Mathieu Pasquier

Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature.

Mitral valve injury after blunt chest trauma is a rare occurrence. We recently admitted a patient with severe traumatic mitral regurgitation who was successfully treated with surgery. Review of the literature aimed at taking an inventory of cases of traumatic nonpenetrating mitral insufficiency that were operated on, since the earliest report in 1964. Eighty-two cases were found and analyzed allowing for a better understanding of the epidemiology, etiology, natural history, pathology, and treatment of this rare condition. The most common lesions reach the papillary muscles (PM), followed by the chordae and then the mitral valve leaflets. Among the 82 cases reported that have been treated with surgery, 57% required a valve replacement. More than half of the patients had a PM injury with a complete or partial rupture. When the rupture is complete, and especially when it involves the anterior PM, the clinical picture is most always acute with clinically important hemodynamic repercussions, often necessitating emergency surgery, most of the time with mitral valve replacement. One must always suspect traumatic mitral injury after blunt chest trauma. The most common mitral lesions affect the PM. The clinical course can be indolent or devastating, and most often requires urgent or delayed surgical treatment, either with mitral valve repair or replacement.

Prevalence and determinants of QT interval prolongation in medical inpatients

Background:  QT interval prolongation carries an increased risk of torsade de pointes and death.

Is trauma in Switzerland any different? Epidemiology and patterns of injury in major trauma - a 5-year review from a Swiss trauma centre

UNLABELLED Switzerland, the country with the highest health expenditure per capita, is lacking data on trauma care and system planning. Recently, 12 trauma centres were designated to be reassessed through a future national trauma registry by 2015. Lausanne University Hospital launched the first Swiss trauma registry in 2008, which contains the largest database on trauma activity nationwide. METHODS Prospective analysis of data from consecutively admitted shock room patients from 1 January 2008 to 31 December 2012. Shock room admission is based on physiology and mechanism of injury, assessed by prehospital physicians. Management follows a surgeon-led multidisciplinary approach. Injuries are coded by Association for the Advancement of Automotive Medicine (AAAM) certified coders. RESULTS Over the 5 years, 1,599 trauma patients were admitted, predominantly males with a median age of 41.4 years and median injury severity score (ISS) of 13. Rate of ISS >15 was 42%. Principal mechanisms of injury were road traffic (40.4%) and falls (34.4%), with 91.5% blunt trauma. Principal patterns were brain (64.4%), chest (59.8%) and extremity/pelvic girdle (52.9%) injuries. Severe (abbreviated injury scale [AIS] score ≥ 3) orthopaedic injuries, defined as extremity and spine injuries together, accounted for 67.1%. Overall, 29.1% underwent immediate intervention, mainly by orthopaedics (27.3%), neurosurgeons (26.3 %) and visceral surgeons (13.9%); 43.8% underwent a surgical intervention within the first 24 hours and 59.1% during their hospitalisation. In-hospital mortality for patients with ISS >15 was 26.2%. CONCLUSION This is the first 5-year report on trauma in Switzerland. Trauma workload was similar to other European countries. Despite high levels of healthcare, mortality exceeds published rates by >50%. Regardless of the importance of a multidisciplinary approach, trauma remains a surgical disease and needs dedicated surgical resources.

Helicopter Rescue Involving the Winching of a Physician

INTRODUCTION We sought to study the operational and medical aspects of helicopter rescue missions involving the use of a winch. SETTING A single helicopter-based medical service of a pre-alpine region of Switzerland. METHODS We prospectively studied consecutive primary rescue interventions involving winching of a physician, from October 1, 1998 to October 1, 2002. Demographic, medical and operational aspects as well as outcome at 48 hours were analyzed. RESULTS We included 133 patients. Most (74%) were male, with traumatic injuries (77%). The median scene time of the nine severely injured patients (Injury Severity Scale [ISS] > 15) was significantly longer compared with the other patients (54 vs 37 minutes; P < .05). The main medical procedures performed were orotracheal intubation (n = 5), fracture reductions (n = 5), major analgesia with sedation (n = 4), and intravenous fluid administration of more than 1,500 mL (n = 4). Fourteen (10%) patients suffering from minor injuries were triaged by the physician and not airlifted to the hospital. All 133 patients were alive at 48 hours. Sixty-nine (52%) were still hospitalized. No secondary interhospital transfer was required. CONCLUSION Our study provides a better knowledge of injury profile, medical aspects, and outcomes of patients rescued necessitating a winching procedure.

A new proposal for management of severe frostbite in the austere environment

Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations.

