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OBJECTIVEBlunt cerebrovascular injuries (BCVIs) affect approximately 1% of patients with blunt trauma. An antithrombotic or anticoagulation therapy is recommended to prevent the occurrence or recurrence of neurovascular events. This treatment has to be carefully considered after severe traumatic brain injury (TBI), due to the risk of intracranial hemorrhage expansion. Thus, the physician in charge of the patient is confronted with a hemorrhagic and ischemic risk. The main objective of this study was to determine the incidence of BCVI after severe TBI.METHODSThe authors conducted a prospective, observational, single-center study including all patients with severe TBI admitted in the trauma center. Diagnosis of BCVI was performed using a 64-channel multidetector CT. Characteristics of the patients, CT scan results, and outcomes were collected. A multivariate logistic regression model was developed to determine the risk factors of BCVI. Patients in whom BCVI was diagnosed were treated with systemic anticoagulation.RESULTSIn total, 228 patients with severe TBI who were treated over a period of 7 years were included. The incidence of BCVI was 9.2%. The main risk factors were as follows: motorcycle crash (OR 8.2, 95% CI 1.9–34.8), fracture involving the carotid canal (OR 11.7, 95% CI 1.7–80.9), cervical spine injury (OR 13.5, 95% CI 3.1–59.4), thoracic trauma (OR 7.3, 95% CI 1.1–51.2), and hepatic lesion (OR 13.3, 95% CI 2.1–84.5). Among survivors, 82% of patients with BCVI received systemic anticoagulation therapy, beginning at a median of Day 1.5. The overall stroke rate was 19%. One patient had an intracranial hemorrhagic complication.CONCLUSIONSBlunt cerebrovascular injuries are frequent after severe TBI (incidence 9.2%). The main risk factors are high-velocity lesions and injuries near cervical arteries.

In prehospital setting, a severe traumatic brain injury (TBI) requires tracheal intubation, sedation and mechanical ventilation pending the initial imagery. An early neurological wake-up test (ENWT), soon after the initial imaging assessment, allows a rapid neurological reassessment. This strategy authorises an initial clinical examination of reference with which will be compared the later examinations. The main objective of this study was to describe the characteristics of the patients who underwent an ENWT, and to determine its causes of failure.We conducted a retrospective, observational, single-centre study including all intubated TBI admitted in the trauma centre. An ENWT was defined as cessation of sedation within 24h after TBI. Data concerning patient characteristics, CT-scan results, and outcomes were extracted from a prospective register of all intubated TBI admitted in the ICU. Characteristic of ENWT and causes of failure were retrieved from patient files. A multivariate logistic regression model was developed to determine the risk factors of ENWT failure.During 7 years, 242 patients with intubated TBI were included. An ENWT was started in 96 patients, for an overall rate at 40%. The ENWT was stopped in 38 patients (39.5%), mostly due to neurological deterioration in 27 cases (71%) or respiratory distress in 10 cases (26%). Significant predictors of ENWT failure were: the presence of subdural hematoma with a thickness5mm on first imagery (OR=3.2; 95%CI [1.01-10.28]), and an initial GCS score5 (OR=7.4; 95%CI [1.92-28.43]). Prevalence of poor outcome at 1year was lesser in patients with successful ENWT compared to those with failure or absence of ENWT: 4% vs. 48% and 49% (p0.0001).The ENWT is achieved in 40% of patients, with a success rate of 60.5%. In presence of a subdural hematoma with a thickness5mm or an initial GCS score5, an ENWT failure may be expected.

Introduction Traumatic brain injury associated coagulopathy is frequent, either in isolated traumatic brain injury in civilian practice and in combat traumatic brain injury. In war zone, it is a matter of concern because head and neck are the second most frequent site of wartime casualty burden. Data focusing on transfusion requirements in patients with war related TBI coagulopathy are limited. Materials and methods A descriptive analysis was conducted of 77 penetrating traumatic brain injuries referred to a French role 3 medical treatment facility in Kabul, Afghanistan, deployed on the Kabul International Airport (KaIA), over a 30 months period. Results On 77 patients, 23 died during the prehospital phase and were not included in the study. Severe traumatic brain injury represented 50% of patients. Explosions were the most common injury mechanism. Extracranial injuries were present in 72% of patients. Traumatic brain injury coagulopathy was diagnosed in 67% of patients at role 3 admission. Red blood cell units (RBCu) were transfused in 39 (72%) patients, French lyophilized plasma (FLYP) in 41 (76%), and fresh whole blood (FWB) in 17 (31%). Conclusion The results of this study support previous observations of coagulopathy as a frequent complication of traumatic brain injury. The majority of patients with war related penetrating traumatic brain injury presented with extracranial lesions. Most of them required a high level of transfusion capacity.

