N'oublions pas le packing de plaie

A manikin model for study of wound-packing interventions to control out-of-hospital hemorrhage

Kragh JF et Al. Am J Emerg Med. 2014 Sep;32(9):1130-1

 

To the Editor,

With hemorrhage being the primary cause of mortality on the battlefield [1-3], wound-packing practice by US military medics in the wars since September 11, 2001, has changed from a conservative to an assertive approach. The foremost emphasis changed from preventing contamination to controlling hemorrhage. As no specific hemostatic dressings were available at the start of the wars, after such dressings were fielded, medics changed their approach by packing wounds with more gauze earlier in casualty care and deeper into subfascial cavitary wounds as a way to control hemorrhage. Although experienced medics and trainers favor an assertive approach, there is limited empirical evidence of improvements. In addition, with the development of various dressings with hemostatic properties [4-6], no systematic approach to trial wound-packing techniques easily has been developed. When a war ends and military medical care shifts toward peacetime duties and garrison work, skill sets in trauma care degrade as skill performance is less often. Furthermore, peacetime training reverts back toward everyday work such as sick call and away from future combat casualty care. The reversion tendency allows less training of new medics in combat casualty care than those who were trained during busy years of sustained combat; like nothing in peacetime, the present danger of combat during wartime focuses attention on hemorrhage control. A challenge for medics to be as well trained in peacetime in combat casualty care as during wartime is a recurring theme of military medicine.

Of the medical advances in prehospital combat casualty care during the current wars, we feel that the most important are regular tourniquets, junctional tourniquets, and wound packing because of their potential capacity to save numerous casualties from the most common cause of death on the battlefield—wound exsanguination. To not backslide on these 3 skills, we continue scholarly work to refine them. We call these skills the “Big 3,” and we have published mostly on tourniquets. To stimulate development of best practices in wound packing, we now focus the present report on an introductory test method to increase awareness of knowledge gaps within the science of wound packing. 

The purpose of the present study is to introduce a laboratory model of hemorrhage with data comparing gauze wound packing and medical device use to better understand out-of-hospital hemorrhage control. In an approved protocol, we used a manikin model designed for the capacity to train medics in techniques of gauze wound packing for hemorrhage control in trauma care. The manikin trainer (Combat Ready Clamp [CRoC] Trainer Manikin; Operative Experience, Inc, North East, MD) had a gunshot wound of the right groin that bled water from the common femoral artery; the wound track went through the thigh posterior to anterior. We measured blood volume lost from bleeding, the application time, and hemorrhage control (yes-no). We had only 1 user who had never packed a wound prehospital and had never been trained in this task. We made 4 tests. The first test was that we used a type of gauze (QuikClot Combat Gauze; Z-Medica, Wallingford, CT) alone in accordance with its instructions for use (IFU) except we used no overwrap for pressure; the overwrap is the fourth and final step of the gauze IFU. The second test was like the first, but we used the full IFU that included use of an overwrap (AirWrap, RevMedx, Wilsonville, OR). The third test was only the A manikin model for study of wound-packing interventions to control out-of-hospital hemorrhage

 use of the overwrap and no gauze; this test included no inflation of the pneumatic bladder within the overwrap. The fourth test included the gauze, the overwrap, and the inflation of the overwrap. Each test had 4 replicates.

The results showed an apparent differential performance of the methods of hemorrhage control, but the test order indicated possible learning that may be a confounder. The fourth test performed better than the first 3 with respect to reduced blood loss (Fig. 1), which may mean that the fourth method is best or that the user learned with experience. Perhaps both are true. Application time also improved (Fig. 2), and the evaluation was sensitive enough to detect longer application times with additional steps in the wound-wrapping process.



There was no surprise that the gauze performed better as indicated by reduced blood loss (Fig. 1) when it was used fully in accordance with its IFU in that the second test performed better than the first. In addition, there was no surprise that the overwrap performed better when it was used fully in accordance with its intent in that the fourth test performed better than the third since the overwrap was designed to wrap over gauze.

