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08/05/2017

Hémorragie: De la glace sur le visage ?

Face Cooling Increases Blood Pressure during Simulated Blood Loss

B. Johnson et Al. Proceedings of Experimental Biology 2017 Chicago 

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Une constatation qui ne devrait pas surprendre ceux qui s'intéressent à la médecine de plongée et au réflexe d'immersion (1, 2, 3, 4), dont le facteur principal de déclenchement est l'exposition de la face à de l'eau froide.

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Introduction

Blood loss causes central hypovolemia and in severe instances, it can decrease blood pressure and lead to cardiovascular decompensation. Simple and quick interventions that can be used to prevent cardiovascular decompensation in pre-hospital settings could be a valuable tool for first responsders. Cooling the forehead and cheeks using an ice/water slurry mixture has been shown to increase blood pressure for over 15 minutes. Therefore, face cooling could be used to mitigate decreases in blood pressure during blood loss.

Purpose

We tested the hypothesis that face cooling during simulated blood loss will increase blood pressure. Methods Ten healthy participants (22 ± 2 years, 3 women) completed two randomized trials on separate days. Both trials began with 30 mmHg of lower body negative pressure (LBNP) to simulate blood loss for 6 minutes. Then, either a 2.5 L plastic bag of an ice/water slurry mixture (0 ± 0°C) (LBNP+FC) or a 2.5 L plastic bag of thermoneutral water (34 ± 1°C) (LBNP+SHAM) was placed on the forehead and eyes and 30 mmHg of LBNP was maintained for an additional 15 minutes.

1-possiblenewt.jpg

We continuously measured blood pressure (Penaz method), heart rate (ECG), stroke volume (Modelflow), cardiac output, total peripheral resistance, and forehead temperature throughout the protocol.

Results

Forehead temperature did not change from LBNP (34.2 ± 0.6°C) to LBNP+SHAM (33.9 ± 1.4°C, P > 0.999) and decreased from LBNP (34.4 ± 0.5°C) to LBNP+FC (11.0 ± 1.6°C, P < 0.001). Mean arterial pressure did not change from LBNP (82 ± 10 mmHg) to LBNP+SHAM (80 ± 8 mmHg, P = 0.978), but markedly increased during LBNP+FC. The peak increase from LBNP (77 ± 9 mmHg) was observed after 3 minutes of LBNP+FC (98 ± 15 mmHg, P < 0.001). Heart rate during LBNP (76 ± 14 bpm, P = 0.978) was not different from LBNP+SHAM (75 ± 13 bpm). Heart rate was lower throughout LBNP+FC beginning at 2 minutes of FC (60 ± 16 bpm) versus LBNP (80 ± 19 bpm, P < 0.001). Stroke volume did not change from LBNP (72 ± 15 mL) to LBNP+SHAM (67 ± 18 mL, P = 0.857). However, stroke volume increased from LBNP (78 ± 16 mL) to LBNP+FC, and peaked after 5 minutes of FC (97 ± 32 mL, P < 0.001). Cardiac output did not change from LBNP (5.4 ± 1.0 L/min) to LBNP+SHAM (4.9 ± 1.0 L/min, P > 0.415). Cardiac output slightly decreased from LBNP (6.2 ± 1.5 L/min) to 2 minutes of LBNP+FC (5.3 ± 1.6 L/min, P = 0.038). Total peripheral resistance did not change from LBNP (15.6 ± 3.7 mmHg/L/min) to LBNP+SHAM (17.3 ± 3.2 mmHg/L/min, P = 0.613). Total peripheral resistance throughout LBNP+FC was greater than LBNP. The peak increase in total peripheral resistance was observed after 2 minutes of LBNP+FC (20.0 ± 6.2 mmHg/L/min) versus LBNP (13.2 ± 3.9 mmHg/L/min, P < 0.001).  

Conclusions

Face cooling during simulated moderate blood loss increases blood pressure through an increase in total peripheral resistance. Although more research is warranted, face cooling during blood loss is a potential simple and quick intervention that could delay cardiovascular decompensation.  Support or Funding InformationUniversity at Buffalo IMPACT Award

| Tags : choc, hémorragie

System to achieve ZERO preventable deaths

A national trauma care system.jpg

Clic sur l'image pour accéder au document

 

10/03/2017

Sauvetage au combat à la mer: Quid ?

