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Vincent Y, Baltazard C, Pfister G, Pons F, Poichotte A, Goudard Y, Hornez E, Malgras B, Boddaert G, Balandraud P, Avaro JP, de Lesquen H. Effectiveness of a specific trauma training on war-related truncal injury management: A pre-post study. Injury 2024; 55:111676. [PMID: 38897902 DOI: 10.1016/j.injury.2024.111676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 05/16/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Non-Compressible Torso Hemorrhage (NCTH) is the leading cause of preventable death in combat casualty care. To enhance the French military surgeons' preparedness, the French Military Health Service designed the Advanced Course for Deployment Surgery (ACDS) in 2008. This study evaluates behavioral changes in war surgery practice since its implementation. METHODS Data were extracted from the OPEX® registry, which recorded all surgical activity during deployment from 2003 to 2021. All patients treated in French Role 2 or 3 Medical Treatment Facilities (MTFs) deployed in Afghanistan, Mali, or Chad requiring emergency surgery for NCTH were included. The mechanism of injury, severity, and surgical procedures were noted. Surgical care produced before (Control group) and after the implementation of the ACDS course (ACDS group) were compared. RESULTS We included 189 trauma patients; 99 in the ACDS group and 90 in the Control group. Most injuries were combat-related (88 % of the ACDS and 82 % of the Control group). The ACDS group had more polytrauma (42% vs. 27 %; p= 0.034) and more e-FAST detailed patients (35% vs. 21 %; p= 0.044). Basics in surgical trauma care were similar between both groups, with a tendency in the ACDS group toward less digestive diversion (n= 6 [6 %] vs. n= 12 [13 %]; p= 0.128), more temporary closure with abdominal packing (n= 17 [17 %] vs. n= 10 [11 %]; p= 0.327), and less re-operation for bleeding (n= 0 [0 %] vs. n= 5 [6 %]; p= 0.046). CONCLUSION The French model of war trauma course succeeded in keeping specialized surgeons aware of the basics of damage control surgery. The main improvements were better use of preoperative imaging and better management of seriously injured patients.
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Affiliation(s)
- Yohann Vincent
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France.
| | | | - Georges Pfister
- Department of Orthopaedic, Trauma and Reconstructive Surgery, HIA Percy, Clamart, France
| | - François Pons
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Antoine Poichotte
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Yvain Goudard
- Department of Visceral Surgery, Laveran Military Teaching Hospital, French Military Health Service, Marseille, France
| | - Emmanuel Hornez
- Digestive surgery, Percy Military teaching hospital, 1 rue Raoul Batany, 92140, Clamart, France; École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Brice Malgras
- Department of Digestive Surgery, Begin Military Teaching Hospital, Saint Mandé, France; French Military Health Service Academy, Ecole du Val de Grace, Paris, France
| | | | - Paul Balandraud
- Department of Visceral Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Jean-Philippe Avaro
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
| | - Henri de Lesquen
- Department of Thoracic and Vascular Surgery, Sainte Anne Military Teaching Hospital, Toulon, France
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Gignoux-Froment F, Martinez T, Derely J, Turc J, Corcostegui SP, Derkenne C, Peigne V, Trousselard M, Bazin A, Lamblin A. Ethical Dilemmas Faced by Military Health Personnel During High-Intensity Conflict: The Crucial Issue of Triage. Mil Med 2024; 189:234-238. [PMID: 38712577 DOI: 10.1093/milmed/usae165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/08/2024] [Accepted: 03/22/2024] [Indexed: 05/08/2024] Open
Abstract
Russia's invasion of Ukraine has triggered the biggest conflict in Europe since the Second World War. It has forced countries to prepare for engagement on a massive scale, namely, a high-intensity war between nation states. A potential massive influx of wounded personnel risks saturating logistical supply chains and requires changes to not only medical care but also a paradigm shift. In this context, the principle of distributive justice is key. The aim is to save as many lives as possible through triage, which consists in "doing the greatest good for the greatest number." This idea is fundamental, as an emergency that has passed is no longer an emergency. However, international texts and treaties not only underline that the sole criterion for triage is clinical severity, but they also fail to take into account the patient's status (civilian, friend, and foe). In a high-intensity warfare situation, these texts, and the medical-surgical triage criteria they provide are insufficient, as caregivers may be required to make decisions based on the status of the patient. The need to make such choices could cause psychological suffering among military caregivers, as individuals are recurrently faced with difficult ethical dilemmas. One way to prevent this happening is to provide predeployment training in wartime medical ethics. The latter would include both instruction in international humanitarian law and practical simulations of clinical situations where the person is faced with an ethical dilemma.
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Affiliation(s)
| | - Thibault Martinez
- Department of Anesthesia and Intensive Care, Percy Military Teaching Hospital, Clamart 92140, France
| | - Jean Derely
- Department of Anesthesia and Intensive Care, Percy Military Teaching Hospital, Clamart 92140, France
| | - Jean Turc
- Civil-military anesthesia-intensive care department, Edouard Herriot University Hospital, Lyon 69003, France
| | | | - Clément Derkenne
- Medical Treatment Facility,1st Special Medical Unit, Versailles-Satory 78000, France
| | - Vincent Peigne
- Intensive Care Department, Chambéry Hospital, Chambéry 73000, France
| | - Marion Trousselard
- Neurosciences and Cognitive Sciences, French Armed Forces Biomedical Research Institute, D19, Brétigny-sur-Orge 91220, France
- French Military Health Service Academy (Ecole du Val de Grâce), Paris 75005, France
- Lorraine University, APEMAC/EPSAM-EA , 4360, Metz, France
| | - Angèle Bazin
- Emergency Department, Bégin Military Teaching Hospital, Saint-Mandé 94160, France
| | - Antoine Lamblin
- French Military Health Service Academy (Ecole du Val de Grâce), Paris 75005, France
- Anesthesia-Intensive Care-Emergency Unit, Laveran Military Teaching Hospital, Marseille 13013, France
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Turnbull C, Clegg L, Santhakumar A, Micalos PS. Blood Product Administration in the Prehospital Setting: A Scoping Review. PREHOSP EMERG CARE 2024:1-14. [PMID: 39159401 DOI: 10.1080/10903127.2024.2386007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Revised: 07/09/2024] [Accepted: 07/16/2024] [Indexed: 08/21/2024]
Abstract
OBJECTIVES Implementing prehospital blood products for treating hemorrhagic shock has been utilized globally in military and civilian settings. This review aims to compare various guidelines for using blood products, including the types of blood products, injuries, biomarkers (hemodynamic measurement) to indicate use, associated treatments and risks, and the logistical concerns of storage and wastage in the prehospital setting. Furthermore, it explores whether prehospital blood transfusions are beneficial and a safe treatment option. METHODS Data were collected using a systematic search and screening process of online databases CINAHL, Medline, and Scopus, as well as by creating a PRISMA flow diagram to screen articles using inclusion and exclusion criteria. Forty-five articles were screened, with twenty-five excluded, resulting in twenty articles in this scoping review. RESULTS The most frequently used blood product used was red blood cells, with twelve studies using either red blood cells alone or in combination with other products. Indications for blood use varied across services, but all aimed to address hemodynamic instability as a primary indication for blood transfusion. Eleven studies recorded no adverse reactions. Only one study reported chills and shivers; however, it was unclear if blood products were the cause. Nine studies avoided logistical issues of storage and wastage to create a feasible rotation system. CONCLUSIONS Prehospital blood was used in medical, trauma, and maternity-related hemorrhage. Many types of blood products are in use, ranging from component therapy to whole blood, with each protocol having different indications of use and treatment guidelines aimed at improving hemodynamic stability.
