[Carotido-cavernous fistula after traumatic brain injury: an unusual vascular complication]. / Fistule carotidocaverneuse post-traumatique : une complication vasculaire inhabituelle.

The authors reported the case of a young man who suffered a cranial traumatism and showed neurological, ophthalmic and orbital signs with orbital bruit, cranial nerve palsy and chemosis while he was in the intensive care unit. Further examinations of imagery made it possible to highlight a high-flow carotid-cavernous fistula which was the origin of these symptoms and which was successfully treated by endovascular way. The aim of this article is to remind the reader of the characteristics of this pathology, in terms of epidemiology, physiopathology, clinical and paraclinical presentation, and therapeutic care.

[Acute cardiovascular complications of cocaine. About two case reports]. / Les complications cardiovasculaires aiguës de la cocaïne. A propos de deux observations.

Concerning any socioprofessional category, some addictive drugs like cocaine are responsible for many complications. The authors relate two case reports of young patients who suffered from cardiovascular accidents due to this drug. The first one was diagnosed with an ischemic stroke caused by carotid artery dissection and a leg distal vascular obliteration, the second one with a myocardial infarction with transient left ventricular dysfunction. Through these two case reports, the authors take stock of the pathophysiological and therapeutic knowledge of cardiovascular accidents after cocaine intake.

Complications of percutaneous tracheostomy.

Percutaneous tracheostomy is a technique that, reputedly, is simple to perform and causes few complications. It is routinely used in intensive care. We present two patients with tracheal stenosis. In one patient, we had to perform an anastomotic resection to cure the patient; in the other patient, we had to place an endoluminal conformer. To our knowledge, this complication has not been reported in association with the use of this technique.

Acute renal failure following collective intoxication by Cortinarius orellanus.

Twenty-six young men with no previous medical history all ingested mushroom soup, exclusively made with Cortinarius orellanus. They were hospitalized 10-12 days after the incident. On admission, 12 patients presented with acute tubulointerstitial nephritis with acute renal failure; 8 required haemodialysis. In addition to symptomatic treatment, 9 patients were given corticosteroids. In this group of 12 patients, 8 recovered rapidly, and the other 4 suffered from chronic renal failure for several months. In the other group of 14 patients, initial leukocyturia was observed in 12 cases, although renal function remained normal during a one-year follow-up. Hepatic acetylation and hydroxylation tests performed after 6 months in 22 patients did not provide any explanation for the strong individual sensitivity to the renal toxicity of this fungus.

Regional intravenous guanethidine blocks in algodystrophy.

Five-hundred-thirteen regional intravenous guanethidine blocks were carried out in 125 cases of algodystrophy (118 adults), after failure of other treatments in 120 cases (Group I) and without previous treatments in 5 (Group II). A positive result occurred in 85 cases of Group I (71%) and in the 5 cases of Group II, after 4.5 +/- 1.7 blocks. In Group I the results did not differ significantly between upper (33 cases) and lower (87 cases) limb or in regard to sex, age, duration of disease, nature of previous treatments. The presence of psychic disorders was accompanied by less frequent (p less than 0.02) positive results. The tolerance was satisfactory in 85.6% of cases: 22 moderate side effects authorized a continuation of the blocks, 22 serious ones indicated interruption, especially one case of thrombophlebitis and another one of very transitory acute ischaemia. The risk of intolerance was significantly raised (p less than 0.02) by age. The regional guanethidine blocks seemed to be a good treatment for algodystrophy after failure of other treatments.

[Erythrocyte concentrated and air transport: evaluation of quality]. / Concentrés érythrocytaires et transport aérien: évaluation de la qualité.

