Arctic Military Conference on Cold Weather Medicine

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Une foule d'informations à connaître

Pansement Israélein: Interrêt de la barre de compression locale

Pressure Applied by the Emergency/Israeli Bandage

Shipman N et Al. Military Medicine, 174, 1:86, 2009

 

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Convertir un garrot dès que c'est possible est important lors de prise en charge prolongée. Un pansement compressif associé à un dispsoitif de compression localisée apparait être efficace.

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The primary objective of the study was to determine the amount of pressure exerted by a bandage modifi ed with a “pressure bar.” The data were collected using Emergency Bandages with and without the pressure bar. In addition to measuring the pressure under the pressure bar, other pressure sensors were used to measure the pressure being exerted to other areas under the elastic Emergency Bandage (at 90°, 180°, and 270°), but not directly under the pressure bar to determine the effectiveness of the pressure bar bandage to apply localized pressure over a wound without applying unnecessary pressure over the other areas. Two sets of statistical tests conducted: “ t-tests” assuming unequal variances from two samples and the “analysis of variance” (ANOVA), single factor. From the results, it is concluded that the Emergency Bandage pressure bar is very effective in elevating the applied pressure directly under the pressure bar while at the same time not applying unnecessary pressure over other areas covered by the bandage, which allows control of hemorrhage at the site of injury (under the pressure bar area) without having to have a full tourniquet effect.

 

 

 

Perfusion of the capillaries of the hand and fingers were found to be adequate by observation of the fingers tips (finger nail quick) and subjective pulse measurement at the wrist (radial artery).

Délais de prise en charge allongés et pansement hémostatique: Danger

Safety of the long-term application of QuikClot Combat Gauze, ChitoGauze PRO and Celox Gauze in a femoral artery injury model in swine - a preliminary study

Otrocka-Domagała I et Al. Pol J Vet Sci. 2016;19(2):337-43. doi: 10.1515/pjvs-2016-0041.

 

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L'impossibilité d'extraire un combattant de la zone de combat pour une chirurgie précoce est un problème, notamment si un pansement hémostatique a été posé. Ce travail ancien interpelle.  Dans un modèle de choc hémorragique porcin  le recours à ce type de pansement, que cela soit le kaolin ou le chitosan, peut être responsable de dégâts tissulaires et de complications emboliques. Le Woundstat, granulés de smectite, avait été interdit d'emploi pour la même raison. D'autres travaux expérimentaux devraient remettre en cause le recours à du kaolin ou du chitosan sur de longues durée d'application (1) (2)

 

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The purpose of this study was to examine the safety of the long-term application of QuikClot Combat Gauze, ChitoGauze PRO and Celox Gauze using a swine model. The study was conducted on nine pigs weighing approximately 30 kg, which were randomly divided into three groups. Under deep anesthesia, the pigs underwent complete transverse cutting of the femoral artery in the groin region. Hemostatic dressings were left in the wound for 24 hours. The animals were euthanized 24 hours after dressing application. In each group, macroscopic and microscopic severe changes and shock symptoms were observed in the lungs, liver, kidneys and heart. Fibrino-gaseous embolic material was found in the pulmonary artery of each group and in the lung vessels of the animals from the ChitoGauze PRO and Celox Gauze groups. In conclusion, the long-term application of the evaluated hemostatic dressings has the risk of coagulopathy and reaching the progressive stage of shock. The residues from the hemostatic dressings can ingress into the systemic circulation, thereby increasing the risk of embolus formation.

 

 

Because of these harmful effects, the evaluated hemostatic dressings are not appropriate for long-term use. Future studies are needed on the consequences of the long-term application of these hemostatic agents.

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Intubation difficle: Pas qu'anatomique

Managing the Physiologically Difficult Airway in Critically Ill Adults
Jabaley CS. Crit Care. 2023 Mar 21;27(1):91. doi: 10.1186/s13054-023-04371-3.

 

Un document très intéressant qui présente de manière très claire les enjeux de l'intubation difficile qui n'est pas qu'anatomique.