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Affiliation(s)
- Caitlin Turnbull
- School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
| | - Lisa Clegg
- School of Nursing, Paramedicine and Healthcare Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
| | - Abishek Santhakumar
- School of Dentistry and Medical Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Peter S Micalos
- School of Dentistry and Medical Sciences, Charles Sturt University, Port Macquarie, New South Wales, Australia
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de Lesquen H, Paris R, Lacheze S, de la Villeon B, Menini W, Lamblin A, Vacher A, Balandraud P, Pasquier P, Avaro JP. Training for a mass casualty incident: Conception, development, and implementation of a crew-resource management course for forward surgical teams. J Trauma Acute Care Surg 2024; 97:S19-S23. [PMID: 38745350 DOI: 10.1097/ta.0000000000004380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
BACKGROUND Since 2021, the predeployment training of French FSTs has included a simulation-based curriculum consisting of organizational and human factors. The purpose of this article is to describe the development of a crew-resource management (CRM) training course dedicated for the forward surgical teams (FSTs) of the French Military Health Service. METHODS The approach was based on three steps: (1) establishment of a conceptual framework of FSTs deployment; (2) development of an aircrew-like CRM training combining lectures, laboratory exercises, and situational training exercises to consider four fundamental "nontechnical" (cognitive and social) skills for effective and safe combat casualty care: (a) leadership, (b) decision-making, (c) coordination, and (d) situational awareness; (3) Implementation of teamwork evaluation tools. RESULTS A multidisciplinary team designed a conceptual framework for FST preparedness, 24 French FSTs completed a high-quality training that takes into account both technical and nontechnical skills to maintain quality of combat care during mass-casualty incidents, FSTs' CRM skills were assessed using an audio/video recording of a simulated mass-casualty incident.
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Affiliation(s)
- Henri de Lesquen
- From the Department of Thoracic and Vascular Surgery (H.d.L., J.-P.A.), Department of Anesthesiology and Intensive Care (W.M.), Sainte Anne Military Hospital, Toulon; Department of Anesthesiology and Intensive Care (R.P., A.L.), Laveran Military Teaching Hospital, Marseille; Département Recherche Expertise Formation Aéromédicale (S.L., A.V.), French Armed Forces Biomedical Research Institute, Brétigny sur Orge; Department of Digestive and Endocrine Surgery (B.d.l.V.), Laveran Military Teaching Hospital, Marseille; French Military Medical Academy (A.L., P.B., P.P., J.-P.A.), École du Val-de-Grâce, Paris; Department of Anesthesiology and Intensive Care (P.P.), Percy Military Teaching Hospital, Clamart; and French Special Operations Forces Medical Component Command (P.P.), Villacoublay, France
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Pasquier P, David M, Petit L, Chery M, Habas S, Patey E, Conort S, Zeller N, Gelmann MO, Peyrefitte S, Castel F, Travers S, Mahé P. Irregular warfare must combine good medicine, with both good tactics and good strategies: Position paper by the French Special Operations Forces Medical Command. J Trauma Acute Care Surg 2024; 97:S67-S73. [PMID: 38569049 DOI: 10.1097/ta.0000000000004336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Military operations are no longer limited to the application of counterterrorism and counterinsurgency strategies; they are now characterized by hybrid, irregular, and unconventional features. While some authors have indicated the need for medical support to adapt to these new modes of military operations, they have focused mainly on the tactical level of care on the battlefield. As Sun Tzu states, "Strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat," further proposals are still needed on the application of both medical tactics and medical strategies in irregular warfare. METHODS Medical experts from the French Special Operations Forces (SOF) Medical Command have identified specific medical challenges that special operations face in the context of the current transformation of armed confrontations into irregular warfare. RESULTS This position paper presents original tactical medical proposals for improving medical support in irregular warfare, ranging from the definition of a Primary-Alternate-Contingency-Emergency medical plan to the promotion of telemedical support. Original strategic medical proposals have highlighted the importance of recognizing medical issues in irregular warfare, including the medical actions carried out through and with local partners and the multiple approaches to countering medical threats. CONCLUSION The SOF medical community must be closely involved with and facilitate the responses to the shift to irregular warfare. International collaboration and interoperability are more necessary than ever, as they will enable a more effective combination of good medicine with both good tactics and good strategies. These perspectives can also be extended to improve medical care in the conventional armed forces and austere civilian settings. LEVEL OF EVIDENCE Therapeutic/Care Management; Level V.
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Affiliation(s)
- Pierre Pasquier
- From the French Special Operations Forces Medical Command (P.P., M.D., L.P., M.C., S.H., E.P., S.C., S.P., F.C., P.M.), Villacoublay; Department of Anesthesiology and Intensive Care (P.P.), Percy Military Teaching Hospital, Clamart; French Military Medical Service Academy (P.P., S.T.), École du Val-de-Grâce; French Surgeon General Office (N.Z., M.-O.G.); and Paris Fire Brigade (S.T.), Paris, France
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Cazes N, Corcostegui SP, Lovi S, Romary E, Desrobert V, Lidzborski L, Derkenne C. Should soldiers take oral tranexamic acid before going into battle? J Trauma Acute Care Surg 2024; 97:S24-S26. [PMID: 38595230 DOI: 10.1097/ta.0000000000004343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
ABSTRACT Tranexamic acid is an inexpensive antifibrinolytic treatment that reduces morbidity and mortality in civilian and military trauma patients. It must be administered within 3 hours of the injury, and its efficacy is greater the earlier it is given. It is already used preventively in the civilian environment in a number of indications to reduce bleeding and bleeding-related mortality. We wondered about the potential benefits of preventive oral administration of tranexamic acid prior to an assault for military personnel with a potential risk of injury.
