Point sur les matériaux hémostatiques

Emerging hemostatic materials for non-compressible hemorrhage control 
Dong R. et Al. ,Natl Sci Rev. 2022 Aug 17;9(11):nwac162.

 

Non-compressible hemorrhage control is a big challenge in both civilian life and the battlefield, causing a majority of deaths among all traumatic injury mortalities. Unexpected non-compressible bleeding not only happens in pre-hospital situations but also leads to a high risk of death during surgical processes throughout in-hospital treatment. Hemostatic materials for pre-hospital treatment or surgical procedures for non-compressible hemorrhage control have drawn more and more attention in recent years and several commercialized products have been developed. However, these products have all shown non-negligible limitations and researchers are focusing on developing more effective hemostatic materials for non-compressible hemorrhage control. Different hemostatic strategies (physical, chemical and biological) have been proposed and different forms (sponges/foams, sealants/adhesives, microparticles/powders and platelet mimics) of hemostatic materials have been developed based on these strategies. A summary of the requirements, state-of-the-art studies and commercial products of non-compressible hemorrhage-control materials is provided in this review with particular attention on the advantages and limitations of their emerging forms, to give a clear understanding of the progress that has been made in this area and the promising directions for future generations.

Couverture de survie: Pas que pour l'hypothermie

Rescue blankets as multifunctional rescue equipment in alpine and wilderness emergencies: a commentary

Wallner B et Al. Scand J Trauma Resusc Emerg Med 30, 17 (2022)

 

Emergency applications of rescue blankets go far beyond protection from hypothermia. In this review alternative applicabilities of these remarkable multifunctional tools were highlighted. Newly fabricated rescue blankets prove impressive robustness. The high tensile strength along with its low weight enable further applications, e.g. immobilization of injured extremities, splinting, wound dressing, a makeshift chest seal in sucking chest wounds, amongst others. Furthermore, the foil can be used as a vapour barrier, as eye protection and it can even be used to construct a stopgap bivouac sack, as alternative tool for transportation in the remote area and a wind shield or a water reservoir in the wilderness. During search-and-rescue missions the light reflection from the gold surface enhances visibility and increases the chance to be found. Rescue blankets are essential parts of first aid kits and backpacks in alpine and wilderness environment with multifunctional applicabilities. In this commentary to a review we want to evaluate the numerous applicabilities of rescue blankets in the treatment of emergencies by wilderness medicine and pre-hospital EMS.

Echographie ciblée: Quelles recommandations ?

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

Via G et Al. J Am Soc Echocardiogr. 2014 Jul;27(7):683.e1-683.e33.

 

BACKGROUNDS:

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS:

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS:

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS:

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

 

Plaidoyer AUSSIE pour + de technicité à l'avant

Treatment at point of injury—A proposal for an enhanced combat first aider and health technician skillset

Pilgrim C. et Al. JMVH 2022, oncline first 

 

Management of trauma in the future operating environment might be significantly different from the recent experience in the Middle East Region if it were to occur in the context of hostilities between coalition, including Australian forces and a near-peer or peer-level threat. Specifically, reliance on rotary-wing aeromedical evacuation may be compromised if air superiority is degraded or denied.

Two alternative approaches may be considered in the context of constrained evacuation capability. First, enhanced treatment of the injured soldier on the ground at or near the point of injury by first responders may broaden the window during which a patient may survive on the battlefield awaiting evacuation. Alternatively, moving the surgical resources to the casualty may also improve the chances of survival for an injured soldier. However, this comes at the cost of risking higher-level assets. The first of these approaches is considered here with an exploration of what life-saving interventions (LSI) can be delivered by first responder soldiers. Numerically dropping as a result of tactical combat casualty care principles but persisting as causes of preventable battlefield death, exsanguinating extremity haemorrhage, tension pneumothorax and airway obstruction are areas where future gains may be possible with an expanded skillset deliverable by combat first aiders and health technicians.

