[Management of SAH]. / Prise en charge de la HSA.

Every year, the neurosurgical intensive care unit at Grenoble's university hospital (CHU) receives a large number of cerebrovascular patients. Data collected in the department during 2023 show that subarachnoid hemorrhage (SAH) is one of the most frequent causes of the pathologies treated. In this article, we focus on the appropriate course of action.

Directive clinique no 439 : Diagnostic et prise en charge du vasa prævia.

OBJECTIF: Résumer les données probantes actuelles et énoncer des recommandations pour le diagnostic et la classification du vasa prævia et pour la prise en charge des femmes ayant reçu ce diagnostic. POPULATION CIBLE: Femmes enceintes présentant un vasa prævia ou des vaisseaux ombilicaux péricervicaux. OPTIONS: En cas de diagnostic soupçonné ou confirmé de vasa prævia ou de vaisseaux ombilicaux péricervicaux, prendre en charge la patiente à l'hôpital ou à domicile, puis pratiquer une césarienne avant terme ou à terme ou entreprendre une épreuve de travail. RéSULTATS: Hospitalisation prolongée, accouchement prématuré, césarienne et morbidité et mortalité néonatales. BéNéFICES, RISQUES ET COûTS: Les femmes ayant un vasa prævia ou des vaisseaux ombilicaux péricervicaux présentent un risque accru d'issues défavorables maternelles, fœtales ou postnatales, à savoir un diagnostic potentiellement erroné, un besoin d'hospitalisation, une restriction inutile des activités, un accouchement précoce et une césarienne inutile. L'optimisation des protocoles de diagnostic et de prise en charge peut améliorer les issues maternelles, fœtales et postnatales. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2022, à partir de termes MeSH et de mots clés liés à la grossesse, au vasa prævia, aux vaisseaux prævia, à l'hémorragie ante partum, au col court, au travail prématuré et à la césarienne. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Fournisseurs de soins obstétricaux, y compris obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle et radiologistes. RéSUMé POUR TWITTER: En cas de cordon et de vaisseaux ombilicaux non protégés dans les membranes près du col (vasa prævia y compris), une caractérisation échographique et une prise en charge avisée s'imposent pour réduire les risques pour le bébé et la mère pendant la grossesse et l'accouchement. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

[Ballistic wound in the pre-hospital and emergency room: Damage Control Resuscitation]. / Plaies balistiques en préhospitalier et aux urgences : Damage Control Resuscitation.

Damage Control Resuscitation (DCR) is a strategy designed to prioritize hemostasis procedures, from the point of injury to surgical management, whether faced with an influx of bleeding casualties or a single casualty with severe hemodynamic instability. Widely disseminated, it provides clear objectives for prioritizing physiological restoration to the anatomy required for short-term survival. Initially applied to surgery, DCR has now been extended to the entire upstream care chain, including first aid and emergency medicine.

[War wounds in the operating theatre: Damage Control Surgery]. / Plaies de guerre au bloc opératoire : Damage ControlSurgery.

In the course of conflicts, the management of severe trauma patients in the operating room has led to the development of surgical and resuscitation techniques that ensure the survival of as many patients as possible. These techniques are based on the principles of Damage Control (DC) by a single, trained team. In this article, we look at the fundamentals of DC, followed by its application in each surgical field. The question of team training is at the heart of this approach.

Curcumin attenuates intracerebral hemorrhage-induced neuronal apoptosis and neuroinflammation by suppressing JAK1/STAT1 pathway.

Intracerebral hemorrhage (ICH) is a kind of fatal stroke with the highest mortality and morbidity in the world. To date, there is no effective treatment strategy for ICH. Curcumin, a major active ingredient of Curcuma longa L., possesses a potential anti-inflammatory activity in many types of disease. In the current study, the mechanism underlying curcumin attenuated ICH-induced neuronal apoptosis and neuroinflammation was explored. Herein, we studied that curcumin decreased brain edema and improved neurological function by using brain edema measurement, assessment of neurological-deficient score, immunofluorescence, and Western blotting analyses after ICH. The results showed that curcumin improved ICH-induced neuronal apoptosis and neuroinflammation. Functionally, the polarization of microglia was assessed by immunofluorescence and Western blotting analyses after ICH in the absence or presence of curcumin. The results suggested that the M1-type microglia were activated after ICH, while the effect was blocked by curcumin treatment, suggesting that curcumin alleviates the neuroinflammation and apoptosis of neurons by suppressing the M1-type polarization of microglia. Mechanically, M1 polarization of microglia was regulated by JAK1/STAT1, and the activation of JAK1/STAT1 was blocked by curcumin. Meanwhile, the protective function of curcumin can be blocked by RO8191, an activator of JAK1. Taken together, our study suggested that curcumin improved the ICH-induced brain injury through alleviating M1 polarization of microglia/macrophage and neuroinflammation via suppressing the JAK1/STAT1 pathway.

