28/11/2023
Conflit en Ukraine: Enseignements, vision UK
Transferable military medical lessons from the Russo-Ukraine war
Hodgetts TJ, et al. BMJ Mil Health 2023;0:1–4
The first year of the war in Ukraine has presented critical lessons for the UK’s Defence Medical Services (DMS) regarding its preparedness to support the nation for warfighting at scale. There are tactical, clinical, and strategic challenges that must be addressed. The war has exposed the limitations of international humanitarian law and the laws of armed conflict in protecting forward field hospitals from deliberate targeting. The DMS may need to employ measures such as disguise, deception, and dispersal to provide care in a contested environment. The historical trend of disinvestment in military medical capability between major conflicts, known as the "Walker Dip," represents a clinical risk that must be mitigated. Even if this is achieved, clinical outcomes during large-scale warfighting are likely to be worse that those the nation has come to expect during more low-intensity conflicts. Effective civilian-military collaboration will be paramount to manage casualties at scale. Both novel and reversionary modes of transportation may be required, such as the mass movement of casualties by train. The need for a sufficient and capable medical workforce, amid global shortages and post-COVID burnout, calls for further investment. The DMS requires innovation and adaptability to harness the ability to adopt external ideas, translate successful innovations and address complex challenges. By addressing tactical vulnerabilities, enhancing clinical preparedness, fostering civilian-military collaboration, and embracing innovation, the DMS will be better equipped to support the UK and allied armed forces in future warfighting at scale.
25/11/2023
Intubation des traumas sévères pénétrants
Prehospital and emergency department airway management of severe penetrating trauma in Sweden during the past decade
Renberg M et Al. Scand J Trauma Resusc Emerg Med. 2023 Nov 24;31(1):85
------------------------------------
On sait cet exercice difficile même entre des mains expérimentées. Cet article le confirme. N'oublions pas; ce qui compte en premier c'est d'oxygéner. Avant de procéder à une intubation, bien évaluer l'état hémodynamique car une induction et une mise sous respirateur peuvent l'altérer, voire être responsable d'un arrêt cardiaque.
------------------------------------
Background:
Prehospital tracheal intubation (TI) is associated with increased mortality in patients with penetrating trauma, and the utility of prehospital advanced airway management is debated. The increased incidence of deadly violence in Sweden warrants a comprehensive evaluation of current airway management for patients with penetrating trauma in the Swedish prehospital environment and on arrival in the emergency department (ED).
Methods:
This was an observational, multicenter study of all patients with penetrating trauma and injury severity scores (ISSs) ≥ 15 included in the Swedish national trauma register (SweTrau) between 2011 and 2019. We investigated the frequency and characteristics of prehospital and ED TI, including 30-day mortality and patient characteristics associated with TI.
Result:
Of 816 included patients, 118 (14.5%) were intubated prehospitally, and 248 (30.4%) were intubated in the ED. Patients who were intubated prehospitally had a higher ISS, 33 (interquartile range [IQR] 25, 75), than those intubated in the ED, 25 (IQR 18, 34). Prehospital TI was associated with a higher associated mortality, OR 4.26 (CI 2.57, 7.27, p < 0.001) than TI in the ED, even when adjusted for ISS (OR 2.88 [CI 1.64, 5.14, p < 0.001]). Hemodynamic collapse (≤ 40 mmHg) and low GCS score (≤ 8) were the characteristics most associated with prehospital TI. Traumatic cardiac arrests (TCAs) occurred in 154 (18.9%) patients, of whom 77 (50%) were intubated prehospitally and 56 (36.4%) were intubated in the ED. A subgroup analysis excluding TCA showed that patients with prehospital TI did not have a higher mortality rate than those with ED TI, OR 2.07 (CI 0.93, 4.51, p = 0.068), with OR 1.39 (0.56, 3.26, p = 0.5) when adjusted for ISS.
Conclusion:
Prehospital TI was associated with a higher mortality rate than those with ED TI, which was specifically related to TCA; intubation did not affect mortality in patients without cardiac arrest. Mortality was high when airway management was needed, regardless of cardiac arrest, thereby emphasizing the challenges posed when anesthesia is needed. Several interventions, including whole blood transfusions, the implementation of second-tier EMS units and measures to shorten scene times, have been initiated in Sweden to counteract these challenges. Sweden.
| Tags : intubation, airway
20/11/2023
Les anesthésistes: Pièce importante dans les guerres hybrides
A Gray Future: The Role of the Anesthesiologist in Hybrid Warfare
Granholm F et Al. Anesthesiology. 2023 Nov 1;139(5):563-567.
