[Polytraumatized patient. First aid care, transport and resuscitation]. / Le polytraumatisé. Soins immédiats--transport et réanimation.

The initial management of multiple trauma must achieve a triple aim: performing the actions required by a vital emergency, preventing as well as possible the complications associated with the initial lesions, and, most importantly, bringing the injured person into hospital in the best possible conditions for emergency surgery. Achieving these aims requires a perfect coordination of medical and nonmedical rescue. A rough initial categorization is important to decide whether additional medical staff is desirable, choose the type of transport planned (by ambulance, helicopter...) as well as the department or hospital due to receive the patient. Four actions must be accomplished, most often jointly, all of them contributing to the quality of treatment: 1. picking up/freeing/immobilizing the injured person, 2. controlling the hypovolemic collapse and the traumatic shock, 3. dealing with the associated distresses, 4. suppressing pain. The techniques used to pick up, free and immobilize the injured person require a close co-operation with the rescuing staff (stretcher bearers, fire department, first-aid workers). The hypovolemic shock is treated by volume replacement, mainly with colloids. Local hemostasis may sometimes be necessary. Anti-shock trousers should be widely used in cases of multiple trauma. Dealing with the associated distresses gives priority to ventilation. The indications of ventilatory support must be very wide whenever coma or signs of respiratory distress are noted, more so with an associated shock. The indications of aspiration of a gaseous or fluid pleural effusion must also be discussed. Maximal suppression of pain must be kept in mind throughout all these operations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative pulmonary embolism]. / Les embolies pulmonaires post-opératoires.

Post-operative thrombo-embolic disease remains a frequent occurrence in spite of advances in their prophylaxis. Evaluation of 60 case-reports of this disease which often includes peripheral manifestations and always pulmonary manifestations, enables to specify the role of the procedure itself (mostly orthopaedic surgery 60%), pelvic surgery 20%, the chronology of events (possibility of early embolism between D1 and D3 and usual occurrence of manifestations between D8 and D18, and the importance of the background, whether investigated or not: deficiencies in anti-thrombin III, protein C and S: 4 cases. The diagnosis is based on clinical signs (non-specific) and the laboratory tests, especially scintigraphy (screening) and angiography, absolutely necessary for the diagnosis and evaluation of the amputation coefficient (Miller index). With a diagnosis of pulmonary embolism, it is always necessary to look for a proximal venous thrombosis. The treatment, calls for heparin (quite seldom), thrombolytics (Urokinase, Plasminogen in our experience), the indication of which must take into consideration the delays and the nature of the previous procedure, and finally surgery (massive forms where thrombolytics are contraindicated). The thrombo-embolic manifestations with thrombogenic thrombopenia secondary to heparin are quite frequent, in a surgical environment (10 cases) and difficult to treat.

[Rheologic particulars of venous flow. Physiopathologic consequences]. / Particularités rhéologiques de l'écoulement veineux. Conséquences physiopathologiques.

Hemorheological parameters must be taken into account for a better knowledge of venous flow properties. The postcapillary venules are the region of lowest shear rates and therefore the region of highest whole blood viscosity. Red cell aggregation plays a major role in blood viscosity, especially at low shear rate. This microrheological parameter can be increased in pathological circumstances, including a low capillary flow, venular insufficiency, elevated hematocrit, high levels of acute phase proteins. At the level of the capillaries, microcirculatory stasis leads to a low oxygen supply and consequently to poor metabolic state lowering local ATP levels. As a result, both platelet and white blood cell functions are compromised. Hemorheological studies have shown that both deep venous thrombosis and chronic venous insufficiency are associated with high blood viscosity mainly due to an increased red cell aggregation. This hemorheological vicious circle--stasis promoting hyperviscosity leading to further stasis--could be broken up by therapeutic intervention including hemodilution, fibrinolytic drugs or other specific agents.

[Uremic-hemolytic syndrome occurring in extra-uterine pregnancy. Apropos of a case]. / Syndrome urémo-hémolytique survenant au décours d'une grossesse extra-utérine. A propos d'un cas.

One case of uremic-haemolytic syndrome associated with an ectopic pregnancy is reported. The main signs are, from the clinical standpoint, a diffuse haemorrhagic syndrome and, from the biological standpoint, a haemolytic anemia, renal failure and thrombopenia. This pathology, exceptionally associated with an early pregnancy, required an intensive resuscitation with blood transfusion, hemodialysis and plasma exchanges. From a surgical standpoint, two procedures were necessary following salpingectomy, to drain intraperitoneal and sub-aponeurotic blood collections. The course, thereafter, was uneventful.

