Penetrating thoracic injuries: a retrospective analysis from a French military trauma centre.

BACKGROUND: Penetrating thoracic injuries (PTIs) is a medicosurgical challenge for civilian and military trauma teams. In civilian European practice, PTIs are most likely due to stab wounds and mostly require a simple chest tube drainage. On the battlefield, combat casualties suffer severe injuries, caused by high-lethality wounding agents.The aim of this study was to analyse and compare the demographics, injury patterns, surgical management and clinical outcomes of civilian and military patients with PTIs. METHODS: All patients with PTIs admitted to a Level I Trauma Centre in France or to Role-2 facilities in war theatres between 1 January 2004 and 31 May 2016 were included. Combat casualties' data were analysed from Role-2 medical charts. The hospital manages military casualties evacuated from war theatres who had already received primary surgical care, but also civilian patients issued from the Paris area. During the study period, French soldiers were deployed in Afghanistan, in West Africa and in the Sahelo-Saharan band since 2013. RESULTS: 52 civilian and 17 military patients were included. Main mechanisms of injury were stab wounds for civilian patients, and gunshot wounds and explosive fragments for military casualties. Military patients suffered more severe injuries and needed more thoracotomies. In total, 29 (33%) patients were unstable or in cardiac arrest on admission. Thoracic surgery was performed in 38 (55%) patients (25 thoracotomies and 13 thoracoscopies). Intrahospital mortality was 18.8%. CONCLUSION: War PTIs are associated with extrathoracic injuries and higher mortality than PTIs in the French civilian area. In order to reduce the mortality of PTIs in combat, our study highlights the need to improve tactical en route care with transfusion capabilities and the deployment of forward surgical units closer to the combatants. In the civilian area, our results indicated that video-assisted thoracoscopic surgery is a reliable diagnostic and therapeutic technique for haemodynamically stable patients.

Conservative vs. surgical approach for degenerative meniscal injuries: a systematic review of clinical evidence.

OBJECTIVE: Analyzing the available evidence by comparing the role of arthroscopic surgery and conservative treatment in the management of degenerative meniscopathy. MATERIALS AND METHODS: A literature search was carried out on the PubMed, EMBASE, Scopus, and PEDro databases in May 2019 to identify all the randomized controlled trials (RCTs) comparing arthroscopic surgery to conservative management of painful but stable degenerated menisci. The quality of the RCTs was assessed using the Cochrane Risk of Bias Assessment. RESULTS: A total of 10 studies, including 1525 patients and dealing with conservative treatment vs. arthroscopic surgery were included in this review. In eight studies the effectiveness of exercise therapy was compared to surgery; in one study the effectiveness of intra-articular steroid injection was compared to surgery; in one study the effectiveness of placebo surgery was compared to partial meniscectomy. In all studies, no significant inter-group difference in terms of knee pain and knee function were observed at any follow-up evaluation. CONCLUSIONS: Degenerative meniscal tears, without symptoms of locking and catching, can be successfully managed by a proper regimen of physical therapy as a first line treatment. Surgical approach might be considered in case of poor response after conservative treatment.

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.

Successful management of a severe combat penetrating brain injury.

We report the case of successful management of a transcranial penetrating high-energy transfer injury in a 20-year-old soldier. The bullet traversed both cerebral hemispheres and lacerated the superior sagittal sinus rendering him unconscious. We detail the care received at all stages following injury from 'Buddy Aid' on the battlefield, resuscitation by a forward medical team through to prompt neurosurgery within 2 h of injury. Subsequent aeromedical evacuation and continuing aggressive critical care has allowed the patient to survive with acceptable neurological impairment after what is generally considered an unsurvivable injury.

Combined factor V and VIII deficiency and pregnancy--need for an early protocol-based multidisciplinary management.

We report the medical management of a 32-year-old primigravida, after she was found to have a combined factor V (FV) and factor VIII (FVIII) deficiency during pregnancy. A routine coagulation profile performed during the 6th month of pregnancy showed a prolonged activated partial thromboplastin time (aPTT) of 78 seconds, giving a patient/control ratio of 2.29, combined with a prothrombin time (PT) of 28 seconds. An investigation of the coagulation factors showed a combined FV and FVIII deficiency of 29% and 21% respectively. The bleeding risk was considered to be high. A multidisciplinary approach permitted a specific and individualized FVIII substitution protocol. At 39 weeks of amenorrhea, the patient was admitted to the labor room. An infusion of 2000IU of FVIII was implemented over 5 minutes; soon thereafter, PT was 17 seconds, aPTT patient/control ratio had decreased to 1.9 and FV and FVIII reached 38% and 36% respectively. Six hours later, the patient delivered an infant weighing 2850g who had an Apgar score of 10. No bleeding was detected. The patient was then closely monitored for 2 hours in the recovery room. Twelve hours after administration of the first dose of FVIII, another infusion of 2000IU of FVIII was administered. This substitution treatment was continued every 12 hours in ever-decreasing doses, allowing maintenance of FVIII level >50% for 5days. At D7 post-partum, the patient was discharged uneventfully.

[Bilateral carotid artery dissection in a severe preeclamptic setting: an unusual cause of postpartum headache]. / Dissection artérielle carotidienne bilatérale dans un contexte de prééclampsie sévère : une cause inhabituelle de céphalées du post-partum.

