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17/11/2014

Pneumothorax et vol en altitude : Possible ?

Cleared for takeoff: The effects of hypobaric conditions on traumatic pneumothoraces

Majercik S. et All. J Trauma Acute Care Surg. 2014;77: 729-733

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La présence d'un pneumothorax traumatique non résolu ne serait pas (ou plus ) une contre-indication à un voyage aérien. C'est ce que suggère ce travail
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BACKGROUND: Current guidelines suggest that traumatic pneumothorax (tPTX) is a contraindication to commercial airline travel, and patients should wait at least 2 weeks after radiographic resolution of tPTX to fly. This recommendation is not based on prospective, physiologic study. We hypothesized that despite having a radiographic increase in pneumothorax size while at simulated altitude, patients with a recently treated tPTX would not exhibit any adverse physiologic changes and would not report any symptoms of cardiorespiratory compromise.

 

METHODS: This is a prospective, observational study of 20 patients (10 in Phase 1, 10 in Phase 2) with tPTX that has been treated by chest tube (CT) or high flow oxygen therapy. CT must have been removed within 48 hours of entering the study. Subjects were exposed to 2 hours of hypobaria (554 mm Hg in Phase 1, 471 mm Hg in Phase 2) in a chamber in Salt Lake City, Utah. Vital signs and subjective symptoms were recorded during the ‘‘flight.’’ After 2 hours, while still at simulated altitude, a portable chest radiograph (CXR) was obtained. tPTX sizes on preflight, inflight, and postflight CXR were compared.

 

RESULTS: Sixteen subjects (80%) were male. Mean (SD) age and ISS were 49 (5) years and 10.5 (4.6), respectively. Fourteen (70%) had a CT to treat tPTX, which had been removed 19 hours (range, 4Y43 hours) before the study. No subject complained of any cardiorespiratory symptoms while at altitude. Radiographic increase in tPTX size at altitude was 5.6 (0.61) mm from preflight CXR. No subject developed a tension tPTX. No subject required procedural intervention during the flight. Four hours after the study, all tPTX had returned to baseline size.

 

CONCLUSION: Patients with recently treated tPTX have a small increase in the size of tPTX when subjected to simulated altitude. This is clinically well tolerated. Current prohibitions regarding air travel following traumatic tPTX should be reconsidered and further studied.

 

| Tags : pneumothorax

12/06/2014

Traumatisé de guerre: Cela évolue

Systematic review of the prevalence and characteristics of battle casualties from NATO coalition forces in Iraq and Afghanistan

Hoencamp R. et All. Injury, Int. J. Care Injured 45 (2014) 1028–1034

Background: The North Atlantic Treaty Organization (NATO) coalition forces remain heavily committed on combat operations overseas. Understanding the prevalence and characteristics of battlefield injury of coalition partners is vital to combat casualty care performance improvement. The aim of this systematic review was to evaluate the prevalence and characteristics of battle casualties from NATO coalition partners in Iraq and Afghanistan. The primary outcome was mechanism of injury and the secondary outcome anatomical distribution of wounds.
 
Methods: This systematic review was performed based on all cohort studies concerning prevalence and characteristics of battlefield injury of coalition forces from Iraq and Afghanistan up to December 20th 2013. Studies were rated on the level of evidence provided according to criteria by the Centre for Evidence Based Medicine in Oxford. The methodological quality of observational comparative studies was assessed by the modified Newcastle-Ottawa Scale.
 
Results: Eight published articles, encompassing a total of n = 19,750 battle casualties, were systematically analyzed to achieve a summated outcome. There was heterogeneity among the included studies and there were major differences in inclusion and exclusion criteria regarding the target population among the included trials, introducing bias. The overall distribution in mechanism of injury was 18% gunshot wounds, 72% explosions and other 10%. The overall anatomical distribution of wounds was head and neck 31%, truncal 27%, extremity 39% and other 3%.
 

Battlefield .jpg

 
Conclusions: The mechanism of injury and anatomical distribution of wounds observed in the published
articles by NATO coalition partners regarding Iraq and Afghanistan differ from previous campaigns. There was a significant increase in the use of explosive mechanisms and a significant increase in the head and neck region compared with previous wars.