Multi-Injury Casualty Stream Simulation in a Shipboard Combat Environment

 

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L'attention portée à la prise en charge des blessés de guerre se porte essentiellement aux blessés lors de combat se déroulant au sol. Il ne faut pas oublier aussi ce qui se passe sur (voire sous) la surface de la mer. Ce qui est vrai à terre ne l'est probablement pas à la mer. Le trauma des membres est certainement moins prééminent. Les mécanismes ballistiques, l'environnement de prise en charge sont totalement différents aussi les réponses, c'est à dire la manière de conduire le sauvetage au combat,  le sont également. Cependant la rareté des engagements sur mer rend difficile la mise sur pied d'une conduite basée sur les faits, d'où l'intérêt des outils de simulation statistique. C'est ce que propose cet  article.

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Accurate forecasts of casualty streams are essential for estimating personnel and materiel requirements for future naval combat engagements. The scarcity of recent naval combat data makes accurate forecasting difficult.  Furthermore, current forecasts are based on single injuries only, even though empirical evidence indicates most battle casualties suffer multiple injuries. These anticipated single-injury casualty streams underestimate the needed medical resources.  This article describes a method of simulating realistic multi-injury casualty streams in a maritime environment by combining available shipboard data with ground combat blast data.  The simulations, based on the Military Combat Injury Scale, are expected to provide a better tool for medical logistics planning.

 

Trauma Category AIREX(%) UNDEX(%)
     
Amputations (a) 3.00 3.00
Asphyxiations 1.34 3.50
Burns 25.30 15.09
Concussions/Internal Organs 2.85 9.29
Contusions/Abrasions 7.06 16.28
Fractures 6.70 11.52
Miscellaneous 4.96 12.08
Nonfatal Immersions 2.00 2.00
Penetrating Wounds 44.88 20.49
Sprains/Strains/Dislocations 1.91 6.75
Total 100.00 100.00
AIREX, attacks above the waterline; UNDEX, attacks at or below the waterline.
(a) Amputations and nonfatal immersions are subject matter expertadjusted values

| Tags : naval

06/03/2017

PTSD: Les soignants aussi

PTSD in those who care for the injured

Luftman K. et Al. Injury, Int. J. Care Injured 48 (2017) 293–296

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PTSD, les soignants aussi. Cela peut paraître évident mais ce qui interpelle, c'est l'importance du phénomène.

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Background: Post Traumatic Stress Disorder (PTSD) has become a focus for the care of trauma victims, but the incidence of PTSD in those who care for injured patients has not been well studied. Our hypothesis was that a significant proportion of health care providers involved with trauma care are at risk of developing PTSD.

Methods: A system-wide survey was applied using a modified version of the Primary Care PTSD Screen [PC-PTSD], a validated PTSD screening tool currently being used by the VA to screen veterans for PTSD. Pre-hospital and in-hospital care providers including paramedics, nurses, trauma surgeons, emergency medicine physicians, and residents were invited to participate in the survey. The survey questionnaire was anonymously and voluntarily performed online using the Qualtrix system. Providers screened positive if they affirmatively answered any three or more of the four screening questions and negative if they answered less than three questions with a positive answer. Respondents were grouped by age, gender, region, and profession.

Results: 546 providers answered all of the survey questions. The screening was positive in 180 (33%) and negative in 366 (67%) of the responders. There were no differences observed in screen positivity for gender, region, or age. Pre-hospital providers were significantly more likely to screen positive for PTSD compared to the in-hospital providers (42% vs. 21%, P < 0.001). Only 55% of respondents had ever received any information or education about PTSD and only 13% of respondents ever sought treatment for PTSD.

Conclusion: The results of this survey are alarming, with high proportions of healthcare workers at risk for PTSD across all professional groups. PTSD is a vastly underreported entity in those who care for the injured and could potentially represent a major problem for both pre-hospital and in-hospital providers. A larger, national study is warranted to verify these regional results

| Tags : ptsd

Réduire une épaule luxée: Le choix !

