[Defusing of victims of the terrorist attacks in Paris. Elements of assessment one-month post-event]. / Defusing des victimes des attentats de Paris. Éléments d'évaluation un mois après.

The terrorist attacks (fusillades and suicide attacks) in Paris on 13 November 2015 have had a major psychic impact on all individuals directly or secondarily exposed to them. Medico-psychological unit (CUMP) of the Paris Île-de-France region's immediate care services were immediately mobilized and rapidly strengthened by all regional medico-psychological units (CUMP) throughout the country. Psychological assistance has been provided in several key points of Paris and specifically in the 11th district City Hall of Paris where Lyon's Medico-psychological unit was located. These specific immediate psychological assistances, referred to as a "defusing process" by the medico-psychological unit (CUMP), are mostly devoted to provide the victims with an entry point to a psychological healthcare relationship and give them a first sense of soothing and relief even though they do not prevent further psychological care follow up for the victims. Nonetheless, the potential therapeutic effect of this "defusing process" has not yet been sufficiently established nor demonstrated by any scientific study. A phoning survey was carried out one-month post-terrorist attacks and interviewed the 129 victims who benefited from the "defusing process" conducted by Lyon's medico-psychological unit (CUMP) in order to collect data and assess its effects. These people, whether directly exposed, bereaved relatives or witnesses, whose average age is 35, are mostly living in the Île-de-France region. Most of them present a high score on the IES-R scale, whether they were directly exposed, bereaved relatives or witnesses. Almost all of them (96.5%) experienced at least one medical care contact within this one-month post-trauma period with psychotropic medication for 37% of them. Regarding the defusing conducted by Lyon's medico-psychological unit (CUMP) in the 11th district City Hall of Paris, it appears that 93% of the victims who were looked after indicated that they were satisfied and 87.4% of them stated that they were soothed afterwards.

Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients.

BACKGROUND: This study aimed to evaluate the accuracy of prehospital parameters, including vital signs and resuscitation (fluids, vasopressor), to predict trauma-induced coagulopathy (TIC, fibrinogen <1·5 g/l or PTratio > 1·5 or platelet count <100 × 109 /l), and a massive transfusion (MT, ≥10 RBC units within the first 24 h). METHODS: From a trauma registry (2011-2015), in which patients are prospectively included, we retrospectively retrieved the heart rate (HR), systolic blood pressure (SBP), volume of prehospital fluids and administration of noradrenaline. We calculated the shock index (SI: HR/SBP), the MGAP prehospital triage score and the Injury Severity Score (ISS). We also identified patients who had positive criteria from the Resuscitation Outcome Consortium (ROC, SBP < 70 mmHg or SBP 70-90 and HR > 107 pulse/min). For these parameters, we drew a ROC curve and defined a cut-off value to predict TIC or MT. The strength of association between prehospital parameters and TIC as well as MT was assessed using logistic regression, and cut-off values were determined using ROC curves. RESULTS: Among the 485 patients included in the study, TIC was observed in 112 patients (23%) and MT in 22 patients (5%). For the prediction of TIC, ISS had good accuracy (AUC: 0·844, 95% confidence interval, CI: 0·799-0·879), as did the volume of fluids (>1000 ml) given during prehospital care (AUC: 0·801, 95% CI: 0·752-0·842). For the prediction of MT, ISS had excellent accuracy (AUC: 0·932, 95% CI: 0·866-0·966), whereas good accuracy was found for SI (> 0·9; AUC: 0·859, 95% CI: 0·705-0·936), vasopressor administration (AUC: 0·828, 95% CI: 0·736-0·890) and fluids (>1000 ml; AUC: 0·811, 95% CI: 0·737-0·867). Vasopressor administration, ISS and SI were independent predictors of TIC and MT, whereas fluid volume and ROC criteria were independent predictor of TIC but not MT. No independent relationship was found between MGAP and TIC or MT. CONCLUSIONS: Prehospital parameters including the SI and resuscitation may help to better identify the severity of bleeding in trauma patients and the need for blood product administration at admission.

[Effect of ketamine on prevention of postmastectomy chronic pain. A pilot study]. / Effet de la kétamine dans la prévention des douleurs chroniques post-mastectomies. Etude pilote.

