[Use of thrombelastography to guide posttraumatic hemostatic therapy: More coagulation factor concentrates and less allogenic blood transfusion?] / Intérêt de la thromboélastographie pour guider la correction de la coagulopathie post-traumatique : plus de MDS, moins de PSL ?

Viscoelastic technics are used for 10 years and include the ROTEM® and the TEG®. These devices that exploit the viscoelastic properties of the clotting blood, allow a rapid and global analysis of the haemostatic process taking into account all the process interfering with haemostasis such as inflammation. It has been shown that the use of these technics in clinical situations such as trauma, postpartum haemorrhage, gastrointestinal bleeding or cardiac surgery may reduce the need for blood product, the cost and perhaps may improve the outcome of the patients. Thanks to a rapid identification of the underlying coagulation deficit, these technics facilitate decision-making during acute care and help to guide the treatment, particularly with coagulation factor's concentrate.

[Pulmonary resection and ECMO: A salvage therapy for penetrating lung trauma]. / Lobectomie d'hémostase et ECMO : une association salvatrice après plaie pénétrante du thorax.

The majority of chest penetrating trauma patients are successfully managed with tube thoracostomy and general supportive measures. Pulmonary resection for hemorrhagic shock is rarely required after trauma to control bleeding. Both pulmonary injury and massive blood transfusion can lead to acute respiratory distress syndrome (ARDS). The mortality rate in these patients reaches up to 40% despite advanced ventilatory treatment. The use of extracorporeal membrane oxygenation (ECMO) can be started as rescue therapy. We report a case of 24-year-old man with major hemorrhagic shock with cardiac arrest and ARDS after traumatic penetrating lung injury that was successfully treated with pulmonary resection and ECMO.

[Trap in severe trauma: the rotary atlantoaxial dislocation]. / Piège en traumatologie : la luxation C1-C2.

We reported the case of asymptomatic traumatic atlantoaxial dislocation in a 14-year-old woman. Clinical diagnosis of this uncommon dislocation is difficult and often made late. The early diagnosis by CT scan is necessary to avoid secondary aggravation. Integrity of the transverse ligament of the atlas is a determining factor for atlantoaxial stability and allows orthopaedic treatment after reduction using moderate traction on the head.

[Exceptional medical circumstances: interest of an interhospital support strategy within the North Alps emergency trauma network]. / Situations médicales exceptionnelles : intérêt d'une procédure de renfort interhospitalier au sein du réseau Nord-Alpin des urgences.

The Northern French Alps Emergency Network (RENAU) has a main objective the improvement of the quality of the care in the field of the emergency medical treatment. With this French medical system, we developed a procedure allowing the detachment of a medical-surgical team of the university hospital to help general hospital team in the event of immediate vital emergency situation with untransportable patient. We reported the successful implementation of this support strategy for a 51-year-old patient arrived in a hospital of the network in extremely serious hemodynamic shock due to an important hemorrhagic pericardial effusion with tamponnade 1 day after percutaneous closure of the patent foramen ovale (PFO).

[Resuscitation from accidental hypothermia of 22 degrees C with circulatory arrest: importance of prehospital management]. / Survie sans séquelles d'un arrêt cardiaque avec hypothermie sévère à 22 degrés C: importance de la stratégie de prise en charge préhospitalière.

In winter, French Medicalised Ambulance Service rescued a 50-year-old patient after suicide attempts by jump from a bridge in the Seine. The body was discovered after more than 10 minutes of immersion. She was unconscious and in deep hypothermia with circulatory arrest. Basic CPR was started immediately and oral intubation and 100% oxygen ventilation was performed. Ventricular fibrillation appeared but repeated defibrillation failed due to profound hypothermia (rectal temperature: 28 degrees C). The patient was immediately transported to hospital. CPR and mechanical ventilation was continued during transport. The patient was taken in emergency room. The oesophageal temperature was 22 degrees C. Rewarming using extracorporeal circulation was immediately initiated after insertion of femoral access. At 27 degrees C, ventricular fibrillation started and was converted by external defibrillation to a pulse-generating cardiac rhythm. At 360 minutes, the patient's rectal temperature had reached 36 degrees C and she was disconnected from cardiopulmonary bypass with inotropic support. She was transferred to the intensive care unit after 9 hours of resuscitation, rewarming and stabilisation. Mechanical ventilation was needed for 15 days because of adult respiratory distress syndrome. Renal failure, pneumonia also occurred. She was successfully extubated on day 15 and was discharged from intensive care unit on day 21, suffering no neurological side effects.

