Retrospective analysis of tranexamic acid administration in French war-wounded between October 2016 and September 2020

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.

Les actions du service de santé des armées face à la crise COVID-19: sur mer et au-delà des mers, toujours au service des hommes !

« Nous sommes en guerre ! » a déclaré le président Emmanuel Macron lors d’un discours à la nation le 16 mars 2020. Dans le cadre de cette résilience nationale, le service de santé des armées (SSA) s’est engagé dans la lutte contre le COVID-19. Cette revue générale a pour objectif de décrire et de détailler les actions que le SSA a mené dans le cadre de la lutte nationale contre la pandémie de COVID-19 en France, ainsi qu’à l’étranger. Des experts de chaque domaine ont rapporté les actions majeures menées par le SSA lors de la pandémie de COVID-19. En quelques semaines seulement, le SSA a développé des capacités médicales ad hoc pour soutenir les autorités sanitaires nationales. Il a également mis en œuvre des capacités d’évacuations médicales collectives par voie aérienne et maritime. Un hôpital militaire de campagne dédié aux soins intensifs a également été déployé en soutien de l’hôpital civil à Mulhouse. Plus tard, des modules militaires de réanimation ont aidé des centres hospitaliers débordés par l’afflux de malades COVID-19 en Guadeloupe, en Martinique, en Guyane, à Mayotte et en Nouvelle-Calédonie. Une cellule de crise COVID-19 a permis de coordonner les actions des forces armées françaises dans le cadre de la lutte contre la pandémie. Le centre d’épidémiologie et de santé publique des armées a fourni toutes les informations nécessaires pour guider les processus de prises de décisions. Les centres médicaux des armées ont organisé les soins primaires pour les patients militaires, avec un large recours à la télémédecine. Les services de secours de la Brigade des sapeurs-pompiers de Paris et du Bataillon des marins-pompiers de Marseille ont assuré la prise en charge préhospitalière des patients atteints de COVID-19. Les huit hôpitaux d’instruction militaires français ont coopéré avec les agences régionales de santé pour permettre la prise en charge hospitalière des patients les plus graves, mais aussi créer de novo des centres de vaccination. La chaîne de ravitaillement médical des armées a soutenu tous les déploiements d’unités médicales opérationnelles en France et à l’étranger, faisant face à une pénurie croissante de matériel médical. L’institut de recherche biomédicale des armées a réalisé des diagnostics, s’est engagé dans de multiples projets de recherche, a mis à jour quotidiennement la revue de la littérature scientifique sur le COVID-19 et a fourni des recommandations d’experts sur la biosécurité. Enfin, les étudiants des écoles militaires de santé de Lyon-Bron se sont portés volontaires pour participer à la lutte contre la pandémie de COVID-19. En conclusion, dans une crise médicale sans précédent, le SSA a engagé de multiples actions innovantes et adaptatives, toujours en cours, dans la lutte contre le COVID-19. La collaboration entre les systèmes de santé militaires et civils a renforcé l’objectif commun de « sauver le plus grand nombre ».

Opération Code Bleu : mettons en place un numéro d’appel unique (2222) pour les urgences vitales intra-hospitalières !

La survenue d’un arrêt cardiaque intra-hospitalier, quiconstitue la forme la plus extrême de l’urgence vitaleintra-hospitalière (UVIH), constitue un évènementindésirable majeur qui concerne environ 1 à 5 patientspour 1000 admissions. Le pronostic de ces victimesest étroitement dépendant de la mise en œuvre d’unechaîne de survie intra-hospitalière efficace, dont l’élémentle plus important est le déclenchement immédiat dessecours. Chaque minute compte : tout retard engendrénotamment par une incertitude ou une hésitation surle système d’alerte diminue les chances de survie etaugmente les risques de séquelles.