OBJECTIVE: This pilot study was designed to evaluate the feasibility of a trial to estimate the preventive effect of ketamine on postmastectomy pain syndrome (PMPS). STUDY DESIGN: Double-blind, randomized, placebo-controlled pilot trial. PATIENTS AND METHOD: Thirty six patients scheduled for a radical mastectomy with axillary lymph node dissection were randomized in two groups (n=18 per group). Before skin incision, a bolus (0.5 mg/kg of ketamine or placebo) followed by a continuous infusion (0.25 mg/kg per hour of ketamine or placebo) was administered and discontinued at the end of surgical procedure. We studied the incidence and characteristics of PMPS three months after surgery as well as the feasibility of chosen methods. RESULTS: Thirty patients were followed for three months (group ketamine n=12; group placebo n=18). At three months, there was no significant difference in the incidence of chronic pain, but a tendency to a decrease of hyperalgesia near the scar. There was no repercussion on the quality of life. The characteristics of the PMPS are similar to those described in the recent literature (intercostobrachial neuralgia 33%, neuroma pain 39%, and phantom breast pain 22%). The feasibility of the experimental study is established by the absence of difficulty during the clinical investigation period. CONCLUSION: We found no preventive effect of ketamine on the development of PMPS. However, the non-statistically significant effect of ketamine on hyperalgesia three months after surgery could justify a larger study with the same methodology.

[Thoracoabdominal CT scan: a useful tool for the diagnosis of air embolism during an endoscopic retrograde cholangiopancreatography]. / Intérêt d'un scanner corps entier pour le diagnostic d'embolie gazeuse au cours d'une cholangiopancréatographie rétrograde endoscopique.

We report the case of an 82-year-old woman treated with biliary stents for an ampulloma of Vater's papilla, with recurrent stenosis of the common bile duct. She was hospitalized with a cholestasis. An endoscopic retrograde cholangiopancreatography (ERCP) was scheduled to change the biliary stent for a metallic one, under general anaesthesia, with oral intubation. The ERCP was performed initially without any complication, but as the metallic biliary stent was placed, an air embolism occurred and a cardiac arrest happened immediately. The etiologic diagnosis was quickly confirmed by an injected multislice body-scan, which showed liver, right heart and brain gas embolism. Cardiopulmonary resuscitation allowed a complete haemodynamic recovery but a poor neurological recovery. The patient was transferred in intensive care unit, were she died 12 days after, despite hyperbaric oxygen therapy and the disappearance of the air embolism on the following computed tomography scan. This case may be useful to recall the utility of a body-scan for the diagnosis, treatment and follow-up of an air embolism during ERCP.

[New aspects of cardiopulmonary resuscitation]. / Pourquoi la réanimation cardiopulmonaire a-t-elle changée récemment?

OBJECTIVES: To analyse the current knowledge based on the experimental and clinical research studies focused on cardiopulmonary resuscitation. DATA SOURCES: International guidelines and recent review articles. Data collected from the Medline database with the keyword: cardiac arrest (CA). STUDY SELECTION: Research studies published during the last ten years were reviewed. Relevant clinical information was extracted and discussed. DATA SYNTHESIS: Last guidelines include significant modification in the management of cardiac arrest patient. Recognition of CA by lay rescuers is done on the absence of vital sign (no reactivity, no breathing) and it is now only recommended for healthcare providers to check the pulse. It is confirmed that chest compression has to prevail over ventilation and has to be done at a rate of 100 compressions per minutes with a compression-ventilation ratio of 30: 2. A short period of CPR before attempting defibrillation may be considered in adults with out-of-hospital ventricular fibrillation (VF) or pulseless ventricular tachycardia and a delay to EMS response. Defibrillation is provided with biphasic waveform at 150-200 J and is immediately followed by a 2 min period of CPR. Adrenaline remains the drug of choice in cardiac arrest whatever the first rhythm because no benefit has been demonstrated with vasopressin in term of survival. Amiodarone is the first line antiarrhythmic, improves short-term survival and is currently recommended after the second shock for resistant VF. Postresuscitation treatment is now receiving greater emphasis in emergency cardiovascular care, but there is little evidence to support specific therapies with the exception of hypothermia (12-24 h at 32-34 degrees C) that is currently recommended if patient remains unconscious after VF. Revascularization should also be discussed if CA is presumed to be from ischemic origin. CONCLUSION: The last international 2005 guidelines include significant modifications of CPR. However, many questions remain unresolved and controlled studies are still needed before other changes could be recommended for routine practice. Our greatest challenge and highest priority is the training of lay rescuers and healthcare providers in simple, high-quality CPR skills that can be easily taught, remembered, and implemented to save lives.

