14/11/2022
Plaidoyer AUSSIE pour + de technicité à l'avant
Treatment at point of injury—A proposal for an enhanced combat first aider and health technician skillset
Pilgrim C. et Al. JMVH 2022, oncline first
Management of trauma in the future operating environment might be significantly different from the recent experience in the Middle East Region if it were to occur in the context of hostilities between coalition, including Australian forces and a near-peer or peer-level threat. Specifically, reliance on rotary-wing aeromedical evacuation may be compromised if air superiority is degraded or denied.
Two alternative approaches may be considered in the context of constrained evacuation capability. First, enhanced treatment of the injured soldier on the ground at or near the point of injury by first responders may broaden the window during which a patient may survive on the battlefield awaiting evacuation. Alternatively, moving the surgical resources to the casualty may also improve the chances of survival for an injured soldier. However, this comes at the cost of risking higher-level assets. The first of these approaches is considered here with an exploration of what life-saving interventions (LSI) can be delivered by first responder soldiers. Numerically dropping as a result of tactical combat casualty care principles but persisting as causes of preventable battlefield death, exsanguinating extremity haemorrhage, tension pneumothorax and airway obstruction are areas where future gains may be possible with an expanded skillset deliverable by combat first aiders and health technicians.
Earlier administration of blood products by health technicians to casualties with exsanguinating haemorrhage would align military trauma management principles with the civilian world, where blood products can now be administered en route by trained paramedics. Similarly, there is a shift towards managing tension pneumothorax with finger thoracostomy in preference to needle decompression in the hospital and pre-hospital environment in the civilian sector.
Of much greater complexity, management of non-compressible truncal haemorrhage remains problematic on the battlefield. A highly specialised intervention with significant haemodynamic consequences that nevertheless has been shown to be achievable in both military and civilian contexts is REBOA (resuscitative endovascular balloon occlusion of the aorta). This technique is encumbered with a significant training burden but warrants discussion and is most relevant when evacuation times are expected to fall between 1 and 6 hours. Expanding the skillset deliverable by combat first aiders and health technicians may offset delays in evacuation and maintain battlefield casualty survival in the future operating environment and may be obtained leveraging existing Defence training programs.
12/11/2022
Triage: Encore + d'expertise à l'avant
JTS Analyzes Search and Rescue After Action Reports to Uncover Deficiencies,
Develops Performance Improvement Metrics
https://prolongedfieldcare.org/2022/03/18/joint-trauma-system-newsletter-update/
The JTS PI and CTS Operations branches published in-depth review of after action reports (AARs) from over 252 search and rescue (SAR) missions from 2018 - 2021. The report is in response to the U.S. Navy SAR’s request that JTS assess its operations. It analyzes the context in which Naval SAR operations oc- curred as well as medical procedures and patient demographics. JTS identified deficiencies in equipment, personnel, and documentation and developed a list of PI metrics. The need for standardization is keenly felt in the field. AAR comments reinforce the need for standardized equipment like cardiac kits, medication kits, and advanced life support tools. For example, SAR crews report they do not have the equipment or skills to perform rapid intubation of patients. The report was unable to conclude whether or not standardized medication kits are available to SAR teams. The report did find skills of attendant medical personal vary considerably across SAR missions. Thirty-one percent of missions were executed by a single EMT-B, while 19% were executed by a single EMP-P, and 17% were executed by two medical attendants. In some cases, both a registered nurse and physician were present, while other times only one was pre- sent.
JTS identified opportunities for improving documentation. Vague or incomplete information in the after action reports makes it more difficult to conduct accurate assessments. Accurate information is critical for mission success. Casualty classification was one area of deficiency. The report found that there is only an 81% overall accuracy in the SAR Rescuer Skill Type
casualty classification. This puts casualty classification high on the list of performance improvement (PI) priorities. Casualty classification includes all the critical information of the patient, most notably the type and severity of injury and location of the patient. It is imperative that patients are accurately classified at the start of the mission, since this determines everything from prioritizing patient care to the medical and logistical resources. A key metric for success is the comparison between the dispatched category and the assessed category of the casualty. Dispatch’s casualty classification should match the classification assessed upon the arrival at the mission destination. Having accurate information upfront is critical for SAR teams to accurately triage the casualty in advance, which dictates urgency, timing, equipment, and all other areas of mission prep. Inconsistent SAR documentation impacts the ability for SAR teams to record accurate information. For example, the DA4700 form has a list of specific mechanisms of injury (MOI), which are tailored towards battlefield en route care and not necessarily applicable to SAR operations. JTS reported roughly one fifth (55 out of 252 cases) of SAR cases recorded the MOI as either “other” or left blank. “Other” or left unchecked ultimately makes the data less useful and harder to interpret. In cases of hypothermia, the patient’s temperature was only recorded in 13% of cases. An emphasis on documentation training may
fill the gaps in SAR documentation.
