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La sindrome coronarica acuta (SCA) e costituita dalle manifestazioni cliniche, elettrocardiografiche e laboratoristiche associate alla rottura di una placca di ateroma che ha indotto la formazione di un trombo che limita il flusso sanguigno nella rete arteriosa coronarica. Le SCA sono classificate in SCA con elevazione (o sopraslivellamento) del segmento ST (SCA ST+) e in SCA senza elevazione del segmento ST (SCA non ST+). Nelle SCA ST+, il trombo e costituito soprattutto da fibrina, che induce un’occlusione coronarica acuta e totale, responsabile di una necrosi completa del tessuto miocardico entro 6 ore, mentre, nelle SCA non ST+, esso e piuttosto di tipo piastrinico e non ostruisce completamente il lume arterioso. Il dolore toracico e il segno di allarme piu comune. Il fattore tempo e l’elemento chiave nella gestione delle SCA. Il ruolo dei servizi di aiuto medico di urgenza (SAMU) e dei servizi mobili di urgenza e di rianimazione (SMUR)-centro 15 e essenziale e permette una presa in carico tempestiva. L’elettrocardiogramma a 18 derivazioni (6 derivazioni standard e 12 derivazioni precordiali V1-V9 e V3r, V4r, VE) e l’esame da realizzare prioritariamente. Esso permette di distinguere le SCA ST+ dalle SCA non ST+. Quale che sia il tipo di SCA, il trattamento comporta l’assunzione di aspirina, di clopidogrel e di eparina, un’ansiolisi e un trattamento antalgico. Nelle SCA non ST+, la valutazione degli indicatori laboratoristici di sofferenza miocardica (troponina) puo permettere un orientamento diagnostico e terapeutico gia nella fase preospedaliera. L’apporto recente di nuove e potenti molecole antiaggreganti piastriniche e anticoagulanti ha modificato le strategie decisionali e la gestione delle SCA nel preospedaliero, per assicurare una riperfusione ottimale e con la migliore tempistica.

Background Out-of-hospital cardiac arrest (OHCA) is a major public health concern in France, given that there are 61.5 cases per 100,000 inhabitants a year. The impact of bystander action, performed before the arrival of emergency medical services (EMS), on survival has never been studied in France. Purpose Determine whether bystander cardiopulmonary resuscitation (CPR), performed before the arrival of EMS, was correlated with an increased 30-day survival rate after an OHCA. Methods 24,885 out-of-hospital cardiac arrests witnessed in France from 1 January 2012 to 1 May 2018 were analysed to determine whether CPR, performed before the arrival of EMS, was correlated with survival. Data from the Electronic Registry of Cardiac Arrests was used. The association between the effect of CPR performed before the arrival of EMS and 30-day survival rate was studied, using propensity analysis (which included variables such as age and sex of the patient, location, cause, and year of cardiac arrest, initial cardiac rhythm, EMS response time and no-flow time). Results CPR was performed before the arrival of EMS in 14,904 cases (59.9%) and was not performed in 9,981 cases (40.1%). The 30-day survival rate was 10.2% when CRP was performed by bystanders versus 3.9% when CRP was not performed before the EMS arrival (p The effect of bystander CPR on survival Conclusion Bystander CPR performed before the arrival of EMS was associated with an increased 30-day survival rate after an out-of-hospital cardiac arrest in France.

Paraquat poisoning has almost disappeared from metropolitan France following its ban from the European market ten years ago. However, due to neighboring countries still authorizing paraquat use, French Guyana seems in a different situation. Here we aimed to report a series of paraquat-poisoned patients admitted to the emergency department of the Western French Guyana Hospital in Saint-Laurent du Maroni, to raise awareness of national health authorities on this persistent major issue.We conducted a retrospective observational study describing the clinical features, the prognostic factors and the final outcome of paraquat-poisoned patients admitted to the emergency department between January 2008 and August 2014.Twenty-six paraquat-poisoned patients were included in the study. The median estimated paraquat dose intentionally ingested was 105 mg/kg (interquartile range, IQR: 359). Eighteen patients were treated with the cyclophosphamide/dexamethasone combination and seventeen with N-acetylcysteine in addition to the usual supportive care. Six patients survived and twenty died within a median 36h delay after admission (IQR: 130). Death was associated with cardiovascular (65%) and respiratory (35%) failure. Based on a bivariate analysis, predictive factors of death included (p≤0.05): advanced age, higher ingested paraquat dose, altered renal function, hypokalemia, acidosis, and dark blue dithionite test, observed on hospital admission.Paraquat poisoning still persists in French Guyana despite its withdrawal from the market. It is possible to determine the probability of death on patient admission based on routine clinical and biological parameters. There is an urgent need to request neighboring countries to ban paraquat with the aim of eradicating this dramatically life-threatening poisoning.

