Care of victims of suicide bombing

Summary: Suicide bombers often target crowds. This commentary discusses the additional features required in a medical response beyond conventional mass casualty care, including forensic documentation, preservation of evidence, suspect tissue identification and viral status, victim counselling and postexposure prophylaxis. We propose a pathway for care of victims of a suicide bomb, adapting elements from protocols for child abuse, sexual assault and needle-stick exposure.

Utilization profile of the Canadian-led coalition Role 2 Medical Treatment Facility in Iraq: the growing requirement for multinational interoperability

Background: The Canadian Armed Forces deployed a Role 2 Medical Treatment Facility (R2MTF) to Iraq in November 2016 as part of Operation IMPACT. We compared the multinational interoperability required of this R2MTF with that of similar facilities previously deployed by Canada or other nations. Methods: We reviewed data (Nov. 4, 2016, to Oct. 3, 2017) from the electronic Disease and Injury Surveillance Report and the Daily Medical Situation Report. Clinical activity was stratified by Global Burden of Diseases category, ICD-10 code, mechanism of injury, services used, encounter type, nationality and blood product usage. We reviewed the literature to identify utilization profiles for other MTFs over the last 20 years. Results: In total, 1487 patients were assessed. Of these, 5.0% had battle injuries requiring damage-control resuscitation and/or damage-control surgery, with 55 casualties requiring medical evacuation after stabilization. Trauma and disease non-battle injuries accounted for 44% and 51% of patient encounters, respectively. Other than dental conditions, musculoskeletal disorders accounted for most presentations. Fifty-seven units of fresh frozen plasma and 64 units of packed red blood cells were used, and the walking blood bank was activated 7 times. Mass casualty activations involved coordination of health care and logistical resources from more than 12 countries. In addition to host nation military and civilian casualties, patients from 15 different countries were treated with similar frequency. Conclusion: The experience of the Canadian R2MTF in Iraq demonstrates the importance of multinational interoperability in providing cohesive medical care in coalition surgical facilities. Multinational interoperability derives from a unique relationship between higher medical command collaboration, international training and adherence to common standards for equipment and clinical practice.

Contexte: Les Forces armées canadiennes ont déployé une installation de traitement médical de rôle 2 (ITMR2) en Iraq en novembre 2016 dans le cadre de l'opération IMPACT. Nous avons comparé l'interopérabilité multinationale requise par cette ITMR2 à celle d'installations semblables déjà déployées par le Canada ou d'autres pays. Méthodes: Nous avons examiné les données (du 4 novembre 2016 au 3 octobre 2017) du rapport électronique de surveillance des maladies et des blessures et du rapport quotidien sur la situation médicale. L'activité clinique a été stratifiée selon la catégorie du fardeau mondial des maladies, le code de la CIM­10, le mécanisme de traumatisme, les services utilisés, le type de contact, la nationalité et l'utilisation de produits sanguins. Enfin, nous avons aussi examiné la littérature pour déterminer les profils d'utilisation d'autres ITM au cours des 20 dernières années. Résultats: Au total, 1487 patients ont été évalués. De ce nombre, 5,0 % avaient subi des blessures au combat qui nécessitaient une réanimation ou une intervention chirurgicale de contrôle des dommages, ou les deux, et 55 blessés avaient eu besoin d'évacuation médicale après stabilisation. Les traumatismes et les maladies non liées au combat représentaient respectivement 44 % et 51 % des contacts avec les patients. Outre les troubles dentaires, les troubles musculosquelettiques étaient à l'origine de la plupart des présentations. Par ailleurs, 57 unités de plasma frais congelé et 64 unités de concentré de globules rouges ont été utilisées, et la banque de sang ambulante a été activée 7 fois. La mobilisation nécessaire pour traiter un nombre massif de victimes a nécessité la coordination des soins de santé et des ressources logistiques de plus de 12 pays. En plus des victimes militaires et civiles du pays hôte, des patients de 15 pays différents ont été traités à une fréquence semblable. Conclusion: L'expérience de l'ITMR2 canadienne en Iraq démontre l'importance de l'interopérabilité multinationale quant à la prestation de soins médicaux cohérents dans les installations chirurgicales de la coalition. L'interopérabilité multinationale découle d'une relation unique s'appuyant sur la collaboration des membres du commandement médical supérieur, de la formation internationale et le respect de normes communes pour l'équipement et la médecine clinique.

