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Travers S, Carfantan C, Luft A, Aigle L, Pasquier P, Martinaud C, Renard A, Dubourg O, Derkenne C, Kedzierewicz R, Franchin M, Bay C, Cap AP, Ausset S. Five years of prolonged field care: prehospital challenges during recent French military operations. Transfusion 2019; 59:1459-1466. [PMID: 30980759 DOI: 10.1111/trf.15262] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 01/18/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.
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Affiliation(s)
- Stéphane Travers
- 2ème Centre Médical des Armées, 12ème Antenne Médicale, French Military Health Service, Villacoublay, France.,French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France
| | - Cyril Carfantan
- French Military Health Service - Operational Headquarters, Paris, France
| | - Antoine Luft
- French Military Health Service - Operational Headquarters, Paris, France
| | - Luc Aigle
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,10ème Centre Médical des Armées, 154ème Antenne Médicale, French Military Health Service, Aubagne, France
| | - Pierre Pasquier
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,French Military Health Service, Percy Military Hospital, Clamart, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France.,Centre de Transfusion Sanguine des Armées, French Military Health Service, Clamart, France
| | - Aurelien Renard
- Emergency Department, Saint Anne Military Hospital, French Military Health Service, Toulon, France
| | - Olivier Dubourg
- CMIA Saint-Denis, Antenne Médicale de St Pierre, French Military Health Service, La Réunion, France
| | - Clement Derkenne
- Paris Fire Brigade Medical Emergency Department, French Military Health Service, Paris, France
| | - Romain Kedzierewicz
- Paris Fire Brigade Medical Emergency Department, French Military Health Service, Paris, France
| | - Marilyn Franchin
- 2ème Centre Médical des Armées, 12ème Antenne Médicale, French Military Health Service, Villacoublay, France
| | - Christian Bay
- French Military Health Service - Ground Forces Headquarters, Tours, France
| | - Andrew P Cap
- Medical Corps, US Army, US Army Institute of Surgical Research, Fort Sam Houston, Texas
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce Military Academy, Paris, Paris, France
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Boutonnet M, Raynaud L, Pasquier P, Vitiello L, Coste S, Ausset S. Critical Care Skill Triad for Tactical Evacuations. Air Med J 2018; 37:362-366. [PMID: 30424853 DOI: 10.1016/j.amj.2018.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 06/08/2018] [Accepted: 07/22/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Providing medical support to French soldiers deployed on war theater everywhere around the world is the first mission of the French Military Medical Service (FMMS). En-route critical care is critical to maintain the continuum of care and safety during forward and tactical medical evacuation (MEDEVAC). The FMMS has developed specific training programs to ensure optimal en-route critical care air transport. These courses need to be continuously adjusted to the returns of experience and to the operational changes. The aim of our survey was to characterize the critical care skills required for tactical MEDEVAC on fixed wing aircraft. METHODS A 10-items survey was sent to 22 flight surgeons previously deployed in the Sahel-Saharan Strip. Eight questions focused on basic critical care skills. The 2 last items assessed the flight surgeons' willingness to follow a pre deployment course in a critical care unit and in a transfusion center. RESULTS Fourteen of the 22 flight surgeons responded to the survey. All but one responder had to deal with at least one critical care skill. The most frequent critical care skills required were the management of mechanical ventilation, catecholamine infusion and blood product transfusion. Five of the 14 responders reported on-board blood product transfusion, including red blood cells, lyophilized plasma and fresh whole blood. CONCLUSION Our survey highlights the need for the MEDEVAC teams to be skilled in critical care medicine. We defined a triad of critical care skills required for the management of severe casualties, including the management of mechanical ventilation, catecholamine infusion and blood product transfusion.