Percutaneous dilatational tracheostomy for saturating influx of COVID-19 patients: Experience of military ENT physicians deployed in Mulhouse, France

OBJECTIVES

The main objective was to demonstrate the feasibility of percutaneous tracheostomy performed under difficult conditions by military ENT physicians during their deployment in the military intensive care field hospital of the French Military Medical Service in Mulhouse to confront the exceptional COVID-19 pandemic. The secondary objective was to assess reliability and safety for patient and caregivers, with a risk of iatrogenic viral contamination.

MATERIAL AND METHODS

A single-center retrospective study was conducted between March 25 and April 25, 2020, in 47 COVID-19 patients requiring prolonged mechanical ventilation. The inclusion criterion was having undergone percutaneous tracheostomy.

RESULTS

Eighteen consecutively included patients had successfully undergone percutaneous tracheostomy despite unfavorable anatomical conditions (short neck: 83.3%, overweight or obese: 88.9%). Median time to completion was 11 days after intubation, with an average duration of 7minutes. The procedure was technically compliant in 83.3% of cases, and considered easy (on self-assessment) in 72.2%, with 2 minor per-procedural complications. No crossover to surgery was required. There was only 1 major post-procedural complication (late hemorrhage).

CONCLUSION

This study showed the feasibility of percutaneous tracheostomy by an ENT physician under COVID-19 biohazard conditions. The technique was fast, easy and safe and met safety requirements for patient and staff.

SEIS: Insight's Seismic Experiment for Internal Structure of Mars

By the end of 2018, 42 years after the landing of the two Viking seismometers on Mars, InSight will deploy onto Mars' surface the SEIS (Seismic Experiment for Internal Structure) instrument; a six-axes seismometer equipped with both a long-period three-axes Very Broad Band (VBB) instrument and a three-axes short-period (SP) instrument. These six sensors will cover a broad range of the seismic bandwidth, from 0.01 Hz to 50 Hz, with possible extension to longer periods. Data will be transmitted in the form of three continuous VBB components at 2 sample per second (sps), an estimation of the short period energy content from the SP at 1 sps and a continuous compound VBB/SP vertical axis at 10 sps. The continuous streams will be augmented by requested event data with sample rates from 20 to 100 sps. SEIS will improve upon the existing resolution of Viking's Mars seismic monitoring by a factor of ∼ 2500 at 1 Hz and ∼ 200 000 at 0.1 Hz. An additional major improvement is that, contrary to Viking, the seismometers will be deployed via a robotic arm directly onto Mars' surface and will be protected against temperature and wind by highly efficient thermal and wind shielding. Based on existing knowledge of Mars, it is reasonable to infer a moment magnitude detection threshold of M w ∼ 3 at 40 ∘ epicentral distance and a potential to detect several tens of quakes and about five impacts per year. In this paper, we first describe the science goals of the experiment and the rationale used to define its requirements. We then provide a detailed description of the hardware, from the sensors to the deployment system and associated performance, including transfer functions of the seismic sensors and temperature sensors. We conclude by describing the experiment ground segment, including data processing services, outreach and education networks and provide a description of the format to be used for future data distribution.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s11214-018-0574-6) contains supplementary material, which is available to authorized users.

Comment appréhender une tuerie de masse pour les équipes Smur primo-intervenantes ?

Le risque terroriste présent sur l’ensemble de notre territoire depuis plusieurs années conduit les équipes de Samu–Smur à intervenir sur les lieux d’une tuerie de masse aux côtés de forces de sécurité, voire en tant que primointervenants. De telles circonstances exposent les équipes à un environnement de travail inhabituel et hostile. Cette mise au point, proposée en complément de la recommandation formalisée d’experts sur la prise en charge de tuerie de masse, répond aux interrogations qui naissent sur le terrain en pareilles circonstances. Elle facilite une juste appréciation des événements, aide à réguler ses émotions, dans le but d’augmenter la capacité des soignants à agir, tout en réduisant la phase de sidération initiale, elle-même responsable d’une inertie à même d’impacter le pronostic des blessés en choc hémorragique. Des procédures anticipées, sous forme de check-lists, guident les actions à mener de manière sereine. Les équipes médicales préhospitalières doivent apporter sur le terrain non seulement une compétence médicale, mais également une compétence tactique et décisionnelle pour accélérer les flux d’évacuation. Le premier médecin engagé doit aider à la décision aux côtés du commandant des opérations de secours, du commandant des opérations de police et de gendarmerie et des médecins intégrés aux forces de sécurité intérieure en attendant le directeur des secours médicaux. Il doit donc également faire preuve d’une compétence de chef d’équipe.