The effect of aerosolized indomethacin on lung inflammation and injury in a rat model of blunt chest trauma

Background: Acute lung contusion from blunt chest trauma (BCT) is characterized by an intense inflammatory response in the pulmonary parenchyma, which is associated with acute lung injury (ALI), acute respiratory distress syndrome and ventilator-associated pneumonia. We hypothesized that aerosolized indomethacin may reduce pulmonary inflammation and ALI in a rat model of BCT. Methods: Sprague-Dawley rats were anesthetized and received a tracheotomy for administration of aerosolized medication through a catheter. The BCT procedure involved free-dropping a hollow metal weight (200 g) from a height of 25.5, 38.3 or 51.2 cm onto the right thorax. We administered 1 mg/kg of indomethacin or 1 mL/kg of saline intratracheally 15 minutes after BCT. The sham group had a similar procedure without the exposure to BCT and treatment. Three hours postimpact, we obtained arterial blood gas and analyzed bronchoalveolar lavage for protein concentration, polymorphonuclear leukocytes (PMN) and cytokine levels, and lung tissue samples were taken for histopathological analysis. Results: The rats' mean arterial pressure and heart rate dropped immediately postimpact but recovered close to that of the sham group after 30 minutes in both control and treatment groups. Compared to BCT alone, indomethacin significantly reduced the total protein level in the lungs (1.06 ± 0.39 mg/mL v. 3.75 ± 1.95 mg/mL, p = 0.006) and alveolar FD-70 leak (0.23 ± 0.19 µg/mL v. 0.53 ± 0.19 µg/mL, p = 0.02). Indomethacin also significantly attenuated the acute inflammatory response in percent PMN (13.33 ±7.5% v. 28.0 ± 12.96%, p = 0.04). Tumour necrosis factor-α and interleukin-6 decreased in the indomethacin group, but the decreases were not significant compared with other groups. Conclusion: Aerosolized indomethacin has a protective effect against alveloar tissue permeability and inflammatory response induced by BCT.

Contexte: La contusion pulmonaire aiguë causée par un traumatisme thoracique fermé (TTF) se caractérise par une intense réaction inflammatoire dans le parenchyme pulmonaire, liée à une atteinte pulmonaire aiguë (APA), à un syndrome de détresse respiratoire et à la pneumonie associée à la ventilation mécanique. Nous avons émis l'hypothèse que l'indométacine en aérosol pouvait réduire l'inflammation pulmonaire et l'APA dans un modèle murin de TTF. Méthodes: Des rats Sprague-Dawley ont été anesthésiés et ont subi une trachéotomie pour l'administration du médicament en aérosol par un cathéter. Le TTF a été infligé par un poids de métal creux (200 g) en chute libre d'une hauteur de 25,5, 38,3 ou 51,2 cm sur le thorax droit. Nous avons administré 1 mg/kg d'indométacine ou 1 mL/kg de solution saline dans la trachée 15 minutes après le TTF. Un groupe a été soumis à une intervention similaire fictive, sans exposition au TTF ni au traitement. Trois heures après l'impact, nous avons obtenu des gaz artériels et analysé le liquide de lavage bronchoalvéolaire pour connaître les taux de protéines, de leucocytes polymorphonucléaires (PMN) et de cytokines; nous avons aussi prélevé des échantillons de tissu pulmonaire pour des analyses histopathologiques. Résultats: La pression artérielle et la fréquence cardiaque moyennes des rats ont immédiatement chuté après l'impact, mais sont revenues près des valeurs du groupe soumis à l'intervention fictive après 30 minutes dans le groupe témoin et le groupe traité. Comparativement au TTF seul, l'indométacine a significativement réduit le taux de protéines totales dans les poumons (1,06 ± 0,39 mg/mL c. 3,75 ± 1,95 mg/mL, p = 0,006) et la fuite alvéolaire de FD-70 (0,23 ± 0,19 µg/mL c. 0,53 ± 0,19 µg/mL, p = 0,02). L'indométacine a aussi significativement atténué la réaction inflammatoire aiguë en pourcentage de PMN (13,33 ±7,5 % c. 28,0 ± 12,96 %, p = 0,04). Le facteur de nécrose tumorale α et l'interleukine-6 ont diminué dans le groupe sous indométacine, mais ces baisses n'ont pas été significatives comparativement aux autres groupes. Conclusion: L'indométacine en aérosol exerce un effet protecteur contre la perméabilité du tissu alvéolaire et la réaction inflammatoire induite par le un TTF.