A two-year retrospective review of the determinants of pre-hospital analgesia administration by alpine helicopter emergency medical physicians to patients with isolated limb injury†

Up to 75% of pre‐hospital trauma patients experience moderate to severe pain but this is often poorly recognised and treated with insufficient analgesia. Using multi‐level logistic regression analysis, we aimed to identify the determinants of pre‐hospital analgesia administration and choice of analgesic agent in a single helicopter‐based emergency medical service, where available analgesic drugs were fentanyl and ketamine. Of the 1156 patients rescued for isolated limb injury, 657 (57%) received analgesia. Mean (SD) initial pain scores (as measured by a numeric rating scale) were 2.8 (1.8), 3.3 (1.6) and 7.4 (2.0) for patients who did not receive, declined, and received analgesia, respectively (p < 0.001). Fentanyl as a single agent, ketamine in combination with fentanyl and ketamine as a single agent were used in 533 (84%), 94 (14%) and 10 (2%) patients, respectively. A high initial on‐scene pain score and a presumptive diagnosis of fracture were the main determinants of analgesia administration. Fentanyl was preferred for paediatric patients and ketamine was preferentially administered for severe pain by physicians who had more medical experience or had trained in anaesthesia.

Cooling rate of 9.4 °C in an hour in an avalanche victim

A 47-year-old man was caught, during an ascent while practicng ski touring, in an avalanche at 3050 m. Fully buried at a depth f 1 m, he was extricated after 35 min by his companions, who eported a patent airway and started cardio-pulmonary resusciation (CPR). The helicopter rescue physician accessed the victim 2 min later. The ECG tracing showed an asystole. Endotracheal ntubation was carried out and an oesophageal temperature probe nserted, revealing a core body temperature of 28.4 ◦C, 55 min after urial. The patient was airlifted to hospital under continuous CPR. fter a 10-min flight, and 80 min after burial, the oesophageal core emperature in the resuscitation room was 28.0 ◦C, and the serum otassium 7.4 mmol/L. Following extracorporeal rewarming and eturn of spontaneous circulation, he was transferred to the ICU here, unfortunately, he died 24 h later from multi-organ failure. o autopsy was performed, and the cause of death was presumed o be due to irreversible hypothermia. Assuming a normal initial temperature of 37 ◦C,1 the patient’s ore body temperature dropped by 9.4 ◦C/h, the fastest cooling rate ublished to date in an avalanche victim. Although obtaining a relible field measurement of core temperature is challenging,2,3 the robe of our thermometer was oesophageal, as recommended.4 he fast cooling rate thus demonstrated may have resulted from combination of the light clothing worn by the victim and the low mbient temperature (−12 ◦C). Owing to difficulties in obtaining a reliable measurement in cariac arrest avalanche victims, the core temperature is currently roposed only as a proxy measurement, when the duration of burial more or less than 35 min, which is the preferential triage key) is nknown.4 Current guidelines recommend a cut-off of 32 ◦C, which s the temperature below which hypothermia is considered to be a otential cause of cardiac arrest.4 Interestingly, assuming various rates of cooling, our patient ould have lowered his core temperature to 32 ◦C in 15–32 min Fig. 1). This temperature drop compares well with data measured xperimentally during the first 30 min following snow burial of naesthetised piglets.5 Therefore, our case would suggest that the burial duration cutff of 35 min should either be revised to a lower figure, or that greater weight should be placed on circumstances surrounding urial, as cooling rates may be much faster than assumed thus far. his is obviously important if the cut-off of a core body temperature f 32 ◦C remains in the guidelines. In addition, the rate of our patients’ temperature drop during he first 30 min is astonishingly parallel to that of piglets breathng ambient air. In our case, core body temperature continued to rop after extrication. These results raise the question whether

Retrospective analysis of 616 air-rescue trauma cases related to the practice of extreme sports