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Affiliation(s)
- Mathieu Boutonnet
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France.
| | - Laurent Raynaud
- Department of Anesthesiology and Intensive Care, Bégin Military Teaching Hospital, Saint-Mandé, France
| | - Pierre Pasquier
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France
| | | | | | - Sylvain Ausset
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France
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Vitalis V, Carfantan C, Montcriol A, Peyrefitte S, Luft A, Pouget T, Sailliol A, Ausset S, Meaudre E, Bordes J. Early transfusion on battlefield before admission to role 2: A preliminary observational study during "Barkhane" operation in Sahel. Injury 2018; 49:903-910. [PMID: 29248187 DOI: 10.1016/j.injury.2017.11.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/10/2017] [Accepted: 11/22/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Haemorrage is the leading cause of death after combat related injuries and bleeding management is the cornerstone of management of these casualties. French armed forces are deployed in Barkhane operation in the Sahel-Saharan Strip who represents an immense area. Since this constraint implies evacuation times beyond doctrinal timelines, an institutional decision has been made to deploy blood products on the battlefield and transfuse casualties before role 2 admission if indicated. The purpose of this study was to evaluate the transfusion practices on battlefield during the first year following the implementation of this policy. MATERIALS AND METHODS Prospective collection of data about combat related casualties categorized alpha evacuated to a role 2. Battlefield transfusion was defined as any transfusion of blood product (red blood cells, plasma, whole blood) performed by role 1 or Medevac team before admission at a role 2. Patients' characteristics, battlefield transfusions' characteristics and complications were analysed. RESULTS During the one year study, a total of 29 alpha casualties were included during the period study. Twenty-eight could be analysed, 7/28 (25%) being transfused on battlefield, representing a total of 22 transfusion episodes. The most frequently blood product transfused was French lyophilized plasma (FLYP). Most of transfusion episodes occurred during medevac. Compared to non-battlefield transfused casualties, battlefield transfused casualties suffered more wounded anatomical regions (median number of 3 versus 2, p = 0.04), had a higher injury severity score (median ISS of 45 versus 25, p = 0,01) and were more often transfused at role 2, received more plasma units and whole blood units. There was no difference in evacuation time to role 2 between patients transfused on battlefield and non-transfused patients. There was no complication related to battlefield transfusions. Blood products transfusion onset on battlefield ranged from 75 min to 192 min after injury. CONCLUSION Battlefield transfusion for combat-related casualties is a logistical challenge. Our study showed that such a program is feasible even in an extended area as Sahel-Saharan Strip operation theatre and reduces time to first blood product transfusion for alpha casualties. FLYP is the first line blood product on the battlefield.
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Affiliation(s)
- V Vitalis
- French Medical Unit, Medical Centre of Lyon, France
| | - C Carfantan
- French Military Medical Service, Operational Headquarters, France
| | - A Montcriol
- Sainte Anne Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Toulon, France
| | - S Peyrefitte
- French Medical Unit, Naval Special Operations Commandos Command, Lanester, France
| | - A Luft
- French Military Medical Service, Operational Headquarters, France
| | - T Pouget
- French Military Blood Institute, Clamart, France
| | - A Sailliol
- French Military Blood Institute, Clamart, France
| | - S Ausset
- Percy Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Clamart, France & Val de Grâce Military Academy, Paris, France
| | - E Meaudre
- Sainte Anne Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Toulon, France
| | - J Bordes
- Sainte Anne Military Teaching Hospital, Anaesthesia and Intensive Care Unit, Toulon, France; 7th Paratrooper Forward Surgical Unit, France.
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Bordes J, Joubert C, Esnault P, Montcriol A, Nguyen C, Meaudre E, Dulou R, Dagain A. Coagulopathy and transfusion requirements in war related penetrating traumatic brain injury. A single centre study in a French role 3 medical treatment facility in Afghanistan. Injury 2017; 48:1047-1053. [PMID: 27938877 DOI: 10.1016/j.injury.2016.11.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 10/30/2016] [Accepted: 11/19/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited. MATERIALS AND METHODS A descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period. RESULTS On 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%). CONCLUSION The results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.
