Tuerie de masse ou violence urbaine: Vite vers l'hôpital !

Comparison of the causes of death and wounding patterns in urban firearm-related violence and civilian public mass shooting events.

Maghami S et al. J Trauma Acute Care Surg. 2020 Feb;88(2):310-313.

 

 

BACKGROUND:

There are no reports comparing wounding pattern in urban and public mass shooting events (CPMS). Because CPMS receive greater media coverage, there is a connation that the nature of wounding is more grave than daily urban gun violence. We hypothesize that the mechanism of death following urban gunshot wounds (GSWs) is the same as has been reported following CPMS.

METHODS:

Autopsy reports of all firearm-related deaths in Washington, DC were reviewed from January 1, 2016, to December 31, 2017. Demographic data, firearm type, number and anatomic location of GSWs, and organ(s) injured were abstracted. The organ injury resulting in death was noted. The results were compared with a previously published study of 19 CPMS events involving 213 victims.

RESULTS:

One hundred eighty-six urban autopsy reports were reviewed. There were 171 (92%) homicides and 13 (7%) suicides. Handguns were implicated in 180 (97%) events. One hundred eight (59%) gunshots were to the chest/upper back, 85 (46%) to the head, 77 (42%) to an extremity, and 71 (38%) to the abdomen/lower back. The leading mechanisms of death in both urban firearm violence and CPMS were injury to the brain, lung parenchyma, and heart. Fatal brain injury was more common in CPMS events as compared with urban events involving a handgun.

CONCLUSION:

There is little difference in wounding pattern between urban and CPMS firearm events. Based on the organs injured, rapid point of wounding care and transport to a trauma center remain the best options for mitigating death following all GSW events.

 

Rachis et extraction de véhicules

An explorative, biomechanical analysis of spine motion during out-of-hospital extrication procedures.

Häske D et Al. Injury. 2020 Feb;51(2):185-192.

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Un travail qui interpelle par ses  implications potentielles sur la manière d'extraire les combattants de véhicules qu'ils soient terrestres ou aéronautiques.

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OBJECTIVES:

The extrication of patients following a road traffic collision is among the basic procedures in emergency medicine. Thus, extrication is a frequently performed procedure by most of the emergency medical services worldwide. The appropriate extrication procedure depends on the patient's current condition and accompanying injuries. A rapid extrication should be performed within a few minutes, and the cervical spine (at least) should be immobilized. To our knowledge, the scientific literature and current guidelines do not offer detailed recommendations on the extrication of injured patients. Thus, the aim of the current study is to compare the effectiveness of spinal stabilization during various out-of-hospital extrication procedures.

METHODS: This is an explorative, biomechanical analysis of spine motion during different extrication procedures on an example patient. Movement of the cervical spine was measured using a wireless human motion tracker. Movement of the thoracic and lumbar spine was quantified with 12 strain gauge sensors, which were positioned paravertebrally on both sites along the thoracic and lumbar spine. To interpret angular movement, a motionscore was developed based on newly defined axioms on the biomechanics of the injured spine.

RESULTS: Self-extrication showed the least spinal movement (overall motionscore sum = 667). Movement in the cervical spine could further be reduced by applying a cervical collar. The extrication by a rescue boa showed comparable results in overall spinal movement compared to the traditional extrication via spineboard (overall motionscore sum = 1862vs. 1743). Especially in the cervical spine, the spinal movement was reduced (motionscore sum = 339 vs. 595). However, the thoracic spine movement was increased (motionscore sum = 812 vs. 432).

Self- extrication without a cervical collar	Self- extrication with a cervical collar	Rapid extrication	Rapid extrication with rescue boa	Rapid extrication with a slide board and rescue boa	Rapid extrication with a patient transfer sheet
C1 – C7	flexion/extension	25	6	117	132	199	27
	rotation	28	6	287	165	216	32
	lateral bending	76	19	191	42	65	52
	sum	129	31	595	339	480	111
Th1 – Th9	flexion/extension	18	17	69	91	76	24
	rotation	157	122	286	598	559	156
	lateral bending	65	52	77	123	107	85
	sum	240	191	432	812	742	265
Th10 – L2	flexion/extension	21	46	83	109	82	43
	rotation	99	185	146	180	114	114
	sum	120	231	229	289	196	157
L3 – L5	flexion/extension	38	251	143	254	117	25
	rotation	73	93	286	93	178	64
	lateral bending	67	67	58	75	117	102
	sum	178	411	487	422	412	191
Total sum		667	864	1743	1862	1830	724

CONCLUSION: In case of a suspected cervical spine injury, guided self-extrication seems to be the best option. If the patient is not able to perform self-extrication, using a rescue boa might reduce cervical spinal movement compared to the traditional extrication procedure. Since promising results are shown in the case of extrication using a patient transfer sheet that has already been placed below the driver, future developments should focus on novel vehicle seats that already include an extrication device.

Penthrox: Pour la sédation procédurale ?

Inhaled methoxyflurane for the reduction of acute anterior shoulder dislocation in the emergency department.

Umana E et Al. CJEM. 2019 Jul;21(4):468-472. doi: 10.1017/cem.2018.493. Epub 2019 Feb 11.

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Le methoxyflurane est proposé comme agent d'analgésie avec pour avantage une relative simplicité de mise en oeuvre mais aussi son auto-administration par le patient lui même. Bien que moins efficace que d'autres agents tel que le propofol, son emploi pour la réalisation de gestes douloureux est également proposé avec pour avantage une moindre sédation post procédure. C'est ce que décrit avec succès cet article à propos d'un geste courant: la réduction de luxation d'épaule. Un petit bémol, le méthoxyflurane est un agent d'anesthésie ayant des propriétés sédatives importante qui sont minimisée avec le mode d'administration du Penthrox (maximum de 2X3ml initial et au maximum 3mlX5 par semaine).

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OBJECTIVES:

Methoxyflurane is an inhalation analgesic used in the emergency department (ED) but also has minimal sedative properties. The major aim of this study was to evaluate the success rate of methoxyflurane for acute anterior shoulder dislocation (ASD) reduction. The secondary aim was to assess the impact of methoxyflurane on ED patient flow compared to propofol.

METHODS:

A health record review was performed for all patients presenting with ASD who underwent reduction with either methoxyflurane or propofol over a 13-month period (December 2016 - December 2017). The primary outcome was reduction success for methoxyflurane, while secondary outcomes such as recovery time and ED length of stay (LOS) were also assessed compared to propofol. Patients with fracture dislocations, polytrauma, intravenous, or intramuscular opioids in the pre-hospital setting, no sedation for reduction, and alternative techniques of sedation or analgesia for reduction were excluded.

RESULTS:

A total of 151 patients presented with ASD during the study period. Eighty-two patients fulfilled our inclusion criteria. Fifty-two patients had ASD reduction with propofol while 30 patients had methoxyflurane. Successful reduction was achieved in 80% (95% CI 65.69% to 94.31%) patients who used methoxyflurane. The median recovery time and ED LOS were 30 minutes [19.3-44] and 70.5 minutes [49.3-105], which was found to be shorter for the methoxyflurane group, who had successful reductions compared to sedation with propofol.

CONCLUSION:

Methoxyflurane was used successfully in 30% of the 82 patients undergoing reduction for ASD, while potentially improving ED efficiency.