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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).

mz-2015-00061n_0008.gif

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

09/01/2016

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

25/12/2015

Transfusion de CGR: Les + graves seulement

Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study

Perel P et Al. PLoS Med. 2014 Jun 17;11(6):e1001664

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Les données qui suivent sont extraites de la cohorte des patients inclus dans l'étude CRASH2. Cette réinterprétation des données a pour objectif d'analyser le lien entre la mortalité à 28 jours et la transfusion de CGR. Les auteurs retrouvent un effet délétère de la transfusion de CGR pour les patients les moins à risque de mortalité. Ceci est en faveur des démarches de stratégies transfusionnelles sinon restrictives du moins raisonnées en fonction du contexte notamment préhospitalier où cette pratique associée à l'apport de fractions coagulantes semble être d'un grand intérêt(1).

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Background:

Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.

Methods and Findings:

A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: ,6%, 6%–20%, 21%–50%, and .50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction ,0.0001). Transfusion was associated with an increase in all-cause mortality among patients with , 6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p,0.0001, and OR 2.31, 95% CI 1.96–2.73, p,0.0001, respectively), but with a decrease in all-cause mortality in patients with .50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p,0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p,0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (,6%) predicted risk of death (p-value for interaction ,0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.

pmed.1001664.g001.jpg


Conclusions:

The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.

| Tags : hémorragie

19/12/2015

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%.

PelvicFractures.jpg

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

PelvicImmobilisation.jpg

19/11/2015

Stratégie Low Flow: Encore confirmée

Efficacy of limited fluid resuscitation in patients with hemorrhagic shock: a meta-analysis

Duan C. et Al. Int J Clin Exp Med. 2015; 8(7): 11645–11656.

ijcem0008-11645-f2.jpg

23/10/2015

Quelle place pour les facteurs de la coagulation ?

PlaceFactCoag.jpg

Clic sur l'image pour suivre la conférence

21/03/2015

Tourniquet: Efficace, uniquement si serré fort

Forward Assessment of 79 Prehospital Battlefield Tourniquet Use in the Current War

King DR et Al. J Spec Oper Med. 2012 Winter;12(4):33-8.

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La pose libérale d'un garrot est présentée comme étant un facteur essentiel de survie des blessés des membres. Encore faut il que ces derniers soient posés de manière correcte. Le document présenté laisse planer un gros doute. En effet il met en évidence qu'un garrot est mis en place 3 fois sur 4 alors qu'il n'y a pas de lésion vasculaire notable et que la plupart des garrots posés ne sont pas suffisamment serrés et sont en fait des garrots veineux. Pire seuls 1/3 des blessés ayant des lésions artérielles se voient appliquer un garrot artériel. C'est dire qu'une attention particulière doit être portée sur l'abolition du pouls artériel distal. Il s'agit là d'un enjeu pédagogique majeur.

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Introduction:

Battlefield tourniquet use can be lifesaving, but most reports are from hospitals with knowledge gaps remaining at the forward surgical team (FST). The quality of tourniquet applications in forward settings remain unknown. The purpose of this case series is to describe observations of tourniquet use at an FST in order to improve clinical performance.

Methods:

War casualties with tourniquet use presenting to an FST in Afghanistan in 2011 were observed. We identified appliers by training, device effectiveness, injury pattern, and clinical opportunities for improvement. Feedback was given to treating medics.

Results:

Tourniquet applications (79) were performed by special operations combat medics (47, 59%), flight medics (17, 22%), combat medics (12, 15%), and general surgeons (3, 4%). Most tourniquets were Combat Application Tourniquets (71/79, 90%). With tourniquets in place upon arrival at the FST, most limbs (83%, 54/65) had palpable distal pulses present; 17% were pulseless (11/65). Of all tourniquets, the use was venous in 83% and arterial in 17%. In total, there were 14 arterial injuries, but only 5 had effective arterial tourniquets applied.