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Affiliation(s)
- J Bordes
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France.
| | - C Joubert
- Sainte Anne Military Teaching Hospital, Neurosurgery Unit, Toulon, France
| | - P Esnault
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France
| | - A Montcriol
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France
| | - C Nguyen
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France
| | - E Meaudre
- Sainte Anne Military Teaching Hospital, Intensive Care Unit, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - R Dulou
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France; Val-de-Grâce Military Teaching Hospital, Neurosurgery Unit, Paris, France
| | - A Dagain
- Sainte Anne Military Teaching Hospital, Neurosurgery Unit, Toulon, France; French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
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Falzone E, Pasquier P, Hoffmann C, Barbier O, Boutonnet M, Salvadori A, Jarrassier A, Renner J, Malgras B, Mérat S. Triage in military settings. Anaesth Crit Care Pain Med 2017; 36:43-51. [DOI: 10.1016/j.accpm.2016.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 04/05/2016] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
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Malgras B, Barbier O, Petit L, Rigal S, Pons F, Pasquier P. Surgical challenges in a new theater of modern warfare: The French role 2 in Gao, Mali. Injury 2016; 47:99-103. [PMID: 26264878 DOI: 10.1016/j.injury.2015.07.035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Revised: 06/10/2015] [Accepted: 07/27/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION On January 11th 2013, France launched Operation Serval in Mali following Resolution 2085 of the Security Council of the United Nations. Between January and March 2013, more than 4000 French soldiers were deployed to support the Malian National Army and the African Armed Forces. METHODS All of the patients who had surgery during Operation Serval were entered into a computerised database. Patients' demographic data (age, sex, status) and types of performed surgical procedures (specialties, injury mechanisms) were recorded. RESULTS 268 patients were operated on in Gao's Role 2 with a total of 296 surgeries. Among those operated on, 40% were Malian civilians, 24% were French soldiers, and 36% were soldiers of the International Coalition Forces. The majority of the surgeries were orthopaedic, and visceral surgeries were common as well, representing 43% of the total surgeries. Specialised surgical procedures including neurosurgery, thoracic, and vascular surgery were also performed. Forty percent of the surgeries were scheduled. War-related traumatic surgeries represented 22% of the surgical procedures, with non-war related surgeries and non-trauma emergency surgeries making up the rest. CONCLUSION this analysis confirms the specific characteristic of asymmetric warfare that it results in a relatively reduced number of war-related casualties. Forward surgical teams have to deal with a wide range of injuries requiring several surgical specialties. Surgeries dedicated to medical aid provided to the population also represented an important part of the surgical activity. Because of the diversity and the technicality of the surgical procedures in Role 2, surgeons had to be trained in war surgery covering all of the surgical specialties, while they maintained their specific skills. In France in 2007, the French Military Health Service Academy (École du Val-de-Grâce, Paris, France) offered an advanced course in surgery for deployment in combat zones, with a special focus on damage control surgeries and the management of mass casualties incidents.
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Affiliation(s)
- Brice Malgras
- 14th Parachutist Forward Surgical Team, France; Department of Digestive Surgery, Val de Grace Military Teaching Hospital, 74 boulevard de Port Royal, 75005 Paris, France.
| | - Olivier Barbier
- 14th Parachutist Forward Surgical Team, France; Department of Orthopedic Surgery, Begin Military Teaching Hospital, 69 avenue de Paris, 94160 Saint Mandé, France
| | - Ludovic Petit
- Medical Unit of the 8th French Military Parachutist Unit, avenue Jacques Desplats, 81100 Castres, France
| | - Sylvain Rigal
- Clinic of Traumatology and Orthopaedics, Percy Military Teaching Hospital, 101 avenue de Henri Barbusse, 92140 Clamart, France
| | - François Pons
- French Military Health Service Academy, Ecole du Val de Grace, 1 place Alphonse Laveran, 75005 Paris, France
| | - Pierre Pasquier
- 14th Parachutist Forward Surgical Team, France; Intensive Care Unit, Begin Military Teaching Hospital, 69 avenue de Paris, 94160 Saint Mandé, France
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Pasquier P, Boutonnet M, Jault P, Pelée de Saint Marice G, Ausset S. Platelets in the 'Code Red' transfusion request policy initiated by pre-hospital physicians. Injury 2015; 46:2086-7. [PMID: 26283083 DOI: 10.1016/j.injury.2015.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 07/30/2015] [Indexed: 02/02/2023]
Affiliation(s)
- Pierre Pasquier
- Department of Anaesthesiology and Intensive Care, Percy Military Teaching Hospital, France.
| | - Mathieu Boutonnet
- Department of Anaesthesiology and Intensive Care, Percy Military Teaching Hospital, France.
| | - Patrick Jault
- Department of Anaesthesiology and Intensive Care, Percy Military Teaching Hospital, France.
| | | | - Sylvain Ausset
- Department of Anaesthesiology and Intensive Care, Percy Military Teaching Hospital, France.
