[Severe Caffeine Intentional Intoxication and Delayed Elimination: a Case Report]. / Intoxication volontaire grave à la caféine et retard d'élimination : à propos d'un cas clinique.

We report a massive intoxication by caffeine (20 g) with positive clinical evolution despite potentially lethal plasma concentrations (244 µg/mL) and delayed elimination.

A pig model for blunt chest trauma: no pulmonary edema in the early phase.

OBJECTIVE: Chest trauma remains a leading cause of trauma-death. Since lung contusion is one of the most important lesions implicated, the aim of this experimental study was to evaluate the cardiorespiratory consequences of an isolated lung contusion model. METHODS: Twenty-eight anesthetized pigs were studied during four hours. We induced a right lung contusion with five bolt shots (70 joules each) using a 22-caliber charge in twenty of them. Eight others pigs constituted the control group. The trauma consequences were assessed by histology, measurements of arterial oxygenation, plasma cytokines, pressure-volume mechanics, hemodynamic monitoring using the PiCCO system and a pulmonary artery catheter. The extra-vascular lung water was measured using the gravimetric method. RESULTS: Histology confirmed an isolated right lung contusion without cardiac injury. Compared to baseline values, the trauma group was characterized by a decrease in cardiac index (3.3 ± 0.8 vs 3.9 ± 1.2 l/min/m(2); P < .05) and mean arterial pressure (80 ± 21 vs 95 ± 16 mmHg; P < .05) without preload or afterload modification. Oxygenation (PaO2/FiO2: 349 ± 87 vs 440 ± 75; P < .05) and static compliance (26.3 ± 7.4 vs 30.3 ± 7.8 ml/cmH2O; P < .05) were also impaired during two hours compared to baseline. No edema was noticed in either group whatever the lung considered. All measured cytokines were below the detection threshold. CONCLUSIONS: An isolated right lung contusion is associated with rapid but transient cardiorespiratory impairments. Despite the large extent of the lung contusion, no pulmonary edema appeared during the period studied.

Short-term effects of low-volume resuscitation with hypertonic saline and hydroxyethylstarch in an experimental model of lung contusion and haemorrhagic shock.

OBJECTIVES: This study aimed to assess the short-term respiratory tolerance and haemodynamic efficiency of low-volume resuscitation with hypertonic saline and hydroxyethylstarch (HS/HES) in a pig model of lung contusion and controlled haemorrhagic shock. We hypothesised that a low-volume of HS/HES after haemorrhagic shock did not impact contused lungs in terms of extravascular lung water 3hours after trauma. METHODS: A lung contusion resulting from blunt chest trauma was induced in 28 anaesthetised female pigs with five bolt-shots to the right thoracic cage, followed by haemorrhagic shock and fluid resuscitation. Pigs were randomly allocated into two groups: fluid resuscitation by 4ml/kg of HS/HES, or fluid resuscitation by 10ml/kg of normal saline (NS). Monitoring was based on transpulmonary thermodilution and a pulmonary artery catheter. After 3h, animals were euthanized to measure extravascular lung water (EVLW) by gravimetry. RESULTS: Blunt chest trauma was followed by a transient collapse and hypoxaemia in both groups. Post-mortem gravimetric assessment demonstrated a significant difference between EVLW in the NS-group (8.1±0.7ml/kg) and in the HS/HES-group (6.2±0.6ml/kg, P=0.038). Based on a pathological EVLW threshold of > 7ml/kg, results indicated that only the NS-group experienced moderate pulmonary oedema, contrary to the HS/HES-group. After haemorrhagic shock, HS/HES infusion enabled the restoration of effective mean arterial pressure and cardiac index. Intrapulmonary shunting increased transiently after fluid resuscitation but there was no significant impairment of oxygenation. CONCLUSION: In this pig model of lung contusion, the short-term assessment of fluid resuscitation after haemorrhagic shock with 4ml/kg of HS/HES showed that pulmonary oedema was avoided compared to fluid resuscitation with 10ml/kg of NS.

Lightning initiation: Strong pulses of VHF radiation accompany preliminary breakdown.

We analyze lightning initiation process using magnetic field waveforms of preliminary breakdown (PB) pulses observed at time scales of a few tens of microseconds by a broad-band receiver. We compare these pulses with sources of narrow-band very high frequency (VHF) radiation at 60-66 MHz recorded by two separate Lightning Mapping Arrays (LMAs). We find that almost none of the observed PB pulses correspond to geo-located VHF radiation sources, in agreement with previous results and with the hypothesis that processes generating VHF radiation and PB pulses are only weakly related. However, our detailed analysis discovers that individual peaks of strong VHF radiation seen by separate LMA stations correspond surprisingly well to the PB pulses. This result shows that electromagnetic radiation generated during fast stepwise extension of developing lightning channels is spread over a large interval of frequencies. We also show that intense VHF radiation abruptly starts with the first PB pulse and that it is then continuously present during the entire PB phase of developing discharges.

