Exsuffler: Aiguille de 6,44cm ?

Sufficient catheter length for pneumothorax needle decompression: a meta-analysis

Clemency BM et Al. Prehosp Disaster Med. 2015 Jun;30(3):249-53

Abstract

Introduction Needle thoracostomy is the prehospital treatment for tension pneumothorax. Sufficient catheter length is necessary for procedural success. The authors of this study determined minimum catheter length needed for procedural success on a percentile basis.

METHODS:

A meta-analysis of existing studies was conducted. A Medline search was performed using the search terms: needle decompression, needle thoracentesis, chest decompression, pneumothorax decompression, needle thoracostomy, and tension pneumothorax. Studies were included if they published a sample size, mean chest wall thickness, and a standard deviation or confidence interval. A PubMed search was performed in a similar fashion. Sample size, mean chest wall thickness, and standard deviation were found or calculated for each study. Data were combined to create a pooled dataset. Normal distribution of data was assumed. Procedural success was defined as catheter length being equal to or greater than the chest wall thickness.

RESULTS:

The Medline and PubMed searches yielded 773 unique studies; all study abstracts were reviewed for possible inclusion. Eighteen papers were identified for full manuscript review. Thirteen studies met all inclusion criteria and were included in the analysis. Pooled sample statistics were: n=2,558; mean=4.19 cm; and SD=1.37 cm. Minimum catheter length needed for success at the 95th percentile for chest wall size was found to be 6.44 cm. Discussion A catheter of at least 6.44 cm in length would be required to ensure that 95% of the patients in this pooled sample would have penetration of the pleural space at the site of needle decompression, and therefore, a successful procedure. These findings represent Level III evidence. 

ATLS: Référence en ballistique ? Bof !

Myths and Misinformation About Gunshot Wounds may Adversely Affect Proper Treatment.

Hafertepen SC et Al. World J Surg. 2015 Jul;39(7):1840-7

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La pertinence de l'ATLS est régulièrement battue en brèche pour les systèmes de prise en charge des traumatisés organisés en réseau. Historiquement il s'agissait d'apporter des connaissances de base à des équipes novices en la matière. Une revue cochrane n'est pas du tout en faveur. Un éditorial récent, mais il n'est pas isolé, exprime bien le caractère non adapté de ce concept à la réalité des trauma center actuels. Certains vont très loin dans la critique mettant en évidence dans le contenu même des dernières révisions la retranscription de données non validées. C'est le cas du document proposé. Au delà du caractère structurant réel d'un acronyme, c'est bien d'un contenu basique (trop) et souvent erroné dont nous devons être conscient.

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BACKGROUND:

Poorly designed experiments and popular media have led to multiple myths about wound ballistics. Some of these myths have been incorporated into the trauma literature as fact and are included in Advanced Trauma Life Support (ATLS). We hypothesized that these erroneous beliefs would be prevalent, even among those providing care for patients with gunshot wounds (GSWs), but could be addressed through education.

METHODS:

ATLS course content was reviewed. Several myths involving wound ballistics were identified. Clinically relevant myths were chosen including wounding mechanism, lead poisoning, debridement, and antibiotic use. Subsequently, surgery and emergency medicine services at three different trauma centers were studied. All three sites were busy, urban trauma centers with a significant amount of penetrating trauma. A pre-test was administered prior to a lecture on wound ballistics followed by a post-test. Pre- and post-test scores were compared and correlated with demographic data including ATLS course completion, firearm/ballistics experience, and years of post-graduate medical experience (PGME).

RESULTS:

One-hundred and fifteen clinicians participated in the study. A mean pre-test score of 34 % improved to 78 % on the post-test with associated improvements in all areas of knowledge (p < 0.001). Years of PGME correlated with higher pre-test score (p = 0.021); however, ATLSstatus did not (p = 0.774).

CONCLUSIONS:

Erroneous beliefs involving wound ballistics are prevalent even among clinicians who frequently treat victims of GSWs and could lead to inappropriate treatment. Focused education markedly improved knowledge. The ATLS course and manual promulgate some of these myths and should be revised.