The impact of "early" versus "late" initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis.

BACKGROUND: The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of "early" versus "late" RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic. METHODS: A literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to "early" versus "late"/"standard" criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS). RESULTS: Thirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with "early" RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384-1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of "early" (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies. CONCLUSIONS: Our conclusion based on this evidence synthesis is that "early" initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS.

Diagnosis of Febrile Illnesses Other Than Ebola Virus Disease at an Ebola Treatment Unit in Sierra Leone.

Patients with febrile illnesses presenting to an Ebola treatment unit in Sierra Leone had a wide range of diagnoses other than Ebola virus disease. Rapid diagnostic tests were useful in confirming these diagnoses, reducing the length of patient stay with valuable consequences. These alternative diagnoses should assist in future planning.

Erythropoietin improves skeletal muscle microcirculation through the activation of eNOS in a mouse sepsis model.

BACKGROUND: Sepsis and septic shock remain the major causes of morbidity and mortality in intensive care units. One mechanism that leads to organ failure is microcirculatory dysfunction. Erythropoietin (EPO) is a glycoprotein produced by the kidney that primarily regulates erythropoiesis, but it also can exert hemodynamic, anti-inflammatory, and tissue protective effects. We previously reported that administration of EPO to septic mice improves mouse skeletal muscle capillary perfusion and tissue bioenergetics. The objective of this study was to explore the potential mechanism(s) involved. METHODS: Sepsis was induced by intraperitoneal (i.p.) injection of a fecal suspension (12.5 g in 0.5 saline/mouse) in mice. At 18 hours after sepsis induction, a single dose of rHuEPO (400 U/kg) was given to the mice. Mouse capillary perfusion density and nicotinamide adenine dinucleotide (NADH) fluorescence in skeletal muscle were observed using intravital microscopy. Endothelial cells derived from the skeletal muscle were treated with rHuEPO (5 U/mL) and endothelial nitric oxide synthase (eNOS) activation and activity were assessed. RESULTS: Septic mice had decreased capillary perfusion density and increased tissue NADH fluorescence indicating impaired tissue bioenergetics, whereas animals treated with rHuEPO demonstrated an improvement in capillary perfusion density and decreased skeletal muscle NADH fluorescence. The beneficial effect of rHuEPO did not occur in septic mice treated with l-NAME (an NOS inhibitor, 20 mg/kg) or mice genetically deficient in eNOS. Treatment of endothelial cells with rHuEPO resulted in activation of eNOS as indicated by increased eNOS phosphorylation and NO production. CONCLUSIONS: Our results suggest that eNOS plays an important role in mediating the beneficial effect of rHuEPO on microcirculation in this septic mouse model.

The effect of erythropoietin on microcirculation perfusion and tissue bioenergetics of the small intestine in a hemorrhagic shock and resuscitation rat model.

