27/08/2016
Interventions salvatrices: Bien sûr mais lesquelles ?
Major incident triage: A consensus based definition of the essential life-saving interventions during the definitive care phase of a major incident
Vassallo J. et Al. Injury, Int. J. Care Injured 47 (2016) 1898–190
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Plus le contexte d'intervention est difficile soit du fait de l'environnement soit du fait du danger tactique et plus le choix des nterventions médicales doit être réflechi et restreint et mis en oeuvre par uintervenant pas forcément médecin mas formé spécifiquement à la pratique d'une action nécessaire à la survie. Ce travail identiife ainsi une trentaine de conduites essentielles à un réseau de traumatisés graves. Lire aussi cet article
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Introduction: Triage is a key principle in the effective management of major incidents. The process currently relies on algorithms assigning patients to specific triage categories; there is, however, little guidance as to what these categories represent. Previously, these algorithms were validated against injury severity scores, but it is accepted now that the need for life-saving intervention is a more important outcome. However, the definition of a life-saving intervention is unclear. The aim of this study was to define what constitutes a life-saving intervention, in order to facilitate the definition of an adult priority one patient during the definitive care phase of a major incident.
Methods: We conducted a modified Delphi study, using a panel of subject matter experts drawn from the United Kingdom and Republic of South Africa with a background in Emergency Care or Major Incident Management. The study was conducted using an online survey tool, over three rounds between July and December 2013. A four point Likert scale was used to seek consensus for 50 possible interventions, with a consensus level set at 70%.
Results: 24 participants completed all three rounds of the Delphi, with 32 life-saving interventions reaching consensus.
Conclusions: This study provides a consensus definition of what constitutes a life-saving intervention in the context of an adult, priority one patient during the definitive care phase of a major incident. The definition will contribute to further research into major incident triage, specifically in terms of validation of an adult major incident triage tool.
| Results of the Delphi Process – Life-Saving Interventions. | |
| 1 | Intubation for actual airway obstruction |
| 2 | Intubation for impending airway obstruction |
| 3 | Surgical airway for airway obstruction |
| 4 | Surgical airway for impending airway obstruction |
| 5 | Needle thoracocentesis |
| 6 | Finger thoracostomy |
| 7 | Tube thoracostomy |
| 8 | Application of a chest seal (commercial/improvised) |
| 9 | Positive Pressure Ventilation for ventilatory inadequacy |
| 10 | Application of a tourniquet for haemorrhage control |
| 11 | Use of haemostatic agents for haemorrhage control |
| 12 | Insertion of an intra-osseous device for resuscitation purposes |
| 13 | Receiving uncross-matched blood |
| 14 | Receiving≥4 units of blood/blood products |
| 15 | Administration of tranexamic acid |
| 16 | Laparotomy for trauma |
| 17 | Thoracotomy for trauma |
| 18 | Pericardial window for trauma |
| 19 | Surgery to gain proximal vascular control |
| 20 | Interventional radiology for haemorrhage control |
| 21 | Application of a pelvic binder |
| 22 | ALS/ACLS protocols for a patient in a peri-arrest situation |
| 23 | ALS/ACLS protocols for a patient in cardiac arrest |
| 24 | Neurosurgery for the evacuation of an intra-cranial haematoma |
| 25 | Craniotomy |
| 26 | Burr Hole Insertion |
| 27 | Spinal nursing for a C1-3 fracture |
| 28 | Administration of a seizure-terminating medication |
| 29 | Active rewarming for initial core temp<32° celcius |
| 30 | Passive rewarming for initial core temp<32° celcius |
| 31 | Correction of low blood glucose |
| 32 | Administration of chemical antidotes |
| Tags : triage
11/08/2016
Transfusion, Thrombosis and Bleeding Management
Special Issue: Transfusion, Thrombosis and Bleeding Management
January 2015 - Volume 70, Issue Supplement s1 - Pages 1–e41
1365-2044/asset/olbannerleft.gif?v=1&s=bd83df57543a1d11ffc15f630bb1301f0be80859)
Clic sur l'image pour accéder au numéro en ligne
Blood – the most important humour? (pages 1–e1)