 

Laryngoscope: Le manche compte

The effect of laryngoscope handle size on possible endotracheal intubation success in university football, ice hockey, and soccer players.

Delaney JS et Al. Clin J Sport Med. 2012 Jul;22(4):341-8

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Un laryngoscope avec un manche court serait plus facile à utiliser. On rappelle que le laryngodcope truphatek dispose d'un manche court.

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OBJECTIVE:

To assess the effectiveness of a standard long-handle laryngoscope and a short-handle laryngoscope on ease of possible intubation in football, ice hockey, and soccer players.

DESIGN:

Prospective crossover study.

SETTING:

University Sport Medicine Clinic.

PARTICIPANTS:

Sixty-two university varsity football (62 males), 45 ice hockey (26 males and 19 females), and 39 soccer players (20 males, 19 females).

INTERVENTIONS:

Athletes were assessed for different airway and physical characteristics. Three different physicians then assessed the use of laryngoscopes of different handle sizes in supine athletes who were wearing protective equipment while in-line cervical spine immobilization was maintained.

MAIN OUTCOME MEASURES:

The ease of passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was assessed using both a standard long-handle and a short-handle laryngoscope.

RESULTS:

Use of a short-handle laryngoscope was easier for all physicians in all sports as compared with a standard-sized laryngoscope. Passage of a laryngoscope blade into the posterior oropharynx of a supine athlete was easiest in soccer players and most difficult in football and ice hockey players for both sizes of laryngoscope. Interference from chest or shoulder pads was a common cause for difficulty in passing the laryngoscope blade into the posterior oropharynx for football and ice hockey players.

CONCLUSIONS:

In the rare instances that an endotracheal intubation is to be attempted on an unconscious athlete, a short-handle laryngoscope may provide the best chance for successful intubation.

Vidéolaryngoscopie: Un standard ? Pas si sûr et pas partout !

Videolaryngoscope as a standard intubation device

Xue FS et Al. Br. J. Anaesth. (2015) 115 (1): 137-138

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Un éditorial récent, présentant la vidéolaryngoscopie comme le standard pour toute intubation (1),  dans le BJA a déclenché plusieurs réactions. Nous rapportons là l'une d'elle qui apporte un gros bémol à cette position (ce n'est pas la seule). La vidéolaryngoscopie ( ou plutôt les vidéolaryngoscopes car le choix est grand) doivent certainement trouver leur(s) place(s): . Non pas permettre une intubation facile mais améliorer la sécurité des patients/blessés pris en charge. L'objectif de l'intubation n'est pas de voir le plan glottique mais d'insérer une sonde dans une trachée, ce qui n'est pas la même chose. Dans notre contexte de traumatologie faciale il est fort probable que la vidéolaryngoscopie soit inopérante. Que faire alors ? Ne pas pouvoir s'appuyer sur des pratiques ayant fait leurs preuves ne parait pas actuellement raisonnable même si la maîtrise de ces dernières demande un investissement personnel. On en revient à une chose essentielle qui est l'entraînement à des pratiques qui certes sont peu fréquentes mais qui feront la différence et qui font que l'on peut parler de médicalisation de l'avant.

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The editorial article by Zaouter and colleagues (1) recommending videolaryngoscopy as a new standard of care was of great interest. Videolaryngoscopes are indeed promising intubation devices because they provide an improved laryngeal view.

However, we do not agree with the authors that videolarygnoscopes should replace direct laryngoscopes and be used for all intubations in current practice. The quantitative review and meta-analysis regarding the performance of video- and direct laryngoscopes indicate that in patients with a normal airway, the success rate of intubation with videolarygnoscopes is approximately the same as with direct laryngoscopes, but the intubation time is significantly prolonged with videolaryngoscopes; that is, tracheal intubation in patients with a normal airway can be achieved quickly and in a cost-efficient manner with direct laryngoscopes.