Discussion:

Tourniquets are liberally applied to extremity injuries on the battlefield. 17% were arterial and 83% were venous tourniquets. When ongoing bleeding or distal pulses were appreciated, medics tightened tourniquets under surgeon supervision until distal pulses stopped. Medics were generally surprised at how tight a tourniquet must be to stop arterial flow–convert a venous tourniquet into an arterial tourniquet. Implications for sustainment training should be considered with regard to this life-saving skill.

07/02/2015

RFE Choc hémorragique

rfe ChocHem.jpg

 Clic sur l'image pour accéder au document

| Tags : choc, hémorragie

13/01/2015

Attentats: Importance du garrot

The Initial Response to the Boston Marathon Bombing. Lessons Learned to Prepare for the Next Disaster 

Gates JD et AL. Ann Surg. 2014 Dec;260(6):960-6

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Le concept du garrot tactique est familier aux équipes militaires. L'expérience rapportée montre que ce concept doit également le devenir dans le monde de la médecine préhospitalière. 26 soit près de 10% blessés pris en charge ont fait l'objet d'une pose de garrot. Ainsi en cas d'attentat la pose précoce d'un garrot en cas d'hémorragie des membres est elle une mesure fondamentale de mise en condition de survie.

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OBJECTIVE:

We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions.

BACKGROUND:

Multiple casualty incidents from natural or man-made incidents remain a constant global threat. Adequate preparation and the appropriate alignment of resources with immediate needs remain the key to optimal outcomes.

METHODS:

A collaborative effort among Boston's trauma centers (2 level I adult, 3 combined level I adult/pediatric, 1 freestanding level I pediatric) examined the details and outcomes of the initial response. Each center entered its respective data into a central database (REDCap), and the data were analyzed to determine various prehospital and early in-hospital clinical and logistical parameters that collectively define the citywide medical response to the terrorist attack.

RESULTS:

A total of 281 people were injured, and 127 patients received care at the participating trauma centers on that day. There were 3 (1%) immediate fatalities at the scene and no in-hospital mortality. A majority of the patients admitted (66.6%) suffered lower extremity soft tissue and bony injuries, and 31 had evidence for exsanguinating hemorrhage, with field tourniquets in place in 26 patients. Of the 75 patients admitted, 54 underwent urgent surgical intervention and 12 (22%) underwent amputation of a lower extremity.

Tourniquet Boston.jpg

CONCLUSIONS:

Adequate preparation, rapid logistical response, short transport times, immediate access to operating rooms, methodical multidisciplinary care delivery, and good fortune contributed to excellent outcomes.

30/10/2014

Plaquettes synthétiques: Possible ? Mais oui

Tuning Ligand Density on Intravenous Hemostatic Nanoparticles Dramatically Increases Survival Following Blunt Trauma

Proc Natl Acad Sci U S A. 2014 Jul 15;111 (28) 10293-10298

Des plaquettes synthétiques pour arrêter le saignement ? Certains l'ont fait grâce à la technologie des nanoparticules (1, 2). Un espoir qui reste à confirmer.

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Explosions account for 79% of combat-related injuries, leading to multiorgan hemorrhage and uncontrolled bleeding. Uncontrolled bleeding is the leading cause of death in battlefield traumas as well as in civilian life. We need to stop the bleeding quickly to save lives, but, shockingly, there are no treatments to stop internal bleeding. A therapy that halts bleeding in a site-specific manner and is safe, stable at room temperature, and easily administered is critical for the advancement of trauma care. To address this need, we have developed hemostatic nanoparticles that are administered intravenously. When tested in a model of blast trauma with multiorgan hemorrhaging, i.v. administration of the hemostatic nanoparticles led to a significant improvement in survival over the short term (1 h postblast). No complications from this treatment were apparent out to 3 wk. This work demonstrates that these particles have the potential to save lives and fundamentally change trauma care.

