[Severe atropine poisoning mimicking acute stroke]. / Intoxication grave à l'atropine mimant une urgence neurovasculaire.

INTRODUCTION: Atropine is a strong antagonist of muscarinic receptors widely used in various diseases because of its anticholinergic action. CASE-REPORT: We report here a case of accidental poisoning due to ingestion of atropine eyes drops that caused severe neurologic disorders mimicking an acute stroke. Correct diagnosis was finally made by detecting atropine in the cerebrospinal fluid of the patient. CONCLUSIONS: Atropinic poisoning can induce misleading neuropsychiatric disorders mimicking stroke. Therefore, this diagnosis should be considered in patients presenting an unexplained encephalopathy with anticholinergic manifestations, especially when bilateral mydriasis occurs.

A non-surgical device for faecal diversion in the management of perineal burns.

BACKGROUND: Burns to the perineal, buttock and upper thigh areas are frequently exposed to continual faecal contamination which results in sepsis, graft loss, delayed wound healing and shrinkage of scars. A temporary diverting colostomy may be required. Two specifically designed intrarectal catheters were evaluated for their safety and ability to divert faeces away from the burn and allow wound healing. METHODS: A prospective study was conducted involving patients at the burns centre. Either the Zassi Bowel Management System or the Flexi-Seal Fecal Management System were used. These differed only in the presence of a specific intraluminal balloon in the Zassi system to facilitate retention of infused irrigates. Data regarding skin graft success, wound contamination and adverse events were collected. RESULTS: The study included eight participants, five of whom were treated successfully without colostomy. Four participants experienced complications, comprising one bowel occlusion, one anal ulceration and two reversible cases of anal atony. CONCLUSION: A specifically designed intrarectal catheter can divert faeces to allow wound healing, and may avert colostomy. More studies are necessary to evaluate safety.

[Multi-organ failures during septic shock from Escherichia coli urinary tract infection: catastrophic antiphospholipid syndrome?]. / Défaillance multiviscérale au cours d'un choc septique d'origine urinaire à Escherichia coli: syndrome catastrophique des anticorps antiphospholipides?

INTRODUCTION: Although the presence of antiphospholipid antibodies is not an uncommon fact during infection, their responsibility in serious manifestations can still be debated and questions the existence of an actual catastrophic antiphospholipid syndrome or multivisceral faintings, triggered by the infection only, since the presence of antiphospholipid antibodies is not pathogenous. CASE: A 68-year-old man presented during an Escherichia coli urinary tract infection a septic shock with renal and cardiac insufficiencies, hepatic cytolysis and cholestasis and disseminated intravascular coagulation. There was a significant titer of antiphospholipid antibodies IgG (50 UGPL/ml) with an antibêta2-glycoprotein-1 positivity. The patient quickly recovered with antibiotherapy and intravenous immunoglobulins. DISCUSSION: Diagnosing the pathogeny of multivisceral faintings is founded of the clinical manifestations published during the catastrophic antiphospholipid syndrome, the evolution and the persistence of post recovery antibodies and the comparison with the visceral bouts that the sepsis exclusively as revealed.

[Treatment of inguinal hernia in a difficult environment: feasibility and efficacy of ilioinguinal and iliohypogastric blocks]. / Cure de hernie inguinale en environnement difficile : faisabilité et efficience du bloc ilio-inguinal et iliohypogastrique.

Hernia repair is a very frequent surgical procedure; it is estimated that one African in five undergoes this procedure during his lifetime. Patients and methods. We evaluated the feasibility of this surgery under ilioinguinal and iliohypogastric nerve blocks in difficult environments. The medical-surgical group supporting Operation Unicorn has treated 48 inguinal hernias as medical aid to population, including 34 with these nerve blocks. Results. The block did not fail in any case. The mean time until discharge was 6.85 h, which meant that outpatient surgery was possible. Discussion and conclusion. This type of anesthesia is interesting in difficult environments. It is a safe, inexpensive, and easy to learn technique. These qualities should promote its use in countries with a low GNP.

[Ischemic strokes as a presenting feature of marantic endocarditis despite heparin treatment]. / Accidents cérébraux ischémiques sous héparine révélateurs d'endocardites marastiques.

We report on two patients hospitalized in intensive care unit for ischemic strokes presenting the feature of marantic endocarditis complicating lung's adenocarcinoma. These two cases turned out to be very interesting because of the occurrence of ischemic strokes even though the patients were receiving the recommended treatment, namely anticoagulation with heparin, in well-adjusted doses. The management of nonbacterial thrombotic endocarditis remains a challenge and its mortality is still high.

Cytomegalovirus infection in severe burn patients monitoring by real-time polymerase chain reaction: A prospective study.