C. R. Bailey, A. A. Klein and B. J. Hunt
Version of Record online: 1 DEC 2014 | DOI: 10.1111/anae.12930
Review Articles
L. Green, S. Allard and R. Cardigan
☛ CPD available at http://www.learnataagbi.org
Corrected by:
Corrigendum: Modern banking, collection, compatibility testing and storage of blood and blood components
Vol. 70, Issue 3, 373, Version of Record online: 11 FEB 2015
Evidence and triggers for the transfusion of blood and blood products (pages 10–e3)
A. Shah, S. J. Stanworth and S. McKechnie
Pre-operative anaemia (pages 20–e8)
B. Clevenger and T. Richards
The pathophysiology and consequences of red blood cell storage (pages 29–e12)
D. Orlov and K. Karkouti
Red cell transfusion and the immune system (pages 38–e16)
S. Hart, C. M. Cserti-Gazdewich and S. A. McCluskey
The current place of aprotinin in the management of bleeding (pages 46–e17)
D. Royston
The current place of tranexamic acid in the management of bleeding (pages 50–e18)
B. J. Hunt
Practical management of major blood loss (pages 54–e20)
R. Gill
Management of peri-operative anti-thrombotic therapy (pages 58–e23)
J. J. van Veen and M. Makris
Laboratory monitoring of haemostasis (pages 68–e24)
A. Fowler and D. J. Perry
Point-of-care monitoring of haemostasis (pages 73–e26)
S. V. Mallett and M. Armstrong
Haemostatic management of obstetric haemorrhage (pages 78–e28)
R. E. Collis and P. W. Collins
Haemostatic management of cardiac surgical haemorrhage (pages 87–e31)
M. W. Besser, E. Ortmann and A. A. Klein
The pathogenesis of traumatic coagulopathy (pages 96–e34)
A. Cap and B. J. Hunt
Management of traumatic haemorrhage – the European perspective (pages 102–e37)
H. Schöchl, W. Voelckel and C. J. Schlimp
Management of traumatic haemorrhage – the US perspective (pages 108–e38)
R. P. Dutton
Surgery in patients with inherited bleeding disorders (pages 112–e40)
P. K. Mensah and R. Gooding
The management of abnormal haemostasis in the ICU (pages 121–e41)
A. Retter and N. A. Barrett
13/06/2016
Trauma Center: Formateur pour la guerre ?
Skill sets and competencies for the modern military surgeon: Lessons from UK military operations in Southern Afghanistan
Ramassamy A. et Al. Injury. 2010 May;41(5):453-9.
Introduction:
British military forces remain heavily committed on combat operations overseas.UK military operations in Afghanistan (Operation HERRICK) are currently supported by a surgical facility at Camp Bastion, in Helmand Province,in the south of the country. There have been no large published series of surgical workload on Operation HERRICK. The aim of this study is to evaluate this information in order to determine the appropriate skill set for the modern military surgical team.
Method:
A retrospective analysis of operating theatre records between 1st May 2006 and 1st May 2008 was performed. Data was collated on a monthly basis and included patient demographics, operation type and time of operation.
Results:
During the study period 1668 cases required 2210 procedures. Thirty-two per cent were coalition forces (ISAF),27% were Afghan security forces (ANSF)and 39% were civilians. Paediatric casualties accounted for 14.7% of all cases. Ninety-three per cent of cases were secondary to battle injury and of these 51.3% were emergencies. The breakdown of procedures,by specialty, was 66% (1463) orthopaedic, 21% (465) general surgery, 6% (139) head and neck, 5% (104) burns surgery and a further (50) non-battle, non-emergency procedures. There was an almost twofold increase in surgical workload in the second year (1103 cases) compared to the first year of the deployment (565 caps e<s ,0.05).
Discussion:
Surgical workload over the study period has clearly increased markedly since the initial deployment of ISAF forces to Helmand Province. A 6-week deployment to Helmand Province currently provides an equivalent exposure to penetrating trauma as 3 years trauma experience in the UK NHS. The spectrum of injuries seen and the requisite skill set that the military surgeon must possess is outside that usually employed within the NHS. A number of different strategies; including the deployment of trainee specialist registrars to combat hospitals, more focused pre-deploymentmilitary surgery training courses, and wet-laboratory work are proposed to prepare for future generations of surgeons operating in conflict environments
12/04/2016
Plaies crâniennes: Un avenir est possible !