Resume Background Les fractures du bassin instable hemodynamiquement sont un defi diagnostique et therapeutique. La prise en charge actuelle repose sur le controle des hemorragies pelviennes en associant la stabilisation osseuse et l’embolisation des arteres pelviennes. La mortalite de ces patients a haut risque depasse cependant les 30 %. Recemment le packing preperitoneal dont le principe hemostatique repose sur le tamponnement de la cavite pelvienne a ete decrit. L’objectif de ce travail est d’evaluer l’interet de cette nouvelle procedure. L’efficacite de l’algorithme standard reposant sur la stabilisation osseuse et l’embolisation est evaluee par l’analyse des traumatismes du bassin chez 200 traumatises graves pris en charge a l’hopital d’instruction des armees Sainte-Anne. Les resultats sont ensuite compares aux donnees de la litterature relatives au packing preperitoneal. Patients et methode Le profil lesionnel, la prise en charge et la morbi-mortalite a ete evaluee chez 200 traumatises graves. Apres une phase de reanimation initiale, les fractures instables du bassin ont ete traitees par la pose d’une ceinture de contention circonferentielle suivie par la pose d’un fixateur externe. Une arteriographie a ete realisee pour tous les patients presentant une hemorragie avec une instabilite hemodynamique persistante. Resultats La moyenne de l’Injury Severity Score (ISS) etait de 31 (4–75). La moyenne du Trauma Related Injury Severity Score (TRISS) etait a 74 % (3–99). La proportion de patients instables hemodynamiquement etait de 47 %. Quinze patients (41 %) presentaient une hemorragie severe. La mediane du nombre de produit sanguin transfuse etait de 10 (4–42). Huit patients (22 %) ont beneficie d’une embolisation. Pour deux patients la reduction du fracas du bassin par la pose d’un fixateur externe a permis d’obtenir l’hemostase definitive. Deux patients ont beneficies d’une laparotomie premiere pour le controle d’un hemoperitoine. Le taux de mortalite du groupe des patients presentant une hemorragie a ete de 33 % (5/15). Discussion Cette mortalite elevee amene a revoir la place de l’embolisation pelvienne en premiere intention. Elle presente des inconvenients tels que son inefficacite sur les saignements veineux, sa disponibilite et la duree de la procedure. Le packing preperitoneal est une alternative chirurgicale rapide et efficace. Elle semble permettre d’ameliorer l’etat hemodynamique des patients et de diminuer significativement le recours a l’embolisation et aux transfusions massives. L’embolisation reste indiquee pour les patients non repondeurs a la chirurgie. La survie n’est cependant pas amelioree de facon significative.

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.

Resume Objectif Definir la place de l’anesthesie locoregionale (ALR) dans la prise en charge des plaies de la face dans un service d’accueil des urgences (SAU). Type d’etude Etude prospective observationnelle realisee dans le SAU d’un centre hospitalier regional. Patients et methodes Deux cent quarante-six patients successifs presentant une ou plusieurs plaies de la face ont ete inclus du 1 er aout 2004 au 31 decembre 2004. Les donnees concernant le patient, l’operateur, la plaie (evaluee par le nombre de points de suture), la methode anesthesique (ALR, anesthesie locale [AL] ou pas d’anesthesie), la methode de reparation cutanee, la duree de l’intervention, le confort de l’operateur (echelle verbale numerique [EVN] de zero a dix) et la douleur ressentie par le patient (echelle visuelle analogique [EVA] de 0 a 10) aux differents stades de la prise en charge ont ete recueillies. Resultats Par rapport a l’AL, l’ALR de la face a diminue le nombre de ponctions (1,36 vs 4,38 ponctions, p p p Conclusion Quand l’ALR de la face est realisable, elle est plus performante que l’AL pour le traitement des plaies du visage.

Sepsis is a leading cause of morbidity and mortality in burn patients who are immunosuppressed. Infections can be bacterial, fungal, or viral. Herpes simplex virus (HSV) in acute burns, either as opportunistic infection or reactivation of latent virus, has been reported with various incidences. HSV in these patients may cause burn infections, graft loss, respiratory infections, and visceral dissemination [1]. Brain localization, however, has never been reported. We describe here a case of herpes simplex virus type 1 encephalitis in a burn patient.

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.

To reduce the risk of accidental needlestick injuries, first active then passive safety devices were developed on IV catheters. However, whether these catheters are easy to implement and really protect personnel from accidental needlestick is untested.In this prospective randomized survey, we compared a passive safety catheter with an active safety catheter and a nonsafety classic catheter. The main objective was to evaluate the difficulty of inserting the catheters in terms of the number of insertion failures, difficulties introducing the catheter and withdrawing the needle, and the normality of the blood reflux in the delivery system. The second objective was to determine the degree of exposure to patients' blood evaluated as the number of exposures of the staff and blood splashes of the environment, and the staff's sense of protection.Seven hundred fifty-nine assessment cards were collected. The number of failures for the three catheter groups was similar and not statistically different. Introduction of the catheter was more difficult with the active safety catheter. Needle withdrawal was more difficult with the passive safety catheter. The blood reflux was abnormal more often with the safety catheters. The staff's exposure was more frequent with the active safety catheter. The number of blood splashes was more common with the safety catheters.Safety catheters are not superior with regard to failure rate in the catheter's placement. Users feel better protected, but find the use of safety catheters more difficult, and their handling generates more splashing of blood into the environment. The passive safety catheter is more efficient than the active safety catheter with regard to ease of introduction of the catheter into the vein and the staff's exposure to the patient's blood.