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Affiliation(s)
- Nicolas Cazes
- From the Emergency Department (N.C.), Laveran Army Teaching Hospital, Marseille; Paris Fire Brigade (S.-P.C.); and French Military Health System (S.L., E.R., V.D., L.L., C.D.), Paris, France
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Causbie JM, Wisniewski P, Maves RC, Mount CA. Prophylactic antibiotic use for penetrating trauma in prolonged casualty care: A review of the literature and current guidelines. J Trauma Acute Care Surg 2024; 97:S126-S137. [PMID: 38689405 DOI: 10.1097/ta.0000000000004355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
ABSTRACT Prolonged casualty care (PCC), previously known as prolonged field care, is a system to provide patient care for extended periods of time when evacuation or mission requirements surpass available capabilities. Current guidelines recommend a 7- to 10-day course of ertapenem or moxifloxacin, with vancomycin if methicillin-resistant Staphylococcus aureus is suspected, for all penetrating trauma in PCC. Data from civilian and military trauma have demonstrated benefit for antibiotic prophylaxis in multiple types of penetrating trauma, but the recommended regimens and durations differ from those used in PCC, with the PCC guidelines generally recommending broader coverage. We present a review of the available civilian and military literature on antibiotic prophylaxis in penetrating trauma to discuss whether a strategy of broader coverage is necessary in the PCC setting, with the goal of optimizing patient outcomes and antibiotic stewardship, while remaining cognizant of the challenges of moving medical material to and through combat zones. Empiric extended gram-negative coverage is unlikely to be necessary for thoracic, maxillofacial, extremity, and central nervous system trauma in most medical settings. However, providing the narrowest appropriate antimicrobial coverage is challenging in PCC because of limited resources, most notably, delay to surgical debridement. Antibiotic prophylaxis regimen must be determined on a case-by-case basis based on individual patient factors while still considering antibiotic stewardship. Narrower regimens, which focus on matching up the site of infection to the antibiotic chosen, may be appropriate based on available resources and expertise of treating providers. When resources permit in PCC, the narrower cefazolin-based regimens (with the addition of metronidazole for esophageal or abdominal involvement, or gross contamination of central nervous system trauma) likely provide adequate coverage. Levofloxacin is appropriate for ocular trauma. Ideally, cefazolin and metronidazole should be carried by medics in addition to first-line antibiotics (moxifloxacin and ertapenem, Literature Synthesis and Expert Opinion; Level V).
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Affiliation(s)
- Jacqueline M Causbie
- From the Department of Internal Medicine (J.M.C.), Madigan Army Medical Center, Joint Base Lewis-McChord, Washington; Department of Medicine (P.W., C.A.M.), Uniformed Services University of the Health Sciences, Bethesda, Maryland; 2nd Medical Battalion (P.W.), 2nd Marine Logistics Group, Camp Lejeune; and Sections of Infectious Diseases (R.C.M.) and Critical Care Medicine (R.C.M.), Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Vuong A, Derkenne C, Travers S, Javaudin O, Clavier B, Martinaud C, Pasquier P. Performance of far forward iceless blood storage containers in controlled cold environments. Transfusion 2024; 64 Suppl 2:S50-S57. [PMID: 38362814 DOI: 10.1111/trf.17745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/25/2024] [Accepted: 01/26/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND The Golden Hour Box (GHB), an iceless blood container designed for transfusion closest to the point of injury, is used by military medical teams in remote damage control resuscitation. While its performance is well-established in hot environments, it remains underexplored in cold conditions, a significant consideration in emerging global conflict zones. STUDY DESIGN AND METHODS Four GHBs were preconditioned at +4°C or +18°C for 8 h and subsequently exposed to controlled laboratory simulated temperatures of -5, -15, and -25°C for 100 h. The study focused on their capability to maintain an internal temperature between +2 and +6°C, the recommended range for red blood cells unit storage and transport, using calibrated sensors for precise monitoring. RESULTS When exposed to negative Celsius temperatures, GHBs showed varied performance depending on preconditioning temperatures. When preconditioned at +4°C, GHBs maintained an internal temperature within the target range (+2 to +6°C) for 100 h at -5°C, 52 ± 1 h at -15°C, and 29 ± 4 h at -25°C. In contrast, the internal temperature of GHBs preconditioned at +18°C exceeded this range in less than 30 min, then dropped below 2°C more rapidly than those preconditioned at +4°C, occurring within 20 ± 2 h at -15 and 13 ± 1 h at -25°C. CONCLUSION The GHB, when properly preconditioned, effectively maintains internal temperatures suitable for blood product transport in extreme cold. Future research, including analyses of blood performances, is still needed to validate these results in more realistic operational conditions for use in cold environments.
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Affiliation(s)
- Antoine Vuong
- Department of Anesthesiology and Intensive Care, Bégin Military Training Hospital, Saint-Mandé, France
- French Military Medical Service Academy, École du Val-de-Grâce, Paris, France
| | - Clément Derkenne
- French Military Medical Service Academy, École du Val-de-Grâce, Paris, France
- French Military Health Service, 1e Antenne Médicale Spécialisée, Versailles, France
| | - Stéphane Travers
- French Military Medical Service Academy, École du Val-de-Grâce, Paris, France
- Paris Firefighters Brigade, Paris, France
| | | | | | | | - Pierre Pasquier
- French Military Medical Service Academy, École du Val-de-Grâce, Paris, France
- French Special Operations Forces Medical Command, Villacoublay, France
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
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Robaix M, Mathais Q, de Malleray H, Guigues S, Meaudre E, Bordes J, Cardinale M. Independent factors of preventable death in a mature trauma center: a propensity-score analysis. Eur J Trauma Emerg Surg 2024; 50:477-487. [PMID: 37749282 DOI: 10.1007/s00068-023-02367-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/09/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION The rate of potentially preventable deaths (PPD) and preventable deaths (PD) can reach more than 20% of overall trauma mortality. Bleeding is the leading cause of preventable mortality. The aim of our study is to define the independent factors of preventable or potentially preventable mortality in our mature trauma system. MATERIALS AND METHODS We conducted a single-center retrospective study in the Sainte Anne Military Teaching Hospital, Toulon, France, including all severe trauma patients admitted to our trauma center and discharged alive as well as all severe trauma patients who died with a death considered preventable or potentially preventable from January 2013 to December 2020. We matched the two groups using a propensity score and searched for independent factors using a generalized linear model. RESULTS 846 patients were included and analyzed. After matching, our cohort consisted of 245 patients in the survivor group and 49 patients in the preventable deaths group. Pre-hospital delays (73 min vs 54 min P = 0.003) as well as delays before incision in the operating room (80 min vs 52 min P < 0.001) were significantly longer in the PD group. These delays were independent factors of preventable mortality OR 10.35 (95% CI [3.44-31.11] P < 0.001) and OR 37.53 (95% CI [8.51-165.46] P < 0.001) as well as pelvic trauma OR 6.20 (95% CI [1.53-25.20] P = 0.011). CONCLUSION Delays in pre-hospital care, delays in access to the operating room from arrival at the trauma center, and pelvic injuries are independent factors associated with an increased risk of preventable mortality in trauma.
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Affiliation(s)
- Marion Robaix
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Quentin Mathais
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Hilaire de Malleray
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Sarah Guigues
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Eric Meaudre
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
- Ecole du Val de Grâce, French Military Medical Academy, Paris, France
| | - Julien Bordes
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France
- Ecole du Val de Grâce, French Military Medical Academy, Paris, France
| | - Michael Cardinale
- Anaesthesiology and Intensive Care Department, Military Teaching Hospital Sainte Anne, Toulon, France.