INTRODUCTION Extreme sports (ESs) are increasingly popular, and accidents due to ESs sometimes require helicopter emergency medical services (HEMSs). Little is known about their epidemiology, severity, specific injuries and required rescue operations. AIM Our aims were to perform an epidemiological analysis, to identify specific injuries and to describe the characteristic of prehospital procedures in ES accidents requiring HEMSs. METHODS This is a retrospective study, reviewing all rescue missions dedicated to ESs provided by HEMS REGA Lausanne, from 1 January 1998 to 31 December 2008. ES were classified into three categories of practice, according to the type of risk at the time of the fall. RESULTS Among the 616 cases meeting inclusion criteria, 219 (36%) were clearly high-risk ES accidents; 69 (11%) and 328 (53%) were related to potential ES, but with respectively low or indeterminate risk at the time of the fall. In the high-risk ES group, the median age was 32 years and 80% were male. Mortality at 48h was 11%, almost ten times higher than in the other two groups. The proportion of potentially life-threatening injuries (the National Advisory Committee for Aeronautics (NACA) score≥4) was 39% in the high-risk ES group and 13% in the other two groups. Thirty per cent of the cases in the high-risk ES group presented an Injury Severity Score (ISS) >15, compared with 7% in the other groups. Thoracolumbar vertebral fractures were the most common injuries with 32% of all cases having at least one, involving the T12-L2 junction in 56% of cases. The other most frequent injuries were traumatic brain injuries (16%), rib fractures (9%), pneumothorax (8%) and femoral (7%), cervical (7%), ankle (5%) and pelvic (5%) fractures. Median time on site for rescue teams was higher in the confirmed high-risk ES group, with 50% of prehospital missions including at least one environmental difficulty. CONCLUSIONS High-risk ESs led to high-energy accidents, characterized by a large proportion of severe injuries and axial traumas (spine, thorax, pelvis and proximal femur). We identified a considerable percentage of thoracolumbar vertebral fractures, mainly in the T12-L2 junction. HEMSs dedicated to high-risk ESs implied longer and more complex interventions.

Avalanche Victim Resuscitation Checklist adaption to the 2015 ERC Resuscitation guidelines

ig. 1. Avalanche Victim Resuscitation Checklist. The white section is addressed to a Basic Life Support trained first responder, the red section to an Advanced Life Support rained health care provider. Patient ID = Patient Identity; CPR = Cardiopulmonary Resuscitation; BLS = Basic Life Support; ALS = Advanced Life Support; ECLS = Extracorporeal ife Support (Cardiopulmonary Bypass/Extracorporeal Membrane Oxygenation). (a) Time between burial and uncovering the face. (b) If duration of burial is unknown, core hospital management of avalanche victims.1 In 2015, the European Resuscitation Council (ERC) Resuscitation guidelines included for the first time an algorithm for the treatment of avalanche victims.2 To be consistent with the new ERC guidelines which include some substantial modifications, the AVRC has been updated and approved by ICAR MEDCOM in Borovets, Bulgaria, in fall 2016 (Fig. 1, Supplementary Fig. S1 in the online version, at DOI: 10.1016/ j.resuscitation.2017.01.008).

Pre-Hospital Wrist Block for Digital Frostbite Injuries

Three alpinists were climbing in the western European Alps at 3500 m (11,483 ft) when a snowstorm prevented further ascent, and external aid had to be called in the evening. A terrestrial rescue team together with an emergency physician (GZR) was dispatched, as weather conditions precluded any helicopter intervention. The alpinists were reached after 12 hours of difficult rescue team progression in poor conditions [external temperature 15 C (5 F), moderate snowfall, and winds of up to 50 km h 1 (30 miles h )]. The alpinists were physically exhausted, and a 51-year-old, previously healthy man complained of frostbite injuries to both hands. A closed, uninhabited mountain refuge (3100 m, 10,170 ft) was reached after a 2-hour walk, and the decision was made to rest overnight due to safety considerations. Both hands showed frostbite of all distal phalanges with numbness, paleness, and cyanosis of the finger tips. Re-warming was begun in a 40 C (104 F) water bath with povidone-iodine, which caused intolerable pain after about 10 min. The physician decided to perform a bilateral regional anesthesia with wrist blocks. The area was disinfected, and the nerve block was performed as described by Chandran et al. (2010) with three injections of 5 mL of 0.5% ropivacaine for the median, ulnar, and radial nerves, about 3–4 cm proximally to the wrist. Pain in both hands was completely relieved within 10 min. Hyperemia in both hands developed, following both water bath re-warming and wrist blocks. A sterile bandage was applied, and systemic analgesia was initiated orally with acetaminophen and an NSAID (dexketoprofen), in anticipation of the end of the effect of the block, which followed about 2 h later and brought moderate pain. Six hours after arrival in the mountain refuge, improved weather conditions enabled descent to an altitude of 2400 m (7874 ft) where helicopter evacuation to a regional hospital was possible. After 24 hours of hospitalization (Fig. 1), the patient was discharged and followed on an outpatient basis. After transient loss of a nail and superficial skin, the fingers recovered within 8 weeks. A mild cold intolerance persisted.