BACKGROUND: Erythropoietin (EPO) can exert acute hemodynamic and anti-inflammatory effects in addition to erythropoiesis. We tested the hypothesis that EPO given at resuscitation with saline will improve capillary perfusion and tissue oxygenation in the gut using a hemorrhagic shock model. METHODS: Sprague-Dawley rats were bled 30 mL/kg to maintain a mean arterial blood pressure of 40 mm Hg for 50 minutes and then randomized to one of four resuscitation groups (n = 6 per group): blood, blood + recombinant human EPO (rHuEPO), saline, and saline + rHuEPO. Intravenous rHuEPO (1,000 U/kg) was given at the start of resuscitation. Intravital microscopy was used to measure perfused capillary density, flow motion of red blood cell (RBC), and tissue NADH fluorescence 60 minutes after resuscitation. Venous oxygenation saturation (Svo2) was also measured in a second experiment. RESULTS: In the blood +/- rHuEPO resuscitation group, the perfused capillary density, RBC flow motion scores, and NADH fluorescence returned to near normal values. The saline + rHuEPO group compared with the saline group demonstrated an increased RBC flow motion score (2.32 vs. 1.60; p < 0.01); however, the perfused capillary density was not significantly increased (23.03 Cap/mm vs. 21.61 Cap/mm; p = 0.40). The saline + rHuEPO group also demonstrated statistically significant lower NADH fluorescence than the saline group after shock following resuscitation (110% +/- 3.64% vs. 122% +/- 4.26%; p < 0.05) suggesting decreased tissue dysoxia. The Svo2 in the saline + rHuEPO group was higher when compared with the saline group (45% vs. 38% by continuous oximetry; 38% vs. 29% by co-oximetry; p < 0.05). CONCLUSION: Our results suggest that the addition of rHuEPO at the time of saline resuscitation may have beneficial effects in hemorrhagic shock by improving tissue perfusion and decreasing dysoxia in the gut.

C-peptide attenuates acute lung inflammation in a murine model of hemorrhagic shock and resuscitation by reducing gut injury.

BACKGROUND: The study aims to evaluate whether C-peptide can reduce gut injury during hemorrhagic shock (HS) and resuscitation (R) therefore attenuate shock-induced inflammation and subsequent acute lung injury. METHODS: Twelve-week-old male mice (C57/BL6) were hemorrhaged (mean arterial blood pressure maintained at 35 mm Hg for 60 minutes) and then resuscitated with Ringer's lactate, followed by red blood cell transfusion with (HS/R) or without C-peptide (HS/R + C-peptide). Mouse gut permeability, bacterial translocation into the circulatory system and intestinal pathology, circulating HMGB1, and acute lung injury were assessed at different times after R. The mice in the control group underwent sham procedures without HS. RESULTS: Compared to the sham group, the mice in the HS/R group showed increased gut permeability (6.07 ± 3.41 µg of FD4/mL) and bacterial translocation into the circulatory system (10.05 ± 4.92, lipopolysaccharide [LPS] of pg/mL), and increased gut damage; conversely, mice in the HS/R + C-peptide group showed significantly reduced gut permeability (1.59 ± 1.39 µg of FD4/mL; p < 0.05) and bacterial translocation (4.53 ± 1.08 pg of LPS/mL; p < 0.05) with reduced intestine damage. In addition, mice in the HS/R group had increased circulating HMGB1 (21.64 ± 14.17 ng/mL), lung myeloperoxidase) activity (34.4 ± 8.91 mU/g of tissue), and pulmonary protein leakage (2.33 ± 1.16 µg Evans blue/g tissue per minute). Mice in the HS/R + C-peptide group showed decreased HMGB1 (7.27 ± 1.93 ng/mL; p < 0.05), lung myeloperoxidase (23.73 ± 8.39 mU/g of tissue; p < 0.05), and pulmonary protein leakage (1.17 ± 0.42 Evans Blue/g tissue per minute; p < 0.05). CONCLUSION: Our results indicate that C-peptide exerts beneficial effects to attenuate gut injury and dysfunction, therefore diminishing lung inflammation and subsequent injury in mice with HS and R.

Fatal exertional heat stroke in a patient receiving zuclopenthixol, quetiapine and benztropine.

OBJECTIVE: To report a case of fatal exertional heat stroke associated with the use of zuclopenthixol, quetiapine and benztropine. CASE SUMMARY: A 36-year-old male with a history of schizophrenia and bipolar disease was working as a roofer during the third day of a heat wave. His medications included zuclopenthixol, quetiapine, benztropine, carbamazepine and levothyroxine. He developed loss of consciousness late in the day and presented to hospital with a Glasgow Coma Scale 3 and a rectal temperature of 42.2 degrees C. He progressed to severe multiple organ dysfunction and asystole, and expired the following morning. Neuroleptic and anticholinergic agents have long been associated with heat alteration, but there are few reports involving the newer antipsychotic agents. Physicians and pharmacists should ensure that appropriate counseling is given to patients receiving these medications regarding early recognition of signs and symptoms and prompt treatment of heat related illness and heat stroke.