Long-term outcomes of combat casualties sustaining penetrating traumatic brain injury
Weisbrod AB et Al. J Trauma Acute Care Surg. 2012;73: 1525-1530
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Une prise en charge agressive globale des traumatismes cranio-cérébraux permet le retour à une indépendance fonctionnelle. Leur prise en charge doit donc être parfaite dès la prise en charge et la prévention des acsos un leitmotiv.
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BACKGROUND:
Previous studies have documented short-term functional outcomes for patients sustaining penetrating brain injuries (PBIs). However, little is known regarding the long-term functional outcome in this patient population. Therefore, we sought to describe the long-term functional outcomes of combat casualties sustaining PBI.
METHODS:
Prospective data were collected from 2,443 patients admitted to a single military institution during an 8-year period from 2003 to 2011. PBI was identified in 137 patients and constitute the study cohort. Patients were stratified by age, Injury Severity Score (ISS) and admission Glasgow Coma Scale (aGCS) score. Glasgow Outcome Scale (GOS) scores were calculated at discharge, 6 months, 1 year and 2 years. Patients with a GOS score of 4 or greater were considered to have attained functional independence (FI).
RESULTS:
The mean (SD) age of the cohort was 25 (7) years, mean (SD) ISS was 28 (9), and mean (SD) aGCS score was 8.8 (4.0). PBI mechanisms included gunshot wounds (31%) and blast injuries (69%). Invasive intracranial monitoring was used in 80% of patients, and 86.9% of the study cohort underwent neurosurgical intervention. Complications included cerebrospinal fluid leak (8.3%), venous thromboembolic events (15.3%), meningitis (24.8%), systemic infection (27.0%), and mortality (5.8%). The cohort was stratified by aGCS score and showed significant improvement in functional status when mean discharge GOS score was compared with mean GOS score at 2 years. For those with aGCS score of 3 to 5 (2.3 [0.9] vs. 2.9 [1.4], p G 0.01), 32% progressed to FI. For those with aGCS score of 6 to 8 (3.1 [0.7] vs. 4.0 [1.2], p G 0.0001), 63% progressed to FI. For those with aGCS score of 9 to 11 (3.3 [0.5] vs. 4.3 [0.8], p G 0.0001), 74% progressed to FI. For those with aGCS score of 12 to 15 (3.9 [0.7] vs. 4.8 [0.4], p G 0.00001), 100% progressed to FI.
CONCLUSION: Combat casualties with PBI demonstrated significant improvement in functional status up to 2 years from discharge, and a large proportion of patients sustaining severe PBI attained FI.
| Tags : crâne
Sauvetage au combat: Connaître et appliquer la procédure
Preventable deaths in trauma patients associated with non adherence to management guidelines
Marson CA et Al. Rev Bras Ter Intensiva. 2010; 22(3):220-228
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Connaître, maîtriser chacune des composantes d'une procédure et les mettre en oeuvre est un facteur de survie des blessés. Le respect de la procédure du sauvetage au combat apparait fondamental. Il est nécessaire de le rappeler.
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Objectives: To evaluate patients treated for traumatic injuries and to identify adherence to guidelines recommendations of treatment and association with death. The recommendations adopted were defined by the committee on trauma of the American College of Surgeons in advanced trauma life support.
Methods: Retrospective cohort study conducted at a teaching hospital. The study population was victims of trauma ≥ 12 years of age with injury severity scores ≥ 16 who were treated between January 1997 and December 2001. Data collection was divided into three phases: pre-hospital, in-hospital, and post-mortem. The data collected were analyzed using EPI INFO.
Results: We analyzed 207 patients, 147 blunt trauma victims (71%) and 60 (29%) penetrating trauma victims. Trauma victims had a 40.1% mortality rate. We identified 221 non adherence events that occurred in 137 patients. We found a mean of 1.61 non adherence per patient, and it occurred less frequently in survivors (1.4) than in non-survivors (1.9; p=0.033). According to the trauma score and injury severity score methodology, 54.2% of deaths were considered potentially preventable. Non adherence occurred 1.77 times more frequently in those considered potentially preventable deaths compared to other non-survivors (95% CI: 1.12–2.77; p=0.012), and 92.9% of the multiple non adherence occurred in the first group (p=0.029).
Conclusions: Non adherence occurred more frequently in patients with potentially preventable deaths. Non adherence to guidelines recommendations can be considered a contributing factor to death in trauma victims and can lead to an increase in the number of potentially preventable deaths.
| Tags : procedure evdg
30/01/2016
Retex 13/11/2015
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28/01/2016
TXA: Interrogations
Les études CRASH2 et MATTERS ont mis en évidence l'intérêt de l'emploi du TXA en traumatologie grave.
