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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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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

Sauvetage au combat: Connaître et appliquer la procédure

Preventable deaths in trauma patients associated with non adherence to management guidelines

Marson CA et Al. Rev Bras Ter Intensiva. 2010; 22(3):220-228

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Connaître, maîtriser chacune des composantes d'une procédure et les mettre en oeuvre est  un facteur de survie des blessés. Le respect de la procédure du sauvetage au combat apparait fondamental. Il est nécessaire de le rappeler.

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Objectives: To evaluate patients treated for traumatic injuries and to identify adherence to guidelines recommendations of treatment and association with death. The recommendations adopted were defined by the committee on trauma of the American College of Surgeons in advanced trauma life support.


Methods: Retrospective cohort study conducted at a teaching hospital. The study population was victims of trauma ≥ 12 years of age with injury severity scores ≥ 16 who were treated between January 1997 and December 2001. Data collection was divided into three phases: pre-hospital, in-hospital, and post-mortem. The data collected were analyzed using EPI INFO.


Results: We analyzed 207 patients, 147 blunt trauma victims (71%) and 60 (29%) penetrating trauma victims. Trauma victims had a 40.1% mortality rate. We identified 221 non adherence events that occurred in 137 patients. We found a mean of 1.61 non adherence per patient, and it occurred less frequently in survivors (1.4) than in non-survivors (1.9; p=0.033). According to the trauma score and injury severity score methodology, 54.2% of deaths were considered potentially preventable. Non adherence occurred 1.77 times more frequently in those considered potentially preventable deaths compared to other non-survivors (95% CI: 1.12–2.77; p=0.012), and 92.9% of the multiple non adherence occurred in the first group (p=0.029).

NonAdherence.jpeg


Conclusions: Non adherence occurred more frequently in patients with potentially preventable deaths. Non adherence to guidelines recommendations can be considered a contributing factor to death in trauma victims and can lead to an increase in the number of potentially preventable deaths.

 

| Tags : procedure evdg

30/01/2016

Retex 13/11/2015

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28/01/2016

TXA: Interrogations

 Les études CRASH2 et MATTERS ont mis en évidence l'intérêt de l'emploi du TXA en traumatologie grave.

Il s'agit d'un dérivé de la lysine qui agit en se liant au plasminogène bloquant ainsi l'interaction plasminogène-fibrine, donc la fibrinolyse du caillot. Le TXA franchit la barrière sang-cerveau, diffuse dans le LCR et le globe oculaire

Persistent malgré tout quelques interrogations en matière d'innocuité persistent. Si l'étude crash2 n' pas montré de risque thromboembolique majeurs, ce n'est pas le cas d' l'étude MATTERS avec environ 10 fois plus d'épisodes thrombo-emboliques en cas d'usage de  TXA. Par ailleurs il est rapporté un risque d'hypotension lors de l'administration rapide de TXA et de convulsions lors de l'emploi de posologies élevées. Ceci ne remet pas en cause le recours précoce au TXA dont l'emploi ne doit pas être banalisé et respecter un certain nombre de règles: probabilité forte de coagulopathie traumatique notamment attesté par une hypotension sévère , 1ère dose le plus tôt possible (au mieux dans la première heure) et pas après 3h,  deuxième dose dans les 08h00, administration lente pour éviter hypotension, pas de surdosage facteur de crises convulsives, ne pas administrer en même temps/même ligne que du PLYO. 

Un certain nombre d'études complémentaires sont en cours:

1. L'étude  "Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage" a pour objectif d'affiner notre connaissance de l'emploi du TXA.

2.L'étude "Design of the Study of Tranexamic Acid during Air Medical Prehospital Transport (STAAMP) Trial: Addressing the Knowledge Gaps" a pour objet d'étuider la mortalité à 30 jours de traumatisés sévères pris en charge par medevac héliportées. 

3. L'étude "Tranexamic Acid Mechanisms and Pharmacokinetics In Traumatic Injury (TAMPITI Trial)"  vise quand à elle à confirmer un certain nombre d'hypothèses sur le mécanisme d'action.

Par ailleurs, le TXA n'est pas le seul antifibrinolyique utilisable.

 

Antifibrinolytic agents in current anaesthetic practice. Ortmann E. et Al. BJA 111 (4): 549–63 (2013).

Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg2012; 147: 113-119

Napolitano LM, Cohen MJ, Cotton BA, et al. Tranexamic acid in trauma: how should we use it? J Trauma Acute Care Surg 2013; 74: 1575-1586.

Pusateri AE, Weiskopf RB, Bebarta V, et al. Tranexamic acid and trauma: current status and knowledge gaps with recommended research priorities. Shock 2013; 39: 121-126

| Tags : coagulopathie

23/01/2016

Maîtriser l'airway +++, entre autres

Augmentation of point of injury care: Reducing battlefield
mortality—The IDF experience

Benov A. et Al. Injury. 2015 Nov 18. pii: S0020-1383(15)00697-X. doi: 10.1016/j.injury.2015.10.078.

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Une publication particulièrement intéressante car elle émane de collègues militaires qui interviennent dans un contexte très particulier de prise en charge de blessés tels qu'on peut les rencontrer en opérations extérieures mai dans un contexte de réseau de traumatologie civile puisque que les hôpitaux de recueil de ces blessés sont les hôpitaux civils. Les données présentées ne portent que sur la prise en charge de combattants.

Un des points analysé est la performance des équipes dans certains gestes considérés comme essentiel, notamment la gestion des voies aériennes. Comme dans l'armée française l'intubation orotrachéale et la criciothyrotomie représentent les deux procédures mises en oeuvre par des médecins. Manifestement, il existe une grande maîtrise de la coniotomie alors que celle de l'Intubation est moins évidente: 41% de succès et une moyenne de 2 tentatives. Ceci reste problématique lorsque la prise en charge des blessés se fait loin d'un trauma center et qu'il faut envisager la gestion de ces voies aériennes et l'initiation d'une ventilation pendant plusieurs heures (jours ?). Pour ces raisons et même si la probabilité d'être confronté à une telle situation est faible, ce travail rapporte les 2/3 des blessés ne sont pas urgent et que 5% seulement des nécessitent un geste sur les voies aériennes, il s'agit d'un point fondamental en matière de réduction de morts indues.

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STUDY OBJECTIVE:

In 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled "My Brother's Keeper" was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical carehas evolved due "My Brother's Keeper" between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014).

METHODS:

Records of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis.

RESULTS:

The plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively.

CONCLUSIONS:

Significant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.

| Tags : airway

ATLS: pas de plue value pour la catastrophe

Triage performance of Swedish physicians using the ATLS algorithm in a simulated mass casualty incident: a prospective cross-sectional survey

Lampi et al.Scand J Trauma Resusc Emerg Med. 2013; 21: 90.

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On revient une fois de plus sur l'intérêt relativement limité de l'apport de l'ATLS dans un système de santé avancé. L'émergence de nouvelles modalités d'enseignement en ligne, l'introduction de la simulation médicale,  le contenu relativement basique souvent non en phase avec les pratiques médicales du moment et un modèle économique qui interpelle font que l'on doit se poser la question de sa pertinence. Cet article exprime que cet apport n'est pas prouvé en médecine de catastrophe, du  moins sur un aspect important qu'est l'emploi de la mnémonique ABCDE. 

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Background: In a mass casualty situation, medical personnel must rapidly assess and prioritize patients for treatment and transport. Triage is an important tool for medical management in disaster situations. Lack of common international and Swedish triage guidelines could lead to confusion. Attending the Advanced Trauma Life Support (ATLS) provider course is becoming compulsory in the northern part of Europe. The aim of the ATLS guidelines is provision of effective management of single critically injured patients, not mass casualties incidents. However, the use of the ABCDE algorithms from ATLS, has been proposed to be valuable, even in a disaster environment. The objective for this study was to determine whether the mnemonic ABCDE as instructed in the ATLS provider course, affects the ability of Swedish physician’s to correctly triage patients in a simulated mass casualty incident.

Methods: The study group included 169 ATLS provider students from 10 courses and course sites in Sweden; 153 students filled in an anonymous test just before the course and just after the course. The tests contained 3 questions based on overall priority. The assignment was to triage 15 hypothetical patients who had been involved in a bus crash. Triage was performed according to the ABCDE algorithm. In the triage, the ATLS students used a colour-coded algorithm with red for priority 1, yellow for priority 2, green for priority 3 and black for dead. The students were instructed to identify and prioritize 3 of the most critically injured patients, who should be the first to leave the scene. The same test was used before and after the course.

