mass civilian shootings: are we ready to face this new threat? · treatment is aimed at stopping...
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Mass civilian shootings: Are we ready to face this new threat?
COL A Puidupin (MD), CPT C Hoffmann (MD),CPT N Cazes (MD), COL S
Margerin (PCD), LTC T Provost-Fleury (MD), LTC O Gacia (MD)
French Armed Forces Health Service, Paris, Clamart, Marseille
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outlines:
1. New threat
2. Lessons learned from the battlefield
3. Strategy
4. Management of Mass Civilian shooting
« The opinions or assertions expressed herein are the private
views of the authors and are not to be considered as official
or as reflecting the views of the French Military Health Service
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3 Waves of clandestine supply of small guns :
• Eastern Europe (1989) • Balkans: former Yugoslavia (1991-2001) • Libya (2011)
Antoine JC. Le trafic d’armes en provenance
d’Europe de l’Est.
La banalisation et le renouveau dû aux Printemps
arabes.
Revue « Regard sur l’Est ». 15 février 2012.
1. New threat:
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3 spots of « Global War on Terrorism » :
• Central Asia: Afghanistan, Pakistan • Middle East: Syria, Iraq • West Africa: Mali, Burkina Faso, Chad, Niger, Nigeria
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London: 7th July 2005
Victims: 56 death, 700 injured
Usual terrorists’attack :
Threat due to terrorism:
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Mass hostage taking
Paris Porte de Vincennes (9th January 2015):
20 hostages • 4 hostages killed by terrorist, terrorist killed by RAID/BRI
New threat due to terrorism:
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Mass hostage taking
Marseille-Marignane Airport (25th december 1994):
160 Hostages
• 4 Hijackers killed by GIGN
Paris Porte de Vincennes (9th January 2015):
20 Hostages • 4 Hostages killed by terrorist, terrorist killed by RAID/BRI
New threat because of terrorism:
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Mass shooting
Oslo and Utoeya Island (22th July 2011)
• Bomb attack against Governement of Oslo
• Gun shooting during youngsters meeting on Utoeya Island • Death toll: 77 • Injured: 220
Charlie Hebdo in Paris (7th January 2015):
• Death toll:12 • Injured:11
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Tunis (18th March 2015)
2 Terrorists
21 Casualties
(Including 20 foreign tourists),
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Répartition des blessures
selon le mécanisme lésionnel
(thèse Hoffmann)
2.Lessons learned from battlefield Epidemiology
Wound type sorting
according to lesion
mechanism (Hoffmann
thesis)
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Where Do Battlefield Casualties Die?
87.3% Pre hospital (4016/4596)
87.3%(n=4,016)
12.7%(n=580)
0
10
20
30
40
50
60
70
80
90
100
Pre-MTF DOW
Pe
rce
nt
Mortality Site
Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press.
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What is the Cause of Death?
91%(n=888)
7.9%(n=77) 1.1%
(n=11)0
10
20
30
40
50
60
70
80
90
100
Hemorrhage Airway Obstruction Tension Pneumothorax
Pe
rce
nt
Physiologic Cause
Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press.
Extremity [119/888] = 13.5% Junctional [171/888] = 19.2% Truncal [598/888] = 67.3%
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Haus-Cheymol R, Mayet A, Verret C, Duron S, Meynard JP, Pommier de Santi V, Decam C, Pons F,
Migliani R. Blessures par arme à feu dans les armées. Rapport préliminaire. 2010.
(thèse Hoffmann)
Which Part of the Body? Head & Neck
Lower limbs
Upper limbs
Limbs
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Bellamy RF. The causes of death in conventional land warfare : Implications for combat casualty care
research Mil Med 1984 ; 149 : 55-62
(Deaths avoided thanks to proper care)
20 to 30% of Causes of Death
Notion of Preventable Death:
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Where Can We Save the Most Lives?
Eastridge BJ, Mabry RL, Seguin PG, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. Journal of Trauma, 2012. In press. Eastridge BJ, Hardin M, Cantrell J, et al. Died of wounds on the battlefield: causation and implications for improving combat casualty care. Journal of Trauma, 2011. 71(Suppl 1):4-8.
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Surface Ship Survivability.
Naval War Publication 3–20.31. Washington, DC: Department of Defense; 1996.
Damage control
OBJECTIVES OF DAMAGE CONTROL
The three basic objectives of shipboard damage control are
PREVENTION, MINIMIZATION, and RESTORATION
3. Military Strategy
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Damage control surgery
Rotondo MF. 'Damage control': an approach for improved survival in
exsanguinating penetrating abdominal injury.
J Trauma 1993 ;35 :S375-82
Letal
“bloody vicious cycle” (Moore)
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INCISION
“damage control”
STOP BLEEDING
STOP CONTAMINATION
LESS THAN ONE HOUR
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Damage control surgery
+ Damage control resuscitation
Holcomb JB. Damage control resuscitation. J Trauma 2007 ;62 :S36-7
Rotondo MF. 'Damage control': an approach for improved survival in
exsanguinating penetrating abdominal injury.
