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02/07/2015

Evasan stratégiques: Que fait on ?

Thèse Vitalis.jpg

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| Tags : evasan

21/06/2015

Un nouveau concept de triage ?

Medical evacuation and triage of combat casualties in Helmand Province, Afghanistan: October 2010-April 2011

Clarke JE et Al. Mil Med. 2012 Nov;177(11):1261-6

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Un article de synthèse sur l'organisation de la chaîne de prise en charge des blessés par nos confrères anglais, avec notamment l'emploi d'une évolution majeure pour le un système anglo-saxon (lire ce document): le recours à des EVASAN médicalisées par des personnels ayant une pratique régulière de la prise en charge de patients en état critique. Cet article est intéressant car il insiste sur l'importance du triage et le rôe prééminent que peuvent jouer les role 2 notamment si les élongations sont importantes.

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Medical evacuation of combat casualties in Operation Enduring Freedom-Afghanistan is achieved primarily by helicopter, because of distances involved as well as ground-based threats. In Helmand Province, evacuation from the point of injury may occur on a variety of helicopter evacuation platforms with disparate levels of attendant medical expertise. Furthermore, triage to a medical treatment facility may involve varying echelons of care before definitive management. Consequently, considerable differences in medical care may be encountered between point of injury and definitive treatment. We discuss the role of helicopter-based medical evacuation in Helmand, Afghanistan, as well as triage and timelines to the most appropriate medical facilities. Based on our experience and available evidence, we have made recommendations to regional commanders which favor the utilization of prehospital critical care teams aboard helicopter-based evacuation platforms and direct triage to the highest echelon of care available when feasible

| Tags : triage, medevac, evasan

Médecin EXPERIMENTÉ: Pronostic amélioré

Determining the composition and benefit of the pre-hospital medical response team in the conflict setting

Davis PR et Al. J R Army Med Corps. 2007 Dec;153(4):269-73

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La composition des équipes d'evasan tactique fait débat. La présence d'un médecin serait associée à une meilleure survie des blessés les plus graves, surtout si les délais de prise en charge par une équipe chirurgicales sont longs. Encore faut il que ce médecin ait de réelles compétences en matière de traumatologie et d'exercice de la médecine préhospitalière en situation isolée.

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Aim: To determine the optimal composition of the pre-hospital medical response team (MERT) and the value of prehospitalvcritical care interventions in a military setting, and specifically to determine both the benefit of including a doctor in the pre-hospital response team and the relevance of the time and distance to definitive care.

Method: A comprehensive review of the literature incorporating a range of electronic search engines and hand searches of key journals.

Results: There was no level 1 evidence on which to base conclusions. The 15 most relevant articles were analysed in detail. There was one randomized controlled trial (level 2 evidence) that supports the inclusion of a doctor on MERT. Several cohort studies were identified that analysed the benefits of specific critical care interventions in the pre-hospital setting.

Conclusions: A doctor with critical care skills deployed on the MERT is associated with improved survival in victims of major trauma. Specific critical care interventions including emergency endotracheal intubation and ventilation, and intercostal drainage are associated with improved survival and functional recovery in certain patients.

| Tags : evasan, medevac

01/05/2015

Medevac tactique:Médicalisation utile pour 30% des blessés

En-Route Care Capability From Point of Injury Impacts Mortality After Severe Wartime Injury

Morrison JJ et AL. Ann Surg 2013;257: 330–334

 

Il est difficile de se faire une idée de l'efficience de nos organisations de relève des blessés de guerre. En effet les 2/3 de ses derniers sont peu graves et ne nécessitent pas de pratiques avancées. Le conflit afghan a permis de confirmer la pertinence d'un certain nombre de faits: Une stratégie de conditionnement basé sur l'analyse des causes évitables de décès, l'importance de la mise en place d'un réseau structuré de prise en charge préhospitalière et hospitalière. Ce document confirme que la médicalisation avancée améliore la probabilité de survie des  blessés de gravité intermédiaire qui représentent tout de même près du  1/3 des cas rencontrés et qui justifient nos organisations. Ceci confirme que la maîtrise de pratiques de base de réanimation préhospitalière devrait donc être l'un des piliers de l'organisation des évacuations médicales tactiques. 

 

OBJECTIVE:

The objective of this study is to characterize modern point-of-injury (POI) en-route care platforms and to compare mortality among casualties evacuated with conventional military retrieval (CMR) methods to those evacuated with an advanced medical retrieval (AMR) capability.

BACKGROUND:

Following a decade of war in Afghanistan, the impact of en-route care capabilities from the POI on mortality is unknown.

METHODS:

Casualties evacuated from POI to one level III facility in Afghanistan (July 2008-March 2012) were identified from UK and US trauma registries. Groups comprised those evacuated by a medically qualified provider-led, AMR and those by a medic-led CMR capability. Outcomes were compared per incremental Injury Severity Score (ISS) bins.

RESULTS:

Most casualties (n = 1054; 61.2%) were in the low-ISS (1-15) bracket in which there was no difference in en-route care time or mortality between AMR and CMR. Casualties in the mid-ISS bracket (16-50) (n = 583; 33.4%) experienced the same median en-route care time (minutes) on AMR and CMR platforms [78 (58) vs 75 (93); P = 0.542] although those on AMR had shorter time to operation [110 (95) vs 117 (126); P < 0.001]. In this mid-ISS bracket, mortality was lower in the AMR than in the CMR group (12.2% vs 18.2%; P = 0.035). In the high-ISS category (51-75) (n = 75; 4.6%), time to operation was lower in the AMR than the CMR group (66 ± 77 vs 113 ± 122; P = 0.013) but there was no difference in mortality.

