RECO SFAR Traumatismes abdominaux

 

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Plaie du coeur: Un retex brestois

Un cas clinique peu fréquent mais classique de plaie du coeur par balle où tous les grands principes du sauvetage au combat se retrouvent.

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Trauma airways: Une revue

Airway trauma: a review on epidemiology, mechanisms of injury, diagnosis and treatment.

Prokakis C et Al. J Cardiothorac Surg. 2014 Jun 30;9:117.

 

Airway injuries are life threatening conditions. A very little number of patients suffering air injuries are transferred live at the hospital. The diagnosis requires a high index of suspicion based on the presence of non-specific for these injuries symptoms and signs and a thorough knowledge of the mechanisms of injury. Bronchoscopy and chest computed tomography with MPR and 3D reconstruction of the airway represent the procedures of choice for the definitive diagnosis. Endotracheal intubation under bronchoscopic guidance is the key point to gain airway control and appropriate ventilation. Primary repair with direct suture or resection and an end to end anastomosis is the treatment of choice for patients suffering from tracheobronchial injuries (TBI). The surgical approach to the injured airway depends on its location. Selected patients, mainly with iatrogenic injuries, can be treated conservatively as long as the injury is small (<2 cm), a secure and patent airway and adequate ventilation are achieved, and there are no signs of sepsis. Patients with delayed presentation airway injuries should be referred for surgical treatment. Intraoperative evaluation of the viability of the lung parenchyma beyond the site of stenosis/obstruction is mandatory to avoid unnecessary lung resection.

Violences urbaines et tueries massives: Des profils proches ?

Comparison of the Causes of Death and Wounding Patterns in Urban Firearm-Related Violence and Civilian Public Mass Shooting Events.

Maghami S et Al  J Trauma Acute Care Surg. 2019 Aug 5. doi: 10.1097/TA.0000000000002470.

 

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Tueries massives et actes isolés de vilence urbaines par armes à feu, les profils lésionnels et causes de décès sont très proches. La première cause de décès évitable apparaît être les lésions thoraciques.

 

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 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 to a previously published study of 19 CPMS events involving 213 victims.

RESULTS:

186 urban autopsy reports were reviewed. There were 171 (92%) homicides and 13 (7%) suicides. Handguns were implicated in 180 (97%) events. One hundred eight gunshots (59%) 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 to 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.

Lactates en préhospitalier: Oui

Prognostic value of lactate in prehospital care as a predictor of early mortality.

Martín-Rodríguez F et Al. Am J Emerg Med. 2019 Sep;37(9):1627-1632. doi: 10.1016/j.ajem.2018.11.028.

 

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Les outils d'aideau diagnostic comme l'échographie tendent à devenir d'emploi routinier en préhospitalier. Le dosage des lactates fait partie de ces outils.

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BACKGROUND:

Prehospital Emergency Medical Services must attend to patients with complex physiopathological situations with little data and in the shortest possible time. The objective of this work was to study lactic acid values and their usefulness in the prehospital setting to help in clinical decision-making.

STUDY DESIGN:

We conducted a longitudinal prospective, observational study on patients over 18 years of age who, after being evaluated by the Advanced Life Support Unit, were taken to the hospital between April and June 2018. We analyzed demographic variables, prehospital lactic acid values and early mortality (<30 days). The area under the curve of the receiver operating characteristic was calculated for the prehospital value of lactic acid.

RESULTS:

A total of 279 patients were included in our study. The median age was 68 years (interquartile range: 54-80 years). Overall 30-day mortality was 9% (25 patients). The area under the curve for lactic acid to predict overall mortality at 30 days of care was 0.82 (95% CI: 0.76-0.89).

 

The lactate value with the best sensitivity and specificity overall was 4.25 mmol/L with a sensitivity of 84% (95% CI: 65.3-93.6) and specificity of 70% (95% CI: 65.0-76.1).

CONCLUSIONS:

The level of lactic acid can be a complementary tool in the field of prehospital emergencies that will guide us early in the detection of critical patients.

Numéro special THOR

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FST, chirurgie et USAparticulièrement innovant

Où comment faire évoluer la chirurgie de guerre par la mise en place d'un écosystème spécifique

 

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TCCC: Un écosystème spécifique

Un regard sur l'émergence des nouvelles modalités de prise en charge des blessés de guerre avec pour point d'orgue l'innovation conduite et la construction d'un écosystème complet autour de la prise en charge du blessé de guerre. Une démarche à comprendre et à bien méditer.

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Saignements majeurs: 5ème révision EU

 

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ATLS 9ème Edition

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Irak/Syrie: Quelle activité ?