[Place of preperitoneal pelvic packing in severe pelvic traumatisms: 20 cases in a French level 1 trauma center]. / Place du packing pré-péritonéal pelvien dans les traumatismes graves du bassin : étude à partir de 20 cas réalisés dans un trauma center de niveau 1 français.

BACKGROUND: The overall mortality of hemodynamically unstable patients with pelvic trauma is high. Their management is controversial concerning places of arterioembolization and pelvic packing associated with pelvic stabilization. The aim of this study was to collect the pre-peritoneal pelvic packing (PPP) performed in our institution over 10years in order to propose a management algorithm. METHOD: From January 2010 to December 2020, all patients with a hemodynamically unstable pelvic fracture who had PPP combined with pelvic stabilization were included. Data were collected prospectively and analyzed retrospectively. The main judgement criteria were early hemorrhage-induced mortality (<24h) and overall mortality (<30d). RESULTS: Twenty patients had PPP out of 287 polytrauma patients with pelvic fracture. The first-line PPP proposed in our algorithm significantly reduced the number of red blood cells (RBCs) (P=0.0231) and improved systolic blood pressure (SBP) (P<0.001) within 24hours of first-line PPP (compared with preoperative). Six patients (30%) were embolized postoperatively for active bleeding not necessarily pelvic. The overall mortality at 30days was 50% (10/20). CONCLUSION: PPP is a fast, easy, effective and safe procedure for venous, bone and sometimes arterial bleeding. PPP is part of damage control surgery and we propose it as a first-line procedure. AE remains complementary in a second step.

Lactoferrin and hematoma detoxification after intracerebral hemorrhage.

In this minireview we discuss the role of lactoferrin (LTF) in detoxifying hematoma after intracerebral hemorrhage (ICH). Subsequent to ICH, neutrophils enter the ICH-affected brain, where they release various granule contents, including LTF. LTF is an iron-binding glycoprotein that binds Fe3+ with high affinity. Unlike other iron-binding proteins, LTF can retain Fe3+ at the low pH associated with inflamed tissue. LTF's ability to sequester Fe3+ is of particular importance to ICH pathogenesis, because large quantities of free iron, which is pro-oxidative and pro-inflammatory, are generated in the ICH-affected brain owing to blood hemolysis. LTF delivered to ICH-affected brain, either as a therapeutic agent or through infiltrated polymorphonuclear neutrophils (cells containing high levels of LTF), could limit the pathogenesis of ICH. LTF is a protein with a high isoelectric point (8.7), a property that enables it to bind to negatively-charged apoptotic cells or proteins. Here, LTF could act as a bridging molecule that couples the apoptotic cells to LTF receptors on the cellular membranes of microglia/macrophages to facilitate the efferocytosis/erythrophagocytosis of apoptotic cells and damaged red blood cells. Thus, by virtue of sequestrating iron and facilitating efferocytosis, LTF may contribute to hematoma detoxification and hematoma/inflammation resolution after ICH.

[Neurological complications of coitus: Review of literature]. / Complications neurologiques du coït : revue de la littérature.

