Rachis: Immobilisation et plaies cervicales par balle

Unstable Cervical Spine Fracture After Penetrating Neck Injury: A Rare Entity in an Analysis of 1,069 Patients

Lustenberger T. et All.
JTrauma. 2011;70:870–872

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En gros pas besoin de mettre en place une minerve en cas de plaie du cou sauf si le blessé est incosncient ou présente des signes neurologiques périphériques.

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Background: The value of cervical spine immobilization after penetrating trauma to the neck is the subject of lively debate. The purpose of this study was to review the epidemiology of unstable cervical spine injuries (CSI) after penetrating neck trauma in a large cohort of patients.

Methods: This is a retrospective analysis of patients admitted with penetrating neck injuries to a Level I trauma center from January 1996 through December 2008. A penetrating neck injury was defined as a gunshot wound (GSW) or stab wound (SW) between the clavicles and the base of the skull. Univariate and multivariate analyses were performed to investigate associations between injury mechanisms, the presence of CSI instability, and mortality. Risk factors independently associated with the presence of a CSI were identified.

Results: A total of 1,069 patients met inclusion criteria, of which 463 patients (43.3%) and 606 patients (56.7%) were sustaining GSW and SW, respectively. Overall, 65 patients (6.1%) were diagnosed with a CSI with a significantly higher incidence after GSWs compared with SWs (12.1% vs. 1.5%; p < 0.001). In four patients (0.4%), the CSI was considered unstable, all of them following GSW. All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of admission. Risk factors independently associated with the presence of a CSI were GSW to the neck and a Glasgow Coma Scale score.

Conclusion: The overall incidence of unstable CSI after penetrating trauma to the neck is exceedingly low at 0.4%. Following GSW to the neck, an unstable CSI was noted in

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Détail de la publication:

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In four patients (0.4%), the CSI was considered unstable, all of them after GSW to the neck (0.9% for GSW vs. 0% for SW; p = 0.035). All patients with unstable CSI had obvious neurologic deficits or altered mental status at the time of initial presentation: two patients presented with tetraplegia and two patients had a GCS score of 3 on admission with subsequent brain death during their SICU stay. Stabilization of the spine was performed in both patients with tetraplegia but was without significant neurologic recovery after surgery.

 

 

Syndrome compartimental du globe oculaire

Les syndromes compartimentaux peuvent tuer. On pense bien sûr au syndrome des loges, au syndrome compartimental abdominal. On peut en rapprocher la tamponnade cardiaque, le pneumothorax compressif et les hypertensions intracrâniennes. Il est moins naturel de penser au syndrome compartimental orbitaire. Pourtant un geste simple permet de réduire ce risque lors de trauma de la face, c'est la cantholyse externe.

 

Voici en quelques schémas comment la réaliser.

 

En réalisant ce geste simple, vous soulagez la pression intraorbitaire et améliorer  la perfusion rétinienne.

Hydroxyethylamidon: Attention !

Cette revue de littérature rappelle quelques données essentielles sur l'emploi des HEA pour le remplissage vasculaire. Il en ressort que le bien fondé de cette pratique n'est pas validé y compris pour les HEA de 3ème génération 130/0,4 dont fait partie le voluven pourtant les moins sujets à complications. Ces dernières sont repréesntées par le risque d'insuffisance rénale, la tendance au saignement et une tendance à l'augmentation de la mortalité. Il n'est pas sans intérêt de faire remarquer que l'HYPERHES est un soluté contennat un HEA de type 2005.

Première lecture

REVIEW ARTICLE
The Efficacy and Safety of Colloid Resuscitation in the Critically Ill
Christiane S. Hartog, MD, Michael Bauer, MD, and Konrad Reinhart, MD

(Anesth Analg 2011;112:156 –64)