The First 30 Months Experience in the Non-Doctrinal Operation Inherent Resolve Medical Theater

Schauer SG et Al. Mil Med. 2018 Nov 5. doi: 10.1093/milmed/usy273

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Les auteurs rapportent le soutien médical de combats menés essentiellement par des troupes amies. La lecture des fichiers associés à la publication s'impose. Pose de garrot et réchauffement sont les gestes préhospitaliers les plus fréquents. Il faut noter, au niveau des structures chirurgicales  la fréquence des drainages thoraciques, des intubations et des laparotomies.

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Introduction:

U.S. military forces were redeployed in 2014 in support of Operation Inherent Resolve (OIR), operating in an austere theater without the benefit of an established medical system. We seek to describe the prehospital and hospital-based care delivered in this medically immature, non-doctrinal theater.

Materials and Methods:

We queried the Department of Defense Trauma Registry (DODTR) for all encounters associated with OIR from August 2014 through June 2017. We sought all available prehospital and hospital-based data.

Results:

There were a total of 826 adults that met inclusion; 816 were from Iraq and the remaining 10 were from Syria. The median age was 21 years and the most frequent mechanism of injury was explosives (47.7%). Median composite injury severity scores were low (9, IQR 2.75-14) and the most frequent seriously injured body region was the extremities (23.0%). Most subjects (94.9%) survived to hospital discharge. Open fractures were the most frequent major injury (26.0%). In the prehospital setting, opioids were the most frequently administered medication (9.3%) and warming blanket application (48.7%) and intravenous line placement (24.8%) were the most frequent interventions. In the emergency department, Focused Assessment with Sonography in Trauma exams (64.3%) was the most frequently performed study and endotracheal intubations were the most frequent (29.9%) procedure. In the operating room, the most frequently performed procedure was exploratory laparotomy (12.3%).

Conclusions:

Host nation military males injured by explosion comprised the majority of casualties. Open fracture was the most common major injury. Hence, future research should focus upon the unique challenges of delivering care to members of partner forces with particular focus upon interventions to optimize outcomes among patients sustaining open fractures.

Module de chirurgie vitale: Bilan

Deployment of the Surgical Life-saving Module (SLM) in 2017: lessons learned in setting up and training operational surgical units

Malgras B et Al. https://doi.org/10.1016/j.injury.2019.03.001

Introduction

The military operations carried out by the French armed forces, occasionally require the use of the Surgical Life-saving Module (SLM), to ensure the surgical support of its soldiers. Due to its extreme mobility and capacity of fast deployment, SLM is particularly useful in small-scale military operations, such as Special Forces missions. In 2017, the French SLM was for the first time used to ensure surgical support of allied forces, which were lacking forward surgical capabilities.

Materials and Methods: the SLM is a mobile, heliborne, airborne, surgical structure with parachuting capability onto land or sea, therefore essentially focused on life-saving procedures, also known as "damage control" surgery. Due to the need for mobility and rapid implementation, the SLM is limited to a maximum of 5 interventions or, in terms of injuries, to 1 or 2 seriously injured patients.

Results

Over a period of 2 months, 5 medical teams were successively deployed with the SLM. A total of 157 casualties were treated. The most common injuries were caused by shrapnel 561%), followed by firearms (36%), and blunt trauma (2.5%). Injuries included the limbs (56%), thorax (18%), abdomen (13%), head (11%), and neck (2%). The average ISS was 8.5 (1-25) with 26 patients presenting with an ISS greater than or equal to 15. The average NISS was 10.8 (1-75) with 34 casualties having an NISS equal to or greater than 15. The surgical procedures were broken down as follows: 126 dressings, 16 laparotomies, 7 thoracotomies, 12 isolated thoracic drains (without thoracotomy), 1 cervicotomy, 12 amputations, 7 limb splints, 2 limb fasciotomies, 2 external fixators and 1 femoral fracture traction.

Conclusions

The numerous SLM deployments in larger operations highlighted its ability to adapt both in terms of equipment and personnel. Continuous management of equipment logistics, robust personnel training, and appropriate organization of the evacuation procedures, were the key elements for optimizing combat casualty care. As a consequence, the SLM appears to be an operational surgical unit of choice during deployments.

Transfusion: Numéro spécial Trauma

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Blessés admis en role 2: Le bilan afghan

A Review of Casualties Transported to Role 2 Medical Treatment Facilities in Afghanistan.

Kotwal RS  et Al. Mil Med. 2018 Mar 1;183(suppl_1):134-145

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Ce document met en évidence tout l'apport d'une chaine coordonnée de prise en charge du traumatisé par des équipes entraînées appliquant une stratégie médico-chirurgicale moderne.

