Think about acute shisha carbon monoxide intoxication: that's one small step for the patient, one giant leap for our society.

The number of people in the world consuming chicha is constantly increasing. However, several studies have shown that regular shisha smokers, whether active or passive, are exposed to the same risks as tobacco smokers. Shisha is also responsible for acute carbon monoxide (CO) poisoning, which is often unknown to emergency doctors, leading to under-diagnosis of this pathology and inappropriate treatment. We report in this series 3 cases of acute carbon monoxide poisoning following active or passive consumption of chicha. The prehospital percentage carboxyhemoglobin level measured by the pulse CO-oximeter is 22 and 27% for active smokers and 10% for the passively intoxicated patient. The individual and societal consequences of CO intoxication are significant. We believe it is important to make all those involved in emergency medicine aware of this pathology in order to treat it correctly from the initial phase and thus reduce its morbi-mortality and the risks of long-term complications.

REBOA Use in a Medicalized Prehospital Setting Proposal for a First Protocol Based on the Delphi Method.

BACKGROUND: The resuscitative endovascular balloon occlusion of the aorta (REBOA) technique controls abdominal, pelvic, junctional, and postpartum hemorrhage via aortic endoclamping. There are no protocols or clear indications guiding REBOA use in a two-tiered prehospital emergency medical system, as found in France. We conducted a Delphi study to clarify the indications and contraindications for REBOA application in such a system. METHODS: We performed a Delphi study in three rounds with an international group of doctors with REBOA expertise and clinical experience (members of the EndoVascular and Trauma Management Society). Based on the consensus answers, complemented by existing data in the literature, we developed a protocol for REBOA use in a medicalized prehospital setting. RESULTS: We identified 10 questions that were not answered in the literature and submitted them to 21 experts. Over three rounds, consensus was reached on these 10 questions. The most important ones were "In your opinion, in a hemorrhagic patient, vascularly well-filled and whose hemodynamics remain unstable with 3mg/h of norepinephrine, should we inflate a REBOA to prevent the patients death and get them to the operating room alive?" and "In the case of REBOA placement (zone I) in the prehospital setting, would you agree that the maximum occlusion duration is approximately 30 minutes, with a partial or intermittent occlusion when possible?" CONCLUSION: We propose a protocol for REBOA use in a medicalized prehospital setting. This protocol clarifies that hemorrhagic shock, despite a noradrenaline (also known as norepinephrine) dose of 0.6µg/kg/min, is considered too serious for the patient to be transported to the trauma center without REBOA. Moreover, it clarifies that a zone 1 REBOA should be inflated for maximum 30 minutes and with a partial occlusion strategy, if possible. This protocol should be updated based on feedback following the establishment of prehospital REBOA and large randomized studies.

[The healthcare chain aiding casualties in Afghanistan]. / La chaîne de santé au secours du blessé en Afghanistan.

Rules govern the triage of casualties before evacuation and the organisation of the healthcare chain downstream. The two main links in the chain are combat lifesaving techniques and the role 3 medical treatment facility. An example of the French armed forces health service in Kabul, in Afghanistan.

Evaluation of the implementation of personal protective equipment for French military firefighters in a CBRN context.

INTRODUCTION: Military firefighters are the first responders in the event of a chemical, biological, radiation, and nuclear (CBRN) event in the Marseille area. They receive initial training to intervene safely in a CBRN context. We wanted to evaluate the use of CBRN personal protective equipment (PPE) at a distance from this training. METHOD: A prospective observational bicentric descriptive study on 20 operational firefighters operating on rescue and emergency vehicles. Two PPE dressing sessions, separated by 3 months, were evaluated and timed. A reminder of the correct procedure was given by the investigator after the first dressing. RESULTS: On average, 60.5 percent of the steps were correctly performed during the first dressing and 83 percent during the second dressing. Between the two dressings, there was a significant improvement (p < 0.01) in the team verification of the dressing and the chronological order of the dressing as well as the actions to be taken before dressing (remembering to make oneself comfortable, to urinate, to drink). The second dressing is on average 21 seconds faster than the first. Professional training and exercise experience of the firefighters in CBRN improve the success and speed of dressing in the absence of a prior reminder. CONCLUSION: Shorter and more frequent training and exercises, which simulate real-life situations for firefighters, lead to safer, more competent and faster donning of PPE.

Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock: A Randomized Clinical Trial.