The strength of this report is that it introduces a method of analyzing wound-packing techniques that generated hypotheses for testing. Hypothesis-driven experiments will follow this hypothesis generating report to check differential performance of techniques such as preliminarily studied here. The method permits learning curve analysis to see how fast users can be in hemorrhage control; we have previously found that tourniquet use, for example, appears to take more than 30 tests before users flatten their learning curve [7].

Determining optimal care techniques and training regimens may help to improve clinical performance. The limitation of the present report is its introductory design; the preliminary finding is only able to generate hypotheses. Future directions include analyses of techniques and learning curves.

 

John F. Kragh Jr., MD

US Army Institute of Surgical Research

Joint Base San Antonio

Fort Sam Houston, TX

Uniformed Services University of the Health Sciences

F. Edward Hébert School of Medicine Bethesda, MD

Corresponding author at: US Army Institute of Surgical Research

Damage Control Resuscitation, 3698 Chambers Pass

Ste B, Joint Base San Antonio

Fort Sam Houston, TX

E-mail address: [e-mail]

 

John Steinbaugh

RevMedx, Inc, Wilsonville, OR

Donald L. Parsons, PA-C

Combat Medic Training

US Army Medical Department Center and School

Joint Base San Antonio, Fort Sam Houston, TX

 

Robert L. Mabry, MD

Emergency Medical Services Fellowship

San Antonio Military Medical Center

Joint Base San Antonio

Fort Sam Houston, TX

Bijan S. Kheirabadi, PhD

Michael A. Dubick, PhD

Damage Control Resuscitation

US Army Institute of Surgical Research

Joint Base San Antonio

 

Fort Sam Houston, TX

Garrot: Pas de jeu avant de serrer

No slackers in tourniquet use to stop bleeding

Polston RW et Al.  J Spec Oper Med. 2013 Summer;13(2):12-9.

 

La performance d'un garrot tient pour beaucoup à la manière dont il va être posé. Le garrot en dotation comporte un dispositif de serrage de type tourniquet. L'efficacité de ce dispositif est en grande partie liée à l'absence de jeu au niveau de la sangle du garrot avant le serrage. Il est fondamental de positionner le garrot à la racine du membre, de le mettre en tension manuellement en tirant sur la sangle de façon à effectuer un premier serrage du garrot  et ensuite de renforcer ce serrage par la barre du tourniquet. On rappelle qu'en principe l'efficacité est obtenue à partir de 3 tours. (la fiche technique). Le travail présenté ci après est éloquent sur l'intérêt de prohiber tout jeu avec de tourner la barre de torsion.

 

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Background: Tourniquets on casualties in war have been loose in 4%?9% of uses, and such slack risks death from uncontrolled bleeding. A tourniquet evidence gap persists if there is a mechanical slack?performance association.

Objective: The purpose of the present study was to determine the results of tourniquet use with slack in the strap versus no slack before windlass turning, in order to develop best practices. Methods: The authors used a tourniquet manikin 254 times to measure tourniquet effectiveness, windlass turns, time to stop bleeding, and blood volume lost at 5 degrees of strap slack (0mm, 25mm, 50mm, 100mm, and 200mm maximum).

Results: When comparing no slack (0mm) to slack (any positive amount), there were increases with slack in windlass turns (p < .0001, 3-fold), time to stop bleeding (p < .0001, 2-fold), and blood volume lost (p < .0001, 2-fold). When comparing no slack to 200mm slack, the median results showed an increase in slack for windlass turns (p < .0001), time to stop bleeding (p < .0001), and blood volume lost (p < .0001).

 

Conclusions: Any slack presence in the strap impaired tourniquet performance. More slack had worse results. Trainers can now instruct tourniquet users with concrete guidance.

Garrot: Comment positionner la boucle ?

Emergency tourniquet effectiveness in four positions on the proximal thigh.

Kragh JF et Al. J Spec Oper Med. 2014 Spring;14(1):26-9.