BACKGROUND: Cytomegalovirus (CMV) infection has been shown to occur not rarely in critically ill patients in the past decade. However, little data are available on CMV infection in burn patients whereas their susceptibility to CMV infection has been proved. METHODS: We prospectively assessed CMV viremia by real-time polymerase chain reaction and clinical outcome in immunocompetent burn patients with total burn surface area greater than 15%. RESULTS: Twenty-nine patients were enrolled. The rate of CMV infection was of 71% in CMV seropositive burn patients, and of 12.5% in CMV seronegative burn patients. CMV reactivation was associated with a higher IGS 2 score on admission. High grade CMV viremia was associated with longer mechanical ventilation duration, higher infection number, higher transfused red blood cell number, and longer ICU stays. There were no differences on mortality rate between patients with and without CMV reactivation. CONCLUSION: CMV infection rate is considerable in burn patients with TBSA greater than 15%. This infection seems to be mostly due to reactivation of latently existing virus.

[Carotid dissection during angioplasty for vasospasm induced by subarachnoid haemorrhage. The use of multimodal cerebral monitoring]. / Dissection carotidienne au cours d'une angioplastie pour vasospasme après hémorragie sous-arachnoïdienne. Apport du monitorage cérébral "multimodal".

We report the case of a 54-year-old woman presenting subarachnoid haemorrhage. She experienced multiple vasospasms and treatment included triple-H (hypervolaemia, hypertension, and haemodilution) and endovascular therapies. Right internal carotid dissection complicated angioplasty of the right middle cerebral artery. Combined brain tissue partial pressure of oxygen monitoring and transcranial echo-Doppler could have facilitated early diagnosis. Despite successful revascularization of right internal carotid by stenting, this complication caused acute stroke with refractory intracranial hypertension.

[Life-threatening bleeding due to craniofacial injury treated by ligature of the external carotid artery]. / Hémorragie massive au cours d'un traumatisme craniofacial traitée par ligature de la carotide externe.

Life-threatening bleeding following craniofacial injury is rare. The rich collateral circulation between external and internal carotid arteries complicates the problem of controlling haemorrhage. We report the case of a 63-year-old man who presented a life-threatening haemorrhage following maxillofacial trauma and a severe head injury with subdural haematoma requiring neurosurgical evacuation. Although we had an interventional radiology unit, facial haemostasis was achieved by an unilateral ligation of the external carotid artery. There were three reasons behind our decision: multiple bleeding excluding selective endovascular embolization, efficiency and speed of the ligation of the external carotid, only one place for this cephalic surgery in two phases (neurosurgery and neck surgery). The role of ligation of the external carotid artery for life-threatening bleeding following facial injury is discussed.

[Immunomodulation in severe leptospirosis with multiple organ failure: plasma exchange, intravenous immunoglobulin or corticosteroids?]. / Immunomodulation au cours d'un cas de leptospirose grave avec défaillance multiviscérale : échanges plasmatiques, immunoglobulines ou corticoïdes ?

We report a case of severe leptospirosis complicated with a multiple organ failure syndrome. A 62-year-old patient presented a picture associating fever, asthenia and myalgias, particularly intense on the calves. The assessment showed acute renal failure, hyperbilirubinemia, severe rhabdomyolysis and thrombocytopenia. Although initial management associating amoxicilline and continuous veino-venous hemodiafiltration, evolution was unfavourable, with SDRA and increase of hyperbilirubinemia. Administration of a bolus of 500 mg of methylprednisolone, associated with intravenous immunoglobulin (0,4 g/kg per day during five days), led to a rapid clinical and biological improvement. Immunomodulation aspects during leptospirosis are discussed.

Prospective randomized comparison of progressive dilational vs forceps dilational percutaneous tracheostomy.

This trial prospectively compares two methods of percutaneous tracheostomy, both routinely used in ICU: the Ciaglia progressive dilational tracheostomy and the Griggs forceps dilational tracheostomy. One hundred patients were randomized using a single-blinded envelope method to receive progressive or forceps percutaneous tracheostomy performed at the bedside. Operative time, the occurrence of hypoxaemia or hypercapnia and complications were recorded. The progressive technique took longer than the forceps technique (median 7 (range 2-26) vs. 4 (1-16) minutes, P = 0.0005). Hypercapnia occurred in both groups but was more marked with the progressive technique (56 (16) vs. 49 (13) mmHg, P = 0.0082). Minor complications (minor bleeding, transient hypoxaemia, damage to posterior tracheal wall without emphysema) were also more frequent with the progressive technique (31 vs. 9 complications, P < 0.0001). Six major complications occurred with the progressive technique, none with the forceps technique (P = 0.0085): tension pneumothorax, posterior tracheal wall injury with subcutaneous emphysema, loss of airway with hypoxaemia, loss of stoma with impossible re-catheterization, and two conversions to another technique. In conclusion, progressive dilational tracheostomy took longer, caused more hypercapnia and more minor and major difficulties than forceps dilational tracheostomy.

Nitric oxide inhalation is useful in the management of right ventricular failure caused by myocardial contusion.

We report a severe head injury and blunt chest trauma with sternal and multiple rib fractures with high-energy impact in a 22-year-old man. Twelve hours after the accident, haemodynamic status of the patient rapidly worsened because of right ventricular (RV) failure due to myocardial contusion, requiring increasing doses of catecholamine. Nitric oxide inhalation was used to decrease RV afterload, and produced an immediate improvement in haemodynamic status, permitting a decrease in catecholamine administration. From days 2 through 8, cardiac function continued to improve, and was normal on day 9. Nitric oxide inhalation was stopped on day 4.