[Perioperative heart rate in patients taking beta-blockers: reality and efficiency of the treatment]. / Analyse des fréquences cardiaques durant la période péri-opératoire chez des patients prenant des bêtabloquants: réalité et efficacité du traitement.

OBJECTIVE: To compare perioperative heart rate (HR) control of patients chronically exposed to beta-blockers (BB) with those of patients whom BB treatment was initiated one week preoperatively. METHODS: HR was noticed at three successive time periods: the anaesthesia visit, just before induction of anaesthesia, and during surgery (maximum and minimum HR). HR, presented as mean+/-SD, was compared among 3 groups of patients: BB chronic treatment, preoperative BB, and a control group not taking BB. RESULTS: Four hundred (and) six patients were included: 181 chronic BB patients, 20 preoperative BB, and 205 control patients. As compared to the control group, HR of chronic BB patients were lower (P<0.05) than those of the control group at the three time period of the study. In the preoperative BB patient group, one week BB treatment resulted in a mean 30% reduction of HR. Just before induction of anaesthesia, HR of preoperative BB patients was lower than that of chronic BB patients (55+/-11 vs 67+/-13 b/min; P<0.05). CONCLUSION: Beta-blockers treatment initiated one week before surgery could be more effective on perioperative HR control than chronic BB treatment.

Comparison of the effects of mepivacaine and lidocaine on rat myocardium.

BACKGROUND AND OBJECTIVE: To compare the inotropic and lusitropic effect of lidocaine and mepivacaine on rat papillary muscle. METHODS: Effects of lidocaine and mepivacaine (10-8-10-3 M) were studied in rat left ventricular papillary muscles in vitro at a calcium concentration of 1 mmol, under low (isotony) and high (isometric) loads. RESULTS: Lidocaine induced a significant negative inotropic effect in isotonic and isometric conditions whereas mepivacaine did not. Mepivacaine only induced a negative inotropic effect when added as a bolus for the highest concentration and this effect was significantly more pronounced with lidocaine than with mepivacaine (active force at 10-3 M: 63 +/- 10 vs. 84 +/- 10% of baseline, P < 0.05). Increasing calcium concentration resulted in a greater positive inotropic effect in the control (199 +/- 11% of baseline) and mepivacaine groups (197 +/- 22% of baseline) when compared to the lidocaine group (163 +/- 19% of baseline, P < 0.05 vs. lidocaine and control groups), suggesting an impairment on intracellular Ca2+ handling by lidocaine. A negative lusitropic effect under low load was observed only for mepivacaine and suggested an impairment of sarcoplasmic reticulum function. Lidocaine and mepivacaine did not modify post-rest potentiation but significantly depressed the force-frequency relationship. CONCLUSIONS: The negative inotropic and lusitropic effects induced by lidocaine were more important than that of mepivacaine and may involve an impairment of intracellular Ca2+ handling.

[Transorbital fiberoptic intubation: a predictable difficult intubation in cephalic surgery]. / Intubation transorbitaire: une intubation difficile prévisible en chirurgie céphalique.

Management of the difficult adult airway is a crucial problem in anaesthesia. It is the first cause of anaesthetic mortality and morbidity. We report here the case of a patient who could only be intubated through the orbital cavity. We discuss our technique of intubation compared to the other rare procedures described in the literature. We also focus on our anaesthetic protocol and the interest of preserving spontaneous ventilation for intubation. Use of short acting anaesthetic drugs can help to achieve such conditions.

[Necrotizing bacterial skin and software tissue infection with muscular involvement revealing of cancer of the colon]. / Dermohypodermite bactérienne nécrosante (DHBN) avec atteinte musculaire à Clostridium septicum révélatrice d'un cancer du côlon.

We report the case of a 38-year-old woman with a necrotizing bacterial skin and soft tissue infection with muscular involvement. The clinical picture was similar to a gaseous gangrene of the right lower limb with a septic shock and multiple organ failure, without predisposing factor such as trauma, and necessitating a hip amputation. The primary site of the disease was a perforated colic adenocarcinoma with peritoneal and retroperitoneal infection. The association of necrotizing skin and soft tissue infection with muscular involvement due to Clostridium septicum to a neoplasma is classical and in front of such an infection a neoplasma should be researched.