 

La procédure du sauvetage au combat précise que le garrot doit être posé à la racine du membre. Elle ne précise cependant pas comment le dispositif de serrage doit être placé: en avant sur le côté en arrière du membre. Ce travail tente de répondre à cette question.

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Objective: The purpose of the present study is to determine the performance of tourniquet use by the placement of the tourniquet's windlass on the extremity in four positions: medial, lateral, anterior, and posterior? to inform tourniquet instructors and develop best tourniquet practices.

Methods: A HapMed™ Leg Tourniquet Trainer was used as a manikin to test the effectiveness of an emergency tourniquet, the Special Operations Forces Tactical Tourniquet. Two users made 10 tests, each in four positions.

Results: Effectiveness rates of tourniquet use were 100% in all four positions. The two tourniquet users were both right-hand dominant and used their right hand to turn the windlass. One user turned the windlass clockwise, and the other turned it counterclockwise. The association between time to stop bleeding and tourniquet position was statistically significant but associations between time to stop bleeding and the user, user-by-position, and windlass turn number were not statistically significant. The association between tourniquet position and pressure under the tourniquet was statistically significant, and the association between user and pressure under thetourniquet was statistically significant, but the user-by-position and windlass turn number were not statistically significant. The associations betweentourniquet position and blood loss volume, user and blood loss volume, and user-by-position and blood loss volume were statistically significant. Conclusions: The present study found that tourniquet effectiveness rates were uniformly 100% irrespective of whether the windlass position was medial, lateral, anterior, or posterior. These excellent clinical and statistical results indicate that users may continue to place the tourniquets as they prefer upon the proximal thigh

 

Garrot jonctionnel: CROC et SAM ?

Testing of junctional tourniquets by military medics to control simulated groin hemorrhage.

Kragh JF et Al. J Spec Oper Med. 2014 Fall;14(3):58-63.

 

Ce qui est certain, c'est ce qui est écrit sur cette image

Difficile d'avoir une idée précise sur les performances relatives des matériels proposés par les industriels. Ce qui suit éclaire un peu.

BACKGROUND:

Junctional hemorrhage is a common cause of death on the battlefield, but there is no documented direct comparison for the use of junctional tourniquet models by US medics. The purpose of this testing is to assess military medic experience with the use of junctional tourniquets in simulated out-of-hospital trauma care.

METHODS:

Nine medics (seven men and two women) used four different junctional tourniquets: Combat Ready Clamp™ (CRoC™; http://www.combatmedicalsystems.com), Abdominal Aortic and Junctional Tourniquet™ (AAJT™; http://www.compressionworks.net), Junctional Emergency Treatment Tool (JETT™; http://www.narescue .com), and SAM Junctional Tourniquet® (SJT®; http:// www.sammedical.com/products). These medics also acted as simulated casualties. Effectiveness percentages, as measured by stopped distal pulse by Doppler auscultation, and time to effectiveness were recorded in two tests per tourniquet (72 total tests). Tourniquet users ranked their preference of model by answering the question: "If you had to go to war today and you could only choose one, which tourniquet would you choose to bring?"

RESULTS:

All tourniquets used were safe under the conditions of this study. Both the SJT and the CRoC had high effectiveness percentages; their rate difference was not statistically significant. The SJT and the CRoC had fast times to effectiveness; their time difference was not statistically significant. Users preferred the SJT and the CRoC; their ranked difference was not statistically significant.

CONCLUSION:

The SJT and the CRoC were equally effective and fast and were preferred by the participants

Plaquettes synthétiques: Possible ? Mais oui

Tuning Ligand Density on Intravenous Hemostatic Nanoparticles Dramatically Increases Survival Following Blunt Trauma

Proc Natl Acad Sci U S A. 2014 Jul 15;111 (28) 10293-10298

Des plaquettes synthétiques pour arrêter le saignement ? Certains l'ont fait grâce à la technologie des nanoparticules (1, 2). Un espoir qui reste à confirmer.