The situation is further complicated by the fragmented nature of the available guidance for SAR teams. JTS discovered SAR teams rely on guidelines from multiple sources, bringing into question source credibility and guidance consistency.
The lack of training is at the root of the deficiencies. Additionally, actual mission engagements do not provide for redundancy which would lead to proficiency, proving that personnel training is of paramount importance. For instance, in one exercise, Special Operations assets had to be utilized for Casualty Evacuation (CASEVAC) purposes because the CASEVAC plan proved insufficient during the course of the exercise. The AARs recommended regular testing and evaluation of CASEVAC plans.
Response to the JTS SAR report has been positive and supportive. LCDR Paul Roszko, Director of Emergency Medical Services, Navy Medical Forces, called the report “excellent” and viewed the findings as an opportunity to improve trauma training across the Services. The report prompted Rosko to question why there is not standardized casualty cards or simulations. He would like to take real-life cases and turn them into vignettes or simulations for squadron training. JTS does include an example of a SAR casualty vignette as a tool to improve SAR training. “The data is clear that the SAR community does a lot more than just treat trauma patients,” said Rozko. “Perhaps identifying a few common medical cases or other types of commonly encountered injuries and specifying what our "standard of care" reference point is would allow the JTS PI team to provide more feedback on the quality of care provided.”
23/10/2022
Drone: Pour quoi faire ?
SOFINS 2019: A quoi pourrait servir un drone pour le soutien médical du combattant ?
Clic sur l'image pour accéder au document
| Tags : drone
21/10/2022
Plyo intraosseux ? Pas si simple
Intraosseous administration of freeze-dried plasma in the prehospital setting
Rittblat M et Al. Isr Med Assoc J. 2022 Sep;24(9):591-595.
Background:
Freeze dried plasma (FDP) is a commonly used replacement fluid in the prehospital setting when blood products are unavailable. It is normally administered via a peripheral intravenous (PIV) line. However, in severe casualties, when establishing a PIV is difficult, administration via intraosseous vascular access is a practical alternative, particularly under field conditions.
Objectives:
To evaluate the indications and success rate of intraosseous administration of FDP in casualties treated by the Israel Defense Forces (IDF).
Methods:
A retrospective analysis of data from the IDF-Trauma Registry was conducted. It included all casualties treated with FDP via intraosseous from 2013 to 2019 with additional data on the technical aspects of deployment collected from the caregivers of each case.
Results:
Of 7223 casualties treated during the study period, intravascular access was attempted in 1744; intraosseous in 87 of those. FDP via intraosseous was attempted in 15 (0.86% of all casualties requiring intravascular access). The complication rate was 73% (11/15 of casualties).
"According to the manufacturer’s specifications, the reconstituted lyophilized plasma product is delivered from a glass bottle with the rate of infusion determined primarily by gravity. This procedure precludes the care providers from applying external pressure to increase the plasma infusion rate. Therefore, the pressure gradient is determined primarily by gravity with respect to height of the bottle."
Complications were more frequent when the event included multiple casualties or when the injury included multiple organs. Of the 11 failed attempts, 5 were reported as due to slow flow of the FDP through the intraosseous apparatus. Complications in the remaining six were associated with deployment of the intraosseous device.
Conclusions:
Administration of FDP via intraosseous access in the field requires a high skill level.
| Tags : intraosseux
16/09/2022
La chirurgie: Encore plus à l'avant
Treatment at Point of Injury. Forward movement of surgical assets to address non compressible truncal haemorrhage
Pilgrim CHC et Al. JMVH 2022, 30: 41-50.
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C'est la chirurgie qui va sauver les blessés du tronc. Encore faut il que ces blessés soient pris en charge par une équipe chirurgicale. D'où le principe de constituer de petites équipes chirurgicales mettant en oeuvre des techniques choisies et limitées dans un environnement très austère au plus près des combats. C'est le principe du module de chirurgie vitale. Les combats actuels (haute intensité mais avec des effectifs plutôt limités) prônent pour le développement de cette stratégie. Le document présenté est une réflexion australienne en la matière.