[Thrombopenia induced by heparin in orthopedic surgery. Apropos of 12 cases]. / Les thrombopénies induites par l'héparine en chirurgie orthopédique. A propos de 12 cas.

Treatment with heparin for the prevention of thrombosis in orthopaedic surgery may sometimes be responsible for thrombopenia. This can be associated with arterial or venous thrombotic complications. Twelve cases of heparin-induced thrombopenia are reported here. Three cases were demonstrated by a diminution of the platelet count which reversed when heparin treatment was discontinued. Nine patients presented with arterial and/or venous thromboses whose progress was favourable in the long term. The replacement of heparin treatment by anti-vitamin K from the 5th or 6th day can avoid the thrombotic complications of heparin-induced thrombopenia.

[Thrombogenic thrombopenia related to heparin. Clinical, biological and therapeutic results. Apropos of 32 cases]. / Thrombopénies thrombogéniques liées à l'héparine. Résultats cliniques, biologiques et thérapeutiques. A propos de 32 cas.

Heparin induced thrombocytopenia is characterized by often dramatic evolution of thrombotic arterial and venous complications. These occurred or are worsened in curative or preventive heparin therapy and the treatment remains delicate. The authors report 32 observations of thrombocytopenia complicated with thromboembolic events; seven deaths are to mention. The tests of platelet aggregation with standard heparin and platelets poor patient's plasma confirm the diagnosis in 28 cases of 30 very early studied and in 2 cases around the 6th day only after the stop of standard heparin. The choice of anticoagulant therapy is carried out the negative tests of platelet aggregation with low molecular weight heparin (L.M.W.H.) (CY 216, CY 222 Choay, PK 10109 Pharmuka). In L.M.W. heparin therapy, clinical and biological improvement is obtained in 26 cases of 30 treated cases. In three cases, the rapid climbing of platelet countings is not present although negative tests of platelet aggregation with selected L.M.W.H. In one case, after a initial climbing of platelet countings, the thrombocytopenia recurs rapidly with L.M.W. heparin after a operation. The immediate or secondary passage with K-antivitamins, platelet antiaggregant stabilized medium and long term's evolution.

[Use of a low molecular weight heparin, CY 222, in the treatment of consumption coagulopathy]. / Utilisation d'une héparine de bas poids moléculaire, la CY 222, dans le traitement des coagulopathies de consommation.

UNLABELLED: Among the different treatments used for consumption coagulopathies, the most contested is classical heparin because of the risk of worsening of a hemorrhagic syndrome. A low molecular weight heparin was evaluated to determine possible improvement of this risk. METHODS: Treatment with CY 222 (Choay) was administered over 2 years to 29 patients (mean age 40 years, range 15-74) with coagulation coagulopathies. Diagnosis was based on the presence of 3 of the following 5 signs: platelets less than 150,000/mm, fibrinogen less than 2 g/l, QT less than 50%, ethanol test positive, PDF greater than 20 micrograms/ml. Etiology could be classed in 3 groups: gravido-puerperal (12 cases), medical disorders (15 cases), post-traumatic (2 cases). Dosage was 150 U/kg every 18 hours subcutaneously. The usual symptomatic treatment included: transfusion of red cells, frozen fresh plasma, platelets and antithrombin III as necessary. A hemorrhage syndrome was present in 16 cases. The course of the disease was evaluated on clinical findings and surveillance of hemostasis parameters; anti-Xa activity was determined in 15 patients. RESULTS: Hemorrhage was arrested and biological values normalized in 22 patients (76%) including 15 (52%) survivors. In the 7 cases where the coagulopathy was not improved, the hemorrhagic syndrome persisted in 4. In the 22 successful outcomes, the hemostasis was corrected within 48 to 72 hours, with the exception of the thrombopenia, which persisted up to the 6th day. Mean anti-Xa activity was 0.32 +/- 0.16 anti-Xa U/ml. CONCLUSION: Results of this preliminary, non-randomized study show CY 222 to be as effective as heparin in the treatment of consumption coagulopathies.

[Severe thrombopenia associated with treatment with pentosan polysulfate]. / Thrombopénie grave associée au traitement par polysulfate de pentosane.