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Explosions account for 79% of combat-related injuries, leading to multiorgan hemorrhage and uncontrolled bleeding. Uncontrolled bleeding is the leading cause of death in battlefield traumas as well as in civilian life. We need to stop the bleeding quickly to save lives, but, shockingly, there are no treatments to stop internal bleeding. A therapy that halts bleeding in a site-specific manner and is safe, stable at room temperature, and easily administered is critical for the advancement of trauma care. To address this need, we have developed hemostatic nanoparticles that are administered intravenously. When tested in a model of blast trauma with multiorgan hemorrhaging, i.v. administration of the hemostatic nanoparticles led to a significant improvement in survival over the short term (1 h postblast). No complications from this treatment were apparent out to 3 wk. This work demonstrates that these particles have the potential to save lives and fundamentally change trauma care.

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Pansements hémostatiques: Actualisation 2014

Review of New Topical Hemostatic Dressings for Combat Casualty Care

Benett BL et Al Mil Med. 2014 May;179(5):497-514

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third- generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

Plaie de l'abdomen: Comprimez avec le genou !

Abdominal aortic and iIiac artery compression following penetrating trauma: A study of feasibility

Douma et Al. Prehosp Disaster Med. 2014 Jun;29(3):299-302

Introduction 

Penetrating junctional trauma is a leading cause of preventable death on the battlefield. Similarly challenging in civilian settings, exsanguination from the vessels of the abdomen, pelvis, and groin can occur in moments. Therefore, iliac artery or abdominal aortic compression has been recommended. Based on prior research, 120 lbs (54 kg) or 140 lbs (63 kg) of compression may be required to occlude these vessels, respectively. Whether most rescuers can generate this amount of compression is unknown.

Objective 

To determine how many people in a convenience sample of 44 health care professionals can compress 120 lbs and 140 lbs.

Methods 

This study simulated aortic and iliac artery compression. Consent was obtained from 44 clinicians (27 female; 17 male) from two large urban hospitals in Edmonton, Alberta, Canada. Participants compressed the abdominal model, which consisted of a medical scale and a 250 ml bag of saline, covered by a folded hospital blanket and placed on the ground. In random order, participants compressed a force they believed maintainable for 20 minutes (“maintainable effort”) and then a maximum force they could maintain for two minutes (“maximum effort”). Compression was also performed with a knee. Descriptive statistics were used to evaluate the data.

Results 

Compression was directly proportional to the clinician's body weight. Participants compressed a mean of 55% of their body weight with two hands at a maintainable effort, and 69% at a maximum effort. At maintainable manual effort, participants compressed a mean of 86 lbs (39 kg). Sixteen percent could compress over 120 lbs, but none over 140 lbs. At maximum effort, participants compressed a mean of 108 lbs (48 kg). Thirty-four percent could compress greater than 120 lbs and 11% could compress greater than 140 lbs. Using a single knee, participants compressed a mean weight of 80% of their body weight with no difference between maintainable and maximum effort.

Conclusion 

This work suggests that bimanual compression following penetrating junctional trauma is feasible. However, it is difficult, and is not likely achievable or sustainable by a majority of rescuers. Manual compression (used to temporize until device application and operative rescue) requires a large body mass. To maintain 140 lbs of compression (for example during a lengthy transport), participants needed to weigh 255 lbs (115 kg). Alternatively, they needed to weigh 203 lbs (92 kg) to be successful during brief periods. Knee compression may be preferable, especially for lower-weight rescuers.

Pansements hémostatiques: Utilité non démontrée

Haemostatic dressings in prehospital care

Hewitt Smith A. et Al.  Emerg Med J 2013; 30:784–789

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Une revue de littérature qui confirme que le bien fondé de l'emploi des pansements hémostatiques n'est pas si solide que cela. Pansement compressif et packing de plaie sont des valeurs sûres.