A systematic and technical guide on how to reduce a shoulder dislocation

Alkaduhimi, et Al. Turk J Emerg Med. 2016 Dec; 16(4): 155–168. 

Objectives

Our objective is to provide a systematic and technical guide on how to reduce a shoulder dislocation, based on techniques that have been described in literature for patients with anterior and posterior shoulder instability.

Materials and methods

A PubMed and EMBASE query was performed, screening all relevant literature on the closed reduction techniques. Studies regarding open reduction techniques and studies with fracture dislocations were excluded.

Results

In this study we give an overview of 23 different techniques for closed reduction and 17 modifications of these techniques.

Discussion

In this review article we present a complete overview of the techniques, that have been described in the literature for closed reduction for shoulder dislocations. This manuscript can be regarded as a clinical guide how to perform a closed reduction maneuver, including several technical tips and tricks to optimize the success rate and to avoid complications.

Conclusion

There are 23 different reduction techniques with 17 modifications of these techniques. Knowledge of the different techniques is highly important for a good reduction.

Trauma center: Niveau 1 ou 2 ?

Patient Outcomes at Urban and Suburban Level I Versus Level II Trauma Centers.

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Il est admis que la prise en charge des traumatisés dans des structures optimisées comme les trauma center de niveau 1 améliore la survie. Il semblerait que ceci mérite encore d'être encore discuté tout particulièrement en zone urbaine ou sub-urbaine et quand les équipes chirurgicales des TC de niveau 2 ont reçu une formation adaptée. Bien équipé ne signifie pas performance, les auteurs mettent en avant la qualité des équipes opérant dans le centre avant la disponibilité d'équipement spécialisé ne correspondant pas forcément aux besoins quotidiens. 

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STUDY OBJECTIVE:

Regionalized systems of trauma care and level verification are promulgated by the American College of Surgeons. Whether patient outcomes differ between the 2 highest verifications, Levels I and II, is unknown. In contrast to Level IIcenters, Level I centers are required to care for a minimum number of severely injured patients, have immediate availability of subspecialty services and equipment, and demonstrate research, substance abuse screening, and injury prevention. We compare risk-adjusted mortality outcomes at Levels I and II centers.

METHODS:

This was an analysis of data from the 2012 to 2014 Los Angeles County Trauma and Emergency Medical Information System. The system includes 14 trauma centers: 5 Level I and 9 Level II centers. Patients meeting criteria for transport to a trauma center are routed to the closest center, regardless of verification level. All adult patients (≥15 years) treated at any of the traumacenters were included. Outcomes of patients treated at Level I versus Level II centers were compared with 2 validated risk-adjusted models: Trauma Score-Injury Severity Score (TRISS) and the Haider model.

RESULTS:

Adult subjects (33,890) were treated at a Level I center; 29,724, at a Level II center. We found lower overall mortality at Level II centers compared with Level I, using TRISS (odds ratio 0.68; 95% confidence interval 0.59 to 0.78) and Haider (odds ratio 0.84; 95% confidence interval 0.73 to 0.97).

CONCLUSION:

In this cohort of patients treated at urban and suburban trauma centers, treatment at a Level II trauma center was associated with overall risk-adjusted reduced mortality relative to that at a Level I center. In the subset of penetrating trauma, no differences in mortality were found. Further study is warranted to determine optimal trauma system configuration and allocation of resources.

17/02/2017

Visualisation mentale: Mieux que l'ATLS

Mental practice: a simple tool to enhance team-based trauma resuscitation.

Lorello GR et Al CJEM. 2016 Mar;18(2):136-42. doi: 10.1017/cem.2015.4. Epub 2015 Apr 10.

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l'ATLS (Advanced trauma life support) est souvent présenté comme la panacée en matière de prise en charge du traumatisé. Il n'est pas inintéressant d'avoir une analyse très critique de ce type de formation dont le but originel était d'apporter, en 2 jours et demi, des connaissances de base à des équipes peu formées à la pris en charge de traumatisés sévères. Aussi doit on considérer qu'elle a été d'un apport fondamental dans les pays ne disposant pas de réseaux avancés. Si le contenu structuré et le recours à des ateliers pratiques apparaît attrayant , le contenu médical est régulièrement non conforme aux bonnes pratiques et les enseignants souvent non experts du sujet (1, 2). Il a pu être proposé de traduire l'acronyme ATLS par "Archaic Trauma Life Support"(3). Le travail proposé confirme bien les limites de cette formation qui ne parait plus adapté au contexte actuel pour des professionnels de l'affaire (4). Quand on s'adresse à des étudiants avancés dans leur cursus de formation, la préparation d'un exercice de simulation en équipe par l'imagerie mentale est plus efficace. 