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Alruqi F, Aglago EK, Cole E, Brohi K. Factors Associated With Delayed Pre-Hospital Times During Trauma-Related Mass Casualty Incidents: A Systematic Review. Disaster Med Public Health Prep 2023; 17:e525. [PMID: 37947290 DOI: 10.1017/dmp.2023.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Critically injured patients have experienced delays in being transported to hospitals during Mass Casualty Incidents (MCIs). Extended pre-hospital times (PHTs) are associated with increased mortality. It is not clear which factors affect overall PHT during an MCI. This systematic review aimed to investigate PHTs in trauma-related MCIs and identify factors associated with delays for triaged patients at incident scenes. METHODS This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, CINAHL, MEDLINE, and EMBASE were searched between January and February 2022 for evidence. Research studies of any methodology, and grey literature in English, were eligible for inclusion. Studies were narratively synthesized according to Cochrane guidance. RESULTS Of the 2025 publications identified from the initial search, 12 papers met the inclusion criteria. 6 observational cohort studies and 6 case reports described a diverse range of MCIs. PHTs were reported variably across incidents, from a median of 35 minutes to 8 hours, 8 minutes. Factors associated with prolonged PHT included: challenging incident locations, concerns about scene safety, and adverse decision-making in MCI triage responses. Casualty numbers did not consistently influence PHTs. Study quality was rated moderate to high. CONCLUSION PHT delays of more than 2 hours were common. Future MCI planning should consider responses within challenging environments and enhanced timely triage decision-making.
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Affiliation(s)
- Fayez Alruqi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Emergency Medical Services Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Elom K Aglago
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
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Pfister G, Aries P, de Lesquen H, Mathieu L. Nine years of surgical activity in the deployed French military role 2 medical treatment facility in Mali. BMJ Mil Health 2023:e002553. [PMID: 37879647 DOI: 10.1136/military-2023-002553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION In January 2013, France launched a military operation in Mali, which ended in August 2022. This study aimed to analyse the global activity performed by a surgical team within the role 2 medical treatment facility (MTF) deployed in Gao during this period, in order to adapt medical battlefield support and combat casualty care teaching. METHODS A retrospective study was conducted using the French surgical database OpEX (French Military Health Service) from January 2013 to August 2022. All patients operated on were included. RESULTS During this period, 1298 patients with a median age of 29 (range: 23-38) years were included. Among them, 229 (17.6%) underwent a combat-related trauma surgery (CRTS), 234 (18.0%) underwent a non-CRTS, 167 (12.9%) underwent a non-trauma-related surgery and 668 (51.5%) underwent a scheduled surgery in the context of medical supply to the population.Among the CRTS group, 195 (85.2%) patients underwent an orthopaedic procedure, 73 (31.8%) required a general surgery. Finally, 15 (6.6%) wounded required a specialised surgery. CONCLUSIONS In line with the activity described in the role 2 MTF deployed in other contemporary asymmetric conflicts, this activity is moderate, especially if only combat-related injuries are considered; medical support to the population occupied most of the surgical activity. For CRTS, most of the traumas are limb traumas. Other traumas are composed of various lesions, which are often life-threatening. This fact imposes the presence of an orthopaedic surgeon with the appropriate equipment, as well as a general surgeon with a wide range of skills, in asymmetric conflicts.
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Affiliation(s)
- Georges Pfister
- Department of Orthopaedic, Trauma and Reconstrucive Surgery, HIA Percy, Clamart, France
| | - P Aries
- Department of Anesthesia and Surgical Intensive Care, HIA Clermont-Tonnerre, Brest, Bretagne, France
| | - H de Lesquen
- Thoracic and Vascular Surgery, HIA Sainte Anne, Toulon, France
| | - L Mathieu
- Department of Orthopaedic, Trauma and Reconstrucive Surgery, HIA Percy, Clamart, France
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12
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Hong C, He Y, Bowen PA, Belcher AM, Olsen BD, Hammond PT. Engineering a Two-Component Hemostat for the Treatment of Internal Bleeding through Wound-Targeted Crosslinking. Adv Healthc Mater 2023; 12:e2202756. [PMID: 37017403 PMCID: PMC10964210 DOI: 10.1002/adhm.202202756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/01/2023] [Indexed: 04/06/2023]
Abstract
Primary hemostasis (platelet plug formation) and secondary hemostasis (fibrin clot formation) are intertwined processes that occur upon vascular injury. Researchers have sought to target wounds by leveraging cues specific to these processes, such as using peptides that bind activated platelets or fibrin. While these materials have shown success in various injury models, they are commonly designed for the purpose of treating solely primary or secondary hemostasis. In this work, a two-component system consisting of a targeting component (azide/GRGDS PEG-PLGA nanoparticles) and a crosslinking component (multifunctional DBCO) is developed to treat internal bleeding. The system leverages increased injury accumulation to achieve crosslinking above a critical concentration, addressing both primary and secondary hemostasis by amplifying platelet recruitment and mitigating plasminolysis for greater clot stability. Nanoparticle aggregation is measured to validate concentration-dependent crosslinking, while a 1:3 azide/GRGDS ratio is found to increase platelet recruitment, decrease clot degradation in hemodiluted environments, and decrease complement activation. Finally, this approach significantly increases survival relative to the particle-only control in a liver resection model. In light of prior successes with the particle-only system, these results emphasize the potential of this technology in aiding hemostasis and the importance of a holistic approach in engineering new treatments for hemorrhage.
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Affiliation(s)
- Celestine Hong
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Yanpu He
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Porter A. Bowen
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Angela M. Belcher
- Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Bradley D. Olsen
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
| | - Paula T. Hammond
- Department of Chemical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Institute for Soldier Nanotechnologies, Massachusetts Institute of Technology, Cambridge, Massachusetts 02139, USA
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13
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Pinna T, Py N, Aigle L, Travers S, Pasquier P, Cazes N. Retrospective analysis of tranexamic acid administration in French war-wounded between October 2016 and September 2020. BMJ Mil Health 2023:e002321. [PMID: 36717157 DOI: 10.1136/military-2022-002321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 01/15/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Since 2013, the French Army Health Service, in agreement with international experts, has recommended the administration of 1 g of tranexamic acid (TXA) in trauma patients in haemorrhagic shock or at risk of bleeding within 3 hours of the trauma. METHODS The aim of this analysis was to describe the administration of TXA in French military personnel wounded during military operations in the Sahelo-Sahelian band between October 2016 and September 2020. Data were collected from forward health records and hospital data from the French hospital where the casualty was finally evacuated. Underuse of TXA was defined as the lack of administration in casualties who had received a blood transfusion with one or more of red blood cells, low-titre whole blood or French lyophilised plasma within the first 24 hours of injury and overuse as its administration in the non-transfused casualty. RESULTS Of the 76 patients included, 75 were men with an average age of 28 years. Five patients died during their management. 19 patients received TXA (25%) and 16 patients were transfused (21%). Underuse of TXA occurred in 3 of the 16 patients (18.8%) transfused. Overuse occurred in 6 of 60 (10%) non-transfused patients. CONCLUSION The analysis found an important underuse of TXA (almost 20%) and highlighted the need for optimising the prehospital clinical practice guidelines to aid prehospital medical practitioners more accurately in administering TXA to casualties that will require blood products.