The available supply of blood products determines the resuscitation capabilities after natural disasters or armed conflicts. Air flight reduces transport delay. The purpose of the present study was to assess the quality of red blood cell concentrates (RCC) immediately after air transport (j0) and after preservation (j30). We exposed RCC to a real air flight (P) or to low pressure (V) corresponding to an air transport in experimental conditions. The quality of RCC was altered immediately after only the real air flight (hemolysis P = 0.11% versus 0.04% for witness (T)). These alterations were not observed immediately after the simulated flight (hemolysis V = 0.02%). After preservation, the RCC was altered both for those exposed to an air flight or to a low pressure (hemolysis: P = 1.09%, V = 0.78%, T = 0.25%). Other biological alterations (pH, K+, hemoglobin level) suggested that pressure variations are not the only one responsible constraint. Other studies are necessary to point the mechanism and the optimal life of conservation after flight. Exposure of preserved red blood cells to air transport alters their therapeutic properties during aging. However, the therapeutic use of RCC thus transported is not questioned.

[Blood preservation and air transport: study of physical constraints (temperature and pressure)]. / Conservation du sang et transport aérien: étude des contraintes physiques (température et pression)

We study physical compulsions of packed red cells during air transport. We found important variations of pressure and temperatures in blood transport box. These variations explain the biological alterations found in the first part. New rules for blood air transport are proposed.

[MRI in post-traumatic cerebral fat embolism]. / IRM dans l'embolie graisseuse cérébrale post-traumatique.

We report two cases of posttrauma cerebral fat embolism evaluated with MRI. Due to sensitivity, MRI is the best examination for detecting focal abnormalities of the grey or white matter. MRI helps to make the diagnosis in atypical cases and allows assessment of both extension and course of the embolism.

[Acute post-traumatic aortic insufficiency: transesophageal echocardiography in the diagnosis and therapy of the lesions]. / Insuffisance aortique valvulaire aiguë post-traumatique: apport de l'échocardiographie transoesophagienne pour le diagnostic lésionnel et le traitement.

A 58-year-old car driver suffered a road accident responsible for severe blunt thoraco-abdominal trauma. Transoephageal echocardiography, performed following the secondary development of a diastolic murmur, confirmed the presence of aortic incompetence due to commissural avulsion and guided the surgical treatment, which consisted of commissural suspension under cardiopulmonary bypass via a mini transverse trans-sternal incision. The rarity of acute aortic valve incompetence following non-penetrating thoracic trauma is illustrated by the data of the literature. This lesion is due to either avulsion of a sigmoid cusp or commissure, or laceration of the valvular tissue. Transthoracic echocardiography confirms the reality of aortic incompetence suggested clinically by appearance of a diastolic murmur, but confirmation of the mechanism of the lesions is based on transoesophageal echocardiography which allows perfectly safe and rapid visualization of the mechanism of the valvular lesion, investigation of associated lesions and guidance of therapeutic management.

-The value of MRI in cerebral fat embolism-. / Intérêt de l'IRM dans l'embolie graisseuse cérébrale.

We report two clinical cases of cerebral fat embolism, thereby demonstrating the value of MRI.

[Risks of hydrogen peroxide irrigation in military surgery]. / Risques de l'irrigation au peroxyde d'hydrogène en chirurgie de guerre.

Two cases of severe complications due to injection of hydrogen peroxide under pressure into areas of muscular attrition in war wounds are reported. In both cases the administration of hydrogen peroxide was associated with tachypnoea, with major arterial desaturation and a precordial "mill-wheel" murmur was heard. In one case, these symptoms were followed by hemiplegia caused by paradoxical arterial gas embolism, and in the other case by a pulmonary oedema confirmed by computerized tomography. Both patients recovered under hyperbaric oxygen therapy. The release of gaseous oxygen under the effect of tissue catalase and the membrane peroxydasic activity of hydrogen peroxide initiate such complications. The injection of hydrogen peroxide under pressure into a closed or partially closed cavity should therefore be strictly prohibited.

[Liver transplantation after exertion-induced heat stroke associated with fulminant liver failure]. / Transplantation hépatique après coup de chaleur d'exercice avec insuffisance hépatique fulminante.