Results: The triage section of the test was completed by 142 of the 169 participants both before and after the course. The results indicate that there was no significant difference in triage knowledge among Swedish physicians who attended the ATLS provider course. The results also showed that Swedish physicians have little experience of real mass casualty incidents and exercises.

Conclusion: The mnemonic ABCDE doesn’t significantly affect the ability of triage among Swedish physicians. Actions to increase Swedish physicians’ knowledge of triage, within the ATLS context or separately, are warranted

12/01/2016

Dexamethasone: Hémostatique cérébral ?

Steroid-loaded Hemostatic Nanoparticles Alleviate Injury Progression after Blast Trauma

Hubbard WD et Al.. ACS Macro Lett., 2015, 4 (4), pp 387–391

The purpose of this study was to investigate whether hemostatic dexamethasone-loaded nanoparticles (hDNP) functionalized with a peptide that binds with activated platelets could reduce cellular injury and improve functional outcomes in a model of blast trauma. Functionalized nanoparticles, or synthetic platelets, offer a wide variety of benefits and advantages compared to alternatives, such as increased biocompatibility and targeting of the injury site (DePalma, 2005). Blood loss is the primary cause of death at acute time points post injury in both civilian and battlefield traumas. Currently, there is a shortage in treatments for internal bleeding, especially for rapid administration in open field combat. In a recent U.K. study, less than fifty percent of soldiers diagnosed with primary blast lung injury (PBLI), the most common fatal blast injury, survived to reach a medical facility (Smith, 2011). This study examines potential therapeutic effects of hDNP on subacute recovery in brain pathology and behavior after blast polytrauma. An established polytrauma model that simulates severe injury, including PBLI and blast-induced neurotrauma (BINT), can be used to evaluate life-saving therapeutics (Hubbard, 2014). Poly(lactic-co-glycolic acid)-based nanoparticles with poly(ethylene glycol) arms and the arginine-glycine-aspartic acid (RGD) peptide to target activated platelets were fabricated. A blast-induced polytrauma rodent model was used to evaluate the functionalized nanoparticles at an acute stage. After anesthesia, Male Sprague Dawley rats were exposed to a single, representative “free field” blast wave from an Advanced Blast Simulator at Virginia Tech at a peak overpressure of 28 psi for 2.5 ms duration, operating above 50% lethality risk, in a sidethorax orientation (Hubbard, 2014). After injury, animals were immediately injected intravenously with hDNP, control dexamethasone-loaded nanoparticles (cDNP), or lactated ringers (LR) and physiological parameters were monitored. Sham animals were not injected or exposed to the blast wave. Open field assays were performed on surviving animals to measure levels of anxiety. At one week post-blast, brains were extracted and sections from the amygdala were obtained for immunofluorescent staining using glial fibrillary acidic protein (GFAP; activated astrocytes), cleaved caspase-3 (apoptosis), and SMI-71 (blood-brain barrier). According to physiological monitoring immediately after blast, oxygen saturation was significantly decreased in the control and LR groups compared to the active and sham groups. Using the open field test, elevated anxiety parameters were found in the control and LR groups compared to the hDNP group. GFAP was significantly elevated in the control group compared to the hDNP and sham groups in the amygdala. Caspase-3 was also significantly elevated in the control group compared to the hDNP group. SMI-71 was significantly reduced in the LR group compared to the sham group. hDNP treatment has the potential to assist recovery after internal hemorrhage. Immediate intervention to assuage hemorrhage, one source for injury pathology, is crucial to mitigate debilitating injury mechanisms that lead to cognitive and emotional deficits (Shetty, 2014).

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It is possible that through prevention of microhemorrhaging of the blood-brain barrier (BBB), hDNP was able to mitigate cellular injury and improve cognitive outcomes. Future studies will evaluate the effect on inflammatory and hypoxia-related proteins after hDNP administration post-trauma.

| Tags : blast, hémorragie

Prédire le besoin transfusionnel tôt ?

Automated analysis of vital signs to identify patients with substantial bleeding before hospital arrival: a feasibility study

Liu J et Al. Shock. 2015 May;43(5):429-36.