OBJECTIVE: To report a case of hyperventilation caused by topiramate therapy and propose a pathophysiologic mechanism for this disorder. CASE SUMMARY: A 52-year-old woman with refractory seizure disorder was admitted to the burn care unit with burns over 10% of her body. Her seizure medications, unchanged and well tolerated for several months, included carbamazepine 1200 mg, lamotrigine 500 mg, phenobarbital 80 mg, and topiramate 150 mg per day. During hospitalization, despite a relatively normal arterial pH, the woman developed persistent hyperventilation, with respiratory rates up to 50 breaths/min. Alkalinization did not reduce the hyperventilation. Thoracic contrast-enhanced computed tomographic scan ruled out pulmonary embolism and persistent pneumonia. Salicylate and biguanide screening were negative; results of repeated thyroid and liver function tests were normal. Cerebral magnetic resonance imaging excluded a cerebral pathology. After cerebrospinal fluid (CSF) analysis showed acidosis (pH 7.14), topiramate was withdrawn and the patient's general condition rapidly improved. Forty-eight hours later, the CSF pH had increased to 7.26. The woman was discharged from the burn care unit on the 42nd hospital day. DISCUSSION: Hyperchloremic normal anion gap metabolic acidosis, which can lead to hyperventilation, has been reported as an adverse effect of topiramate treatment. However, our patient had respiratory alkalosis. Concurrent etiologies of peripheral hyperventilation were excluded, leaving central neurogenic hyperventilation as the remaining etiology. Such central neurogenic hyperventilation associated with topiramate has previously been reported in intensive care. Our case report demonstrates CSF acidosis. Withdrawing topiramate reduced both CSF acidosis and hyperventilation. The mechanism of topiramate-induced CSF acidosis remains unclear. According to the Naranjo probability scale, the relationship of hyperventilation to administration of topiramate in our patient was probable. CONCLUSIONS: Normal doses of topiramate may provoke central neurogenic hyperventilation, as a result of CSF acidosis. The acid–base status of critically ill patients receiving topiramate should be monitored carefully.

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.

Propofol infusion syndrome (PRIS) is a new clinical entity reported in critically ill patients. Lactic acidosis, cardiac failure and rhabdomyolysis are the features. Lactic acidosis related to short-term propofol administration has been described during general anaesthesia. Lactic acidosis could be an early marker of PRIS. We report here a case of very early lactic acidosis in a 66-year-old-man receiving propofol during a neurosurgery. The outcome was good after discontinuation of propofol.

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.

To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.

Introduction Ebola Virus Disease (EVD) causes severe diarrhoea and vomiting, leading to dehydration and electrolyte abnormalities. Treatment remains supportive and often requires intravenous (IV) access. IV catheters are difficult to insert and maintain in this context. Our primary objective was to compare peripheral venous catheters (PVCs) and central venous catheters (CVCs) for volume resuscitation in patients with EVD. Material and methods We performed a prospective observational study between January and March 2015 at the Conakry Healthcare Workers Ebola Treatment Unit (ETU). The primary judgement criterion was the ratio of the daily infused volume of fluids to the prescribed volume (DIV/PV). Results Fourteen patients were admitted. Twenty-eight PVCs and 8 CVCs were inserted. CVCs had a longer survival time (96 ± 34 hours versus 33.5 ± 21 hours, P

We report a case of transient acquired and isolated factor VII deficiency associated with severe head trauma. A 16-year-old boy was involved in a motor vehicle accident. CT scan showed frontal brain contusion and a cerebral haematoma (5 cm). First prothrombine time (PT) was normal. Rapidly, a severe coagulopathy developed, unresponsiving to fresh frozen plasma and vitamin K. Haemostatic markers analysis showed an isolated deficiency of factor VII at 15%. No inhibitory activity against factor VII could be detected. We successfully treated the deficiency with intermittent intravenous human factor VII (factor VII-LFB) during 10 days. Factor VII return to normal at 84%. Physiopathological and therapeutic aspects of this rare pathology are presented.

We report a case of intracranial dural arteriovenous (DAVF) draining into the spinal medullary veins. A 49-year-old woman presented a rapidly progressive ascending myelopathy resulting in a C3-C4 tetraplegia associated with acute respiratory failure at the twelfth hour. MRI revealed swelling of the cervical spinal cord, hyperintensity on T2 and enhancement of enlarged veins on MR angiography. A conventional angiography showed the DAVF with venous drainage into the spinal vein extending to the conus medullaris. After embolization, neurological recovery occurred during the first week, allowing tracheal extubation on day 2. Clinical, radiological and therapeutic aspects of this uncommon pathology are presented.

Resume Le LTV 1000™ (BREAS medical®) est un ventilateur de transport dote d’une turbine qui comprime l’air ambiant et assure la ventilation du patient independamment d’une source d’oxygene hyperbare. Objectifs Evaluer la fraction d’oxygene reellement delivree par le LTV 1000™ alimente par de l’oxygene normobare delivre au moyen d’un extracteur d’oxygene et/ou d’un debitmetre de bouteille d’oxygene. Methodes Les fractions d’oxygene delivrees par le LTV 1000™ alimente par un extracteur d’oxygene (debit 5 l.mn-1) et des debits croissants d’oxygene pur normobare ont ete mesurees a differents niveaux de PEP (ventilation minute 10 l.mn-1). Les fractions d’oxygene ont egalement ete mesurees avec alimentation du ventilateur par oxygene pur issu d’un debitmetre de bouteille seul, ainsi qu’avec alimentation par extracteur seul et des ventilations minutes elevees. Resultats Les fractions d’oxygene delivrees allaient de 43 % a 75 % en fonction du debit d’oxygene normobare. La consommation maximale d’oxygene en bouteille etait de 5 l.mn-1. Le niveau de PEP n’a pas influence ces resultats. Alimente par oxygene pur issu d’un debitmetre, le LTV 1000™ a delivre des fractions d’oxygene concordant avec les abaques fournies par le constructeur. L’augmentation importante du volume minute a reduit notablement la fraction d’oxygene delivree quand le ventilateur etait alimente par un extracteur d’oxygene seul. Conclusion Le LTV 1000TM en mode basse pression utilise avec un extracteur d’oxygene et/ou un debitmetre peut permettre d’economiser l’oxygene hyperbare.