Comparison of lung injury after normal or small volume optimized resuscitation in a model of hemorrhagic shock.

OBJECTIVE: To compare lung injury induced by a hemorrhagic shock resuscitated with normal saline or with small volumes of a hypertonic/hyperoncotic solution. DESIGN AND SETTING: Randomized, controlled, laboratory study in an animal research laboratory. SUBJECTS: Nineteen pigs (43 +/- 4 kg). INTERVENTIONS: After anesthesia and mechanical ventilation animals were bled to induce a 2-h deep shock and resuscitated for 2 h using normal saline (NS, 2 ml/kg per minute, n = 7) or the association of 7.2% NaCl with 6% hydroxyethylstarch 200/0.5 (HSHES, 4 ml/kg in 10 min followed by 0.2 ml/kg per minute, n = 7) to reach cardiac index and mixed venous oxygen saturation goals. Lungs were removed 6[Symbol: see text]h after the initiation of hemorrhage. Five animals were used as controls without hemorrhage. MEASUREMENTS AND RESULTS: Resuscitation goals were achieved using 90 +/- 17 ml/kg NS or 6.8 +/- 1.9 ml/kg HSHES. Lung injury was noted in both hemorrhage groups but was not influenced by the type of resuscitation. Extravascular lung water was measured at 9.6 +/- 1.8 ml/kg in the NS group, 9.2 +/- 1.6 ml/kg in the HSHES, group and 6.4 +/- 1 m/kg in the control group. The degree of histological alveolar membrane focal thickening and interstitial neutrophil infiltration were significantly more pronounced in the hemorrhage groups with no difference between the two types of fluid loading. Finally, pulmonary levels of IL-8 were higher after hemorrhage regardless of the type of resuscitation. CONCLUSIONS: When included in an optimized and goal directed resuscitation, the use of normal saline or a small volume of hypertonic/hyperoncotic solution does not result in a different early hemorrhage-induced lung injury.

Accuracy and limits of transpulmonary dilution methods in estimating extravascular lung water after pneumonectomy.

STUDY OBJECTIVES: The measurement of extravascular lung water index by double indicator (EVLWIdi) or the measurement of extravascular lung water index by transpulmonary thermodilution (EVLWItt) could be useful after pneumonectomy. Since pulmonary blood flow and volume are altered after pneumonectomy, the validity of these methods is uncertain. This study has compared measurements of EVLWIdi and EVLWItt with measurement of extravascular lung water index by gravimetry (EVLWIg) in a porcine model of pulmonary edema induced after right pneumonectomy. DESIGN: Randomized laboratory study. SETTING: Animal research laboratory. SUBJECTS: Twenty-seven female pigs; mean weight, 35 +/- 5 kg (+/- SD). INTERVENTIONS: The pigs were anesthetized, placed on mechanical ventilation, and allocated to a two-lung group (n = 10) or a right pneumonectomy group (n = 17). EVLWIdi and EVLWItt were measured at baseline, 60 min after pneumonectomy, and 60 min after IV injection of oleic acid (OA). MEASUREMENTS AND RESULTS: There was a good correlation between EVLWIg and EVLWIdi values (r = 0.96, p < 0.0001 in the two-lung group; and r = 0.81, p = 0.02 in the pneumonectomy group). EVLWIdi underestimated EVLWIg in the two-lung group (- 3 mL/kg; 95% confidence interval [CI], - 7 to + 2 mL/kg) and in the pneumonectomy group (- 0.9 mL/kg; 95% CI, - 3.3 to + 1.5 mL/kg). After pneumonectomy, EVLWItt decreased in mean by 27% and increased in mean by 70% after OA acid. There was a good correlation between EVLWIg and EVLWItt values (r = 0.96, p < 0.0001 in the two-lung group; and r = 0.90, p < 0.0001 after pneumonectomy). EVLWItt slightly overestimated gravimetric value in the two-lung group (+ 1.5 mL/kg; 95% CI, - 1.5 to + 4.2 mL/kg) and largely overestimated gravimetric value after pneumonectomy (+ 5 mL/kg; 95% CI, + 3.4 to + 6.8 mL/kg). CONCLUSION: Double-indicator and transpulmonary thermodilution methods could be useful in monitoring extravascular lung water index (EVLWI) after pneumonectomy, but transpulmonary thermodilution largely overestimates EVLWI.

Liver Trauma in the Kitchen: Preparing Whipped Cream with a Siphon Is Not without Risk.