[Ischaemia of the lower limbs: anaesthesia and intensive care]. / Anesthésie-réanimation d'un patient en ischémie aiguë des membres inférieurs.

OBJECTIVES: To appreciate the severity of a patient with acute limb ischaemia, to know how to manage these patients during the perioperative period. DATA SOURCES: References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: acute limb, ischaemia, prognosis, complications, rhabdomyolysis, hyperkalaemia, compartment syndrome, fasciotomy. DATA SYNTHESIS: Ischaemia of the lower limbs is a medico-surgical emergency. The ischaemia implies a decrease of cellular energetic stocks and an increase in intracellular calcium. During reperfusion, the calcium paradox is exacerbated and ROS formation produces membrane damage. Tissue oedema and a local and general inflammatory syndrome occur. Clinical symptoms of acute ischaemia include pallor, pulselessness, decrease of temperature and pain. Occurrence of neurological symptoms is a sign of severity. Prognosis of patients relates directly to preexisting collateral circulation, aetiology of the occlusion (thrombosis vs embolus), duration of ischaemia, topography of the occlusion (severity of proximal occlusions as the acute aortic occlusion), and co-morbidity (renal failure, heart failure). The temperature of the ischaemic limb, quality of the downstream circulation, extension of the thrombus, arterial pressure and association to a venous thrombosis are other prognostic factors of lower limb ischaemia. The first treatment to be initiated is high doses of heparin. Once the diagnosis is made, the number of preoperative tests will be as small as possible because of the urgency of revascularization. Arteriography will be performed only when really needed and when its realization will not delay revascularization and will not alter the patient's prognosis. Where general anesthesia is required, the choice of anaesthetic agents will be based on their haemodynamic stability. During severe acute limb ischaemia, monitoring of invasive pressure is recommended, as well as regular dosages of potassium, arterial gases and CPK. Preoperatively in case of severe ischaemia, (proximal occlusion lasting more than 6 hours), preventive treatment, including controlled reperfusion with heparinized serum is indicated. Surveillance and prevention of a rhabdomyolysis and renal failure are imperative. Immediately after reperfusion, a dosage of potassium must be performed; moreover that hyperkalaemia is favoured by acidosis or renal failure. Postoperative haemodialysis is performed in case of hyperkalaemia or renal failure. Occurrence of compartment syndrome has to be checked and fasciotomy must be performed in case of a doubt on the microcirculation integrity.

[Perioperative administration of betablockers: a practice survey]. / Administration périopératoire de bêtabloquants: enquête de pratique.

OBJECTIVES: To evaluate the anaesthesiologists' attitude concerning the perioperative administration of betablockers (BB), especially prophylactic BB, in order to prevent postoperative cardiac complications. METHODS: A questionnaire including 20 items was sent to 700 anaesthesiologists of 4 French departments (Ain, Isere, Loire et Rhone). RESULTS: The response rate was 30%. Eighty-eight percent of respondents prescribed the BB with the premedication, on the day of the surgery in patients who were on regular BB. Before major surgery, 37% percent of respondents always or usually introduced prophylactic BB in patients with high cardiac risk. Atenolol was the drug of choice for 68% of perioperative BB users. Seventy-one percent of anaesthesiologists using prophylactic BB asked for a cardiologic opinion before starting BB therapy. CONCLUSION: In practice, anaesthesiologists continued BB during the perioperative period in patients who were on chronic treatment with BB. However, prophylactic perioperative administration of BB in patients with high cardiac risk is still inadequate and dependent on a cardiologic opinion.

[New aspects and perspectives on cardiac arrest]. / Prise en charge de l'arrêt cardiaque: actualité et perspectives.

OBJECTIVES: To analyse the current knowledge based on the experimental and the clinical research studies focused on the main fields of cardiopulmonary resuscitation. DATA SOURCES: International guidelines and recent review articles. Data collected from the Medline database with the key word: cardiac arrest. STUDY SELECTION: Research studies published during the last ten years were reviewed. Relevant clinical information was extracted and discussed when it induced changes in guidelines. DATA SYNTHESIS: Promising improvements on basic and advanced life supports are proposed. Chest compressions prevail over ventilation. Alternatives to classical chest compressions are tested. Ventilatory volume must be reduced from 1000 to approximatively 500 mL for each breath with oxygen. Biphasic waveform defibrillators and automated external defibrillators will be considered as the best devices in the near future. Some non-catecholaminergic vasopressors could reduce the use of epinephrine for advanced cardiac life support. Lidocaine could be replaced by amiodarone as anti-arrhythmic drug of choice. New post-resuscitation therapeutic strategies are evaluated, especially coronary reperfusion when the cause of cardiac arrest is cardiac. CONCLUSION: Many fields of cardiopulmonary resuscitation are investigated. Some relevant informations are included in the last international guidelines published in 2000, but most of them need complementary studies before other changes could be recommended for routine practice.