In fact, the most convincing literature to date supports the use of videolaryngoscopes only in unanticipated, difficult, or failed intubations with direct laryngoscopy. The available evidence also shows that videolaryngoscopes are associated with better intubation success and faster intubation time only for inexperienced operators, but they provide no benefit in either of these outcomes with experienced operators. Thus, we argue that videolaryngoscopes are not the best care for all patients and the direct laryngoscope is not an outdated intubation device, especially for providers able to complete substantial training in controlled circumstances, such as experienced anaesthetists, who are often called as airway experts. Furthermore, there are several different types of videolaryngoscopes available, each with a different blade shape, user interface and geometry, and tube insertion strategy. So far, there is inconclusive evidence to indicate which videolaryngoscope design could be more advantageous in various clinical situations. Thus, the open questions remain. Which videolaryngoscope is the most cost-effective device for routine or difficult intubation? Which one is the optimum to become a new standard of care? Given that device-specific proficiency is critical for successful use of any intubation device, if videolaryngoscopes are used as routine intubation devices, do anesthesiologists need to learn and achieve clinical competence for all devices? Perhaps, there might be a need to revise the current airway training programmes because they do not include videolaryngoscopic intubation training in the minimal skill set acquired by a trainee during an airway rotation.7 In addition, most of current difficult airway algorithms are developed as rescue guides in the event of difficult or failed direct laryngoscopy, and these algorithms rely on videolaryngoscopes as rescue tools for difficult or failed direct laryngoscopy.

Although use of videolaryngoscopes is rapidly growing in clinical practice, there is still no evidence-based airway algorithm where tracheal intubation relies mainly on videolaryngoscopy. If videolaryngoscopes are used as the routine first-line intubation devices, one pertinent question is, what should one do in the event of a difficult or failed videolaryngoscopy? It must be emphasized that despite the very good visualization of the glottis, videolaryngoscopy does not give a 100% success rate. In a two-centre study, the GlideScope videolaryngoscope failed once every 33 patients with a difficult airway and once every 16 patients with failed direct laryngoscopy. Thus, if videolaryngoscopes are part of a new airway management protocol in which they are routinely used as first-line intubation devices, there would be a need to reconsider airway management algorithms and adopt a strategy to manage failures.

Finally, Zaouter and colleagues (1) advise integration of videos obtained during videolaryngoscopic intubation into an anaesthesia information management system. To the best of our knowledge, most videolaryngoscopes used in current practice have no such function to transmit moment-by-moment videos into an anaesthesia information management system, and some of them even have no functional design for recording and saving intubation pictures. Perhaps, the manufacturers of videolaryngoscopes should be encouraged to provide such electronic additions to their products in order to integrate imaging of the patient's tracheal intubation into anaesthesia electronic charting. We believe that with further developments and refinements in technology, this may no longer be an issue.

Gestion des contraintes thermiques

Management of Heat and Cold Stress – Guidance to NATO Medical Personnel

Findings of Task Group HFM-187

Egalement:  Consensus recommendations on training and competing in the heat

Point sur le blessé cervico-facial de guerre

Clic sur l'image pour accéder au document 

Echo des voies aériennes

Focused ultrasound for airway management

http://viewer.zmags.com/publication/698570e2#/698570e2/1Tutoriel Philips

 

SANS HĖSITER: IL FAUT S'Y METTRE +++

Clic sur l'image pour accéder au document

Autres sources 1 2 3

Deux exemples

1. Visualisation de l'épiglotte:

- Vue transverse

- Vue parasagittale

2. Repérage du cartilage cricoïdienne en coupe sagittale ou parasagittale

 3. Réalisation d'une coniotomie

 

 

Crico: Plutôt avec une canule à ballonet

The Efficacy of Spontaneous and Controlled Ventilation With Various Cricothyrotomy Devices: A Quantitative In Vitro Assessment in a Model Lung

Michalek-Sauberer M et Al. J Trauma. 2011;71: 886 – 892

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La procédure du sauvetage au combat indique la réalisation d'une coniotomie en cas d'obstruction des voies aériennes. Le minitrach portex II doit être considéré plutôt comme un dispositif d'oxygénation. En effet il est rarissime que les obstructions soient complètes. Dans de telles conditions les fuites sont telle qu'une ventilation effective n'est pas possible sauf à utiliser un dispositif de jet ventilation de type manujet. L'article présenté exprime très bien les limites des dispositifs sans ballonet