L'ATLS demeure néanmoins un bon moyen d'appréhender pour les novices les bases fondamentales de la prise en charge des traumatisés. Ce n'est pas le seul et il existe d'autres approches notamment le DIU de traumatisés sévères (5) ou l'European Trauma Course (6), dernier donnant un grande place à la simulation.

INTRODUCTION:

Effective trauma resuscitation requires the coordinated efforts of an interdisciplinary team. Mental practice (MP) is defined as the mental rehearsal of activity in the absence of gross muscular movements and has been demonstrated to enhance acquiring technical and procedural skills. The role of MP to promote nontechnical, team-based skills for trauma has yet to be investigated.

METHODS:

We randomized anaesthesiology, emergency medicine, and surgery residents to two-member teams randomly assigned to either an MP or control group. The MP group engaged in 20 minutes of MP, and the control group received 20 minutes of Advanced Trauma Life Support (ATLS) training. All teams then participated in a high-fidelity simulated adult trauma resuscitation and received debriefing on communication, leadership, and teamwork. Two blinded raters independently scored video recordings of the simulated resuscitations using the Mayo High Performance Teamwork Scale (MHPTS), a validated team-based behavioural rating scale. The Mann-Whitney U-test was used to assess for between-group differences.

RESULTS:

Seventy-eight residents provided informed written consent and were recruited. The MP group outperformed the control group with significant effect on teamwork behaviour as assessed using the MHPTS: r=0.67, p<0.01.

CONCLUSIONS:

MP leads to improvement in team-based skills compared to traditional simulation-based trauma instruction. We feel that MP may be a useful and inexpensive tool for improving nontechnical skills instruction effectiveness for team-based trauma care.

 

 

01/02/2017

Echo: Pour le thorax surtout

Traumatic cardiac injury: Experience from a level-1 trauma centre

Mishra B. et Al. Chin J Traumatol. 2016 Dec 1;19(6):333-336.

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Disposer d'un appareil d'échographie est d'un grand intérêt. Encore faut-il maîtriser cette technique (1) sous peine de se tromper dans les priorités de prise en charge. Le recours a cette technique reste débattu pour la prise en charge de traumatismes pénétrants. L'échographie thoracique est probablement à valeur ajoutée tant sur l'imagerie pleurale que péricardique. C'est ce que présente ce travail. Ce document rapporte également l'inefficacité en terme de survie de péricardocentèse pourtant prôné par l'ATLS.

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Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short thera- peutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI.

METHODS:

Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15.

RESULTS:

Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio be- tween blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p =0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%.

CONCLUSION:

High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Trauma: Le terrorisme + grave que la violence

Violence-related Versus Terror-related Stabbings: Significant Differences in Injury Characteristics.

Rozenfeld M et Al. Ann Surg. 2017 Jan 24. doi: 10.1097/SLA.0000000000002143
 
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Les évènements récents ont confronté notre système de santé à de nouveaux enjeux. Ces derniers impose une réflexion sur notre organisation historiquement basée sur la prise en charge de traumatisés de la route. L'experience israélienne est intéressante car elle devrait nous pousser à faire évoluer notre système.
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OBJECTIVE:

To demonstrate the gap between injury epidemiology of terror-related stabbings (TRS) and non-terror-related intentional stabbings.

BACKGROUND:

Terror attacks with sharp instruments have multiplied recently, with many victims of these incidents presented to hospitals with penetrating injuries. Because most practical experience of surgeons with intentional stabbing injuries comes from treating victims of interpersonal violence, potential gaps in knowledge may exist if injuries from TRS significantly differ from interpersonal stabbings (IPS).