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Critically injured trauma patients benefit from timely transport and care. Accordingly, the provision of rapid transport and effective treatment capabilities in appropriately close proximity to the point of injury will optimize time and survival. Pre-transport tactical combat casualty care, rapid transport with en route casualty care, and advanced damage control resuscitation and surgery delivered early by small, mobile, forward-positioned Role 2 medical treatment facilities have potential to reduce morbidity and mortality from trauma. This retrospective review and descriptive analysis of trauma patients transported from Role 1 entities to Role 2 facilities in Afghanistan from 2008 to 2014 found casualties to be diverse in affiliation and delivered by various types and modes of transport. Air medical evacuation provided transport for most patients, while the shortest transport time was seen with air casualty evacuation. Although relatively little data were collected for air casualty evacuation, this rapid mode of transport remains an operationally important method of transport on the battlefield. For prehospital care provided before and during transport, continued leadership and training emphasis should be placed on the administration and documentation of tactical combat casualty care as delivered by both medical and non-medical first responders.

Military Medicine: Numéro spécial 2018

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Aggressions collectives par arme de guerre

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Settings standard for CCC

Le TCCC dans la vraie vie

Survey of Casualty Evacuation Missions Conducted by the 160th Special Operations Aviation Regiment During the Afghanistan Conflict.

Redman TT et Al. J Spec Oper Med. Summer 2018;18(2):79-85

 

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Une vision des techniques mises en oeuvre en préhospitalier par des équipes américaines en afghanistan. Les pratiques gestuelles mies en oeuvre sur le terrain et en cours d'évacuation sont décrites. Ces dernières doivent être maîtrisées, ce qui est un vrai challenge en terme de formation et d'implication des équipes

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BACKGROUND:

Historically, documentation of prehospital combat casualty care has been relatively nonexistent. Without documentation, performance improvement of prehospital care and evacuation through data collection, consolidation, and scientific analyses cannot be adequately accomplished. During recent conflicts, prehospital documentation has received increased attention for point-of-injury care as well as for care provided en route on medical evacuation platforms. However, documentation on casualty evacuation (CASEVAC) platforms is still lacking. Thus, a CASEVAC dataset was developed and maintained by the 160th Special Operations Aviation Regiment (SOAR), a nonmedical, rotary-wing aviation unit, to evaluate and review CASEVAC missions conducted by their organization.

METHODS:

A retrospective review and descriptive analysis were performed on data from all documented CASEVAC missions conducted in Afghanistan by the 160th SOAR from January 2008 to May 2015. Documentation of care was originally performed in a narrative after-action review (AAR) format. Unclassified, nonpersonally identifiable data were extracted and transferred from these AARs into a database for detailed analysis. Data points included demographics, flight time, provider number and type, injury and outcome details, and medical interventions provided by ground forces and CASEVAC personnel.

RESULTS:

There were 227 patients transported during 129 CASEVAC missions conducted by the 160th SOAR. Three patients had unavailable data, four had unknown injuries or illnesses, and eight were military working dogs. Remaining were 207 trauma casualties (96%) and five medical patients (2%). The mean and median times of flight from the injury scene to hospital arrival were less than 20 minutes. Of trauma casualties, most were male US and coalition forces (n = 178; 86%). From this population, injuries to the extremities (n = 139; 67%) were seen most commonly. The primary mechanisms of injury were gunshot wound (n = 89; 43%) and blast injury (n = 82; 40%). The survival rate was 85% (n = 176) for those who incurred trauma. Of those who did not survive, most died before reaching surgical care (26 of 31; 84%).

CONCLUSION:

Performance improvement efforts directed toward prehospital combat casualty care can ameliorate survival on the battlefield. Because documentation of care is essential for conducting performance improvement, medical and nonmedical units must dedicate time and efforts accordingly. Capturing and analyzing data from combat missions can help refine tactics, techniques, and procedures and more accurately define wartime personnel, training, and equipment requirements. This study is an example of how performance improvement can be initiated by a nonmedical unit conducting CASEVAC missions.

March: Aussi chez les chinois

Expert consensus on the evaluation and diagnosis of combat injuries of the Chinese People’s Liberation Army

Zong W et Al Mil Med Res. 2018 Feb 13;5(1):6

 The accurate assessment and diagnosis of combat injuries are the basis for triage and treatment of combat casualties. A consensus on the assessment and diagnosis of combat injuries was made and discussed at the second annual meeting of the Professional Committee on Disaster Medicine of the Chinese People's Liberation Army (PLA). In this consensus agreement, the massive hemorrhage, airway, respiration, circulation and hypothermia (MARCH) algorithm, which is a simple triage and rapid treatment and field triage score, was recommended to assess combat casualties during the first-aid stage, whereas the abbreviated scoring method for combat casualty and the MARCH algorithm were recommended to assess combat casualties in level II facilities. In level III facilities, combined measures, including a history inquiry, thorough physical examination, laboratory examination, X-ray, and ultrasound examination, were recommended for the diagnosis of combat casualties. In addition, corresponding methods were recommended for the recognition of casualties needing massive transfusions, assessment of firearm wounds, evaluation of mangled extremities, and assessment of injury severity in this consensus.

