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BackgroundWhile the role of Extended Focused Assessment with Sonography in Trauma (eFAST) is well defined in the management of severe blunt trauma, its performance in injuries caused by stab wounds has been poorly assessed.MethodsProspective single centre study which included all patients with stab wounds to the thorax or abdomen between December 2016 and December 2018. All patients underwent initial investigation with both eFAST and CT scan, except in cases of haemodynamic or respiratory instability, and in cases with a positive diagnosis by eFAST in which case surgery without CT scan was performed.ResultsOf the 200 consecutive patients included, 14 unstable patients underwent surgery immediately after eFAST. In these 14 patients, 9 had cardiac tamponade identified by eFAST and all were confirmed by surgery. In the remaining 186 patients, the median time between eFAST and CT scan was 30 min (IQR 20–49 min). Test characteristics (including 95% CI) for eFAST compared with reference standard of CT scan for detecting pneumothorax were as follows: sensitivity 77% (54%–92%), specificity 93% (90%–97%), positive predictive value (PPV) 60% (49%–83%), negative predictive value (NPV) 97% (93%–99%). Test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemothorax were as follows: sensitivity 97% (74%–99%), specificity 96% (92%–98%), PPV 83% (63%–93%) and NPV 99% (96%–100%). Finally, test characteristics (including 95% CI) for eFAST compared with CT scan for detecting haemoperitoneum were as follows: sensitivity 75% (35%–97%), specificity 97% (93%–99%), PPV 55% (23%–83%) and NPV 99% (96%–99%).ConclusionsIn patients admitted with stab wounds to the torso, eFAST was not sensitive enough to diagnose pneumothorax and haemoperitoneum, but performed better in the detection of cardiac tamponade and haemothorax than the other injuries. More robust multicentre studies are needed to better define the role of eFAST in this specific population.

Competitive flows syndrome result in severe regional hypoxemia when the deoxygenated flow from the native left ventricle (LV) competes with oxygenated flow from extracorporeal life support (ECLS) pump with potentially severe consequences for the cerebral and coronary circulations. Fast correction of hypoxemia could be obtained by decreasing native LV flow by infusion of a short-acting beta-blocker (esmolol). Our purpose was to retrospectively review the efficacy of esmolol in this situation and hypothesize on the potential mechanisms of action and the associated risks. This is a retrospective analysis of five clinical cases, who underwent lung transplantation and a femoro-femoral venoarterial (VA) ECLS. The patients presented severe hypoxemia (SpO2< 85%) measured through photoplethysmography on a right hand finger. From the patients' medical records and anesthesia flowcharts, hemodynamic, right heart catheterization, echocardiography variables, and arterial blood gas results were noted before and after injection of esmolol. Mechanical ventilation and VA ECLS function variables were optimized and unchanged before and after esmolol injection. All patients had terminal respiratory failure with pulmonary hypertension and conserved LV systolic function. Immediately following esmolol injection (1.3 ± .7 mg/kg; mean ± 1 SD), SpO2increased from 73% ± 12 to 95% ± 6; blood to arterial partial pressure in CO2(PaCO2) decreased from 52 ± 18 to 35 ± 7 mmHg systolic pulmonary artery pressure decreased from 61 ± 8 to 50 ± 12 mmHg; the pulmonary artery oxygen saturation (SvO2); increased from 51% ± 24 to 77% ± 12; systemic arterial pressure or catecholamine requirements were unchanged. In conclusion, these results suggest that injection of esmolol allowed rapid correction of regional hypoxemia occurring during lung transplantation despite femoro-femoral VA ECLS. The mechanism is probably a decreased cardiac output of the native LV due to esmolol-induced negative inotropic and chronotropic effects without significant adverse effects on systemic tissue perfusion.

Persistent or chronic intestinal ischemic injury (i3) can lead to severe malnutrition and acute mesenteric ischemia. Although recommended, revascularization of splanchnic arteries is sometimes unrealizable.

