Successful organ transplantation after treatment of fatal cyanide poisoning with hydroxocobalamin.

BACKGROUND: Cyanide-poisoned patients are potential organ donors provided that organs are not damaged by the poison or by antidotal treatment. CASE STUDY: A patient with third-degree burns and smoke inhalation-associated cyanide poisoning confirmed by measurements of whole blood cyanide was found in cardiac arrest and administered epinephrine and hydroxocobalamin (5 g + 5 g). Cardiac activity resumed, but the patient was declared brain dead on the third day of hospitalization when coma deteriorated to a shock state with refractory hypoxemia. Kidneys, heart, and liver were removed and transplanted into four patients. Gross pre-transplantation inspection of the donor organs and renal histology showed no evidence that hydroxocobalamin caused organ toxicity. Donor organs functioned normally through follow-up periods of several months. CONCLUSION: Anoxic cardiac arrest following acute cyanide poisoning treated with hydroxocobalamin (5 g + 5 g) was not a contraindication to organ transplantation after confirmed encephalic death in this patient.

[Premixed 50% nitrous oxide and oxygen: theoretical recalls and practical modalities]. / Mélange équimolaire oxygène-protoxyde d'azote (MEOPA). Rappels théoriques et modalités pratiques d'utilisation.

The concept of premixed 50% nitrous oxide and oxygen dated back to 1961 in England, where it is commercialised under the name Entonox. In France, after a so marginal use, premixed 50% nitrous oxide and oxygen now knows such a revival since we first consider the pain provoked by the cure. To use correctly premixed 50% nitrous oxide and oxygen, we need to know the main properties of the nitrous oxide. The four commercial versions, now on the market, are presented (Kalinox, Medimix, Antasol, Oxynox. Except a few contraindications, these indications are large, as well at hospital as outside. In less than 10% of the cases, side effects are possible. Conditions of administration are given in details. The limits of the technic and the particular precautions of use are precised.

Preliminary results on the prediction of countershock success with fibrillation power.

In a study of artifact-free ventricular fibrillation episodes in 54 patients, 28 of whom experienced return of spontaneous circulation (ROSC), the power of different indicators to predict the ROSC was compared. Taking the average of sensitivity, specificity and positive and negative predictive value, the dominant frequency reaches 76%, the mean amplitude 72% and fibrillation power 71%. There is little correlation between the three indicators.

[Acute neurotoxic organophosphate poisoning: insecticides and chemical weapons]. / Intoxications aiguës par neurotoxiques organophosphorés: insecticides et armes chimiques.

OBJECTIVE: To review clinical and therapeutic bases of an organophosphate poisoning, either with insecticide or nerve agent. DATA SOURCES: References were obtained from computerized bibliographic research (Medline), from personal data (academic memoir, documents under approbation of the National Defense Office), from Internet's data. DATA SYNTHESIS: Generally, organophosphate poisoning occurs during accidental exposure with agricultural insecticide or suicide. The effects of organophosphate compounds are due to the inhibition of the enzyme acetylcholinesterase. The intoxication symptoms can be divided into muscarine-like, nicotine-like effects, effects on the central nervous system and symptoms related to the dysfunction of the neuromuscular junction. The interest of biological acetylcholinesterase's measuring is minimal because it is weakly specific or sensitive. The immediate severity is due to hypoxia. Respiratory failure results from the lack of central drive inflated with excessive bronchial secretions, bronchospasm and respiratory muscles paralysis. The secondary complications are early myopathies whose gravity is correlated with the decrease of acetylcholinesterases, or later neuropathies induced by a different mechanism. Beside the symptomatic measures, atropine is the specific anticholinergic treatment. When promptly used, oximes can regenerate cholinesterases. The attempted effects of the treatment are mouth dryness, pupilar dilatation and flushing of the skin. Nerve agents are lethal toxics which have a short onset time and produce severe neurological pathology. In a terrorist incident, it is as important to identify rapidly the toxic agent and provide emergency decontamination as to manage medical care. An effective response must be multidisciplinary, involving clinicians, toxicologists, Emergency Medical Service and public's health personnel.