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| Tags : hémorragie

23/10/2014

Pansements hémostatiques: Actualisation 2014

Review of New Topical Hemostatic Dressings for Combat Casualty Care

Benett BL et Al Mil Med. 2014 May;179(5):497-514

This review analyzes the new (2008-2013) hemostatic agents and dressings for enhanced efficacy in preclinical studies, and investigates supportive findings among case reports of effectiveness and safety in hospital and prehospital literature. A literature search was conducted using PubMed, National Library of Medicine using key words and phrases. The search revealed a total of 16 articles that fit the criteria established for third-generation hemostatic dressings. There were a total of 9 preclinical, 5 clinical, and 2 prehospital studies evaluated. Evaluation of these third- generation studies reveals that mucoadhesive (chitosan) dressings, particularly Celox Gauze and ChitoGauze, clearly show equal efficacy to Combat Gauze across many dependent variables. Chitosan-based products are ideal prehospital dressings because they are shown to work independently from the physiological clotting mechanisms. Many first-, second-, and third-generation chitosan-based dressings have been in use for years by the United States and other NATO militaries at the point of injury, and during tactical evacuation, in Operation Enduring Freedom and Operation Iraqi Freedom without reported complications or side effects. Based on the reported efficacy and long-term safety of chitosan-based products, increased use of Celox Gauze and ChitoGauze within the Department of Defense and civilian venues merits further consideration and open debate.

14/09/2014

Plaie de l'abdomen: Comprimez avec le genou !

Abdominal aortic and iIiac artery compression following penetrating trauma: A study of feasibility

Douma et Al. Prehosp Disaster Med. 2014 Jun;29(3):299-302

Introduction 

Penetrating junctional trauma is a leading cause of preventable death on the battlefield. Similarly challenging in civilian settings, exsanguination from the vessels of the abdomen, pelvis, and groin can occur in moments. Therefore, iliac artery or abdominal aortic compression has been recommended. Based on prior research, 120 lbs (54 kg) or 140 lbs (63 kg) of compression may be required to occlude these vessels, respectively. Whether most rescuers can generate this amount of compression is unknown.

Objective 

To determine how many people in a convenience sample of 44 health care professionals can compress 120 lbs and 140 lbs.

Methods 

This study simulated aortic and iliac artery compression. Consent was obtained from 44 clinicians (27 female; 17 male) from two large urban hospitals in Edmonton, Alberta, Canada. Participants compressed the abdominal model, which consisted of a medical scale and a 250 ml bag of saline, covered by a folded hospital blanket and placed on the ground. In random order, participants compressed a force they believed maintainable for 20 minutes (“maintainable effort”) and then a maximum force they could maintain for two minutes (“maximum effort”). Compression was also performed with a knee. Descriptive statistics were used to evaluate the data.

Results 

Compression was directly proportional to the clinician's body weight. Participants compressed a mean of 55% of their body weight with two hands at a maintainable effort, and 69% at a maximum effort. At maintainable manual effort, participants compressed a mean of 86 lbs (39 kg). Sixteen percent could compress over 120 lbs, but none over 140 lbs. At maximum effort, participants compressed a mean of 108 lbs (48 kg). Thirty-four percent could compress greater than 120 lbs and 11% could compress greater than 140 lbs. Using a single knee, participants compressed a mean weight of 80% of their body weight with no difference between maintainable and maximum effort.

Conclusion 

This work suggests that bimanual compression following penetrating junctional trauma is feasible. However, it is difficult, and is not likely achievable or sustainable by a majority of rescuers. Manual compression (used to temporize until device application and operative rescue) requires a large body mass. To maintain 140 lbs of compression (for example during a lengthy transport), participants needed to weigh 255 lbs (115 kg). Alternatively, they needed to weigh 203 lbs (92 kg) to be successful during brief periods. Knee compression may be preferable, especially for lower-weight rescuers.

| Tags : hémorragie

31/05/2014

Pansements hémostatiques: Utilité non démontrée

Haemostatic dressings in prehospital care

Hewitt Smith A. et Al.  Emerg Med J 2013; 30:784–789

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Une revue de littérature qui confirme que le bien fondé de l'emploi des pansements hémostatiques n'est pas si solide que cela. Pansement compressif et packing de plaie sont des valeurs sûres.

