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.

[Actions of the French Military Medical Service in the war against COVID-19: mari transve mare, hominibus semper prodesse !] / 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 !

"We are at war!" declared President Emmanuel Macron during a speech to the nation on March 16, 2020. As part of this national resilience, the French Military Medical Service was engaged in the fight against COVID-19. This general review aims to describe and detail the actions undertaken by the French Military Medical Service in the national fight against the COVID-19 pandemic in France, as well as abroad. Experts in each field reported on the major actions taken by the French Military Medical Service during the COVID-19 pandemic in France, both domestically and overseas, beginning in spring 2020. In just a few weeks, the French Military Medical Service developed ad hoc medical capabilities to support the national health authorities. It has also implemented collective medical evacuation capabilities by air and sea. A military field hospital dedicated to intensive care was also deployed to support the civilian hospital in Mulhouse. Later, military intensive care modules helped hospitals overwhelmed by the influx of COVID-19 patients in Guadeloupe, Martinique, Guyana, Mayotte and New Caledonia. A COVID-19 crisis unit coordinated the actions of the French armed forces in the fight against the pandemic. The French military center for epidemiology and public health provided all the necessary information to guide the public health and medical decision-making processes. Army medical centers organized primary care for military patients, with extensive use of telemedicine. The emergency medical services of the Paris Fire Brigade and the Marseille Marine Fire Battalion provided pre-hospital care for patients with COVID-19. The eight French military training hospitals cooperated with the civilian regional health agencies to provide hospital care for the most severe patients, but also to create de novo vaccination centers. The military medical supply chain has supported all deployments of operational medical units in France and abroad, facing a growing shortage of medical equipment. The Armed forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the scientific literature review on COVID-19 daily, and provided expert recommendations on biosecurity. Finally, students from the Lyon-Bron military health schools volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the French military medical service engaged in multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. Collaboration between military and civilian health systems has reinforced the common goal of "saving the most.".

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.

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.

Triage in military settings.

Triage, a medical term derived from the French word "trier", is the practical process of sorting casualties to rationally allocate limited resources. In combat settings with limited medical resources and long transportation times, triage is challenging since the objectives are to avoid overcrowding medical treatment facilities while saving a maximum of soldiers and to get as many of them back into action as possible. The new face of modern warfare, asymmetric and non-conventional, has led to the integrative evolution of triage into the theatre of operations. This article defines different triage scores and algorithms currently implemented in military settings. The discrepancies associated with these military triage systems are highlighted. The assessment of combat casualty severity requires several scores and each nation adopts different systems for triage on the battlefield with the same aim of quickly identifying those combat casualties requiring lifesaving and damage control resuscitation procedures. Other areas of interest for triage in military settings are discussed, including predicting the need for massive transfusion, haemodynamic parameters and ultrasound exploration.

[Low-pressure tamponade mimicking cholecystitis]. / Tamponnade à pression basse mimant une cholécystite.

Low-pressure tamponade is rare and little known with difficult clinical recognition. We report a case of this pathology in a patient admitted for abdominal severe sepsis. Pericardiocentesis led to identification of Salmonella typhimurium pericarditis. This case report emphasizes the clinical recognition difficulty and the interest of early fast echography in case of hemodynamic emergency.

[Epidemiology of war injuries, about two conflicts: Iraq and Afghanistan]. / Type et épidémiologie des blessures de guerre, à propos de deux conflits actuels : Irak et Afghanistan.

Since March 2003, military operations in Iraq "Operation Iraqi Freedom" (OIF) and in Afghanistan "Operation Enduring Freedom" (OEF), have made many wounded and killed in action (KIA). This article proposes to highlight the specific epidemiology of combat casualties, met in these both non-conventional and asymmetric conflicts. Personal protective equipments, Kevlar helmet and body armor, proved their efficiency in changing features of war injuries. Health Force Services organized trauma care system in different levels, with three main objectives: immediate basic medical care in battalion aid station, forward surgery and early aeromedical evacuation. The Joint Theater Trauma Registry (JTTR), a war injury registry, provides medical data, analyzed from the combat theater to the military hospital in United States. This analysis concluded that during modern conflicts, most injuries are caused by explosive devices; injuries are more severe and interestingly more specifically the head region and extremities than the trunk. Hemorrhage is the first cause of death, leading to the concept of avoidable death. Specific databases focused on mechanisms and severity of injuries, diagnostic and treatment difficulties, outcomes can guide research programs to improve war injuries prevention and treatment.

[Obstetrical epidural analgesia during labour: one dural puncture, repeated postural headaches, three blood patches ]. / Analgésie péridurale obstétricale pour le travail: une brèche dure-mérienne, des céphalées posturales, trois blood patchs

We report the case of a patient in whom three blood patches had to be performed to treat a post-dural puncture headache following the insertion of an epidural catheter for labour analgesia. There are few data about repeated blood patches used to treat recurring symptoms after failure of a previous blood patch. The technical guidelines used to perform a first blood patch should be followed for the next procedure as well. The role of the cerebrospinal fluid leaking in the symptoms has to be verified, to avoid performing a useless blood patch and to miss another cause, which needs an urgent treatment.

[Blast lung injuries]. / Lésions pulmonaires liées aux explosions.

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.