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Background:

Guidelines for the management of a difficult airway recommend performing a cricothyrotomy in a “can’t intubate/can’t ventilate” situation. We investigated the tidal volumes delivered by controlled and spontaneous ventilation by seven commercially available cricothyrotomy sets (cuffed: Quicktrach II, Portex Cricothyroidotomy Kit, and Melker cuffed cannula and uncuffed: Airfree, 4.0-mm ID Quicktrach, 6.0-mm inner diameter Melker, and 13-gauge Ravussin cannula) and two improvised devices (14-gauge intravenous cannula and spike and drip chamber device).

Methods:

A LS800 model lung, set at different values for compliance and resistance and modified with different upper airway diameter, was ventilated via the respective cricothyrotomy device mechanically and using a selfinflating bag. With the 13-gauge Ravussin cannula and the 14-gauge intravenous cannula, a Manujet injector was used for jet ventilation. Spontaneous ventilation was simulated with a Michigan 560i lung.

Results:

During controlled or manual ventilation, all cuffed cricothyrotomy devices yielded adequate tidal volumes. Uncuffed devices provided tidal volumes
300 mL only with an upper airway diameter of 3 mm. With a Manujet injector, adequate tidal volumes required an upper airway diameter between 3 mm and 5 mm. A spike and drip chamber device does not provide suitable emergency airway access. Spontaneous ventilation at adequate inspiratory pressure levels required a device inner diameter of at least 4 mm.

 

 

Conclusion:

As expected, cuffed cricothyrotomy devices yield the best results during controlled, manual, and spontaneous ventilation. With uncuffed cricothyrotomy devices, ventilation becomes ineffective when the upper airway obstruction allows for an upper airway diameter
3 mm.

 

BIG et FAST: Evolutions récentes

Le BIG et Le FAST1 sont les dispositifs historiques d'accès intraosseux par impaction. Ils ont évolué. La nouvelle version du BIG est le NIO, celle du FAST1 est le FASTX. On rappelle que le BIG est en o dotation dans l'armée français et que différence fondamentale le BIG ne s'applique pas en sternal, alors qu'il s'agit du site de pose exclusif du FAST. On peut penser que ce dernier est moins polyvalent qu'un système permettant un abord huméral, tibial ou iliaque (lire la fiche mémento).

 

Hyperthermie d'effort: Quoi de neuf ?

Exertional Heat Stroke: New Concepts Regarding Cause and Care

Casa DJ  et All. Curr Sports Med Rep. 2012 May-Jun;11(3):115-23

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Une bibliographie très riche pour ce qui est pour nous une préoccupation régulière. Lire aussi (1, 2,3)

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When athletes, warfighters, and laborers perform intense exercise in the heat, the risk of exertional heat stroke (EHS) is ever present. The recent data regarding the fatalities due to EHS within the confines of organized American sport are not promising: during the past 35 years, the highest number of deaths in a 5-year period occurred from 2005 to 2009. This reminds us that, regardless of the advancements of knowledge in the area of EHS prevention, recognition, and treatment, knowledge has not been translated into practice. This article addresses important issues related to EHS cause and care. We focus on the predisposing factors, errors in care, physiology of cold water immersion, and return-to-play or duty considerations

Echo en hélico: Avec formation solide !

Prospective evaluation of prehospital trauma ultrasound during aeromedical transport.

Press GM et Al. J Emerg Med. 2014 Dec;47(6):638-45

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L'apport de l'échographie est incontournable pour la prise en charge des traumatisés. Son emploi en prehospitalier est proposé. Pour autant la mise en oeuvre de ce moyen d'exploration n'est pas si simple et demande une grande expertise. Le travail présenté porte sur la mise en oeuvre de ce type d'exploration par technicinens paramédicaux expérimentés et ayant suivi une formation sur une période de deux mois. malgré cela leur performance reste modeste. Un examen négatif de permet pas de conclure. Ceci plaide pour un peu de modération concernant l'engouement actuel. Comme pour tout il faut investir sur la formation pour être performant.

