12/12/2014
Prehospital management of chest injuries
The prehospital management of chest injuries: a consensus statement. Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh
Lee C. et AL. Emerg Med J 2007;24:220–224
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Un document un peu ancien des nos confrères britanniques mais qui reste d'actualité.
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This paper provides a guideline for the management of prehospital chest injuries after a consensus meeting held by the
Faculty of Prehospital Care, Royal College of Surgeons of Edinburgh, Edinburgh, UK, in January 2005. An overview of
the prehospital assessment, diagnosis and interventions for life threatening chest injury are discussed, with the application of
skills depending on the training, experience and competence of the individual practitioner
| Tags : thorax
30/11/2014
ATLS ? Peut être mais pas pour les seniors !
Training to Manage Ballistic Trauma
Boffard KG et Al. in Ballistic Trauma A Practical Guide
La prise en charge d'un polytraumatisé nécessite une approche très structurée et coordonnée qui fait intervenir de multiples professionnels de la médecine d'urgence. L'ATLS est un cours qui fait référence en matière de traumatologie notamment dans les pays anglo-saxons. Son apport réel est discuté notamment dans les pays qui bénéficie d'un environnement hospitalier conséquent (1, 2). L'intérêt réel de cette formation est en train de se repositionner notamment du fait de nouveaux concepts de prise en charge et l'apparition des formation en équipe par simulation en mode immersif. Le document proposé fait le point sur les démarches actuelles de formation à un tel type de prise en charge. Il présente l'ATLS comme une formation plutôt destinée aux plus jeunes, l'expertise nécessaire tant individuelle que collective devant faire appel des des enseignements beaucoup plus conséquents.
Clic sur l'image pour accéder au document
Soutien médical des interventions à risque
Tactical Medicine: A Joint Forces Field Algorithm
Waldman M et Al. Military Medicine, 179, 10:1056, 2014
Les forces de l'ordre interviennent de plus en plus dans un contexte de violence extrême qui impose la planification du soutien médical de ces opérations selon des principes militaires. Une telle approche est fait par les équipes israélienne. Le document proposé détaille l'algorithme proposé ci dessous.
clic sur l'image pour accéder au document
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
| 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
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.
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.
| 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).
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
Les lésions dépendent du type de 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.
58% des Décès sont liés à plus de 2 causes potentiellement évitables
Les causes de décès ne sont pas les mêmes en combat à pied ou en véhicule
| Tags : balistique, blast, traumatologie, explosion, jonctionnel
16/07/2013
Consensus statement of the ESICM task force on colloid volume therapy in critically ill patients
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.
| Tags : hémorragie, traumatologie
Management of bleeding and coagulopathy following major trauma: an updated European guideline
| Tags : hémorragie, traumatologie
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
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.
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.
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 ?
21/03/2013
Immobilisation du rachis: Dès que possible ! Surtout si VBIED
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.
| Tags : rachis, balistique
03/03/2013
Réduire une luxation d'épaule antéro-interne
Il existe de nombreuses technique de réduction (voir ici). Quelques vidéos ici
1. Prendre en charge la douleur procédurale:
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
| 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