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IntroductionIn April 2020, the military medical planning needs to be recalibrated to support the COVID-19 crisis during a large-scale combat operation carried out by the French army in Sahel.Material and MethodsSince 2019, proper positioning of Forward Surgical Teams (FSTs) has been imperative in peer-to-near-peer conflict and led to the development of a far-forward surgical asset: The Golden Hour Offset Surgical Team (GHOST). Dedicated to damage control surgery close to combat, GHOST made the FST aero-mobile again, with a light logistical footprint and a fast setting. On 19 and 25 March 2020, Niger and Mali confirmed their first COVID-19 cases, respectively. The pandemic was ongoing in Sahel, where 5,100 French soldiers were deployed in the Barkhane Operation.ResultsFor the first time, the FST had to provide, continuously, both COVID critical care and surgical support to the ongoing operation in Liptako. Its deployment on a Main Operating Base had to be rethought on Niamey, to face the COVID crisis and support ongoing operations. This far-forward surgical asset, embedded with a doctrinal Role-1, sat up a 4-bed COVID intensive care unit while maintaining a casualty surgical care capacity. A COVID training package has been developed to prepare the FST for this innovative employment. This far-forward surgical asset was designed to support a COVID-19 intensive care unit before evacuation, preserving forward surgical capability for battalion combat teams.ConclusionFar-forward surgical assets like GHOST have demonstrated their mobility and effectiveness in a casualty care system and could be adapted as critical care facilities to respond to the COVID crisis in wartime.

Riassunto Le fistole eso-tracheo-bronchiali benigne acquisite dell’adulto sono situazioni cliniche rare, ma sempre complesse. Questa patologia si verifica, il piu delle volte, in pazienti debilitati da un lungo ricovero in terapia intensiva e associa una contaminazione cronica dell’albero bronchiale a una grave malnutrizione. La strategia terapeutica e multidisciplinare e combina il trattamento medico con una gestione endoscopica e chirurgica. Deve concentrarsi sulla definizione del momento ottimale per la riparazione chirurgica, mentre la tecnica utilizzata dipendera dalla sede della fistola. Se si deve privilegiare la riparazione ideale, a volte puo essere necessaria l’esclusione temporanea o definitiva del tubo digerente. Dopo un breve richiamo fisiopatologico ed eziologico, la strategia terapeutica viene descritta in dettaglio e illustrata con l’ausilio di foto e video.

Riassunto Le vie d’accesso toracoaddominali sono privilegiate in chirurgia aortica, in chirurgia esofagea e in alcuni campi della chirurgia generale standard o d’urgenza. Una buona conoscenza anatomica del diaframma e della regione toracoaddominale consente di adattare al meglio il gesto alle circostanze. Dalla scelta dello spazio intercostale, dal tipo di dissecazione e dalla sezione del diaframma dipendono il comfort dell’esposizione e, in parte, l’impatto generale dell’intervento. Il ramo posteriore del nervo frenico e particolarmente esposto durante queste vie d’accesso e una buona conoscenza dell’anatomia del diaframma permette una sezione e una riparazione adeguate. Due scenari possono condurre a queste vie d’accesso toracoaddominali. Nel campo della chirurgia standard, o immediatamente, per permettere una buona esposizione, o secondariamente, per ingrandire una via d’accesso addominale verso il torace, oppure l’opposto. Inoltre, puo trattarsi di una via d’accesso d’urgenza dettata da particolari circostanze cliniche (patologia traumatica a torace chiuso o aperto, ferita penetrante toracoaddominale), quando devono essere allargati una laparotomia verso il torace o, al contrario, un accesso toracico verso l’addome. In queste condizioni, il chirurgo deve essere in grado di controllare, in un’unica installazione, tutti gli elementi vascolari degli organi sopra- e sottodiaframmatici e di accedervi. Queste vie d’accesso toracoaddominali non sono indirizzate esclusivamente ai chirurghi toracici o vascolari, ma a tutti i chirurghi dediti alla chirurgia generale standard o d’urgenza. In questo articolo, gli elementi anatomici necessari alla realizzazione di queste vie d’accesso vengono affrontati in un primo tempo. In un secondo tempo, viene dettagliata la tecnica chirurgica, a seconda delle circostanze incontrate, con i dettagli della toracotomia posterolaterale con frenotomia, della toraco-freno-laparotomia destra o sinistra, della toracolaparotomia o della sternolaparotomia. Questo articolo e un aggiornamento dell’articolo precedente integrato con nuovi video per una perfetta comprensione.