OBJECTIVES: Describe the course of fulminant liver failure after exertional heat stroke. CASE REPORT: A 30-year-old man acclimated to the tropical climate, collapsed and became comatose with hyperthermia during a commando march in Gabon. Thirty-six hours later, the biological examination revealed moderate rhabdomyolysis and fulminant liver failure. An orthotoptic liver transplantation was performed at the 48th hour. Acute renal failure with severe rhabdomyolysis developed on the 4th day post-surgery while the patient was perfectly alert. His condition thereafter deteriorated and he died of chronic rejection 11 months after liver transplantation. DISCUSSION: In its most serious forms exertional heat stroke is a multiple organ dysfunction syndrome of poorly understood pathogenesis. The reported case suggests that exertional heat stroke can cause fulminant liver failure, resulting either from the direct effect of heat on the hepatic parenchyma, or from acute hepatic ischemia due to blood redistribution made worse by the hypersecretion of antidiuretic hormone, a potent portal vasoconstrictor, which occurs in the heat acclimated subject.

[Pulmonary embolism to the rescue in cardiac tamponade]. / L'embolie pulmonaire au secours de la tamponnade cardiaque.

The association of cardiac tamponade and pulmonary embolism has not previously been described. We report the case of a patient, who presented with such an association, due to an underlying pulmonary carcinoma. When a major pericardial effusion is associated with pulmonary hypertension, some echocardiographic signs of tamponade may appear, such as a moderate right ventricular collapse, or the absence of a paradoxical septum. The presence of pulmonary hypertension in this context of tamponade may have paradoxically saved the life of this patient.

[Anaesthesia and amiodarone-associated hyperthyroidism]. / Anesthésie et hyperthyroïdie associée à l'amiodarone.

Amiodarone can induce severe hyperthyroidism that justifies its withdrawal and initiation of antithyroid drugs. Impossibility to stop amiodarone, failure to control hyperthyroidism and unfavourable evolution can lead to thyroidectomy. Cardiac manifestations, persistence of hyperthyroidism and interactions between amiodarone and anaesthetic or haemodynamic drugs may contraindicate anaesthesia. We report nine consecutive cases of amiodarone-associated hyperthyroidism that prompted us to perform thyroidectomy under general anaesthesia. The features and anaesthetic data of patients were noted. The antithyroid medical treatment failed in all patients. After thyroidectomy, evolution was favourable in all nine cases, without any intra or postoperative complication, in spite of the extent of hyperthyroidism and the severity of the associated cardiac problems. Despite potential high risks, thyroidectomy for amiodarone-induced hyperthyroidism does not seem to increase morbidity or mortality and allows a quick return to euthyroidism and reintroduction of amiodarone.

[Acute poisoning by chemical warfare agent: sulfur mustard]. / Intoxication aiguë par arme chimique vésicante: l'ypérite.

OBJECTIVE: To review story, mechanism of action, clinical and therapeutic bases of a sulfur mustard poisoning, by accidental, terrorism or war exposure. DATA SOURCES: References were obtained from computerised bibliographic research (Medline), from personnel data (academic memoir, documents under approbation of the National Defense Office) and from the Library of Military Medical Service. DATA SYNTHESIS: Sulfur mustard is a chemical warfare agent with peace time results: leak, accidental handling, acts of terrorism. Sulfur mustard is a vesicant agent, an organochlorine agent, who alkylate DNA. Under liquid or gas form its main target are skin and lungs. Clinical effects are like burns with loss of immunity, with respiratory failure, ophthalmic, gastrointestinal and haematological signs. The last studies have improved knowledge about the mechanism of action, detection, protection and treatment. Methods for determination of sulfur mustard are based on gas chromatographic method and mass spectrometry. During sulfur mustard contamination the first priorities of treatment are to remove victims from the contaminated place and to initiate decontamination. Emergency workers and materials must take protection to avoid secondary contamination of emergency unit. With treatment of vital functions and respiratory failure, the new ways of treatment are about N-acetyl cysteine for lung injury, poly (ADP-ribose) polymerase inhibitors, calmodulin antagonists and Ca(++) chelators. Interactions between sulfur mustard and anaesthetic agents are not well known and are based on clinical observations. CONCLUSION: Emergency care unit can be confronted with sulfur mustard during accidental contamination or acts of terrorism. First and most efficacy priorities of treatment are to remove and to decontaminate victims. New means of detection and treatment are studied since several years but are not still appropriate to human victims or mass treatment.

