Ultra-forward surgical support for special operations forces. Conception, development and certification of the French Special Operations Surgical Team (SOST) airborne capability.

When special operations forces (SOF) are in action, a surgical team (SOST) is usually ground deployed as close as possible to the combat area, to try and provide surgical support within the golden hour. The French SOST is composed of 6 people: 2 surgeons, 1 scrub nurse, 1 anaesthetist, 1 anesthetic nurse and 1 SOF paramedic. It can be deployed in 45 min under a tent or in a building. However, some tactical situations prevent the ground deployment. A solution is to deploy the SOST in a tactical unprepared aircraft hold, to make it possible to offer DCS, to treat non-compressible exsanguinating trauma, without any ground logistical footprint. This article describes the stages of the design, development and certification process of the airborne SOST capability. The authors report the modifications and adaptations of the equipment and the surgical paradigms which make it possible to solve the constraints linked to the aeronautical and combat environment. Study type/level of evidence Care management Level of Evidence IV.

Relationship between creatine kinase and liver enzymes in war wounded with rhabdomyolysis.

BACKGROUND: Rhabdomyolysis is a frequent complication in war wounded. Its complex pathophysiology suggests that it not only affects kidneys but also other organs such as the liver. The aim of this study was to evaluate the relationship between creatine kinase (CK) and liver enzymes in war wounded with rhabdomyolysis. METHODS: War wounded admitted to the intensive care unit of Percy Military Hospital between 2009 and 2017 with a rhabdomyolysis (CK peak >1,000 U/L) were included. They were divided in two groups: mild (CK peak <10,000 U/L) and severe rhabdomyolysis (CK peak ≥10,000 U/L). Demographic characteristics, peaks in transaminases, alkaline phosphatase (ALP), bilirubin, and CK were recorded. Mann Whitney-U test and, Fisher's exact test were used as appropriate. A Pearson's correlation test was used to determine the correlation between CK and liver enzymes after a log-normal transformation of the data. RESULTS: Fifty-one patients were included (31 in the mild and 20 in the severe rhabdomyolysis group). Patients in the severe rhabdomyolysis group were more likely victims of explosions (85% vs 39%, p = 0.003). The transaminases peak was significantly higher in the severe rhabdomyolysis group (median AST peak 398 (270-944) vs 91 (63-157) U/L, p <0.0001, and median ALT peak 106 (77-235) vs 45 (34-71) U/L, p<0.0001). Bilirubin and ALP were higher in the severe rhabdomyolysis group (39 (25-49) vs 14(11-23) U/L, p = 0.0031 and 84 (55-170) vs 52 (39-85) U/L, p = 0.0063, respectively). We found a significant positive linear correlation between CK and ALT (r = 0.73, p<0.0001), AST (r = 0.89, p<0.0001), ALP (r = 0.41, p = 0.0035), and bilirubin (r = 0.37, p = 0.0083). CONCLUSION: We found a statistically significant positive correlation between CK and liver enzymes in rhabdomyolysis war wounded, indicating that hepatic damage occurs when rhabdomyolysis is severe and associated with elevated bilirubin and ALP. Further studies are needed to confirm this phenomenon and elucidate the pathophysiological mechanism. LEVEL OF EVIDENCE: IV STUDY TYPE: Diagnostic.

Prolonged tactical tourniquet application for extremity combat injuries during war against terrorism in the Sahelian strip.

PURPOSE: This study reports on complications following extended tourniquet application in patients with combat extremity injuries treated by the French Military Health Service in the Sahelian strip. METHODS: A retrospective review was performed in a French forward medical treatment facility deployed in Gao, Mali, between 2015 and 2020. All patients treated for an extremity injury with the application of at least one tourniquet for a minimum of 3 h were included. Prehospital data were injury pattern, associated shock, tourniquet location, and duration. Subsequent complications and surgical procedures performed were analyzed. RESULTS: Eleven patients with a mean age of 27.4 years (range 21-35 years) were included. They represented 39% of all patients in whom a tourniquet was applied. They had gunshot wounds (n = 7) or multiple blast injuries (n = 4) and totaled 14 extremity injuries requiring tourniquet application. The median ISS was 13 (interquartile range: 13). Tourniquets were mostly applied proximally on the limb for a mean duration of 268 min (range 180-360 min). Rhabdomyolysis was present in all cases. The damage control surgeries included debridement, external fixation, vascular repair, and primary amputation. Ten injuries were complicated by compartment syndrome requiring leg or thigh fasciotomy in the field or after repatriation. Two severely injured patients died of their wounds, but the others had a favorable outcome even though secondary amputation was sometimes required. CONCLUSIONS: Extended and proximal tourniquet applications led to significant morbidity related to compartment syndrome and rhabdomyolysis. Hemorrhagic shock, mass casualty incident, and tactical constraints often precluded revising the temporary tourniquet applied under fire.