      Despite evidence from clinical studies and meta-analyses that resuscitation with colloids or crystalloids is equally effective in critically ill patients, and despite reports from high-quality clinical trials and meta-analyses regarding nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of hydroxyethyl starch (HES) solutions, colloids remain popular and the use of HES solutions is increasing worldwide. We investigated the major rationales for colloid use, namely that colloids are more effective plasma expanders than crystalloids, that synthetic colloids are as safe as albumin, that HES solutions have the best risk/benefit profile among the synthetic colloids, and that the third-generation HES 130/0.4 has fewer adverse effects than older starches. Evidence from clinical studies shows that comparable resuscitation is achieved with considerably less crystalloid volumes than frequently suggested, namely, 2-fold the volume of colloids. Albumin is safe in intensive care unit patients except in patients with closed head injury. All synthetic colloids, namely, dextran, gelatin, and HES have dose-related side effects, which are coagulopathy, renal failure, and tissue storage. In patients with severe sepsis, higher doses of HES may be associated with excess mortality. The assumption that third-generation HES 130/0.4 has fewer adverse effects is yet unproven. Clinical trials on HES 130/0.4 have notable shortcomings. Mostly, they were not performed in intensive care unit or emergency department patients, had short observation periods of 24 to 48 hours, used cumulative doses below 1 daily dose limit (50 mL/kg), and used unsuitable control fluids such as other HES solutions or gelatins. In conclusion, the preferred use of colloidal solutions for resuscitation of patients with acute hypovolemia is based on rationales that are not supported by clinical evidence. Synthetic colloids are not superior in critically ill adults and children but must be considered harmful depending on the cumulative dose administered. Safe threshold doses need to be determine in studies in high-risk patients and observation periods of 90 days. Such studies on HES 130/0.4 are still lacking despite its widespread and increasing use. Because there are safer and
equally effective alternatives in the form of crystalloids, use of synthetic colloids should be avoided except in the context of clinical studies.

Seconde lecture

La Société Française d'anesthésie-réanimation rappelle d'ailleurs également ce risque hémorragique y compris pour les HEA 10/0,4 notamment lors d'adminsitration aiguë.

"

L’albumine, les gélatines et l’amidon 130 000/0,4 (Voluven®) n’interfèrent pas, ou quasiment pas avec l’hémostase. La prudence reste toutefois conseillée :
- chez les patients insuffisants rénaux
- en cas de perfusion prolongée ou de volume de colloïdes important ;
- en cas de troubles de l’hémostase acquis ;
- chez les patients traités par antiplaquettaires ou anticoagulants ;
 - en présence d’une anémie ou thrombopénie profonde ;
- chez les patients porteurs d’une maladie de Willebrand ;
- chez les patients de groupe sanguin O (ces patients ont spontanément un taux de Willebrand plus bas) ;
- en présence d’un saignement chirurgical actif ;
- en présence d’une transfusion massive ou d’une hypothermie.

Comentaires

Ainsi les effets secondaires des HEA ne sont pas que liés à eur adminsitration répétitive. Dans nos conditions d'emploi , il apparait nécessaire d'observer une certaine retenue dans ll'usage des HEA. Ceci plaide pour l'utilisation des solutés cristalloïdes tel que le Ringer lactate, le sérum salé hypertonique et pose la question d'un recours plus large au gélatines fluides modifiées malgré leur risque allergique (?)

Réduire l'hémorragie: IL FAUT ADMINISTRER DE L'EXACYL

Le consensus européen sur la prise en charge des hémorragies de cause traumatique évoque le recours à l'acide tranexaminique. L'exacyl a largement démontré son efficacité comme moyen pharmacologique d’épargne sanguine péri-opératoire. Son intérêt en traumatologie n'était pas jusqu'à présent bien documenté. L'étude Crash 2 publiée dans le lancet apporte un éclairage nouveau. 

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with signifi cant haemorrhage (CRASH-2): a randomised, placebo-controlled trial

June 15, 2010 DOI:10.1016/S0140-6736(10)60835-5

10 096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10 060 and 10 067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14·5%] tranexamic acid group vs 1613 [16·0%] placebo group; relative risk 0·91, 95% CI 0·85–0·97; p=0·0035). The risk of death due to bleeding was  significantly reduced (489 [4·9%] vs 574 [5·7%]; relative risk 0·85, 95% CI 0·76–0·96; p=0·0077). 

Il n'existe pas de protocole d'emploi bien formalisé. Dans l'étude crash 2, une dose de charge de 1 g est administrée en 10 minutes, suivie d'un entretien de 1 g perfusé en 08 h. De faibles posologies seraient efficaces. Certains proposent le régime suivant: bolus IV de 10 mg.kg-1 suivi d’une perfusion continue de 1 mg.kg-1 .h-1. Ce médicament est disponible en dotation. 

Pour en savoir plus  1  et  2  et  3 

Association Hypersalé et HEA: Plus d'arythmies ?

