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Resume Malgre une amelioration des techniques de monitorage hemodynamique, les signes cliniques restent les indicateurs habituels dans la decision d’un remplissage vasculaire au cours de l’insuffisance circulatoire aigue, ainsi que dans l’evaluation de l’efficacite therapeutique. Ils ont l’avantage d’etre immediatement et facilement accessibles. La baisse du volume circulant entraine immediatement une reaction sympathoexcitatrice et une modification complexe des debits regionaux qui conditionne l’heterogeneite de la reaction clinique. La sedation est un element cle qui modifie la reactivite de l’organisme a la baisse du volume circulant. Pris isolement, les signes cliniques manquent de sensibilite et de specificite en raison d’influences multifactorielles independantes du volume circulant. Les circonstances de survenue et l’anamnese sont donc des donnees fondamentales pour decider du remplissage vasculaire. Les manœuvres posturales, en particulier le lever de jambes passif, ameliorent la sensibilite des signes cliniques statiques. Chez le malade ventile, des indices predictifs de l’efficacite du remplissage vasculaire, issus de la courbe de plethysmographie et de l’EtCO2, peuvent etre obtenus rapidement avec le materiel de monitorage non invasif habituel. En replacant les signes cliniques dans leur contexte circonstanciel et en les associant, on peut obtenir un faisceau d’argument, permettant d’indiquer precocement le remplissage vasculaire en attendant un monitorage plus sophistique pour affiner secondairement la therapeutique.

Resume Objectif. – Evaluation preliminaire d'un thromboelastometre rotatif (Rotem™) dans le monitorage extemporane de l'hemostase en reanimation. Type d'etude. – Prospective, ouverte. Patients et methodes. – L'appareil : le Rotem™ est un thromboelastometre rotatif qui mesure en continu et retranscrit numeriquement les proprietes viscoelastiques d'un caillot en formation apres activation in vitro de l'hemostase. Une double analyse a ete effectuee chez 83 patients porteurs de troubles de l'hemostase, pour lesquels 122 prelevements extemporanes par Rotem™ et au laboratoire pour les parametres usuels (TCA, TP, Fibrinogene, plaquettes). Vitesse de manipulation et delai des resultats du Rotem™ ont ete etudies. Une analyse comparative des parametres et diagnostics obtenus selon chaque methode a ete effectuee. Resultats. – La duree moyenne de manipulation du Rotem™ etait de 2 minutes 51 secondes ± 1 minute 48 secondes et le delai d'obtention des resultats de 13 ± 6 minutes. La comparaison entre parametres a montre que la concentration en fibrinogene etait bien correlee (coefficient de Pearson r > 0,7) avec la vitesse de coagulation (angle α) et la fermete du caillot (MCF), le nombre de plaquettes etait bien correle avec le MCF. Le TP et le TCA avaient une correlation mediocre avec les parametres Rotem™ (r ≤ 0,53). La concordance diagnostique etait bonne entre les deux techniques avec un coefficient κ pondere mesure a 0,68. Le profil d'hypocoagulabilite au Rotem™ etait associe au meme diagnostic sur les parametres usuels du laboratoire dans 92 % des cas. Le profil d'hypercoagulabilite etait associe a des valeurs supranormales au laboratoire dans 78 % des cas. Un profil normal au Rotem™ etait associe a des parametres de laboratoire normaux dans 49 % des cas. Differents reactifs utilises sur plusieurs tests simultanes ont permis d'affiner le diagnostic thromboelastographique. Un algorithme d'utilisation du Rotem™ a montre son interet predictif des anomalies retrouvees au laboratoire. Conclusion. – Le Rotem™ est un dispositif de manipulation facile dont les diagnostics rapides et concordants par rapport a la biologie classique le rendent utilisable dans l'urgence hemorragique. Il permet aussi d'approcher les etats d'hypercoagulabilite pour lesquels l'implication therapeutique reste a determiner. Le Rotem™ offre une approche dynamique multifactorielle sur sang total de l'hemostase qui en fait un outil de choix du monitorage de l'hemostase en complement du bilan analytique classique.