Direct oral anticoagulant plasma level measurement in clinical practice: A French single-institution retrospective study.

INTRODUCTION: To describe patient characteristics and clinical situations where DOAC assays were ordered and determine whether the assays indications and subsequent patient management were consistent with current guidelines. METHODS: Retrospective study of data from patients with prescriptions for three DOACs: dabigatran, rivaroxaban and apixaban treated at Percy Military Hospital (France) between 2016 and 2019. RESULTS: During the study period, 196 DOAC measurements were performed on 148 patients (median age: 82.5 years). The most frequently prescribed DOAC was rivaroxaban (57.5%) and the commonest indication was nonvalvular atrial fibrillation (77%). Measurements were performed on 3.5% of patients with an active prescription for DOAC, and DOAC prescriptions complied with the product's characteristic summary in 62.8% of cases. The number of assays performed increased 2.5-fold between 2017 and 2019. Most DOAC assays were ordered due to emergency surgery or procedures (46.9%), bleeding (19.9%) or a risk of drug accumulation (13.8%). Time from the last DOAC dose to sample collection was specified in the medical file in only 25.5% of cases. Reasons for ordering DOAC measurements were consistent with the guidelines in 87.2% of cases. Subsequent clinical decisions were consistent with the guidelines in 86.2% of cases. CONCLUSIONS: DOAC assays ordering frequency was rare but increased during study. Acute clinical situations were the most common source of test orders. A correct interpretation of the results and subsequent management occurred in most but not all cases, indicating the need for additional education for physicians to raise awareness about tests indications and results interpretation.

Traum'cast: an online, open-access educational video podcast series for teaching military trauma care to all healthcare providers.

The aim of this paper was to describe the development of 'Traum'cast', an ambitious project to create a high-quality, open-access, 12-week video podcast programme providing evidence-based continuing medical education for civilian and military healthcare practitioners dedicated to the management of trauma caused by weapons of war. The management of such patients became a particular public health issue in France following the 2015 terrorist attacks in Paris, which highlighted the need for all healthcare professionals to have appropriate knowledge and training in such situations. In 2016, the French Health General Direction asked the French Military Medical Service (FMMS) to create a task force and to use its unique and considerable experience to produce high-quality educational material on key themes including war injuries, combat casualty care, triage, damage control surgery, transfusion strategies, psychological injury and rehabilitation. The material was produced by FMMS and first broadcast in French and for free, on the official FMMS YouTube channel in September 2020. Traum'cast provides evidence-based continuing medical education for civilian and military healthcare practitioners. Traum'cast is an educational innovation that meets a public health requirement.

A decade in the battlefield (2004-2014): A French military perspective on the high mortality associated with non-exclusively orthopedic or brain combat injuries.

BACKGROUND: During the last few decades, French armed forces have regularly deployed in asymmetric conflicts. Surgical support for casualties of these conflicts occurs in NATO role 2 and 3 medical treatment facilities (MTF); definitive surgical care occurs in France following a strategic medical evacuation. The aim of this study was to describe the combat injury profile of these soldiers who presented with either non-exclusively orthopedic and/or brain injuries. METHODS: This descriptive study is a retrospective analysis of the surgical management of French casualties performed in role 2 or 3 MTF in Afghanistan, Mali, Niger, Djibouti and the Central African Republic between January 2004 and December 2014. RESULTS: One hundred patients were included. Forty had fragment wounds. The most severe lesions were of the head, neck or thorax. The average injury severity score (ISS) was 34.9 (IC 95% 29.8-40). 17 damage control procedures were performed. Thirty patients died with a mean ISS of 61 (IC 95% 56-67); 5 deaths were considered as preventable. The most frequent surgical procedures in the MTF were digestive (n=31) and thoracic surgery (n=19). Thirty patients needed second-look surgery in France; eleven had severe complications. No patient died following medical evacuation to France. CONCLUSIONS: Results from this study indicated that the mortality following non-exclusively brain or orthopedic injuries remains high in modern asymmetric conflicts. Level of Evidence IV.

Tourniquet Training Program Assessed by a New Performance Score.