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Affiliation(s)
- Thibault Pinna
- Service des urgences, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | - N Py
- Service d'anesthésie-réanimation, HIA Percy, Clamart, France
| | - L Aigle
- État-major, Écoles militaires de Santé Lyon-bron, Bron, France
| | - S Travers
- Division santé, Brigade de Sapeurs-Pompiers de Paris, Paris, France
| | - P Pasquier
- 1ère chefferie du service de santé - forces spéciales, Service de santé des armées, Villacoublay, France
| | - N Cazes
- Emergency Medical Service, Bataillon de Marins-Pompiers de Marseille, Marseille, France
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14
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Py N, Pons S, Boye M, Martinez T, Ausset S, Martinaud C, Pasquier P. An observational study of the blood use in combat casualties of the French Armed Forces, 2013-2021. Transfusion 2023; 63:69-82. [PMID: 36433844 DOI: 10.1111/trf.17193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/30/2022] [Accepted: 09/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The French Armed Forces conduct asymmetric warfare in the Sahara-Sahel Strip. Casualties are treated with damage control resuscitation to the extent possible. Questions remain about the feasibility and sustainability of using blood for wider use in austere environments. METHODS We performed a retrospective analysis of all French military trauma patients transfused after injury in overseas military operations in Sahel-Saharan Strip, from the point of injury, until day 7, between January 11, 2013 to December 31, 2021. RESULTS Forty-five patients were transfused. Twenty-three (51%) of them required four red blood cells units (RBC) or more in the first 24H defining a severe hemorrhage. The median blood product consumption within the first 48 h, was 8 (IQR [3; 18]) units of blood products (BP) for all study population but up to 17 units (IQR [10; 27.5]) for the trauma patients with severe hemorrhage. Transfusion started at prehospital stage for 20 patients (45%) and included several blood products: French lyophilized plasma, RBCs, and whole blood. Patients with severe hemorrhage required a median of 2 [IQR 0; 34] further units of BP from day 3 to day 7 after injury. Eight patients died in theater, 4 with severe hemorrhage and these 4 used an average of 12 products at Role 1 and 2. CONCLUSION The transfusion needs were predominant in the first 48 h after the injury but also continued throughout the first week for the most severe trauma patients. Importantly, our study involved a low-intensity conflict, with a small number of injured combatants.
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Affiliation(s)
- Nicolas Py
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Sandrine Pons
- French Military Blood Institute, Saint Anne Military Training Hospital, Toulon, France
| | - Matthieu Boye
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Thibault Martinez
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France
| | - Sylvain Ausset
- French Military Medical Schools, Lyon, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France
| | - Christophe Martinaud
- École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,French Military Blood Institute, Clamart, France
| | - Pierre Pasquier
- Federation of Anesthesiology, Intensive Care Unit, Burns and Operating Theater, Percy Military Training Hospital, Clamart, France.,École du Val-de-Grâce, French Military Medical Service Academy, Paris, France.,Special Operation Forces Medical Headquarter, Villacoublay, France
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15
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Arnoux B, Corcostegui SP, Gillard J, Travers S, Boutonnet M, Lecuyer T, Carfantan C, Luft A. Level of Onboard Care for Critical Patients: Analysis of the French Armed Forces Air Medical Evacuations From the Sahel Since 2013. Air Med J 2022; 41:473-475. [PMID: 36153145 DOI: 10.1016/j.amj.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/25/2022] [Accepted: 04/25/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Since 2013, the French Armed Forces have been engaged in the Sahel. The aim of our work was to study the characteristics of severe patients evacuated according to the composition of the air medical staff (ie, an anesthesiologist/intensive care physician [AICP] or an emergency physician [EP]). METHODS This was a retrospective cohort analysis including all French service members repatriated from the Sahel with a speedy evacuation priority between 2013 and 2019. RESULTS A total of 191 patients were evacuated. The causes were trauma for 103 patients and disease for 88. Trauma patients included war injuries (n = 58) and nonbattle injuries (n = 44). For disease patients, the main pathologies were cardiovascular (n = 17), infectious (n = 17), neurologic (n = 15), and gastrointestinal (n = 12). Highly dependent patients were significantly (P < .001) more likely to be managed by an AICP (n = 41) than an EP (n = 5). Moderately dependent patients managed by an AICP (n = 51) were more frequently unstable hemodynamically (n = 5 vs. n = 0, P < .05) and referred to an intensive care unit (n = 24 vs. n = 2, P < .001) than those managed by an EP (n = 41). There were no deaths in flight. CONCLUSION Greater use of EPs, especially for transporting stabilized patients, would provide more personnel trained in long-distance air transport.
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Affiliation(s)
| | | | - Jonathan Gillard
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
| | | | | | - Thomas Lecuyer
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
| | - Cyril Carfantan
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
| | - Antoine Luft
- Direction Centrale du Service de Santé des Armées, Ministère des Armées, Paris, France
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16
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Van Wyck D, Kolls BJ, Wang H, Cantillana V, Maughan M, Laskowitz DT. Prophylactic treatment with CN-105 improves functional outcomes in a murine model of closed head injury. Exp Brain Res 2022; 240:2413-2423. [PMID: 35841411 DOI: 10.1007/s00221-022-06417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
The treatment of traumatic brain injury (TBI) in military populations is hindered by underreporting and underdiagnosis. Clinical symptoms and outcomes may be mitigated with an effective pre-injury prophylaxis. This study evaluates whether CN-105, a 5-amino acid apolipoprotein E (ApoE) mimetic peptide previously shown to modify the post-traumatic neuroinflammatory response, would maintain its neuroprotective effects if administered prior to closed-head injury in a clinically relevant murine model. CN-105 was synthesized by Polypeptide Inc. (San Diego, CA) and administered to C57-BL/6 mice intravenously (IV) and/or by intraperitoneal (IP) injection at various time points prior to injury while vehicle treated animals received IV and/or IP normal saline. Animals were randomized following injury and behavioral observations were conducted by investigators blinded to treatment. Vestibulomotor function was assessed using an automated Rotarod (Ugo Basile, Comerio, Italy), and hippocampal microglial activation was assessed using F4/80 immunohistochemical staining in treated and untreated mice 7 days post-TBI. Separate, in vivo assessments of the pharmacokinetics was performed in healthy CD-1. IV CN-105 administered prior to head injury improved vestibulomotor function compared to vehicle control-treated animals. CN-105 co-administered by IP and IV dosing 6 h prior to injury also improved vestibulomotor function up to 28 days following injury. Microglia counted in CN-105 treated specimens were significantly fewer (P = 0.03) than in vehicle specimens. CN-105 improves functional outcomes and reduces hippocampal microglial activation when administered prior to injury and could be adapted as a pre-injury prophylaxis for soldiers at high risk for TBI.
