care, and to practise regional anaesthesia techniques specifically for trauma.

We firmly believe that it is best to train in the teams that are going to deploy together, and fully immersive simulation scenarios allow the trauma team to rehearse together in the actual roles that they will fulfil on deployments. Post-scenario debriefs allow the opportunity for in-depth discussion of complex issues that may be encountered in the post-Afghanistan era. This allows the development of mental models and we are able to manipulate scenarios further to alter timelines for resupply and casualty evacuation, and discuss the actual implications to the medical facility of performing surgery.

In 2013 we designed a Level-3 Continuous Professional Development matrix that was published by the Royal College of Anaesthetists (RCoA) [7] and our trainees are expected to complete the Military Anaesthesia Higher Module [8] before CCT. The MOST course is mapped across competences in both of these and we are grateful to the RCoA for its support, as it is invaluable for the revalidation of military anaesthetists.

We agree that ATLS is a very basic course. Within the UK-DMS we continue to look to exercise and test the whole system and have a suite of courses that include advanced pre-hospital care on the Medical Emergency Response Team [9] (MERT) course, through BATLS and MOST to the Hospital Exercise HOSPEX [10] which allows a whole-system macro-simulation, crucial for those just about to deploy or commence a standby commitment.

• 1 Wiles MD. ATLS: Archaic Trauma Life Support? Anaesthesia 2015; 70: 893–906.
• 2 Mercer SJ, Whittle CL, Mahoney PF. Lessons from the battlefield: human factors in Defence Anaesthesia. British Journal of Anaesthesia 2010; 105: 9–20.
• 3 Hodgetts TJ, Mahoney PF, Russell MQ, Byers M. ABC to <C>ABC: Redefining the military trauma paradigm. Emergency Medicine Journal 2006; 23: 745–6.
• 4 Mercer SJ, Whittle C, Siggers B, Frazer RS. Simulation, human factors and Defence Anaesthesia. Journal of the Royal Army Med Corps 2010; 156(S1): 365–9.
• 5 Mercer SJ, Arul S, Pugh H, Midwinter MJ. Performance improvement through best practice team management – human factors in complex trauma. Journal of the Royal Army Medical Corps 2014; 160: 105–8.
• 6 Midwinter MJ, Woolley T. Resuscitation and coagulation in the severely injured trauma patient. Philosophical Transactions of the Royal Society B: Biological Sciences 2010; 366: 192–203.
• 7 Mercer SJ. Training and revalidation in Defence Anaesthesia. Bulletin of the Royal College of Anaesthetists 2013; 80: 16–8.
• 8Woolley T, Birt DJ. Competencies for the military anaesthetist. Bulletin of The Royal College of Anaesthetists 2008; 52: 2661–6.
• 9 Haldane A. Advanced airway management - a Medical Emergency Response Team perspective. Journal of the Royal Army Medical Corps 2010; 156: 159–61.
• 10 Arora S, Sevdalis N. HOSPEX and concepts of simulation. Journal of the Royal Army Medical Corps 2008; 154: 202–5

Paroi postérieure: Rester à l'écart

Cricothyroidotomy catheters: an investigation of mechanisms of failure and the effect of a novel intracatheter stylet

Hebbard PD et Al. Anaesthesia. 2015 Oct 28. doi: 10.1111/anae.13269

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L'étude NAP4 a mis en avance l'importance de maîtriser les techniques d'oxygénation transtrachéale et la cricothyrotomie. Il n'est pas étonnant que, dans les démarches d'entrainement et de recherche en gestion des situations de CICO, apparaissent des interrogations sur la survenue des complications liées à ces techniques. Les atteintes de la paroi postérieures sont l'une d'entre elles. Elles s'observent aussi lors de l'emploi de simple cathéter et peuvent déboucher sur des complications grave notamment lors d'emploi de techniques de jet ventilation. C'est ce que rapporte le document proposé. D'après ce document il semble que l'on puisse réduire ce risque en orientant l'aiguille à 45° dès sa pénétration dans la lumière trachéale. 

