Psychological, cognitive, and physiological impact of hazards casualties' trainings on first responders: the example of a chemical and radiological training. An exploratory study.

Background: First responders are among the first to respond to hazards casualties. They might operate in volatile, uncertain, complex, and ambiguous (VUCA) environments. While they have underlined the need to improve their knowledge and training to face these environments, there are few data regarding the stress induced by these trainings. Chemical, biological, radiological, and nuclear (CBRN) hazards casualties' trainings seem to be a good model of "in vivo" stress. First responders must operate in a hostile and encountered environment with a CBRN protective equipment that places demand on their psychological, cognitive, and physiological capacities. Current research recognizes that the activity of the parasympathetic system (PSS) can be used as an objective marker of stress adaptation, measured as heart rate variability (HRV). Objectives: To compare between baseline and simulation the evolution of the parasympathetic activity (primary outcome), anxiety, emotions, cognitive load, and body posture awareness (secondary outcomes). Methods: A total of 28 first responders attended to three simulated scenarios requiring CBRN management of casualties. One day before simulation, we collected HRV data (baseline). The simulations' day (pre-, post-simulation) we collected anxiety score (STAI-Y B), emotions (SPANE), cognitive load (NASA TLX), body posture awareness (PAS) and HRV. The morning after we collected the PAS score (recovery). We compare data' evolution between different times of the simulation. Results: (i) A high level of anxiety at baseline [Median 51 (46; 56)] which decreased between pre- and post-simulation (p = 0.04; F = 2.93); (ii) a post-simulation decrease in negative feelings (p = 0.03); (iii) a decrease in body awareness after simulation which returned to the initial level at recovery (p = 0.03; F = 3.48); (iv) a decrease in mean RR between baseline, pre- and post-simulation (p = 0.009; F = 5.11). There were no significant difference between times on others analysis of HRV. Conclusion: Prior to simulation, participants experienced anticipatory anxiety. Simulations training practiced regularly could be one way to combat anticipatory anxiety.

Mobile blood depots in ground ambulances in compliance with French legislation: A feasibility study.

BACKGROUND: Prehospital transfusion is a way of improving the management of hemorrhagic shock. In France, prehospital transfusion is struggling to develop, both because of logistical difficulties and particularly restrictive legislation. To comply with this, we propose to store the blood products (BPs) in ground ambulances with refrigerated boxes allowing remote continuous monitoring of storage conditions, called "NelumBox" (Tec4med Lifescience GmbH). To open them, the ambulance's team needs a code that is only given by the Transfusion Center if the request meets all required regulatory criteria. STUDY DESIGN AND METHODS: We conducted a prospective simulation-based feasibility study using dummy BPs. Two ambulances were equipped. Simulations were triggered unexpectedly, including during on-call hours. The ability to quickly access the BPs was the main judgment criterion. The quality of hemovigilance during these simulations was also examined. RESULTS: Twenty-two simulations were performed. The ambulance's team was able to access the BPs in 100% of cases. The average waiting time for receiving the unlocking code was 5 min 27 s (SD = 2 min 12 s, MAX = 12 min 00 s). The transfusion traceability was compliant with regulations in 100% of cases. The transfusion center was able to remotely monitor BPs storage conditions for the entire duration of their stockage in the NelumBox. DISCUSSION: The present procedure is efficient, repeatable, and fast. It guarantees a strict transfusion safety without slowdown a severe trauma management, while complying with French regulations.

Where Do We Stand on "Buddy Transfusion" During Military Operations?

Warm fresh whole-blood transfusion between comrades on the battlefield, also known as "buddy transfusion," has been thrust back into the limelight for several years now. It means drawing blood on the battlefield, once a bleeding soldier needs a transfusion, from one of their uninjured companions and immediately infusing it. It is a lifesaving procedure, effective and hardy. This work aims to answer the main questions that military caregivers might have about it: interest of this procedure, donor and recipient safety, and hemostatic capacity of the blood collected this way.

Association between prehospital shock index and mortality among patients with COVID-19 disease.

BACKGROUND: There exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission and mortality. Here we investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting. METHODS: We retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) and with oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia. RESULTS: We analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years]. Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10-3). Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30. The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l-1. Multivariate logistic regression analysis on matched population after IPTW propensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95%CI): 0.93-0.98;p = 10-3), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02-1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03-1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87-0.98;p = 0.01 P < 10-3) and GCSi (aOR, 0.90; 95% CI: 0.82-0.99;p = 0.04). Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality. CONCLUSION: Neither prehospital initial SI nor lactatemia were associated with ICU admission and 30-day mortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results.

Musculoskeletal diseases among French military high-speed boat pilots.