13/05/2014

Lésions rachidiennes: Plus fréquentes qu'envisagé

Spinal Injuries in United States Military Personnel Deployed to Iraq and Afghanistan

An Epidemiological Investigation Involving 7877 Combat Casualties From 2005 to 2009

Schoenfeld AJ et All. Spine 2013;38:1770–1778

Les lésions du rachis sont plus fréquentes que ce qui était supposé. Ce travail rapporte qu'une atteinte du rachis est présente dans 11% des cas. Une des explications est que l'amélioration des conditions de prise en charge permet la survie de blessés plus graves qu'auparavant, qui autrefois ne survivait pas à leurs blessures.

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In the years 2005 to 2009, 872 (11.1%) casualties with spine injuries were identified among a total of 7877 combat wounded. The mean age of spine casualties was 26.6 years. Spine fractures were the most common injury morphology, comprising 83% of all spinal wounds. The incidence of combat-related spinal trauma was 4.4 per 10,000, whereas that of spine fractures was 4.0 per 10,000. Spinal cord injuries occurred at a rate of 4.0 per 100,000.

SpinalAFGIRAK2.jpg

Spinal cord injuries were most likely to occur in Afghanistan (incident rate ratio: 1.96; 95% confi dence interval: 1.68–2.28), among Army personnel (incident rate ratio: 16.85; 95% confidence interval: 8.39–33.84), and in the year 2007 (incident rate ratio: 1.90; 95% confi dence interval: 1.55–2.32). Spinal injuries from gunshot were significantly more likely to occur in Iraq (17%) than in Afghanistan (10%, P = 0.02).

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| Tags : rachis

10/02/2014

Inhalation de fumées: Héparine en aérosol ?

Inhaled Anticoagulation Regimens for the Treatment of Smoke Inhalation–Associated Acute Lung Injury: A Systematic Review*

Miller AC et Al. Crit Care Med 2014; 42:413–419

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L'inhalation de fumées est fréquentes lors de la prise en charge de victilmes par explosion. Laprise en charge de brNébiliser 5000 à 1000U d'héparine inhalé avec 3ml de NacétylCystéine et de l'albuterol améliorerait la survie 

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OBJECTIVE:

Inhaled anticoagulation regimens are increasingly being used to manage smoke inhalation-associated acute lung injury. We systematically reviewed published and unpublished preclinical and clinical trial data to elucidate the effects of these regimens on lung injury severity, airway obstruction, ventilation, oxygenation, pulmonary infections, bleeding complications, and survival.

DATA SOURCES:

PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Relevant unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, MINDCULL.com, Current Controlled Trials, and Google.

STUDY SELECTION:

Inclusion criteria were any preclinical or clinical study in which 1) animals or subjects experienced smoke inhalation exposure, 2) they were treated with nebulized or aerosolized anticoagulation regimens, including heparin, heparinoids, antithrombins, or fibrinolytics (e.g., tissue plasminogen activator), 3) a control and/or sham group was described for preclinical studies, and 4) a concurrent or historical control group described for clinical studies. Exclusion criteria were 1) the absence of a group treated with a nebulized or aerosolized anticoagulation regimen, 2) the absence of a control or sham group, and 3) case reports.

DATA EXTRACTION:

Ninety-nine potentially relevant references were identified. Twenty-seven references met inclusion criteria including 19 preclinical references reporting 18 studies and eight clinical references reporting five clinical studies.

DATA SYNTHESIS:

A systematic review of the literature is provided. Both clinical and methodological diversity precluded combining these studies in a meta-analysis.

CONCLUSIONS:

The high mortality associated with smoke inhalation-associated acute lung injury results from airway damage, mucosal dysfunction, neutrophil infiltration, airway coagulopathy with cast formation, ventilation-perfusion mismatching with shunt, and barotrauma. Inhaled anticoagulation regimens in both preclinical and clinical studies improve survival and decrease morbidity without altering systemic markers of clotting and anticoagulation. In some preclinical and clinical studies, inhaled anticoagulants were associated with a favorable effect on survival. This approach appears sufficiently promising to merit a well-designed prospective study to validate its use in patients with severe smoke inhalation-associated acute lung injury requiring mechanical ventilation.