J Trauma 1993 ;35 :S375-82
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Small volume ressucitation and inotropic support if necessary
DAMAGE CONTROL ressucitation
Ratios during Massive Transfusion
1:1 Ratios 1 RBC / 1 FFP
Treatment is aimed at stopping the bleeding and
correcting hypo perfusion:
Tranexamic Acid
Rossaint R, Bouillon B, Cerny V,Coats TJ, Duranteau J, Fernandez-Montejar E, et al. Management
of bleeding following major trauma: an updated European guideline. Crit Care 2010;14:R52
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• Whole Blood Transfusion
FOCUS on Military skills
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• Relevance of the FLYP to control the coagulopathy of war injuries
• Safety of FLYP
• French lyophilized plasma
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Damage control
Damage control surgery
+ Damage control resuscitation
+
Holcomb JB. Damage control resuscitation. J Trauma 2007 ;62 :S36-7
Rotondo MF. 'Damage control': an approach for improved survival in
exsanguinating penetrating abdominal injury.
J Trauma 1993 ;35 :S375-82
Damage control Ground zero
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– Fluid Resuscitation: Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral pulses are the best field indicators of shock.
• (a) If not in shock – No IV fluids necessary
– PO fluids permissible if conscious and can swallow
Damage control ground zero
Treatment is aimed to stop the bleeding
and at correcting hypoperfusion
during pre hospital period
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“an instrument of the devil that sometimes saves lives.”
Coupland. Care in the Field for Victims of Weapons of War: Geneva: International
Committee of the Red Cross 2001
Tourniquet
STOP BLEEDING
Hemostatic Dressing
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Extremity Hemorrhage Control!
Kragh, and al – Tourniquet Study
• Ibn Sina Hospital, Baghdad, 2006
• Tourniquets are saving lives on the battlefield
• 31 lives saved in 6 months by use of pre hospital tourniquets
• Author estimates 3000 lives were saved with tourniquets in this conflict as of 2012
Kragh JF, Walters TJ, Baer DG, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 2009. 249(1):1-7.
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Is tourniquet « safe »?
In Israël:
– Whithin 4 years, 91 Injured, tourniquet applied in less than15 mins (80%),
– Efficency Upper Limbs>Lower Limbs, (93% vs 71%)
– 550 Injured, 0 death after tourniquet
– 50% unnecessary
– 5 % complications (Duration > 150mins) but short MEDEVAC time (between 1.5 hr and 3 hr)
Dror Lakstein, J Trauma. 2003;54:S221–S225.
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• Education =>Trauma System: First Aid Guide Lines
Mogadiscio, Somalia (1993)
Mabry J, United States Army Rangers in Somalia: an analysis of
combat casualties on an urban battlefield. J Trauma 2000 ; 9 : 515-29.).
Tactical Combat
Casualty Care (T3C)
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PHTR RESEARCH ELIMINATING PREVENTABLE DEATH ON THE BATTLEFIELD
Kotwal RS, Montgomery HR, Kotwal BM, Champion HR, Butler FK, Mabry RL, Cain JS, Blackbourne LH, Mechler KK, Holcomb JB Archives of Surgery, 2011. 146(12): 1350-8.
INTRODUCTION: The 75th Ranger Regiment comprehensively integrated TCCC training with a pre hospital trauma registry (PHTR) through a command-directed casualty response system. This system is evaluated in terms of battlefield survival.
METHODS: Battle injury data were analyzed for combat missions conducted by the 75th Ranger Regiment in Afghanistan and Iraq over 8.5 years, from October 2001 through March 2010. Each casualty was scrutinized for preventable adverse outcomes and opportunities to improve care. Comparisons were made to official Department of Defense (DoD) casualty data for the military as a whole.
RESULTS: 419 battle injury casualties. Regiment’s 10.7% KIA, 1.7% DOW, and 7.6 CFR rates were lower than the 16.4%, 5.8%, and 10.3 rates for U.S. military as a whole. Of 32 fatalities, 0 were DOW from infection, 0 were potentially survivable through additional pre hospital medical intervention, and 1 was potentially survivable in the hospital setting. Substantial pre hospital care was provided by non-medical personnel.
CONCLUSION: Tactical leader management of a casualty response system that trains all personnel in TCCC and receives continuous feedback from PHTR data resulted in unprecedented reduction of KIA, DOW, and preventable combat death.
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Categorization of triage
Urgent => 2H
Priority => 4H
Routine => 24H
Triage in Afghanistan
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• Triage is aimed at avoiding Preventable Death
Death that could have been avoided thanks to adequate medical-surgical care.
Holcomb Ann Surg 2007 C. Willy Chir urg. 2008
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Damage Control Surgery Damage Control Ground Zero
Holcomb Ann Surg 2007 C. Willy Chir urg. 2008
Holcomb JB. Damage control resuscitation. J Trauma 2007 ;62 :S36-7
• Stop bleeding on site
• Immediat treatment in MTF=>
Damage control Surgery
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Gerhardt al. Evaluation of combat casualty care outcomes after the introduction of
emergency medicine providers and an EMS systems approach to the setting of
tactical ground combat.
Ann Em Med 2005 ; 46 : 45-6.).
Survival Improvement (44%) after the introduction of EMT
(Shock Trauma Platoon)
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In case of Mass Civilian Shooting
4. Are we ready?
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First Aid and EMT
SWAT
Special Weapons And Tactics: SWAT
ORGANISATION?
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EDUCATION AND TRAINING?
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EQUIPMENT?
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Conclusion: American Journal of Emergency Medicine