[Out-of-hospital cardiac arrest in children with bacterial tracheitis]. / Laryngotrachéites bactériennes révélées par un arrêt cardiaque en préhospitalier.

UNLABELLED: Bacterial tracheitis is a severe cause of acute infectious upper-airway obstruction. Its characteristics include thick purulent secretions with or without plaques or pseudomembrane formation. Fatal complications are infrequent if an appropriate treatment is conducted. CASE REPORT: We report on 2 cases of bacterial tracheitis revealed by out-of-hospital cardiac arrest. At presentation in winter, both children first had the symptoms of viral croup. However, no response to the appropriate therapy for this disease was observed. A cardiac arrest occurred on the second day. Bronchoscopy allowed diagnosis. Findings on initial examination were erythema, edema and purulent secretions. Bacterial cultures of tracheal secretions were positive with Staphylococcus aureus. Serology with influenza A virus was also positive. Despite antibiotics and mechanical ventilation, both children died in the pediatric intensive care unit, consecutively to irreversible ischemic brain injury. CONCLUSION: Bacterial tracheitis remains a life-threatening upper-airway infection. Prompt recognition and accurate diagnosis could lead to decreased mortality. It is essential to reassess any croup whose outcome is not rapidly favourable. Such patients should be monitored in a pediatric intensive care unit.

[Evolution of strategies of revascularisation in acute coronary syndromes with ST elevation. Analysis of the data of RESURCOR]. / Evolution des stratégies de revascularisation des syndromes coronaires aigus avec sus-décalage du segment ST. analyse des données du RESURCOR.

The aim of this study was to describe the changes in strategy of revascularisation in acute coronary syndromes with ST elevation (ACS ST+) since setting up a health care network. The authors analysed the incidence of coronary angioplasty and of intravenous thrombolysis from a prospective permanent hospital register of patients with ACS ST+ in the three Northern Alps departments from october 1st 2002 to december 31st 2004. Respectively, 171 patients were enrolled in 2002 and 675 in 2003, and 588 in 2004. The use of percutaneous coronary intervention increased (57, 69, and 78% in 2002, 2003, 2004, p< 0.01) in relation to the increased use of immediate secondary percutaneous coronary intervention (27, 36, 43%, p< 0.01) although the use of primary percutaneous coronary intervention did not changed (30, 33, 35%, p= 0.17). These results were observed in hospitals with and without Percutaneous Coronary Intervention facilities. An increase in prehospital (49, 67, 68%, p= 0.02) and hospital thrombolysis (48, 68, 73%, p= 0.03) was only observed in patients managed in institutions without Percutaneous Coronary Intervention facilities. The average delay to arterial punction (120. 124, 100 minutes, p< 0.01) and to intravenous thrombolysis (40, 30, 25 minutes, p< 0.01) decreased during the same period. Patients with ACS ST+ more commonly benefit from coronary revascularisation at increasingly shorter intervals to treatment. This would seem to be related to the better coordination of practitioners after the implantation of a health care network.

[Misleading diagnosis of a migratory epigastric pain in mobile emergency units: spontaneous rupture of the oesophagus]. / Diagnostic trompeur d'une douleur épigastrique migratrice en préhospitalier: la rupture spontanée de l'oesophage.

The local mobile emergency unit took charge of a patient who suffered from a sudden migratory epigastric pain in the back. The clinical picture led to an initial diagnosis of an aorta dissection. Admitted to Grenoble UH's emergency unit, the radiological examination ruled out a cardiovascular pathology. Emergency surgery, performed only a few hours after the symptoms began, allowed to correctly diagnose a spontaneous rupture of the oesophagus. Fast and specialised medical treatment avoided the risk of an unfavourable development of the Boerhaave's syndrome. It is essential that mobile emergency units personnel are made aware of this rare pathology, even though it remains particularly difficult to diagnose due to its rather non-specific symptoms.

[Epidemiological analysis of drug self-poisonings treated by a mobile intensive care unit]. / Analyse epidémiologique des intoxications médicamenteuses volontaires aiguës: prise en charge par un service mobile d'urgence et de réanimation.