SmokeInhalation.jpg

Depiction of airway changes in the setting of smoke inhalation–associated acute lung injury. Trachea and bronchi injury is characterized by mucosal hyperemia, increased microvascular permeability, exfoliation of the epithelial lining, mucous secretion, and an acute inflammatory cell influx (A–C) (57). As early as 1 hr postexposure, affected respiratory tract epithelium may display clumping, swelling, loss of cilia, blebbing, and surface erosion (B) (55). Within hours, sloughing of the respiratory mucosa progresses, a fibrinocellular pseudomembrane begins to form, and neutrophils begin to influx into the major airways (55). By 6 hr postinjury, the injured bronchi and bronchiole epithelium remains largely intact with focal areas of necrosis and sloughing (A, B) (56). Surface lining cells appear enlarged with cytoplasmic vacuolization, and neutrophils have begun to marginate and focally concentrate at points of epithelial necrosis (56). In addition, basal cells are normal in appearance, and the subepithelial connective tissue may appear slightly edematous with contained neutrophil infiltrates (56). By 24 hr, the ciliated and secretory lining cells are largely destroyed (C) (56). Cellular debris is admixed with fibroid material, mucus, and neutrophils creating a pseudomembranous fibrinocellular network that is adherent to both the cell-denuded basal lamina and the intact basal cells (C, D) (56). By 72 hr, injured epithelial areas are largely resurfaced by a stratified reparative epithelium with interposed areas of fibrinocellular exudate (D) (56). This epithelium is three to five cells thick, with flattened, nonciliated cells along the surface, and these cells are likely derived from proliferating and migrating basal cells (56). Subepithelial edema and inflammatory cell infiltrates begin to diminish (56). Complete repair of the respiratory tract epithelium with return of normal cilia populations may take up to 2–4 wk depending on the severity of smoke exposure.

| Tags : brûlure

21/11/2013

Le plasma lyophilisé: Bon pour le cerveau du traumatisé qui saigne

Early treatment with lyophilized plasma protects the brain in a large animal model of combined traumatic brain injury and hemorrhagic shock

Imam AM et Al. J Trauma Acute Care Surg. 2013;75: 976-983

accéder aux abstracts de la WTA publiés dans J trauma Acute care

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Bien sûr une étude animale, mais une de plus qui milite pour un emploi précoce du plasma lyophylisé.

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BACKGROUND: Combination of traumatic brain injury (TBI) and hemorrhagic shock (HS) can result in significant morbidity and mortality. We have previously shown that early administration of fresh frozen plasma (FFP) in a large animal model of TBI and HS reduces the size of the brain lesion as well as the associated edema. However, FFP is a perishable product that is not well suited for use in the austere prehospital settings. In this study, we tested whether a shelf-stable, low-volume, lyophilized plasma (LSP) product was as effective as FFP.

METHODS:

Yorkshire swine (42-50 kg) were instrumented to measure hemodynamic parameters, intracranial pressure, and brain tissue oxygenation. A prototype, computerized, cortical impact device was used to create TBI through a 20-mm craniotomy: 15-mm cylindrical tipimpactor at 4 m/s velocity, 100-millisecond dwell time, and 12-mm penetration depth. Volume-controlled hemorrhage was induced(40-45% total blood volume) concurrent with the TBI. After 2 hours of shock, animals were treated with (1) normal saline (NS, n = 5), (2) FFP (n = 5), and (3) LSP (n = 5). The volume of FFP and LSP matched the shed blood volume, whereas NS was 3 times the volume. Six hours after resuscitation, brains were sectioned and stained with TTC (2, 3, 5-Triphenyltetrazolium chloride), and lesion size (mm3) and swelling (percent change in volume compared with the contralateral, uninjured side) were measured.

RESULTS:

This protocol resulted in a highly reproducible brain injury, with clinically relevant changes in blood pressure, cardiac output, tissue hypoperfusion, intracranial pressure, and brain tissue oxygenation. Compared with NS, treatment with LSP significantly ( p G 0.05) decreased brain lesion size and swelling (51% and 54%, respectively).

