09/10/2024
Analgésie par inhalation ? Pas un plébiscite
Inhaled analgesics for the treatment of prehospital acute pain—A systematic review
Hyldmo PK et Al. Acta Anaesthesiol Scand. 2024 Sep 26. doi: 10.1111/aas.1452
Background
Many prehospital emergency patients receive suboptimal treatment for their moderate to severe pain. Various factors may contribute. We aim to systematically review literature pertaining to prehospital emergency adult patients with acute pain and the pain-reducing effects, adverse events (AEs), and safety issues associated with inhaled analgetic agents compared with other prehospital analgesic agents.
Methods
As part of an initiative from the Scandinavian Society of Anaesthesia and Intensive Care Medicine, we conducted a systematic review (PROSPERO CRD42018114399), applying the PRISMA guidelines, Grading of Recommendations Assessment, Development, and Evaluation (GRADE), and Cochrane methods, searching the Cochrane Library, Epistemonikos, Centre for Reviews and Dissemination, PubMed, and EMBASE databases (updated March 2024). Inclusion criteria were the use of inhaled analgesic agents in adult patients with acute pain in the prehospital emergency care setting. All steps were performed by minimum of two individual researchers. The primary outcome was pain reduction; secondary outcomes were speed of onset, duration of effect, and relevant AEs.
Results
We included seven studies (56,535 patients in total) that compared inhaled agents (methoxyflurane [MF] and nitrous oxide [N2O]) to other drugs or placebo. Study designs were randomized controlled trial (1; n = 60), randomized non-blinded study (1; n = 343), and randomized open-label study (1; n = 270). The remaining were prospective or retrospective observational studies. The evidence according to GRADE was of low or very low quality. No combined meta-analysis was possible. N2O may reduce pain compared to placebo, but not compared to intravenous (IV) paracetamol, and may be less effective compared to morphine and MF. MF may reduce pain compared to paracetamol, ketoprofen, tramadol, and fentanyl. Both agents may be associated with marked but primarily mild AEs.
Conclusion
We found low-quality evidence suggesting that both MF and N2O are safe and may have a role in the management of pain in the prehospital setting. There is low-quality evidence to support MF as a short-acting single analgesic or as a bridge to IV access and the administration of other analgesics. There may be occupational health issues regarding the prehospital use of N2O.
REBOA préhospitalier: Attention !
Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center
Tullos A et Al. J Vasc Surg. 2024 Jul;80(1):64-69
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Une technique dont on comprend l'intérêt théorique. Mais la vraie vie semble un peu différente. La mise en place d'un REBOA nécessite la présence d'une équipe chirurgicale très proche et ce n'est pas le cas le plus souvent en condition de combat.. L'environnement nécessaire au succès de cette technique n'est pas, le plus souvent, présent.
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Objective:
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to manage
severe hemorrhagic shock. Popularized in medical care during military conflicts, the concept has emerged as a lifesaving technique that is utilized around the United States. Literature on risks of REBOA placement, especially vascular injuries, are not well-reported. Our goal was to assess the incidence of vascular injury from REBOA placement and the risk factors associated with injury and death among these patients at our institution.
Methods:
We performed a retrospective cohort study of all patients who underwent REBOA placement between September 2017 and June 2022 at our Level 1 Trauma Center. The primary outcome variable was the presence of an injury related to REBOA insertion or use. Secondary outcomes studied were limb loss, the need for dialysis, and mortality. Data were analyzed using descriptive statistics, χ2, and t-tests asappropriate for the variable type.
Results:
We identified 99 patients who underwent REBOA placement during the study period. The mean
age of patients was 43.1 ± 17.2 years, and 67.7% (67/99) were males. The majority of injuries were from blunt trauma (79.8%; 79/99). Twelve of the patients (12.1%; 12/99) had a vascular injury related to REBOA placement. All but one required intervention. The complications included local vessel injury (58.3%; 7/12), distal embolization (16.7%; 2/12), excessive bleeding requiring vascular consult (8.3%; 1/12), pseudoaneurysm requiring intervention (8.3%; 1/12), and one incident of inability to remove the REBOA device (8.3%; 1/12). The repairs were performed by vascular surgery (75%; 9/12), interventional radiology (16.7%; 2/12), and trauma surgery (8.3%; 1/12). There was no association of age, gender, race, and blunt vs penetrating injury to REBOA-related complications. Mortality in this patient population was high (40.4%), but there was no association with REBOA-related complications. Ipsilateral limb loss occurred in two patients with REBOA-related injuries, but both were due to their injuries and not to REBOA-related ischemia.
Conclusions:
Although vascular complications are not unusual in REBOA placement, there does not appear to be an association with limb loss, dialysis, or mortality if they are addressed promptly. Close
coordination between vascular surgeons and trauma surgeons is essential in patients undergoing REBOA placement
Combat à haute intensité: Tout repenser !
Casualty care implications of large-scale combat operations
Mason H. Remondelli MH et Al. J Trauma Acute Care Surg. 2023 Aug; 95(2 ): S180–S184.