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Contemporary battlefield trauma surgery in the Middle East Region has been characterised by aeromedical evacuation by rotatory wing (RWAME) with relative impunity. Therefore, future health planning needs to consider an environment whereby RWAME movement may be degraded or denied by a near-peer, peer or superior threat. To that end, an exploration of alternative approaches to surgical management of injured personnel is pertinent. Life-saving surgical intervention may be delivered by deploying mobile surgical assets forward rather than
relying on evacuation of casualty rearward. Shortly after the arrival of surgical resources to the point of injury, temporising damage control procedures may begin, removing the delay associated with casualty preparation, package and transfer. Essentially, the concept is to significantly augment Role 1 activities for a time-limited period to increase the evacuation window allowing patients to survive that would otherwise die on the battlefield if rapid evacuation capability was degraded or denied. An exploration of the surgical procedures, anaesthetic considerations and transport logistics associated with these interventions is presented in this paper. Limitations on the concept include tactical training requirement of forward deployed medical staff, definition and description of surgical intervention offered and prerequisite civilian skillset, attendant load list, and considerations of anaesthetic delivery and casualty hold elements.
08/06/2022
Trauma Prehospitalier: Aides
| Tags : traumatologie
16/02/2022
Triage en cas d'attaque terroriste: Des limites
Triage in Complex, Coordinated Terrorist Attacks
Pepper M et Al. Prehosp Disaster Med. 2019 Aug;34(4):442-448.
Introduction:
Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed.
Methods:
Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs).
Discussion:
Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage."
Conclusion:
Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.
| Tags : triage
18/01/2022
Echo Pleurale: ??
Not so FAST-Chest ultrasound underdiagnoses traumatic pneumothorax
Santorelli JE et Al.
J Trauma Acute Care Surg. 2022 Jan 1;92(1):44-48.
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Le fait de ne rien voir à l'échographie ne signifie pas qu'il n'y a rien. Cette étude prend le contre-pied de l'outil miracle que l'échographie représente pour certains.
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Background: Ultrasonography for trauma is a widely used tool in the initial evaluation of trauma patients with complete ultrasonography of trauma (CUST) demonstrating equivalence to computed tomography (CT) for detecting clinically significant abdominal hemorrhage. Initial reports demonstrated high sensitivity of CUST for the bedside diagnosis of pneumothorax. We hypothesized that the sensitivity of CUST would be greater than initial supine chest radiograph (CXR) for detecting pneumothorax.
Methods: A retrospective analysis of patients diagnosed with pneumothorax from 2018 through 2020 at a Level I trauma center was performed. Patients included had routine supine CXR and CUST performed prior to intervention as well as confirmatory CT imaging. All CUST were performed during the initial evaluation in the trauma bay by a registered sonographer. All imaging was evaluated by an attending radiologist. Subgroup analysis was performed after excluding occult pneumothorax. Immediate tube thoracostomy was defined as tube placement with confirmatory CXR within 8 hours of admission.
Results: There were 568 patients screened with a diagnosis of pneumothorax, identifying 362 patients with a confirmed pneumothorax in addition to CXR, CUST, and confirmatory CT imaging. The population was 83% male, had a mean age of 45 years, with 85% presenting due to blunt trauma. Sensitivity of CXR for detecting pneumothorax was 43%, while the sensitivity of CUST was 35%. After removal of occult pneumothorax (n = 171), CXR was 78% sensitive, while CUST was 65% sensitive (p < 0.01). In this subgroup, CUST had a false-negative rate of 36% (n = 62). Of those patients with a false-negative CUST, 50% (n = 31) underwent tube thoracostomy, with 85% requiring immediate placement.
Conclusion: Complete ultrasonography of trauma performed on initial trauma evaluation had lower sensitivity than CXR for identification of pneumothorax including clinically significant pneumothorax requiring tube thoracostomy. Using CUST as the primary imaging modality in the initial evaluation of chest trauma should be considered with caution.
16/11/2021
PLP: A ne pas mettre au rebus !
Contemporary utility of diagnostic peritoneal aspiration in trauma
Morgan Schellenberg M et Al. J Trauma Acute Care Surg. 2021 Nov 1;91(5):814-819.