[Nerium oleander self poisoning treated with digoxin-specific antibodies]. / Traitement par anticorps antidigitalique d'une intoxication volontaire par laurier rose.

A chronically depressed 44-year-old man was rescued by the French medicalised ambulance service four hours after the ingestion of Nerium oleander leaves in a suicide attempt. Cardiotoxicity was evidenced by the presence of bradycardia with mental confusion and vomiting. The patient was empirically treated in the prehospital phase with a single dose of digoxin-specific Fab antibody fragments (Digidot). In spite of this treatment, the patient presented a new episode of important bradycardia (25 b/minute). Thereafter, the patient's rhythm stabilized and neurological signs and vomiting resolved. The patient recovered uneventfully and was discharged from the intensive care unit two days later.

[Insertion of catheter for temporary transvenous ventricular pacing at prehospital scene after sudden malfunction of pacemaker]. / Pose d'une sonde d'entraînement électrosystolique endocavitaire en préhospitalier suite à un dysfonctionnement de stimulateur cardiaque.

A 70-year-old patient who had been fitted with a pacemaker for 27 years consulted his cardiologist to check the latest device, which had been changed in 1998. During the examination there was a sudden malfunction of the pacemaker, which became uncontrollable, resulting in an escape rhythm of 15 beats/min and circulatory insufficiency. Attempted treatment by isoprénaline and external transcutaneous systolic stimulation failed, and an intraventricular catheter was therefore positioned successfully as an emergency prehospital manoeuvre. This produced good haemodynamic stability, allowing the transfer of the patient to hospital where his pacemaker was changed.

Prehospital use of minimally invasive direct cardiac massage (MID-CM): a pilot study.

BACKGROUND: Internal cardiac compressions are more efficient than closed chest compressions (CCC) in cardiac arrest (CA). AIM OF THE STUDY: To evaluate the prehospital feasibility of performing a new method of minimally invasive direct cardiac massage (MID-CM TheraCardia Inc.). METHODS: Prospective non-randomized open study, after ethical committee approval. Inclusion of 18-85 years old patients in witnessed CA if BLS>5 min and unsuccessful ACLS>20 min after CA. The MID-CM is an atraumatic manual cardiac pumping system deployed in the thoracic cavity through a small incision. Evaluation of: ease of insertion and performing MID-CM, complications, end-tidal CO(2) (PETCO(2)), non invasive arterial blood pressure (NIBP) and return of spontaneous circulation (ROSC). Values are mean+/-SD (min-max). RESULTS: Twenty-five patients included. Mean age 59+/-16 years (26-85); BLS started at 8+/-5 min (0-20), compressions started at 47+/-10 min (29-74) after CA. Dissection and insertion was fast and easy (<1 min). Deployment of the MID-CM was difficult in two patients because of pericardium adhesions and cardiomegaly. In six patients compressions were more difficult because of a 'stone heart' phenomenon. Compressions were possible during ambulance transport of four patients. There was a good palpable carotid pulse in all patients receiving internal compressions. There was a trend in increase of PETCO(2) compared to CCC. NIBP could be measured during MID-CM compressions in 9 patients (systolic>85 mmHg), never during CCC. Seven patients had a ROSC, but only four patients were admitted alive. There was no long term survival. One patient had a serious complication (heart rupture). DISCUSSION: Prehospital use of MID-CM is possible, but it is not comparable to any other resuscitation technique. Training of medical teams is mandatory to obtain good skills and to avoid complications. Further studies are necessary to evaluate efficiency and survival compared to closed chest compressions.

Co-amoxiclav pharmacokinetics during posttraumatic hemorrhagic shock.