Groupe O: Plus de mortalité ?

The impact of blood type O on mortality of severe trauma patients: a retrospective observational study.

Takayama W et Al. Crit Care. 2018 May 2;22(1):100. doi: 10.1186/s13054-018-2022-0

 

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BACKGROUND:

Recent studies have implicated the differences in the ABO blood system as a potential risk for various diseases, including hemostatic disorders and hemorrhage. In this study, we evaluated the impact of the difference in the ABO blood type on mortality in patients with severe trauma.

METHODS:

A retrospective observational study was conducted in two tertiary emergency critical care medical centers in Japan. Patients with trauma with an Injury Severity Score (ISS) > 15 were included. The association between the different blood types (type O versus other blood types) and the outcomes of all-cause mortality, cause-specific mortalities (exsanguination, traumatic brain injury, and others), ventilator-free days (VFD), and total transfusion volume were evaluated using univariate and multivariate competing-risk regression models. Moreover, the impact of blood type O on the outcomes was assessed using regression coefficients in the multivariate analysis adjusted for age, ISS, and the Revised Trauma Score (RTS).

RESULTS:

A total of 901 patients were included in this study. The study population was divided based on the ABO blood type: type O, 284 (32%); type A, 285 (32%); type B, 209 (23%); and type AB, 123 (13%). Blood type O was associated with high mortality (28% in patients with blood type O versus 11% in patients with other blood types; p <  0.001). Moreover, this association was observed in a multivariate model (adjusted odds ratio = 2.86, 95% confidence interval 1.84-4.46; p <  0.001). The impact of blood type O on all-cause in-hospital mortality was comparable to 12 increases in the ISS, 1.5 decreases in the RTS, and 26 increases in age.

 

The comparison of characteristics and outcomes between blood type O and other blood types

	Type O n = 284	Non-O type n = 617	p value
Characteristics
Age, years (SD)	57.3 (20.0)	56.2 (19.4)	0.442
Female, n (%)	64 (22.5)	142 (23)	0.873
Charlson Comorbidity Index, median (IQR)	0 (0–2)	0 (0–1)	0.829
Uncrossmatched type O RBC transfusion, n (%)	28 (9.9)	37 (6)	0.051
RTS, (SD)	6.85 (1.4)	7.13 (1.2)	0.003
ISS, median (IQR)	18 (16–25)	19 (16–25)	0.160
AIS head, median (IQR)	4 (3–4)	4 (3–4)	0.582
AIS face, median (IQR)	0 (0–0)	0 (0–0)	0.783
AIS chest, median (IQR)	0 (0–2)	0 (0–3)	0.342
AIS abdomen, median (IQR)	0 (0–0)	0 (0–0)	0.561
AIS extremities, median (IQR)	0 (0–2)	0 (0–2)	0.443
AIS surface, median (IQR)	0 (0–0)	0 (0–0)	0.652
Outcomes
In-hospital mortality, n (%)	80 (28.2)	71 (11.5)	< 0.001
Death due to exsanguination, n (%)	23 (8.1)	15 (2.4)	< 0.001
Death due to TBI, n (%)	43 (15.1)	44 (7.1)	< 0.001
Death due to other causes, n (%)	15 (1.8)	11 (5.3)	0.005
Ventilator-free days, mean (SD)	18.7 (12.2)	23.1 (9.4)	< 0.001
Units of RBCs administered within 24 h, mean (SD)	3 (9)	2 (7)	0.112

 

Categorical variables are expressed as numbers (%); continuous variables are presented as medians (25–75 percentiles = interquartile range (IQR))

AIS Abbreviated Injury Scale; ISS Injury Severity Score; RBC red blood cell; RTS Revised Trauma Score; SD standard deviation; TBI traumatic brain injury

 

Furthermore, blood type O was significantly associated with higher cause-specific mortalities and shorter VFD compared with the other blood types; however, a significant difference was not observed in the transfusion volume between the two groups.

CONCLUSIONS:

Blood type O was significantly associated with high mortality in severe trauma patients and might have a great impact on outcomes. Further studies elucidating the mechanism underlying this association are warranted to develop the appropriate intervention.