The management of penetrating thoracic injuries in moribund or unstable patients is clearly described in contrast to that of stable patients, particularly for those with a cardiac box injury. This anatomic location suggests a potentially lethal cardiac injury and requires urgent therapeutic decision making. The present study aims at determining when surgical exploration is beneficial for stable patients presenting with penetrating cardiac box injuries (PCBIs).This was a retrospective study of stable civilian patients with PCBI referred to level I trauma centers in the Marseille area between January 2009 and December 2019. Using post hoc analysis of the management outcomes, patients whose surgery was considered therapeutic (group A) were compared with those whose surgery was considered nontherapeutic and with nonoperated patients (group B).A total of 155 patients with PCBI were included, with 88% (n = 137) of stab wound injuries. Overall, surgical exploration was performed in 54% (n = 83), considered therapeutic in 71% (n = 59), and performed by video-assisted thoracoscopy surgery in 42% (n = 35) with a conversion rates of 14% (n = 5). Initial extended fast assessment with sonography for trauma revealed the presence of hemopericardium in 29% (n = 29) in group A versus 9.5% (n = 7) in group B, p = 0.010, and was associated with a negative predictive value of 93% regarding the presence of a cardiac injury. Chest tube flow was significantly higher in patients who required surgery, with a median (interquartile range) of 600.00 (350.00-1200.00) mL versus 300.0 (150.00-400.00) mL ( p = 0.001).Extended fast assessment with sonography for trauma and chest tube flow are the cornerstones of the management of stable PCBI. Video-assisted thoracoscopy represents an interesting approach to check intrathoracic wounds while minimizing surgical morbidity.Therapeutic/Care Management; Level IV.

BACKGROUND Recent terrorist attacks in France highlight a weakness in massive casualties management and advocate for simulation-based education to improve the whole process. OBJECTIVE The purpose of this paper is to describe both the conception and the production of Traumasims, a serious game (SG) dedicated to on-scene triage in case of massive casualties. METHODS A group of 14 experts in prehospital care as well as emergency and trauma surgery co-produced an SG with Medusims: Traumasims. Clinical benchmarks were identified by the expert panel. Features of high-fidelity simulation-based education were applied to improve the learning of these clinical benchmarks. The SG thus integrates feedback at the end of each scenario, the repetition of scenarii, increasing degrees of difficulty, and individualized teaching. Traumasims was designed according to principles of virtual reality for education purposes: training and assessment. RESULTS Using 3-D real-time video game technology, trainees are in the position of a doctor organizing a casualty collection point (CCP). Immersion is guaranteed by first-person gaming and interaction with caregivers and wounded avatars. To simulate victims, 48 avatars were produced based on real cases, individually tested and care-dependent evolutive. By varying numbers of caregivers and victims, trainees experienced scenarii of massive casualties with increasing difficulty. A personal debriefing was integrated at the end of each simulation. This debriefing allows for an individualized learning curve for each trainee. CONCLUSIONS The development of Traumasims involved a collaborative platform with interdisciplinary actors from the French Military Health Service (FMHS) and its emergency health-care system. This SG was designed to meet the simulation training needs highlighted by recent terrorist attacks. CLINICALTRIAL none

Andra is in charge of the long-term management of all radioactive waste in France. It has acquired between 2000 and 2008 a vast amount of stress data around the area selected to host the French deep geological repository for high activity and long-lived radioactive waste. The minimum principal stress was estimated from hydraulic fracturing tests and the fracture closure pressure was interpreted during the shut-in phase. However, in the Callovo-Oxfordian claystone, this method results in a minimum horizontal stress that is much larger than the vertical stress even when vertical fractures were clearly generated. As the uncertainty on the weight of the overlying sediments is low, the validity of this technique in a tight claystone formation with very limited leak-off is questioned. Several tests were reinterpreted using the flow-back data and the pressure rebounds when they were recorded. The new interpretation gives consistent results between the wells drilled around the Meuse/Haute-Marne underground research laboratory and the magnitude of the minimum principal stress matches well the actual orientation of the induced fractures. These data support the use of flowback tests as the preferred stress determination technique in tight formations.