LSP.jpg

CONCLUSION: In a clinically realistic combined TBI + HS model, early administration of plasma products decreases brain lesion size and edema. LSP is as effective as FFP, while offering many logistic advantages. 

| Tags : tbi, coagulopathie

07/09/2013

Blast des membres

Blast-related fracture patterns: a forensic biomechanical approach

Ramasamy A. et All. J. R. Soc. Interface (2011) 8, 689–698

Dehors et dedans, ce n'est pas la même chose

blast

Les lésions dépendent du type de blast

blast

| Tags : blast

La cheville et le pied: C'est grave AUSSI

Outcomes of IED Foot and Ankle Blast Injuries

Ramasamy A et All. J Bone Joint Surg Am. 2013;95:e25(1-7)

Background: Improvements in protection and medical treatments have resulted in increasing numbers of modernwarfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome.

Methods: U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identified with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms.

Results: Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identified. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors ofamputation. At the time of final follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury,and only nine (14%) of the service members were fit to return to their preinjury duties.

Conclusions: This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rateand frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population

 

On insiste beaucoup sur la gravité des lésions des membres inférieurs car elles sont sources d'hémorragies graves. Cette gravité est aussi fonctionnelle. Les auteurs de ce document insistent sur la fréquence de l'atteinte de la cheville et du pied (plus d'une fois sur 2), sur la gravité de l'atteinte de la cheville et de l'arrière pied et de la fréquence des amputations près d'une fois sur 3

Causes de DC évitables: Actualisation UK

Identifying future ‘unexpected’ survivors: a retrospective cohort study of fatal injury patterns in victims of improvised explosive devices

 

To identify potentially fatal injury patterns in explosive blast fatalities in order to focus research and mitigation strategies, to further improve survival rates from blast trauma.

DESIGN:

Retrospective cohort study.

PARTICIPANTS:

UK military personnel killed by improvised explosive device (IED) blasts in Afghanistan, November 2007-August 2010.

SETTING:

UK military deployment, through NATO, in support of the International Security Assistance Force (ISAF) mission in Afghanistan.

DATA SOURCES:

UK military postmortem CT records, UK Joint Theatre Trauma Registry and associated incident data.

MAIN OUTCOME MEASURES:

Potentially fatal injuries attributable to IEDs.

RESULTS:

We identified 121 cases, 42 mounted (in-vehicle) and 79 dismounted (on foot), at a point of wounding. There were 354 potentially fatalinjuries in total. Leading causes of death were traumatic brain injury (50%, 62/124 fatal injuries), followed by intracavity haemorrhage (20.2%, 25/124) in the mounted group, and extremity haemorrhage (42.6%, 98/230 fatal injuries), junctional haemorrhage (22.2%, 51/230 fatal injuries) and traumatic brain injury (18.7%, 43/230 fatal injuries) in the dismounted group.

CONCLUSIONS:

Head trauma severity in both mounted and dismounted IED fatalities indicated prevention and mitigation as the most effective strategies to decrease resultant mortality. Two-thirds of dismounted fatalities had haemorrhage implicated as a cause of death that may have been anatomically amenable to prehospital intervention. One-fifth of the mounted fatalities had haemorrhagic trauma which currently could only be addressed surgically. Maintaining the drive to improve all haemostatic techniques for blast casualties, from point of wounding to definitive surgical proximal vascular control, alongside the development and application of novel haemostatic interventions could yield a significant survival benefit. Prospective studies in this field are indicated.


Cette publication est très importante car elle insiste sur l'absolue nécessité de poursuivre les efforts en vue de prévenir le trauma aussi bien en matière de protection balistique, de réduction des délais de transports pour permettre la prise en charge d'hémorragie intra-cavitaires et l'aspect fondamental d'arrêter toutes les hémorragies sur le terrain notamment pas la mise en oeuvre d'une nouvelle catégorie de garrots pour les hémorragies jonctionnelles (voir 1, 2, 3, 4, 5, 6)


Les morts par IED sont plus sévèrement atteints dans un véhicule qu'à pied.

balistique,blast,traumatologie,explosion,jonctionnel

58% des Décès sont liés à plus de 2 causes potentiellement évitables

balistique,blast,traumatologie,explosion,jonctionnel

Les causes de décès ne sont pas les mêmes en combat à pied ou en véhicule

balistique,blast,traumatologie,explosion,jonctionnel


16/07/2013

Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients

hémorragie,traumatologie

 

We recommend not to use HES with molecular weight C200 kDa and/or degree of substitution[0.4 in patients with severe sepsis or risk of acute kidney injury and suggest not to use 6% HES130/0.4 or gelatin in these populations. We recommend not to use colloids in patients with head injury and not to administer gelatins and HES in organ donors. We suggest not to use hyperoncotic solutions for fluid resuscitation. We conclude and recommend that any new colloid should be introduced into clinical practice only after its patient-important safety parameters are established. 