Two cases of severe thrombocytopaenia associated with acute thrombo-embolic manifestations during treatment by pentosan polysulphate, a low molecular weight heparinoid, are reported. Plasma samples from both patients caused in vitro aggregation in the presence of pentosan polysulphate. Interruption of the drug led to the recovery of the platelet count. The hypothesis of an immunoallergic mechanism similar to heparin associated thrombocytopaenia is supported. Furthermore, it seemed likely to be found with all the polysulphated X glycosaminoglycans. During treatment by pentosan polysulphate, platelet count should be monitored to avoid this potentially life-threatening syndrome.

[Acute respiratory distress syndrome in adults in colchicine poisoning]. / Syndrome de détresse respiratoire aiguë de l'adulte au cours des intoxications par la colchicine.

Two cases of adult respiratory distress syndrome were treated in a series of 26 patients suffering from colchicine overdose. The syndrome appeared between the 24th and 72nd hours. It was characterized by the presence of interstitial as well as alveolar oedema seen on chest roentgenograms. Haemodynamic investigation showed a hyperkinetic state with moderate precapillary pulmonary arterial hypertension. In addition, multivisceral phenomena were observed in all cases. Post-mortem examination revealed interstitial and alveolar pulmonary oedema with haemorrhagic or macrophagic alveolitis often accompanied by hyaline membrane. The physiopathology of ARDS occurring in colchicine poisoning appeared to involve such different factors as infection, the presence of a state of shock and disseminated intravascular coagulopathy. The direct toxic action of colchicine on pneumocyte microtubules and the inhibition of surfactant production were a probable cause. The responsibility of colchicine in leukocyte aggregation remains to be determined.

[Hemorheologic disorders in the threatened myocardial infarct syndrome]. / Perturbations hémorhéologiques dans le syndrome de menace d'infarctus du myocarde.

Haemorrheological disturbances have already been described in ischaemic heart disease. However, it has not been established whether these changes are secondary to the ischaemia and/or myocardial infarction or whether they play a role in initiating or sustaining the haemodynamic abnormalities which cause infarction. We report our results observed in 14 patients aged 48 to 75 years admitted to the coronary care unit with a diagnosis of acute coronary insufficiency defined as typical persistent anginal pain resistant to glyceryl trinitrate associated with specific ECG changes (without pathological Q waves or increased serum CPK concentrations). Blood samples were obtained on admission for determination of: haematocrit, total blood viscosities at different levels of shear with the patients hematocrit and with corrected hematocrits, total blood filtrability, plasma viscosity and plasma albumin fraction. All patients received 800 mg lidocaine, 40 mg chlorezepate, adequate anticoagulant doses of heparin and a specific antianginal drug: amiodarone, nifedipine or diltiazem. Six patients had a favourable outcome and were discharged from the Coronary Care Unit without myocardial infarction (Group I); the remaining 8 patients (Group II) developed documented changes of myocardial infarction between the 12th and 4th day after admission (see the Table in the text). The haemorrheological parameters on admission of the two patients groups were compared. The abnormalities observed were significantly more severe in the group developing myocardial infarction. This suggests that these changes may play a major role in initiating conditions leading to myocardial necrosis. These observations confirm the results of other workers who have also shown a relationship between the severity of infarction and the incidence of haemodynamic complications and changes in blood viscosity and filtrability.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute choriocapillaris occlusion in pregnancy and puerperium. Toxemias, thrombotic microangiopathies]. / La choriocapillaropathie obstructive aiguë et état gravido-puerpéral. Toxémies, micro-angiopathies thrombotiques.

Six cases of gravidic toxemia (4) and thrombotic thrombocytopenic purpura (Moschowitz's disease) in puerperium with choriocapillaris occlusion, were examined. At the acute stage, the vision is improved, ophthalmoscopy of the fundus revealed cystlike bullous exudative subretinal with retinal detachment, yellowish spots (of retinal pigment epithelium) and often minimal localized arteriolar narrowing. The evolution included retina application pigmentary disturbances and Elschnig's spots. Fluorescein angiography showed delayed filling of the capillaris and dye leakage in the subretinal space (first hypofluorescence and late hyperfluorescence). There are various stages of ischaemic involvement but in all cases visual symptoms may be due to central obstructive choroidopathy with delayed filling and occlusion. The retinal detachment in toxemia or Moschowitz disease in pregnancy in secondary to microcirculatory choroidal damage (short ciliary vessels essentially) with rupture of blood retinal barrier. Other constatations are made in disseminated intravascular coagulation, periarteritis nodosa, accelerated nephrosclerosis, hemolytic uremic syndrome in puerperium, and these suggested possible relationship between the various conditions.