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Emergency catheter cricothyroidotomy often fails. Case reports have concentrated on kinking and displacement of the catheter as the major causes. We investigated catheter tip penetration of the trachea. Using insertion angles of 90°, 75°, 60°, 45° and 30° we advanced 14 G intravenous catheters into fresh isolated sheep tracheas during high pressure oxygen insufflation. At all angles, the catheter tip became blocked by pushing into the mucosa with submucosal gas injection on one or more attempts. Full thickness rupture with extratracheal gas also occurred on insertions at 90° and 60°. We then tested a Luer-mounted prototype wire stylet which remains in situ during insufflation. Using the same methodology, the stylet was able to be placed and prevented blockage at all angles of insertion. Mucosal trauma and submucosal gas injection occurred on insertions at 90° and 75°. Our results should guide further stylet design.

Coniotomie: D'abord chirurgicale

Evaluation of novel Surgicric
cricothyroidotomy device

King W et Al. Anaesthesia. 2015 Nov 17. doi: 10.1111/anae.13275

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Ce travail est intéressant car il met en avant l'intérêt des techniques chirurgicales par rapport à une technique de référence qui est l'emploi du set de Melker et d'un nouveau kit: le Surgicric. Il montre également que la survenue de lésions de la paroi postérieure n'est pas une vue de l'esprit, cette complication étant la plus fréquente avec ce nouveau kit.

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A can't intubate, can't ventilate scenario can result in morbidity and death. Although a rare occurrence (1:50 000 general anaesthetics), it is crucial that anaesthetists maintain the skills necessary to perform cricothyroidotomy, and are well-equipped with appropriate tools. We undertook a bench study comparing a new device, Surgicric^® , with two established techniques; the Melker Emergency Cricothyroidotomy, and a surgical technique. Twenty-five anaesthetists performed simulated emergency cricothyroidotomy on a porcine model, with the primary outcome measure being insertion time. Secondary outcomes included success rate, tracheal trauma and ease of use.

The surgical technique was fastest. The median (IQR [range]) was 81 (62-126 [37-300]) s, followed by the Melker 124 (100-217 [71-300]) s, and the Surgicric 127 (68-171 [43-300]), p = 0.003. The Surgicric device was the most traumatic, as evaluated by a blinded Ear, Nose and Throat surgeon. Subsequently, the authors contacted the device manufacturer, who has now modified the kit in the hope that its clinical application might be improved. Further studies are required to evaluate the revised model.

 

Laryngoscopie directe: LA BASE

Videolaryngoscopy in trauma

Eggleton A. Anaesthesia 2015, 70, 1454–1466

In their paper on airway management in cervical spine injury [1], focusing on videolaryngoscopy, Duggan and Griesdale mention characteristics that predispose to failure of videolaryngoscopy, including anatomical abnormality, local scarring, radiotherapy, and airway masses. An additional factor worth considering, especially in the context of trauma, is the impact of oropharyngeal blood on the videolaryngoscopic view, which can obscure the larynx or camera lens and obstruct the light source, reducing illumination. Recent personal experiences with a McGrath
MAC videolaryngoscope (Aircraft Medical, Edinburgh, UK) found that dried blood lining the oropharynx reduced reflection, producing a dull on-screen image, requiring conversion to direct laryngosc opy. It seems likely that videolaryngoscopy will replace direct laryngoscopy as the standard method of intubation, but the auth ors are correct in saying it will remain necessary to maintain ski lls in both techniques.

Reference

1. Duggan LV, Griesdale DEG. Secondary cervical spine injury during airway management: beyond a one-size-fits-all

approach. Anaesthesia 2015; 70: 769–73

Stratégie Low Flow: Encore confirmée

Efficacy of limited fluid resuscitation in patients with hemorrhagic shock: a meta-analysis

Duan C. et Al. Int J Clin Exp Med. 2015; 8(7): 11645–11656.

Demain: Quels enjeux ?