Il s'agit d'un dérivé de la lysine qui agit en se liant au plasminogène bloquant ainsi l'interaction plasminogène-fibrine, donc la fibrinolyse du caillot. Le TXA franchit la barrière sang-cerveau, diffuse dans le LCR et le globe oculaire
Persistent malgré tout quelques interrogations en matière d'innocuité persistent. Si l'étude crash2 n' pas montré de risque thromboembolique majeurs, ce n'est pas le cas d' l'étude MATTERS avec environ 10 fois plus d'épisodes thrombo-emboliques en cas d'usage de TXA. Par ailleurs il est rapporté un risque d'hypotension lors de l'administration rapide de TXA et de convulsions lors de l'emploi de posologies élevées. Ceci ne remet pas en cause le recours précoce au TXA dont l'emploi ne doit pas être banalisé et respecter un certain nombre de règles: probabilité forte de coagulopathie traumatique notamment attesté par une hypotension sévère , 1ère dose le plus tôt possible (au mieux dans la première heure) et pas après 3h, deuxième dose dans les 08h00, administration lente pour éviter hypotension, pas de surdosage facteur de crises convulsives, ne pas administrer en même temps/même ligne que du PLYO.
Un certain nombre d'études complémentaires sont en cours:
1. L'étude "Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage" a pour objectif d'affiner notre connaissance de l'emploi du TXA.
2.L'étude "Design of the Study of Tranexamic Acid during Air Medical Prehospital Transport (STAAMP) Trial: Addressing the Knowledge Gaps" a pour objet d'étuider la mortalité à 30 jours de traumatisés sévères pris en charge par medevac héliportées.
3. L'étude "Tranexamic Acid Mechanisms and Pharmacokinetics In Traumatic Injury (TAMPITI Trial)" vise quand à elle à confirmer un certain nombre d'hypothèses sur le mécanisme d'action.
Par ailleurs, le TXA n'est pas le seul antifibrinolyique utilisable.
| Tags : coagulopathie
23/01/2016
Maîtriser l'airway +++, entre autres
Augmentation of point of injury care: Reducing battlefield
mortality—The IDF experience
Benov A. et Al. Injury. 2015 Nov 18. pii: S0020-1383(15)00697-X. doi: 10.1016/j.injury.2015.10.078.
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Une publication particulièrement intéressante car elle émane de collègues militaires qui interviennent dans un contexte très particulier de prise en charge de blessés tels qu'on peut les rencontrer en opérations extérieures mai dans un contexte de réseau de traumatologie civile puisque que les hôpitaux de recueil de ces blessés sont les hôpitaux civils. Les données présentées ne portent que sur la prise en charge de combattants.
Un des points analysé est la performance des équipes dans certains gestes considérés comme essentiel, notamment la gestion des voies aériennes. Comme dans l'armée française l'intubation orotrachéale et la criciothyrotomie représentent les deux procédures mises en oeuvre par des médecins. Manifestement, il existe une grande maîtrise de la coniotomie alors que celle de l'Intubation est moins évidente: 41% de succès et une moyenne de 2 tentatives. Ceci reste problématique lorsque la prise en charge des blessés se fait loin d'un trauma center et qu'il faut envisager la gestion de ces voies aériennes et l'initiation d'une ventilation pendant plusieurs heures (jours ?). Pour ces raisons et même si la probabilité d'être confronté à une telle situation est faible, ce travail rapporte les 2/3 des blessés ne sont pas urgent et que 5% seulement des nécessitent un geste sur les voies aériennes, il s'agit d'un point fondamental en matière de réduction de morts indues.
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STUDY OBJECTIVE:
In 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled "My Brother's Keeper" was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical carehas evolved due "My Brother's Keeper" between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014).
METHODS:
Records of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis.
RESULTS:
The plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively.
CONCLUSIONS:
Significant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.
| Tags : airway
ATLS: pas de plue value pour la catastrophe
Triage performance of Swedish physicians using the ATLS algorithm in a simulated mass casualty incident: a prospective cross-sectional survey
Lampi et al.Scand J Trauma Resusc Emerg Med. 2013; 21: 90.
