Retour d'expérience sur les transports Smur des patients Covid-19

Dès la fin du mois de février 2020, les urgentistes français ont été confrontés à une situation inédite et complexe dans la gestion des cas les plus sévères d'infections pulmonaires associées au nouveau coronavirus (SARSCoV- 2). Les informations en provenance de Chine et les recommandations initiales de l'Organisation mondiale de la santé ont rapidement amené à considérer l'intubation et la ventilation mécanique précoce des malades atteints par la pneumonie de la Covid-19. Or, dès la fin du mois de mars 2020, grâce aux retours d'expérience et de prise en charge, d'abord de la part des réanimateurs et urgentistes italiens, puis espagnols, les pratiques et les recommandations concernant les modalités d'oxygénation et de ventilation des patients Covid-19 ont évolué. Le caractère exceptionnel de cette pandémie et la grande adaptabilité des services de Samu/Smur de France, en l'espace de quelques semaines, pour prendre en charge ces patients oxygénodépendants, justifient que nous en fassions le retour d'expérience, et ce, d'autant plus que nous sommes exposés à un risque de recrudescence d'infections respiratoires graves associées au SARS-CoV-2 à court terme, risquant de saturer une nouvelle fois notre système de santé. Nous détaillons donc ici le retour d'expérience des prises en charge médicales préhospitalières concernant principalement les supports d'oxygénation et de ventilation mécanique.Alternate abstract: At the end of February 2020, French emergency physicians were faced with a new and complex situation in the management of critical cases of SARS-CoV-2 infection. First information from China and the initial recommendations of the World Health Organization (WHO) quickly led us to consider early intubation and mechanical ventilation of patients with hypoxemic COVID-19 pneumonia. However, since the end of March 2020, feedback from Italian intensive care and emergency physicians, then Spanish, led to change in clinical practices and guidelines about oxygenation and mechanical or noninvasive ventilation of COVID-19 patients have evolved. The exceptional character of this pandemic and the great adaptability of French pre-hospital emergency medical services (Samu/Smur) in a few weeks, to manage those oxygen dependent patients, justified our feedback, especially because we are exposed to a risk of resurgence of serious short-term SARS-CoV-2-associated acute respiratory distress syndrome (ARDS), which could once again saturate our health system. We therefore detail here the feedback of pre-hospital medical care, mainly concerning the management of oxygenation and ventilation supports.

Utilisation des curares en réanimation

Résumé L’usage des curares en réanimation répond essentiellement a deux objectifs : améliorer les conditions d’intubation et faciliter la ventilation des patients en SDRA. Les conditions de l’intubation qui sont souvent celles de l’urgence imposent l’administration d’un curare d’action rapide : succinylcholine ou rocuronium. Le cisatracurium est le curare de référence pour la curarisation continue. La curarisation diminue les pressions intra-thoraciques et améliore les échanges gazeux mais pas la survie des patients ayant un ARDS. La relation entre neuromyopathie de réanimation et curarisation reste discutée. Summary The use of muscle relaxants in intensive care patients aims facilitating tracheal intubation and improving mechanical ventilation in ARDS patients. Since tracheal intubation is performed most of the time in emergency, succinylcholine is the gold standard for rapid sequence induction avoiding gastric content inhalation. However succinylcholine has contra-indications that favour the use of rocuronium in some patients. Patients who require muscle paralysis to be maintained, receive most of the time a continuous infusion of cisatracurium. Continuous administration of muscle relaxants improves gas exchanges and aims decreasing barotrauma in ARDS patients. Muscle relaxant administration in ICU patients is thought to be associated with ICU-acquired neuromuscular pathology although this remains to be clearly demonstrated owing to the multiple mechanisms that could be implicated.

[Diaphragmatic rupture and right ipsilateral intercostal hernia in chronic cough]. / Rupture diaphragmatique et hernie intercostale droites homolatérales sur toux aiguë.

INTRODUCTION: We are reporting the case of a 64-year-old patient with chronic cough who has been diagnosed with an intercostal hernia with pleural and hepatic content associated with a diaphragmatic hernia of non-traumatic origin. CASE REPORT: The patient was treated for an acutely febrile cough with signs of respiratory distress. Thoracic scan showed an intercostal hernia containing an encysted hematoma and a right anterior diaphragmatic hernia with epiploic content. The COVID PCR was negative. This is one of the rare reported cases of intercostal hernia associated with a homolateral diaphragmatic rupture. Visceral and thoracic surgery enabled treatment of the two hernial orifices by raphy as well as omentectomy of the necrotic omentum ascending to the right pulmonary hilum. CONCLUSION: These two parietal complications of chronic cough should be considered in case of intercostal flap or acute respiratory distress. Surgery must then be carried out as a matter of urgency to reduce the content of the hernias and treat the musculoaponeurotic dehiscent orifices.

[Place of biomarkers in the renutrition of patients with serious Covid-19 infection: discussion around a clinical case]. / Place des biomarqueurs dans la renutrition des patients ayant une infection grave à Covid-19 : discussion autour d'un cas clinique.

Covid-19 infection is a potentially serious disease. Overweight, obesity, and diabetes are comorbidities frequently found in the severe form of the disease. Appropriate nutritional management of the patient is an integral part of care. We will discuss the renutrition of a 76-year-old, obese (BMI = 35kg/m2), malnourished patient, according to the 2021 Haute Autorité de santé criteria, with Covid-19 infection, admitted to the intensive care unit at the Bordeaux University Hospital for an acute respiratory distress syndrome. Adaptation of nutritional intakes was achieved by clinical and biological monitoring. A refeeding syndrome was treated on the first day of hospitalization in the intensive care unit. After thiamine supplementation and when kalemia and phosphatemia have been normalized, renutrition was started. Parenteral nutrition as a complement to oral nutrition was used. Parenteral nutrition was well tolerated; recommended caloric and protein intakes were achieved by the fourth day of hospitalization. The clinical evolution was favorable. In conclusion, patients with Covid-19 infection should be considered malnourished when admitted to the intensive care unit. Macro and micronutrient intakes adapted to metabolically stressed patients are essential. Biological monitoring including monitoring of ionogram, phosphate, uremia, creatinine, liver function tests and blood glucose is essential in the nutritional management of patients with serious Covid-19 infection.