In France, a deep geological disposal for high-level radioactive waste (HLW) and intermediate level long life radioactive waste (IL-LLW) called Cigéo is planned to be constructed in a deep Callovo-Oxfordian claystone (COx) formation, if it is authorized. The heat emitted from the waste leads to a temperature increase in the low permeability host porous formation, which induces a pore pressure increase essentially due to the difference between the thermal expansion of the pore water and the solid skeleton. This study aims at assessing the effect of nonlinear behavior of COx, especially creep, on the THM response of the HLW repository. Different approaches, from perfectly MohrCoulomb model and simplified time-dependent models (power and Norton) to an advanced model, have been considered. These approaches lead to common conclusions that (1) the creep reduces the pore pressure increase compared to poro-elastic approach; (2) the nonlinear instantaneous response in the near-field resulting from cell drilling does not affect the THM response in the far field and (3) the thermal load does not induce any supplementary damage of the host rock

The French National Radioactive Waste Management Agency (Andra) is in charge of studying the disposal of high-level and intermediate-level long-lived waste (HLW and ILW-LL) in a deep geological repository (Cigéo project) within the host formation is the Callovo-Oxfordian claystone (COx). The heat emitted from waste packages induces a thermo-hydro-mechanical (THM) coupling within the structural elements and the host rock. This study focuses on the behavior of the concrete lining of an ILW-LL cell subjected to THM loading during its construction and operational phases. The mechanical behavior of the host rock is represented by an elasto-visco-plastic model taking into account the anisotropies in stiffness and strength. The coupled THM formulation is based on the Biot theory. Different simulations including full THM coupling and HM coupling with or without creep behavior of COx claystone have been performed to show the effect of the thermal load (generated by the waste packages), of the water seepage and of the creep strain of the host rock on the stress evolution in the concrete liner. The results show the preponderant role of the creep strain of COx claystone on the stress state of the liner during the operational phase, while the effect of the heat loading is moderate and that of the seepage is not significant.

Resume La thoracotomie de ressuscitation est une procedure exceptionnelle dont la pratique reste, en France, marginale. Ses objectifs sont au nombre de 5 et repondent point par point aux causes d’arret cardiaque traumatique : lever une tamponnade pericardique, controler une hemorragie cardiaque, realiser un massage cardiaque interne, clamper l’aorte thoracique descendante et controler les lesions pulmonaires et les autres hemorragies intrathoraciques. Cette demarche s’integre dans une strategie de Damage control, avec un objectif de temps operatoire inferieur a 60 minutes. Elle est indiquee chez les patients victimes d’un arret cardiaque traumatique penetrant si la duree de la RCP est

Resuscitation thoracotomy is a rarely performed procedure whose use, in France, remains marginal. It has five specific goals that correspond point-by-point to the causes of traumatic cardiac arrest: decompression of pericardial tamponade, control of cardiac hemorrhage, performance of internal cardiac massage, cross-clamping of the descending thoracic aorta, and control of lung injuries and other intra-thoracic hemorrhage. This approach is part of an overall Damage Control strategy, with a targeted operating time of less than 60minutes. It is indicated for patients with cardiac arrest after penetrating thoracic trauma if the duration of cardio-pulmonary ressuscitation (CPR) is15minutes, or10minutes in case of closed trauma, and for patients with refractory shock with systolic blood pressure65mm Hg. The overall survival rate is 12% with a 12% incidence of neurological sequelae. Survival in case of penetrating trauma is 10%, but as high as 20% in case of stab wounds, and only 6% in case of closed trauma. As long as the above-mentioned indications are observed, resuscitation thoracotomy is fully justified in the event of an afflux of injured victims of terrorist attacks.

Resume La prise en charge des traumatismes penetrants abdominaux, pelviens, vasculaires et des confins depend du statut hemodynamique du blesse et du type de lesions, sachant que l’association lesionnelle est la regle. Leur gravite est liee au risque hemorragique initial puis au risque septique secondaire et enfin aux sequelles des associations lesionnelles. En cas d’instabilite hemodynamique, l’objectif de la prise en charge est l’obtention rapide de l’hemostase et de la coprostase. Cette attitude conduira a realiser une laparotomie d’emblee pour les plaies abdominales, un packing sous-peritoneal (PSP) et la mise en place d’un ballon d’occlusion aortique (REBOA) au dechoquage pour les plaies pelviennes, la pose d’un shunt vasculaire temporaire (SVT) pour les traumatismes des vaisseaux proximaux des membres et la ligature pour les lesions hemorragiques des vaisseaux distaux et enfin le controle des saignements exteriorises au moyen de garrot tourniquet, de pansement compressifs jonctionnels ou de compresses hemostatiques pour les plaies des confins. En cas de stabilite hemodynamique, des examens d’imagerie preoperatoire permettront un bilan lesionnel plus precis, notamment en ce qui concerne les lesions retroperitoneales ou thoraco-abdominales, difficilement explorable chirurgicalement. Les voies d’abord chirurgicales seront larges, systematisees, agrandies a la demande permettant d’appliquer les principes du damage control.