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Dépister un saignement significatif à partir des éléments standards de monitorage préhospitalier serait possible à en croire cet article. Il existe actuellement un grand nombre de recherche dans ce domaine. A suivre.

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Trauma outcomes are improved by protocols for substantial bleeding, typically activated after physician evaluation at a hospital. Previous analysis suggested that prehospital vital signs contained patterns indicating the presence or absence of substantial bleeding. In an observational study of adults (aged Q18 years) transported to level I trauma centers by helicopter, we investigated the diagnostic performance of the Automated Processing of the Physiological Registry for Assessment of Injury Severity (APPRAISE) system, a computational platform for real-time analysis of vital signs, for identification of substantial bleeding in trauma patients with explicitly hemorrhagic injuries. We studied 209 subjects prospectively and 646 retrospectively. In our multivariate analysis, prospective performance was not significantly different from retrospective.

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The APPRAISE system was 76% sensitive for 24-h packed red blood cells of 9 or more units (95% confidence interval, 59% Y 89%) and significantly more sensitive (P G 0.05) than any prehospital Shock Index of 1.4 or higher; sensitivity, 59%; initial systolic blood pressure (SBP) less than 110 mmHg, 50%; and any prehospital SBP less than 90 mmHg, 50%. The APPRAISE specificity for 24-h packed red blood cells of 0 units was 87% (88% for any Shock Index Q1.4, 88% for initial SBP G110 mmHg, and 90% for any prehospital SBP G90 mmHg). Median APPRAISE hemorrhage notification time was 20 min before arrival at the trauma center. In conclusion, APPRAISE identified bleeding before trauma center arrival. En route, this capability could allow medics to focus on direct patient care rather than the monitor and, via advance radio notification, could expedite hospital interventions for patients with substantial blood loss.

09/01/2016

Le consensus d'hartford

Les événements récents ont mis en évidence l'importance de l'organisation des soins en cas d'attentats multisites notamment par armes de guerre. Le consensus d'Hartford est une démarche majeure conduite par nos alliés américains sur la survenue de telles situations. Très globalement il s'agit d'une chaîne de survie à mettre en place, ou bien sûr les professionnels de  santé ont leur place mais aussi et surtout le citoyen et les forces de l'ordre. L'acronyme THREAT réssume la démarche: pour Threat Suppression, pour Hemorrage Control, RE pour Rapid Extrication to safety, A pour Assessment by medical provider, T pour transport to definitive care.

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1/1/1 ou 1/1/2 ?

Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial

Holcomb JB et All. JAMA Surg. 2013 Feb;148(2):127-36

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La reconnaissance et la mise en place de la meilleure stratégie thérapeutique du choc hémorragique traumatique sont des enjeux fondamentaux qui se posent aux équipes de réanimation préhospitalières et hospitalières. L'application du concepts du damage control resuscitation (1) vise par la mise en place d'un stratégie raisonnée d'arrêt des hémorragies (2), d'un remplissage vasculaire mesuré (3) et d'une politique transfusionnelle spécifique (4). Parmi ces mesures, il apparaît important de garantir l'apport équilibré de plasma, de plaquettes et de CGR dans un ration  élevé 1/1/1 ou 1/1/2. Deux études se sont attachées à ce point: L'étude PROMMTT et l'étude PROPPR ici présentée. La première confirme le bénéfice d'une telle stratégie avec une moindre mortalité chez les patients bénéficiant de rapport élevé supérieur mais uniquement dans les 6 premières heures. L'étude PROPPR semble confirmer ces données avec une moindre mortalité précoce par hémorragie mais ne réussit pas à confirmer l'intérêt d'un ratio 1/1/1 par rapport à un ratio 1/1/2 sur la mortalité à long terme.

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IMPORTANCE:

Severely injured patients experiencing hemorrhagic shock often require massive transfusion. Earlier transfusion with higher blood product ratios (plasma, platelets, and red blood cells), defined as damage control resuscitation, has been associated with improved outcomes; however, there have been no large multicenter clinical trials.

OBJECTIVE:

To determine the effectiveness and safety of transfusing patients with severe trauma and major bleeding using plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio.