Background: Focused Assessment with Sonography for Trauma (FAST) has supplanted diagnostic peritoneal lavage (DPL) as the preferred bedside evaluation for traumatic hemoperitoneum. Diagnostic peritoneal aspiration (DPA) is a simpler, faster modification of DPL with an unclear role in contemporary practice. This study delineated modern roles for DPA and defined its diagnostic yield.
Methods: All trauma patients presenting to our Level I center who underwent DPA were included (May 2015 to May 2020). Demographics, comorbidities, clinical/injury data, and outcomes were collected. The diagnostic yield and accuracy of DPA were calculated against the criterion standard of hemoperitoneum at exploratory laparotomy or computed tomography scan.
Results: In total, 41 patients underwent DPA, typically after blunt trauma (n = 37, 90%). Patients were almost exclusively hypotensive (n = 20, 49%) or in arrest (n = 18, 44%). Most patients had an equivocal or negative FAST and hypotension or return of spontaneous circulation after resuscitative thoracotomy (n = 32, 78%); or had a positive FAST and known cirrhosis (n = 4, 10%). In two (5%) patients, one obese, the catheter failed to access the peritoneal cavity. Diagnostic peritoneal aspiration sensitivity, specificity, positive predictive value, and negative predictive value were 80%, 100%, 100%, and 90%, with an accuracy of 93%. One (2%) complication, a small bowel injury, occurred.
Conclusion: Despite near ubiquitous FAST availability, DPA remains important in diagnosing or excluding hemoperitoneum with exceedingly low rates of failure and complications. Diagnostic peritoneal aspiration is most conclusive when positive, without false positives in this study. Diagnostic peritoneal aspiration was most used among blunt hypotensive or postarrest patients who had an equivocal or negative FAST, in whom the preliminary diagnosis of hemoperitoneum is a critically important decision making branch point.
17/07/2021
Transfuser avant l'hôpital: Pas suffisant pour réduire la mortalité
Effect of Prehospital Red Blood Cell Transfusion on Mortality and Time of Death in Civilian Trauma Patients
Background:
Current management principles of hemorrhagic shock after trauma emphasize earlier transfusion therapy to prevent dilution of clotting factors and correct coagulopathy. London's Air Ambulance (LAA) was the first UK civilian prehospital service to routinely offer prehospital red blood cell (RBC) transfusion (phRTx). We investigated the effect of phRTx on mortality.
Methods:
Retrospective trauma database study comparing mortality before implementation with after implementation of phRTx in exsanguinating trauma patients. Univariate logistic regression was performed for the unadjusted association between phRTx and mortality was performed, and multiple logistic regression adjusting for potential confounders.
Results:
We identified 623 subjects with suspected major hemorrhage. We excluded 84 (13.5%) patients due to missing data on survival status. Overall 187 (62.3%) patients died in the before phRTx period and 143 (59.8%) died in the after phRTx group. There was no significant improvement in overall survival after the introduction of phRTx (P = 0.554). Examination of prehospital mortality demonstrated 126 deaths in the pre-phRTx group (42.2%) and 66 deaths in the RBC administered group (27.6%). There was a significant reduction in prehospital mortality in the group who received RBC (P < 0.001).
Conclusions:
phRTx was associated with increased survival to hospital, but not overall survival. The “delay death” effect of phRTx carries an impetus to further develop inhospital strategies to improve survival in severely bleeding patients.
DCR: Tout ne réduit pas la mortalité à l'hôpital ?
After 800 MTP Events, Mortality due To Hemorrhagic Shock Remains High And Unchanged Despite Several In-Hospital Hemorrhage Control Advancements
Duchesne, J et Al. SHOCK: May 27, 2021 doi: 10.1097/SHK.0000000000001817
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La mise en oeuvre de moyens adaptés d'hémostase comme le REBOA est proposé dans une stratégie de DCR conduite à l'hôpital. Pourtant cette publication ne milite pas pour une amélioration de la survie de patients présentants un trauma pénétrants et requérants une transfusion massive. Seules la pose de garrot et la transfusion de sang total permettent de réduire la mortalité dans un système de prise en charge adapté. La réalisation encore plus précoce pourrait être une solution.
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Background:
Numerous advancements in hemorrhage control and volume replacement that comprise damage control resuscitation (DCR) have been implemented in the last decade to reduce deaths from bleeding. We sought to determine the impact of DCR interventions on mortality over 12 years in a massive transfusion protocol (MTP) population. We hypothesized that mortality would be decreased in later years, which would have used more DCR interventions.