Detection of microorganisms by blood cultures (BCs) is essential in managing patients with bacteraemia. Rather than the number of punctures, the volume of blood drawn is considered paramount in efficient and reliable detection of microorganisms. We performed a 1-year prospective multicentre study in adult emergency departments of three French university hospitals comparing two methods for BCs: a unique blood culture (UBC) collecting a large volume of blood (40 mL) and the standard method of multiple blood cultures (MBC). The performances of both methods for bacterial contamination and efficient microbial detection were compared, each patient serving as his own control. Amongst the 2314 patients included, three hundred were positive for pathogens (n = 245) or contaminants (n = 55). Out of the 245 patients, 11 were positive for pathogens by UBC but negative by MBC and seven negative by UBC but positive by MBC (p 0.480). In the subgroup of 137 patients with only two BCs, UBC was superior to MBC (p 0.044). Seven and 17 patients had contaminated BCs by UBC and MBC only, respectively (p 0.062). Considering the sums of pathogens missed and contaminants, UBC significantly outperformed MBC (p 0.045). Considering the complete picture of cost savings, efficient detection of microorganisms and decrease in contaminations, UBC offers an interesting alternative to MBC.

Objectifs Cette etude a ete realisee afin d’evaluer l’effet antalgique de la neurocryostimulation (NCS) sur les douleurs post-traumatiques en medecine d’urgence. Methodes: Cette etude prospective s’est deroulee durant 12 jours dans un service d’urgence. Tous les patients âges de plus de 12 ans se presentant aux urgences avec une douleur post-traumatique evoluant depuis moins de 24 heures etaient inclus. Apres une appreciation de l’intensite de leur douleur lors de l’admission (t0) par une echelle visuelle analogique (EVA, score de 0 a 100), ces derniers ont beneficie directement d’une seance de NCS. L’intensite de la douleur a ete reevaluee a l’issue de cette cryotherapie (t1) puis a la sortie des urgences (t2).

RésuméLa prise en charge en urgence de patients présentant un syndrome coronaire aigu (SCA) repose sur un diagnostic clinique et électrocardiographique précis. La stratification initiale du risque est l’étape clé. L’orientation, ultime étape, dépend du degré de l’urgence et de la stratégie de reperfusion envisagée dès la phase pré-hospitalière. La prise en charge d’un patient présentant un SCA nécessite donc une collaboration étroite entre les médecins de l’urgence et les cardiologues selon des protocoles pour un accès facilité au cathétérisme si nécessaire.Les défis de la prise en charge des SCA en pré-hospitalier reposent sur plusieurs facteurs:a)la « maîtrise » par l’urgentiste de nouvelles molécules anti-agrégantes et anticoagulantes pour adapter leurs prescriptions au profil du patient;b)le développement de filières en fonction des spécificités régionales (considérations géographiques et répartition des centres interventionnels) de mutualisations entre les établissements, afin de réduire le temps d’accès aux salles de cathétérisme des patients à haut risque;c)l’organisation en réseau où le SAMU joue un rôle essentiel pour la coordination entre les différents acteurs médicaux;d)l’analyse en routine de l’évolution des pratiques professionnelles en corrélation avec les recommandations de la Haute Autorité de santé;e)et l’intégration de la médecine pré-hospitalière aux programmes de prévention en santé pour mieux décrypter les représentations de la maladie coronaire et encourager les patients et leurs proches à utiliser le « 15 ».SummaryRisk stratification in the prehospital setting is key in the emergency management of patients with acute coronary syndromes (ACS), based on clinical diagnosis and specific electrocardiographic criteria. The orientation is the ultimate stage of this decision support and depends on the degree of urgency and the strategy chosen. The management of ACS patients requires close collaboration between emergency physicians and cardiologists, using simplified protocols to facilitate access to catheterization if judged necessary. Multiple other challenges exist in the prehospital management of ACS:a)‘control’ by emergency physicians of new antiplatelet and anticoagulant molecules, adjusting their prescription to patient profiles;b)the development of clusters based on regional specifics (e.g. geographic considerations and distribution of percutaneous coronary intervention centers) to reduce delay to catheterization in high-risk patients;c)the network organization, where the SAMU is essential for coordination between different medical teams;d)the routine evaluation of evolving practices in terms of quality of care;e)and the integration of prehospital medicine into healthcare programs to better understand the manifestations of coronary artery disease and to encourage patients and their families to use the emergency medical system. The task faced by emergency physicians is to adopt strategies that more closely align to patients’ needs.

