Garrot automatique: En préhospitalier ?

Le garrot XMETIX 7

Les garrots automatiques sont quotidiennement utilisés dans les blocs opératoires, essentiellement des garrots alimentés par de petits dispositifs de compression électrique parfaitement régulés. Ce garrot miniaturisé fonctionne donc sur batterie avec une autonomie donnée pour 5 heures et générant une pression d'occlusion automatiquement régulée pouvant aller jusqu'à 300 mmHg .

C'est un garrot mécanique qui va mettre en tension une sangle grâce à un micromoteur électrique.

On ne trouve pas pour l'instant d'analyse indépendante sur la performance de ce tourniquet donc le concept est intéressant. On peut quand même se poser des questions sur la réalité de son autonomie et la qualité de la régulation automatique lors d'une MEDEVAC terrestre ou héliportée. Le niveau maximum de la pression d'occlusion parait en effet un peu bas pour une application sur un treillis.

 

Des gants non stériles pour le parage des plaies ?

Sterile vs Nonsterile Gloves for the Repair of Wounds and Lacerations: A Systematic Review and Meta-Analysis

Haman Y et Al.JAMA Surg. 2023 Dec 13. doi: 10.1001/jamasurg.2023.5814. 

 

Le recours au port de gants stériles n'est pas utile lors du parage de plaies en condition d'isolement et de recomplètement difficile.

 

Dispositifs supraglottiques:Pléthore ?

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care 

Copeland GB et Al. Military Medicine, Volume 187, Issue 7-8, July-August 2022, Pages e862–e876

 

Pour rappel ce type de dispositifs n'est pas recommandé en traumatologie du fait du risque de déplacement et d'inhalation et ce malgré une simplicité apparente d'emploi. De plus la diversité des ces dispositifs doit interpeller.

 

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Background

Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings.

Materials and Methods

We conducted a market review of 25 SGA devices that may meet inclusion into the medics’ aid bag. The company’s official “Instructions for Use” document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device.

Results

Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device’s features, indications, and contraindications based on the manufacturer’s product information documentation.

Conclusions

There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

 

Histoire de FiO2

Maximizing Oxygen Delivery in Portable Ventilators.

Blakeman T. et Al. Mil Med. 2022 Feb 4:usab561. doi: 10.1093/milmed/usab561

Background: 

Military transport of critically ill/injured patients requires judicious use of resources. Maintaining oxygen (O2) supplies for mechanically ventilated is crucial. O2 cylinders are difficult to transport due to the size and weight and add the risk of fire in an aircraft. The proposed solution is the use of a portable oxygen concentrator (POC) to supply O2 for mechanical ventilation. As long as power is available, a POC can provide an endless supply of O2. Anecdotal evidence suggests that as little as 3 L/min of O2 could manage as many as 2/3 of the mechanically ventilated military aeromedical transport patients.

Materials and methods: 

We evaluated two each of the AutoMedx SAVe II, Hamilton T1, Zoll 731, and Ventec VOCSN portable ventilators over a range of settings paired with 1 and 2 Caire SAROS POCs at ground level and simulated altitudes of 8,000 feet, 16,000 feet, and 22,000 feet. The Ventec VOCSN has the capability of utilizing an internal O2 concentrator that uses pulsed dose technology, which was also evaluated. Each ventilator was attached to a Michigan Instruments Training Test Lung. Output from the POC was bled into each ventilator via the mechanism provided with each device. A Fleisch pneumotach was used to measure delivered tidal volume (VT), and a fast-response O2 analyzer was used to measure FiO2 within the simulated lung. Ventilator parameters and FiO2 were continuously measured and recorded at each altitude. One-way analysis of variance was used to determine statistically significant differences (P < .05) in FiO2 between ventilators and among the same ventilator model at each testing condition.