INTRODUCTION: Sexual activity is composed of different phases (excitation, plateau, resolution). Each phase is associated with cardiovascular, respiratory, muscular and hormonal modification which can have an influence on the nervous system. This impact has been studied many times in literature, but no study has synthetized the complications related to coitus or orgasm. METHOD: Systematic review of literature on neurological complications, except headache, of coitus based on Medline and Embase. RESULTS: We screened 1424 articles and selected 46 for this review. 7 (15 %) were clinical or epidemiologic studies, 6 (13 %) were reviews of literature and 33 (72 %) were cases or series of cases reports. 12 articles (26 %) talked about strokes, 10 (22 %) about subarachnoid hemorrhage, 9 (20 %) about reversible cerebral vasoconstriction syndrome. We found 3 (7 %) articles for each of the following complication: intraparenchymal, hematoma and epilepsy. Autonomic hypereflexia was treated in 3 articles (7 %). Only 1 article was included concerning ictus, spinal cord injury, neuralgia and cataplexia. These events can be considered as rare as emergencies related to sexual activity represent only 0.1 % of all emergencies and among these, 12 % are neurological. 31 of the reported cases concerned vascular events (stroke or hemorrhage) and 18 (58 %) of these patients had a patent malformation (aneurism, intracardiac shunt, foramen ovale). CONCLUSION: This is one of the first review of literature trying to synthetise the neurological complications of coitus. Many articles exist in literature. It is necessary to prevent the occurrence of these complications in a population already at risk of neurological events.

[The lethal triad of hemorrhage]. / La triade létale de l'hémorragie.

Coagulopathy, acidosis and hypothermia form the lethal triad in trauma patients with acute hemorrhage. The prevention of this chain reaction relies on an adapted management from the first care in pre-hospital situation: rapid arrest of bleeding, fight against hypothermia, limited vascular filling with an early recourse to vasoactive amines. Pre-hospital transfusion is still rare, whereas in the hospital, an adapted transfusion strategy can wait for or support a surgical or radiological hemostasis procedure.

[Procoagulant hemostatic dressings and hemorrhages]. / Pansements hémostatiques procoagulants et hémorragies.

When faced with a hemorrhage, there are many ways to achieve hemostasis. War medicine and terrorist attacks have taught us the wide use of the tactical tourniquet since hemorrhagic injury is the leading cause of death, mainly in pre-hospital care. The existence of hemorrhagic areas not accessible to tourniquets and the possibility of conversion of a tourniquet by other non-ischemic local hemostasis means have demonstrated the relevance of compression by internal or external packing. Procoagulant hemostatic dressings have progressed in their efficacy over four generations. History and development.

[The ABC's of the tactical tourniquet]. / Le b.a.-ba du garrot tactique.

Uncontrolled bleeding is the leading cause of preventable death. After rapid diagnosis of the injury, early stoppage of the bleeding and maintenance of effective coagulation are, in the pre-hospital setting, the two mainstays of treatment of hemorrhagic shock. The latter requires a trained and experienced medical and paramedical team to prevent patient morbidity and mortality.

[Bleeding management in the operating theatre]. / Gestion du saignement au bloc opératoire.

Despite all the measures taken preoperatively, bleeding may persist and require surgical control. Before considering treatment, it is necessary to establish the diagnosis with the origin of the bleeding. The surgical procedure depends on the aetiology. There are many surgical options and adjuvant measures to consider. They should be known by the operating theatre nurse, who is a major player in surgical management. Successful control of bleeding requires quality multidisciplinary collaboration.

[Dealing with the bleeding patient, being effective with (almost) nothing]. / Face au patient hémorragique, être efficace avec (quasiment) rien.

The practice of pre-hospital care, whether you are a professional rescuer, a nurse, a doctor or a simple citizen, sometimes exposes you to the management of a patient who presents an acute hemorrhage. The prognosis is quickly life-threatening if the safety, assessment, life-saving gestures and activation of the rescue chain are not carried out. A basic, inexpensive first aid kit can further reduce morbidity and mortality. Training first responders in life-saving techniques is a public health issue.

[Management of patients with haemorrhage malignant wounds]. / Prise en charge des patients porteurs de plaies tumorales hémorragiques.

Patients with tumor wounds have many symptoms that impair their quality of life and their general condition. Hemorrhaging is one of them. It can be a challenge for the caregivers and the medical team and will have an impact on the patient. There is no consensus on the management of this symptom, but the literature provides some food for thought. Simple measures can be easily implemented depending on the patient's risk factors, the wound and the oncological context.

High fever after sublingual administration of misoprostol for treatment of post-partum haemorrhage: a hospital-based, prospective observational study in Argentina.