Objectif Evaluer les sentiments de 42 medecins juniors au moment de l’annonce de la mort et leurs difficultes selon le contexte (âge, causes et circonstances…).

Introduction Si les suicides font l’objet d’une statistique reguliere en France, les tentatives sont mal connues d’un point de vue epidemiologique.

Resume Le syndrome de Tako-tsubo ou ballonisation transitoire de l’apex du ventricule gauche (VG) est une entite de decouverte recente mimant un syndrome coronarien aigu (SCA) en l’absence de lesions coronaires significatives associees. Il concerne surtout les femmes âgees exposees a un stress intense. Sa physiopathologie precise est inconnue et son traitement reste empirique. Le pronostic est souvent favorable en dehors de complications aigues imprevisibles.

Le syndrome coronarien ou coronaire aigu (SCA) est constitue des manifestations cliniques, electrocardiographiques et biologiques liees a la rupture d’une plaque d’atherome ayant induit la formation d’un thrombus limitant le flux sanguin dans le reseau arteriel coronaire. Les SCA sont classes en SCA avec elevation (ou sus-decalage) du segment ST (SCA ST+) et en SCA sans elevation du segment ST (SCA non ST+). Dans les SCA ST+, le thrombus est constitue principalement de fibrine entrainant une occlusion coronaire aigue totale responsable d’une necrose complete du tissu myocardique dans les 6 heures, tandis que dans les SCA non ST+, il est plutot de type plaquettaire n’obstruant pas completement la lumiere arterielle. La douleur thoracique est le signe d’appel le plus courant. Le facteur temps est l’element cle dans la prise en charge des SCA. Le role des SAMU-SMUR-Centres 15 est essentiel, permettant une prise en charge rapide. L’electrocardiogramme 18 derivations (six derivations standards et 12 derivations precordiales V1-V9 et V3r, V4r, VE) est l’examen a realiser en toute priorite. Il permet de distinguer les SCA ST+ des SCA non ST+. Quel que soit le type de SCA, le traitement comporte la prise d’aspirine, de clopidogrel, d’heparine, une anxiolyse et un traitement antalgique. La strategie de reperfusion des SCA ST+ repose sur la thrombolyse prehospitaliere suivie d’une angioplastie si le delai douleur-traitement est inferieur a 3 heures. Au-dela, une angioplastie eventuellement facilitee par l’administration d’antiglycoproteine (anti-GP) IIbIIIa doit etre envisagee si elle est realisable dans un delai de 90 minutes. Dans les SCA non ST+, l’evaluation des marqueurs biologiques de souffrance myocardique (troponine) peut permettre une orientation diagnostique et therapeutique des la phase prehospitaliere. La fibrinolyse est clairement contre-indiquee. L’administration d’anti-GP-IIbIIIa peut etre envisagee chez les patients a haut risque qui vont beneficier d’une angioplastie.

La mortalidad de la sepsis grave (definida como una disfuncion o hipoperfusion organica inducida por una infeccion) y del shock septico (hipotension arterial refractaria a la reposicion liquida, asociada a la disfuncion o hipoperfusion organica) tratada en una unidad de reanimacion sigue siendo elevada (del orden del 45%), mientras que se espera un aumento de su incidencia en los proximos 25 anos (por el incremento de su deteccion). No obstante, se ha podido registrar recientemente una disminucion significativa de su mortalidad en varios ensayos terapeuticos aislados, basados en una monitorizacion dirigida hacia el tratamiento global de la oxigenacion tisular o que empleaba nuevas vias de tratamiento, que son sobre todo la utilizacion de corticoides en dosis moderadas, la modulacion de la activacion de la hemostasia por la proteina C activada y la aplicacion sistematica de referenciales de cuidados en la reanimacion. Al igual que en el infarto de miocardio, la combinacion de estas nuevas medidas terapeuticas debe realizarse en un ambito global de optimizacion precoz y rapida (6-24 horas). Este nuevo esquema de tratamiento deberia garantizar en el futuro una reduccion considerable de la mortalidad y de la morbilidad de la sepsis (reduccion esperada del 25% durante los proximos 5-10 anos).