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On revient une fois de plus sur l'intérêt relativement limité de l'apport de l'ATLS dans un système de santé avancé. L'émergence de nouvelles modalités d'enseignement en ligne, l'introduction de la simulation médicale, le contenu relativement basique souvent non en phase avec les pratiques médicales du moment et un modèle économique qui interpelle font que l'on doit se poser la question de sa pertinence. Cet article exprime que cet apport n'est pas prouvé en médecine de catastrophe, du moins sur un aspect important qu'est l'emploi de la mnémonique ABCDE.
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Background: In a mass casualty situation, medical personnel must rapidly assess and prioritize patients for treatment and transport. Triage is an important tool for medical management in disaster situations. Lack of common international and Swedish triage guidelines could lead to confusion. Attending the Advanced Trauma Life Support (ATLS) provider course is becoming compulsory in the northern part of Europe. The aim of the ATLS guidelines is provision of effective management of single critically injured patients, not mass casualties incidents. However, the use of the ABCDE algorithms from ATLS, has been proposed to be valuable, even in a disaster environment. The objective for this study was to determine whether the mnemonic ABCDE as instructed in the ATLS provider course, affects the ability of Swedish physician’s to correctly triage patients in a simulated mass casualty incident.
Methods: The study group included 169 ATLS provider students from 10 courses and course sites in Sweden; 153 students filled in an anonymous test just before the course and just after the course. The tests contained 3 questions based on overall priority. The assignment was to triage 15 hypothetical patients who had been involved in a bus crash. Triage was performed according to the ABCDE algorithm. In the triage, the ATLS students used a colour-coded algorithm with red for priority 1, yellow for priority 2, green for priority 3 and black for dead. The students were instructed to identify and prioritize 3 of the most critically injured patients, who should be the first to leave the scene. The same test was used before and after the course.
Results: The triage section of the test was completed by 142 of the 169 participants both before and after the course. The results indicate that there was no significant difference in triage knowledge among Swedish physicians who attended the ATLS provider course. The results also showed that Swedish physicians have little experience of real mass casualty incidents and exercises.
Conclusion: The mnemonic ABCDE doesn’t significantly affect the ability of triage among Swedish physicians. Actions to increase Swedish physicians’ knowledge of triage, within the ATLS context or separately, are warranted
12/01/2016
Dexamethasone: Hémostatique cérébral ?
Steroid-loaded Hemostatic Nanoparticles Alleviate Injury Progression after Blast Trauma
Hubbard WD et Al.. ACS Macro Lett., 2015, 4 (4), pp 387–391
The purpose of this study was to investigate whether hemostatic dexamethasone-loaded nanoparticles (hDNP) functionalized with a peptide that binds with activated platelets could reduce cellular injury and improve functional outcomes in a model of blast trauma. Functionalized nanoparticles, or synthetic platelets, offer a wide variety of benefits and advantages compared to alternatives, such as increased biocompatibility and targeting of the injury site (DePalma, 2005). Blood loss is the primary cause of death at acute time points post injury in both civilian and battlefield traumas. Currently, there is a shortage in treatments for internal bleeding, especially for rapid administration in open field combat. In a recent U.K. study, less than fifty percent of soldiers diagnosed with primary blast lung injury (PBLI), the most common fatal blast injury, survived to reach a medical facility (Smith, 2011). This study examines potential therapeutic effects of hDNP on subacute recovery in brain pathology and behavior after blast polytrauma. An established polytrauma model that simulates severe injury, including PBLI and blast-induced neurotrauma (BINT), can be used to evaluate life-saving therapeutics (Hubbard, 2014). Poly(lactic-co-glycolic acid)-based nanoparticles with poly(ethylene glycol) arms and the arginine-glycine-aspartic acid (RGD) peptide to target activated platelets were fabricated. A blast-induced polytrauma rodent model was used to evaluate the functionalized nanoparticles at an acute stage. After anesthesia, Male Sprague Dawley rats were exposed to a single, representative “free field” blast wave from an Advanced Blast Simulator at Virginia Tech at a peak overpressure of 28 psi for 2.5 ms duration, operating above 50% lethality risk, in a sidethorax orientation (Hubbard, 2014). After injury, animals were immediately injected intravenously with hDNP, control dexamethasone-loaded nanoparticles (cDNP), or lactated ringers (LR) and physiological parameters were monitored. Sham animals were not injected or exposed to the blast wave. Open field assays were performed on surviving animals to measure levels of anxiety. At one week post-blast, brains were extracted and sections from the amygdala were obtained for immunofluorescent staining using glial fibrillary acidic protein (GFAP; activated astrocytes), cleaved caspase-3 (apoptosis), and SMI-71 (blood-brain barrier). According to physiological monitoring immediately after blast, oxygen saturation was significantly decreased in the control and LR groups compared to the active and sham groups. Using the open field test, elevated anxiety parameters were found in the control and LR groups compared to the hDNP group. GFAP was significantly elevated in the control group compared to the hDNP and sham groups in the amygdala. Caspase-3 was also significantly elevated in the control group compared to the hDNP group. SMI-71 was significantly reduced in the LR group compared to the sham group. hDNP treatment has the potential to assist recovery after internal hemorrhage. Immediate intervention to assuage hemorrhage, one source for injury pathology, is crucial to mitigate debilitating injury mechanisms that lead to cognitive and emotional deficits (Shetty, 2014).
