Blessés par balle: Civil et guerre, différent !

The profile of wounding in civilian public mass shooting fatalities.

 

Smith ER et Al. J Trauma Acute Care Surg. 2016 Mar 8. [Epub ahead of print]

 

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Des armes différentes, des distances de tir différentes, l'absence de protection balistique expliquent des lésions différentes. Dans cette publication, ce ne sont pas les lésions des membres qui sont les plus fréquentes mais les lésions du torse. A méditer pour la prise en charge des blessés, prise en charge qui semble devoir être différente en contexte civil de ce qui peut être fait dans un contexte de conflits armées, même asymétrique. D'autres expériences ont été rapportées exprimant la grande complexité du problème (1, 2, 3)

 

Ceci est d'autant plus vrai que la chaîne de relève est complètement différente avec notamment un accès aux structures chirurgicales beaucoup plus rapide qu'en contexte militaire. 

 

 

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Background: The incidence and severity of civilian public mass shootings (CPMS) continue to rise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different than in military combat fatalities and thus may require a new management strategy.

 

Methods: A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. CPMS was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if pre-hospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author.

 

Results: A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases. Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity. 

 

Conclusion: The overall and fatal wounding patterns following CPMS are different than those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries.

Douleur: Pendant l'évacuation, Kétamine = Morphine ?

Prehospital Pain Medication Use by U.S. Forces in Afghanistan

Shackelford SA et Al. Mil Med. 2015 Mar;180(3):304-9

 

We report the results of a process improvement initiative to examine the current use and safety of prehospital pain medications by U.S. Forces in Afghanistan. Prehospital pain medication data were prospectively collected on 309 casualties evacuated from point of injury (POI) to surgical hospitals from October 2012 to March 2013. Vital signs obtained from POI and flight medics and on arrival to surgical hospitals were compared using one-way analysis of variance test. 119 casualties (39%) received pain medication during POI care and 283 (92%) received pain medication during tactical evacuation (TACEVAC). Morphine and oral transmucosal fentanyl citrate were the most commonly used pain medications during POI care, whereas ketamine and fentanyl predominated during TACEVAC.

  

Ketamine was associated with increase in systolic blood pressure compared to morphine (+7 ± 17 versus −3 ± 14 mm Hg, p = 0.04). There was no difference in vital signs on arrival to the hospital between casualties who received no pain medication, morphine, fentanyl, or ketamine during TACEVAC. In this convenience sample, fentanyl and ketamine were as safe as morphine for prehospital use within the dose ranges administered. Future efforts to improve battlefield pain control should focus on improved delivery of pain control at POI and the role of combination therapies.

Douleur: Kétamine d'abord ?

Prehospital and En Route Analgesic Use in the Combat Setting: A Prospectively Designed, Multicenter, Observational Study

Lawrence N. Petz  LN et Al. , Mil Med. 2015 Mar;180(3 Suppl):14-8

 

 Background:

Combat injuries result in acute, severe pain. Early use of analgesia after injury is known to be beneficial. Studies on prehospital analgesia in combat are limited and no prospectively designed study has reported the use of analgesics in the prehospital and en route care setting. Our objective was to describe the current use of prehospital analgesia in the combat setting.

 

Methods:

This prospectively designed, multicenter, observational, prehospital combat study was undertaken at medical treatment facilities (MTF) in Afghanistan between October 2012 and September 2013. It formed part of a larger study aimed at describing the use of lifesaving interventions in combat. On arrival at the MTF, trained on-site investigators enrolled eligible patients and completed standardized data capture forms, which included the name, dose, and route of administration of all prehospital analgesics, and the type of provider who administered the drug. Physiological data were retrospectively ascribed as soon as practicable. The study was prospectively approved by the Brooke Army Medical Center institutional review board.

Results:

Data were collected on 228 patients, with 305 analgesia administrations recorded. The predominant mechanism of injury was blast (50%), followed by penetrating (41%), and blunt (9%). The most common analgesic used was ketamine, followed by morphine.

A combination of analgesics was given to 29% of patients; the most common combination was ketamine and morphine. Intravenous delivery was the most commonly used route (55%). Patients transported by the UK Medical Emergency Response Team (MERT) or U.S. Air Medical Evacuation (Dust-off) team were more likely to receive ketamine than those evacuated by U.S. Pararescue Jumpers (Pedro). Patients transported by Medical Emergency Response Team or Pedro were more likely to receive more than 1 drug. Patients who received only ketamine had a higher pulse rate ( p < 0.005) and lower systolic blood pressure ( p = 0.01) than other groups, and patients that received hydromorphone had a lower respiratory rate ( p = 0.04).

Conclusions: In our prospectively designed, multicenter, observational, prehospital combat study, ketamine was the most commonly used analgesic drug. The most frequently observed combination of drugs was ketamine and morphine. The intravenous route was used for 55% of drug administrations.

 

Epaule luxée ! Réduire seul

Simple self-reduction method for anterior shoulder dislocation

Reiner Wirbel et al. Journal of Acute Disease (2014)207-210

 

C'est la plus fréquente des luxations. La diversité des méthodes de réduction illustre bien la difficulté qu'il peut y avoir à la réduire sans avoir recours à une anesthésie/sédation. C'est encore plus vrai en cas d'isolement extrême. Une méthode à connaître.