In 2016, the French Navy acquired a new high-speed boat, called ECUME. It exposes crewmembers to significant Whole Body Vibrations. This work explores the musculoskeletal diseases among this population. We conducted a retrospective declarative epidemiologic study using anonymous questionnaires. Eighty-four sailors were included. Fifty-six (66.7%) report acute traumas during a nautical raid during the 12 months study period. Sixty (71.4%) report chronic pains, which they associate with their nautical activity. Among them, only 16 (26.7%) have consulted a doctor, but 32 (53.3%) report consuming medication, including 18 through selfmedication. More than half rely to alternatives medicine, especially osteopathy. The traumatic risk of ECUME riding is obvious. Many crewmembers minimize their symptoms, and consult rarely a physician. They give preference to selfmedication and alternative medicines.

Evaluation of hemostatic capacities among commando candidates: Would their blood suit a hemorrhagic war-injured patient in case of blood donation on the battlefield?

BACKGROUND: In case of a warm fresh whole blood transfusion on the battlefield, the blood donation usually occurs just after a combat phase and often after several days on the fields. To explore the hemostatic capacity of such blood, we analyzed the blood of volunteers attending the commando course of the French Navy, considering this course as an experimental model, placing them into the same physiological conditions as those faced by deployed fighters. METHODS: Venous blood was collected at the beginning of the course, mimicking their baseline status, and a second time 6 weeks later, from the remaining candidates, during the actual commando training, mimicking the stress conditions. For each candidate, we observed the differences between the two blood samples. RESULTS: Of the 112 men that attended the first day of the course, only 17 remained 6 weeks later. In the second blood samples, we noted significant increased leucocytes and platelets counts and significant decreased hematocrit and hemoglobin levels. Thrombin generation assays showed significantly lower normalized peak heights (-31%), lower normalized endogenous thrombin potential values (-29%), and lower velocity index (-35%). Normalized lag time and time to peak did not differ. Viscoelastometric testing revealed a significant increasing in clot firmness as assessed by maximum amplitude and amplitude at 6 minutes. The clot speed was significantly increased. CONCLUSION: This work brings new data on coagulation during prolonged and considerable physical exercise. No obvious deleterious modification of hemostatic properties was observed. The decrease of the endogenous thrombin potentials may reflect a better ability to control the thrombin generation once started. Altogether, these results suggest that this blood could suit well a hemorrhagic war-injured patient. LEVEL OF EVIDENCE: Prospective observational cohort study, Level III.

Whole blood transfusion closest to the point-of-injury during French remote military operations.

To improve the survival of combat casualties, interest in the earliest resort to whole blood (WB) transfusion on the battlefield has been emphasized. Providing volume, coagulation factors, plasma, and oxygenation capacity, WB appears actually as an ideal product severe trauma management. Whole blood can be collected in advance and stored for subsequent use, or can be drawn directly on the battlefield, once a soldier is wounded, from an uninjured companion and immediately transfused.Such concepts require a great control of risks at each step, especially regarding ABO mismatches, and transfusion-transmitted diseases. We present here the "warm and fresh" WB field transfusion program implemented among the French armed forces. We focus on the followed strategies to make it applicable on the battlefield, even during special operations and remote settings, and safe for recipients as well as for donors.

Tactical damage control resuscitation in austere military environments.

BACKGROUND: Despite the early uses of tourniquets and haemostatic dressings, blood loss still accounts for the vast majority of preventable deaths on the battlefield. Over the last few years, progress has been made in the management of such injuries, especially with the use of damage control resuscitation concepts. The early application of these procedures, on the field, may constitute the best opportunity to improve survival from combat injury during remote operations. DATA SOURCES: Currently available literature relating to trauma-induced coagulopathy treatment and far-forward transfusion was identified by searches of electronic databases. The level of evidence and methodology of the research were reviewed for each article. The appropriateness for field utilisation of each medication was then discussed to take into account the characteristics of remote military operations. CONCLUSIONS: In tactical situations, in association with haemostatic procedures (tourniquet, suture, etc), tranexamic acid should be the first medication used according to the current guidelines. The use of fibrinogen concentrate should also be considered for patients in haemorrhagic shock, especially if point-of-care (POC) testing of haemostasis or shock severity is available. If POC evaluation is not available, it seems reasonable to still administer this treatment after clinical assessment, particularly if the evacuation is delayed. In this situation, lyophilised plasma may also be given as a resuscitation fluid while respecting permissive hypotension. Whole blood transfusion in the field deserves special attention. In addition to the aforementioned treatments, if the field care is prolonged, whole blood transfusion must be considered if it does not delay the evacuation.

Comparison of Penetrating Neck Injury Management in Combat Versus Civilian Trauma: A Review of 55 Cases.