It is possible that through prevention of microhemorrhaging of the blood-brain barrier (BBB), hDNP was able to mitigate cellular injury and improve cognitive outcomes. Future studies will evaluate the effect on inflammatory and hypoxia-related proteins after hDNP administration post-trauma.
| Tags : blast, hémorragie
Prédire le besoin transfusionnel tôt ?
Automated analysis of vital signs to identify patients with substantial bleeding before hospital arrival: a feasibility study
Liu J et Al. Shock. 2015 May;43(5):429-36.
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Dépister un saignement significatif à partir des éléments standards de monitorage préhospitalier serait possible à en croire cet article. Il existe actuellement un grand nombre de recherche dans ce domaine. A suivre.
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Trauma outcomes are improved by protocols for substantial bleeding, typically activated after physician evaluation at a hospital. Previous analysis suggested that prehospital vital signs contained patterns indicating the presence or absence of substantial bleeding. In an observational study of adults (aged Q18 years) transported to level I trauma centers by helicopter, we investigated the diagnostic performance of the Automated Processing of the Physiological Registry for Assessment of Injury Severity (APPRAISE) system, a computational platform for real-time analysis of vital signs, for identification of substantial bleeding in trauma patients with explicitly hemorrhagic injuries. We studied 209 subjects prospectively and 646 retrospectively. In our multivariate analysis, prospective performance was not significantly different from retrospective.
The APPRAISE system was 76% sensitive for 24-h packed red blood cells of 9 or more units (95% confidence interval, 59% Y 89%) and significantly more sensitive (P G 0.05) than any prehospital Shock Index of 1.4 or higher; sensitivity, 59%; initial systolic blood pressure (SBP) less than 110 mmHg, 50%; and any prehospital SBP less than 90 mmHg, 50%. The APPRAISE specificity for 24-h packed red blood cells of 0 units was 87% (88% for any Shock Index Q1.4, 88% for initial SBP G110 mmHg, and 90% for any prehospital SBP G90 mmHg). Median APPRAISE hemorrhage notification time was 20 min before arrival at the trauma center. In conclusion, APPRAISE identified bleeding before trauma center arrival. En route, this capability could allow medics to focus on direct patient care rather than the monitor and, via advance radio notification, could expedite hospital interventions for patients with substantial blood loss.
09/01/2016
Le consensus d'hartford
Les événements récents ont mis en évidence l'importance de l'organisation des soins en cas d'attentats multisites notamment par armes de guerre. Le consensus d'Hartford est une démarche majeure conduite par nos alliés américains sur la survenue de telles situations. Très globalement il s'agit d'une chaîne de survie à mettre en place, ou bien sûr les professionnels de santé ont leur place mais aussi et surtout le citoyen et les forces de l'ordre. L'acronyme THREAT réssume la démarche: T pour Threat Suppression, H pour Hemorrage Control, RE pour Rapid Extrication to safety, A pour Assessment by medical provider, T pour transport to definitive care.
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1/1/1 ou 1/1/2 ?
Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial
Holcomb JB et All. JAMA Surg. 2013 Feb;148(2):127-36
______________________________
La reconnaissance et la mise en place de la meilleure stratégie thérapeutique du choc hémorragique traumatique sont des enjeux fondamentaux qui se posent aux équipes de réanimation préhospitalières et hospitalières. L'application du concepts du damage control resuscitation (1) vise par la mise en place d'un stratégie raisonnée d'arrêt des hémorragies (2), d'un remplissage vasculaire mesuré (3) et d'une politique transfusionnelle spécifique (4). Parmi ces mesures, il apparaît important de garantir l'apport équilibré de plasma, de plaquettes et de CGR dans un ration élevé 1/1/1 ou 1/1/2. Deux études se sont attachées à ce point: L'étude PROMMTT et l'étude PROPPR ici présentée. La première confirme le bénéfice d'une telle stratégie avec une moindre mortalité chez les patients bénéficiant de rapport élevé supérieur mais uniquement dans les 6 premières heures. L'étude PROPPR semble confirmer ces données avec une moindre mortalité précoce par hémorragie mais ne réussit pas à confirmer l'intérêt d'un ratio 1/1/1 par rapport à un ratio 1/1/2 sur la mortalité à long terme.
______________________________
IMPORTANCE:
Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials.
OBJECTIVE:
To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio.
DESIGN, SETTING, AND PARTICIPANTS:
Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013.
INTERVENTIONS:
Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled).
MAIN OUTCOMES AND MEASURES:
Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status.
RESULTS:
No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.
CONCLUSIONS AND RELEVANCE:
Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.
| Tags : hémorragie
19/12/2015
Military medicine in the 21st
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Amputé des jambes: Le bassin aussi !
The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices
Cross AM et Al. J R Nav Med Serv 2014;100(2):152-6
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Excepté l'extraction d'urgence de blessés sous le feu, la prise en charge den cas d'amputation traumatique doit inclure la forte probabilité de traumatisme du bassin. Une utilisation large des immobilisations pelviennes doit donc être à l'esprit. On rappelle simplement la gravité et la difficulté de prise en charge des hémorragies liées aux fractures de bassin.
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AIMS:
A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.
METHODS:
A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.
RESULTS:
Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n = 31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n = 46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n = 28) the incidence of pelvic fracture was 39%.
CONCLUSIONS:
The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group
| Tags : hémorragie, immobilisation, blast
17/12/2015
Médicaliser: Pour faire quoi ?
Doctor on board ? What is the optimal skill-mix in military pre-hospital care ?
Calderbank P. et Al. Emerg Med J (2010). doi:10.1136/emj.2010.097642
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Le document proposé à la lecture porte sur l'intérêt de la présence d'un médecin dans la plus avancée des structures medevac qui existe actuellement: Les MERT-E des anglais. Seule 1 medevac sur 5 justifiait la présence d'un médecin. L'intervention la plus fréquemment réalisée a été l'intubation/induction en séquence rapide. Bien loin devant d'autres gestes comme la thoracostomie ou le drainage thoracique. Ceci étant dit ce constat est fait dans un contexte spécifique afghan qui ne correspond pas aux opérations actuelles où les délais de prise en charge chirurgicales peuvent être long. Cette pratique est donc essentielle à maîtriser et procède d'une véritable stratégie de formation, avec une rythmicité semestrielle, débutée dès la formation initiale, associant un parcours structuré de mises à jour technique personnelle (passage en bloc opératoire, participation à des ateliers sur simulateurs de taches) et collective. Il s'agit d'un exemple parmi d'autres où une implication personnelle forte doit être présente.
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Background
In a military setting, pre-hospital times may be extended due to geographical or operational issues. Helicopter casevac enables patients to be transported expediently across all terrains. The skill-mix of the prehospital team can vary. Aim To quantify the doctors’ contribution to the Medical Emergency Response TeameEnhanced (MERT-E).
Methods
A prospective log of missions recorded urgency category, patient nationality, mechanism of injury, medical interventions and whether, in the crew’s opinion, the presence of the doctor made a positive contribution.
Results
Between July and November 2008, MERT-E flew 324 missions for 429 patients. 56% of patients carried were local nationals, 35% were UK forces. 22% of patients were T1, 52% were T2, 21.5% were T3 and 4% were dead. 48% patients had blast injuries, 25% had gunshot wounds, 6 patients had been exposed to blast and gunshot wounds. Median time from take-off to ED arrival was 44 min. A doctor flew on 88% of missions. It was thought that a doctor’s presence was not clinically beneficial in 77% of missions. There were 62 recorded physician’s interventions: the most common intervention was rapid sequence induction (45%); other interventions included provision of analgesia, sedation or blood products (34%), chest drain or thoracostomy (5%), and pronouncing life extinct (6%).