Ce travail expérimental chez le rat attire l'attention sur les effets pro-arythmogènes de l'association HEA-Hypersalé. Ces effets seraient responsables d'une mortalité plus élevée en cas de choc hémorragique. 

Small volume7.5% NaCl with 6% dextran-70 or  6% and 10% hetastarch are associated with arrhythmias and death after 60 minutes of severe hemorrhagic shock in the rat  in vivo

 

Letson H et all. DOI:10.1097/TA.0b013e3181e99c63

 

Conclusions:

Small volumes of 7.5% NaCl led to fewer arrhythmias and a 2.6 times survival benefit over untreated rats, and a partial resuscitation of MAP into the “permissive range.” Dextran-70 or HES in 7.5% NaCl were proarrhythmic and HES led to increased mortality(p  0.05). Because optimal heart function is critical for successful resuscitation, care should be exercised when using dextran-70 or 6 and 10% HESin small volume hypertonic saline solutions for early hypotensive resuscitation.

Commentaires

La stratégie de remplissage vasculaire en conditions de combat est d'initier ce dernier dès que le pouls radial n'est pas perçu et associé à une anomalie de la conscience. Il faut utiliser un soluté salé pur à 7,5% administré en 20 minutes, suivi en cas d'inefficacité de 500 ml d'HEA type  et à défaut d'un second soluté hypersalé à 7,5%. Le recours à l'administration d'adrénaline titrée est requis dès la perfusion de la seconde poche.

Cette stratégie résulte d'un compromis entre ce qui est possible en condition tactique et l'état de l'art et des recommandations.

Approfondir

1. La RPC de la SFAR (de1997, un peu ancienne)

2. Les recommandations anglaises

3. Les recommandations américaines

4. Les recommandations européennes pour la prise en charge du traumatisé sévère

 

Remplissage vasculaire: Un document à méditer !

 

ICI

Mettez cela en perspective avec les conditions de combat

NICE has issued preliminary recommendations on the pre-hospital initiation of fluid replacement therapy in trauma for consultation. The guidance covers the management of adults with trauma injury in whom there is evidence of obvious or probable blood loss. It does not cover the management of isolated closed head injury.

In summary:

1. It is recommended that in the pre-hospital management of adults with trauma injuries, intravenous fluid (IV fluid) should not be administered if a radial pulse can be felt (or, for penetrating torso injuries, if a central pulse can be felt).

2. In the absence of a radial pulse (or a central pulse for penetrating torso injuries), it is recommended that IV fluid in boluses of no more than 250 ml should be administered, followed by reassessment until a radial (or central) pulse is palpable.

3. The administration of IV fluid should not delay transportation to hospital, but when given in accordance with 2 above, administration may take place en route to hospital.

4. It is recommended that crystalloid solutions should normally be administered in the pre-hospital setting.

5. There is inadequate evidence, and a lack of professional consensus, on which to base recommendations on the pre-hospital use of IV fluid in children with trauma injury. However, it is recommended that the general principles for IV fluid administration in children should be based on those recommended for adults. Thus, in children considered to be at risk of hypovolaemia, IV fluids should be administered in aliquots with frequent re-assessment of the child's physiological state and transfer to hospital should not be delayed.

6. It is recommended that only paramedics or other healthcare professionals who have been appropriately trained in advanced life-support techniques and pre-hospital care should administer IV fluid therapy to trauma patients in the pre-hospital setting and that training should incorporate the above recommendations.

Remplissage: Cristalloïdes vs Colloïdes

Une publication récente met à nouveau en garde contre le recours immodéré aux solutés colloïdes pour le remplissage vasculaire. Bien qu'employé en routine les colloïdes ne sont pas dénués d'effets secondaires et leur intérêt est remis en question. On rappelle que le soluté chois pour équiper la trousse individuelle du combattant est un flacon de 250 ml de sérum salé à 7.5%, choix dicté par l'excellent compromis efficacité en terme de remplissage, anti-oedémateux cérébral et poids.