METHODS:

A retrospective study of 1615 patients from intentional stabbing events recorded in the Israeli National Trauma Registry during the period of "Knife Intifada" (January 2013-March 2016). All stabbings were divided into TRS and IPS. The 2 categories were compared in terms of sustained injuries, utilization of hospital resources, and clinical outcomes.

RESULTS:

TRS patients were older, comprised more females and were ethnically homogenous. Most IPS incidents happened on weekdays and at night hours, whereas TRS events peaked midweek during morning and afternoon hours. TRS patients had more injuries of head, face, and neck, and severe head and neck injuries. IPS patients had more abdomen injuries; however, respective injuries in the TRS group were more severe. Greater injury severity of the TRS patients reflected on their higher hospital resources utilization and greater in-hospital mortality.

CONCLUSIONS:

Victims of terror stabbings are profoundly different in their characteristics, sustain injuries of a different profile and greater severity, require more hospital resources, and have worse off clinical outcomes, emphasizing the need of the healthcare systems to adjust itself appropriately to deal successfully with future terror attacks.

10/12/2016

Maintenir la pression: Hydroxocobalamine ou adré ?

A prospective, randomized trial of intravenous hydroxocobalamin versus whole blood transfusion compared to no treatment for Class III hemorrhagic shock resuscitation in a prehospital swine model.

 
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Faire en sorte qu'il y ait plus de NO éliminé pour augmenter les résistances artérielles. Une autre manière. A relativiser toutefois car avec l'arrêt des hémorragies, la transfusion sanguine précoce doit rester l'objectif principal.
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OBJECTIVES:

The objective was to compare systolic blood pressure (sBP) over time in swine that have had 30% of their blood volume removed (Class III shock) and treated with intravenous (IV) whole blood or IV hydroxocobalamin, compared to nontreated controlanimals.

METHODS:

Thirty swine (45 to 55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring. Animals were hemorrhaged a total of 20 mL/kg over a 20-minute period. Five minutes after hemorrhage, animals were randomly assigned to receive 150 mg/kg IV hydroxocobalamin solubilized in 180 mL of saline, 500 mL of whole blood, or no treatment. Animals were monitored for 60 minutes thereafter. A sample size of 10 animals per group was determined based on a power of 80% and an alpha of 0.05 to detect an effect size of at least a 0.25 difference (>1 standard deviation) in mean sBP between groups. sBP values were analyzed using repeated-measures analysis of variance (RANOVA). Secondary outcome data were analyzed using repeated-measures multivariate analysis of variance (RMANOVA).

RESULTS:

There were no significant differences between hemodynamic parameters of IV hydroxocobalamin versus whole blood versus control group at baseline (MANOVA; Wilks' lambda; p = 0.868) or immediately posthemorrhage (mean sBP = 47 mm Hg vs. 41 mm Hg vs. 37 mm Hg; mean arterial pressure = 39 mm Hg vs. 28 mm Hg vs. 34 mm Hg; mean serum lactate = 1.2 mmol/L vs. 1.4 mmol/L vs. 1.4 mmol/L; MANOVA; Wilks' lambda; p = 0.348). The outcome RANOVA model detected a significant difference by time between groups (p < 0.001). Specifically, 10 minutes after treatment, treated animals showed a significant increase in mean sBP compared to nontreated animals (mean sBP = 76.3 mm Hg vs. 85.7 mm Hg vs. 51.1 mm Hg; p < 0.001). RMANOVA modeling of the secondary data detected a significant difference in mean arterial pressure, heart rate, and serum lactate (p < 0.001). Similar to sBP, 10 minutes after treatment, treated animals showed a significant increase in mean arterial pressure compared to nontreated animals (mean arterial pressure = 67.7 mm Hg vs. 61.4 mm Hg vs. 40.5 mm Hg). By 10 minutes, mean heart rate was significantly slower in treated animals compared to nontreated animals (mean heart rate = 97.3 beats/min vs. 95.2 beats/min vs. 129.5 beats/min; p < 0.05). Serum lactate, an early predictor of shock, continued to rise in the control group, whereas it did not in treated animals. Thirty minutes after treatment, serum lactate values of treated animals were significantly lower compared to nontreated animals (p < 0.05). This trend continued throughout the 60-minute observation period such that 60-minute values for lactate were 1.4 mmol/L versus 1.1 mmol/L versus 3.8 mmol/L. IV hydroxocobalamin produced a statistically significant increase in systemic vascular resistance compared to control, but not whole blood, with a concomitant decrease in cardiac output.