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Cet article met en exergue la nécessité de repenser en profondeur l'organisation de la chaîne santé , la place prépondérante de la transfusion sanguine et l'intérêt de petites équipes chirurgicales mobiles intervenant "enterrées" au plus près des combats
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Tourniquet en milieu froid: Des spécificités
Analysis of tourniquet pressure over military winter clothing and a short review of combat casualty care in cold weather warfare
Cold weather warfare is of increasing importance. Haemorrhage is the most common preventable cause of death in military conflicts. We analysed the pressure of the Combat Application Tourniquet® Generation 7 (CAT), the SAM® Extremity Tourniquet (SAMXT) and the SOF® Tactical Tourniquet Wide Generation 4 (SOFTT) over different military cold weather clothing setups with aleg tourniquet trainer. We conducted a selective PubMed search and supplemented this with own experiences in cold weather medicine. The CAT and the SAMXT both reached the cut off value of 180 mmHg in almost all applications. The SOFTT was unable to reach the 180 mmHg limit in less than 50% of all applications in some clothing setups. We outline the influence of cold during military operations by presenting differences between military and civilian cold exposure. We propose a classification of winter warfare and identify caveats and alterations of Tactical CombatCasualty Care in cold weather warfare, with a special focus on control of bleeding. The application of tourniquets over military winter clothing is successful in principle, but effectiveness may vary for different tourniquet models. Soldiers are more affected and impaired by cold than civilians. Militaryc ommanders must be made aware of medical alterations in cold weather warfare.
01/10/2024
REBOA préhospitalier: Une mortalité inchangée à 30 j, désillusion ?
Importance
Hemorrhage is the most common cause of preventable death after injury. Most deaths occur early, in the prehospital phase of care.
Objective
To establish whether prehospital zone 1 (supraceliac) partial resuscitative endovascular balloon occlusion of the aorta (Z1 P-REBOA) can be achieved in the resuscitation of adult trauma patients at risk of cardiac arrest and death due to exsanguination.
Design, Setting, and Participants
This was a prospective observational cohort study (Idea, Development, Exploration, Assessment and Long-term follow-up [IDEAL] 2A design) with recruitment from June 2020 to March 2022 and follow-up until discharge from hospital, death, or 90 days evaluating a physician-led and physician-delivered, urban prehospital trauma service in the Greater London area. Trauma patients aged 16 years and older with suspected exsanguinating subdiaphragmatic hemorrhage, recent or imminent hypovolemic traumatic cardiac arrest (TCA) were included. Those with unsurvivable injuries or who were pregnant were excluded. Of 2960 individuals attended by the service during the study period, 16 were included in the study.
Main Outcomes and Measures
The main outcome was the proportion of patients in whom Z1 REBOA and Z1 P-REBOA were achieved. Clinical end points included systolic blood pressure (SBP) response to Z1 REBOA, mortality rate (1 hour, 3 hours, 24 hours, or 30 days postinjury), and survival to hospital discharge.
Results
Femoral arterial access for Z1 REBOA was attempted in 16 patients (median [range] age, 30 [17-76] years; 14 [81%] male; median [IQR] Injury Severity Score, 50 [39-57]). In 2 patients with successful arterial access, REBOA was not attempted due to improvement in clinical condition. In the other 14 patients (8 [57%] of whom were in traumatic cardiac arrest [TCA]), 11 successfully underwent cannulation and had aortic balloons inflated in Z1.
The 3 individuals in whom cannulation was unsuccessful were in TCA (failure rate = 3/14 [21%]). Median (IQR) pre-REBOA SBP in the 11 individuals for whom cannulation was successful (5 [46%] in TCA) was 47 (33-52) mm Hg. Z1 REBOA plus P-REBOA was associated with a significant improvement in BP (median [IQR] SBP at emergency department arrival, 101 [77-107] mm Hg; 0 of 10 patients were in TCA at arrival). The median group-level improvement in SBP from the pre-REBOA value was 52 (95% CI, 42-77) mm Hg (P < .004). P-REBOA was feasible in 8 individuals (8/11 [73%]) and occurred spontaneously in 4 of these. The 1- and 3-hour postinjury mortality rate was 9% (1/11), 24-hour mortality was 27% (3/11), and 30-day mortality was 82% (9/11). Survival to hospital discharge was 18% (2/11). Both survivors underwent early Z1 P-REBOA.
Conclusions and Relevance In this study, prehospital Z1 P-REBOA is feasible and may enable early survival, but with a significant incidence of late death.
Poser un garrot: Pas n'importe comment !
Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war
Butler F et All. Journal of Trauma and Acute Care Surgery 97(2S):p S45-S54, August 2024
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Un point de situation important à lire. Il met en exergue le danger des garrots posé de manière indue avec deux trois enjeux de formation:
- La reconnaissance du caractère massif d'une hémorragie justifiant de la pose d'un garrot
- La reconnaissance des non indications de pose de garrot:
- La réévaluation dans les 02h00 de l'indication du garrot et de sa conversion éventuelle.
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