Microbiology of French military casualties repatriated from overseas for an open traumatic injury

BACKGROUND

This study aimed to describe the microbiological epidemiology of repatriated French soldiers with an open traumatic injury, and to measure the proportion of multidrug-resistant bacteria (MDRB).

METHODS

Retrospective study including all French soldiers repatriated in 2011 and 2012 in Parisian military hospitals for open traumatic injury. Results of clinical samples and MDRB screening were collected. The antibiotic susceptibility was assessed using the agar disk diffusion method. Characterization of resistance mechanisms was performed using PCR. Genotyping of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) isolates was performed using rep-PCR.

RESULTS

A total of 139 patients were included; 70% of them were repatriated from Afghanistan. At admission, 24/88 were positive for MDRB (28%), mainly ESBL-E but no carbapenemase-producing Enterobacteriaceae and vancomycin-resistant Enterococcus faecium were identified. Forty-five patients had lesion sample collection, and 28/45 had a positive culture. The most frequently isolated pathogens were Enterobacter cloacae, Pseudomonas aeruginosa, and Escherichia coli. For eight patients, a MDRB was isolated from the wound, mainly ESBL-E (7/8) but also one methicillin-resistant Staphylococcus aureus and one imipenem-resistant Acinetobacter baumannii. Among ESBL-E, the PCR evidenced the high prevalence of CTX-M15 enzymes. Rep-PCR performed on the 23 ESBL-producing E. coli isolates highlighted numerous profiles.

CONCLUSIONS

Controlling the spread of ESBL-E is currently challenging for French Armed Forces. Despite any evidence of an epidemic clone, a high-level compliance with hygiene precautions is required throughout the chain of care to avoid cross contamination.

Could the orthopaedic surgeon deployed in austere setting perform flaps on the leg?

The orthopaedic military surgeons deployed in operations are led to perform soft tissue coverage on the lower limb. The purpose of this study was to evaluate if flaps performed by surgeons' non-specialist in reconstructive surgery are associated with good outcome. All patients operated for a flap on the leg in French Forward Surgical Team deployed in theatre of operations between 2003 and 2013 were retrospectively reviewed. Forty-nine patients were included, for a total of 54 flaps' procedures. Indications were open fractures in 25 cases and osseous infections in 29 cases. No flap was performed on French soldiers. All the flaps were pedicle. Outcome was favourable for more than 90% of flaps with no statistical difference between muscular and fasciocutaneous flap and with regard to the indication. In conclusion, an orthopaedic surgeon deployed in austere setting with significant good outcome can perform reconstructive surgery with legs' flaps.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

[Blast lung injuries]

In armed conflicts and during terrorist attacks, explosive devices are a major cause of mortality. The lung is one of the organs most sensitive to blasts. Thus, today it is important that every GP at least knows the basics and practices regarding treatment of blast victims. We suggest, following a review of the explosions and an assessment of the current threats, detailing the lung injuries brought about by the explosions and the main treatments currently recommended.

[Cardiac arrest at induction of a patient with thyrotoxicosis. Have you thought of anaphylaxis?]

We report the occurrence of cardiac arrest shortly after the anaesthetic induction for thyroidectomy in a patient with decompensated thyrotoxicosis associated with taking amiodarone. After investigation, it was revealed that the cardiac arrest was linked to an anaphylactic reaction to suxamethonium. This accident, unrelated to hyperthyroidism, reminds us of the relative frequency and severity of anaphylactic reactions related to curare. This event, in the context of severe cardiac insufficiency, due to an amiodarone-associated thyrotoxicosis, is described here for the first time. Its diagnosis requires to remain consistent. Its support must be in compliance with the recommendations of learned societies of anaesthesia.