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Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot,be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans

 

Tourniquet jonctionnel: Réflexions US

Management of Junctional Hemorrhage in Tactical Combat Casualty Care: TCCC Guidelines–Proposed Change 13-03

Kotwal RS et Al. J Spec Oper Med. 2013 Winter;13(4):85-93.

Clic sur l'image pour accéder au document

L'industrie nous propose des "garrots jonctionnels". Difficile de se faire une idée précise. Les US ont intégré le CRoC au TCCC. Cependant ce dispositif n'est pas si simple à monter. Cet article offre une lecture intéressante sur le sujet.  Le tourniquet abdominal ne doit pas être appliqué plus d'une heure. Les autres le peuvent pour une durée maximum de 4 heures. Enfin le Sam Junctional Tourniquet est homologué par la FDA en tant que ceinture pelvienne.

 

 

Le point sur le contrôle des hémorragies externes

An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma

Bulger EM et Al. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163-73.

Cet article fait le point à partir de données publiées sur les grands principes d'arrêt des hémorragies externes: Compression directe, garrot artériel en cas d'inefficacité, relatif faible niveau de preuves pour les pansements hémostatiques à utiliser néanmoins comme agent de packing de plaies, nécessité de poursuivre la recherche sur les dispositifs de compression jonctionnelle.

 

ATTENTION Il s'agit de préhospitalier CIVIL

Clic sur l'image pour accéder au document

 

Garrot abdominal: Il est efficace

Abdominal Aortic Tournique Use in Afghanistan

Anonymous. J Spec Oper Med. 2013 Summer;13(2):1-2.

La prise en charge des blessés de guerre a pour objectif essentiel d'obtenir l'arrêt des hémorragies le plus précocement possible. Parmi les dispositifs récemment proposés on trouve le garrot abdominal. On rapporte ici l'emploi couronné de succès d'un tel dispositif.

 

Electricité et hémorragie non compressible ?

Vasoconstriction by Electrical Stimulation: New Approach to Control of Non-Compressible Hemorrhage

Mandel Y et AL. Sci Rep. 2013; 3: 2111.

Non-compressible hemorrhage is the most common preventable cause of death on battlefield and in civilian traumatic injuries. We report the use of microsecond pulses of electric current to induce rapid constriction in femoral and mesenteric arteries and veins in rats. Electrically-induced vasoconstriction could be induced in seconds while blood vessels dilated back to their original size within minutes after stimulation. At higher settings, a blood clotting formed, leading to complete and permanent occlusion of the vessels. The latter regime dramatically decreased the bleeding rate in the injured femoral and mesenteric arteries, with a complete hemorrhage arrest achieved within seconds. The average blood loss from the treated femoral artery during the first minute after injury was about 7 times less than that of a non-treated control. 

This new treatment modality offers a promising approach to non-damaging control of bleeding during surgery, and to efficient hemorrhage arrest in trauma patients

The tourniquet manual

Clic sur l'image pour accéder au document

 

Pansement hémostatique: Restons critiques !

 An Evidence-Based Review of the Use of a Combat Gauze (QuikClot) for Hemorrhage Control

Gegel BT et Al. Am Surg. 2011 Feb;77(2):162-5.

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L'efficacité des pansements hémostatiques apparaît être une évidence. Ils sont utilisés de manière large sans véritables fondements scientiifiques prouvés.  Une analyse critique s'impose, ce d'autant qu'il s'agit de produits onéreux et que l'industrie a bien façonné notre manière de raisonner. Cet article le rappelle. 