Metabolic disorders and fluid overload are indications of continuous renal replacement therapy (CRRT) including continuous venovenous hemofiltration in patients on extracorporeal membrane oxygenation (ECMO). Direct connection of CRRT machine to the ECMO circuit provides many advantages. Nevertheless, because pressures in CRRT lines relate to ECMO blood flow, high ECMO blood flow may be associated with high pressures in CRRT lines. Thus, management of CRRT pressure lines becomes challenging. We evaluated a protocol for managing high CRRT pressures. Connections were performed according to a standardized protocol to maintain CRRT lines in the correct pressure ranges without modifying ECMO settings or inhibiting pressure alarms. To achieve this goal, the way of connecting of CRRT lines was adapted following a standardized protocol. Connection was first attempted between pump and oxygenator in the 12 patients. In five cases, high pressures in CRRT lines were successfully managed by changing the connection segment. Continuous renal replacement therapy parameters were within target levels and reduction of serum creatinine was 37%. In conclusion, management of high pressures in CRRT lines induced by ECMO could be achieved without modifying ECMO blood flow or inhibiting CRRT alarms. Iterative stops were avoided allowing efficient procedures.

ABSTRACTInfective endocarditis (IE) remains a life-threatening infectious disease with high morbidity and mortality. The objectives of the present study are to assess the host proteolytic activities of the vegetations and their cytotoxic potential in a rat model of experimental IE. Rats were infected with a strain of Enterococcus faecalisof particularly low virulence and weak protease expression. We tested the presence of proteases released by infiltrated leukocytes (matrix metalloproteinases and elastase) or produced in situwithin the septic vegetation, such as those linked to the fibrinolytic system (plasmin and plasminogen activators). We also assessed the tissue damage induced by the infective thrombus in vitroand ex vivo. The model of IE was characterized by larger and more extensive vegetations in infected than in nonseptic rats and by an intense neutrophil infiltrate interfacing with the injured underlying tissue. Neutrophil extracellular DNA was shown to trap bacteria and to produce increased levels of cell-free DNA in plasma. Matrix metalloproteinase-9, elastase, and plasminogen activators were increased in septic versus nonseptic vegetations (as shown by zymography and immunohistology). Finally, proteolysis of the extracellular matrix and apoptosis were shown to be associated with host proteases. Bacteria exhibited no detectable proteolytic activity or direct cytotoxic effects. Bacterial membranes/dead bacteria were sufficient to induce leukocyte recruitment and activation that could promote vegetation formation and growth. Our results suggest that, despite the lack of bacterial proteases, the continuous attractant signals coming from bacterial colonies may lead to a chronic and deleterious aggression toward myocardial/valvular tissues by host proteases.

Cardiac arrest is a significant medical emergency that can occur in outpatient medical facilities. Early defibrillation has been demonstrated to be critical to an individual’s survival of a cardiac arrest. The 2010 guidelines of the European Resuscitation Council advocate that defibrillators should be available throughout outpatient medical facilities, including dental offices. Nevertheless, the underwhelming amount of available data showed that dental offices were under equipped with defibrillators.

Medical emergencies can occur in dental practice and dental surgeons have to be able to handle them effectively. The intravenous route has long been advocated for dental surgeon in emergency. Since 2006, recommendations from the British Resuscitation Council tend to discourage this route of administration for dental practitioners in emergency. In France there is no consensus on this subject and most French dental schools still teach intravenous route in case of medical emergency.

An increasing proportion of the population is medically at risk. Dental providers can encounter a cardiac arrest (CA) while treating their patients. Several studies have assessed qualified dental surgeons on the management of medical emergencies, but to our knowledge there is no reported study about dental students. The aim of this study was to evaluate final‐year dental students in their ability to recognize a cardiac arrest and to apply cardiopulmonary resuscitation (CPR). We evaluated, with a questionnaire, how seventy‐six final‐year dental students self‐assessed their capacity in the management of CA. Then we randomly selected twenty‐two of the final‐year students and compared their answers on the self‐assessment questionnaire to their objective ability to perform CPR. Though 53 percent of the students who answered the questionnaire felt they were able to manage a CA, the performance of the twenty‐two students selected to demonstrate CPR was poor. Only two performed an appropriate CPR, and none combined an adequate CA diagnosis with an appropriate CPR. In conclusion, the predoctoral dental students evaluated in this study were not able to diagnose and manage a CA. The findings indicate that the teaching of cardiac arrest management should be revised. Students should learn and review the theoretical and practical components of cardiac arrest recognition and management in a more intensive manner.