------------------------------------------------

BACKGROUND:

Ultrasound is widely considered the initial diagnostic imaging modality for trauma. Preliminary studies have explored the use of trauma ultrasound in the prehospital setting, but the accuracy and potential utility is not well understood.

OBJECTIVE:

We sought to determine the accuracy of trauma ultrasound performed by helicopter emergency medical service (HEMS) providers.

METHODS:

Trauma ultrasound was performed in flight on adult patients during a 7-month period. Accuracy of the abdominal, cardiac, and lung components was determined by comparison to the presence of injury, primarily determined by computed tomography, and to required interventions.

RESULTS:

HEMS providers performed ultrasound on 293 patients during a 7-month period, completing 211 full extended Focused Assessment with Sonography for Trauma (EFAST) studies. HEMS providers interpreted 11% of studies as indeterminate. Sensitivity and specificity for hemoperitoneum was 46% (95% confidence interval [CI] 27.1%-94.1%) and 94.1% (95% CI 89.2%-97%), and for laparotomy 64.7% (95% CI 38.6%-84.7%) and 94% (95% CI 89.2%-96.8%), respectively. Sensitivity and specificity for pneumothorax were 18.7% (95% CI 8.9%-33.9%) and 99.5% (95% CI 98.2%-99.9%), and for thoracostomy were 50% (95% CI 22.3%-58.7%) and 99.8% (98.6%-100%), respectively. The positive likelihood ratio for laparotomy was 10.7 (95% CI 5.5-21) and for thoracostomy 235 (95% CI 31-1758), and the negative likelihood ratios were 0.4 (95% CI 0.2-0.7) and 0.5 (95% CI 0.3-0.8), respectively. Of 240 cardiac studies, there was one false-positive and three false-negative interpretations (none requiring intervention).

CONCLUSIONS:

HEMS providers performed EFAST with moderate accuracy. Specificity was high and positive interpretations raised the probability of injury requiring intervention. Negative interpretations were predictive, but sensitivity was not sufficient for ruling out injury.

Intervention médico-psychologique: Revue

Soutien médico-psychologique en situation de crise dans une unité : l'exemple de l’intervention suite au décès de trois militaires dans un accident de la voie publique

Moroge S. et Al. Médecine et Armées, 2014, 42, 2, 155-162

Le décès de trois militaires d'une base de défense du sud de la France, alors qu'ils rejoignaient un autre régiment avant d'être projetés au Mali dans le cadre de l'opération « Serval », a saisi la communauté militaire. La soudaineté de ces décès dans un accident de la voie publique, en métropole, à la veille d'un départ en opération extérieure, a été particulièrement marquante. Nous évoquerons ici l'intervention médico-psychologique afin de souligner les réactions psychiatriques observées. Nous détaillerons ensuite toutes les modalités d'intervention possibles suite à un évènement grave, afin  d’éclairer le médecin d’unité sur la nature des soins post-immédiats à apporter aux militaires.

 Dossier "Sauvetage au combat"

01 Pierret C. Les traumatismes jonctionnels en situation de guerre.Medecine et Armees 2014-4.291-9.(format pdf, 175 kB).

02 Precloux P. Operation Pamir bilan et analyse activite des postes medicaux role 1 RSA 2011. Medecine et Armees 2014-4. 299-309.(format pdf, 315 kB).

03 Leyral J. Echographie de l avant au Role 1 quelle formation pour medecin unite.Medecine et Armees 2014-4.309-14.(format pdf, 98 kB).

04 Favier LC.Quelles devraient etre les indications de l echographie en Role 1. Medecine et Armees 2014-4.315-20.(format pdf, 140 kB).

05. Danguy M. Actualisation des garrots de type tourniquet. Medecine et Armees 2014-4. 321-8.(format pdf, 149 kB).

06. Mathieu L. Délabrements etendus par blast a haute intensite.nouvelle entite lesionnelle EEI. Medecine et Armees 2014-4. 329-5.(format pdf, 198 kB).

