[Pre-hospitalization treatment with Abciximab in the preparation of patients for primary angioplasty in the acute phase of myocardial infarct. Immediate and long-term (one month) results]. / Traitement préhospitalier par abciximab des patients candidats à une angioplastie primaire en phase aiguë d'infarctus du myocarde. Résultats immédiats et à l mois.

Percutaneous transluminal coronary angioplasty (PTCA) is an alternative to fibrinolysis in the treatment of acute myocardial infarction (AMI). However, after balloon PTCA, the rate of early re-occlusion, of re-infarctus and of restenosis remains high. Stent implantation with antiplatelet drug regimen (aspirin, ticlid) limits these risks. Abciximab (new GPIIb/IIIa receptors inhibitor) reduces PTCA complications rate in the acute coronary syndromes. Intravenous administration of abciximab can restore a normal flow in the infarcted related coronary artery (IRA) after few minutes. A monocentric, non randomized, prospective pilot study was iniated to assess the feasibility of pre-hospital treatment with abciximab in preparation to primary PTCA stenting in AMI (primary endpoint) and to appreciate potential benefits in initial IRA patency as well as prevention of PTCA thrombotic complications (secondary endpoint). Between April 1997 and January 1998, 38 AMI were treated with abciximab in pre-hospital phase (group A). Mobil Intensive Care Unit (MICU) team implemented the treatment and guaranteed immediate transport to the cathlab (abciximab bolus-coronary angiography time = 37 +/- 17 min). Immediate results were compared to those of 198 paired patients who were treated for AMI during the same period (Group T). Initial IRA flow TIMI grade 3 was significantly higher in group A, 24%, than in group T, 9% (p < 0.017). The rates of per-procedural complications (no flow, distal embolism), of local complications, of transfusions were not significantly different. During 1 month follow-up, there was no significant difference between group A and group T concerning death, re-MI, stent thrombosis and new revascularization. To conclude, the pre-hospital treatment with abciximab in AMI is feasible by MICU medical team without any delay of the cathlab admission. It is associated with no increased hemorrhagic complications rate. The abciximab pre-hospital treatment improves the initial IRA patency. These encouraging preliminary results expect to be confirmed by larger, multicentric, randomized and prospective studies.

[Torsades de pointes and hypomagnesemia]. / Torsades de pointe et hypomagnésémie.

The authors report a case of "Torsades de pointe" occurring in a patient subjected to intensive surgical care and presenting several causes of magnesium loss: mutilating abdominal surgery, exteriorized gastric fistula, administration of Henle's loop diuretics, electrolytic disorders and exclusive parenteral nutrition without any magnesium Mg supplement. The arrhythmia appeared in the third week and the usual treatment was ineffective. The level of plasma magnesium was below the measurable values on three separate occasions. The administration of magnesium sulphate corrected the dysrhythmia which did not recur. Experimental and clinical data demonstrating the antiarrhythmic effect of magnesium are recalled. The electrophysiological explanation is based on the inhibition of potassium and calcium flow across the cell membrane; magnesium ion has a stabilizing membrane effect and an antagonistic effect on ectopic automaticity. They are particularly important on slowly depolarizing tissue (nodal cells) or partially depolarized cells (ischaemic or digitalis treated cardiac tissue). In intensive care, circumstances for magnesium depletion by digestive or renal losses and by lack of parenteral magnesium supplement are frequently combined. Systematic intravenous administration of magnesium is necessary when such conditions are found and whenever ventricular or auricular dysrhythmias occur.

[Postoperative pernicious malarial attack in a subject, a native of an endemic zone]. / Accès pernicieux palustre postopératoire chez un sujet originaire d'une zone d'endémie.

The case of an Angolan woman who underwent, in her country, an hysterectomy requiring the transfusion of two whole blood units is reported. In the immediate postoperative period, acute renal failure with anuria set in, justifying the patient's transfer to an intensive care unit in France. Upon admission, she had a thick blood film and serology work-up for Plasmodium falciparum, both of which were negative. On the 20th day, the patient presented a pernicious malarial crisis with a concurrent rise in IgG and IgM titres, indicating recent contamination. The mode of infection is discussed: contaminating anopheline bites associated with the interruption of chemoprophylaxis rigorously followed up till then; post transfusion malaria, almost unavoidable in an endemic country; accidental inoculation by Plasmodium falciparum of the dialysis equipment. Finally, the possibility of pernicious malaria aggravating the initial acute renal failure and hypocalcaemia is also discussed.

[Cricothyrotomy in emergency context: assessment of a cannot intubate cannot ventilate scenario]. / Cricothyroïdotomie en situation d'urgence : évaluation d'un scénario dynamique associant intubation et ventilation impossibles.