[Perioperative medical complications in orthognathic surgery]. / Complications médicales périopératoires de la chirurgie orthognathique.

PURPOSE: To describe per and postoperative medical complications. STUDY DESIGN: Prospective, observational study. PATIENTS: Between July and December 1999, 59 patients scheduled for programmed orthognathic surgery were included. METHODS: Anaesthetic and surgical procedures were standardised including patient information and training of surgical ward' nurses. During perioperative periods (in operative and recovery theater and in surgical ward), all the events were qualified on an anaesthetic spreadsheet for a qualitative analysis (description of events and treatment procedures). RESULTS: Two main complications were described 1) one atelectasia due to blood inhalation during the recovery period and 2) local sepsis in surgical ward. These two events were medically treated and recovered. No need of blood transfusion or stay in ICU were noted. CONCLUSION: Anaesthetic and surgical cooperation is associated with poor morbidity of this functional surgery performed in young subjects.

Severe heart failure secondary to 5-fluorouracil and low-doses of folinic acid: usefulness of an intra-aortic balloon pump.

OBJECTIVES: To report 5-fluorouracil in combination with folinic acid as a cause of severe nonischemic heart failure and to demonstrate the potential usefulness of an intra-aortic balloon pump. DESIGN: Case report. SETTING: An adult, 19-bed medical/surgical intensive care unit of a university hospital. PATIENTS: A patient, who developed severe heart failure secondary to 5-fluorouracil infusion with low-dose folinic acid, which was introduced to treat a rectal cancer, was transferred from a cancer institute to our intensive care unit 4 days after the treatment was initiated. INTERVENTIONS: Electrocardiography, determination of level of cardiac enzymes, echocardiography, radial arterial catheterization, mechanical ventilatory support, continuous venovenous hemodialysis, vasopressors, and secondary intra-aortic balloon pump. MEASUREMENT AND MAIN RESULTS: During shock, the patient's systolic blood pressure progressively decreased to 70 mm Hg, despite inotropic agents and vasopressors. Transesophageal echocardiography showed a calculated left ventricular ejection fraction within 20% with global hypokinesia. Electrocardiography showed sinus tachycardia with only nonspecific ST-T changes. Results of serial determination of levels of cardiac enzymes were not significant for myocardial infarction. Treatment with an intraaortic balloon pump was initiated and resulted in a dramatical improvement within 48 hrs. The patient was gradually weaned from vasopressors and the intra-aortic balloon pump. By the tenth day, echocardiography showed a septoapical hypokinesia with a 50% left ventricular ejection fraction. On the 30th day, the echocardiography was considered normal. CONCLUSION: Intravenous 5-fluorouracil in combination with low doses of folinic acid can induce severe nonischemic heart failure. In such a case, an intra-aortic balloon pump could be useful by providing left ventricular function support when inotropic agents and vasopressors fail to restore normal hemodynamics.

Time course of oxidative stress after major burns.

OBJECTIVE: To evaluate oxidative stress resulting from major burns in humans. DESIGN: Prospective clinical study with control group. SETTING: Mechanically ventilated adult patients admitted with more than 30% total burn surface area. PATIENTS AND PARTICIPANTS: 20 patients with a mean body surface burned area of 54%. MEASUREMENTS AND RESULTS: The oxidative stress evaluation was based on measurements of trace elements, vitamins, antioxidant enzymatic activity and end-products of lipid peroxidation. During the first 5 days after injury burn patients exhibit a decrease in selenium and antioxidant vitamins (C, beta-carotene, lycopene) and an increase in lipid peroxidation products (TBARS). CONCLUSION: Our results suggest that major burn is associated with oxidative stress during the 5 days after the initial injury, as demonstrated by a simultaneous decrease in antioxidant vitamins and a large increase in TBARS.