CONCLUSIONS:

This study characterizes en-route care capabilities from POI in modern combat. Conventional platforms are effective in most casualties with low injury severity. However, a definable injury severity exists for which evacuation with an AMR capability is associated with improved survival.

| Tags : evasan

07/08/2013

EVASAN: Médicalisé, c'est mieux

Performance improvement evaluation of forward aeromedical evacuation platforms in Operation Enduring Freedom

Apodaca A et All., J Trauma Acute Care Surg. 2013;75: S157YS

BACKGROUND: The following three helicopter-based medical evacuation platforms operate in Southern Afghanistan: the US Army emergency medical technician (basic)Yled DUSTOFF, US Air Force paramedic-led PEDRO, and UK physician-led medical emergency response team (MERT). Nearly 90% of battlefield deaths occur in the prehospital phase, comparative outcomes for these en route care platforms are unknown. The objective of this investigation was to characterize the nature of injuries in patients transported by three evacuation platforms. In addition, it aimed to compare observed versus predicted mortality among these provider groups.

METHODS: A performance improvement study involving 975 coalition patients injured in Southern Afghanistan, transported from the point of injury to a military hospital, was performed. All patients were alive on admission with prehospital documentation recorded in the US Department of Defense Trauma Registry from June 2009 to June 2011. The main outcome measure was in-hospital mortality and observed versus predicted (Trauma and Injury Severity Score [TRISS]) survival were the primary end points.

RESULTS: MERT transported more amputation and polytrauma casualties and included patients with higher mean Injury Severity Score (ISS) compared with PEDRO and DUSTOFF (16 [13] vs. 11 [10] and 10 [10] respectively; p G 0.001). DUSTOFF was excluded from the subgroup analysis owing to insufficient numbers of severely injured casualties with only one death. The overall mortality for MERT and PEDRO was similar (4.2% vs. 4.6%, p= 0.967). Stratifying by ISS, there was lower mortality in MERT compared with PEDRO in the range of 20 to 29 (4.8% vs. 16.2%, p = 0.021). The observed mortality among PEDRO casualties was as predicted with the exception of the range of 20 to 29, while mortality in MERTwas lower than predicted for all ISS groups with greater than 10.

 

CONCLUSION: MERT achieves greater than predicted survival, which may be related to the additional capabilities onboard. This supports the adoption of a versatile medical evacuation system with scalable crew and equipment configurations that adapt to meet the medical, tactical, and operational needs of future conflicts.

| Tags : evasan

17/07/2013

La douleur: S'en occuper ACTIVEMENT

Pain Following Battlefield Injury and Evacuation: A Survey of 110 Casualties from the Wars in Iraq and Afghanistan

Buckenmaier III CC et All. Pain Med. 2009 Nov;10(8):1487-96.

Objective. Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. Painmanagement practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. An exploratory study was undertaken to examine pain and other outcomes during evacuation and at Landstuhl Regional Medical Center (LRMC), Germany. 

Design. A mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded U.S. soldiers evacuated from Iraq and Afghanistan to LRMC. Setting and Patients. A total of 110 wounded soldiers evacuated from Iraq and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0–10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann–Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation.

Results. Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05).

PainTransport.jpg

Average percent pain relief achieved was 45.2%  26.6% during transport and 64.5%  23.5% while at LRMC (P < 0.001).

douleur,analgésie,evasan

Participants with CPNB catheters placed at LRMC reported significantlyy less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs

PainTransport2.jpg

Conclusions. Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes


31/05/2013

Mieux on est formé, plus on fait

Army flight medic performance of paramedic level procedures: Indicated vs performed

Bier SA et all. - J Emerg Med. 2013 May;44(5):962-9.

Of 984 interventions found to be indicated on the 406 charts that met inclusion criteria, 36% were rated as EMT-P level. Seventeen percent were indicated but not performed. EMT-Bs failed to perform indicated procedures 35% of the time vs. 3% in the EMT-P group (p < 0.001). For paramedic-level procedures, EMTBs failed to make 76% of appropriate interventions, compared to <1% in the EMT-P group (p < 0.001). Conclusions: There seems to be a substantial number of procedures beyond the scope of standard Army flight medic training being required for Army AMT missions. It seems that when advance interventions are indicated, those trained to the EMT-P level perform them significantly more often than those trained to Army standard. Conclusions: Based on the findings of this study, the authors suggest the Army consider adopting the standards required for civilian AMT

GestesIndiquésVSRéa1.jpeg

Commentaire:Notez la part de pédiatrie

evasan

evasan

Commentaire: EMT-B = Auxilaire sanitaire. EMT P = Technicien de niveau plutôt infirmiers formés exclusivement à la gestion de soins critiques. Pas d'équivalence avec la vision française (entre infirmier anesthésiste/réa ?)

Ceci milite pour la présence dans les vecteurs d'EVASAN notamment aériens de personnels paramédicaux spécifiques habitués à la mise en oeuvre de standards de soins critiques

| Tags : evasan