[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.

[Tetraplegia in the course of coma from drug intoxication]. / Tétraplégie au décours d'un coma par intoxication médicamenteuse.

It is reported a case of quadriplegia occurring in a 67-year-old women after she commits suicide with flunitrazepam. The patient stayed during around twenty hours unconscious, in the sitting position, with an extreme flexion of the neck on the left side. After injection of flumazenil the patient's consciousness was restored. Nevertheless a complete sensitive and motor deficit at the C4 and C5 level was then observed. Several diagnosis such as peripheral neuropathy, infectious disease, or arterial occlusion were eliminated and we finally postulated that the regulation of the spinal blood flow had likely been disturbed by the prolonged flexion of the neck, the hypotension and the putative respiratory depression. The fact that the patient suffered from cervicarthrosis would have already impaired the spinal blood flow regulation and consequently had probably damaged the spinal cord. No clinical improvement of the quadriplegia was noticed and the patient died in the intensive care unit thirteen days after admission. Such an exceptional complication after a toxic coma remind us the necessity to avoid long lasting vicious position of the cervical spine in anaesthesia and emergency practice.

Central venous catheter placement in children: evaluation of electrocardiography using J-wire.

Misplacement of a central venous catheter may lead to myocardial perforation and dysrhythmia. Atrial electrocardiography (ECG) through a saline column is an effective but complex method to determine the accurate location of catheters. We evaluated a simplified variant of this technique using the guidewire as an internal electrode in 23 children (5-16 years old) undergoing spinal surgery. Catheters were placed using a Seldinger technique after jugular or subclavian venous puncture. Each time the operator recognized the atrial signal, the catheter was found to be correctly placed on the chest radiograph (20/23). In three patients, the atrial signal was not obtained. A technical error was responsible in one case whereas the two others were related to aberrant migrations of the catheter either into a subclavian vein or into the pleura. In this latter case, the complication was unrecognized on the first radiograph despite malposition having been predicted by atrial ECG. We conclude that a method using atrial ECG guidance is sensitive and specific, and may be an alternative to the classical chest radiograph to detect accurate placement of central venous catheters in children.

Plasma viscosity and haematocrit in the course of acute myocardial infarction.

Plasma viscosity and haematocrit were determined in 44 patients with acute myocardial infarction on the 1st, 2nd, 3rd and 10th day of hospitalization. The highest haematocrit value for the entire group was found on the 1st day of acute myocardial infarction--43.3 SD +/- 4.6% declining progressively to 38.8 SD +/- 3.5% on the 10th day (P less than 0.001). Plasma viscosity for the entire group was normal on the first day of acute myocardial infarction (1.44 SD +/- 0.10 cp) and started to increase on the second day (1.51 SD +/- 0.16 cp, P less than 0.001). A relationship was found between reinfarction or death (17 patients) occurring during hospitalization and changes in haematocrit and plasma viscosity. In this group plasma viscosity rose to 1.63 SD +/- 0.19 cp on the second day of acute myocardial infarction (P less than 0.001 vs plasma viscosity value on the first day). This elevation persisted on the third day. Haematocrit values in this group were 47.9 SD +/- 3.6% on the first day of acute myocardial infarction declining progressively and significantly afterwards. In the remaining patients both plasma viscosity and haematocrit were normal and did not change. No correlation of plasma viscosity and haematocrit were found when tested for other clinical complications, sex, age, maximal creatine phosphokinase values and coronary risk factors. We suggest that variations in haematocrit and plasma viscosity during acute myocardial infarction exist in a group of patients in whom reinfarction or death occurs. The changes in haematocrit and plasma viscosity precede the complications by 4-8 days.(ABSTRACT TRUNCATED AT 250 WORDS)