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Trauma is a leading cause of morbidity and mortality. Uncontrolled hemorrhage related to the traumatic event is often the major cause of complications and death. The use of hemostatic agents may be one of the easiest and most effective methods of treating hemorrhage. The US military recommends a hemostatic combat gauze (QuikClot Combat Gauze) as the first-line hemostatic agent for use in treatment of severe hemorrhage. This review provides essential information for evidence-based use of this agent. The PICO (patient, intervention, comparison, outcome) question guiding this search for evidence was: Is QuikClot Combat Gauze, a hemostatic agent, effective and safe in controlling hemorrhage in trauma patients in the prehospital setting? The evidence appraised was a combination of lower-level human and animal research. It did not conclusively demonstrate that this combat gauze is an effective hemostatic agent for use in trauma patients, but the results are promising in supporting its use. The evidence does not describe serious side effects, exothermic reaction, and thromboemboli formation associated with other hemostatic agents. Further inves tigation to determine the effectiveness of hemostatic agents, specifically QuikClot Combat Gauze, in the management of trauma casualties in the prehospital setting is required. These should include large-scale, multicenter, prehospital randomized controlled trials.

Tourniquet abdominal: En théorie cela fonctionne

The Evaluation of an Abdominal Aortic Tourniquet for the Control of Pelvic and Lower Limb Hemorrhage

Taylor D. et Al.Mil Med. 2013;178(11):1196-201

Despite improved body armor, hemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, groin, and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a prehospital device capable of preventing pelvic and proximal lower limb hemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure, and abdominal girth were recorded. Doppler ultrasound was used to identify blood flow in the common femoral artery (CFA). The AAT was applied while the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. A total of 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, body mass index, and abdominal girth. This study shows the AAT to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving.

Garrot abdominal: Une paire de main et des bras musclés

Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report

Douma M et Al. Ann Emerg Med. 2013 Oct 23. pii: S0196-0644(13)01452-2

La prise en charge des traumatismes vasculaires de l'abdomen, du pelvis et des membres nécessite une intervention chirurgicale rapide. Il est dans ces cas nécessaire de tarir sinon de réduire le débit de saignement de telle sorte que le blessé arrive vivant dans la structure adaptée (1). Ceci est difficile quand les lésions ne sont pas ou difficilement garrotables notamment lors de traumatismes jonctionnels. Des équipements spécifiques ont été développé pour assurer une compression en amont des lésions et permettre de réduire ces débits de saignements. Ces dispositifs présenté par ailleurs (2, 3 , 4) n'ont pas encore fait leur preuve même si des rapports isolés en soulignent l'intérêt. Certains comme les pantalons antichocs sont considérés comme ayant peu d'indications du moins mal cernées (5) . Ces équipements sont rarement disponibles.

Pourtant la compression abdominale bi-manuelle est possible et en fait connue depuis longtemps notamment en obstétrique sous forme de compression utérine bi-manuelle (6, 7, 8). 

C'est ce qu'illustre le cas clinique présenté. Il existe bien sûr des facteurs limitant comme la corpulence aussi bien du blessé que du sauveteur. Il faut en effet exercer une pression abdominale de l'ordre de 40 kg pour occlure l'aorte abdominal (9).

Pansement hémostatique: Utile?

Comparison of ChitoFlex®, CELOX™, and QuikClot® in control of hemorrhage

Devlin JJ et all. J Emerg Med. 2011 Sep;41(3):237-45

Un article qui complète le précédent et qui doit appeler à de la mesure sur l'emploi des pansements hémostatiques. Bien qu'il existe de nombreux travaux comparatifs prônant l'intérêt de tel ou tel dispositifs, le bien fondé de leur emploi extensif ne peut toujours pas être affirmé en condition de combat. Les messages pédagogiques doivent donc avant tout porter sur l'application correcte des pansements compressifs et le packing de plaie.

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BACKGROUND:

Exsanguinating extremity wounds remain the primary source of battlefield mortality. Operating forces employ three agents in Iraq: HemCon® (HemCon Medical Technologies, Inc., Portland, OR), QuikClot® (Z-Medica Corporation, Wallingford, CT), and CELOX™ (SAM Medical, Tualatin, OR). Anecdotal reports suggest that these agents are less useful on small entrance, linear-tract injuries. ChitoFlex® (HemCon Medical Technologies, Inc., Portland, OR) has been introduced but is untested.

STUDY OBJECTIVES:

To compare the equivalency of the ChitoFlex® dressing, QuikClot® ACS+™ dressing, CELOX™, and standard gauze in their effectiveness to control bleeding from non-cavitary groin wounds.