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Massive haemorrhage still accounts for up to 40% of mortality after traumatic injury. The importance of limiting blood loss after injury in order to prevent its associated complications has led to rapid advances in the development of dressings for haemostatic control. Driven by recent military conflicts, there is increasing evidence to support their role in the civilian prehospital care environment. This review aims to summarise the key characteristics of the haemostatic dressings currently available on the market and provide an educational review of the published literature that supports their use. Medline and Embase were searched from start to January 2012. Other sources included both manufacturer and military publications. Agents not designed for use in prehospital care or that have been removed from the market due to significant safety concerns were excluded. The dressings reviewed have differing mechanisms of action. Mineral based dressings are potent activators of the intrinsic clotting cascade resulting in clot formation. Chitosan based dressings achieve haemostasis by adhering to damaged tissues and creating a physical barrier to further bleeding. Acetylated glucosamine dressings work via a combination of platelet and clotting cascade activation, agglutination of red blood cells and local vasoconstriction. Anecdotal reports strongly support the use of haemostatic dressings when bleeding cannot,be controlled using pressure dressings alone; however, current research focuses on studies conducted using animal models. There is a paucity of published clinical literature that provides an evidence base for the use of one type of haemostatic dressing over another in humans

 

07/04/2014

Le point sur le contrôle des hémorragies externes

An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma

Bulger EM et Al. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163-73.

Cet article fait le point à partir de données publiées sur les grands principes d'arrêt des hémorragies externes: Compression directe, garrot artériel en cas d'inefficacité, relatif faible niveau de preuves pour les pansements hémostatiques à utiliser néanmoins comme agent de packing de plaies, nécessité de poursuivre la recherche sur les dispositifs de compression jonctionnelle.

 

ATTENTION Il s'agit de préhospitalier CIVIL

PrehospTourniquet.jpg

Clic sur l'image pour accéder au document

 

| Tags : hémorragie, garrot

24/02/2014

Garrot abdominal: Il est efficace

Abdominal Aortic Tournique Use in Afghanistan

Anonymous. J Spec Oper Med. 2013 Summer;13(2):1-2.

La prise en charge des blessés de guerre a pour objectif essentiel d'obtenir l'arrêt des hémorragies le plus précocement possible. Parmi les dispositifs récemment proposés on trouve le garrot abdominal. On rapporte ici l'emploi couronné de succès d'un tel dispositif.

AAT Afghanistan.JPG

 

| Tags : garrot, hemorragie

18/02/2014

Electricité et hémorragie non compressible ?

Vasoconstriction by Electrical Stimulation: New Approach to Control of Non-Compressible Hemorrhage

Mandel Y et AL. Sci Rep. 2013; 3: 2111.

Non-compressible hemorrhage is the most common preventable cause of death on battlefield and in civilian traumatic injuries. We report the use of microsecond pulses of electric current to induce rapid constriction in femoral and mesenteric arteries and veins in rats. Electrically-induced vasoconstriction could be induced in seconds while blood vessels dilated back to their original size within minutes after stimulation. At higher settings, a blood clotting formed, leading to complete and permanent occlusion of the vessels. The latter regime dramatically decreased the bleeding rate in the injured femoral and mesenteric arteries, with a complete hemorrhage arrest achieved within seconds. The average blood loss from the treated femoral artery during the first minute after injury was about 7 times less than that of a non-treated control. 

Electrical.JPG

This new treatment modality offers a promising approach to non-damaging control of bleeding during surgery, and to efficient hemorrhage arrest in trauma patients

07/01/2014

Pansement hémostatique: Restons critiques !

 An Evidence-Based Review of the Use of a Combat Gauze (QuikClot) for Hemorrhage Control

Gegel BT et Al. Am Surg. 2011 Feb;77(2):162-5.

_________________________________________________________________________

L'efficacité des pansements hémostatiques apparaît être une évidence. Ils sont utilisés de manière large sans véritables fondements scientiifiques prouvés.  Une analyse critique s'impose, ce d'autant qu'il s'agit de produits onéreux et que l'industrie a bien façonné notre manière de raisonner. Cet article le rappelle. 