07 Mathieu L. Traumatismes par blast de arriere pied lies aux attaques de vehicules par EEI. Medecine et Armees 2014-4.337-44.(format pdf, 273 kB).

08 Gunepin M. Evacuations medicales intra-theatres pour raisons dentaires au cours operation Serval. Medecine et Armees 2014-4.345-51.(format pdf, 126 kB).

09 Crehange G. Etude de la qualite de l air a Kaboul. Medecine et Armees 2014-4.353-61.(format pdf, 113 kB).

10 Sanmartin N. Attentat au sarin de Tokio.Enseignement pour les plans de secours. Medecine et Armees 2014-4. 263-71.(format pdf, 319 kB).

11 Bornert G. Eau atmospherique une ressource alternative pour la production d eau destinee a la consommation humaine. Medecine et Armees 2014-4.372.82.(format pdf, 233 kB).

Immobilisation: Matériel spécifique ?

Improvised traction splints: a wilderness medicine tool or hindrance?

Weichenthal L et Al. Wilderness Environ Med. 2012 Mar;23(1):61-4

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Immobiliser un membre le plus tôt possible et ce de manière efficace est un des enjeux de la mise en condition d'évacuation. Il s'agit là de prévenir le mieux possible toute complication secondaire, de réduire le saignement et la douleur. Pour cela existe de nombreux équipements proposés par l'industrie. Miass sont ils vraiment utiles ? Pas si évident si l'on en croit le document proposé. Il pourrait exister à l'évidence des moyens simples et efficaces surtout moins coûteux d'atteindre ces objectifs.

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OBJECTIVES:

To investigate whether a traction splint made from improvised materials is as efficacious as commercially available devices in terms of traction provided and perceived comfort and stability.

METHODS:

This was a prospective randomized crossover study utilizing 10 healthy, uninjured volunteers. The subjects were randomized to be placed in 4 different traction devices, in differing order, each for 30 minutes. Three of the traction splints are commercially available: The HARE, Sager, and Faretech CT-EMS. The fourth traction device was an improvised splint made as described in Medicine for the Backcountry: A Practical Guide to Wilderness First Aid. At the end of 30 minutes the pounds of force created by each device was measured. The volunteers were also asked at that time to subjectively report the comfort and stability of the splint separately on a scale from 1 to 10.

RESULTS:

All traction splints performed similarly with regard to the primary outcome measure of mean pounds of traction created at the end of 30 minutes of application with results ranging from 10.4 to 13.3 pounds. There was little difference reported by participants in regard to stability or comfort between the 4 traction devices.

CONCLUSIONS:

In this small pilot study, an improvised traction splint was not inferior to commercially available devices. Further research in needed in this area.

Tourniquet et chaleur extrême ?

Laboratory testing of emergency tourniquets exposed to prolonged heat

Davidson JP et Al. J Spec Oper Med. 2015 Spring;15(1):34-8.

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Il a été démontré que la fiabilité mécanique des tourniquets pouvait être altérée si ces derniers n'étaient pas protégés (1,2,3). Le travail présenté porte sur l'effet de l'exposition prolongée à de hautes températures sur l'efficacité des garrots. Apparemment il n'y aurait pas d'effet propre.

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BACKGROUND: 

Environmental exposure of tourniquets has been associated with component damage rates, but the specific type of environmental exposure, such as heat, is unknown. Emergency-tourniquet damage has been associated with malfunction and loss of hemorrhage control, which may risk loss of life during first aid. The purposes of the study are to determine the damage rate of tourniquets exposed to heat and to compare the rate to that of controls. 

METHODS: 

Three tourniquet models (Combat Application Tourniquet®; SOF® Tactical Tourniquet; Ratcheting Medical Tourniquet®) were tested using a manikin (HapMed Leg Tourniquet Trainer; www.chisystems.com) that simulates extremity hemorrhage. The study group of 15 tourniquets (five devices per model, three models) was exposed to heat (oven at 54.4° C [130° F] for 91 days), and 15 tourniquets similarly constituted the control group (unexposed to heat). Damage, hemorrhage control, distal pulse stoppage, time to effectiveness, pressure (mmHg), and blood loss volumes were measured. 