OBJECTIVE: To characterise the occurrence of fever (≥38.0°C) after treatment for post-partum haemorrhage (PPH) with sublingual misoprostol 800 mcg in Latin America, where elevated rates of misoprostol's thermoregulatory effects and recipients' increased susceptibility to high fever have been documented. METHODS: A prospective observational study in hospitals in Argentina enrolled consenting women with atonic PPH after vaginal delivery, eligible to receive misoprostol. Corporal temperature was assessed at 30, 60, 90 and 120 min post-treatment; other effects were recorded. The incidence of high fever ≥ 40.0°C (primary outcome) was compared to the rate observed previously in Ecuador. Logistic regressions were performed to identify clinical and population-based predictors of misoprostol-induced fever. RESULTS: Transient shivering and fever were experienced by 75.5% (37/49) of treated participants and described as acceptable by three-quarters of women interviewed (35/47). The high fever rate was 12.2% (6/49), [95% Confidence Interval (CI) 4.6, 24.8], compared to Ecuador's rate following misoprostol treatment (35.6% (58/163) [95% CI 28.3, 43.5], P = 0.002). Significant predictors of misoprostol-induced fever (model dependent) were as follows: pre-delivery haemoglobin < 11.0g/dl, rapid placental expulsion, and higher age of the woman. No serious outcomes were reported prior to discharge. CONCLUSIONS: Misoprostol to treat PPH in Argentina resulted in a significantly lower rate of high fever than in Ecuador, although both are notably higher than rates seen elsewhere. A greater understanding of misoprostol's side effects and factors involved in their occurrence, including genetics, will help alleviate concerns. The onset of shivering may be the simplest way to know if fever can also be expected.

OBJECTIF: Caractériser la survenue de fièvre (≥ 38,0°C) après traitement d'une hémorragie post-partum (HPP) avec du misoprostol sublingual à 800 mcg en Amérique latine, où des taux élevés d'effets thermorégulateurs du misoprostol et une sensibilité accrue des receveurs à une forte fièvre ont été documentés. MÉTHODES: Une étude observationnelle prospective dans des hôpitaux en Argentine a recruté des femmes consentantes atteintes d'HPP atonique après un accouchement vaginal éligibles pour recevoir du misoprostol. La température corporelle a été évaluée 30, 60, 90 et 120 minutes après le traitement; d'autres effets ont été enregistrés. L'incidence d'une fièvre élevée ≥40,0°C (critère principal) a été comparée au taux observé précédemment en Equateur. Des régressions logistiques ont été effectuées pour identifier les prédicteurs cliniques et ceux basés sur la population de la fièvre induite par le misoprostol . RÉSULTATS: Des frissons transitoires et de la fièvre ont été ressentis par 75% (37/49) des participantes traitées et décrits comme acceptables par les trois quarts des femmes interrogées (35/47). Le taux de fièvre élevé était de 12% (6/49), [intervalle de confiance (IC) à 95%: 4,6, 24,8] contre 35,6% en Equateur après traitement au misoprostol (58/163) [IC95%: 28,3, 43,5], p = 0,002). Les prédicteurs significatifs de la fièvre induite par le misoprostol (selon le modèle) étaient: hémoglobine avant l'accouchement <11,0 g/dL, expulsion placentaire rapide et âge plus élevé de la femme. Aucun résultat sévère n'a été signalé avant le sortie d'hôpital. CONCLUSIONS: Le misoprostol pour traiter l'HPP en Argentine a entraîné un taux de fièvre élevée significativement plus bas qu'en Equateur, bien que les taux dans les deux pays soient notablement plus élevés que les taux observés ailleurs. Une meilleure compréhension des effets secondaires du misoprostol et des facteurs impliqués dans leur apparition, y compris la génétique, aidera à atténuer les inquiétudes. L'apparition de frissons peut être le moyen le plus simple de savoir si l'on peut également s'attendre à de la fièvre.

[Haemorrhagic complications following ibrutinib intake after dermatological surgery]. / Complication hémorragique secondaire à la prise d'ibrutinib après chirurgie dermatologique.

INTRODUCTION: Ibrutinib is a selective oral inhibitor of Bruton's tyrosine kinase. It is used in haematology to treat lymphoid B disorders. Haemorrhagic complications in dermatological surgery are occasionally associated with the use of anti-platelet and/or anticoagulant medication. Herein, we report a case of haemorrhage under ibrutinib following skin surgery. PATIENTS AND METHODS: A 70-year-old male patient began treatment with ibrutinib for chronic lymphocytic leukaemia had 2 basal cell carcinomas of the face. The next day he had a persistent haemorrhage lasting more than 48h, with no effects on the final scarring result. DISCUSSION: Ibrutinib is a tyrosine kinase inhibitor whose mechanism of action plays a role in platelet adhesion. It is known to cause haemorrhaging, either spontaneously or following invasive procedures, especially at the beginning of treatment. In the case of low-risk haemorrhagic procedures in which bleeding may be controlled by mechanical haemostasis, ibrutinib should be discontinued 3 days before and after surgery. In the event of recent initiation of ibrutinib and in the absence of urgent dermatological management, it is preferable to schedule any surgical procedures 3 months after the start of ibrutinib.