Earlier administration of blood products by health technicians to casualties with exsanguinating haemorrhage would align military trauma management principles with the civilian world, where blood products can now be administered en route by trained paramedics. Similarly, there is a shift towards managing tension pneumothorax with finger thoracostomy in preference to needle decompression in the hospital and pre-hospital environment in the civilian sector.

Of much greater complexity, management of non-compressible truncal haemorrhage remains problematic on the battlefield. A highly specialised intervention with significant haemodynamic consequences that nevertheless has been shown to be achievable in both military and civilian contexts is REBOA (resuscitative endovascular balloon occlusion of the aorta). This technique is encumbered with a significant training burden but warrants discussion and is most relevant when evacuation times are expected to fall between 1 and 6 hours. Expanding the skillset deliverable by combat first aiders and health technicians may offset delays in evacuation and maintain battlefield casualty survival in the future operating environment and may be obtained leveraging existing Defence training programs.

Triage: Encore + d'expertise à l'avant

JTS Analyzes Search and Rescue After Action Reports to Uncover Deficiencies,
Develops Performance Improvement Metrics

https://prolongedfieldcare.org/2022/03/18/joint-trauma-system-newsletter-update/

The JTS PI and CTS Operations branches published in-depth review of after action reports (AARs) from over 252 search and rescue (SAR) missions from 2018 - 2021. The report is in response to the U.S. Navy SAR’s request that JTS assess its operations. It analyzes the context in which Naval SAR operations oc- curred as well as medical procedures and patient demographics. JTS identified deficiencies in equipment, personnel, and documentation and developed a list of PI metrics. The need for standardization is keenly felt in the field. AAR comments reinforce the need for standardized equipment like cardiac kits, medication kits, and advanced life support tools. For example, SAR crews report they do not have the equipment or skills to perform rapid intubation of patients. The report was unable to conclude whether or not standardized medication kits are available to SAR teams. The report did find skills of attendant medical personal vary considerably across SAR missions. Thirty-one percent of missions were executed by a single EMT-B, while 19% were executed by a single EMP-P, and 17% were executed by two medical attendants. In some cases, both a registered nurse and physician were present, while other times only one was pre- sent.

JTS identified opportunities for improving documentation. Vague or incomplete information in the after action reports makes it more difficult to conduct accurate assessments. Accurate information is critical for mission success. Casualty classification was one area of deficiency. The report found that there is only an 81% overall accuracy in the SAR Rescuer Skill Type
casualty classification. This puts casualty classification high on the list of performance improvement (PI) priorities. Casualty classification includes all the critical information of the patient, most notably the type and severity of injury and location of the patient. It is imperative that patients are accurately classified at the start of the mission, since this determines everything from prioritizing patient care to the medical and logistical resources. A key metric for success is the comparison between the dispatched category and the assessed category of the casualty. Dispatch’s casualty classification should match the classification assessed upon the arrival at the mission destination. Having accurate information upfront is critical for SAR teams to accurately triage the casualty in advance, which dictates urgency, timing, equipment, and all other areas of mission prep. Inconsistent SAR documentation impacts the ability for SAR teams to record accurate information. For example, the DA4700 form has a list of specific mechanisms of injury (MOI), which are tailored towards battlefield en route care and not necessarily applicable to SAR operations. JTS reported roughly one fifth (55 out of 252 cases) of SAR cases recorded the MOI as either “other” or left blank. “Other” or left unchecked ultimately makes the data less useful and harder to interpret. In cases of hypothermia, the patient’s temperature was only recorded in 13% of cases. An emphasis on documentation training may
fill the gaps in SAR documentation.

The situation is further complicated by the fragmented nature of the available guidance for SAR teams. JTS discovered SAR teams rely on guidelines from multiple sources, bringing into question source credibility and guidance consistency.