TCCC: Point 2015

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IOT: Affaire de tous et pas de spécialiste

A review of pre-admission advanced airway management in combat casualties, Helmand Province 2013

Pugh HEJ, et al. J R Army Med Corps 2014;0:1–6. doi:10.1136/jramc-2014-000271

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Parmi les enjeux de la médicalisation de l'avant, ou en d'autres termes du prolonged field care, il y a la maîtrise de la gestion des voies aériennes, notamment l'intubation et la coniotome. Ce document qui analyse tous les blessés ayant bénéficié d'une manoeuvre avancée avant leur prise en charge au role 3 de Camp Bastion.Très clairement la prise en charge des blessés par des personnels expert de part leur emploi en UK permet l'obtention de 100 % de réussite alors que ce geste conduit par les équipes US n'atteint un taux de succès que de 64%. Les équipes UK n'ont pas eu besoin d'avoir recours à la coniotomie. Cette dernière est réalisée à 14 reprises par les équipes US avec 1 seul échec vrai. Les vraies complications étaient une intubation sélective à 3 reprises et un placement oesophagien. Notons la place relativement restreinte du tube laryngé de King. Une fois de plus il faut insister sur la nécessité de maîtrise de l'abord trachéal par tout personnel médical. Alors si cette éventualité n'est pas fréquente, les conditions actuelles avec les éloignements et la durée des MEDEVAC font qu'acquérir et entretenir cette maîtrise  est fondamental et que chacun soit conscient de cette nécessité. 

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Objectives

Airway compromise is the third leading cause of potentially preventable combat death. Pre-hospital airway management has lower success rates than in hospital. This study reviewed advanced airway management focusing on cricothyroidotomies and supraglottic airway devices in combat casualties prior to admission to a Role 3 Hospital in Afghanistan.

Methods

This was a retrospective review of all casualties who required advanced airway management prior to arrival at the Role 3 Hospital, Bastion, Helmand Province over a 30-week period identified by the US Joint Theatre Trauma Registry. The notes and relevant X-rays were analysed. The opinions of US and UK clinical Subject Matter Experts (SME) were then sought.

Results

Fifty-seven advanced airway interventions were identified. 45 casualties had attempted intubations, 37 (82%) were successful and of those who had failed intubations, one had a King LT Airway (supraglottic device) and seven had a rescue cricothyroidotomy. The other initial advanced airway interventions were five attempted King LT airways and seven attempted cricothyroidotomies. In total, 14 cricothyroidotomies were performed; in this group, there were nine complications/significant events.

Conclusions

The SMEs suggested that dedicated surgical airway kits should be used and students in training should be taught to secure the cricothyroidotomy tube as well as how to insert it. This review re-emphasises the need to "ensure the right person, with the right equipment and the right training, is present at the right time if we are to improve the survival of patients with airway compromise on the battlefield".

ABC of PHEM

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Et l'albumine ?

Is limited prehospital resuscitation with plasma more beneficial than using a synthetic colloid? An experimental study in rabbits with parenchymal bleeding

Kheirabadi BS et Al. J Trauma Acute Care Surg. 2015;78: 752-759

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Il existe de grands débats sur la manière optimale d'assurer le remplissage vasculaire des blessés de guerre. Pour certains le fluide de référence est un hydroxyéthylamidon, pour d'autres un cristalloïde isotonique et en ce qui nous concerne les deux avec la mise en avant du sérum salé hypertonique premier suivi d'HEA. Actuellement il existe une tendance à promouvoir une autre stratégie faisant appel pour les blessés les plus graves au plasma voire la transfusion de sang frais. L'étude proposée avait pour objectif de confirmer l'intérêt d'une démarche "plasma premier". Une des surprises a été de constater que ce n'est pas cette dernière qui permettait d'obtenir le meilleur taux de survie mais l'emploi d'albumine, et ce de loin. Ces données expérimentales certes très partielles permettent aux auteurs (?)  de rediscuter les conclusions de travaux anciens notamment de l'étude SAFE (1,2). Les solutés d'albumine utilisés par cette dernière ont une osmolarité de 260 mosm/kg (versus 305 mosm/kg pour le sérum salé). Les effets délétères notamment chez le traumatisé crânien pourraient être dus non pas à  l'extravasation d'albumine dans le parenchyme cérébral lésé mais à l'hypoosmolarité de l'albumex 4%, ces deux mécanismes concourrant à la plus grande fréquence d'HTIC dans le groupe albumine (3).  A méditer