Results: 

Delivered FiO2 varied widely between ventilator models and between devices of the same model with some testing conditions. Differences in FiO2 between ventilators at a majority (98.5%) of testing conditions were statistically significant (P < .05) but not all were clinically important. The Zoll 731 delivered the highest and most consistent FiO2 over all ventilator/POC settings at all altitudes. Differences in FiO2 at a given ventilator/POC setting from ground level to 22,000 feet were not clinically important (<5%) with this device. The VOCSN utilizing the integrated internal O2 concentrator delivered the lowest FiO2 across all ventilator/POC settings and altitudes. Due to the inability of the SAVe II to operate at the minute ventilation and positive end expiratory pressure (PEEP) settings required by the testing protocol, the device was only tested at one ventilator setting. The Hamilton T1 failed to operate appropriately at the highest VT/PEEP setting at 16,000 feet and all but one ventilator setting at 22,000 feet. The delivered FiO2 was not included in the analysis for those ventilator settings. The highest delivered FiO2 was 0.85 ± 0.05 at the 250 mL VT setting using 2 POCs (P < .0001) at ground level with the Zoll 731.

Conclusions: 

Oxygen delivery utilizing POCs is dependent upon multiple factors including ventilator operating characteristics, ventilator settings, altitude, and the use of pulsed dose or continuous flow O2. Careful patient selection would be paramount to provide safe mechanical ventilation using this method of O2 delivery.

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

O2 préhospitalier en circuit fermé: possible

Le recours à l'oxygène peut être compliqué notamment pour des raisons logistiques . Le recours à de l'oxygène chimique est possible mais limité. Si l'emploi de circuits fermés visant à récupérer l'oxygène exhalé est courant en anesthésie ou dans certaines modalités de plongée il l'est moins en médecine préhospitalière.

 

Un dispositif se propose de combler ce manque : le FIDO de la société suédoise Mirola.  (pdf fr)

Mirola_spin

 

 

 

 

Exsufflation: Attention , éviter le péricarde !

Risk of Harm in Needle Decompression for Tension Pneumothorax
Thompson P et Al.  J Spec Oper Med. 2023 Apr 10;ZU1D-3DL9. doi: 10.55460/ZU1D-3DL9

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Les recommendations américaines sont parfois un peu hâtives. C'est le cas de celles portant sur la longueur préconisée du cathéter d'exsufflation. 

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Comme quoi le "suivisme" évoqué récemment par un homme politique françias n'est pas toujours bon.
Introduction: Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site.

Methods: Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests.

Results: The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79).

Conclusion: The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

GE: La pile à combustible, l'avenir

PIle à combustible méthanol

 

Clic sur l'image pour accéder au document

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.

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.

Stérilisateur de l'avant ?

FRONT-LINE Field Sterilizer

 

Clic sur l'image pour accéder au document

Dispositifs supraglottiques:Pléthore ?

Review of Commercially Available Supraglottic Airway Devices for Prehospital Combat Casualty Care 

Copeland GB et Al. Military Medicine, Volume 187, Issue 7-8, July-August 2022, Pages e862–e876

 

Pour rappel ce type de dispositifs n'est pas recommandé en traumatologie du fait du risque de déplacement et d'inhalation et ce malgré une simplicité apparente d'emploi. De plus la diversité des ces dispositifs doit interpeller.

 

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

 

Background

Airway obstruction is the second leading cause of potentially survivable death on the battlefield. The Committee on Tactical Combat Casualty Care lists airway optimization among the top 5 battlefield research and development priorities; however, studies show that combat medics lack access to the recommended supraglottic airway (SGA) devices. SGA devices are an alternative airway management technique to endotracheal tube intubation. Reports have shown SGA devices are easier to use and take fewer attempts to provide patent airflow to the patient when compared to endotracheal tube intubation. Military settings require a higher degree of skill to perform airway management on patients due to the environment, limited availability of equipment, and potential chaos of the battlefield. Finding the optimal SGA device for the military setting is an unmet need. The International Organization for Standardization describes basic functional requirements for SGA devices, as well as patient configurations and size limitations. Beyond that, no SGA device manufacturer states that their devices are intended for military settings.