Study Design:
This was a retrospective review of all MTP patients treated at a large regional Level I trauma center from 2008–2019. Interventions by year of implementation examined included MTP 1:1 ratio (2009), liquid plasma (2010), tranexamic acid (2012), pre-hospital tourniquets (2013), REBOA/TEG (2017), satellite blood station (2018), and whole blood transfusion (2019). Relative risk and odds of mortality for DCR interventions were examined.
Results:
There were 824 MTP patients included. The cohort was primarily male (80.6%) injured by penetrating mechanism (68.1%) with median (IQR) age 31 years (23–44) and NISS 25 (16–34). Overall mortality was unchanged [(38.3% to 56.6%); P = 0.26]. Tourniquets (P = 0.02) and WB (P = 0.03) were associated with lower unadjusted mortality; only tourniquets remained significant after adjustment (OR:0.39;95%CI:0.17–0.89; P = 0.03).
Conclusions:
Despite lower mortality with use of tourniquets and WB, mortality rates due to hemorrhage have not improved at our high MTP volume institution, suggesting implementation of new in-hospital strategies is insufficient to reduce mortality. Future efforts should be directed towards moving hemorrhage control and effective resuscitation interventions to the injury scene.
04/06/2021
Extraction de blessé: L'avenir
12/04/2021
KIA pour les UK en Afghanistan
Killed in action (KIA): an analysis of military personnel who died of their injuries before reaching a definitive medical treatment facility in Afghanistan (2004-2014)
Introduction: The majority of combat deaths occur before arrival at a medical treatment facility but no previous studies have comprehensively examined this phase of care.
Methods: The UK Joint Theatre Trauma Registry was used to identify all UK military personnel who died in Afghanistan (2004-2014). These data were linked to non-medical tactical and operational records to provide an accurate timeline of events. Cause of death was determined from records taken at postmortem review. The primary objective was to report time between injury and death in those killed in action (KIA); secondary objectives included: reporting mortality at key North Atlantic Treaty Organisation timelines (0, 10, 60, 120 min), comparison of temporal lethality for different anatomical injuries and analysing trends in the case fatality rate (CFR).
Results: 2413 UK personnel were injured in Afghanistan from 2004 to 2014; 448 died, with a CFR of 18.6%. 390 (87.1%) of these died prehospital (n=348 KIA, n=42 killed non-enemy action). Complete data were available for n=303 (87.1%) KIA: median Injury Severity Score 75.0 (IQR 55.5-75.0). The predominant mechanisms were improvised explosive device (n=166, 54.8%) and gunshot wound (n=96, 31.7%).In the KIA cohort, the median time to death was 0.0 (IQR 0.0-21.8) min; 173 (57.1%) died immediately (0 min). At 10, 60 and 120 min post injury, 205 (67.7%), 277 (91.4%) and 300 (99.0%) casualties were dead, respectively.
Whole body primary injury had the fastest mortality. Overall prehospital CFR improved throughout the period while in-hospital CFR remained constant.
Conclusion: Over two-thirds of KIA deaths occurred within 10 min of injury. Improvement in the CFR in Afghanistan was predominantly in the prehospital phase.
06/04/2021
Inexpérimenté mais sûr de soi ! Constat alarmant
Inexperienced but Confident: A Survey of Advanced Life Support Providers and Life-saving Interventions in the Israel Defense Forces
Haddad N et Al. Military Medicine, Volume 186, Issue Supplement_1, January-February 2021,
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Suivre une formation ne veut pas dire savoir faire. Il est impératif de VÉRIFIER le savoir faire
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Objective:
The objective of this study was to assess the current experience of Israel Defense Forces' (IDF) advanced life support (ALS) providers in performing life-saving interventions (LSIs), the rate of doctors and paramedics achieving the Trauma and Combat Medicine Branch benchmarks, and the rate of providers feeling confident in performing the interventions although not achieving the benchmarks.
Methods:
This study was based on an online survey delivered to IDF ALS providers. The survey investigated demographics; experience in performing endotracheal intubation, cricothyroidotomy, tube thoracostomy, and intraosseous access on human patients; and confidence in performing these LSIs. All benchmarks chosen referred to the number of times performed in the previous year. The benchmarks were 20 for intubation, 3 for cricothyroidotomy, 4 for tube thoracostomy, and 3 for intraosseous access.