During the last few decades, the increasing use of asymmetric and multimodal tactics by terrorists has led anesthesiologists worldwide to analyze and discuss their role in mass casualty scenarios in more depth. Now anesthesiologists must address the new situation of hybrid threats and hybrid warfare. This will have a direct impact on anesthesiology and intensive care, and in the end, the health and well-being of critical patients of all ages. To be able to respond to a hybrid threat efficiently and effectively, it is imperative that anesthesiologists play an early and integral role in mitigation and response planning.
12/11/2023
Haute intensité: Réflexions canadiennes
Medical support for future large-scale combat operations
Tien H. et Al. https://doi.org/10.3138/jmvfh-2022-0006
---------------------------------
C'est un plaidoyer pour plus des équipes beaucoup plus techniques à l'avant, de petite taille et mobiles.
---------------------------------
Introduction: Medical teams were extremely successful in saving lives during the war in Afghanistan. However, this war was a counterinsurgency (COIN) operation where Allied forces enjoyed air superiority and complete unhampered communications. A future war against a peer adversary may present differently. A narrative review was conducted to make recommendations about how medical support to large-scale combat operations may need to be modified from current doctrine, which was developed for COIN operations. Methods: This narrative review examined the evolution of pre-hospital (tactical combat casualty care [TCCC]) and hospital (NATO echelons of care) doctrine underlying medical support to land operations developed during operations in Afghanistan and Iraq. It analyzed the outcomes of several battles from the current Russo-Ukrainian conflict and considered the implications of how medical support should be provided to large-scale combat operations. Results: Military planners should expect that timely medical evacuation to surgical care cannot be assumed in a peer-to-peer war, as air superiority and reliable communications cannot be assured. As well, modern munitions are likely to cause substantially more casualties than previous COIN operations, with a higher proportion of burns and primary blast injuries. Discussion: Canadian Forces Health Services should actively review its TCCC guidelines and doctrine for providing medical support to land operations. As air superiority and constant communication cannot be assured during peer-to-peer large-scale combat operations, there may be a need to focus on prolonged tactical field care and smaller, more mobile surgical teams.
Compression aortique transgastrique ?
Gastroesophageal resuscitative occlusion of the aorta: Physiologic tolerance in a swine model of hemorrhagic shock
Tiba M. et Al. J Trauma Acute Care Surg . 2020 Dec;89(6):1114-1123.
Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been shown to be effective for management of noncompressible torso hemorrhage. However, this technique requires arterial cannulation, which can be time-consuming and not amendable to placement in austere environments. We present a novel, less invasive aortic occlusion device and technique designated gastroesophageal resuscitative occlusion of the aorta (GROA). In this study, we aimed to characterize the physiological tolerance and hemodynamic effects of a prototype GROA device in a model of severe hemorrhagic shock and resuscitation and compare with REBOA.
Methods: Swine (N = 47) were surgically instrumented for data collection. A 35% controlled arterial hemorrhage was followed by randomizing animals to 30-minute, 60-minute, or 90-minute interventions of GROA, REBOA, or control.
Following intervention, devices were deactivated, and animals received whole blood and crystalloid resuscitation. Animals were monitored for an additional 4 hours.
Results: All animals except one GROA 90-minute application survived the duration of their intervention periods. Survival through resuscitation phase in GROA, REBOA, and control groups was similar in the 30-minute and 60-minute groups. The 90-minute occlusion groups exhibited deleterious effects upon device deactivation and reperfusion with two GROA animals surviving and no REBOA animals surviving. Mean (SD) arterial pressure in GROA and REBOA animals increased across all groups to 98 (31.50) mm Hg and 122 (24.79) mm Hg, respectively, following intervention. Lactate was elevated across all GROA and REBOA groups relative to controls during intervention but cleared by 4 hours in the 30-minute and 60-minute groups. Postmortem histological examination of the gastric mucosa revealed mild to moderate inflammation across all GROA groups.
Conclusion: In this study, the hemodynamic effects and physiological tolerance of GROA was similar to REBOA. The GROA device was capable of achieving high zone II full aortic occlusion and may be able to serve as an effective method of aortic impingement.
