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20/04/2018

Coniotomie: Au moins 15 ml

Surgical cricothyrotomy: the tracheal-tube dilemma.

 
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L'emploi de tube trachéo d'au moins 5 mm voire 6 mm est requis pour permettre une ventilation alvéolaire optimale par coniotomie. Ce diamètre est adapté à celui de la membrane cricoïdienne. Cependant les auteurs du document présenté mettent en avant une taille insuffisante du ballonet qui ne permettrait pas une occlusion trachéale correcte. Une réponse est faite à leur interrogation. Il faut gonfler le ballonet avec au moins 15 ml d'air.
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Editor—In a recent issue of the British Journal of Anaesthesia, Higgs and colleagues1 published guidelines for the management of tracheal intubation in critically ill adults. I appreciate the authors' successful efforts for implementation of comprehensive guidelines to improve airway management and patient safety in the intensive-care-unit environment. In accordance with current evidence and expert opinion, the authors recommend an open surgical approach (surgical cricothyrotomy) for emergency front-of-neck access in adult patients. They highlight the benefits of this technique: it is fast, reliable, has a high success rate, and provides definitive access to the airway. After incision of the cricothyroid membrane, insertion of a tracheal tube via a bougie stylet is advocated. The use of tracheal tubes with an inner diameter (ID) of 5.0 or 6.0 mm is advised, presumably because of the dimensions of the cricothyroid membrane.

Insertion of ‘standard’ tracheal tubes with an ID of 5.0 or 6.0 mm generates a dilemma of potentially limiting the benefits of the surgical technique. The cuff diameter of a tracheal tube of ID 6.0 mm with a high-volume low-pressure cuff is 18–19 mm, or about 13 mm in a tracheal tube of ID 5.0 mm. The upper limits of normal for coronal and sagittal diameters of the trachea in men of 20–79 yr average 25–27 mm, and in women 21–23 mm. The disparity between the diameters of the inflated cuff and the trachea potentially generates a leak.

Insufflation of oxygen via a standard tracheal tube should provide sufficient oxygenation. But, further gains of a surgical approach with tracheal-tube insertion, such as confirmation of success by waveform capnography, protection against aspiration, and application of PEEP, are possibly impeded because of insufficient cuff seal. Thus, are standard tracheal tubes superior for this challenging scenario?

Given its advantages, surgical cricothyrotomy is the recommended technique in the ‘cannot intubate, cannot oxygenate’ scenario. To overcome the problem of leakage caused by the mismatch of small tracheal-tube cuff and tracheal diameters, we equip all cricothyrotomy kits for adults with micro-laryngeal tubes (MLTs) ID 5.0 and 6.0 mm (Rüsch® micro-laryngeal endotracheal tube; Teleflex Medical GmbH, Belp, Switzerland). Designed for laryngeal or tracheal surgery and patients with tracheal stenosis, these tubes offer smaller inner (5.0 or 6.0 mm) and outer (7.3 and 8.7 mm) diameters to provide better visualisation and access to the surgical site. But, the cuff diameter averages 31 mm, about the cuff diameter of a standard ID 8.0 mm tube. It is possible to place an ID 5.0 or 6.0 mm tube through the incision in the cricoid membrane, whilst simultaneously achieving a sufficient seal in adults, enabling positive pressure ventilation, sufficient expiration, capnography, etc. We have used this successfully in mannequin tests and in emergencies. I recommend routine use of MLTs instead of standard tracheal tubes for surgical cricothyrotomy procedures in adults, and encourage the authors to take these considerations into account for future updates of their excellent guidelines.

 

Réponse

Response to 'Surgical cricothyroidotomy-the tracheal tube dilemma'.

 

 

Tracheal tube Cuff diameters inflated using different volumes of air, (mm)-including diameter stated on packaging

Table 1Tracheal tube Cuff diameters inflated using different volumes of air, (mm)-including diameter stated on packaging
Tube inner diameter (mm) Stated cuff diameter (mm) 12 ml inflated (mm) 15 ml inflated (mm) 20 ml inflated (mm)
5.0 18 25 26 27
5.5 21 25 27 30
6.0 22 26 28 30

19/04/2018

Morts évitables Civil vs Militaire: Parle-t-on de la lmême chose ?

Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review.