Resume Les hemorragies faciales massives au cours des traumatismes crânio-faciaux sont considerees comme rares. La richesse de la circulation collaterale entre les carotides internes et externes explique les difficultes d’hemostase. Nous rapportons 4 cas d’hemorragies faciales massives associees a des traumatismes crâniens graves. Differentes methodes d’hemostase ont ete utilisees (tamponnement nasal, reduction des fractures, traitement endovasculaire, ligature des carotides externes). La ligature d’une ou des deux carotides externes est un moyen efficace, et sa simplicite peut en faire une technique de choix dans certaines situations.

We report two cases of neurogenic pulmonary oedema following subarachnoid haemorrhage. A 58-year-old woman became increasingly dyspneic and needed oxygen support during a few days. A 53-year-old woman rapidly developed clinical and laboratory signs of respiratory failure, recovering in 48 hours. In both cases, chest radiography showed bilateral diffuse infiltrates, electrocardiogram revealed ST abnormalities, and cardiac troponin I level was elevated. In both patients, pro brain natriuretic peptide level was increased whereas global cardiac function was normal. The factors initiating its secretion are discussed.

The tracheo-innominate artery fistula is a rare but life-threatening complication of the tracheotomy. Its care management requires a rapid airway control to allow haemostasis by compression and ventilation. The haemostasis must be immediate and two techniques exist: surgery opencast (sternotomy) or interventional radiology. The choice between the two depends largely on the technical platform available. Our case report describes a tracheo-innomninate artery fistula surgically managed with success. The patient carried an anatomic variant, the two carotids come from innominate artery.

Introduction Les pneumopathies acquises sous ventilation mecanique (PAVM) precoces sont frequentes chez les patients traumatises crâniens graves (TCG) [1] . Cependant, la litterature reste pauvre sur ce topique. L’impact sur l’oxygenation cerebrale et le pronostic fonctionnel futur reste notamment non elucide. L’objectif de cette etude est donc de determiner l’incidence et les facteurs de risque de PAVM precoce chez le patient TCG et d’en evaluer l’impact sur l’oxygenation cerebrale et le score de GOS a 6 mois. Materiel et methodes Analyse retrospective d’une cohorte prospective observationnelle de tous les patients TCG admis en reanimation a l’HIA Sainte-Anne, Toulon, de janvier 2007 a decembre 2013. Les criteres d’exclusion ont ete : GCS minimal > 9 et deces dans les 48 premieres heures. Le Clinical Pulmonary Infection Score a ete utilise quotidiennement pour detecter les patients suspects de PAVM precoce [2] . La confirmation a ete microbiologique par mini lavage broncho-alveolaire. Des analyses uni et multivariee par regression logistique ont ete utilisees pour determiner les facteurs de risque de PAVM precoce, leur impact sur l’oxygenation cerebrale mesuree par PtiO2 et le pronostic fonctionnel a 6 mois. Resultats Durant la periode d’etude, 203 patients ont ete analyses. L’incidence des PAVM precoces a ete de 46,3 % [45,4–47,2] (n = 94). Les germes documentes sont representes dans le Tableau 1 . Les patients presentant une PAVM precoce ont ete le plus souvent des hommes (88 % vs 69 %, p = 0,001), ayant inhale (23 vs 12 %, p = 0,03), avec un score ISS superieur (25 [16–29] vs 18 [10–29], p = 0,01) et un taux d’hematome sous dural plus important (63 vs 37 %, p = 0,0002). L’utilisation de barbituriques et l’hypothermie therapeutique etaient plus frequentes dans le groupe PAVM precoce : 33 vs 11 % (p = 0,0001) et 47 vs 19 % (p Discussion Les PAVM precoces sont frequentes chez le TCG. Notre serie retrouve comme principaux facteurs de risque le sexe masculin, l’hypothermie therapeutique et l’inhalation prehospitaliere. De facon inedite, un impact defavorable sur l’oxygenation cerebrale et sur le pronostic fonctionnel ulterieur a ete montre.

Introduction Une epidemie de maladie a virus Ebola (MVE) touche actuellement l’Afrique de l’Ouest. Les patients infectes presentent une diarrhee abondante et des vomissements, responsables d’une deshydratation et de troubles ioniques [1] . Le traitement est symptomatique et necessite frequemment un abord intraveineux (IV). Les conditions de soins difficiles (equipements de protection individuels, climat, obstacles culturels et linguistiques a l’acceptation des soins) compliquent l’obtention et le maintien des abords vasculaires. L’objectif de cette etude est de comparer la voie veineuse peripherique (VVP) a la voie veineuse centrale (VVC) dans la prise en charge des patients avec MVE. Patients et methodes Il s’agit d’une etude prospective, realisee entre janvier et mars 2015 au centre de traitement Ebola pour soignants de Conakry. Les caracteristiques de l’ensemble des abords IV poses ont ete recueillies. Le critere de jugement principal etait le ratio volume de perfusion effectif/volume prescrit (VE/VP). Resultats Parmi les 14 patients admis, 13 ont eu au moins un abord vasculaire. L’indication majoritaire etait la rehydratation (87 %), suivie par l’administration de traitement IV. Vingt-huit VVP et 8 VVC ont ete posees avec un taux de succes a la premiere tentative de 86,7 % et 75 %. Il n’y a eu aucun accident d’exposition virale lie aux abords IV ; 37,5 % des VVC ont eu une complication mineure, il n’y a eu aucune complication majeure. La duree mediane de survie des VVC etait superieure (96 ± 34 vs 33,5 ± 21, p p = 0,12). Le VE/VP etait superieur dans le groupe VVC (moyenne 0,95 ± 0,08 vs 0,7 ± 0,27, p p = 0,002). Chaque VVC permettaient d’eviter une mediane de 4,5 (IC 95 % 2–5,5) ponctions vasculaires par patient ( Tableau 1 et Fig. 1 ). Discussion Aucune etude n’a compare les modalites d’abord IV pour les patients avec MVE. La VVP est cependant recommandee en premiere intention [2] . Le faible taux de survie observe pourrait compromettre la delivrance effective des volumes de perfusion prescrits, perennisant l’hypovolemie et majorant le risque de defaillance d’organe. La VVC a ete utilisee avec succes en conditions epidemiques [3] ou elle a montre une diminution de l’exposition des soignants au risque viral. Notre etude confirme qu’il s’agit d’une alternative fiable et sure a la VVP dans ce contexte. Elle suggere une amelioration de la delivrance du remplissage vasculaire, composante prioritaire de la prise en charge des patients avec MVE. Une evaluation prospective de l’impact clinique du type d’abord vasculaire dans cette pathologie est souhaitable.