Objectives: To point out prognosis factors of local recurrence after endoscopic cordectomies for Tis, T1a, T1b, and T2 glottic squamous cell carcinomas. Study Design: A cohort of 110 patients treated from January 1990 to December 2000 at a single institution was retrospectively analyzed: 21 had Tis, 76 T1a, 7 T1b, and 6 T2 (mean follow-up 42 mo; range 1–160 mo). Methods: The depth and extension of the excision were graded according to the European Laryngological Society Classification. Univariate analysis was used to review the impact on disease-free survival of factors related to the host, the tumor, and the treatment. Results: According to the Kaplan-Meier method, the 5 year overall survival and the disease-free survival were 87% and 75%, respectively. The rates of cause-specific survival, ultimate local control with laser alone, and laryngeal preservation were 97%, 84%, and 90%, respectively. Univariate analysis by the log rank test revealed that vocal muscle infiltration (P = .001) and subglottic involvement (P = .02) have a significant impact on disease-free survival. Of the 22 patients with local recurrence (17 T1a, 1 T1b, and 4 T2), 9 were managed with total laryngectomy, 5 with partial laryngectomy, 4 with further laser cordectomy, 2 with radiotherapy, and 2 had no curative treatment. Conclusion: Transoral laser surgery for early glottic carcinoma is a valid alternative to radiotherapy and partial laryngectomy in terms of oncologic results. It offers low morbidity and excellent retreatment options in case of local failure. Careful patient selection for laser surgery is essential to secure good results.

Intoxication, by cyanurate and its chlorated derivatives in children, is increasingly reported in the literature due to accidental ingestion compared to accidental inhalation. We report a case in a 5-year-old child who presented with acute lung injury due to accidental inhalation of gas formed after a reaction of sodium dichloroisocyanurate tablets with water. Prevention remains the best way to reduce the risk of children being intoxicated by inhalation of the gas formed after contact of tablets with water.

Resume Nous rapportons l’observation d’un homme de 64 ans hospitalise pour prise en charge d’une epistaxis droite recidivante. Le bilan standard d’hemostase (TP, TCA, numeration plaquettaire) retrouvait un allongement isole du TCA a 105 s pour un temoin a 33 s. Le patient ne presentait pas d’histoire hemorragique anterieure. Le bilan d’hemostase complet avec etude des facteurs de coagulation montrait un facteur VIII effondre a 5 %, ainsi que la presence d’un auto-anticorps dirige contre le facteur VIII dose a 4,5 unites Bethesda·mL –1 . Le bilan etiologique retrouvait une infection pulmonaire a Chlamydia pneumoniae . Le traitement comportait deux volets : a) le controle de l’hemorragie par mechages anterieurs (quatre au total) et par perfusion de facteur VIIa recombinant (NovoSeven ® ) ; b) l’eradication de l’auto-anticorps anti-FVIII par la mise en route d’une corticotherapie et d’une bi-antibiotherapie efficace sur Chlamydia pneumoniae . L’evolution a ete favorable avec d’une part tarissement de l’epistaxis et d’autre part normalisation du bilan d’hemostase, disparition de l’auto-anticorps et guerison de l’infection pulmonaire (disparition du syndrome inflammatoire biologique et de l’image pulmonaire en quelques semaines).

Septic shock is reported as the most common cause of death in intensive care units. Worldwide data indicate a 30 to 60% mortality rate. This death rate has not really changed since the early 1970s despite improved antibiotic therapy, cardiovascular support, and various advances in the management and treatment of sepsis. Septic shock pathophysiology may be related to several altered blood vessel functions associated or not with obvious anatomical injury. Normally, endothelial cells act as a signaling sensor for blood messages to vascular smooth muscle cells. They play a pivotal role in the regulation of local vascular tone. Endothelial injury due to systemic inflammation and induction of the coagulation cascade has been well recognized in the pathophysiology of septic shock. A better understanding of endothelial cell abnormalities occurring during septic shock might prove to be a good way to optimize septic shock therapy.

Resume Les auteurs rapportent l'observation d'un enfant de 22 mois, hospitalise pour un volumineux hematome du scalp survenu 72 heures apres une chute. Deux drainages ont ete pratiques a 48 heures d'intervalle en raison d'une recidive. Le patient, ne de parents consanguins, avait des antecedents d'hemorragies recidivantes depuis la naissance. Un bilan standard de l'hemostase comprenant taux de prothrombine, temps de cephaline active, temps de saignement, fibrinogene et plaquettes etait normal. Dans ce contexte, le dosage des facteurs de la coagulation a permis de mettre en evidence un deficit constitutionnel severe isole en facteur XIII (activite inferieure a 2 %). Un nouveau drainage a ete pratique sous couvert d'une injection de concentre de facteur XIII. Les suites operatoires ont ete simples. Un traitement prophylactique a ete propose, a raison d'une injection de 50 UI·kg −1 de concentre de facteur XIII toutes les 5 semaines.