Accéder au consensus

Management of bleeding and coagulopathy following major trauma: an updated European guideline

hémorragie,traumatologie

Accéder aux recommandations

29/06/2013

Coagulopathie du trauma: Que faire ?

 Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient

David JS et All. Anesthesiology 2013; 119:191–200 

CoagulopathieTrauma.jpeg

Un point très clair du problème

| Tags : coagulopathie

Pneumothorax: A partir de quel volume d'air le dépiste-t-on ?

The intrapleural volume threshold for ultrasound detection of pneumothoraces: An experimental study on porcine models

Oveland NP et All. Scand J Trauma Resusc Emerg Med. 2013; 21: 11.

Pneumo.jpg

Tous les pneumothorax sont dépistés à l'échographie pour des volumes d'air de moins de 50 ml, de manière bien plus précoce que l'analyse d'une radiographie comme le montre la figure ci-dessus

| Tags : pneumothorax

Blessés thoraciques: Données UK

The UK military experience of thoracic injury in the wars in Iraq and Afghanistan

Poon H. et All. Injury. 2013 Feb 20. pii: S0020-1383(13)00073-9.

INTRODUCTION:

Thoracic injury during warfare is associated with a high incidence of morbidity and mortality. This study examines the pattern and mortality of thoracic wounding in the counter-insurgency conflicts of Iraq and Afghanistan, and outlines the operative and decision making skills required by the modern military surgeon in the deployed hospital setting to manage these injuries.

METHODS:

The UK Joint Theatre Trauma Registry was searched between 2003 and 2011 to identify all patients who sustained battle-related thoracic injuries admitted to a UK Field Hospital (Role 3). All UK soldiers, coalition forces and local civilians were included.

RESULTS:

During the study period 7856 patients were admitted because of trauma, 826 (10.5%) of whom had thoracic injury. Thoracic injury-related mortality was 118/826 (14.3%). There were no differences in gender, age, coalition status and mechanism of injury between survivors and non-survivors. Survivors had a significantly higher GCS, Revised Trauma Score and systolic blood pressure on admission to a Role 3 facility. Multivariable regression analysis identified admission systolic blood pressure less than 90, severe head or abdominal injury and cardiac arrest as independent predictors of mortality.

 

TrauThoAfgUK.jpeg.jpg

CONCLUSIONS:

Blast is the main mechanism of thoracic wounding in the recent conflicts in Iraq and Afghanistan. Thoracic trauma in association with severe head or abdominal injuries are predictors of mortality, rather than thoracic injury alone. Deploying surgeons require training in thoracic surgery in order to be able to manage patients appropriately at Role 3.

Commentaires

La plupart des traumatisés ne nécessite pas de chirurgie. Les survivants arrivent plus vite mais il ne semble pas qu'un délai un peu plus long soit associé avec une surmortalité. La gravité du traumatisme thoracique n'apparait pas être lié avec la mortalité. il existeune amélioration du pronostic rapporté à l'amélioration de la prise en charge globale.

| Tags : traumatologie, thorax

21/04/2013

Quel(s) score(s) en traumatologie de guerre ?

TraumaScoring.JPG

Clic sur l'image pour accéder à l'information

21/03/2013

Immobilisation du rachis: Dès que possible ! Surtout si VBIED

SpinalTITRE.jpeg

J Trauma Acute Care Surg. 2013;74: 1112-1118

Si l'atteinte du rachis cervical était dans les derniers conflits est de l'ordre de 1 à 2%, ce taux est monté à 5-8% dans le conflit irakien. Ceci s'explique par l'émergence d'un nouveau mécanisme d'aggression par IED. La procédure du sauvetage au combat stipule que l'imobilisation du rachis cervical ne doit pas être réalisée sous le feu direct de l'ennemi. La frequence des lésions du rachis dans les combats actuels l'impose cependant dès que blessé et sauveteurs sont à l'abri surtout si il s'agit d'un VBIED. C'est que suggère cette publication édifiante qui porte sur l'analyse des lésions du rachis cervical chez les soldats décédés. 