[Use of rFVIIa (Novoseven) in the case of a patient with mitral valvular prothesis and anticoagulant accident]

We report the case of an haemorrhagic shock observed in a woman who received heparin for a cardiac valve in mitral position, efficiently treated with rFVIIa. The haemorrhagic complications under anticoagulation treatment remain rare, but can lead to real therapeutic dilemma. The use of rFVIIa has been evaluated in different clinical situations, including traumatic or post-operative haemorrhagic shock. The use of rFVIIa in the treatment of haemorrhagic complication under anticoagulation treatment is discussed.

Percutaneous epiphysiodesis using transphyseal screws (PETS)

We describe a new technique of percutaneous epiphysiodesis using transphyseal screws (PETS) and our experience with it in 32 cases of limb-length inequality and nine angular knee deformities. A subgroup of 18 patients with postfracture limb overgrowth formed a clinical model for study of the real efficacy of PETS. It proved a reliable method with few complications and many advantages such as simplicity of technique, short operating time, rapid postoperative rehabilitation, and reversibility. Bone-length inequality decreased from a preepiphysiodesis average of 2.47 cm (range, 1.5-4.6) to 0.51 cm at skeletal maturity. The tibiofemoral angle reduced from a preoperative average of 7.66 degrees to 0.86 degrees at maturity. The screws began to exert significant growth inhibition within 6 months of insertion, slowing down the distal femoral and upper tibial physes by 68 and 56%, respectively. They achieved maximum growth retardation over the ensuing 12 months, slowing down the distal femoral physis by 89% and the proximal tibial physis by 95%. At skeletal maturity, total femoral growth was 45% and total tibial growth was 52% that of the normal side. Key

[Osteomalacia of renal origin disclosing Gougerot-Sjögren syndrome]

Latent renal tubular diseases are common in Sjögren's syndrome but rarely complicated by osteomalacia. The authors report a 28 years old woman's case where osteomalacia reveal the disease. In the other hand, pseudo-lymphoma is suspected from radiographic features. According to several studies, the authors review different types of renal diseases and describe different physiopathological hypotheses about bone involvement and pseudo-lymphomas.

[Disclosure of systemic lupus erythematosus in a case of hepatitis caused by ibuprofen]

We report the case of an hepatitis induced by ibuprofen in a young 32 years old woman, which allowed to discover an until then unknown systemic lupus erythematosus. After an analysis of the data of the literature, we are able to estimate at more than a 50% the specificity of the above mentioned induced effect of this drug for the diagnosis of lupus. Thus, non only a meningitis, but also an hepatitis induced by the ibuprofen need a systematic research of a connective tissue disease.

[Surgical treatment of pulmonary metastases. Apropos of 26 cases]

Twenty-six patients with known primary tumors were treated surgically for pulmonary metastases between 1951 and 1979. The metastases were diagnosed more often (58% of cases) by routine radiological examinations than because of thoracic symptoms. While diagnosis of the primary tumor and the metastases was simultaneous in three cases, the average lapse of time between the two diagnoses was 5 years and 1 month in the other cases. In four cases, it was 10 years or more. Lung X-rays showed single tumors more often than multiple tumors (12%). Broncho-fibroscopy was usually normal, but a preoperative biopsy showed the metastatic nature of the tumor in 5 cases. Ablation was by lobectomy (42%), pneumonectomy (23%) or atypical resection (27%). The hospital mortality rate was 7.6%. The survival rate at 1, 3 and 5 years (71%, 39%, and 17%) is identical to that of primitive bronchial tumors, and seems to be influenced by certain factors, such as the locus of the primitive tumor (with a particularly bad prognosis for ENT tumors), the lapse of time between the diagnoses of the primary and secondary tumors, the fact that there is one, rather than several, metastases, or that the metastases are monolateral rather than bilateral, and, finally, the limited nature of the exeresis. These factors prompt regular, systematic and prolonged radiological monitoring in search of further pulmonary metastases.