[An unusual cause of acute respiratory distress: obstructive bronchial aspergillosis]. / Une cause inhabituelle de détresse respiratoire aiguë: l'aspergillose bronchique obstructive.

We report the case of a 77-Year-old immunocompetent woman who required intensive care for acute dyspnea revealing complete atelectasia of the left lung related to an aspergillus mycelium plug blocking the principal bronchus. The clinical course was favorable after deobstruction by thermocoagulation and oral itraconazole given for six Months. The patient was free of parenchymatous or endobronchial sequelae. Adjuvant oral corticoid therapy was given temporarily during the second Month of treatment when signs of transition towards allergic aspergillosis developed. Four Months after discontinuing the antifungal treatment, the patient developed a new episode of acute dyspnea caused by atelectasia limited to the right lower lobe. Treatment by itraconazole was resumed and continued as long-term therapy. No recurrence has been observed for eighteen Months. The diagnostic and therapeutic problems raised by Aspergillus fumigatus are well known in the immunocompromised subject, but can also be encountered in the immunocompetent subject.

[The risk of thromboembolism in airline passengers]. / Risque thromboembolique et voyage en avion.

Long carrier flights favor thromboembolism. The risk is well known to the general public but is probably really very low. The risk is however pertinent due to the volume of air travel in the world. Sitting in the same position for a long time induced venous stasis which is the principal factor favoring thrombosis in travelers, irrespective of the means of transportation. Long carrier flights also expose passengers to specific factors related to air travel: coagulation disorders and alterations of the endothelium related to hypobarism, hypoxia and low hygrometry in the cabin. Presence of pathogenic thrombophilia is not a constant factor. The prevention of venous thrombosis in air travelers calls upon simple measures: abundant hydration, avoiding use of alcohol and tobacco, walking and dorsal flexion of the feet. The only preventive option with proven efficacy is the use of elastic contention which reduces the risk of thromboembolic events. There is no consensus concerning the use of drugs proposed by certain authors; prudence should be the rule. All passengers should become aware of the risk of thromboembolism related to sitting in the same position for a long time.

[A postoperative syndrome of confusion and stupor or a central anticholinergic syndrome?]. / Syndrome confusionnel et stuporeux postopératoire ou syndrome anticholinergique central?

A case is reported of a 23 year old man who sustained a central anticholinergic syndrome after undergoing upper limb surgery under regional anaesthesia and sedation with 2 mg midazolam and 75 micrograms fentanyl. The disturbances consisted of excitation and inhibition. On the 4th postoperative day, he developed progressive coma, quickly and totally reversed with 2 mg physostigmine. Chronic benzodiazepine therapy seems to be a facilitating factor of central anticholinergic syndrome. The low rate of this postoperative complication seems to proceed from failure to recognize it. Differential diagnosis and place of physostigmine therapy are discussed.

[Nosocomial pneumonia following surgery of esophageal tumors (apropos of 50 cases)]. / Pneumonies nosocomiales après chirurgie pour tumeur de l'oesophage (à propos de 50 cas).

Esophagus cancer surgery often becomes complicated with fistulas and above all with infections. In 50 cases, the authors relate 7 fistulas and 60 nosocomial infections among which pneumonia takes the first place. The pneumonia diagnosis has been established on the criteria of the "National Nosocomial Infection Study" and on bacteriologic samples. Those mostly isolate Gram-bacilli and streptococci. The diagnosis and etiologic factors leading to prophylactic measures are studied.