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BACKGROUND:

Reports of survival benefits of early transfusion of plasma with red blood cells (1:1 ratio) in trauma patients suggest that plasma may be a better fluid to replace Hextend for battlefield resuscitation. We studied possible advantages of prehospital resuscitation with plasma compared with Hextend or albumin in a model of uncontrolled hemorrhage.

METHODS:

Male New Zealand white rabbits (3.3 T 0.1 kg) were anesthetized, instrumented, and subjected to a splenic injury with uncontrolled bleeding. Ten minutes after injury (mean arterial pressure [MAP] G 40 mm Hg), the rabbits received small and equal volumes (15 mL/kg) of rabbit plasma (n = 10), Hextend (n = 10), or 5% human albumin (n = 9) or no fluid. Fluids were administered in two bolus injections (20 minutes apart) and targeted to aMAP of 65 mm Hg. Animals were monitored for 2.5 hours or until death, and their blood losses were measured. Arterial blood samples were collected at different times and analyzed for ABG, CBC, and coagulation tests.

RESULTS:

There were no differences in baseline measures among groups. Splenic injury caused similar hemorrhages (9.1 T 0.4 mL/kg at 10 minutes) and decreased MAP in all subjects. Subsequent resuscitation initiated additional bleeding. At 60 minutes after injury (20 minutes after resuscitation), longer activated partial thromboplastin time and lower fibrinogen concentrations were apparent compared with baseline values with differences among groups. Thrombelastography analysis indicated faster and stronger clot formation with plasma and albumin resuscitation than with Hextend use. Shock indices were increased in all groups, but smaller changes were measured in the albumin group. Total blood loss did not differ among resuscitated rabbits but was higher (p G 0.05) than among nonresuscitated animals. Survival rates were 11% (untreated), 40% (Hextend and plasma), and 89% (albumin, p G 0.05).

CONCLUSION:

Resuscitation with plasma or albumin better preserved coagulation function than did Hextend. However, despite these improvements, plasma resuscitation did not reduce blood loss or improve survival, while albumin administration seemed beneficial

Lent/régulier: Mieux pour le crâne ?

Resuscitation speed affects brain injury in a large animal model of traumatic brain injury and shock

Sillesen M et Al. Scand J Trauma Resusc Emerg Med. 2014 Aug 14;22:46

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En matière de remplissage vasculaire,  on s'intéresse souvent à la nature des solutés et aux quantités perfusées. On s'intéresse moins aux vitesses de perfusion. Pourtant cette dernière a son importance. Le travail présenté est intéressant car il rapport qu'outre la nature du soluté importante mais aussi sa vitesse d'administration. Ainsi il semblerait que dans un modèle expérimental de traumatisme crânien l'emploi de solutés cristalloïdes de sérum salé isotonique soit responsable d'une augmentation de l'oedeme cérébal et du volume des lésions intracraniennes quel que soit le régime d'administration. Ce travail retrouve par ailleurs l'intérêt sur la maîtrise de l'oedeème cérébral  de l'apport de fraction coagulantes de manière procédurée par rapport au bolus. Si l'on replace ce document dans le contexte d'isolement et de maintien en survie de nos blessés notamment cranio-cérébraux en état de choc, cela implique une formation spécifique des équipes qui devront par ailleurs pouvoir disposer d'équipements adaptés comme celui_ci (1)

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BACKGROUND:

Optimal fluid resuscitation strategy following combined traumatic brain injury (TBI) and hemorrhagic shock (HS) remain controversial and the effect of resuscitation infusion speed on outcome is not well known. We have previously reported that bolus infusion of fresh frozen plasma (FFP) protects the brain compared with bolus infusion of 0.9% normal saline (NS). We now hypothesize reducing resuscitationinfusion speed through a stepwise infusion speed increment protocol using either FFP or NS would provide neuroprotection compared with a highspeed resuscitation protocol.