SpinalABSTRACT.jpeg

| Tags : rachis, balistique

03/03/2013

Réduire une luxation d'épaule antéro-interne

La méthode FARES

Il existe de nombreuses technique de réduction (voir ici). Quelques vidéos ici

1. Prendre en charge la douleur procédurale:

2934978635.jpg

2. Réaliser la manoeuvre de réduction:

The FARES method, FARES standing for "FAst, REliable and Safe (sic)", is a one-operator technique to reduce anterior shoulder dislocation. This technique utilises a new combination of mechanisms - traction, oscillation, and leverage to reduce the humeral headback to the glenoid. With the patient lying supine, the operator holds the patient's hand on the affected side while the arm is at the side, allowing elbow fully extended and the forearm in neutral position. In the original paper, no sedation or analgesic was required because comparing the pain scores of the different methods was one of the objectives in their study. Next, the operator gently applies longitudinal traction and slowly the arm is abducted. At the same time, continuous vertical oscillating movement at a rate of 2-3 "cycles" per second is applied throughout the whole reduction process. The vertical movement should be short-ranged at about 5 cm aboveand below the horizontal plane. Since passing the 90° abduction, the arm is gently externally rotated with the palm now facing upward while keeping the vertical oscillation and traction. Reduction usually occurs at 120° abduction. If reduction does not occur immediately, continue the oscillatory movement while slightly increase the traction force until reduction occurs. After successful reduction, the arm is internally rotated and adducted across the chest to bring the forearm to rest in front of the patient

Voir une vidéo

| Tags : réduction

04/02/2013

Causes de mortalité: Actualisation 2012

Death on the battlefield (2001Y2011): Implications for the future of combat casualty care

Eastridge BJ et all. J Trauma Acute Care Surg. 2012;73: S431YS437

BACKGROUND:Critical evaluation of all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among US combat fatalities, is central to identifying gaps in knowledge, training, equipment, and execution of battlefield trauma care. The impetus to produce this analysis was to develop a comprehensive perspective of battlefield death, concentrating on deaths that occurred in the preYmedical treatment facility (pre-MTF) environment.

METHODS:The Armed Forces Medical Examiner Service Mortality Surveillance Division was used to identify Operation Iraqi Freedom and Operation Enduring Freedom combat casualties from October 2001 to June 2011 who died from injury in the deployed environment. The autopsy records, perimortem records, photographs on file, and Mortality Trauma Registry of the Armed Forces Medical Examiner Service were used to compile mechanism of injury, cause of injury, medical intervention performed, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) on all lethal injuries. All data were used by the expert panel for the conduct of the potential for injury survivability assessment of this study.

RESULTS:For the study interval between October 2001 and June 2011, 4,596 battlefield fatalities were reviewed and analyzed. The stratification of mortality demonstrated that 87.3% of all injury mortality occurred in the pre-MTF environment. Of the pre-MTF deaths, 75.7% (n = 3,040) were classified as nonsurvivable, and 24.3% (n = 976) were deemed potentially survivable (PS). The injury/physiologic focus of PS acute mortality was largely associated with hemorrhage (90.9%). The site of lethal hemorrhage was truncal (67.3%), followed by junctional (19.2%) and peripheral-extremity (13.5%) hemorrhage.

CONCLUSION:Most battlefield casualties died of their injuries before ever reaching a surgeon. As most pre-MTF deaths are nonsurvivable, mitigation strategies to impact outcomes in this population need to be directed toward injury prevention. To significantly impact the outcome of combat casualties with PS injury, strategies must be developed to mitigate hemorrhage and optimize airway management or reduce the time interval between the battlefield point of injury and surgical intervention. Understanding battlefield mortality is a vital component of the military trauma system. Emphasis on this analysis should be placed on trauma system optimization, evidence-based improvements in Tactical Combat Casualty Care guidelines, data-driven research, and development to remediate gaps in care and relevant training and equipment enhancements that will increase the survivability of the fighting force. (J Trauma Acute Care Surg. 2012;73: S431YS437. Copyright * 2012 by Lippincott Williams & Wilkins

02/12/2012

Hémostase et transfusion par A. Godier IAR IDF

iar.JPG

CLIC sur le logo pour accéder au cours

| Tags : hémorragie

14/08/2012

Evasan hélico: Bien mieux avec du personnel compétent !