Almost 50% of military trauma patients who need transfusions develop a coagulopathy. Immediately treating this coagulopathy improves the patient?s prognosis. Field military hospitals often lack laboratory devices needed to diagnose a clinically significant coagulopathy and have limited blood product resources such as plasma. Point-of-care (POC) devices for the measurement of prothrombin time (PT) are available and have been tested in a variety of situations, including hemorrhagic surgery. The authors compared a POC device, the Coaguchek XS Pro (F. Hoffmann-La Roche Ltd., Basel, Switzerland), with laboratory measures for determining the PT in military trauma patients in a field hospital.This single-center prospective study was designed to compare POC coagulation monitoring with traditional laboratory testing. It was conducted at the French military hospital located at Kabul International Airport. All patients with trauma injuries resulting from war operations were included. A blood sample was drawn immediately on admission. PT was determined both in the laboratory and with use of the Coaguchek XS pro.Forty patients with war trauma were enrolled during a 3-month period. The authors recorded 69 measurements. The two methods were correlated with a correlation coefficient of 0.78 (p.001). The Bland-Altman plot showed a mean difference of 5.8% (95% confidence interval ?14.9% to 26.6%). Using a PT cutoff of 60%, POC had a sensitivity of 77.1% and a specificity of 94.1%. RESULTS from POC PT measurement were available within a mean of 25.8 minutes before laboratory measures.The Coaguchek XS Pro device can be used successfully in an austere environment without compromising its performance.

Objective Acute respiratory distress syndrome (ARDS) is a leading cause of mortality in burn patients. Smoke inhalation, pneumonia and inflammation process are the major causes of ARDS in burn patients. The American European Consensus Conference (AECC) definition proposed in 1994 has recently been revised by the Berlin definition. Our objective was to describe the epidemiology of ARDS comparing the Berlin definition with the AECC definition in a retrospective cohort of burn patients. Methods We reviewed admitted burn adult patients for a two year period, and investigated patient who received mechanical ventilation for more than 48 h and in whom pneumonia was diagnosed. Results 40 patients were analyzed. According to the AECC definition, 11 patients met criteria for ALI (27.5%), and 29 patients for ARDS (72.5%). According to the Berlin definition, all patients met criteria for ARDS: 4 (10%) for a severe ARDS, 25 (62.5%) for a moderate ARDS, 11 (27.5%) for a mild ARDS. Inhalation injury was diagnosed in 10 patients (25%). Categorizing patients with the Berlin definition showed statistically significative difference of mortality within the three groups, but not with the AECC definition. Conclusion The Berlin definition seems to be more accurate than the AECC definition to assess the severity of ARDS in term of outcome in burn patients. This definition may facilitate prompt recognition of ARDS in burn patients, and promote protective ventilation strategy to a larger number of patients.

Objective The purpose of this review is to present the progressive extension of the concept of damage control resuscitation, focusing on the prehospital phase. Article type Review of the literature in Medline database over the past 10 years. Data source Medline database looking for articles published in English or in French between April 2002 and March 2013. Keywords used were: damage control resuscitation, trauma damage control, prehospital trauma, damage control surgery. Original articles were firstly selected. Editorials and reviews were secondly studied. Data synthesis The importance of early management of life-threatening injuries and rapid transport to trauma centers has been widely promulgated. Technical progress appears for external methods of hemostasis, with the development of handy tourniquets and hemostatic dressings, making the crucial control of external bleeding more simple, rapid and effective. Hypothermia is independently associated with increased risk of mortality, and appeared accessible to improvement of prehospital care. The impact of excessive fluid resuscitation appears negative. The interest of hypertonic saline is denied. The place of vasopressor such as norepinephrine in the early resuscitation is still under debate. The early use of tranexamic acid is promoted. Specific transfusion strategies are developed in the prehospital setting. Conclusion It is critical that both civilian and military practitioners involved in trauma continue to share experiences and constructive feedback. And it is mandatory now to perform well-designed prospective clinical trials in order to advance the topic.

Background: Long term oxygen therapy improves survival in hypoxemic patients with chronic obstructive pulmonary disease (COPD). Because pressure support ventilation with a home care ventilator is largely unsupervised, there is considerable risk of leakage occurring, which could affect delivered FiO2. We have therefore conducted a bench study in order to measure the effect of different levels of O2 supply and degrees of leakage on delivered FiO2. Ventilator tested: Legendair W (Airox™, Pau, France). Thirty-six measures were performed in each four ventilators with zero, 5 and 10 l.min-1 leakage and 1,2,4 and 8 l O2 flow. Findings: FiO2 decreased significantly with 5 l.min-1 leakage for all O2 flow rates, and with 10 l.min-1 at 4 and 8 l. min-1 O2. Conclusion: During application of NIV on home ventilators, leakage can dramatically decrease inspired FiO2 making it less effective. It is important to know the FiO2 dispensed when NIV is used for COPD at home. We would encourage industry to develop methods for FiO2 regulation Chronic use of NIV for COPD with controlled FiO2 or SpO2 requires further studys.

