Combat Casualties Treated With Intranasal Ketamine for Prehospital Analgesia: A Case Series.

Optimal pain management is challenging in Tactical Combat Casualty Care (TCCC), particularly in remote and austere settings. In these situations, appropriate treatment for prehospital analgesia can be limited or delayed due to the lack of intravenous access. Several guidelines suggest to implement intranasal (IN) analgesia in French Armed Forces for forward combat casualty care (Sauvetage au Combat), similar to the US TCCC. Four medical teams from the French Medical Military Service were deployed to the Middle East and Sahel from August 2017 to March 2019 and used IN ketamine for analgesia in 76 trauma patients, out of a total of 259 treated casualties. IN administration of ketamine 50mg appeared to be safe and effective, alone or in addition to other opioid analgesics. It also had minimal side effects and led to a reduction in the doses of ketamine and morphine used by the intravenous (IV) route. The French Military Medical Service supports current developments for personal devices delivering individual doses of IN ketamine. However, further studies are needed to analyze its efficacy and safety in combat zones.

Medicolegal issues of peri-anaesthetic dental injuries: A 21-years review of liability lawsuits in France.

BACKGROUND/AIM: Peri-anaesthetic dental injuries (PDI) represent a major source of potential malpractice claims against anesthesiologists. Studies about the medico-legal aspects of PDI have mainly focused on liability insurance cases thus not encompassing those cases brought to court. The aim of this study was to assess the medico-legal issues of PDI-related liability lawsuits in France. MATERIAL AND METHODS: A review of judicial decisions pertaining to PDI was conducted on a French legal database, spanning the period between January 2000 and October 2021. Characteristics of decisions, patients and anesthesiologists, peri-operative care, dental injuries, and convictions were collected when available for analysis. RESULTS: Twenty-four judicial decisions fulfilled the inclusion criteria and were analyzed. All cases of dental injuries took place during elective surgery, 16 in the private sector and 8 in the public sector. Most injuries concerned two or more teeth and the most predominant dental injuries were luxation or avulsion (70.8% of cases). Eight cases resulted in a final verdict in favor of the plaintiff, four in the private sector (conviction rate: 25%), and four in the public sector (conviction rate: 50%). The causes of conviction were either a lack of information (5/8), a breach in the standard of care or technical negligence (3/8). The average amount of indemnification for the plaintiff was 3614 Euros (3753 Euros in 2022 inflation-adjusted Euros) excluding legal fees. CONCLUSIONS: The analysis of PDI-related liability lawsuits shows that medico-legal issues differ from those of PDI-related insurance claims. Avulsion and luxation of multiple anterior teeth during elective surgery appear to be a risk factor for liability lawsuits. In addition, inadequacy of patient information about PDI-risk seems to be a risk factor for conviction. Lastly, dental injuries are less at risk of civil conviction than other anesthesia-related damages.

Use of ketamine for prehospital pain control on the battlefield: A systematic review.

BACKGROUND: Intravenous ketamine is commonly used for pain management in the civilian prehospital setting. Several studies have evaluated its effectiveness in the military setting. To date, there has been no report reviewing the published data on the use of ketamine in this context. The objective of this systematic review was to analyze the content and quality of published data on the use of ketamine for prehospital pain management in military trauma. METHODS: The MEDLINE database was searched for studies on ketamine use in combat prehospital settings, at point of injury or during evacuation, published between 2000 and 2019. The systematic review was conducted following PRISMA guidelines, and the protocol was registered on PROSPERO (CRD42019115728). Civilian reports and case series lacking systematic data collection were excluded. RESULTS: Eight studies were included with 2029 casualties receiving ketamine. All but one were American reports from Afghanistan and Iraq conflicts. Studies implied retrospective cohorts or prospective observational analysis. Ketamine use rose from 3.9% during the period preceding its addition to the Tactical Combat Casualty Care guidelines in 2012 to 19.8% thereafter. It was the most common analgesic administered (up to 52% of casualties) in one of the studies. Ketamine was more likely given during tactical medical evacuation when no analgesic was provided at the point of injury. The median total intravenous dose was 50 mg. Pain intensity decreased from moderate or severe to mild or none, sometimes after only one dose. In one study, ketamine administration during tactical evacuation was associated with increased systolic blood pressure as opposed to morphine. Incoherent speech, extremity movements, and hallucinations were the main adverse events reported. CONCLUSION: Published data on ketamine use in military trauma are rare and heterogeneous. Though, all studies tend to strengthen the belief in the efficacy and safety of ketamine when given at 50-mg to 100-mg intravenous for prehospital analgesia in combat casualties. LEVEL OF EVIDENCE: Systematic Review, Level IV.

Terrorist threat: Creating a nationwide damage control training program for non-trauma care providers.

INTRODUCTION: The current terrorist threat challenges nations to train numerous non-trauma care providers with different backgrounds in damage control (DC) strategies. The purpose of this work was to propose a specific DC training program. METHODS: A Task Force of 16 civilian and military physicians met for a 24-hour session, to propose the construction of a DC training program for non-specialised caregivers. RESULTS: Existing DC training programs are heterogeneous, mainly theoretical and almost only for physicians. A program entitled Damage Control for Terrorist Attack Victims (DC-TAV) was then proposed. Identified training targets were care providers from prehospital and hospital staffs, with no experience in trauma care. The training objectives were the improvement of individual and collective skills in managing terrorist attacks casualties. The tools selected for training concerned e-learning on a dedicated digital teaching platform (including a core section of four modules with types and mechanisms of injury, basic DC techniques, triage, organisation of emergency medical response and two complementary modules for doctors with DC resuscitation including remote transfusion and DC surgery), hands-on workshops with procedural simulation and full-scale simulation exercises, technical (tourniquets, haemostatic gauzes, needle thoracostomy, chest tube drainage, management of airway, coniotomy) and non-technical (leadership, communication, coordination and triage, decision-making, appropriate use of resources) skills. Finally, an evaluation of the DC-TAV program was planned. CONCLUSIONS: The DC-TAV program is an ambitious, civilian-military, nationwide and long-term program, based on a harmonised standard of care and including multidimensional training. Further studies are required to assess its efficacy.