Hydroxo.jpg

CONCLUSIONS:

Intravenous hydroxocobalamin was more effective than no treatment and as effective as whole blood transfusion, in reversing hypotension and inhibiting rises in serum lactate in this prehospital, controlled, Class III swine hemorrhage model.

| Tags : choc

Tueries massives par armes à feu: Penser différemment !

The profile of wounding in civilian public mass shooting fatalities.

 
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Manifestement, lors de tueries massives par armes à feu, le garrot c'est bien mais cela ne fait pas tout. L'extraction rapide des blessés, une prise en charge préhospitalière revue par rapport à nos habitudes pour un transport sans délais vers un bloc opératoire apparaissent être des mesures cruciales.
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BACKGROUND:

The incidence and severity of civilian public mass shootings (CPMS) continue to r.ise. Initiatives predicated on lessons learned from military woundings have placed strong emphasis on hemorrhage control, especially via use of tourniquets, as means to improve survival. We hypothesize that both the overall wounding pattern and the specific fatal wounds in CPMS events are different from those in military combat fatalities and thus may require a new management strategy.

METHODS:

A retrospective study of autopsy reports for all victims involved in 12 CPMS events was performed. Civilian public mass shootings was defined using the FBI and the Congressional Research Service definition. The site of injury, probable site of fatal injury, and presence of potentially survivable injury (defined as survival if prehospital care is provided within 10 minutes and trauma center care within 60 minutes of injury) was determined independently by each author.

RESULTS:

A total 139 fatalities consisting of 371 wounds from 12 CPMS events were reviewed. All wounds were due to gunshots. Victims had an average of 2.7 gunshots. Relative to military reports, the case fatality rate was significantly higher, and incidence of potentially survivable injuries was significantly lower. Overall, 58% of victims had gunshots to the head and chest, and only 20% had extremity wounds. The probable site of fatal wounding was the head or chest in 77% of cases.

Active Mass shooting.jpg

Only 7% of victims had potentially survivable wounds. The most common site of potentially survivable injury was the chest (89%). No head injury was potentially survivable. There were no deaths due to exsanguination from an extremity.

CONCLUSION:

The overall and fatal wounding patterns following CPMS are different from those resulting from combat operations. Given that no deaths were due to extremity hemorrhage, a treatment strategy that goes beyond use of tourniquets is needed to rescue the few victims with potentially survivable injuries.

24/09/2016

Transfusion en vol: Sécurité assurée

Risk Management Analysis of Air Ambulance Blood Product Administration in Combat Operations

 

BACKGROUND:

Between June-October 2012, 61 flight-medic-directed transfusions took place aboard U.S. Army Medical Evacuation (medevac) helicopters in Afghanistan. This represents the initial experience for pre-hospital blood product transfusion by U.S. Army flight medics.

METHODS:

We performed a retrospective review of clinical records, operating guidelines, after-action reviews, decision and information briefs, bimonthly medical conferences, and medevac-related medical records.

RESULTS:

A successful program was administered at 10 locations across Afghanistan. Adherence to protocol transfusion indications was 97%. There were 61 casualties who were transfused without any known instance of adverse reaction or local blood product wastage. Shock index (heart rate/systolic blood pressure) improved significantly en route, with a median shock index of 1.6 (IQR 1.2-2.0) pre-transfusion and 1.1 (IQR 1.0-1.5) post-transfusion (P < 0.0001). Blood resupply, training, and clinical procedures were standardized across each of the 10 areas of medevacoperations.

DISCUSSION:

Potential risks of medical complications, reverse propaganda, adherence to protocol, and diversion and/or wastage of limited resources were important considerations in the development of the pilot program. Aviation-specific risk mitigation strategies were important to ensure mission success in terms of wastage prevention, standardized operations at multiple locations, and prevention of adverse clinical outcomes. Consideration of aviation risk mitigation strategies may help enable other helicopter emergency medical systems to develop remote pre-hospital transfusion capability. This pilot program provides preliminary evidence that blood product administration by medevac is safe.

| Tags : transfusion

22/09/2016

SmO2: Utile ?