[Oesophageal bullous detachment with massive haemorrhage revealing acquired haemophilia A in autoimmune bullous dermatosis]. / Décollement bulleux de l'œsophage responsable d'une hémorragie massive révélant une hémophilie A acquise au cours d'une dermatose bulleuse auto-immune.

INTRODUCTION: Acquired haemophilia A (AHA) is a rare coagulopathy caused by the development of factor VIII antibodies. Various aetiologies have been established but a number of cases have been reported in association with autoimmune bullous dermatosis (AIBD). We report a new case of this type of association revealed by oesophageal involvement of AIBD. PATIENTS AND METHODS: A male patient was treated for AIBD. Due to the inefficacy of local steroids and the emergence of oral and laryngeal blisters, the patient was treated with systemic steroids. He developed a gastrointestinal haemorrhage complicated by haemorrhagic shock. Endoscopy revealed complete peeling of the oesophagus. Laboratory tests showed lengthening of ACT, reduced factor VIII levels, and the presence of anti-factor VIII antibodies. A diagnosis was made of AHA associated with AIBD. Prolongation of systemic corticosteroids and initiation of rituximab resulted in normalisation of haemostasis. DISCUSSION: AIBD and AHA frequently develop concomitantly, as was the case with our patient. The haemorrhagic complications were severe. The aim of AHA treatment is to stop acute bleeding and eliminate antibodies, and for this reason rituximab was chosen. CONCLUSION: Oesophageal bullous detachment is rare in AIBD but, as seen here, it may be responsible for massive haemorrhage, especially in the event of associated AHA. This feature underscores the need for evaluation of haemostasis in the early stages and during relapses for all patients with AIBD.

[Understanding haemostasis to improve its management]. / L'hémostase, comprendre c'est maîtriser.

Haemostasis represents all the complex and interdependent mechanisms which enable bleeding to stop. This process involves the vessel walls, platelets, coagulation factors and von Willebrand factor. In the event of a disorder, the specific characterisation of the condition is the first stage of the diagnosis. Treatment is mainly based on substitution. All these disorders and their complications require multidisciplinary and specialised care.

[Misuse and adverse effects of new direct oral anticoagulants: A prospective observational study in patients admitted to an emergency unit of a French university hospital]. / Mésusage et iatrogénie des anticoagulants oraux directs (AOD) : étude observationnelle dans le service des urgences du CHU de Limoges.

INTRODUCTION: The use of direct oral anticoagulants (NOAC) is complex: indications, dosage adjustments and precautions. Emergency departments (ED) are increasingly faced with patients receiving NOAC. The aim of this study was to evaluate the misuse and the adverse effects (AE) of NOAC. METHODS: All subjects with NOAC admitted to the Limoges University Hospital ED from 1/8/2013 to 1/4/2014 were included in a prospective observational study. Misuse was identified from the NOAC summary of product characteristics and from the 2014 ANSM guideline (indication, dose, co-medications, age, hepatic and renal function); adverse effects were recorded. RESULTS: A total of 198 subjects were included receiving rivaroxaban (68.7 %), dabigatran (30.8 %) or apixaban (0.5 %). Main indications were embolic prevention in patients with non-valvular atrial fibrillation (78.7 %) and curative treatment of venous thromboembolism (17.2 %). In 16.2 % of the cases, the treatment was not in according to the guidelines: 78 % for prescribing errors (incorrect dosage according to age, renal function, co-medications) and 22 % for wrong initial indication. AE related to NOAC were encountered in 25.8 % patients. Hemorrhagic events were diagnosed in 36 patients with no according to the guidelines in 11.1 % of them. Hemorrhagic events resulted in 3 deaths (8.3 %). Thrombotic events occurred in 15 patients, all these patients were issued with appropriate guidelines. CONCLUSION: Through the view of an ED, this study confirms a part of misuse and highlights the risk of spontaneous bleeding of NOAC despite appropriate use.