Resume Les lesions cervicales post-traumatiques ont une frequence variable en fonction de la violence du traumatisme (3 a 30 %) et augmentent avec l’âge. Les signes cliniques sont souvent trompeurs ce qui justifie un large recours a l’imagerie radiologique. Une strategie fondee sur la clinique, les circonstances traumatiques et l’âge doit permettre un choix raisonne de l’imagerie, stratifie en fonction du risque de lesion traumatique du rachis cervical. Un patient, conscient, sans intoxication, sans signe neurologique focal, sans autre lesion associee et sans cervicalgie spontanee ou provoquee par la palpation des apophyses epineuses ne justifie pas d’examen radiologique. Dans les autres cas, l’imagerie est indispensable et le choix existe entre des radiographies standards et une tomodensitometrie helicoidale. La tomodensitometrie a une meilleure sensibilite que les cliches standards dans la detection des fractures et des luxations cervicales. Elle permet de preciser les lesions constatees sur les cliches standards ou explorer les zones difficiles d’acces (charnieres). Elle est utile en premiere intention chez les patients dont le risque de lesion cervicale est eleve : patient traumatise inconscient, polytraumatises, traumatisme crânien severe, troubles neurologiques focaux, traumatisme a cinetique elevee, âge superieur a 50 ans. L’IRM est un examen de 2e intention, justifie en cas d’irritation medullaire a TDM normale et en cas de doute sur lesion discoligamentaire ou vasculaire. L’instabilite ligamentaire est depistee par des cliches dynamiques, a distance du traumatisme.

Resume La prise en charge initiale du patient polytraumatise est axee sur le depistage et le traitement precoce d’une hemorragie et de ses consequences. Il n’y a pas de place pour l’improvisation et l’experience de l’equipe a une incidence pronostique. La concentration des moyens dans des structures specialisees (trauma centers) repond a cette qualite de prestation mais leur eloignement potentiel du lieu initial de l’accident, dans une pathologie ou le facteur temps est essentiel, donne aux hopitaux de proximite un role determinant dans la prise en charge initiale. En effet, tout retard peut avoir une incidence pronostique pejorative immediate mais aussi retardee par le biais de l’hypoperfusion tissulaire : ceci justifie une reanimation symptomatique precoce des la phase prehospitaliere et une strategie chirurgicale initiale restrictive limitee au controle de l’hemorragie. Le catheterisme arteriel pour mesure continue de la pression arterielle est l’element central du monitorage. Un bilan radiologique initial simple au lit du malade permet de prendre des decisions therapeutiques urgentes adaptees ce qui lui confere une place de choix en amont du bilan exhaustif secondaire en radiologie. L’echocardiographie et le Doppler transcrânien sont des techniques non invasives prometteuses dans l’evaluation et le monitorage initial de ces malades.

Resume Nous rapportons une observation de symptomes neurologiques survenus au decours d'opacifications digestives iteratives par le sulfate de baryum pouvant evoquer une encephalopathie au baryum. Suspectee par la presence de baryum dans les liquides biologiques, l'intoxication systemique s'est produite en dehors de toute notion de brache intestinale ou vasculaire et pose le problame de la diffusion extraluminale de ce sel lourd administre per os, dans des conditions normales d'utilisation.

We report a case of fatal outcome poisoning by massive exposure to hydrogen sulfide of a sewer worker. This rare event was associated with a moderate intoxication of two members of the rescue team. The death was due to asystole and massive lung oedema. Autopsy analysis showed diffuse necrotic lesions in lungs. Hydrogen sulfide is a direct and systemic poison, produced by organic matter decomposition. The direct toxicity mechanism is still unclear. The systemic toxicity is due to an acute toxicity by oxygen depletion at cellular level. It is highly diffusable and potentially very dangerous. At low concentration, rotten egg smell must trigger hydrogen sulfide suspicion since at higher concentration it is undetectable, making intoxication possible. In case of acute intoxication, there is an almost instantaneous cardiovascular failure and a rapid death. Hydrogen sulfide exposure requires prevention measures and more specifically the use of respiratory equipment for members of the rescue team.

Objectives : We studied whether the Soccer World Cup Tournament in 1998 had an impact on the number of distress calls received by an emergency service. Methods: Time series analysis was used retrospectively to study the relative frequency of telephone calls to a French emergency dispatching center during the period of the World Cup. Results: Between 1 May 1997 and 15 August 1998 a total of 109,139 calls were recorded. During the period of the World Cup (10 June–12 July 1998) there was an overall decrease in rescue requests, distress calls, treatments in a mobile intensive care unit, and ambulance runs. There was no significant decrease during the French team matches except that between France and Italy. Discussion: Rescue requests vary with the occurrence of public events. The decline which we discovered affected not the period of specific matches but the duration of the entire tournament. These results raise the question of the specificity of distress calls to an emergency dispatching center that receives not only medical requests but also general questions concerning illnesses.

We describe an original method to block the lateral cutaneous rami of the subcostal and iliohypogastric nerves or'iliac crest point block'to complete plexular block of the lower limb for hip surgery. The local anaesthetic is injected in front of an osterofibrous orifice of the iliac crest. In nine cases out of ten, the lateral cutaneous rami of the iliohypogastric nerve pass through this orifice and in one case out of ten, it is the one arising from the subcostal nerve. This complementary block allows the surgical incision at the level of the great trochanter.