Results:
During the survey period, 175 IDF ALS providers started the survey, but only 138 (79%) completed it, 93 (67%) of them were paramedics. Doctors had higher rates than paramedics of failing to achieve the benchmarks for intubation (96 vs. 57%, P < .001) and intraosseous access (100 vs. 66%, P < .001). All respondents failed to achieve the benchmark for cricothyroidotomy, and all but one paramedic failed to achieve the tube thoracostomy benchmark. Doctors had lower rates of high confidence when failing to achieve the benchmark for intubation (35 vs. 64%, P = .008) and intraosseous access (7 vs. 31%, P = .005) compared to paramedics.
Conclusion:
IDF ALS providers have alarmingly limited experience in performing LSIs. Many of them are confident in their ability despite not achieving evidence-based benchmarks. Additional training is required, maybe as a part of an annual medical fitness test.
05/02/2021
Stage de préparation OPEX ?: Insuffisant !
Introduction:
Military-Civilian partnerships (MCPs), such as the Navy Trauma Training Center, are an essential tool for training military trauma care providers. Despite Congressional and military leadership support, sparse data exist to quantify participants' clinical opportunities in MCPs. These preliminary data from an ongoing Navy Trauma Training Center outcomes study quantify clinical experiences and compare skill observation to skill performance.
Materials and methods:
Participants completed clinical logs after each patient encounter to quantify both patients and procedures they were involved with during clinical rotations; they self-reported demographic data. Data analyses included descriptive statistics and chi-square statistics to compare skills observed to skills performed between the first and second half of the 21-day course.
Results:
A sample of 47 Navy personnel (30 corpsmen, 10 nurses, 3 physician assistants, 4 physicians) completed 551 clinical logs. Most logs (453/551) reflected experiences in the emergency department, where corpsmen and nurses each spent 102.0 hours, and physician assistants and physicians each spent 105.4 hours. Logs completed per participant ranged from 1 to 31, (mean = 8). No professional group was more likely than others to complete the clinical logs. Completion rates varied by cohort, both overall and by clinical role. Of emergency department logs, 39% reflected highest acuity patients, compared with 21% of intensive care unit logs, and 61% of operating room logs. Penetrating trauma was reported on 16.5% of logs. Primary and secondary trauma assessments were the most commonly reported clinical opportunities, followed by obtaining intravenous access and administration of analgesic medications. With few exceptions, logs reflected skill observation versus skill performance, a ratio that did not change over time.
Conclusion:
Prospective real-time data of actual clinical activity is a crucial measure of the success of MCPs. These preliminary data provide a beginning perspective on how these experiences contribute to maintaining a skilled military medical force.
09/12/2020
ATLS: Pas suffisant à la guerre
Time to Update Army Medical Doctrine
Knight RM et Al. et Al. Mil Med . 2020 Dec 3;usaa540
Une analyse de l'organisation US qui pointe la nécessité actuelle de réorganiser la prise en charge des blessés de guerre par des équipes formées et entraînées aux techniques de réanimation de l'avant. Cette analyse pointe du doigt l'inadapttaion des roles 1, l'importance des medevac et l'inadéquation de l'ATLS au combat moderne.
27/11/2020
Trauma du larynx: Faites une échographie !
Novel role of focused airway ultrasound in early airway assessment of suspected laryngeal trauma
Adi et al. Ultrasound J (2020) 12:37
Case presentation
We report a case series that illustrate the diagnostic value of focused airway ultrasound in the diagnosis of laryngeal trauma in patients presenting with blunt neck injury.
Conclusion
Early recognition, appropriate triaging, accurate airway evaluation, and prompt management of such injuries are essential. In this case series, we introduce the potential role of focused airway ultrasound in suspected laryngeal trauma, and the correlation of these exam findings with that of computed tomography (CT) scanning, based on the Schaefer classification of laryngeal injury.
23/11/2020
Médicine tactique: Apport de la période afghane
Evolution of Pararescue medicine during operation Enduring Freedom
Stephen Rush S. et Al. Mil Med . 2015 Mar;180(3 Suppl):68-73.