Objectif : Cette enquête a pour but de recenser les urgences médicales survenant dans les services d'odontologie et de faire l'état des moyens, de la formation et des protocoles mis en oeuvre pour y faire face. Méthode : Elle a été menée de décembre 2007 à juin 2008 auprès des pôles et services d'odontologie des centres hospitaliers universitaires français. Un questionnaire portant sur le matériel d'urgence disponible, la formation des praticiens, les procédures d'urgence et la survenue des urgences médicales sur une période de un an a été envoyé à tous les chefs de services. Résultats : Sur les 32 pôles et services contactés, 28 ont répondu au questionnaire. Le matériel d'urgence disponible est très variable selon les services. La majorité d'entre eux ne dispose pas des médicaments recommandés ni du matériel spécialisé nécessaire tel qu'un défibrillateur. Concernant la formation des praticiens, 75 % d'entre eux n'ont eu aucune formation particulière pour la gestion des urgences médicales. Dans près de la moitié des services, il n'y a pas de procédure définie pour faire appel à des moyens de secours extérieurs au service. On relève une moyenne de 20 urgences médicales par an et par service. La majorité d'entre elles sont des malaises vagaux mais on retrouve également des accidents plus graves qui peuvent mettre en jeu le pronostic vital du patient. Conclusion : Même si l'incidence des urgences médicales semble faible dans les services hospitaliers d'odontologie, il est nécessaire que les praticiens disposent du matériel et soient formés à leur prise en charge. (Med Buccale Chir Buccale 2009 ; 15 : 87-92).

Les patients (pts) âgés représentent une part croissante du recrutement en réanimation [1]. Leur prise en charge dans les péritonites postopératoires (PPO) pose de multiples questions dont celui des infections à bactéries multi-résistantes (BMR) chez ces pts souvent multi-hospitalisés. Nous rapportons notre expérience chez les pts âgés (≥80ans).

Classiquement, les syndromes coronariens aigus se manifestent par une douleur thoracique rétrosternale, constrictive et irradiante. Toutefois, chez certains patients, il peut exister des manifestations atypiques, notamment chez les personnes âgées. De plus, certains infarctus peuvent simuler un malaise vagal.Nous présentons le cas d’un homme de 87 ans qui, arrivant chez son chirurgien dentiste, fait un malaise de type vagal avec pâleur, sueurs, bradycardie et hypotension, sans douleur thoracique ni dyspnée. L’électrocardiogramme a permis de diagnostiquer un infarctus étendu du myocarde antérieur.Tout chirurgien dentiste devrait savoir qu’un malaise vagal ne cédant pas aux premières mesures peut être révélateur d’un syndrome coronarien aigu.

Classiquement, les syndromes coronariens aigus se manifestent par une douleur thoracique rétrosternale, constrictive et irradiante. Toutefois, chez certains patients, il peut exister des manifestations atypiques, notamment chez les personnes âgées. De plus, certains infarctus peuvent simuler un malaise vagal.

Les aminosides sont souvent prescrits en probabiliste (germe et concentration minimale inhibitrice (CMI) inconnus). Pour atteindre l’objectif pic de concentration plasmatique (Cmax)/CMI>8 il faut utiliser les concentrations critiques supérieures (CCS) définies par l’European Committee on Antimicrobial Susceptibility Testing (qui sont de 8mg/L pour l’amikacine (AMK), et de 4mg/L pour la gentamicine (GN)). L’Agence nationale de sécurité du médicament (ANSM) recommande d’utiliser les posologies les plus élevées dans le traitement probabiliste des infections sévères ; 30mg/kg pour l’AMK et 8mg/kg pour la GN. L’objectif étant d’avoir un Cmax≥8xCCS ; soit 32mg/L pour la GN et 64mg/L pour l’AMK. Le but de cette étude est d’évaluer les Cmax avec 8mg/kg de GN et 30mg/kg d’AMK en réanimation.

Les bactériémies sont un élément de mauvais pronostic au cours des infections graves qui n’a jamais été analysé au cours des péritonites postopératoires (PPO). L’objectif de notre étude était d’évaluer l’impact des bactériémies sur la mortalité de PPO.

The main objective was to determine risk factors for presence of multidrug resistant bacteria (MDR) in postoperative peritonitis (PP) and optimal empirical antibiotic therapy (EA) among options proposed by Infectious Disease Society of America and the Surgical Infection Society guidelines.