The lack of training is at the root of the deficiencies. Additionally, actual mission engagements do not provide for redundancy which would lead to proficiency, proving that personnel training is of paramount importance. For instance, in one exercise, Special Operations assets had to be utilized for Casualty Evacuation (CASEVAC) purposes because the CASEVAC plan proved insufficient during the course of the exercise. The AARs recommended regular testing and evaluation of CASEVAC plans.

Response to the JTS SAR report has been positive and supportive. LCDR Paul Roszko, Director of Emergency Medical Services, Navy Medical Forces, called the report “excellent” and viewed the findings as an opportunity to improve trauma training across the Services. The report prompted Rosko to question why there is not standardized casualty cards or simulations. He would like to take real-life cases and turn them into vignettes or simulations for squadron training. JTS does include an example of a SAR casualty vignette as a tool to improve SAR training. “The data is clear that the SAR community does a lot more than just treat trauma patients,” said Rozko. “Perhaps identifying a few common medical cases or other types of commonly encountered injuries and specifying what our "standard of care" reference point is would allow the JTS PI team to provide more feedback on the quality of care provided.”

Sang complet: OUI CHAUD et dans les 6 1ères heures.

Whole blood at the tip of the spear: A retrospective cohort analysis of warm fresh whole blood resuscitation vert: Dans les 06sus component therapy in severely injured combat casualties

Surgery . 2022 Feb;171(2):518-525. Gurney JM et Al. 

 

Background

Death from uncontrolled hemorrhage occurs rapidly, particularly among combat casualties. The US military has used warm fresh whole blood during combat operations owing to clinical and operational exigencies, but published outcomes data are limited. We compared early mortality between casualties who received warm fresh whole blood versus no warm fresh whole blood.

Methods

Casualties injured in Afghanistan from 2008 to 2014 who received ≥2 red blood cell containing units were reviewed using records from the Joint Trauma System Role 2 Database. The primary outcome was 6-hour mortality. Patients who received red blood cells solely from component therapy were categorized as the non–warm fresh whole blood group. Non– warm fresh whole blood patients were frequency-matched to warm fresh whole blood patients on identical strata by injury type, patient affiliation, tourniquet use, prehospital transfusion, and average hourly unit red blood cell transfusion rates, creating clinically unique strata. Multilevel mixed effects logistic regression adjusted for the matching, immortal time bias, and other covariates.

Results

The 1,105 study patients (221 warm fresh whole blood, 884 non–warm fresh whole blood) were classified into 29 unique clinical strata. The adjusted odds ratio of 6-hour mortality was 0.27 (95% confidence interval 0.13–0.58) for the warm fresh whole blood versus non–warm fresh whole blood group. The reduction in mortality increased in magnitude (odds ratio = 0.15, P = .024) among the subgroup of 422 patients with complete data allowing adjustment for seven additional covariates.

There was a dose-dependent effect of warm fresh whole blood, with patients receiving higher warm fresh whole blood dose (>33% of red blood cell–containing units) having significantly lower mortality versus the non–warm fresh whole blood group.

Conclusion

Warm fresh whole blood resuscitation was associated with a significant reduction in 6-hour mortality versus non–warm fresh whole blood in combat casualties, with a dose-dependent effect. These findings support warm fresh whole blood use for hemorrhage control as well as expanded study in military and civilian trauma settings.

Histoire d'effets de protection

Warfighter Personal Protective Equipment and Combat Wounds

Michael J Klausner MJ et Al.  Med J (Ft Sam Houst Tex)  . 2021 Apr-Jun;(PB 8-21-04/05/06):72-77

Background:

Personal protective equipment (PPE) is crucial to force protection and preservation. Innovation in PPE has shifted injury patterns, with protected body regions accounting for decreased proportions of battlefield trauma relative to unprotected regions. Little is known regarding the PPE in use by warfighters at the time of injury.

Methods:

We queried the Prehospital Trauma Registry (PHTR) for all encounters from 2003-2019. This is a sub-analysis of casualties with documented PPE at the time of medical encounter. When possible, encounters were linked to the Department of Defense Trauma Registry (DODTR) for outcome data. Serious injuries are defined as an abbreviated injury scale of 3 or greater.