Materials and Methods

We conducted a market review of 25 SGA devices that may meet inclusion into the medics’ aid bag. The company’s official “Instructions for Use” document, Google Scholar, and FDA reports were reviewed to obtain information for each SGA device.

Results

Twenty-five commercially available SGA devices are explored from manufacturer online sources. A commercially available device list is shown later in this paper, which provides the device’s features, indications, and contraindications based on the manufacturer’s product information documentation.

Conclusions

There are a variety of devices that require further testing to determine whether they should be included in sets, kits, and outfits.

 

QUICK CHEST TUBE KIT

Le Quick chest Tube Kit et le Quick chest decompression kit

Clic sur l'image pour accéder au document

 

Olaes Bandage: En mieux

OLAES HEMOSTATIC BANDAGE

 

Déjà performant, l'OLAES MODULAR BANDAGE se voit associé à un pansement hémostatique.               [Vidéo]

 

 

Vers une nouvelle TIC ?

Projet START, le kit de soin nouvelle génération du soldat

Vu sur le site du MINARM. Un projet issu de la mission innovation. Un même contenu mais un contenant mieux adapté. Il faut dire qu'il y en a des TIC/IFAK.

 

 

Pansements compressifs: Le test de la NAMRU

Pas nouveau mais instructif dans le contexte de bataille commerciale entre les industriels

Clic sur l'image pour accéder au rapport

SAM JT extender:Pourles plaies axillaires

La SAM Junctional tourniquet se voit doter d'un dispositif complémentaire de compression axillaire

Clic sur l'image pour accéder au site du fabricant

Easywarm: Une autre couverture chauffante

Clic sur l'image pour accéder au document

Miniaturisation: La précision n'est pas au rendez-vous !

Accuracy of low-weight versus standard syringe infusion pump devices depending on altitude.

 

Blancher M  et Al. Scand J Trauma Resusc Emerg Med. 2019 Jul 11;27(1):65. doi: 10.1186/s13049-019-0643-1

 

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L'engouement pour la miniaturiation des équipements (PSE, Laryngoscope, Echographe) est grand. Encore faut il que la performance soit au rendez-vous. Ce n'est pas tout à fait le cas avec certains pousse-seringues, notamment en altitude. Ceci est très dommageable dès lors de la mise en oeuvre de perfusion d"amines pressives.

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BACKGROUND:

Intravenous drug infusions in critically ill patients require accurate syringe infusion pumps (SIPs). This is particularly important during transportation of critically ill patients by helicopter emergency medical services (HEMS), where altitude may influence device performance. Because weight is a real concern in HEMS, new low-weight devices are very appealing. The aim of this study was to compare infusion flow rates delivered by low-weight versus standard SIP devices, in the prehospital emergency medicine setting, at different altitudes.

METHODS:

We conducted a comparative bench study involving five SIP devices (two standard and three low-weight models) at 300, 1700 and 3000 m altitude. The primary endpoint was the flow rate delivered by SIPs for prespecified values. We used two methods to measure flow. The normative method consisted in measuring weight (method A) and the alternate method consisted in measuring instantaneous flow (method B).

 

RESULTS:

Using method A, no significant differences were found in median flow rates and interquartile range depending on device and altitude for a prespecified 10-mL/h flow. However, method B showed that low-weight SIPs delivered multiple sequential boluses with substantial variations (1.2-15.8 mL/h) rather than a prespecified continuous 5-mL/h flow. At 1700 m altitude, the interquartile range of delivered flows increased only for low-weight devices (p for interaction< 0.001).

CONCLUSIONS:

Despite satisfactory normative tests, low-weight SIPs deliver discontinuous flow with potential clinical implications for critically ill patients receiving vasoactive drugs. This study also highlights a thus far unknown negative impact of altitude on SIP function. We believe that normative requirements for SIP approval should be revised accordingly.