Conclusion
MERT-E is a high value asset which makes an important contribution to patient care. A relatively small proportion of missions require interventions beyond the capability of well-trained military paramedics; the indirect benefits of a physician are more difficult to quantify.
| Tags : airway
13/11/2015
Demain: Quels enjeux ?
09/11/2015
Plaie cérébrale et coagulopathie
Quelques faits
1. Elle est fréquente voire très fréquente: Greuters et al. Critical Care 2011 15:R2 doi:10.1186/cc9399
2. Elle est + fréquente en cas d'hypoTA: Wafaisade Neurocrit Care. 2010 Apr;12(2):211-9
3. Elle est de mauvais pronostic: J Emerg Trauma Shock. 2013 Jul-Sep; 6(3): 180–185
4. Elle est mise en évidence plutôt par thromboélastographie (r TEG) : Sixta al., J Neurol Neurophysiol 2014, 6:5
| Tags : coagulopathie
08/11/2015
Damage Control: Vraiment bénéfique
Changing Patterns of In-Hospital Deaths Following Implementation of Damage Control Resuscitation Practices in US Forward Military Treatment Facilities
Langan NR et Al. JAMA Surg. 2014;149(9):904-912
Importance
Analysis of combat deaths provides invaluable epidemiologic and quality-improvement data for trauma centers and is particularly important under rapidly evolving battlefield conditions.
Objective
To analyze the evolution of injury patterns, early care, and resuscitation among patients who subsequently died in the hospital, before and after implementation of damage control resuscitation (DCR) policies.
Design, Setting, and participants
In a review of the Joint Theater Trauma Registry (2002-2011) of US forward combat hospitals, cohorts of patients with vital signs at presentation and subsequent in-hospital death were grouped into 2 time periods: pre-DCR (before 2006) and DCR (2006-2011).
Main outcomes and measures
Injury types and Injury Severity Scores (ISSs), timing and location of death, and initial (24-hour) and total volume of blood products and fluid administered.
Results
Of 57 179 soldiers admitted to a forward combat hospital, 2565 (4.5%) subsequently died in the hospital. The majority of patients (74%) were severely injured (ISS > 15), and 80% died within 24 hours of admission. Damage control resuscitation policies were widely implemented by 2006 and resulted in a decrease in mean 24-hour crystalloid infusion volume (6.1-3.2 L) and increased fresh frozen plasma use (3.2-10.1 U) (both P < .05) in this population. The mean packed red blood cells to fresh frozen plasma ratio changed from 2.6:1 during the pre-DCR period to 1.4:1 during the DCR period (P < .01). There was a significant increase in mean ISS between cohorts (pre-DCR ISS = 23 vs DCR ISS = 27; P < .05) and a marked shift in injury patterns favoring more severe head trauma in the DCR cohort.
Conclusions and relevance
There has been a significant shift in resuscitation practices in forward combat hospitals indicating widespread military adoption of DCR. Patients who died in a hospital during the DCR period were more likely to be severely injured and have a severe brain injury, consistent with a decrease in deaths among potentially salvageable patients
| Tags : remplissage
06/11/2015
Prolonged field Care: Novateur ? Pas vraiment
Prolonged Field Care Working Group Position Paper Prolonged Field Care Capabilities
Bal JA et All. J Spec Oper Med. 2015 Fall;15(3):78-80
Le concept du TCCC, issu de l'analyse des décès au combat lors de la guerre de Somalie, a vu toute sa pertinence prouvée en afghanistan. Des gestes simples réalisés par des soldats et des combat medic ont permis d'éviter le décès de nombre de soldats. Ces derniers étaient alors évacués rapidement vers des structures chirurgicales. Le concept afghan permettait cela.
Ce n'est pas le cas des conflits actuels, conflits pendant lesquels le combattant blessé doit se voir appliquer pendant plusieurs heures une démarche de prise en charge (remplissage, analgésie, nursing,..) très proche de la réanimation préhospitalière. C'est bien compte tenu de l'absence de médecins et donc de connaissances en la matière que cette pratique de prise en charge est considérée par nos collègues US comme nouvelle. Ce concept ne doit donc pas probablement être considéré comme novateur pour nous car il s'agit d'une démarche de convergence d'une pratique anglo-saxonne vers notre médicalisation de l'avant.