METHODS:

23 Yorkshire swine underwent a protocol of computer controlled TBI and 40% hemorrhage. Animals were left in shock (mean arterial pressure of 35 mmHg) for two hours prior to resuscitation with bolus FFP (n = 5, 50 ml/min) or stepwise infusion speed increment FFP (n = 6), bolus NS (n = 5, 165 ml/min) or stepwise infusion speed increment NS (n = 7). Hemodynamic variables over a 6-hour observation phase were recorded. Following euthanasia, brains were harvested and lesion size as well as brain swelling was measured.

RESULTS:

Bolus FFP resuscitation resulted in greater brain swelling (22.36 ± 1.03% vs. 15.58 ± 2.52%, p = 0.04), but similar lesion size compared with stepwise resuscitation. This was associated with a lower cardiac output (CO: 4.81 ± 1.50 l/min vs. 5.45 ± 1.14 l/min, p = 0.03). In the NS groups, bolus infusion resulted in both increased brain swelling (37.24 ± 1.63% vs. 26.74 ± 1.33%, p = 0.05) as well as lesion size (3285.44 ± 130.81 mm(3) vs. 2509.41 ± 297.44 mm3, p = 0.04). This was also associated with decreased cardiac output (NS: 4.37 ± 0.12 l/min vs. 6.35 ± 0.10 l/min, p < 0.01).

CONCLUSIONS:

In this clinically relevant model of combined TBI and HS, stepwise resuscitation protected the brain compared with bolusresuscitation.

 

Dépakine chez le blessé cranien en choc ?

Treatment with a histone deacetylase inhibitor, valproic acid, is associated with increased platelet activation in alarge animal model of traumatic brain injury and hemorrhagic shock

Dekker SE et Al. J Surg Res. 2014 Jul;190(1):312-8

 

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Le concept du damaged control resuscitation fait appel en partie à de nouvelles modalités transfusionnelles et d'emploi de fractions coagulantes. D'autres approches sont possibles comme celles visant à restuarer la fonction plaquettaire. C'est ce que permettrait l'adminsitration de médicaments appartenant à la classe des inhibiteurs des histone deacetylase et dont les effets neuroprotecteurs pourraient ainsi être mis à profit.  Le document proposé semble conforter cette approche.

Documents reliés: 1, 2, 3

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BACKGROUND:

We have previously shown that resuscitation with fresh frozen plasma (FFP) in a large animal model of traumatic brain injury (TBI) and hemorrhagic shock (HS) decreases the size of the brain lesion, and that addition of a histone deacetylase inhibitor, valproic acid (VPA), provides synergistic benefits. In this study, we hypothesized that VPA administration would be associated with a conservation of platelet function as measured by increased platelet activation after resuscitation.

MATERIALS AND METHODS:

Ten swine (42-50 kg) were subjected to TBI and HS (40% blood loss). Animals were left in shock for 2 h before resuscitation with either FFP or FFP+VPA (300 mg/kg). Serum levels of platelet activation markers transforming growth factor beta, CD40 L, P-selectin, and platelet endothelial cell adhesion molecule (PECAM) 1 were measured at baseline, postresuscitation, and after a 6-h observation period. Platelet activation markers were also measured in the brain whole cell lysates and immunohistochemistry.