We report the case of a 36-year-old woman suffering from liver injury caused by the malfunction of a whipped cream siphon. When this patient handled the whipped cream siphon, the screwed metallic upper part of the siphon was suddenly dissociated from its base and came violently striking her right hypochondrium. At first, the severity of injury was underestimated. Subsequently, due to the persistence of pain experienced by the patient, an abdominal CT scan was performed. It highlighted a severe liver injury with rupture of a branch of the hepatic artery. The evolution was favorable after completion of an embolization and a secondary capsular rupture.

Midterm effects of fluid resuscitation strategies in an experimental model of lung contusion and hemorrhagic shock.

BACKGROUND: This study compared three different fluid resuscitation strategies in terms of respiratory tolerance and hemodynamic efficacy in a pig model of blunt chest trauma with lung contusion and controlled hemorrhagic shock. We hypothesized that the choice of fluid resuscitation strategy (type and amount of fluids) may impact differently contused lungs in terms of extravascular lung water (EVLW) 20 h after trauma. METHODS: Anesthetized female pigs (n = 5/group) received five bolt shots to the right thoracic cage and allowed to hemorrhage for 30 min, with 25 to 30 mL/kg of blood loss. Pigs were randomly assigned to resuscitation groups that maintained a minimum mean arterial blood pressure of 70 mmHg with one of three methods: normal saline (NS), unrestricted normal saline; NOREPI, low-volume normal saline with norepinephrine; or HS-HES, hypertonic saline with hydroxyethyl starch. Control pigs were anesthetized, but received no injury or treatment. After 20 h, animals were killed to measure EVLW by gravimetry. RESULTS: Fluid loading was significantly different in each group. All three treatment groups had higher EVLW than controls. Moderate, bilateral pulmonary edema was observed in the NS and HS-HES groups. The three treatment groups showed similar reductions in oxygenation. Static pulmonary compliance was diminished in the NS and HS-HES groups, but compliance was similar in NOREPI and control groups. The NOREPI group had pathological lactate levels. CONCLUSIONS: This study demonstrated the impact of fluid resuscitation on contused lungs. Twenty hours after the trauma, all three resuscitation approaches showed modest clinical consequences, with moderate lung edema and reduced compliance in response to the infused volume.

Crocodile head scales are not developmental units but emerge from physical cracking.

Various lineages of amniotes display keratinized skin appendages (feathers, hairs, and scales) that differentiate in the embryo from genetically controlled developmental units whose spatial organization is patterned by reaction-diffusion mechanisms (RDMs). We show that, contrary to skin appendages in other amniotes (as well as body scales in crocodiles), face and jaws scales of crocodiles are random polygonal domains of highly keratinized skin, rather than genetically controlled elements, and emerge from a physical self-organizing stochastic process distinct from RDMs: cracking of the developing skin in a stress field. We suggest that the rapid growth of the crocodile embryonic facial and jaw skeleton, combined with the development of a very keratinized skin, generates the mechanical stress that causes cracking.

Accuracy of the double indicator method for measurement of extravascular lung water depends on the type of acute lung injury.

OBJECTIVE: The double indicator method is sensitive to alterations in the distribution of pulmonary blood flow. This distribution is influenced by the type of lung injury. The aim of this study was to compare measurements of lung water by the double indicator method with measurements obtained by gravimetry in a direct lung injury model induced by tracheal instillation of hydrochloric acid and in an indirect lung injury model induced by the intravenous injection of oleic acid. DESIGN: Prospective, randomized laboratory study. SETTING: Animal research laboratory. SUBJECTS: Forty-two female pigs (28+/-3 kg). INTERVENTIONS: Pigs were anesthetized and ventilated and were allocated into three groups: control (n = 6), hydrochloric acid (4 mL/kg intratracheally, n = 24), or oleic acid (0.1 mL/kg intravenously, n = 12). MEASUREMENTS AND MAIN RESULTS: Hydrochloric acid instillation or oleic acid injection resulted in a similar hypoxemia and induced a two- to three-fold increase in extravascular lung water (EVLW) by gravimetry (EVLWG) at 3 hrs compared with controls. In the oleic acid group, there was a significant correlation between EVLWG and EVLW by double indicator method (EVLWDI; r =.88, p <.0001). The bias for EVLWDI - EVLWG measurements was -5.2 mL/kg (95% confidence interval, -5.7 to -4.7 mL/kg) with 95% limits of agreement of -7 to -3.4 mL/kg. In the hydrochloric acid group, there was no significant correlation between EVLWDI and EVLWG values, and the double indicator method failed to detect pulmonary edema in 65% of the animals (EVLWDI <8 mL/kg). The bias was -7.9 mL/kg (95% confidence interval, -9.3 to -6.5 mL/kg) with 95% limits of agreement of -14.4 to -1.4 mL/kg. CONCLUSIONS: The double indicator method is useful for evaluation of pulmonary edema in indirect lung injury, as induced by oleic acid, but produces misleading values in direct lung injury, as produced by hydrochloric instillation.