PURPOSE: Study the epidemiology, prehospital emergency care and short-term evolution of the drug self poisonings. METHODS: Retrospective analysis from January 1999 to December 2000 of drug self poisonings requiring Grenoble (France) intensive care unit action and patient follow up. RESULTS: 325 patients, 39.3 years old +/- 14.5 have been treated. The drug self poisonings are representing 4.6% of Grenoble mobile intensive care unit activity. The sex-ratio was, for the 15 to 24 years old population, 2.3 females for 1 male. Mobile intensive care unit has been decided in first intention on 56.3%. 556 toxic substances have been reported, psychotropics are prevailing (79.4% of all drug self poisonings). Intubation has been necessary in 24%. 64.4% of the treated population has been hospitalized into intensive care units. The main exit step of the first admission unit was returning home. Death rate was 0.9%. CONCLUSION: Drug self poisoning is an important part of mobile intensive care unit activity. The very low death rate could be related to several criteria: a high efficient rescue unit setting up a symptomatic based medical treatment and the current decreased toxicity of the ingested drugs.

[Acute pulmonary edema during nicardipine and salbutamol therapy for preterm labor in twin pregnancy]. / Oedème aigu du poumon au décours d'une tocolyse par nicardipine et salbutamol lors d'une menace d'accouchement prématuré sur grossesse gémellaire.

We report the case of a 38-year-old parturient at 30 weeks 2 days term of a multiple pregnancy who experienced acute pulmonary edema more than 48 hours after tocolytic treatment with nicardipine and salbutamol. The patient was transferred from a level 1 perinatal center to a level 3 perinatal center by the Grenoble mobile intensive care unit in application of the in utero transfer protocol for preterm labor before 33 weeks with twin pregnancy. This case illustrates the risk of tocolytic treatment and potential adverse effects in the event of preterm labor on twin pregnancy. The question of associating a second tocolytic after failure of the first is also raised.

[In utero medicalized transfers: medical regulation and transport process]. / Transferts in utero médicalisés.

OBJECTIVES: Application of the perinatality plan has led to an increase in utero medicalized transfers with an emergency mobile medical service (SAMU-SMUR). Sometimes pregnancies are transferred very far from the mother's home because of the unavailability of infant care units. This work aims to analyze the reasons for this rising trend in order to improve the features of medicalization, to define contrindications for transfers (after an appropriate medical decision) and to identify the best the modes of medicalized transports. EQUIPMENT AND METHODS: This retrospective study concerned 167 in utero transfers performed by the Grenoble mobile emergency unit from 1998 to 2001. The rise in the number of transports involving newborn children weighing less than 1500 g and born in Grenoble maternities was also analyzed. RESULTS: From 1998 to 2001, the number of in utero medicalized transfers increase twofold. Transfers were made because of threatening premature delivery. Twin pregnancy was involved in 28% of the cases; 50% of the pregnancies had not been delivery at 7 days, and 35% were referred back to the referring institution undelivered. For preterm labor, tocolysis was instituted in 74% of those cases with b-adrenergic agents, 20% with nicarpine, and only one with atosiban. Almost all the newborn children weighting less than 1000 g, as well as 85% of the babies with a 1000-1500 g birthweight, were born in level 3 centers. CONCLUSION: The rising trend for medicalized in utero transfers, which can be observed in mobile emergency medical services since the publication of perinatality orders is undoubtedly linked with the increase of transfers for threats of premature delivery. The improvement concerning perinatal results depends on implementing better transfer practices, which would enable selecting pregnant women presenting high risks of delivering. The use of well-designed procedures and protocols is fundamental in order to limit transfer risks. Atosiban is better tolerated than ss-adrenergic agents and nicarpine, and should be considered for use as a first-line tocolytic agent in in utero transfer for preterm labor, specially for twin pregnancies. A formalized decision making protocol and use of atosiban as tocolytic agent for preterm labor, should help lower the number of medical indications for in utero transfer.