RESULTS:

Circulating P-selectin levels were significantly higher in the FFP+VPA group compared with the FFP alone group (70.85±4.70 versus 48.44±7.28 ng/mL; P<0.01). Likewise, immunohistochemistry data showed elevated P-selectin in the VPA treatment group (22.30±10.39% versus 8.125±3.94%, P<0.01). Serum sCD40L levels were also higher in the FFP+VPA group (3.21±0.124 versus 2.38±0.124 ng/mL; P<0.01), as was brainsCD40L levels (1.41±0.15 versus 1.22±0.12 ng/mL; P=0.05). Circulating transforming growth factor beta levels were elevated in the FFP+VPA group, but this did not reach statistical significance (11.20±1.46 versus 8.09±1.41 ng/mL; P=0.17). Brain platelet endothelial cell adhesion molecule 1 levels were significantly lower in the FFP+VPA group compared with the FFP group (5.22±2.00 pg/mL versus 7.99±1.13 pg/mL; P=0.03).

CONCLUSIONS:

In this clinically relevant large animal model of combined TBI+HS, the addition of VPA to FFP resuscitation results in an early upregulation of platelet activation in the circulation and the brain. The previously observed neuroprotective effects of VPA may be due to a conservation of platelet function as measured by a higher platelet activation response after resuscitation.

Plaie cérébrale et coagulopathie

Quelques faits

1. Elle est fréquente voire très fréquente: Greuters et al. Critical Care 2011 15:R2   doi:10.1186/cc9399 

 

2. Elle est + fréquente en cas d'hypoTA: Wafaisade  Neurocrit Care. 2010 Apr;12(2):211-9

3. Elle est de mauvais pronostic: J Emerg Trauma Shock. 2013 Jul-Sep; 6(3): 180–185

4. Elle est mise en évidence plutôt par thromboélastographie (r TEG) : Sixta al., J Neurol Neurophysiol 2014, 6:5

Un point plus complet

Damage Control: Vraiment bénéfique

Changing Patterns of In-Hospital Deaths Following Implementation of Damage Control Resuscitation Practices in US Forward Military Treatment Facilities

Langan NR et Al. JAMA Surg. 2014;149(9):904-912

Importance

Analysis of combat deaths provides invaluable epidemiologic and quality-improvement data for trauma centers and is particularly important under rapidly evolving battlefield conditions.

Objective

To analyze the evolution of injury patterns, early care, and resuscitation among patients who subsequently died in the hospital, before and after implementation of damage control resuscitation (DCR) policies.

Design, Setting, and participants

In a review of the Joint Theater Trauma Registry (2002-2011) of US forward combat hospitals, cohorts of patients with vital signs at presentation and subsequent in-hospital death were grouped into 2 time periods: pre-DCR (before 2006) and DCR (2006-2011).

Main outcomes and measures

Injury types and Injury Severity Scores (ISSs), timing and location of death, and initial (24-hour) and total volume of blood products and fluid administered.

Results 

Of 57 179 soldiers admitted to a forward combat hospital, 2565 (4.5%) subsequently died in the hospital. The majority of patients (74%) were severely injured (ISS > 15), and 80% died within 24 hours of admission. Damage control resuscitation policies were widely implemented by 2006 and resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and increased fresh frozen plasma use (3.2-10.1 U) (both P < .05) in this population. The mean packed red blood cells to fresh frozen plasma ratio changed from 2.6:1 during the pre-DCR period to 1.4:1 during the DCR period (P < .01). There was a significant increase in mean ISS between cohorts (pre-DCR ISS = 23 vs DCR ISS = 27; P < .05) and a marked shift in injury patterns favoring more severe head trauma in the DCR cohort.

Conclusions and relevance

There has been a significant shift in resuscitation practices in forward combat hospitals indicating widespread military adoption of DCR. Patients who died in a hospital during the DCR period were more likely to be severely injured and have a severe brain injury, consistent with a decrease in deaths among potentially salvageable patients

 

 

Prolonged field Care: Novateur ? Pas vraiment

Prolonged Field Care Working Group Position Paper Prolonged Field Care Capabilities

Bal JA et All. J Spec Oper Med. 2015 Fall;15(3):78-80

Le concept du TCCC, issu de l'analyse des décès au combat lors de la guerre de Somalie, a vu toute sa pertinence prouvée en afghanistan. Des gestes simples réalisés par des soldats et des combat medic ont permis d'éviter le décès de nombre de soldats. Ces derniers étaient alors évacués rapidement vers des structures chirurgicales. Le concept afghan permettait cela.