We report a case of fatal outcome poisoning by massive exposure to hydrogen sulfide of a sewer worker. This rare event was associated with a moderate intoxication of two members of the rescue team. The death was due to asystole and massive lung oedema. Autopsy analysis showed diffuse necrotic lesions in lungs. Hydrogen sulfide is a direct and systemic poison, produced by organic matter decomposition. The direct toxicity mechanism is still unclear. The systemic toxicity is due to an acute toxicity by oxygen depletion at cellular level. It is highly diffusable and potentially very dangerous. At low concentration, rotten egg smell must trigger hydrogen sulfide suspicion since at higher concentration it is undetectable, making intoxication possible. In case of acute intoxication, there is an almost instantaneous cardiovascular failure and a rapid death. Hydrogen sulfide exposure requires prevention measures and more specifically the use of respiratory equipment for members of the rescue team.

Preliminary assessment of a rotary thromboelastometer (Rotem) in the haemostasis monitoring in ICU.Prospective, open.The device: the Rotem is a rotary thromboelastometer, which measures continuously and retranscribes numerically viscoelastic properties of a clot after an in vitro haemostasis activation. 83 patients with various haemostasis disorders that 122 blood samples have been subjected to a double analysis: extemporaneous by Rotem and at the laboratory for conventional haemostasis tests (aPTT, PT, fibrinogen, platelets). We assessed Rotem's manipulation duration, time for the first results. We compared Rotem variables with conventional haemostasis parameters and haemostasis diagnosis with each method.Mean Rotem manipulation duration was measured at 2 minutes 51 seconds+/-1 minute 48 seconds and time for results at 13+/-6 minutes. Plasma fibrinogen level was strongly correlated with the kinetic of clot formation (CFT) and the maximun clot firmness (MCF) measured by Rotem (R0.7, coefficient of Pearson). Platelets were strongly correlated with MCF. The PT and aPTT had a weak correlation with Rotem parameters (Ror =0.53). The diagnosis concordance between the two techniques was good with a pondered kappa coefficient measured at 0.68. Hypocoagulability thromboelastographic profile with Rotem was in agreement with conventional parameters diagnosis in 92 percent of cases. Hypercoagulability thromboelastographic profile was associated with a significant increase of conventional parameters (supranormal value in 78%). Normal thromboelastography profile was associated with normal conventional parameters in 49%. Different reagents used on several simultaneous tests specified the thromboelastographic diagnosis. A diagnostic algorithm showed the interest of the Rotem for the prediction of conventional test results.Rotem is an easy manipulation device whose concordant and rapid results allow its emergency use in the framework of haemorrhagic situations. It also allows an approach of hypercoagulability states so that the therapeutic implication remains to evaluate. The Rotem offers a dynamic multifactorial approach on total blood of haemostasis that is what makes it a prime aid of haemostasis monitoring, in complement of usual analytic haemostasis evaluation.

Objective. To determine the visiting policies of French intensive care units. Design and setting. Descriptive study in intensive care units. Methods. A questionnaire on their official visiting policies was sent to 200 French ICUs. Results. Ninety-five ICUs completed the questionnaire (47.5%). Ninety-two (97%) ICUs reported restricted visiting-hour policies, allowing visits at only one or several preassigned times. Mean total daily visiting time was 168 min (range 30–370). The number of visitors was restricted in 90 ICUs (95%). The type of visitors (immediate relatives only) was restricted in 57 (60%). Visiting was forbidden for children in 10 (11%), and 41 (44%) fixed an age limit for visiting. A gowning procedure was imposed on visitors in 78 (82%). Eighteen (19%) ICUs had no waiting room available, 35 (37%) used a special room for providing families with information in addition to the waiting room, 61 (64%) provided an information leaflet. A structured first meeting was organized in 68 (71%). A last structured family meeting at the ICU discharge was provided in 6 (6%). Conclusions. Responding ICUs provide homogeneously restrictive visiting policies concerning visiting hours, number and type of visitors. However, family reception cannot be reduced to some quantitative factors and depends on multiple other parameters such as the organization of family meetings and the use of an information leaflet. These results should be an interesting starting point to observe any change in mentalities and practices in the future.

We report a case with neurologic symptoms which occurred after iterative radiologic examinations of the gastrointestinal tract with barium sulphate, which were related to a barium encephalopathy. Suspected by the presence of barium in the blood, a systematic intoxication was occurred without any evidence for a gut or a vascular leak. This case raises the question about a possible extraluminal diffusion of such a heavy metal, given orally, in normal conditions of use.

We describe an original method to block the lateral cutaneous rami of the subcostal and iliohypogastric nerves or'iliac crest point block'to complete plexular block of the lower limb for hip surgery. The local anaesthetic is injected in front of an osterofibrous orifice of the iliac crest. In nine cases out of ten, the lateral cutaneous rami of the iliohypogastric nerve pass through this orifice and in one case out of ten, it is the one arising from the subcostal nerve. This complementary block allows the surgical incision at the level of the great trochanter.