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Et bien pas sûr tant les méthodes sont fifférentes
 
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Importance:

Military and civilian trauma experts initiated a collaborative effort to develop an integrated learning trauma system to reduce preventable morbidity and mortality. Because the Department of Defense does not currently have recommended guidelines and standard operating procedures to perform military preventable death reviews in a consistent manner, these performance improvement processes must be developed.

Objectives:

To compare military and civilian preventable death determination methods to understand the existing best practices for evaluating preventable death.

Evidence Review:

This systematic review followed the PRISMA reporting guidelines. English-language articles were searched from inception to February 15, 2017, using the following databases: MEDLINE (Ovid), Evidence-Based Medicine Reviews (Ovid), PubMed, CINAHL, and Google Scholar. Articles were initially screened for eligibility and excluded based on predetermined criteria. Articles reviewing only prehospital deaths, only inhospital deaths, or both were eligible for inclusion. Information on study characteristics was independently abstracted by 2 investigators. Reported are methodological factors affecting the reliability of preventable death studies and the preventable death rate, defined as the number of potentially preventable deaths divided by the total number of deaths within a specific patient population.

Findings:

Fifty studies (8 military and 42 civilian) met the inclusion criteria. In total, 1598 of 6500 military deaths reviewed and 3346 of 19 108 civilian deaths reviewed were classified as potentially preventable. Among military studies, the preventable death rate ranged from 3.1% to 51.4%. Among civilian studies, the preventable death rate ranged from 2.5% to 85.3%. The high level of methodological heterogeneity regarding factors, such as preventable death definitions, review process, and determination criteria, hinders a meaningful quantitative comparison of preventable death rates.

Conclusions and Relevance:

The reliability of military and civilian preventable death studies is hindered by inconsistent definitions, incompatible criteria, and the overall heterogeneity in study methods. The complexity, inconsistency, and unpredictability of combat require unique considerations to perform a methodologically sound combat-related preventable death review. As the Department of Defense begins the process of developing recommended guidelines and standard operating procedures for performing military preventable death reviews, consideration must be given to the factors known to increase the risk of bias and poor reliability.

12/04/2018

Du sel mais pas trop ?

Excess sodium is deleterious on endothelial and glycocalyx barrier function: A microfluidicstudy

Martin JV et Al. J Trauma Acute Care Surg. 2018 Mar 12. doi: 10.1097/TA.0000000000001892

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L'efficacité des solutés de remplissage vasculaire a longtemps été abordée sous l'angle de la compensation volémique. Cette approche a débouchée sur l'emploi de solutés hypertoniques qui ont par ailleurs un intérêt en matière de lutte contre l'oedème cérébral et le syndrome de compartiment digestif. ICependant les méta-analyses faites ne montre pas d'intérêt des solutés en matières de survie. Ces derniers ne sont pas exempts de reproche avec au premier plan les effets sur la coagulopahie du traumatisé. Ce travail apporte une nouvelle pierre à cet argumentaire en montrant une altération importante du glycocalyx ds lors que la natrémie est > à 160 ml/ml. La question de la réduction à 3% des solutés hypersalés employés se pose donc.

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BACKGROUND:

Hypernatremia is a common problem affecting critically ill patients, whether due to underlying pathology or the subsequent result of hypertonic fluid resuscitation. Numerous studies have been published suggesting that hypernatremia may adversely affect the vascular endothelial glycocalyx. Our study aimed to evaluate if high sodium concentration would impair the endothelial and glycocalyx barrierfunction and if stress conditions that simulate the shock microenvironment would exacerbate any observed adverse effects of hypernatremia.

METHODS:

Human umbilical vein endothelial cells (HUVEC) were cultured in microfluidic channels subjected to flow conditions overnight to stimulate glycocalyx growth. Cells were then subjected to sodium (Na) concentrations of either 150 or 160 mEq/L, with Hepes solution applied to media to maintain physiologic pH. Subsets of HUVEC were also exposed to hypoxia/reoxygenation and epinephrine (HR + Epi) to simulate shock insult, then followed by Na treatment. Perfusate was then collected 60 and 120 minutes following treatments. Relevant biomarkers were then evaluated and HUVEC underwent fluorescent staining followed by microscopy.