Ce n'est pas le cas des conflits actuels, conflits pendant lesquels le combattant blessé doit se voir appliquer pendant plusieurs heures une démarche de prise en charge (remplissage, analgésie, nursing,..) très proche de la réanimation préhospitalière. C'est bien compte tenu de l'absence de médecins et donc de connaissances en la matière que cette pratique de prise en charge est considérée par nos collègues US comme nouvelle. Ce concept ne doit donc pas probablement être considéré comme novateur pour nous car il s'agit d'une démarche de convergence d'une pratique anglo-saxonne vers notre médicalisation de l'avant. 

Refroidir sans eau au Mali: Possible !

Couverture Polarskin Pervivolabs

La précocité du refroidissement d'une hyperthermie est fondamentale. Problème comment faire quand on n'a pas d'eau. Cette situation est particulièrement fréquente au sahel. Des produits innovants comme ceux de la gamme Polarskin de la société Pervivolabs, qui dispose d'un distributeur en France,  pourraient apporter une solution. Il faut néanmoins que ces couvertures soient transportées en glacière. Mais ceci est plus facile à trouver que de l'eau.

 

 

Vers la machine à coaguler: Horizon 2040 ?

Deep Bleeder Acoustic Coagulation (DBAC)—part II: in vivo testing of a research prototype system

Sekins KM et Al. Sekins et al. Journal of Therapeutic Ultrasound (2015) 3:17

Background:

Deep Bleeder Acoustic Coagulation (DBAC) is an ultrasound image-guided high-intensity focused ultrasound (HIFU) method proposed to automatically detect and localize (D&L) and treat deep, bleeding, combat wounds in the limbs of soldiers. A prototype DBAC system consisting of an applicator and control unit was developed for testing on animals. To enhance control, and thus safety, of the ultimate human DBAC autonomous product system, a thermal coagulation strategy that minimized cavitation, boiling, and non-linear behaviors was used.

Material and methods:

 

The in vivo DBAC applicator design had four therapy tiles (Tx) and two 3D (volume) imaging probes (Ix) and was configured to be compatible with a porcine limb bleeder model developed in this research. The DBAC applicator was evaluated under quantitative test conditions (e.g., bleeder depths, flow rates, treatment time limits, and dose exposure time limits) in an in vivo study (final exam) comprising 12 bleeder treatments in three swine. To quantify blood flow rates, the “bleeder” targets were intact arterial branches, i.e., the superficial femoral artery (SFA) and a deep femoral artery (DFA). D&L identified, characterized, and targeted bleeders. The therapy sequence selected Tx arrays and determined the acoustic power and Tx beam steering, focus, and scan patterns. The user interface commands consisted of two buttons: “Start D&L” and “Start Therapy.” Targeting accuracy was assessed by necropsy and histologic exams and efficacy (vessel coagulative occlusion) by angiography and histology.

Results:

The D&L process (Part I article, J Ther Ultrasound, 2015 (this issue)) executed fully in all cases in under 5 min and targeting evaluation showed 11 of 12 thermal lesions centered on the correct vessel subsection, with minimal damage to adjacent structures. The automated therapy sequence also executed properly, with select manual steps. Because the dose exposure time limit (tdose ≤ 30 s) was associated with nonefficacious treatment, 60-s dosing and dual-dosing was also pursued. Thrombogenic evidence (blood clotting) and collagen denaturation (vessel shrinkage) were found in necropsy and histologically in all targeted SFAs. Acute SFA reductions in blood flow (20–30 %) were achieved in one subject, and one partial and one complete vessel occlusion were confirmed angiographically. The complete occlusion case was achieved with a dual dose (90 s total exposure) with focal intensity ≈500 W/cm2 (spatial average, temporal average).