Lire aussi:
Revue des moyens d'hémostase des hémorragies non compressibles
Perspectives on the management of non-compressible torso hemorrhage: A narrative review
Leclerc S et Al. Journal of Military, Veteran and Family Health 8(s2) 2022: 73-36
Hemorrhage is one of the leading causes of death after trauma. A significant proportion of these fatalities could be prevented with appropriate bleeding control. This is more easily achieved with direct pressure in compressible areas such as the extremities or major joints. However, bleeding in the chest, abdomen, or pelvis cannot be as easily controlled without advanced procedures that are only available in hospitals. This article describes several technologies to control bleeding in the chest, abdomen, and pelvis that are potentially applicable in combat and pre-hospital settings. However, a review of existing studies quickly shows that convincing clinical evidence is lacking to support most pre-existing technologies, and the majority of studies are in the investigational stage. A universal, effective, and life-saving solution has not yet been identified. Accordingly, research in this area should continue to focus on both refining existing technologies and developing new approaches.
More than 50% of combat casualty deaths on the battlefield occur minutes to hours after a person has been wounded. Approximately 25% of those fatalities could potentially be prevented if rapid hemorrhage control or temporization were feasible. Despite several technologies to temporize non-compressible torso hemorrhage (NCTH), an ideal device and method have not yet been developed, particularly for Role 1 military medical treatment facilities and civilian pre-hospital settings. This article summarizes the devices and adjunct methods currently available to temporize NCTH when surgical and interventional radiology control are not readily accessible. New technologies under investigation are also discussed.
09/11/2023
Couverture de survie: Pas que pour l'hypothermie !
High Tensile Strength Increases Multifunctional Use of Survival Blankets in Wilderness Emergencies
Markus I et Al.Wilderness Environ Med. 2020 Jun;31(2):215-219
Introduction:
Metallic survival blankets are multifunctional medical devices frequently used to provide
thermal insulation in sport and leisure activities and in emergency care. To assess further properties of survival blankets, we investigated their breaking strength under laboratory conditions.
Methods:
An experimental study was performed with 2 commercially available survival blankets used
by emergency medical services. Breaking strength measured with a tensile testing machine was determined consecutively with 10 tests conducted per brand.
Results;
Breaking strength (mean±SD) of the tested brands was 3.8±0.4 kN, (range: 2.8-4.1 kN) and
4.0±0.5 kN (range: 3.2-4.6 kN). When using the windlass of a commercially available tourniquet for the longitudinally folded survival blanket, the windlass bent at a force of 0.8 kN; when using a carabiner, the force exceeded 3.6 kN before failure occurred in both blanket brands.
Conclusions:
Both brands of survival blankets show impressive tensile strength, indicating that they have the potential to serve as temporary pelvic binders or even as makeshift tourniquets when urgent bleeding control is needed
Pour aller plus loin:
1. Emploi dans les plaies thoraciques: https://www.annalsthoracicsurgery.org/article/S0003-4975(2...
2. Garrot (mais -moins efficace qu'un tourniquet): https://www.sciencedirect.com/science/article/pii/S1080603223000431
Trop simplifier: Pas forcément bon, l'exemple de la ventilation
Comparison of Airway Control Methods and Ventilation Success With an Automatic Resuscitator
Rodriguez D. et Al. J Spec Oper Med. 2012; 12(2):65-70.
Mechanical ventilation in an austere environment is difficult owing to logistics, training, and environmental conditions. We evaluated the ability of professional caregivers to provide ventilatory support to a simulated patient using the Simplified Automated Ventilator (SAVe) with a mask hand attended ventilation, mask with single strap unattended ventilation, and supraglottic airway (King LT) ventilation.
All three methods were performed using a SAVe with a set tidal volume of 600 mL and respiratory rate of 10 breaths per minute. The simulator consisted of a head and upper torso with anatomically correct upper airway structures, trachea, esophagus, and lung that also measured the delivered tidal volume, respiratory rate, inspiratory flow, and airway pressures. Volunteers used each airway control method to provide ventilation for 10 minutes in random order. Success of each technique was judged as a mean delivered tidal volume of > 500 mL. The major finding of this study was that medical professionals using the SAVe resuscitator and the manufacturer-supplied face mask with single head strap failed to ventilate the airway model in every case