RESULTS:

Glycocalyx degradation as indexed by hyaluronic acid and syndecan-1 was elevated in all subgroups, particularly those subjected to HR + Epi with Na 160 mEq/L. Thickness of the glycocalyx as evaluated by fluorescent microscopy was reduced to ½ of baseline with Na 160 mEq/L and to 1/3 of baseline with additional insult of HR + Epi. Endothelial activation/injury as indexed by soluble thrombomodulin (sTM) was elevated in all subgroups. A pro-fibrinolytic coagulopathy phenotype was demonstrated in all subgroups with increased tissue-plasminogen activator (tPA) levels and decreased plasminogen activator inhibitor-1 (PAI-1) levels.

CONCLUSIONS:

Our data suggests that hypernatremia results in degradation of the endothelial glycocalyx with further exacerbation by shock conditions. A clinical study utilizing clinical measurements of the endothelial glycocalyx in critically ill or injured patients with acquired hypernatremia would be warranted.

Prélèvement de sang frais: VO2 Altérée

"Immediate effects of blood donation on physical and cognitive performance - A randomizedcontrolled double blinded trial"

 
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Il existe un engouement justifié pour la transfusion de sang frais en traumatologie de guerre. On peut faire remonter cette redécouverte au conflit bosniaque (1). Cependant voir en tout combattant un donneur potentiel est aller un peu vite en besogne. Ce travail, qui émane d'une équipe norvégienne pronant cette pratique (2) peut être interprété comme montrant une baisse de la VO2  de 6% associée à une altération certes non significative des fonctions cognitives. Il paraît dès lors un peu prématuré de vouloir généraliser cette pratique notamment au milieu des équipes intervenant en milieu très isolé, souvent en ayant été exposées à des contraintes physiologiques majeures et où les capacités physiques et cognitives doivent être maintenues. Ce n'est pas le cas de tous les combattants et certains sont certainement éligibles sous réserve du respect des règles d'hémovigilance de base (3).
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BACKGROUND:

The success of implementing Damage Control Resuscitation principles pre-hospital has been at the expense of several logistic burdens including the requirements for resupply, and the question of donor safety during the development of whole blood programs. Previous studies have reported effects on physical performance after blood donation, however none have investigated the effects of blooddonation on cognitive performance.

METHOD:

We describe a prospective double blindedrandomized controlled study comprised of a battery of tests: three cognitive tests, and VO2max testing on a cycle ergometer. Testing was performed 7 days before blinded donation (Baseline day), immediately after donation(Day 0), and 7 days (Day 7) after donation. The inclusion criteria included being active blood donors at the Haukeland University Hospital blood bank where eligibility requirements were met on the testing days and providing informed consent. Participants were randomized to either the experimental (n=26) or control group (n=31). Control group participants underwent a 'mock donation" in which a phlebotomy needle was placed but blood was not withdrawn.

RESULTS:

In the experimental group, mean VO2max declined 6% from 41.35 +/-1.7 /(min.kg) at baseline to 39.0 +/-1.6 /(min.kg) on Day 0, and increased to 40.51 +/-1.5 /(min.kg) on Day 7. Comparable values in the control group were 42.1 +/-1.8 /(min.kg) at baseline, 41.6 +/-1.8 /(min.kg) on Day 1 (1% decline from basline), and 41.8 +/-1.8 /(min.kg) on Day 7. Comparing scores of all three cognitive tests on Day 0 and Day 7 showed no significant differences, p>0.05.

CONCLUSION:

Our main findings are that executive cognitive and physical performance were well-maintained after whole blood donation in healthy blood donors. The findings inform post-donation guidance on when donors may be required to return to duty.

La vitesse ne fait pas tout

Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport.

Chen X et Al.  J Trauma Acute Care Surg. 2018 Apr;84(4):549-557

 

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Ne pas perdre de temps est bien. Mais il ne faut pas oublier également que la réalisation de gestes avancés de réanimation est aussi utile en préhospitalier. Ceci milite pour la constitution d'équipes dont l'expertise en matière de gestion des voies aériennes/Trauma thoracique-Crânien est le métier. Cette question se pose tout particulièrement pour les vecteurs d'EVASAN à voilure tournante.

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BACKGROUND:

Helicopter emergency medical services (HEMS) have demonstrated survival benefits over ground emergency medical services (GEMS) for trauma patient transport. While HEMS speed is often-cited, factors such as provider experience and level of care may also play a role. Our objective was to identify patient groups that may benefit from HEMS even when prehospital time for helicopter utilization is longer than GEMS transport.