This article highlights recent advances made in U.S. Air Force Pararescue Medical Operations in relation to tactical evacuation procedures. Most of these changes have been adopted and adapted from civilian medicine practice, and some have come from shared experiences with partner nations. Patient assessment includes a more comprehensive evaluation for hemorrhage and indications for hemorrhagic control. Ketamine has replaced morphine and fentanyl as the primary sedative used during rapid sequence intubation and procedural sedation. There has been an increasing use of the bougie to clear an airway or nasal cavity that becomes packed with debris. Video laryngoscopy provides advantages over direct laryngoscopy, especially in situations where there are environmental constraints such as the back of a Pave Hawk helicopter. Intraosseous access has become popular to treat and control hemorrhagic shock when peripheral intravenous access is impractical or impossible. Revisions to patient treatment cards have improved the efficacy and compliance of documentation and have made patient handoff more efficient. These improvements have only been possible because of the concerted efforts of U.S. Air Force and partner platforms operating in Afghanistan.
11/11/2020
Plasma préhospitalier. Surtout pour certains
Characterization of unexpected survivors following a prehospital plasma randomized trial
J Trauma Acute Care Surg. 2020 Nov;89(5):908-914
Background: Prehospital plasma improves survival for severely injured trauma patients transported by air ambulance. We sought to characterize the unexpected survivors, patients who survived despite having high predicted mortality after traumatic injury.
Methods: The Prehospital Air Medical Plasma trial randomized severely injured patients (n = 501) to receive either standard care (crystalloid) or two units of prehospital plasma followed by standard care fluid resuscitation. We built a generalized linear model to estimate patient mortality. Area under the receiver operating characteristic curve was used to evaluate model performance. We defined unexpected survivors as patients who had a predicted mortality greater than 50% and survived to 30 days. We characterized patient demographics, clinical features, and outcomes of the unexpected survivors. Observed to expected (O/E) ratios and Z-statistics were calculated using model-estimated mortality for each cohort.
Results: Our model predicted mortality better than Injury Severity Score or Revised Trauma Score parameters and identified 36 unexpected survivors. Compared with expected survivors, unexpected survivors were younger (33 years [24, 52 years] vs. 47 years [32, 59 years], p = 0.013), were more severely injured (Injury Severity Score 34 [22, 50] vs. 18 [10, 27], p < 0.001), had worse organ dysfunction and hospital resource outcomes (multiple organ failure, intensive care unit, hospital length of stay, and ventilator days), and were more likely to receive prehospital plasma (67 vs. 46%, p = 0.031).
Nonsurvivors with high predicted mortality were more likely to receive standard care resuscitation (p < 0.001). Unexpected survivors who received prehospital plasma had a lower observed to expected mortality than those that received standard care resuscitation (O/E 0.56 [0.33-0.84] vs. 1.0 [0.73-1.32]). The number of prehospital plasma survivors (24) exceeded the number of predicted survivors (n = 10) estimated by our model (p < 0.001).
Conclusion: Prehospital plasma is associated with an increase in the number of unexpected survivors following severe traumatic injury. Prehospital interventions may improve the probability of survival for injured patients with high predicted mortality based on early injury characteristics, vital signs, and resuscitation measures.
09/02/2020
Tuerie de masse ou violence urbaine: Vite vers l'hôpital !
Comparison of the causes of death and wounding patterns in urban firearm-related violence and civilian public mass shooting events.
BACKGROUND:
There are no reports comparing wounding pattern in urban and public mass shooting events (CPMS). Because CPMS receive greater media coverage, there is a connation that the nature of wounding is more grave than daily urban gun violence. We hypothesize that the mechanism of death following urban gunshot wounds (GSWs) is the same as has been reported following CPMS.
METHODS:
Autopsy reports of all firearm-related deaths in Washington, DC were reviewed from January 1, 2016, to December 31, 2017. Demographic data, firearm type, number and anatomic location of GSWs, and organ(s) injured were abstracted. The organ injury resulting in death was noted. The results were compared with a previously published study of 19 CPMS events involving 213 victims.
RESULTS:
One hundred eighty-six urban autopsy reports were reviewed. There were 171 (92%) homicides and 13 (7%) suicides. Handguns were implicated in 180 (97%) events. One hundred eight (59%) gunshots were to the chest/upper back, 85 (46%) to the head, 77 (42%) to an extremity, and 71 (38%) to the abdomen/lower back. The leading mechanisms of death in both urban firearm violence and CPMS were injury to the brain, lung parenchyma, and heart. Fatal brain injury was more common in CPMS events as compared with urban events involving a handgun.
CONCLUSION:
There is little difference in wounding pattern between urban and CPMS firearm events. Based on the organs injured, rapid point of wounding care and transport to a trauma center remain the best options for mitigating death following all GSW events.