METHODS:

Forty-eight swine were randomly assigned to one of four treatment groups: standard gauze dressing (SD), ChitoFlex® dressing (CF), QuikClot® ACS+™ dressing (QC), and CELOX™ dressing (CX). A groin injury with limited vessel access was created in each animal. Subjects were resuscitated with 500 mL of hetastarch. The primary endpoint was 180-min survival. Secondary endpoints included total blood loss in mL/kg, incidence of re-bleeding, survival times among the animals that did not survive for 180 min, failure to achieve initial hemostasis, incidence of recurrent bleeding, time to initial re-bleeding, amount of re-bleeding, and mass of residual hematoma.

RESULTS:

Survival occurred in 10 of 12 SD animals, 10 of 12 CF animals, 10 of 12 QC animals, and 9 of 12 CX animals. No statistically significant difference was found.

CONCLUSION:

In our study of limited-access extremity bleeding, ChitoFlex® performed equally well in mitigating blood loss and promoting survival. The ChitoFlex® dressing is an equally effective alternative to currently available hemostatic agents. However, no agents were superior to standard gauze in our model of limited access.

Pansement hémostatique:Vraiment utile ?

Advanced  Hemostatic Dressings Are Not Superior to Gauze for Care Under Fire Scenarios

Watters J et all. J Trauma. 2011;70:1413–1419

Un travail intéressant qui s'interroge sur le vrai intérêt des pansements hémostatiques. Sans remettre en question ce dernier cet article remet en question le positionnement de ce type de matériel. Dans un travail expérimental sur un modèle animal, un packing de plaie avec de la gaze simple serait plus rapide et tout aussi efficace qu'un packing effectué avec le Combat gauze ou le celox gauze.

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Results: All animals survived to study end. There were no differences in baseline physiologic or coagulation parameters or in dressing success rate (SG: 8/8, CG: 4/8, XG: 6/8) or blood loss between groups (SG: 260 mL, CG: 374 mL, XG: 204 mL; p > 0.3). SG (40 seconds ± 0.9 seconds) packed significantly faster than either the CG (52 ± 2.0) or XG (59 ± 1.9). At 120 minutes, all groups had a significantly shorter time to clot formation compared with baseline (p < 0.01). At 30 minutes, the XG animals had shorter time to clot compared with SG and CG animals (p < 0.05). All histology sections had mild intimal and medial edema. No inflammation, necrosis, or deposition of dressing particles in vessel walls was observed. No histologic or ultrastructural differences were found between the study dressings.

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"There are reasons that standard woven gauze bandages have existed for millennia. They are lightweight, absorbent, highly conformable, stable in a variety of environmental conditions, and inexpensive. Multiple advanced hemostatic agents have resulted in superior homeostasis, improved outcomes, and likely saved lives compared with SG when applied according to manufacturers’ recommendations for compression time. However, in a care under fire scenario or in a situation of mass casualties, compression times of 2 minutes to 5 minutes are not feasible. During ongoing battle, only lifethreatening injuries should be addressed and often the wounded must self-apply a tourniquet or dressing. An individual rendering self or buddy aid will need to continue to engage in battle as the first priority. Major vascular injuries, which cannot be controlled through application of a tourniquet, must be addressed as quickly as possible before profound bleeding incapacitates the casualty. Similarly, when there are persons with multiple injuries or wounds to treat, dressings must be rapidly placed and effective without prolonged hold times"

Conclusion: Ce qui compte c'est la compression et le packing de plaie

Stabilisation pelvienne: Vraiment utile !

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

Pizanis A. et All. Injury. 2013 Aug 2. pii: S0020-1383(13)00316-1.

Background: Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge ofthe outcome ofthese techniques is currently based on limited information.

Methods: Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

Results: Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p = 0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

Conclusions: The data suggest that emergency stabilization ofthe pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

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Tourniquet abdominal: Compression axillaire ?

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