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Affiliation(s)
- David Van Wyck
- 3Rd Special Forces Group (A), U.S. Army Special Operations Command, 111 Enduring Freedom Drive (Stop A), Fort Bragg, NC, 28310, USA. .,Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA.
| | - Bradley J Kolls
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Haichen Wang
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Viviana Cantillana
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA
| | | | - Daniel T Laskowitz
- Department of Neurology, Duke University School of Medicine, Durham, NC, 27710, USA.,Department of Neurobiology, Duke University School of Medicine, Durham, NC, 27710, USA.,Aegis-CN LLC., 701 W Main Street, Durham, NC, 27701, USA
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17
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Martinaud C, Fleuriot E, Pasquier P. Implementation of Low Titer Whole Blood for French overseas operations: O positive or negative products in massive hemorrhage? Transfus Clin Biol 2022; 29:164-167. [DOI: 10.1016/j.tracli.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/20/2022] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
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18
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Evaluation of the altitude impact on a point-of-care thromboelastography analyzer measurement: prerequisites for use in airborne medical evacuation courses. Eur J Trauma Emerg Surg 2022; 48:489-495. [PMID: 32583073 DOI: 10.1007/s00068-020-01420-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/15/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Hemorrhagic shock is the first cause of preventable death in combat. Evacuations of wounded by aircraft are increasingly used and severely injured patients can spend consequent time in the air, mostly during strategic evacuation. In these situations, monitoring of blood coagulation may be pivotal in the management of blood product transfusion. Viscoelastic-guided transfusion is relevant in these situations. However, evaluation of these devices used in aircraft is lacking, especially the impact of decreased atmospheric pressure. The aim of this study is to evaluate the performance of an easy-to-carry viscoelastic system (TEG® 6s, Haemonetics). METHODS First, TEG® 6s repeatability, reproducibility, and correlation with chronometric methods and TEG-5000 were assessed on quality controls, healthy volunteers, and patients. Secondly, we tested the influence of vibrations and altitude on TEG® 6s parameters (0ft vs. 8000 ft = 2428 m) and on quality control samples (normal and hypocoagulable). RESULTS TEG® 6s exhibited good correlation with the reference method and TEG® 5000. Repeatability and reproducibility CVs were satisfactory. The tests performed in the hypobaric chamber revealed that performance at 0 ft and 8000 ft (2428 m) for 9 out of 13 parameters was not significantly different. However, we showed a significant increasing of CRT.Alpha (p = 0.049), CK.Alpha, CK.MA (p < 0.001 and p < 0.01, respectively) and CFF.MA increased (p < 0.05). CONCLUSION Our study provides proof of concept to validate testing in an actual aeromedical situation. Indeed, TEG® 6s appears to ease of use, resistance to high altitude conditions, and reliability on healthy humans. It is necessary to carry out a study on hemorrhagic injured patients in an aircraft.
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19
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A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding. Biomaterials 2022; 283:121432. [DOI: 10.1016/j.biomaterials.2022.121432] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
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20
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Abstract
More than 1,000,000 units of lyophilized plasma have been used in France, Germany, and South Africa. Recently, numerous other countries have adopted lyophilized plasma for patients with severe bleeding in prehospital and austere settings.
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21
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Sabate-Ferris A, Pfister G, Boddaert G, Daban JL, de Rudnicki S, Caubere A, Demoures T, Travers S, Rongieras F, Mathieu L. Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip. Eur J Trauma Emerg Surg 2021; 48:3847-3854. [PMID: 34775509 DOI: 10.1007/s00068-021-01828-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. METHODS A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. RESULTS Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. CONCLUSIONS Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.
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Affiliation(s)
- Alexandre Sabate-Ferris
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Georges Pfister
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France
| | - Guillaume Boddaert
- Department of Thoracic and Vascular Surgery, Percy Military Hospital, Clamart, France.,French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France
| | - Jean-Louis Daban
- Department of Anesthesiology and Intensive Care, Percy Military Hospital, Clamart, France
| | - Stéphane de Rudnicki
- Department of Anesthesiology and Intensive Care, Percy Military Hospital, Clamart, France
| | - Alexandre Caubere
- Department of Orthopedic and Trauma Surgery, Saint-Anne Military Hospital, Toulon, France
| | - Thomas Demoures
- Department of Orthopedic and Trauma Surgery, Bégin Military Hospital, Saint-Mandé, France
| | - Stéphane Travers
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.,Medical Department, Fire Brigade of Paris, Paris, France
| | - Fréderic Rongieras
- French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.,Department of Orthopedic and Trauma Surgery, Edouard Herriot Hospital, Lyon, France
| | - Laurent Mathieu
- Department of Orthopedic, Trauma and Reconstructive Surgery, Percy Military Hospital, Clamart, France. .,French Military Health Service Academy, Ecole du Val-de-Grâce, Paris, France.
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22
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Vertu N, Travers S, Pasquier P. Predeployment training for prolonged field care in current combat zones. J Trauma Acute Care Surg 2021; 91:e125. [PMID: 34695066 DOI: 10.1097/ta.0000000000003372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Suresh MR, Valdez-Delgado KK, Staudt AM, Trevino JD, Papalski WN, Greydanus DJ, Twilligear KJ, Mann-Salinas EA, VanFosson CA. In response to: Predeployment training for prolonged field care in current combat zones. J Trauma Acute Care Surg 2021; 91:e126. [PMID: 34695067 DOI: 10.1097/ta.0000000000003371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Valade G, Libert N, Martinaud C, Vicaut E, Banzet S, Peltzer J. Therapeutic Potential of Mesenchymal Stromal Cell-Derived Extracellular Vesicles in the Prevention of Organ Injuries Induced by Traumatic Hemorrhagic Shock. Front Immunol 2021; 12:749659. [PMID: 34659252 PMCID: PMC8511792 DOI: 10.3389/fimmu.2021.749659] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/06/2021] [Indexed: 12/28/2022] Open
Abstract
Severe trauma is the principal cause of death among young people worldwide. Hemorrhagic shock is the leading cause of death after severe trauma. Traumatic hemorrhagic shock (THS) is a complex phenomenon associating an absolute hypovolemia secondary to a sudden and significant extravascular blood loss, tissue injury, and, eventually, hypoxemia. These phenomena are responsible of secondary injuries such as coagulopathy, endotheliopathy, microcirculation failure, inflammation, and immune activation. Collectively, these dysfunctions lead to secondary organ failures and multi-organ failure (MOF). The development of MOF after severe trauma is one of the leading causes of morbidity and mortality, where immunological dysfunction plays a central role. Damage-associated molecular patterns induce an early and exaggerated activation of innate immunity and a suppression of adaptive immunity. Severe complications are associated with a prolonged and dysregulated immune–inflammatory state. The current challenge in the management of THS patients is preventing organ injury, which currently has no etiological treatment available. Modulating the immune response is a potential therapeutic strategy for preventing the complications of THS. Mesenchymal stromal cells (MSCs) are multipotent cells found in a large number of adult tissues and used in clinical practice as therapeutic agents for immunomodulation and tissue repair. There is growing evidence that their efficiency is mainly attributed to the secretion of a wide range of bioactive molecules and extracellular vesicles (EVs). Indeed, different experimental studies revealed that MSC-derived EVs (MSC-EVs) could modulate local and systemic deleterious immune response. Therefore, these new cell-free therapeutic products, easily stored and available immediately, represent a tremendous opportunity in the emergency context of shock. In this review, the pathophysiological environment of THS and, in particular, the crosstalk between the immune system and organ function are described. The potential therapeutic benefits of MSCs or their EVs in treating THS are discussed based on the current knowledge. Understanding the key mechanisms of immune deregulation leading to organ damage is a crucial element in order to optimize the preparation of EVs and potentiate their therapeutic effect.
