Triage en cas d'attaque terroriste: Des limites

Triage in Complex, Coordinated Terrorist Attacks
Pepper M et Al. Prehosp Disaster Med. 2019 Aug;34(4):442-448. 

Introduction:

Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed.

Methods:

Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs).

Discussion:

Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage."

Conclusion:

Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

 

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

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

L'essence du triage

Ce témoignage exprime parfaitement tous les enjeux du sauvetage au combat en montrant qu'il s'agit d'un concept de prise en charge intégrant toutes les dimensions dela traumatologie moderne (préparation,  savoir faire personnel, travail en équipe: son équipe et les autres, délégation, leadership, gestion du stress). 

Etre fort dans sa tête, dans son savoir pour pouvoir former ses personnels et les guider au moment de l'action en ayant pris le recul suffisant.

Actu santé.pdf

Effectuer un triage