Muscle Oxygen Saturation Improves Diagnostic Association Between Initial Vital Signs and Major Hemorrhage: A Prospective Observational Study.

 
 

L'hémorragie reste la cause principale des décès évitable et l'importance de la mise en oeuvre d'une stratégie transfusionnelle précoce est actée. Mais sur quels critères. Au delà des critères cliniques simples, on peut citer le recours au suivi des lactates. Le suivi de paramètres d'oxygénation tissulaire simple est maintenant possible. Ce qu'évoque ce document est l'emploi de la SmO2, élément déjà utilisé en médecine du sport. Le recours à un tel paramètre est donc potentiellement très intéressant si cette pertinence était confirmée et sa mesure valide avec des outils simples.

OBJECTIVES:

During initial assessment of trauma patients, vital signs do not identify all patients with life-threatening hemorrhage. We hypothesized that a novel vital sign, muscle oxygen saturation (SmO2 ), could provide independent diagnostic information beyond routine vital signs for identification of hemorrhaging patients who require packed red blood cell (RBC) transfusion.

METHODS:

This was an observational study of adult trauma patients treated at a Level I trauma center. Study staff placed the CareGuide 1100 tissue oximeter (Reflectance Medical Inc., Westborough, MA), and we analyzed average values of SmO2 , systolic blood pressure (sBP), pulse pressure (PP), and heart rate (HR) during 10 minutes of early emergency department evaluation. We excluded subjects without a full set of vital signs during the observation interval. The study outcome was hemorrhagic injury and RBC transfusion ≥ 3 units in 24 hours (24-hr RBC ≥ 3). To test the hypothesis that SmO2 added independent information beyond routine vital signs, we developed one logistic regression model with HR, sBP, and PP and one with SmO2 in addition to HR, sBP, and PP and compared their areas under receiver operating characteristic curves (ROC AUCs) using DeLong's test.

SmO2.jpg

RESULTS:

We enrolled 487 subjects; 23 received 24-hr RBC ≥ 3. Compared to the model without SmO2 , the regression model with SmO2 had a significantly increased ROC AUC for the prediction of ≥ 3 units of 24-hr RBC volume, 0.85 (95% confidence interval [CI], 0.75-0.91) versus 0.77 (95% CI, 0.66-0.86; p < 0.05 per DeLong's test). Results were similar for ROC AUCs predicting patients (n = 11) receiving 24-hr RBC ≥ 9.

CONCLUSIONS:

SmO2 significantly improved the diagnostic association between initial vital signs and hemorrhagic injury with blood transfusion. This parameter may enhance the early identification of patients who require blood products for life-threatening hemorrhage.

12/09/2016

L'hôpital de proximité: Insuffisant ?

Garrison Clinical Setting Inadequate for Maintenance of Procedural Skills for Emergency Medicine Physicians: A Cross-Sectional Study

Schauer SG et Al. J Spec Oper Med. 2015 Winter;15(4):67-70

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Lire également cet éditorial qui pointe l'insuffisance de l'exercice en hôpital de proximité avec le rôle important que peut jouer la simulation. Les auteurs proposent un  maintien longitudinal des compétences avec des minima en termes de pratiques gestuelles avant projection. 

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BACKGROUND:

Emergency medicine physicians (EPs) are often placed in far-forward, isolated areas in theater. Maintenance of their emergency intervention skills is vital to okeep the medical forces deployment ready. The US Army suggests that working at a Military Treatment Facility (MTF) is sufficient t keep emergency procedural skills at a deployment-ready level. We sought to compare the volume of emergency procedures that providers reported necessary to maintain their skills with the number available in the MTF setting.

METHODS:

EPs were surveyed to quantify the number of procedures they reported they would need to perform yearly to stay deployment-ready. We obtained procedure data for their duty stations and compared the procedure volume with the survey responses to determine if working at an MTF is sufficient to keep providers' skills deployment ready.

RESULTS:

The reported necessary average numbers per year were as follows: tube thoracostomy (5.9), intubation (11.4), cricothyrotomy (4.2), lumbar puncture (5.2), central line (10.0), focused assessment with sonography for trauma (FAST) (21.3), reductions (10.6), splints (10.5), and sedations (11.7). None of the procedure volumes at MTFs met provider requirements with the exception of FAST examinations at the only trauma center.