Importance: Blood transfusion is a mainstay of therapy for trauma-induced coagulopathy, but the optimal modalities for plasma transfusion in the prehospital setting remain to be defined. Objective: To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion. Design, Setting, and Participants: This randomized clinical trial was performed at multiple centers in France involving prehospital medical teams. Participants included 150 adults with trauma who were at risk for hemorrhagic shock and associated coagulopathy between April 1, 2016, and September 30, 2019, with a 28-day follow-up. Data were analyzed from November 1, 2019, to July 1, 2020. Intervention: Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control). Main Outcomes and Measures: The primary outcome was the international normalized ratio (INR) on arrival at the hospital. Secondary outcomes included the need for massive transfusion and 30-day survival. As a safety outcome, prespecified adverse events included thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload. Results: Among 150 randomized patients, 134 were included in the analysis (median age, 34 [IQR, 26-49] years; 110 men [82.1%]), with 68 in the plasma group and 66 in the control group. Median INR values were 1.21 (IQR, 1.12-1.49) in the plasma group and 1.20 (IQR, 1.10-1.39) in the control group (median difference, -0.01 [IQR, -0.09 to 0.08]; P = .88). The groups did not differ significantly in the need for massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 [95% CI, 0.42-8.68]; P = .37) or 30-day survival (hazard ratio for death, 1.07 [95% CI, 0.44-2.61]; P = .89). In the full intention-to-treat population (n = 150), the groups did not differ in the rates of any of the prespecified adverse events. Conclusions and Relevance: In this randomized clinical trial including severely injured patients at risk for hemorrhagic shock and associated coagulopathy, prehospital transfusion of lyophilized plasma was not associated with significant differences in INR values vs standard care with normal saline infusion. Nevertheless, these findings show that lyophilized plasma transfusion is a feasible and safe procedure for this patient population. Trial Registration: ClinicalTrials.gov Identifier: NCT02736812.

Use of French lyophilized plasma transfusion in severe trauma patients is associated with an early plasma transfusion and early transfusion ratio improvement.

BACKGROUND: Early transfusion of high ratio of fresh frozen plasma (FFP) and red blood cells (RBC) is associated with mortality reduction. However, time to reach high ratio is limited by the need to thaw the FFP. French lyophilized plasma (FLYP) used by French army and available in military teaching hospital does not need to be thawed and is immediately available. We hypothesize that the use of FLYP may reduce time to reach a plasma/RBC ratio of 1:1. METHODS: A retrospective study performed in a Level 1 trauma center between January 2012 and December 2015. Severe trauma patients who received 2 U of RBC in the emergency room were included and assigned to two groups according to first plasma transfused: FLYP group and FFP group. RESULTS: Forty-three severe trauma patients in the FLYP group and 29 in the FFP group were included. The time until first plasma transfusion was shorter in the FLYP group than in the FFP group, respectively 15 min (10-25) versus 95 min (70-145) (p < 0.0001). Time until a 1:1 ratio was shorter in the FLYP group than in the FFP group. There were significantly fewer cases of massive transfusion in the FLYP group than in the FFP group with respectively 7% vs. 45% (p < 0.0001). CONCLUSION: The use of FLYP provided significantly faster plasma transfusions than the use of FFP as well as a plasma and RBC ratio superior to 1:2 that was reached more rapidly in severe trauma patients. These results may explain the less frequent need for massive transfusion in the patients who received FLYP. These positive results should be confirmed by a prospective and randomized evaluation. LEVEL OF EVIDENCE: Therapeutic, level IV.

Vittel criteria for severe trauma triage: Characteristics of over-triage.

AIM: Over-triage rates related to the use of Vittel criteria are unknown. We compared severe stable trauma patients with and without significant visceral injuries. STUDY DESIGN: A single-centre retrospective analysis of a single-centre prospective cohort. PATIENTS AND METHODS: Trauma patients with at least one positive Vittel criterion from June 2010 to January 2012 in a level-1 trauma centre. Initial management included a systematic whole-body scanner. All significant lesions in stable trauma patients were recorded. RESULTS: A total of 252 trauma patients were admitted. One hundred and twenty were stable. In this group without vital distress, 72 (60%) had at least one occult lesion, 21 (17.5%) had an isolated orthopaedic injury and 27 (22.5%) had no injury. Thoracic injuries accounted for 44% of visceral injuries, abdominal for 17%, spinal for 16% and cerebral for 15%. Overall, the over-triage rate was 19%. Surgery for significant visceral injury was performed in 13 patients (18%) and arteriography in 4 patients (5.5%). Admission in an intensive care unit was required for 13 patients with occult injuries and for one patient without such a lesion (18% versus 2%, P=0.008). Hospital stays were longer in the group with visceral injuries (4±7 versus 9±8days; P=0.006). CONCLUSION: Vittel criteria use in trauma patients induces an acceptable over-triage rate. A large proportion of stable trauma patients have occult lesions. These visceral injuries frequently require special care. These data highlight the imperative need to transport major trauma patients immediately to a dedicated trauma centre and supports whole-body scanner use.