[Intracranial aneurysm and coronary ectasia]. / Anévrisme intra-crânien et coronaires ectasiques.

BACKGROUND: Coronary aneurysms are uncommon and can exceptionally be associated with other aneurysmal localizations. CASE REPORT: A 34 year-old man with a history of aneurysm of the coronary arteries revealed by myocardial infarction without a wave six months earlier, presented cerebral hemorrhage secondary to an aneurysmal rupture of the anterior communicating artery. DISCUSSION: Other aneurysmal localizations such as the abdominal artery, pulmonary artery, hepatic artery, popliteal artery, coronary venous system or the left ventricle have been associated with coronary artery aneurysm. Only one case of coronary and cerebral aneurysm has been previously reported in the literature in an 8-year-old child with X-linked lymphoproliferative syndrome and EBV-induced infectious mononucleosis. Our case suggests that systemic aneurysmal disease may be a clinical entity and that cerebral angiogram should be discussed in patients with a coronary artery aneurysm.

[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.

[Bolus esmolol prior to tracheal intubation of the elderly patient]. / L'esmolol en bolus avant l'intubation trachéale du sujet âgé.

Twenty-seven patients 76 +/- 7 years old, ASA I or II, scheduled for short eye surgery, were randomized in two groups so as to study and compare the effects of esmolol--injected after induction of general anaesthesia, 2 or 3 mg.kg-1--or topic laryngeal anaesthesia on the haemodynamic consequences of endotracheal intubation. Induction was performed with fentanyl, thiopental and atracurium. The rate-pressure product was significantly lower (less than 11.000 b.min-1.mmHg-1) in the esmolol group. However 4 patients out of 5 who received the higher dosage of esmolol (3 mg.kg-1) had a marked blood pressure fall requiring ephedrine. A vascular collapse was observed in one of them but Buffington's ratio never fell under the critical value. In all cases small doses of ephedrine were efficient. No serious complications were observed in both groups. This preliminary study lacked a control group without esmolol or laryngeal spray. On the other hand, haemodynamic effects of tracheal intubation could be further studied after bolus esmolol or topic anaesthesia in real ASA III cardiovascular patients.

[Training in disaster medicine in Africa: where we are in 2013]. / Le point en 2013 sur la formation à la médecine de catastrophe en Afrique.

This retrospective study, conducted in 26 African countries where French is the first or second language, identified the postsecondary educational institutions teaching disaster medicine. This subject is taught in various institutions in 7 of the 26 countries (27%), including 3 of 47 colleges, 1 of 6 institutes, 1 military health and medical sciences school, and in civil defense agencies in 2 countries. Teaching disaster medicine is often confined to military physicians. This subject must be recognized as a subject in its own right and must be integrated into the medical school curriculum for doctors in French-speaking Africa.

[The intraosseous infusion in adult]. / La perfusion intraosseuse chez l'adulte.

Intraosseous infusion is an old knowledge, abandoned in the 1950s in favor of the peripheral vein, and it was essentially described in pediatrics and military medicine. Since 2005, this way is experiencing a resurgence of interest in emergency medicine particularly in adults after the failure's installation of a peripheral vein in order not to waste the time of care and administration of treatment. New devices that allow intraosseous infusion are currently used in humans. We propose to review the different kind of catheters used, to know the main technical characteristics, indications, contraindications and potential complications. We propose a comparison with the peripheral vein and a comparison between the different catheters.

[Bacterial meningitis in HIV patient: think about co-infections!]. / Méningite bactérienne chez le patient VIH positif: pensez aux co-infections!

The authors report the case of an African 34-year-old patient who was admitted to the intensive care unit for bacterial meningitis due to Streptococcus pneumoniae. A meningeal co-infection due to Cryptococcal neoformans was found the 3rd day in an HIV infection context. Cryptococcus neoformans detection in cerebrospinal fluid, using the India-ink stain, has a low sensibility which imposes the search of cryptococcal antigen and the culture of cerebrospinal fluid. These last two exams have a sensibility of at least 90%.