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Sailliol A, Martinaud C, Cap AP, Civadier C, Clavier B, Deshayes AV, Mendes AC, Pouget T, Demazeau N, Chueca M, Martelet FR, Ausset S. The evolving role of lyophilized plasma in remote damage control resuscitation in the French Armed Forces Health Service. Transfusion 2013; 53 Suppl 1:65S-71S. [PMID: 23301975 DOI: 10.1111/trf.12038] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Freeze-dried plasma was developed by the US Army for the resuscitation of combat casualties during World War II. The French Military Blood Institute began producing French lyophilized plasma (FLYP) in 1949, in accordance with French blood product guidelines. Since 2010, a photochemical pathogen inactivation process has been implemented to reduce the remaining transfusion-related infectious risk. All quality controls for this procedure verify that the hemostatic properties of FLYP are conserved. FLYP is compatible with all blood types, can be stored at room temperature for 2 years, and its reconstitution requires less than 6 minutes. As a result, FLYP allows quick delivery of all the coagulation proteins and the application of a 1:1 ratio of FLYP and red blood cells in the context of a massive transfusion. Hemovigilance data collected in France since 1994 have included FLYP. Results indicate no reporting of infection related to the use of FLYP. Clinical monitoring with a focus on hemostasis was implemented in 2002 and expanded in 2010. The data, obtained from overseas operations, confirmed the indications, the safety and the clinical efficacy of FLYP. Further research is needed to determine specific indications for FLYP in the therapeutic management of civilian patients with severe hemorrhage.
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Affiliation(s)
- Anne Sailliol
- Centre de Transfusion Sanguine des Armées, Clamart, France.
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Use of freeze-dried plasma in French intensive care unit in Afghanistan. ACTA ACUST UNITED AC 2012; 71:1761-4; discussion 1764-5. [PMID: 22182886 DOI: 10.1097/ta.0b013e31822f1285] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Modern warfare causes severe injuries, and despite rapid transportation to theater regional trauma centers, casualties frequently arrive coagulopathic and in shock. Massive hemorrhage management includes transfusion of red blood cells and plasma in a 1:1 ratio. Fresh frozen plasma requires thawing and badly fits the emergency criteria. Since 1994, the French Military Blood Bank has been producing freeze-dried plasma (FDP) and providing it for overseas operation. The aim of our study was to evaluate the use of FDP in war settings and to assess its clinical efficiency and safety. PATIENTS We performed a prospective study of the FDP delivered at the International Security Assistance Force Role 3 Military Medical Treatment Facility in the Kabul Afghanistan International Airport between February 2010 and February 2011. We included every patient who received at least one unit of FDP. Basic clinical data were recorded at admission. Transfusion requirements were monitored. Biological testing were performed before and after administration of FDP including hemoglobin concentration, platelets count, fibrinogen level, prothrombin time (PT), and thromboelastography. RESULTS Eighty-seven casualties received FDP during 93 episodes of transfusion. On average, 3.5 FDP units were transfused per episodes of transfusion. Of the 87 patients studied, 7 died because of nonsurvivable injuries and outcomes were unavailable for 11. The other 59 patients survived. PT significantly declined by an average of 3.3 seconds after FDP transfusion. This moderate decrease in PT reflects continued bleeding and resuscitation. It nevertheless suggests improvement in hemostasis before surgical control of bleeding. All FDP users reported ease of use, clinically observed efficacy equivalent to fresh frozen plasma and the absence of adverse effects associated with FDP. CONCLUSION Our results provide evidence of the effectiveness of FDP for the prevention or correction of coagulopathy and hemorrhage in combat casualties.
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Pasquier P, de Rudnicki S, Donat N, Auroy Y, Merat S. Type et épidémiologie des blessures de guerre, à propos de deux conflits actuels : Irak et Afghanistan. ACTA ACUST UNITED AC 2011; 30:819-27. [DOI: 10.1016/j.annfar.2011.05.018] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 05/31/2011] [Indexed: 11/30/2022]
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