OBJECTIVE: To determine the effects of severe trauma with hemorrhagic shock on amoxicillin and clavulanate concentrations in plasma and their pharmacokinetics. DESIGN: A prospective, open, descriptive study. SETTING: A 12-bed, adult surgical intensive care unit in a university-affiliated hospital in France. SUBJECTS: Subjects were 12 patients (10 men, 2 women) with severe trauma: median (range) Injury Severity Score, 38 (17-48); Acute Physiology and Chronic Health Evaluation II, 16 (7-38); Simplified Acute Physiology Score II, 41 (23-77). Also enrolled were 12 healthy volunteers who were matched on age (+/-5 yrs), gender, and body-surface area (+/-20 cm2). All the trauma patients suffered hemorrhagic shock defined as the association of at least one episode of systolic blood pressure <90 mm Hg and an intravascular volume expansion >2000 mL between trauma and surgery. INTERVENTION: Prophylactic perioperative administration of 2 g of amoxicillin and 0.2 g of clavulanate in combination during the first 12 hrs posttrauma in patients, and at the start of the pharmacokinetic study in volunteers. MEASUREMENTS AND MAIN RESULTS: Serial plasma samples (n = 13) were obtained after the first antibiotic administration to measure antibiotic levels by using high-performance liquid chromatography assays. Compared with volunteers, trauma patients had higher plasma amoxicillin and clavulanate concentrations, attributed to a reduction of the volume of distribution (p =.001 and p =.06, respectively) and, to a lesser extent, of the total body clearance (p =.09 and p =.20, respectively). Consequently, amoxicillin and clavulanate elimination half-lives were similar for the two groups of subjects. The interindividual variabilities for all the amoxicillin pharmacokinetic parameters were higher in patients. CONCLUSIONS: In trauma patients with hemorrhagic shock requiring surgery, the administration of 2 g of amoxicillin and 0.2 g of clavulanate seems adequate, according to the antibiotic concentrations observed in plasma for both drugs. However, further studies exploring antibiotic concentrations in tissues are warranted.

Analgesic efficacy and safety of nefopam vs. propacetamol following hepatic resection.

In order to compare the morphine-sparing effect, analgesic efficacy and tolerance of nefopam and propacetamol given at their highest recommended doses, 120 patients undergoing elective hepatic resection were randomly assigned to receive postoperative intravenous patient-controlled analgesia with morphine alone, or in combination with nefopam (20 mg.4 h-1) or propacetamol (2 g.6 h-1). Compared with the control group (43 [7-92] mg), median [range] cumulative morphine consumption for 24 h after the study started was halved in the nefopam group (21 [3-78] mg, p <0.001) and 20% lower in the propacetamol group (35 [6-84] mg, p = 0.15). Analgesia was superior in the nefopam group despite the lower morphine consumption. Adverse effects were comparable in the three groups, except for significantly more nausea in the control group (39% vs. 17 and 26% in the nefopam and propacetamol groups, respectively) and more sweating in the nefopam group (17% vs. 0 and 3% in the control and propacetamol groups, respectively). Overall patient satisfaction was better (p < 0.001) in patients given nefopam (97%) than those receiving morphine alone (82%) or propacetamol (74%).

[Anesthesia, analgesia and obstetrics: a high-risk association!]. / Anesthésie, analgésie et femme enceinte: une association à haut risque!

The authors review the changes in obstetric anesthesia and analgesia that have contributed to a decreased maternal mortality as well as those accounting for the clinically significant improvements of maternal and neonatal morbidity.

Pharmacokinetics of cefpirome during the posttraumatic systemic inflammatory response syndrome.

OBJECTIVE: To determine the pharmacokinetic parameters of cefpirome, a new so-called fourth-generation cephalosporin, in previously healthy trauma patients with posttraumatic systemic inflammatory response syndrome (SIRS) and to compare them to parameters obtained in matched, healthy volunteers. DESIGN: A prospective study. SETTING: 12-bed surgical intensive care unit in a university hospital. PATIENTS: 9 severe [Injury Severity Score, median (range) 29 (16-50)] trauma patients on mechanical ventilation with proven or suspected cefpirome-susceptible nosocomial infection, with no renal or hepatic failure, and healthy volunteers matched for age (+/- 5 years), sex, and body surface area (+/- 10%) were enrolled. All were men. INTERVENTIONS: Cefpirome (2 g twice daily) was continuously infused over a 0.5 h period alone or concomitantly with ciprofloxacin (400 mg over 1 h, twice daily). MEASUREMENTS AND MAIN RESULTS: Antibiotic concentrations in plasma were measured by high-performance liquid chromatography; their pharmacokinetic parameters were evaluated at 12 time points after the first drug administration using a noncompartmental model. Cefpirome pharmacokinetic parameters for the two groups were similar despite a wider variation for trauma patients. Specifically, the median (range) time during which the cefpirome concentration in plasma remained over 4 mg/l (corresponding to the French lower cutoff determining cefpirome susceptibility) was 9.5 (7- > 12) and 9 (8-12) h for trauma patients and healthy volunteers, respectively. In the group of five patients receiving combined antibiotic therapy, the interindividual variability of pharmacokinetics was wider for ciprofloxacin than for cefpirome. CONCLUSION: No major pharmacokinetic modification was noted when cefpirome was given to trauma patients with posttraumatic SIRS without significant organ failure, indicating that no dosage adjustment seems required in this population. However, larger studies including determination of antibiotic levels in tissues are warranted to confirm these results.