French military general practitioner: ultrasound practice.

OBJECTIVES: Ultrasound has been used in the field and in emergency departments for more than two decades. In a military setting, its use has grown rapidly as it has gained widespread acceptance among emergency physicians and as the range of diagnostic and triage applications has continued to expand. Technological changes have enabled ultrasound devices to become accessible to general practitioners (GP), and it could be of particular interest for military GPs in isolated environments. We have investigated both the training of French military GPs in the area of ultrasonography and the use of ultrasound devices, in daily practice and abroad, in isolated military settings. METHODS: In 2011, a questionnaire was sent to all 147 in-the-field GPs of the French southeast regional military health service. The questionnaire evaluated the training of military GPs in ultrasonography, the use of ultrasound in France in daily practice, and during military operations in isolated environments abroad during 2010. RESULTS: The response rate was 52%. On the one hand, half the responding GPs had been specially trained in ultrasound, mainly (97%) in military institutes. On the other hand, only a quarter of doctors used ultrasound in daily practice. Among those GPs performing ultrasound examinations in France, 75% used it in 2010 during isolated operations abroad. Ultrasound examinations performed in such an austere environment were retrospectively declared useful to guide clinical reasoning (41% of examinations carried out), diagnosis (21%) and decision making as regards evacuation (11%). CONCLUSIONS: The challenge for the future is to make ultrasound courses mandatory for all military GPs going on overseas operations, to develop daily practice, and to investigate effective triage systems, combining both ultrasound imagery and physical examination.

Management of exsanguinating pelvic trauma: Do we still need the radiologist?

BACKGROUND: The hemodynamically unstable pelvic fracture are a diagnostic and therapeutic challenge. The current management is based on the control of pelvic bleeding by combining pelvic ring stabilization and embolization of pelvic arteries. The mortality of these patients, however, exceeds 30%. Recently the preperitoneal packing, based on the hemostatic tamponade of the pelvic cavity has been described. The objective of this study was to evaluate the interest of this new surgical procedure. The effectiveness of the standard algorithm is evaluated by analysis of pelvic injuries in 200 severe trauma treated at the Sainte-Anne Hospital. The results are then compared with literature data on the preperitoneal packing. PATIENTS AND METHODS: The profile injury, management and morbidity and mortality was evaluated in 200 polytrauma. After an initial phase of resuscitation, unstable pelvic fractures were treated with a circumferential belt followed by the application of an external fixator. Arteriography was performed for all patients with persistent hemodynamic instability. RESULTS: The mean injury severity score (ISS) was 31 (4-75). The mean trauma-related injury severity score (TRISS) was 74% (3-99). The proportion of hemodynamically unstable patients was 47%. Fifteen patients (41%) had severe bleeding. The median number of blood transfusion was 10 (4-42); eight patients (22%) underwent embolization. For two patients, reducing the pelvic fracture with an external fixator resulted in permanent hemostasis. Two patients underwent a laparotomy first, for the control of a hemoperitoneum. The mortality rate of the group of patients with hemorrhage was 33% (5/15). DISCUSSION: This high mortality leads to reconsider the place of pelvic embolization as firstline treatment. Some major drawbacks are noted: its effectiveness in treating venous bleeding, availability and duration of the procedure. The preperitoneal packing is a fast and effective surgical alternative. It seems to improve hemodynamic status of patients and significantly reduce the use of embolization and massive transfusion. Embolization is still indicated for patients not responding to surgery. However survival is not significantly improved.

[Intentional Datura stramonium intoxication: an unknown etiology of mydriasis]. / Intoxication volontaire par Datura stramonium: une cause de mydriase mal connue.

Two case reports of Datura stramonium intoxications are presented. The first one was a self poisoning, with a moderate anticholinergic syndrome and a spontaneous improvement. The second one was a recreational use of Datura stramonium for its hallucinogenic properties. The anticholinergic syndrome was marked and the improvement required orotracheal intubation, mechanical ventilation, intraveinous rehydratation, and active cooling to prevent organ failure.