RESULTS: 

Three tourniquets in both groups had damage not associated with heat exposure (p = 1). Heat exposure was not associated with change in effectiveness rates (p = .32); this lack of association applied to both hemorrhage control and pulse stoppage. When adjusted for the effects of user and model, the comparisons of time to effectiveness and total blood loss were statistically significant (p < .0001), but the comparison of pressure was not (p = .0613). 

CONCLUSION: 

Heat exposure was not associated with tourniquet damage, inability to gain hemorrhage control, or inability to stop the distal pulse. 

Tourniquet: Une histoire de pression pas si simple

Tourniquets and Occlusion: The Pressure of Design

Wall PL et Al. Mil Med. 2013 May;178(5):578-87

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Un travail très intéressant qui exprime bien que l'efficacité d'un garrot nécessite un ensemble de gestes parfaitement réalisés, notamment un serrage suffisant qui doit être vérifié après la pose. Il existe en effet avec les garrots de type tourniquet ou pneumatique une chute plus ou moins importante de la pression d'occlusion donc de perte d'occlusion, ce d'autant qu'un relâchement musculaire peut apparaître réduisant d'autant plus cette pression d'occlusion. Les garrots élastiques n'aurait pas cet inconvénient.

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Abstracts: Nerve injuries result from tourniquet pressure. The objective was to determine arterial occlusion and completion pressures with the 3.8-cm-wide windlass Combat Application Tourniquet (CAT) and the 10.4-cm-wide Stretch, Wrap, and Tuck Tourniquet (SWAT-T).

Methods: Sixteen volunteers self-applied and had tourniquets applied to their thighs and arms (CAT and SWAT-T, random order, then blood pressure cuffs).

Results: Occlusion (Doppler signal elimination) pressures were higher than predicted ( p < 0.0001), highest with the CAT ( p < 0.0001), and often lower than completion pressures (completion median, range: CAT 360, 147–745 mm Hg; SWAT-T 290, 136–449 mm Hg; cuff 184, 108–281 mm Hg). Three CAT thigh and 9 CAT arm completion pressures were >500 mm Hg. Pressure decreases and occlusion losses occurred over 1 minute (pressure decrease: CAT 44 ± 33 mm Hg; SWAT-T 6 ± 8 mm Hg; cuff 14 ± 19 mm Hg; p < 0.0001; loss/initially occluded: CAT 17 of 61, SWAT-T 5 of 61, cuff 40 of 64, p < 0.01). CAT pressures before turn did not have a clear relationship with turns to occlusion.

 

Conclusions: Limb circumference/ tourniquet width occlusion pressure predictions are not good substitutes for measurements. The wider SWAT-T has lower occlusion and completion pressures than the CAT. Decreases in muscle tension lead to decreases in tourniquet pressure, especially with the nonelastic CAT, which can lead to occlusion loss.

 

Protection ballistique et exposition céphalique ?

Combat Body Armor and Injuries to the Head, Face, and Neck Region: A Systematic Review

Tong D et Al. Mil Med. 2013 Apr;178(4):421-6

There has been a reported increase in combat-related head, face, and neck (HFN) injuries among service personnel wearing combat body armor (CBA) that have deployed to Iraq and Afghanistan. Modern ceramic plate CBA has decreased the incidence of fatal-penetrating injuries to the torso but offers no protection to the limbs and face which remain exposed to gunshot wounds and fragments from explosive devices. The aim of this review was to systematically summarize the literature reporting on HFN injuries sustained by combat personnel wearing CBA and to highlight recommendations for increased protection to the facial region. Three major contributing factors were identified with this proportional increase in HFN injuries, namely the increased survivability of soldiers because of CBA, fragments injuries from explosive devices, and the lack of protection to the face and limbs. There appears to be no evidence to suggest that by virtue of wearing CBA the likelihood of sustaining an HFN injury increases as such, but a higher incidence of fragment injuries to the HFN region may be due to the more common use of improvised explosive devicess and other explosive devices. Further development of lightweight protection for the face is needed.