 

Risks and risk prediction

Cardiovascular instability, hypoxemia, and cardiac arrest are the most common adverse events associated with tracheal intubation

Risk factors for cardiovascular collapse include age, shock, hypoxemia, advanced critical illness, and propofol administration

Hemodynamic optimization

Etomidate and ketamine may impact hemodynamics less than propofol

A crystalloid bolus prior to intubation has not been associated with improved hemodynamics, even in patients receiving positive pressure ventilation

Given the frequency of cardiovascular instability, vasopressors should be readied as part of preparation for tracheal intubation

Mitigating hypoxemia

Standard pre-oxygenation strategies are inadequate to safely extend the apneic interval in patients with moderate to severe respiratory failure

Non-invasive ventilation can be used with or without high flow nasal oxygen and is more effective than high flow nasal oxygen alone

While historically avoided, bag-mask ventilation improves oxygenation during airway management and can be employed either preemptively or for rescue

First pass success

Multiple attempts at intubation increase the risk of adverse events

Depending on the preferences and expertise of the intubating clinician, video laryngoscopy or direct laryngoscopy with adjuncts may improve first pass success

Checklists improve adherence to complex, multi-step processes and may help prompt preparation for physiologic trespass

 

Trauma: Exsufflation à l'aiguille. Pas sûr du tout

Prehospital needle thoracostomy and the need to implement objective criteria for intervention: A retrospective study

Boever JC et Al. Injury. 2025 Dec 13:112973. doi: 10.1016/j.injury.2025.112973.

 

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Ce travail montre que la décompression à l'aiguille n'est pas un geste anodin? surtout avec les catheter longs poentiellement très traumatiques. Les indications d'une décompression thoracique préhospitalières doivent être rigoureuse incluant la présence d'une détresse circulatoire avec une détresse respiratoire. Une simple asymétrie à l'auscultation ne préjuge pas du carctère compressif d'un pneumothorax. Un échographe n'est pas toujours disponible. Aussi il peut paraître sage de réaliser une décompression par thoracostomie au doigt, geste bien moins agressif que l'emploi d'une aiguille longue. Cet article confirme ce qui est déjà connu (1)

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Background: 

 

Needle thoracostomy (NT) is a frontline intervention for suspected tension pneumothorax in prehospital trauma care. The necessity for intervention in patients with relative indications is unclear, and locoregional protocols guiding NT placement by prehospital personnel vary. This study aims to identify factors associated with a positive response to NT and how often objective measures are utilized to prompt intervention, which may help better define indications for the procedure.

 

Methods: 

 

A retrospective review of adult trauma patient who received prehospital needle decompression was performed utilizing the trauma registry database from a level 1ACS accredited trauma center in Omaha, Nebraska. A positive response was defined as increased oxygen saturation by 10 %, increased systolic blood pressure by 10 mmHg, improved ventilation or breath sounds, or return of spontaneous circulation.

 

Results: 

 

A total of 214 patients were included, with an overall mortality rate of 52 % of which 144 (68 %) sustained blunt trauma and 67 (32 %) penetrating trauma. Mortality was 49 % for blunt trauma and 60 % for penetrating trauma (p = 0.182). Only 63 patients (30 %) responded to NT with an improvement in clinical parameters. The most common indication(s) for NT was documented as absent/reduced breath sounds (n = 118, 55 %), CPR (n = 79, 37 %), and hypoxia (n = 40, 19 %). After excluding patients with CPR en route (n = 135/214, 63 %), positive NT response increased to 48 % and overall mortality rate decreased to 26 %. There was no significant change in systolic blood pressure (mean difference: 0.3 mm Hg, 95 % CI:4.8-5.3, p = 0.910) or heart rate (-1.1 bpm, 95 % CI:5.8-3.6, p = 0.650) post-decompression. The incidence of hypoxia decreased from 68 % to 48 % (p < 0.001). Complications were identified in 14 % of patients and one patient did have a needle inserted into the heart, required a cardiac operation, and had subsequent anoxic brain injury.

 

Conclusions: 

 

This study highlights the low success rates of prehospital NT, with the majority of procedures being performed based on subjective indicators. Prehospital protocols should be refined by incorporating objective criteria, such as confirmed hypoxia, to better identify patients who may benefit from NT.