METHODS:

Adult patients transported by HEMS or GEMS from the scene of injury in the Pennsylvania State Trauma Registry were included. Propensity score matching was used to match HEMS and GEMS patients for likelihood of HEMS, keeping only pairs in which the HEMS patient had longer total prehospital time than the matched GEMS patient. Mixed-effects logistic regression evaluated the effect of transport mode on survival while controlling for demographics, admission physiology, transfusions, and procedures. Interaction testing between transport mode and existing trauma triage criteria was conducted and models stratified across significant interactions to determine which criteria identify patients with a significant survival benefit when transported by HEMS even when slower than GEMS.

RESULTS:

From 153,729 eligible patients, 8,307 pairs were matched. Helicopter emergency medical services total prehospital time was a median of 13 minutes (interquartile range, 6-22) longer than GEMS. Patients with abnormal respiratory rate (odds ratio [OR], 2.39; 95% confidence interval [CI], 1.26-4.55; p = 0.01), Glasgow Coma Scale score of 8 or less (OR, 1.61; 95% CI, 1.16-2.22; p < 0.01), and hemo/pneumothorax (OR, 2.25; 95% CI, 1.06-4.78; p = 0.03) had a significant survival advantage when transported by HEMS even with longer prehospital time than GEMS. Conversely, there was no association between transport mode and survival in patients without these factors (p > 0.05).

CONCLUSION:

Patients with abnormal respiratory rate, Glasgow Coma Scale score of 8 or less, and hemo/pneumothorax benefit from HEMS transport even when GEMS transport was faster. This may indicate that these patients benefit primarily from HEMS care, such as advanced airway and chest trauma management, rather than simply faster transport to a trauma center.

| Tags : evasan

Intra-Osseux: En 1er ? Chez les plus graves

The intraosseous have it : A prospective observational study of vascular access success rates in patients in extremis using video review.

Chreiman KM et Al. J Trauma Acute Care Surg. 2018 Apr;84(4):558-563.

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Attention dans cette étude les abords vasculaires ne sont pas réalisés par les mêmes personnels. Ainsi les VVP sont posées en grande majorité par des infirmiers dont la pratique pour ce geste est grande. Ceci pour dire que l'intérêt de l'intra-osseux est majeur, tout particulièrement quand on emploie un dispositif motorisé tel que l'EZ-IO dont l'apprentissage est simplissime pour qui sait employer une perceuse.

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BACKGROUND:

Quick and successful vascular access in injured patients arriving in extremis is crucial to enable early resuscitation and rapid OR transport for definitive repair. We hypothesized that intraosseous (IO) access would be faster and have higher success rates than peripheral intravenous (PIV) or central venous catheters (CVCs).

METHODS:

High-definition video recordings of resuscitations for all patients undergoing emergency department thoracotomy from April 2016 to July 2017 were reviewed as part of a quality improvement initiative. Demographics, mechanism of injury, access type, access location, start and stop time, and success of each vascular access attempt were recorded. Times to completion for access types (PIV, IO, CVC) were compared using Kruskal-Wallis test adjusted for multiple comparisons, while categorical outcomes, such as success rates by access type, were compared using χ test or Fisher's exact test.

RESULTS:

Study patients had a median age of 30 years (interquartile range [IQR], 25-38 years), 92% were male, 92% were African American, and 93% sustained penetrating trauma. A total of 145 access attempts in 38 patients occurred (median, 3.8; SD, 1.4 attempts per patient). There was no difference between duration of PIV and IO attempts (0.63; IQR, 0.35-0.96 vs. 0.39 IQR, 0.13-0.65 minutes, adjusted p = 0.03), but both PIV and IO were faster than CVC attempts (3.2; IQR, 1.72-5.23 minutes; adjusted p < 0.001 for both comparisons). Intraosseous lines had higher success rates than PIVs or CVCs (95% vs. 42% vs. 46%, p < 0.001).

ovidweb.cgi?S=NDHAFPHPDPDDADPBNCFKOHJCBDCFAA00&Graphic=01586154-201804000-00002%7cFF2%7cM%7cjpg

CONCLUSION:

Access attempts using IO are as fast as PIV attempts but are more than twice as likely to be successful. Attempts at CVC access in patients in extremis have high rates of failure and take a median of over 3 minutes. While IO access may not completely supplant PIVs and CVCs, IO access should be considered as a first-line therapy for trauma patients in extremis.

| Tags : intraosseux