OBJECTIVE: The aim of this study was to assess airway management by emergency physicians in case of a simulated situation where intubation and ventilation were both impossible. STUDY DESIGN: Observational manikin study. METHODS: A manikin (Airman®; Laerdal) allowing simulating difficult airway situations was used. The scenario assessed concerned a patient needing tracheal intubation for severe traumatic brain injury. The manikin was settled to make tracheal intubation under direct laryngoscopy impossible at the first attempt and to make facemask ventilation impossible after the second attempt. Manikin could initially be ventilated through the intubating laryngeal mask Airway (ILMA) but became impossible few seconds after its insertion. With impossible ventilation through the ILMA, arterial oxygen saturation decreased during 2 minutes before an hypoxic cardiac arrest occurred. Physicians could use classic laryngoscope with Macintosh blade, a Gum Elastic Bougie, an ILMA and a cricothyrotomy set. Adhesion to the national airway management algorithm was assessed. Time to cricothyroidotomy decision after ventilation through ILMA became impossible was measured. RESULTS: Twenty-five emergency physicians were assessed. For 14 of them, national expert conference algorithm was perfectly followed. For ten physicians, cricothyroidotomy decision was taken after hypoxic cardiac arrest occurred. CONCLUSION: Simulation with a manikin is useful to assess the adhesion rate to difficult intubation algorithms. Our study shows that the decision making process for cricothyrotomy is too often delayed as soon as ventilation became impossible and oxygenation compromized.

[High-risk airway management in pediatric prehospital emergency medicine]. / Une gestion des voies aériennes à haut risque en médecine pédiatrique préhospitalière.

We report the case of high-risk airway management performed in prehospital conditions in a 3-year-old boy suffering from a severe head and maxillofacial trauma. Tracheal intubation was decided because of a comatose status associated with an acute upper airway obstruction resulting in severe hypoxaemia. One minute after a rapid sequence induction, difficult laryngoscopy was encountered. Two tracheal intubation attempts failed. During maintained laryngoscopy, a pediatric angulated Eschmann-like stylet was blindly blocked into the trachea using a rotational maneuver. A tracheal tube was railroaded over the stylet while a hypoxic bradycardia installed. The young child was tracheostomized upon arrival in the hospital, and recovered without neurological complication. In the present case, neither facemask nor laryngeal mask ventilation would have been efficient because of oral cavity jaw and sub-mental pharyngeal open wounds. Since most paediatric emergency medicine physician are not familiar with infraglottic airway techniques, our observation questions the safety of rapid sequence induction in case of severe maxillofacial trauma and reinforces the value of pediatric Eschmann-like stylet. Minimal airway tools equipment for difficult paediatric airway management is discussed.

[Performance of the glottiscopes: a randomized comparative study on difficult intubation simulation manikin]. / Performance des glottiscopes : une étude comparative randomisée menée sur simulateur d'intubation difficile.

INTRODUCTION: We have prospectively compared simulated-difficult tracheal intubation characteristics of four glottiscopes: Airtraq, GlideScope, McGrath, LMA CTrach with that of the conventional Macintosh laryngoscope. STUDY DESIGN: prospective with the airway devices proposed in a randomly assigned order. MATERIALS AND METHOD: Forty-two physicians, naïve to glottiscope handling accepted participating this study after the learning curve of each airway device was completed. Participants were requested to perform two series of five tracheal intubations on the manikin Airman, the first in standard situation and the second in difficult tracheal intubation simulation. The airway devices were chosen in a randomly assigned order. For each airway tool, the following tracheal intubation characteristics were recorded: laryngeal exposure quality, tracheal intubation and apnea durations. A performance index was calculated and a tracheal intubation difficulty was measured during simulation. RESULTS: More than 1600 supervised tracheal intubations were performed, including 1000 for the learning process of the glottiscopes, which was completed after 10 uses on the manikin. During standard situation, laryngeal exposure quality was similar with the five airway devices. As compared to the Macintosh laryngoscope, GlideScope, McGrath, tracheal intubation duration was shorter (p<0.05) with the Airtraq and longer (p<0.01) with the LMA CTrach. During difficult tracheal intubation simulation, laryngeal exposure and tracheal intubation duration was of better quality and shorter with the four glottiscopes as compared to that of LM, respectively. Performance index during difficult tracheal intubation simulation simulation was significantly more important (p<0.01) with the Airtraq and the LMA CTrach. Airtraq and Macintosh laryngoscope were respectively the simplest (p<0.01) and the most difficult (p<0.01) airway devices to manage a simulated difficult tracheal intubation. CONCLUSION: When difficult airway was simulated on the manikin, the four glottiscopes were superior to the Macintosh laryngoscope to improve laryngeal exposure quality and to reduce duration of tracheal intubation. Airtraq and the LMA CTrach both demonstrated remarkable advantage over GlideScope and McGrath for simulated difficult intubation management.