L'article est le suivant: 

 

The Efficacy and Safety of Colloid Resuscitation in the Critically Ill

Christiane S. Hartog, MD, Michael Bauer, MD, and Konrad Reinhart, MD

(Anesth Analg 2011;112:156 –64)

Despite evidence from clinical studies and meta-analyses that resuscitation with colloids or crystalloids is equally effective in critically ill patients, and despite reports from high-quality clinical trials and meta-analyses regarding nephrotoxic effects, increased risk of bleeding, and a trend toward higher mortality in these patients after the use of hydroxyethyl starch (HES) solutions, colloids remain popular and the use of HES solutions is increasing worldwide. We investigated the major rationales for colloid use, namely that colloids are more effective plasma expanders than crystalloids, that synthetic colloids are as safe as albumin, that HES solutions have the best risk/benefit profile among the synthetic colloids, and that the third-generation HES 130/0.4 has fewer adverse effects than older starches. Evidence from clinical studies shows that comparable resuscitation is achieved with considerably less crystalloid volumes than frequently suggested, namely,
2-fold the volume of colloids.

Albumin is safe in intensive care unit patients except in patients with closed head injury. All synthetic colloids, namely, dextran, gelatin, and HES have dose-related side effects, which are coagulopathy, renal failure, and tissue storage. In patients with severe sepsis, higher doses of HES may be associated with excess mortality. The assumption that third-generation HES 130/0.4 has fewer adverse effects is yet unproven. Clinical trials on HES 130/0.4 have notable shortcomings.

Mostly, they were not performed in intensive care unit or emergency department patients, had short observation periods of 24 to 48 hours, used cumulative doses below 1 daily dose limit (50 mL/kg), and used unsuitable control fluids such as other HES solutions or gelatins.

In conclusion, the preferred use of colloidal solutions for resuscitation of patients with acute hypovolemia is based on rationales that are not supported by clinical evidence. Synthetic colloids are not superior in critically ill adults and children but must be considered harmful depending on the cumulative dose administered. Safe threshold doses need to be determined in studies in high-risk patients and observation periods of 90 days. Such studies on HES 130/0.4 are still lacking despite its widespread and increasing use. Because there are safer and equally effective alternatives in the form of crystalloids, use of synthetic colloids should be avoided except in the context of clinical studies. 

 

Masque laryngé: Êtes vous sûr ?

 

La place des dispositifs laryngés pour le contrôle des voies aériennes en condition de combat est très limitée. Ces dispositifs ne font pas partie des mesures recommandées par le TCCC et le BATLS, car ils ne ne répondent pas aux critères essentiels qui sont d'assurer l'ouverture des voies aériennes en cas de plaie maxillo-faciale, ils ne protègent pas des risques d'inhalation, ils ne dispensent pas de la réalisation d'une sédation, ils sont susceptibles de mobilisation, enfin ils ne représente pas la première ligne de traitement pour la prise en charge d'une détresse respiratoire en condition de combat.

L'article suivant expose un certain nombre de désagrément lié à l'emploi de l'un de ces dispositifs. 

Indian Journal of Anaesthesia 2009; 53 (4):414-424

Troubleshooting ProSeal LMA

Bimla Sharma, Jayashree Sood  , Chand Sahai , V P Kumra

Summary

Supraglottic devices have changed the face of the airway management. These devices have contributed in a bigway in airway management especially, in the difficult airway scenario significantly decreasing the pharyngolaryngeal morbidity. There is a plethora of these devices, which has been well matched by their wider acceptance in clinical practice. ProSeal laryngeal mask airway (PLMA) is one such frequently used device employed for spontaneous as well as controlled ventilation. However, the use of PLMA at times may be associated with certain problems. Some of the problems related with its use are unique while others are akin to the classic laryngeal mask airway (cLMA). However, expertise is needed for its safe and judicious use, correct placement, recognition and management of its various malpositions and complications. The present article describes the tests employed for proper confirmation of placement to assess the ventilatory and the drain tube functions of the mask, diagnosis of various malpositions and the management of these aspects. All these areas have been highlighted under the heading of troubleshooting PLMA. Many problems can be solved by proper patient and procedure selection, maintaining adequate depth of anaesthesia, diagnosis and management of malpositions. Proper fixation of the device and monitoring cuff pressure intraoperatively may bring down the incidence of airway morbidity.

 

"Scoop and run" or "stay and play"

Lire ce documentVaste débat qui voit les deux modalités coexister au sein de structures disposant d'organisations avancées en matière e prise en charge pré-hospitalière. Pourtant au sein du pays prônant le scoop and run, il semble que quelques mérites soient trouver au "stay and play", notamment en zone rurale ne disposant pas dune infrastruture hospitalière très dense. Lire ce document

 

 

Lien vers quelques cours de traumatologie

http://www.darbicetre.com/traumatologie/bibliographie/