Patients with face and neck burns (FNBs) often undergo prehospital intubation, or sustain inhalation injury which are risk factors for pneumonia in specific populations. Early onset pneumonia (EOP) might be caused by initial management. The primary goal of this study was to find risk factors for EOP in FNB patients. This is a retrospective, single-center trial. We screened all FNB patients for EOP with the Clinical Pulmonary Infection Score. Pneumonia diagnosis was with culture from a mini broncho-alveolar lavage. Potential risk factors for EOP were recorded. We included 152 patients, EOP was diagnosed in 58 (38.2%). EOP patients had a greater burned surface area median (20±17% vs. 10±17%; p

The aim of this study is to prospectively compare the accuracies of transcranial color-coded sonography (TCCS) and transcranial Doppler (TCD) in the diagnosis of elevated intracranial pressure.A prospective, blinded, head-to-head comparison of TCD and TCCS methods using intracranial pressure (ICP) measured continuously via an intraparenchymal catheter as the reference standard in 2 groups of 20 neurocritical care patients each: high ICP (group 1) and normal ICP (group 2). Middle cerebral artery (MCA) pulsatility index (PI) recordings from all patients' sonographic reports were selected based on the highest left or right recorded MCA PI. Transcranial Doppler was performed using a dedicated TCD device, and TCCS was performed using a portable ultrasound system.The PI values obtained did not differ significantly between the 2 methods (group 1, P = .46; group 2, P = .11). Linear regression analysis identified a significant relationship between PI obtained with both methods (r = 0.897; P.0001). The duration of PI measurement was statistically longer with TCCS than TCD (group 1, P.01; group 2, P.01). Diagnostic accuracies were good and similar for both methods (TCD area under curve, 0.901; TCCS area under curve 0.870; P = .69).This work is a pilot study comparing TCCS and TCD in the detection of elevated ICP. This study suggests that a bedside portable ultrasound system may be useful to determine MCA PI with accuracy similar to that of a dedicated TCD device.

OBJECTIVE To describe a case of extensive intestinal necrosis with oral intake of calcium polystyrene sulfonate without sorbitol. CASE SUMMARY A 73-year-old woman was admitted to the emergency department with abdominal pain. Abdominal computed tomography (CT) scan showed widespread dilatation of the bowel. The diagnosis of acute colonic pseudoobstruction was made. On day 3, her serum potassium level rose to 5.6 mEq/L. It was treated with hydrocortisone 100 mg/day and calcium polystyrene sulfonate 15 g/day via nasogastric tube from day 3 to day 6. On day 6, the severe abdominal pain recurred, with abdominal tenderness. CT scan showed pneumoperitoneum and peritoneal effusion. At surgery, 2 lenticular jejunal perforations and an ischemic cecum were found. Microscopic findings indicated that the transmural abscess contained massive inflammatory infiltrate and the cecal mucosa showed ulceration and inflammation with a fibrinous and purulent coating. Small gray-purple or blue angulated crystals were embedded in the cecal and most of the jejunal mucosal ulcers. On day 19, the patient died of multiple organ failure after her third laparotomy. DISCUSSION Ion-exchanging resins are given orally or by retention enema for the treatment of hyperkalemia. The most commonly used and best-established resin is sodium polystyrene sulfonate. However, it is known to promote colonic necrosis when sorbitol is also given or especially in patients with renal failure or postoperative ileus. Calcium polystyrene sulfonate is another ion-exchange resin. There are few reports of adverse effects in the literature. Our case is interesting for 2 reasons: the resin given was calcium polystyrene sulfonate and sorbitol was not used. CONCLUSIONS Like sodium polystyrene sulfonate, calcium polystyrene sulfonate is an ion-exchanging resin that can promote bowel necrosis. We believe that it should not be used with sorbitol or when bowel transit time is slowed.

Introduction Le cytomegalovirus (CMV) est un virus ubiquitaire. L’infection a CMV est liee soit a une primo-infection, soit a une reactivation. Celle-ci est provoquee par un « stress » qui va consommer les ressources du systeme immunitaire (SI) et permettre la replication virale, ou a un deficit de ce meme SI. Chez le patient de reanimation, l’infection a CMV est associee a une augmentation de la duree de sejour en reanimation, de la duree de ventilation mecanique, de la mortalite [1]. Le patient brule grave est caracterise par une immunodepression acquise multifactorielle. Sur des modeles murins, il a ete montre que les sujets brules etaient susceptibles de presenter une infection a CMV [2]. D’un point de vue clinique, elle reste encore mal documentee chez ces patients. L’objectif de notre etude etait d’evaluer l’incidence de l’infection a CMV chez les patients brules graves. Materiel et methodes Nous avons inclus les patients avec une surface cutanee brulee (SCB) superieure a 15 % admis dans le centre de traitement des brules de l’HIA Sainte-Anne, Toulon, entre septembre 2008 et septembre 2011. Une serologie CMV etait realisee a l’admission, puis une detection de la viremie par real time quantitative PCR (RTqPCR) etait effectuee une a deux fois par semaine pendant le sejour en reanimation. L’infection a CMV etait definie par une RTqPCR positive en cours de sejour. La reactivation du CMV etait definie par une RTqPCR positive chez un patient seropositif a l’admission. Resultats Au total, 58 patients etaient inclus. L’âge moyen des patients etait de 51 ± 21 ans. La SCB moyenne etait de 31 ± 15 %. La brulure etait d’origine thermique dans 89 % des cas. 36 patients etaient seropositifs pour le CMV a l’admission, 20 seronegatifs (64 % et 36 % respectivement). Une infection a CMV etait diagnostiquee chez 22 des patients seropositifs (61 %), et chez un seul des patients seronegatifs (5 %). L’infection a CMV etait plus frequente chez le patient seropositive que seronegatif (p