Impact of critical careYtrained flight paramedics on casualty survival during helicopter evacuation in the current war in Afghanistan
Mabry RL et all. J Trauma Acute Care Surg. 2012;73: S32YS37

On présente toujours les évacuations aériennes par hélicoptères conduites par les US comme très peu médicalisées du fait des compétences très limitées des combat medics habituellement embarqués.

Il faut réviser cette opinion, car outre le fait que le combat medic US peut être un vrai professionnel de l'urgence ( dès lors qu'il est EMT-P voire I, encore plus si il appartient à une unité comme le 75ème ranger ou les seals). C'est aussi le cas des médicalisations conduites par les unités qui dépendent de la garde nationale. Cette dernière semble en effet appliquer des standards civils armant ses hélicoptères d'au moins deux personnels flight medic dont l'un de niveau EMT-P, formés spécifiquement  et disposant d'une expérience professionnelle en médecine d'urgence de plus de 9 ans, et son binome de formation plus basique.

Une telle manière de procéder permet de réduire la mortalité à 48h des blessés transportés qui passe de 15% pour les blessés transportés par l'army à 8% pour les blessés transportés dans les hélicoptères de la garde nationale.

Image 5.jpg

Image 6.jpg

On voit là finalement l'esquisse d'une convergence enre nos modalités de transport de blessés, celles des anglais qui mettent en oeuvre les MERT-Enhanced et la garde nationale US.

Une exigence: Des professionnels expérimentés de l'urgence doivent être dans les vecteurs d'EVASAN, ce d'autant que les délais de transport sont longs supérieurs à 30 min.

Actualités du TCCC: Ce qui se fait sur le terrain, point 2012

 Prehospital interventions performed in a combat zone: A prospective multicenter study of 1,003 combat wounded.

Lairet JR et all. J Trauma Acute Care Surg. 2012;73: S38YS42.

Un bilan qui porte sur près de 1000 prises en charge préhospitalière. Les gestes les plus fréquemment effectués sont des gestes d'hémostase et il le sont avec efficacité. Près de 700 fiches TCCC sont remplies. 17% des blessés justifient de la pose d'au moins un garrot.

Le geste d'hémostase le plus fréquemment réalisé est la réalisation d'un pansement compressif avec packing (37% des blessés). Il est fait appel à un pansement hémostatique associé au pansement compressif et au packing dans seulement 2,3 % des cas.

L'ouverture des voies aériennes fait appel avant tout à l'emploi de canules naso/oropharyngées mais seulement dans 2,7% des cas. Une intubation est pratiquée dans 2,8% des cas et une coniotomie dans 1,5% des cas.

Les gestes de décompression thoracique restent peu fréquents. Une exsufflation n'est réalisée que dans 1,1% des cas. Le drainage thoracique reste rare (0,6% des cas). Enfin un paansement 3 côtés n'est nécessaire que dans 1,2% des cas.

La prise en charge du choc hémorragique fait appel à une réanimation hypotensive dans seulement 3,9% des blessés. Le remplissage vacsulaire est assuré en grande majorité par le salé isotonique

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La prévention de l'hypothermie fait appel avant tout à des couvertures en laine simple alors que les dispsoitifs avancés de type HPMK ne sont utilisés que dans 5,6% des cas et les couvertures aluminisés simples dans 8,5% des cas.

Une donnée majeure de cette publication est la faible performances des opérateurs concernant les manoeuvres d'ouverture des voies aériennes et de décompression thoracique alors que les manoeurves d'hémosatse sont bien conduites.

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Ce travail exprime bien le fossé qui existe entre ce qui devrait être fait et ce qui est dit être fait. Pour faire le parallèle avec le sauvetage au combat ce qui relève du SC1 est correctement réalisé ais ce qui  qui relève des gestes avancés de sauvetage du niveau SC2 est soit non fait soit réalisé de manière incorrecte.

Ce document apparaît donc devoir être compris comme un rappel au besoin de formation initiale ET continue de qualité, basée sur la pratique réelle de gestes enseignés par des tuteurs ayant l'expérience de ceux-ci et basant leur enseignement sur des faits objectifs collectés à la source dans le cadre d'un registre du sauvetage au combat.