A 30-year-old woman with severe preeclampsia presented at 27 weeks of amenorrhea with left headache, neck pain, blurred vision and numbness of left hemiface that resolved spontaneously within 2 hours. A week later, hypertension remained poorly controlled despite combination of nicardipine and labetalol intravenous therapy; an urgent caesarean section was eventually performed due to onset of HELLP syndrome. At day 5 postpartum, the patient had a Horner syndrome with right ipsilateral disabling tinnitus. A CT-angiography of supra-aortic trunks was performed urgently; it showed a bilateral carotid arterial dissection without stroke, which was subsequently confirmed by MRI angiography. The patient was transferred in neurovascular intensive care unit. Anticoagulant therapy was implemented to prevent cerebral and retinal ischemic lesions. Symptoms resolved quickly and the patient was discharged at day 7 postpartum. MR-angiography performed 4 months later showed a full resolution of the bilateral carotid dissection. Anticoagulant therapy was therefore discontinued.

[Management of penetrating abdominal trauma: what we need to know?]. / Prise en charge des traumatismes pénétrants de l'abdomen : des spécificités à connaître.

Penetrating traumas are rare in France and mainly due to stabbing. Knives are less lethal than firearms. The initial clinical assessment is the cornerstone of hospital care. It remains a priority and can quickly lead to a surgical treatment first. Urgent surgical indications are hemorrhagic shock, evisceration and peritonitis. Dying patients should be immediately taken to the operating room for rescue laparotomy or thoracotomy. Ultrasonography and chest radiography are performed before damage control surgery for hemodynamic unstable critical patients. Stable patients are scanned by CT and in some cases may benefit from non-operative strategy. Mortality remains high, initially due to bleeding complications and secondarily to infectious complications. Early and appropriate surgery can reduce morbidity and mortality. Non-operative strategy is only possible in selected patients in trained trauma centers and with intensive supervision by experienced staff.

[Errors of red cell concentrates recipients: method of analysis using the adverse events notified to the hemovigilance network in 2009]. / Erreurs de destinataire de concentrés de globules rouges : méthode d'analyse à partir de déclarations d'incidents de la chaîne transfusionnelle en 2009.

CONTEXT: Among the adverse events in the blood transfusion process, transfusion to a "wrong" patient is potentially dangerous, as it can lead to an adverse reaction at least in case of ABO incompatible red cell concentrate. MATERIAL AND METHODS: The "Root Cause Analysis" working party of the National Hemovigilance Commission developed a tool to collect this type of adverse event, and tested it on a sample of 43 cases involving red cell concentrates notified between March, 2009 and February, 2010. RESULTS: One hundred and nine failures of a step in the transfusion process were observed, i.e. 2.5 failures per adverse event. Failures may occur early in the process. However, they are mainly found at the time of issuing of the blood component, and further, in the clinical ward. How the failure is eventually detected is not always described when the blood component has been fully transfused, in contrast with the cases where actual transfusion to the wrong patient has been prevented. Knowing the way of failure detection enables an objective approach of the efficacy of the numerous existing safety measures. In this sample, bedside controls (documents check as well as the use of anti-A and anti-B reagents with patient's blood and red cell concentrates) detected the failure in three cases out of 34, which were not detected before, showing an efficacy similar to the administrative control done at reception in the clinical ward. CONCLUSION: The document, set up to analyse step by step these cases of patient errors, will be used in the future to analyse all similar cases, not only with red cell concentrates, but also with platelet concentrates and fresh frozen plasma, ultimately in order to improve their prevention.

[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.

[Amniotic fluid embolism: report of the successful outcome of a case with inaugural cardiac arrest and early DIVC complicated by hemoperitoneum of iatrogen origin and bleeding of an hepatic adenoma]. / Embolie amniotique: à propos de l'issue favorable d'un cas avec arrêt cardiaque inaugural et CIVD précoce compliquée d'un hémopéritoine d'origine iatrogène et d'un saignement sur un adénome hépatique.

Amniotic fluid embolism is a relatively rare clinical entity and with difficult medical recognition. However, it is the second leading cause of maternal mortality. We report here the case of a 32-year-old patient who underwent elective caesarean section complicated by an amniotic fluid embolism with cardiac arrest. The presence of a major disseminated intravascular coagulation favored the occurrence of a retroperitoneal hematoma of iatrogenic origin on attempt of femoral venous catheterization and that of hemoperitoneum on bleeding of an hepatic adenoma. The diagnostic of amniotic fluid embolism was confirmed by the presence of amniotic cells in the bronchoalveolar lavage. The patient survived without sequelae.

Fever of unknown origin: Importance of 18F-FDG PET/CT in the diagnosis of a late infectious complication after aneurysm bypass.

Persistent blood flow in aneurysmal sac after bypass-exclusion is well documented in the literature. Aneurysm enlargement, local compressive symptoms and even sac rupture are commonly described complications. Late secondary infection of popliteal artery aneurysm (PAA) following ligation and venous bypass is exceptional. We report the case of late PAA infection six years after bypass-exclusion in a 75 year-old man which was diagnosed by 18F-FDG PET/CT. The patient was successfully treated by aneurysm resection and antibiotics. The diagnosis of popliteal aneurysm infection is often clinical, echographic and sonographic, but computed tomography scan can be false negative in chronic low-grade infection. 18F-FDG PET/CT is able to accurately diagnose and localize infection with high sensibility and specificity.