Emergency Physician.jpg

CONCLUSIONS:

This suggests the garrison clinical environment is inadequate for maintaining procedure skills. Further research is needed to determine modalities that will provide adequate training volume.

01/09/2016

Trauma sévère: Un docteur sur scène. Et bien pas évident ?

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

Bieler D. et Al. http://dx.doi.org/10.1016/j.injury.2016.08.015

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Une remise en question un peu étonnante de la médicalisation préhospitalière par nos camarades allemands. L'augmentation globale de la qualité des intervenants et de l'organisation explique probablement les résultats de cette analyse.

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Purpose

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

Material and methods

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002–2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

Results

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects.

There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group).

Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p < 0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group.

By contrast, there was no significant difference in mortality within the first 24 h and in mortality during hospitalisation.

Conclusion

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times

Remote damage control resuscitation: ???

THOR Position Paper on Remote Damage Control Resuscitation: Definitions, Current Practice and Knowledge Gaps

Jenkins DH et Al. Shock. 2014 May; 41(0 1): 3–12.

 

The concept of RDCR is in its infancy and there is a significant amount of work that needs to be done to improve outcomes for patients with life-threatening bleeding secondary to injury. The pre-hospital phase of their resuscitation is critical and if shock and coagulopathy can be rapidly identified and corrected prior to hospital admission this will likely reduce morbidity and mortality. The THOR Network is committed to improving outcomes for patients with traumatic injury through education, training and research. This position statement begins to standardize the terms used, provides an acceptable range of therapeutic options, and identifies the major knowledge gaps in the field.

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

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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

PDF(52K)

 

Review Articles

Modern banking, collection, compatibility testing and storage of blood and blood components (pages 3–e2)

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

PDF(121K)

 

Evidence and triggers for the transfusion of blood and blood products (pages 10–e3)

A. Shah, S. J. Stanworth and S. McKechnie

PDF(135K)

 

Pre-operative anaemia (pages 20–e8)

B. Clevenger and T. Richards

PDF(241K)

 

The pathophysiology and consequences of red blood cell storage (pages 29–e12)

D. Orlov and K. Karkouti

PDF(445K)

 

Red cell transfusion and the immune system (pages 38–e16)

S. Hart, C. M. Cserti-Gazdewich and S. A. McCluskey

PDF(133K)

 

The current place of aprotinin in the management of bleeding (pages 46–e17)

D. Royston

PDF(69K)

 

The current place of tranexamic acid in the management of bleeding (pages 50–e18)

B. J. Hunt

PDF(69K)

 

Practical management of major blood loss (pages 54–e20)

R. Gill

PDF(79K)

 

Management of peri-operative anti-thrombotic therapy (pages 58–e23)

J. J. van Veen and M. Makris

PDF(262K)

 

Laboratory monitoring of haemostasis (pages 68–e24)

A. Fowler and D. J. Perry

PDF(67K)

 

Point-of-care monitoring of haemostasis (pages 73–e26)

S. V. Mallett and M. Armstrong

PDF(85K)

 

Haemostatic management of obstetric haemorrhage (pages 78–e28)

R. E. Collis and P. W. Collins

PDF(281K)

 

Haemostatic management of cardiac surgical haemorrhage (pages 87–e31)

M. W. Besser, E. Ortmann and A. A. Klein

PDF(129K)

 

The pathogenesis of traumatic coagulopathy (pages 96–e34)

A. Cap and B. J. Hunt

PDF(105K)

 

Management of traumatic haemorrhage – the European perspective (pages 102–e37)

H. Schöchl, W. Voelckel and C. J. Schlimp

PDF(1142K)

 

Management of traumatic haemorrhage – the US perspective (pages 108–e38)

R. P. Dutton

PDF(61K)

 

Surgery in patients with inherited bleeding disorders (pages 112–e40)

P. K. Mensah and R. Gooding

PDF(180K)

 

The management of abnormal haemostasis in the ICU (pages 121–e41)

A. Retter and N. A. Barrett

PDF(727K)

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