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Trauma is a leading cause of morbidity and mortality. Uncontrolled hemorrhage related to the traumatic event is often the major cause of complications and death. The use of hemostatic agents may be one of the easiest and most effective methods of treating hemorrhage. The US military recommends a hemostatic combat gauze (QuikClot Combat Gauze) as the first-line hemostatic agent for use in treatment of severe hemorrhage. This review provides essential information for evidence-based use of this agent. The PICO (patient, intervention, comparison, outcome) question guiding this search for evidence was: Is QuikClot Combat Gauze, a hemostatic agent, effective and safe in controlling hemorrhage in trauma patients in the prehospital setting? The evidence appraised was a combination of lower-level human and animal research. It did not conclusively demonstrate that this combat gauze is an effective hemostatic agent for use in trauma patients, but the results are promising in supporting its use. The evidence does not describe serious side effects, exothermic reaction, and thromboemboli formation associated with other hemostatic agents. Further inves tigation to determine the effectiveness of hemostatic agents, specifically QuikClot Combat Gauze, in the management of trauma casualties in the prehospital setting is required. These should include large-scale, multicenter, prehospital randomized controlled trials.

08/12/2013

Tourniquet abdominal: En théorie cela fonctionne

The Evaluation of an Abdominal Aortic Tourniquet for the Control of Pelvic and Lower Limb Hemorrhage

Taylor D. et Al.Mil Med. 2013;178(11):1196-201

Despite improved body armor, hemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, groin, and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a prehospital device capable of preventing pelvic and proximal lower limb hemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure, and abdominal girth were recorded. Doppler ultrasound was used to identify blood flow in the common femoral artery (CFA). The AAT was applied while the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. A total of 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, body mass index, and abdominal girth. This study shows the AAT to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving.

| Tags : hémorragie

24/11/2013

Garrot abdominal: Une paire de main et des bras musclés

Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report

Douma M et Al. Ann Emerg Med. 2013 Oct 23. pii: S0196-0644(13)01452-2

La prise en charge des traumatismes vasculaires de l'abdomen, du pelvis et des membres nécessite une intervention chirurgicale rapide. Il est dans ces cas nécessaire de tarir sinon de réduire le débit de saignement de telle sorte que le blessé arrive vivant dans la structure adaptée (1). Ceci est difficile quand les lésions ne sont pas ou difficilement garrotables notamment lors de traumatismes jonctionnels. Des équipements spécifiques ont été développé pour assurer une compression en amont des lésions et permettre de réduire ces débits de saignements. Ces dispositifs présenté par ailleurs (2, 3 , 4) n'ont pas encore fait leur preuve même si des rapports isolés en soulignent l'intérêt. Certains comme les pantalons antichocs sont considérés comme ayant peu d'indications du moins mal cernées (5) . Ces équipements sont rarement disponibles.

Pourtant la compression abdominale bi-manuelle est possible et en fait connue depuis longtemps notamment en obstétrique sous forme de compression utérine bi-manuelle (6, 78). 

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C'est ce qu'illustre le cas clinique présenté. Il existe bien sûr des facteurs limitant comme la corpulence aussi bien du blessé que du sauveteur. Il faut en effet exercer une pression abdominale de l'ordre de 40 kg pour occlure l'aorte abdominal (9).

| Tags : hémorragie, garrot

06/11/2013

Pansement compressif: Un nouveau venu

Le pansement Airwrap

Il existe une grande variété de pansements compressifs. L'armée française utilise le pansement dit israélien de la société Persys Medical et le pansement Olaes modular bandage de la société TacMed Solutions. En plus des bandes de compression, d'autres dispositifs on fait leur apparition visant à contrôler les hémorragies par une compression plus proximale (le CROC, le tourniquet abdominal, le SAMTourniquet, le Junctional emergency treatment tool). Ces dispositifs ont recours à des dispositifs de compression. L'Aiwrap est un pansement compressif proche des pansements en dotation auquel est adjoint une vessie qui une fois gonflée va majorer de manière importante la compression sous le pansement. Son positionnement dans une gamme de produit reste à préciser.

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