Military Medicine

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S'entraîner pour son assurance personnelle : Combien ?

Training Modalities and Self-Confidence Building in ALS Providers

Ilia S et Al. . Mil Med. 2012 Aug;177(8):901-6.

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Un document important qui aborde l'impact de la confiance en soi obtenu par l'entraînement. Plusieurs techniques d'entraînement doivent être associée: Simulation et monde réel. Le recours au modèle animal n'apparaît pas significatif. Des plateaux à partir desquels il faut opter pour une autre méthode sont identifiés: Pour l'intubation 30 sur mannequin et 25 en réel, 40 pour l'exsufflation sur mannequin et 3 en réel et 10 pose de KTIO sur simulateur.

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OBJECTIVE:

Physicians and paramedics in the Israel Defense Forces are trained to perform advanced medical procedures using standardized training modalities, such as manikins. We studied the association of experience using these training modalities with self-reported confidence in procedure performance.

METHODS:

Providers were sent a questionnaire regarding their experience with and self-confidence levels for performing endotracheal intubation, cricothyroidotomy, needle chest decompression, tube thoracostomy, and intraosseous infusion.

RESULTS:

Provider level (physician or paramedic) and gender were associated with reported self-confidence levels. Manikin and supervised and unsupervised patient experience exhibited positive associations with self-confidence, but (animal) model experience did not. For many procedure-training modality pairs, we identified a plateau level above which additional experience was minimally associated with an increase in self-confidence.

CONCLUSIONS:

Among military advanced life support providers, self-confidence levels in procedure performance are positively associated with experience gained from manikins and supervised and unsupervised patient application. We were not able to demonstrate a clear benefit of an animal model in increasing self-confidence. A plateau was generally identified, indicating decreased benefit from the use of a particular training modality for a particular procedure. Modifying training regimens in light of these findings may help maximize the self-confidence of advanced life support providers more efficiently. 

Chlorhexidine et UVC: Pour décontaminer ses instruments

A Novel Method to Decontaminate Surgical Instruments for Operational and Austere Environments

Knox RW et Al. Wilderness Environ Med. 2015 Jul 9. pii: S1080-6032(15)00146-5

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On connait l'efficacité des UVA pour décontaminer l'eau de boisson. Cette capacité est mise à profit dans la méthode SODIS. Les UVC sont également intéressants. En effet décontaminer son matériel chirurgical  sans autoclave ou appareil à chaleur humide n'est pas impossible. En situation isolée l'emploi combiné d'antiseptique et d'UVC est efficace. C'est ce que démontre ce travail.

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OBJECTIVE:

 

The purpose of this investigation was to test a field-expedient, cost-effective method to decontaminate, sterilize, and package surgicalinstruments in an operational (combat) or austere environment using chlorhexidine sponges, ultraviolet C (UVC) light, and commercially available vacuum sealing.

METHODS:

This was a bench study of 4 experimental groups and 1 control group of 120 surgical instruments. Experimental groups were inoculated with a 106 concentration of common wound bacteria. The control group was vacuum sealed without inoculum. Groups 1, 2, and 3 were first scrubbed with a chlorhexidine sponge, rinsed, and dried. Group 1 was then packaged; group 2 was irradiated with UVC light, then packaged; group 3 was packaged, then irradiated with UVC light through the bag; and group 4 was packaged without chlorhexidine scrubbing or UVC irradiation. The UVC was not tested by itself, as it does not grossly clean. The instruments were stored overnight and tested for remaining colony forming units (CFU).

RESULTS:

Data analysis was conducted using analysis of variance and group comparisons using the Tukey method. Group 4 CFU was statistically greater (P < .001) than the control group and groups 1 through 3. There was no statistically significant difference between the control group and groups 1 through 3.

CONCLUSIONS:

Vacuum sealing of chlorhexidine-scrubbed contaminated instruments with and without handheld UVC irradiation appears to be an acceptable method of field decontamination. Chlorhexidine scrubbing alone achieved a 99.9% reduction in CFU, whereas adding UVC before packaging achieved sterilization or 100% reduction in CFU, and UVC through the bag achieved disinfection.