UNLABELLED: The objective was to describe a case series of penetrating neck injuries (PNIs) and compare their management in combat versus civilian trauma. METHODS: From 2012 to 2014, all soldiers and civilians referred to Percy Military Training Hospital for PNI were analyzed. The mechanism of injury, type and site of the lesion, and initial emergency management were noted. RESULTS: Among the 55 patients, 26 were wounded in action, and 29 were civilians. PNIs were commonly stab wounds resulting from an assault. Anatomical zone II, as well as the central neck compartment, was the most affected area. The most affected organ was the larynx. 74% of patients underwent computed tomography angiography (CTA), surgical exploration was performed for 42% of patients, and 33% of patients required intensive care unit monitoring. The differences between the two groups in terms of management were not statistically significant. CONCLUSIONS: The current management is based on clinical examination and CTA and is similar between soldiers and civilians. Surgical exploration is less commonly used than CTA, which is a fast and accurate method to evaluate PNI for stable patients. The classification by compartment seems more relevant than the classification by anatomical zone, particularly in absence of medical imaging.

Prehospital Endotracheal Intubation in Warm Climates: Caution is Required.

BACKGROUND: Out-of-hospital endotracheal intubation is a frequent procedure for trauma care. Nevertheless, in warm climates, sunlight and heat can interfere with the flow of the usual procedure. They can affect the equipment and hinder the operator. There are few data on this issue. The presentation of this case highlights three common complications that may occur when intubating under a hot and bright sun. CASE REPORT: A 23-year-old man had a car accident in Djibouti, at 11:00 a.m., in broad sunlight. The heat was scorching. Due to a severe head trauma, with a Glasgow Coma Scale score of 8, it was decided to perform an endotracheal intubation. The operator faced three problems: the difficulty of seeing inside the mouth in the bright sunlight, the softening of the tube under the influence of the heat, and the inefficiency of colorimetric CO2 detectors in the warm atmosphere in confirming the proper endotracheal tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Solutions are simple, but must be known and planned ahead, prior to beginning the procedure: Putting a jacket over his head while doing the laryngoscopy would solve the problem of dazzle; adjuncts like a stylet or gum elastic bougie have to be used at the outset to fix the softening problem; alternative methods to exhaled CO2 detection, such as the syringe aspiration technique, to confirm the proper tube placement, should be available.

[Pathological link between teeth and maxillary sinus] / Relations pathologiques entre dents et sinus maxillaire

Pathological link between teeth and maxillary sinus. Pathological relationship between the teeth and the maxillary sinus can be explained by their embryological and anatomical relationships. The floor is centered by the apex of antral teeth: premolars and first molars. Any dental disease process may have sinus consequences. Dental caries are the best example. Iatrogenic pathology, including preimplant surgery and benign or malignant tumors are also responsible for sinusitis. Therapeutic for every etiology avoids the complications and sequelae whose forensic incidence remains low.

Relations pathologiques entre dents et sinus maxillaire. Les relations pathologiques entre les dents et le sinus maxillaire s'expliquent par leurs nombreux rapports, tant embryologiques qu'anatomiques. La paroi inférieure du sinus est centrée par les apex des dents dites antrales : les prémolaires et les premières molaires. Ainsi, tout processus pathologique dentaire peut avoir des conséquences sinusiennes. La pathologie carieuse en est le meilleur exemple. La pathologie iatrogène, notamment la chirurgie pré-implantaire, ainsi que les tumeurs bénignes ou malignes sont également responsables de sinusites. Une thérapeutique adaptée à chaque cause permet d'éviter les complications et les séquelles.

Use of a gum elastic bougie in a penetrating neck trauma.

The case of a patient with a zone II penetrating neck injury who was intubated successfully utilizing the gum elastic bougie (GEB) is reported. He presented at a forward operational base in Afghanistan with a shrapnel wound in his neck as well as a cough and hoarseness. There were two wounds on each side of his laryngeal cartilages. The patient's breathing rate gradually increased and labored inhalation developed while the aeromedical evacuation was delayed for tactical reasons. Subcutaneous emphysema and edema concealed the anatomical landmarks, making a cricothyrotomy unsafe, and no fiber optic devices were available on site. Intratracheal intubation was decided upon by the doctors involved. Because of the anticipated difficultly of intubation, the GEB was used from the outset. During direct laryngoscopy, edema, blood, and mucus concealed the anatomic reliefs of the larynx. The glottis was not visible. On the second attempt, "clicks" were clearly perceived and the tube was railroaded over the bougie. Finally, the patient was evacuated to an Afghan military hospital. In this report, the benefit-risk balance for the use of the GEB in penetrating neck trauma is discussed. Although the use of the GEB cannot be recommended in all cases of penetrating neck injury, it should be considered as an option. This technique is not without risk, but in very remote settings or hostile environments, especially when cricothyrotomy is not possible, it can be lifesaving.