Background Hypothermia remains one of the major factors limiting surgery in extensively burned patients. We evaluated the effectiveness of an intravascular rewarming technique using CoolGard 3000™ system and Icy™ catheter to maintain normothermia during surgeries of severe burned patients and compared these findings to a historical control group. Methods This was a controlled non-randomised trial conducted between March 2008 and August 2009. Patients with burns greater than or equal to 40% of the total body surface area were included. Before the first burn excision, the Icy™ catheter was placed in the inferior vena cava via the femoral vein. Warming was then initiated and maintained until the bladder temperature reached over 37.5 °C. The bladder temperature was recorded every 30 min during surgery and for the first hour post-operatively and compared to a historical control group. Results We enrolled 4 patients and 11 surgeries in the CoolGard™ group and compared them to 3 patients and 10 surgeries in the historical cohort. All intraoperative bladder temperatures from T = 30 were statistically different in the two groups. In the CoolGard™ group, no patient became hypothermic and no surgery was aborted because the patient's temperature had rapidly fallen below the threshold temperature (35.5 °C). No device-related complication was reported. Conclusion The use of an intravenous warming catheter is a novel approach to maintain normothermia during surgery in burn victims and may be more effective than traditional methods.

Introduction La prise de poids due a une balance hydrique positive est frequente en reanimation. Celle-ci est un facteur de mauvais pronostic dans plusieurs pathologies tel que le syndrome de detresse respiratoire aigue [1] . En cas de traumatisme crânien grave (TCG), il semble exister, chez l’animal, une correlation entre la balance hydrique et la pression intracrânienne (PIC) [2] . Cependant, cette association est peu documentee dans la litterature chez l’humain. L’objectif de cette etude est donc d’evaluer l’impact de la prise de poids sur la PIC, l’oxygenation cerebrale et le pronostic fonctionnel en cas de TCG. Materiel et methodes Analyse retrospective d’une cohorte prospective observationnelle de tous les patients TCG admis en reanimation a l’HIA Sainte-Anne, Toulon, de janvier 2007 a decembre 2013. Les criteres d’exclusion ont ete les suivants : absence de pesee quotidienne, GCS minimal > 9 et deces dans les 48 premieres heures. Des analyses uni et multivariee par regression logistique ont ete utilisees pour determiner l’impact d’une prise de poids > 5 % sur la PIC, l’oxygenation cerebrale mesuree par la PtiO2 et le pronostic fonctionnel a 1 an. Resultats Durant la periode d’etude, 243 patients TCG ont ete admis en reanimation. Au final, 115 patients ont ete inclus : 62 dans le groupe prise de poids 5 %. Les patients dans le groupe > 5 % etaient caracterises par un score ISS superieur (24 [16–36] vs 16 [12–29], p = 0,01) ainsi que par une incidence accrue de pneumopathie precoce (64 vs 38 %, p = 0,004). La classification TCDB ne variait significativement pas entre les groupes : 3 [2–5] vs 2 [2–5], p = NS. On denombrait plus de patients presentant un ou plusieurs episodes d’hypertension intracrânienne (HTIC) dans le groupe > 5 % : 66 vs 25 %, p 5 % : 23,5 [17,7–30,7] vs 27,6 [20,4–37,3] mmHg, p 5 % : respectivement 15 [10–21] vs 4 [2–9] jours (p 5 % : 4 [1–5] vs 5 [3–5] (p = 0,019). Une prise de poids > 5 % etait un facteur de risque independant d’HTIC durant le sejour (OR = 4,4 [1,3–15,5], p = 0,021) ainsi que de mauvais pronostic fonctionnel defini comme un GOS a 1 an entre 1 et 3 (OR = 3,7 [1,1–12,5], p = 0,039). Discussion Une prise de poids, meme moderee (5 %), chez le patient TCG a donc un impact non negligeable tant sur le deroule de l’hospitalisation et les moyens therapeutiques engages que sur le pronostic fonctionnel ulterieur. Un controle strict du poids semble donc necessaire chez ce type de patient.