Results:

Of 1,357 total casualty encounters in the PHTR, 83 were US military with documented PPE. We link 62 of this cohort to DODTR. The median composite Injury Severity Score (ISS) was 6 (Interquartile range (IQR) 4-21), and 11 casualties (18%) had an ISS >25. The most seriously injured body regions were the extremities (21%), head/neck (16%), thorax (16%), and abdomen (10%). PPE worn at time of injury included helmet (91%), eye protection (73%), front (75%) and rear plates (77%), left/right plates (65%), tactical vest (46%), groin protection (12%), neck protection (6%), pelvic shield (3%), and deltoid protection (3%).

Conclusion:

Our data set demonstrates that the extremities were the most commonly injured body region, followed by head/neck, and thorax. PPE designed for the extremities and neck are also among the least commonly worn protective equipment.

Ambition SSA 2030

Corps et âme

Clic sur l'image

Ouvrir le cou quand on ne voit rien

Definitive Management of a Traumatic Airway: Case Report
Fabich RA et Al. , MILITARY MEDICINE, 185, 1/2:e312, 2020

 

Maxillofacial and neck trauma from penetrating injuries present unique challenges for anesthesia providers and surgeons. In the austere conditions of a combat setting these challenges may be amplified due to limited resources and injury severity. Currently there is a lack of evidence and consensus on how to best manage a traumatized airway in this situation. The authors of this paper present the successful emergency management of a traumatized airway from a severe maxillofacial and neck-penetrating wound. A stepwise team approach using strong communication and a global mental model facilitated definitive airway management in this case allowing for safe transport to definitive care.

Remplissage vasculaire: Quid dans la vrai vie US ?

Trends in Prehospital Blood, Crystalloid, and Colloid Administration in Accordance With Changes in Tactical Combat Casualty Care Guidelines 
Clarke E E. et Al. Military Medicine, Volume 187, Issue 11-12, November-December 2022, Pages e1265–e1270,

Introduction

Hemorrhage is the leading threat to the survival of battlefield casualties. This study aims to investigate the types of fluids and blood products administered in prehospital trauma encounters to discover the effectiveness of Tactical Combat Casualty Care (TCCC) recommendations.

Materials and Methods

This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry with a focus on prehospital fluid and blood administration in conjunction with changes in the TCCC guidelines. We collected demographic information on each patient. We categorized receipt of each fluid type and blood product as a binary variable for each casualty and evaluated trends over 2007–2020 both unadjusted and controlling for injury severity and mechanism of injury.

Results

Our original dataset comprised 25,897 adult casualties from January 1, 2007 through March 17, 2020. Most (97.3%) of the casualties were male with a median age of 25. Most (95.5%) survived to hospital discharge, and 12.2% of the dataset received fluids of any kind. Medical personnel used crystalloids in 7.4% of encounters, packed red blood cells in 2.0%, and whole blood in 0.5% with very few receiving platelets or freeze-dried plasma. In the adjusted model, we noted significant year-to-year increases in intravenous fluid administration from 2014 to 2015 and 2018 to 2019, with significant decreases noted in 2008–2009, 2010–2012, and 2015–2016. We noted no significant increases in Hextend used, but we did note significant decreases in 2010–2012. For any blood product, we noted significant increases from 2016 to 2017, with decreases noted in 2009–2013, 2015–2016, and 2017–2018. Overall, we noted a general spike in all uses in 2011–2012 that rapidly dropped off 2012–2013. Crystalloids consistently outpaced the use of blood products. We noted a small upward trend in all blood products from 2017 to 2019.

Conclusions

Changes in TCCC guidelines did not immediately translate into changes in prehospital fluid administration practices. Crystalloid fluids continue to dominate as the most commonly administered fluid even after the 2014 TCCC guidelines changed to use of blood products over crystalloids. There should be future studies to investigate the reasons for delay in guideline implementation and efforts to improve adherence.