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Affiliation(s)
- Guillaume Valade
- Institut de Recherche Biomédicale des Armées (IRBA), Inserm UMRS-MD-1197, Clamart, France
| | - Nicolas Libert
- Service d'Anesthésie-Réanimation, Hôpital d'instruction des armées Percy, Clamart, France
| | - Christophe Martinaud
- Unité de Médicaments de Thérapie Innovante, Centre de Transfusion Sanguine des Armées, Clamart, France
| | - Eric Vicaut
- Laboratoire d'Etude de la Microcirculation, Université de Paris, UMRS 942 INSERM, Paris, France
| | - Sébastien Banzet
- Institut de Recherche Biomédicale des Armées (IRBA), Inserm UMRS-MD-1197, Clamart, France
| | - Juliette Peltzer
- Institut de Recherche Biomédicale des Armées (IRBA), Inserm UMRS-MD-1197, Clamart, France
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25
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Lutz N, Labrousse T, Borowko R, Lecurou A, Lefort H. [The ABC's of the tactical tourniquet]. REVUE DE L'INFIRMIERE 2021; 70:21-22. [PMID: 34446229 DOI: 10.1016/j.revinf.2021.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Uncontrolled bleeding is the leading cause of preventable death. After rapid diagnosis of the injury, early stoppage of the bleeding and maintenance of effective coagulation are, in the pre-hospital setting, the two mainstays of treatment of hemorrhagic shock. The latter requires a trained and experienced medical and paramedical team to prevent patient morbidity and mortality.
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Affiliation(s)
- Noémie Lutz
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Thomas Labrousse
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Rachel Borowko
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Aurélie Lecurou
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France
| | - Hugues Lefort
- Structure des urgences, hôpital d'instruction des armées Legouest, rue des Frères-Lacretelle, 57000 Metz, France; Structure des urgences, hôpital d'instruction des armées Lavéran, 34 boulevard Lavéran, 13384 Marseille, France.
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26
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Py N, Martinez T, Boyé M, Tourtier JP, Meaudre E, Benbrika W, Ausset S, Pasquier P. The French Pre-Deployment Advanced Course in Anesthesia and Resuscitation: Development and Future Prospects. Mil Med 2021; 186:804-810. [PMID: 33544123 DOI: 10.1093/milmed/usab035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/11/2021] [Accepted: 01/22/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Military anesthesiologists from the French Military Medical Service (FMMS) are part of the Forward Surgical Teams deployed in overseas military operations. The practice of anesthesia in combat zones requires specific skills that are not taught during the initial curriculum for French civilian anesthesiologist. The Pre-Deployment Advanced Course in Anesthesia and Resuscitation (DACAR) program was developed to prepare military anesthesiologist from the FMMS before their deployment in overseas military operations. METHODS Created in 2013 by the French Military Medical Academy, the DACAR program is divided into two modules and carried out once a year. The DACAR program trains all military anesthesiologist residents at the end of their curricula. Since 2019, a number of Certified Registered Nurse Anesthetists have completed the DACAR program. The DACAR program is organized around the main axes of experience feedback from previous deployments in combat zones as well as didactic learning and practical training using high-fidelity simulation. RESULTS Since 2013, a total of 99 trainees completed the DACAR program during six complete cycles of two modules. The DACAR program has gradually been enriched from 14 courses in 2013 to 28 in 2019. Participants' reported satisfaction rates have increased steadily since 2016, when 88% of courses were rated as "interesting" or "very interesting," and only 4% as "not very interesting." By 2019, those figures had improved to 96% and 2%, respectively. CONCLUSION The DACAR program is a structured and adapted military medical course aimed at completing the curriculum of military anesthesiologists from the FMMS before deployment in overseas military operations. Regular audits and updates ensure that the DACAR training program maintains the highest standards of quality and rigor.
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Affiliation(s)
- Nicolas Py
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart 92140, France
| | - Thibault Martinez
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart 92140, France
| | - Matthieu Boyé
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart 92140, France
| | - Jean-Pierre Tourtier
- Federation of anesthesiology and intensive care unit, Bégin Military Training Hospital, Saint Mandé 94160, France.,École du Val-de-Grâce, French military medical academy, Paris 75005, France
| | - Eric Meaudre
- Federation of anesthesiology and intensive care unit, Saint-Anne Military Training Hospital, Toulon 83800, France.,École du Val-de-Grâce, French military medical academy, Paris 75005, France
| | - Widad Benbrika
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart 92140, France.,École du Val-de-Grâce, French military medical academy, Paris 75005, France
| | - Sylvain Ausset
- French military medical schools, Bron 69500, France.,École du Val-de-Grâce, French military medical academy, Paris 75005, France
| | - Pierre Pasquier
- Federation of anesthesiology, intensive care unit, burns and operating theater, Percy Military Training Hospital, Clamart 92140, France.,École du Val-de-Grâce, French military medical academy, Paris 75005, France
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Luft A, Corcostegui SP, Millet M, Gillard J, Boissier J, Rondy P, Bancarel J, Carfantan C. Aeromedical Evacuations Within the French Armed Forces: Analysis of 2,129 Patients. Mil Med 2021; 185:468-476. [PMID: 31642486 DOI: 10.1093/milmed/usz268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION The doctrine of medical support during French military operations is based on a triptych: forward medical stabilization, forward damage control surgery, and early strategic aeromedical evacuation (Strategic-AE). The aim of this study was to describe the last piece, the evacuation process of the French Strategic-AE. METHODS We conducted a retrospective cohort analysis using patient records from 2015 to 2017. All French service members requiring an air evacuation from a foreign country to a homeland medical facility were included. Data collected included age, medical diagnosis, priority categorization, boarding location, distance from Paris, type of plane and flight, medical team composition, timeline, and dispatch at arrival. RESULTS We analyzed 2,129 patients evacuated from 71 countries, most from Africa (1,256), the Middle East (382), and South America (175). Most patients (1,958) were not severely injured, although some considered priority (103) or urgent (68). Diagnoses included disease (48.6%), nonbattle injuries (43%), battle stress (5.3%), and battle injuries (3%). 246 Strategic-AE used medical teams in flight, 136 of them in a dedicated Falcon aircraft. The main etiologies for those evacuations were battle injuries (24%), cardiovascular (15.4%), infections (8%), and neurologic (7.3%). The median time of management for urgent patients was about 16 hours but longer for priority patients (26 hours). Once in France, 1,146 patients were admitted to a surgery department and 96 to an intensive care unit. CONCLUSION This is the first study to analyze the French Strategic-AE system, which is doctrinally unique when compared to its North Atlantic Treaty Organization allies. North Atlantic Treaty Organization allies favor care in the theatre in place of the French early Strategic-AE. However, in the event of a high intensity conflict, a combination of these two doctrines could be useful.