[Dirofilariasis, an unknown parasitosis. One case observed in Paris (author's transl)]

In France, dirofilariasis D. tenuis are rare (less than ten cases were recorded). They manifest themselves by subcutaneous nodules. The fact that sometimes important inflammatory signs exist, could being one to diagnose an infectious etiology. Diagnosis may be made when the nodule is in the periorbital region if the patient comes back from endemic area and specially if he noted a migration of the parasite. It is hardly possible to count on the laboratory exams and it is the biopsy that will prove the existence of the parasite and will assure the cure.

Antihypertensive effect of diacetolol in essential hypertension

1 Diacetolol is the N-acetylated metabolite of acebutolol and possesses beta-adrenergic receptor blocking properties. 2 Its antihypertensive action was assessed in accordance with a double-blind randomised cross-over scheme in 17 patients with moderate essential hypertension previously well controlled with acebutolol. 3 Significant reductions in lying mean arterial blood pressure were observed with daily doses of 200 mg (- 9%), 400 mg (- 10%) and 800 mg (- 14%), and were associated with significant decreases in heart rate and plasma renin activity. 4 The diacetolol mean plasma level measured 8 to 10 h after drug ingestion was proportional to the dose (207 +/- 27, 394 +/- 63 and 823 +/- 135 ng/ml for respectively 200, 400 and 800 mg/day).

[Study of serum concentrations and urinary excretion of secnidazole after oral administration in man. Comparison with tinidazole]

Secnidazole, a derivative of 5-nitro imidazole exhibits trichomonacid, amoebicid and antimicrobial properties; it has been studied in view of its biological fate in healthy volunteers (man and woman) comparatively with tinidazole. Both products were administered orally to the same volunteers at the single dose level of 2 g. The seric concentrations and the pharmacokinetic profile were determined up to the 72nd hour after drug administration. The whole urinary excretion (unchanged product + metabolites) during the same period was determined in percent of the administered dose level. Secnidazole is particularly different from tinidazole owing to its slower blood clearance. The apparent average half-life in the ten volunteers (5 men and 5 women) is about 17 hours for secnidazole and 13 hours for tinidazole. However, for both drugs, a difference between men and women was demonstrated: in female volunteers, the decrease in blood concentrations occurs a little quicker than in male volunteers. Regarding urinary excretion, it is also a little greater in female volunteers than in male volunteers.

Determination of nofedone in human serum by electron-capture GLC

An electron-capture GLC method to measure nofedone in human serum was developed. A homolog of nofedone was added to the serum as an internal standard before the sample was alkalinized with pH 9.5 phosphate buffer and extracted with ethylene dichloride containing 0.5% isopentyl alcohol. This organic phase was extracted with 0.2N HCl, the acidic aqueous phase was neutralized immediately, and the extraction with ethylene dichloride was repeated. The ethylene dichloride phase was evaporated to dryness, and the residue was reacted with heptafluorobutyric anhydride. The derivatives were chromatographed at 290 degrees on a 1% Dexsil 300 column. Data on apparent recovery, accuracy, and specificity are given. The detection limit was 5 ng/ml of serum. Serum levels over time in one patient after intravenous administration of 1 mg/kg and after oral administration of 50, 100, and 150 mg of nofedone are presented.

[Diagnostic and therapeutic problems occasioned by a voluminous cervical schwannoma (author's transl)]

A tumour of the nervous sheath, the schwannoma often entails difficult diagnostic problems linked to its anatomopathological polymorphism. A medical case of a benign schwannoma of the neck has been reported. In this case, it concerns a tumour moreworthy for its size, its adherence, elements which are unusual in a regular tumour which is well inserted in a capsule, and which has entailed difficult therapeutic problems. Its atypical histological shape brought up a debate between its diagnostic on the one of a fibro-myxoma.