IntroductionApplication of a tourniquet is the cornerstone in management of combat-related extremity hemorrhages. Continuous and appropriate training is required to use tourniquets correctly.HypothesisThe aim of this study was to analyze the impact of a refresher training session, conducted directly in the theater of military operations, on the performance of tourniquet use. METHODS: During their deployment (October 2015-April 2016) in the Central African Republic, a first simulation session evaluated soldiers from two combats platoons for the application of the SOFFT (Special Operation Forces Tactical Tourniquet; Tactical Medical Solutions; Anderson, South California USA) tourniquet. After randomization, a R (+) group underwent a refresher training session, while a R (-) group did not. Two months later, a second simulation session was conducted for both groups: R (+) and R (-). A dedicated score (one to seven points), including delay and effectiveness, evaluated the soldiers' performance for tourniquet application. RESULTS: Twenty-six subjects were included in the R (+) group and 24 in the R (-) group. Between the two assessments, the score improved for 61.5% of subjects of the R (+) group and 37.5% subjects of the R (-) group (P=.09). More particularly, the performance score increased from 4.2 (SD=1.4) to 5.5 (SD=0.9; P=.002) in subjects of the R (+) group whose last training for tourniquet application was over six months prior. CONCLUSION: A refresher tourniquet training session, conducted directly in a combat zone, is especially effective for soldiers whose last training session was over six months prior. A dedicated score can assess appropriately the performance of tourniquet training. MartinezT, DuronS, SchaalJV, BaudoinY, BarbierO, DabanJL, BoutonnetM, AussetS, PasquierP. Tourniquet training program assessed by a new performance score. Prehosp Disaster Med. 2018;33(5):519-525.

Concomitant Vascular War Trauma Saturating a French Forward Surgical Team Deployed to Support the Victims of the Syrian War (2013). Interest of the Vascular Damage Control.

Vascular injuries from war require an emergency treatment whose objective is to quickly obtain hemostasis and the restoration of arterial flow. In this context of heavy trauma and limited means, damage control surgery is recommended and is based on the use of temporary vascular shunts (TVSs). We report the management of the simultaneous arrival of 2 vascular injuries of war in a field hospital. Patient 1 presented a ballistic trauma of the elbow with a section of the humeral artery (Gustillo IIIC). A TVS was set up during the external fixation of the elbow. Final revascularization was carried out and aponevrotomies of the forearm were performed. Patient 2 had a riddled knee with an open fracture of the femur, an avulsion of the popliteal artery, and a hemorrhagic shock. A strategy of damage control surgery was carried out with placing an arterial and venous shunt. Aponevrotomies of the leg were carried out before casting. For the traumatisms of the arteries of the members, the use of shunts is reserved for the lesions of the proximal vessels. Many vascular shunts available have the same performances to restore the arterial flow and prevent secondary thrombosis. The time before the final revascularization depends on the clinical condition of the patient. The value of anticoagulation in these cases was not shown.

[Wounded in action: the platinum ten minutes and the golden hour]. / Blessés au combat, dix minutes en platine, une heure en or.

In the battlefield, the majority of casualties die within ten minutes of the trauma. Most injuries result from an explosion and haemorrhage plays a central role. To improve survival rates, the French Army Health Service has developed a chain of survival from the battlefield to France based on prehospital combat casualty care, forward medical support during the first hour and damage control surgery.

Admission risk factors for cerebral vasospasm in ruptured brain arteriovenous malformations: an observational study.

INTRODUCTION: Cerebral vasospasm is a well-documented complication of aneurismal subarachnoid hemorrhage but has not been extensively studied in brain arteriovenous malformations (BAVMs). Here, our purpose was to identify risk factors for cerebral vasospasm after BAVM rupture in patients requiring intensive care unit (ICU) admission. METHODS: Patients admitted to our ICU from January 2003 to May 2010 for BAVM rupture were included in this observational study. Clinical, laboratory and radiological features from admission to ICU discharge were recorded. The primary endpoint was cerebral vasospasm by transcranial Doppler (TCD-VS) or cerebral infarction (CI) associated with vasospasm. Secondary endpoints included the Glasgow Outcome Scale (GOS) at ICU discharge. RESULTS: Of 2,734 patients admitted to our ICU during the study period, 72 (2.6%) with ruptured BAVM were included. TCD-VS occurred in 12 (17%) and CI in 6 (8%) patients. All patients with CI had a previous diagnosis of TCD-VS. A Glasgow Coma Scale score <8 was a risk factor for both TCD-VS (relative risk (RR), 4.7; 95% confidence interval (95% CI), 1.6 to 26) and CI (RR, 7.8; 95% CI, 0.1 to 63). Independent risk factors for TCD-VS by multivariate analysis were lower Glasgow Coma Scale score (odds ratio (OR) per unit decrease, 1.38; 95% CI, 1.13 to 1.80), female gender (OR, 4.86; 95% CI, 1.09 to 25.85), and younger age (OR per decade decrease, 1.39; 95% CI, 1.05 to 1.82). The risk of a poor outcome (GOS <4) at ICU discharge was non-significantly increased in the patients with TCD-VS (RR, 4.9; 95% CI, 0.7 to 35; P = 0.09). All six patients with CI had poor outcomes. CONCLUSIONS: This is the first cohort study describing the incidence and risk factors for cerebral vasospasm after BAVM rupture. Larger studies are needed to investigate the significance of TCD-vasospasm and CI in these patients.