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Affiliation(s)
- Antoine Luft
- Department of Defense, Operational headquarters, French Military Medical Service, 60 boulevard du Général Valin CS 21623, Paris Cedex 15 75509, France
| | - Simon-Pierre Corcostegui
- Special Medical Unit of Satory, French Military Medical Service, Camp des matelots, CS 10702, Versailles Cedex 78013, France
| | - Marianne Millet
- Paris Fire Brigade, French Military Medical Service, 47 rue Saint Fargeau, Paris 75020, France
| | - Jonathan Gillard
- Department of Defense, Operational headquarters, French Military Medical Service, 60 boulevard du Général Valin CS 21623, Paris Cedex 15 75509, France
| | - Jerome Boissier
- Department of Defense, Operational headquarters, French Military Medical Service, 60 boulevard du Général Valin CS 21623, Paris Cedex 15 75509, France
| | - Patrick Rondy
- Department of Defense, Operational headquarters, French Military Medical Service, 60 boulevard du Général Valin CS 21623, Paris Cedex 15 75509, France
| | - Jérôme Bancarel
- Medical Center of Rochefort, French Military Medical Service, BA 721 r Bois Bernard, Rochefort Air 17133, France
| | - Cyril Carfantan
- Department of Defense, Operational headquarters, French Military Medical Service, 60 boulevard du Général Valin CS 21623, Paris Cedex 15 75509, France
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Luft A, Pasquier P, Soucanye de Landevoisin E, Morel-Stum N, Baillon A, Louis S, Menini W, Sagalle Y, Gintte J, Bouquet A, Avaro JP. The Damage Control Resuscitation and Surgical Team: The New French Paradigm for Management of Combat Casualties. Mil Med 2020; 187:e275-e281. [PMID: 33242064 DOI: 10.1093/milmed/usaa322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 07/15/2020] [Accepted: 08/20/2020] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The aim of this work was to introduce the new French forward resuscitation and surgical unit. It's also to discuss the choices and waivers granted to fit the tactical context of modern conflicts and the current epidemiology of combat casualties. MATERIALS AND METHODS A multidisciplinary task force of 11 people proceeded to the conception and the creation of a new military resuscitation and surgical unit. The preliminary work included a scoping review of the combat casualties' epidemiology in modern conflicts and an analysis of the recent French medical-surgical treatment facilities lessons learned. In April 2019, a technical-operational evaluation was conducted to confirm all the technical, ergonomic, and organizational choices made during the design phase. RESULTS The multidisciplinary task force resulted in the creation of the Damage Control Resuscitation and Surgical Team (DCRST). The DCRST focused on the resuscitation strategy, including transfusion of blood products, and the life-saving surgical procedures to be performed as close as possible to the point of injury. It was designed for the resuscitation of two patients: the life-saving surgery of two patients and the very short-term intensive care (<12 hours) of four patients at the same time. The DCRST provided sufficient autonomy to provide take care of four T1 and four T2 or T3 casualties per day for 48 hours. It was armed with 23 soldiers. The technical equipment represented 5,300 kg and 27 m3. All the technical medical equipment could be stored in two 20-foot containers. CONCLUSION The DCRST represents a new paradigm in medical support of French military operations. It offers the advantage of two combat casualties' surgical management at the same time, as close as possible to the combat zone. It responds to a 2-fold epidemiological and logistical challenge.
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Affiliation(s)
- Antoine Luft
- French Military Medical Service - Surgeon General Office, 75509 Paris Cedex 15, France.,French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | - Pierre Pasquier
- French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | | | - Nelly Morel-Stum
- French Military Medical Service- Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - Arthur Baillon
- French Military Medical Service - Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - Serge Louis
- French Military Medical Service - Military Medical Supply and Health Care Product General Office, 45400 Chanteau, France
| | - William Menini
- French Military Medical Service - Sainte Anne military training hospital, 83000 Toulon, France
| | - Yannick Sagalle
- French Military Medical Service - Percy Military Training Hospital, 92 140 Clamart, France
| | - Julie Gintte
- French Military Medical Service - 12th Military Medical Center, 33068 Bordeaux CEDEX, France
| | - Antoine Bouquet
- French Military Medical Service - Surgeon General Office, 60 boulevard du Général Valin CS 21623, 75509 Paris Cedex 15, France
| | - Jean-Philippe Avaro
- French Military Medical Service - Sainte Anne Military Training Hospital, 83000 Toulon, France
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Optimization of the Casualties' Treatment Process: Blended Military Experiment. ENTROPY 2020; 22:e22060706. [PMID: 33286478 PMCID: PMC7517244 DOI: 10.3390/e22060706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 11/17/2022]
Abstract
At the battalion level, NATO ROLE1 medical treatment command focuses on the provision of primary health care being the very first physician and higher medical equipment intervention for casualty treatments. ROLE1 has paramount importance in casualty reductions, representing a complex system in current operations. This study deals with an experiment on the optimization of ROLE1 according to the key parameters of the numbers of physicians, the number of ambulances and the distance between ROLE1 and the current battlefield. The very first step in this study is to design and implement a model of current battlefield casualties. The model uses friction data generated from an already executed computer assisted exercise (CAX) while employing a constructive simulation to produce offense and defense scenarios on the flow of casualties. The next step in the study is to design and implement a model representing the transportation to ROLE1, its structure and behavior. The deterministic model of ROLE1, employing a system dynamics simulation paradigm, uses the previously generated casualty flows as the inputs representing human decision-making processes through the recorder CAX events. A factorial experimental design for the ROLE1 model revealed the recommended variants of the ROLE1 structure for both offensive and defensive operations. The overall recommendation is for the internal structure of ROLE1 to have three ambulances and three physicians for any kind of current operation and any distance between ROLE1 and the current battlefield within the limit of 20 min. This study provides novelty in the methodology of casualty estimations involving human decision-making factors as well as the optimization of medical treatment processes through experimentation with the process model.
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Derkenne C, Travers S, Kedzierewicz R, Jost D, Prunet B, Martinaud C. Performances of iceless containers for lightweight transport of Red Cell Concentrate units during military operations. Transfus Clin Biol 2020; 27:98-102. [DOI: 10.1016/j.tracli.2020.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/12/2020] [Indexed: 10/25/2022]
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Corcostegui SP, Galant J, Pasquier P, Kazemzadegan K, Saint-Jean L, Commeau D, Boutillier du Retail C. Military medical response of the French gendarmerie to terrorist events. BMJ 2020; 368:m803. [PMID: 32127344 DOI: 10.1136/bmj.m803] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Simon-Pierre Corcostegui
- French Military Health Service, 1ère Antenne Médicale Spécialisée, 34 Avenue de la Martinière. 78000 Versailles, France
| | - Julien Galant
- French Military Health Service, 1ère Antenne Médicale Spécialisée, 34 Avenue de la Martinière. 78000 Versailles, France
| | - Pierre Pasquier
- French Military Health Service, Percy Army Training Hospital, Intensive Care Unit, Clamart, France
| | - Kourosh Kazemzadegan
- French Gendarmerie, Groupe d'Intervention de la Gendarmerie Nationale, International Relations Cell, Versailles, France
| | - Luc Saint-Jean
- French Military Health Service, 1ère Antenne Médicale Spécialisée, 34 Avenue de la Martinière. 78000 Versailles, France
| | - Damien Commeau
- French Military Health Service, 1ère Antenne Médicale Spécialisée, 34 Avenue de la Martinière. 78000 Versailles, France
| | - Cédric Boutillier du Retail
- French Military Health Service, 1ère Antenne Médicale Spécialisée, 34 Avenue de la Martinière. 78000 Versailles, France
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Use of ketamine for prehospital pain control on the battlefield: A systematic review. J Trauma Acute Care Surg 2019; 88:180-185. [DOI: 10.1097/ta.0000000000002522] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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