Introduction Une dissection traumatique des arteres cervicales (DTAC) concerne environ 1 % des patients traumatises severes [1] . Un traitement anticoagulant ou antiagregant est recommande en phase aigue afin de prevenir la survenue ou la recidive d’accidents ischemiques [2] . Cette therapeutique ne peut etre envisagee en cas de traumatisme crânien grave (TCG) associe en raison du risque d’aggravation des lesions hemorragiques [3] . Le clinicien doit donc mettre en balance un risque ischemique avec un risque hemorragique. Cependant l’association entre DTAC et TCG est mal documentee dans la litterature. L’objectif de cette etude est de determiner l’incidence et les facteurs de risque de DTAC chez les patients TCG. Materiel et methodes Etude prospective observationnelle, realisee entre janvier 2007 et decembre 2013 a l’HIA Sainte-Anne, Toulon. Tous les patients TCG admis en reanimation ont ete inclus. Les criteres d’exclusion ont ete : GCS minimal > 9, traumatisme penetrant et/ou absence d’angioscanner avec analyse des vaisseaux du cou dans les 24 heures. Les caracteristiques des patients, les resultats d’imagerie et l’evolution ont ete recueillis. Une analyse multivariee par regression logistique a ete realisee afin de determiner les facteurs de risque de DTAC chez le patient TCG. Resultats Durant la periode de l’etude, 243 patients ont ete inclus. 15 ont ete exclus (1 absence d’angioscanner, 5 traumatismes penetrants et 9 GCS > 9). L’incidence des DTAC a ete de 8,8 % [7,9–9,6] ( n = 20). Les patients avec une DTAC ont presente le plus souvent un AVP 2 roues (55 vs 28 %, p = 0,01), a haute velocite (80 vs 49 %, p = 0,008), un GCS prehospitalier inferieur (4 [3–6] vs 7 [4–9], p = 0,006) ainsi qu’un score ISS superieur (40 [28–52] vs 22 [16–32], p p = 0,021), un trait de refend dans le canal carotidien (30 vs 5 %, p p p p Tableau 1 . Quinze patients DTAC (75 %) ont ete decoagules a partir de j1,5 [1–2,75]. On notait 3 complications ischemiques (15 %) et aucune aggravation des lesions hematiques initiales. L’evolution dans les 2 groupes etait similaire (incidence d’HTIC (50 vs 43 %, p = NS), duree de sejour en reanimation (11 vs 9 jours, p = NS) et deces (30 vs 26 %, p = NS). Le GOS median a 1 an etait comparable (4 vs 5, p = 0,75) Discussion L’incidence des DTAC est importante en cas de TCG (environ 9 %). Les principaux facteurs de risque sont un trait de refend dans le canal carotidien, un traumatisme cervical, thoracique ou hepatique. Une anticoagulation efficace semble pouvoir etre debutee precocement sans augmentation du risque hemorragique.

Le baclofene est un medicament utilise dans le traitement de la spasticite musculaire. Son utilisation a ete elargie depuis 2008 hors AMM dans le traitement des addictions, a l’ethanol principalement [1,2]. Les doses potentiellement utilisables sont nettement superieures a celles utilisees dans le traitement de la spasticite. Le surdosage d’un traitement par baclofene peut engager le pronostic vital, et ce risque s’accroit avec l’elargissement de son utilisation. Nous rapportons un cas d’intoxication par le baclofene survenu chez un patient ethylique et insuffisant renal.

Introduction La coagulopathie traumatique, frequente et grave, doit etre rapidement corrigee. Pour les patients les plus graves, le respect du ratio plasma/CGR de 1/1 a 1/2 est retarde en raison du delai incompressible de decongelation du Plasma Frais Congele (PFC). Le PLYO est obtenu par lyophilisation de plasmas deleucocytes, traites par Amotosalen, provenant de 10 donneurs differents au maximum. Son usage est encadre par l’ANSM, notamment lorsqu’il est necessaire de « pouvoir transfuser sans delai du plasma therapeutique ». Reconstitue en moins de 5 min, un PLYO delivre 210 mL de plasma humain utilisable quel que soit le groupe du receveur. Ainsi, lorsqu’elle est necessaire, l’administration de PLYO est rapide. L’objectif principal de cette etude est d’evaluer le delai entre l’entree du patient en SAUV et le debut d’administration de PLYO chez des traumatises graves instables. L’objectif secondaire est d’evaluer la pertinence de son administration. Materiel et methodes Il s’agit d’une etude retrospective monocentrique sur 12 mois concernant les patients traumatises graves (> 1 critere de Vittel) ayant recu du PLYO en SAUV. Pour chaque accueil de patient traumatise grave, 2 PLYO et 2 CGR O negatif sont a disposition en SAUV et utilisables sur decision du « trauma leader ». Les regles habituelles d’hemovigilance sont completees par le remplissage systematique d’une fiche specifique clinico-biologique standardisee. Ces donnees ont ete obtenues a partir du registre de traumatologie de l’etablissement. L’horodatage exact a ete rendu possible par l’analyse video de l’accueil des traumatises graves en SAUV. Resultats Sur 236 patients accueillis en filiere « traumatise grave », 17 patients (7,2 %) ont recu du PLYO : 2 PLYO (16 patients) et 1 PLYO (1 patient). Le delai moyen de debut d’administration a ete de 21 ± 4 min apres l’entree en SAUV. Dans 88 % des cas, ce produit a ete utilise dans le cadre d’une coagulopathie confirmee secondairement par la biologie. Au cours des 24 premieres heures, une transfusion moyenne de 5,8 ± 5,1 CGR et de 3 ± 0,7 PFC a ete necessaire. Cinq patients (29 %) sont decedes au cours des 24 premieres heures. L’ISS moyen etait de 37 ± 15. Il n’a ete rapporte aucun effet indesirable secondaire a la transfusion de PLYO ( Fig. 1 ). Discussion L’utilisation de PLYO permet d’administrer du plasma moins de 25 min apres l’admission en SAUV. Elle est associee a la transfusion en Urgence Vitale Immediate de Concentres de Globules Rouges O negatif. Cette precocite d’administration permet d’optimiser la prise en charge de la coagulopathie traumatique. Le PLYO a certainement une place dans la prise en charge hospitaliere initiale des blesses les plus graves. Ses indications exactes doivent etre mieux precisees et integrees dans un protocole local de transfusion massive et eventuellement guidees par la biologie delocalisee.