DESIGN, SETTING, AND PARTICIPANTS:

Pragmatic, phase 3, multisite, randomized clinical trial of 680 severely injured patients who arrived at 1 of 12 level I trauma centers in North America directly from the scene and were predicted to require massive transfusion between August 2012 and December 2013.

INTERVENTIONS:

Blood product ratios of 1:1:1 (338 patients) vs 1:1:2 (342 patients) during active resuscitation in addition to all local standard-of-care interventions (uncontrolled).

MAIN OUTCOMES AND MEASURES:

Primary outcomes were 24-hour and 30-day all-cause mortality. Prespecified ancillary outcomes included time to hemostasis, blood product volumes transfused, complications, incidence of surgical procedures, and functional status.

RESULTS:

No significant differences were detected in mortality at 24 hours (12.7% in 1:1:1 group vs 17.0% in 1:1:2 group; difference, -4.2% [95% CI, -9.6% to 1.1%]; P = .12) or at 30 days (22.4% vs 26.1%, respectively; difference, -3.7% [95% CI, -10.2% to 2.7%]; P = .26). Exsanguination, which was the predominant cause of death within the first 24 hours, was significantly decreased in the 1:1:1 group (9.2% vs 14.6% in 1:1:2 group; difference, -5.4% [95% CI, -10.4% to -0.5%]; P = .03). More patients in the 1:1:1 group achieved hemostasis than in the 1:1:2 group (86% vs 78%, respectively; P = .006). Despite the 1:1:1 group receiving more plasma (median of 7 U vs 5 U, P < .001) and platelets (12 U vs 6 U, P < .001) and similar amounts of red blood cells (9 U) over the first 24 hours, no differences between the 2 groups were found for the 23 prespecified complications, including acute respiratory distress syndrome, multiple organ failure, venous thromboembolism, sepsis, and transfusion-related complications.

CONCLUSIONS AND RELEVANCE:

Among patients with severe trauma and major bleeding, early administration of plasma, platelets, and red blood cells in a 1:1:1 ratio compared with a 1:1:2 ratio did not result in significant differences in mortality at 24 hours or at 30 days. However, more patients in the 1:1:1 group achieved hemostasis and fewer experienced death due to exsanguination by 24 hours. Even though there was an increased use of plasma and platelets transfused in the 1:1:1 group, no other safety differences were identified between the 2 groups.

| Tags : hémorragie

19/12/2015

Military medicine in the 21st

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Amputé des jambes: Le bassin aussi !

The incidence of pelvic fractures with traumatic lower limb amputation in modern warfare due to improvised explosive devices

Cross AM et Al. J R Nav Med Serv 2014;100(2):152-6

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Excepté l'extraction d'urgence de blessés sous le feu, la prise en charge den cas d'amputation traumatique doit inclure la forte probabilité de traumatisme du bassin. Une utilisation large des immobilisations pelviennes doit donc être à l'esprit. On rappelle simplement la gravité et la difficulté de prise en charge des hémorragies liées aux fractures de bassin.

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AIMS:

A frequently-seen injury pattern in current military experience is traumatic lower limb amputation as a result of improvised explosive devices (IEDs). This injury can coexist with fractures involving the pelvic ring. This study aims to assess the frequency of concomitant pelvic fracture in IED-related lower limb amputation.

METHODS:

A retrospective analysis of the trauma charts, medical notes, and digital imaging was undertaken for all patients arriving at the Emergency Department at the UK military field hospital in Camp Bastion, Afghanistan, with a traumatic lower limb amputation in the six months between September 2009 and April 2010, in order to determine the incidence of associated pelvic ring fractures.

RESULTS:

Of 77 consecutive patients with traumatic lower limb amputations, 17 (22%) had an associated pelvic fracture (eleven with displaced pelvic ring fractures, five undisplaced fractures and one acetabular fracture). Unilateral amputees (n = 31) had a 10% incidence of associated pelvic fracture, whilst 30 % of bilateral amputees (n = 46) had a concurrent pelvic fracture. However, in bilateral, trans-femoral amputations (n = 28) the incidence of pelvic fracture was 39%.

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BKA - Below knee amputation; AKA - Above knee amputation

CONCLUSIONS:

The study demonstrates a high incidence of pelvic fractures in patients with traumatic lower limb amputations, supporting the routine pre-hospital application of pelvic binders in this patient group

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