Resume Un jeune homme de 21 ans, victime d'un accident du travail, a ete hospitalise pour fracture complexe non deplacee du tiers superieur du tibia droit, sans traumatisme crânien associe. Son etat hemodynamique etait stable. Une contention par plâtre cruropedieux a ete effectuee. Deux heures apres son admission, l'examen clinique mettait en evidence une obnubilation (score de Glasgow a 10) d'apparition brutale, sans signe de focalisation. Quatre heures apres l'admission, une aggravation des troubles de conscience (score de Glasgow a 7), accompagnee d'une crise convulsive hemicorporelle gauche, etait notee. La tomodensitometrie cerebrale initiale et la ponction lombaire etaient normales. La radiographie pulmonaire etait normale. Des petechies sur le tronc et l'abdomen etaient progressivement apparues. Une thrombopenie et un allongement du temps de prothrombine etaient notes. L'imagerie par resonance magnetique realisee a la 27 e heure montrait des hypersignaux en T2 au niveau du tronc cerebral et des noyaux gris centraux, evoquant une embolie graisseuse. Au fond d'œil, une hemorragie papillaire en flammeches a ete observee. Le diagnostic d'embolie graisseuse cerebrale a ete conforte par le lavage broncho-alveolaire mettant en evidence des inclusions lipidiques macrophagiques. L'interet de cette observation est de rappeler la possibilite de forme neurologique predominante d'embolie graisseuse et l'interet diagnostique de l'imagerie par resonance magnetique realisee precocement apres le traumatisme.

This review summarizes our current understanding of the neural circuit underlying the larval proleg withdrawal reflex (PWR) of Manduca sexta and describes how PWR function changes in two contexts: metamorphosis and learning. The first form of PWR plasticity occurs during the larval-pupal transformation, when the reflex is lost. One mechanism that contributes to this loss is the weakening of monosynaptic excitatory connection from proleg sensory neurons to proleg retractor motor neurons. This change is associated with the hormonally-mediated regression of proleg motor neuron dendrites, which may break synaptic contacts between the sensory and motor neurons. After pupation, some of the proleg motor neurons die in a segment-specific pattern that persists even after individual motor neurons are isolated from the nervous system and exposed to hormones in vitro. The second form of PWR plasticity involves short-term, activity-dependent changes in neural function during the larval stage. The nicotinic cholinergic connections from proleg sensory neurons to motor neurons exhibit several forms of plasticity including facilitation, depression, post-tetanic potentiation and two types of muscarinic modulation. Larval PWR behavior exhibits two simple forms of learning-habituation and dishabituation-which involve alterations in the central PWR circuit. These studies of a simple circuit illustrate neural mechanisms by which behaviors undergo both short- and long-term modifications.

Maxillo-facial traumas are frequent and most often occur in young patients. Naso-tracheal or orotracheal intubation may be contraindicated in case of combined occlusal fracture and nasal or ethmoido-nasal fracture. This study was carried out a clinical case of a patient treated at the Lille University Hospital for a maxillofacial trauma associating fracture of nose and maxilla. The purpose was to assess the reliability of submental intubation as an alternative to tracheotomy. Submental intubation is a reliable single and safe technique allowing an one-stage surgical treatment in case of complex association of fractures without using tracheotomy. Its use should be implemented on a larger scale.

Leptospirosis is an anthropozoonose, an animal disease transmissible to humans, caused by a spirochete of the genus Leptospira that lives mainly among rodents but also in wetlands. It occurs worldwide, particularly in Asia, Latin America and Africa. In Europe, the incidence is small (except in France and Great Britain, where its frequency has increased in recent years) but the frequency may be underestimated. Some areas overseas are particularly affected. In France, the potential epidemic of leptospirosis is subject to climatic variations, justifying a constant monitoring of the disease provided by the National Reference Centre (CNR) of leptospires. Transmission to humans primarily occurs through contact with environments contaminated by the urine of infected animals. The disease can affect the liver and kidneys (hepatonephritis) as cytolysis, cholestasis and renal failure associated with fever. A coagulopathy usually accompanies the clinical table. Its diagnosis is difficult because of the clinical polymorphism. Early diagnosis of leptospirosis allows effective medical care, improving patient outcomes. This is currently based on gene amplification (PCR) or serology positive by the microscopic agglutination test (MAT), which is the reference method. Its evolution is usually favorable with appropriate antibiotic treatment (aminopenicillin). However 5-10% of symptomatic patients have a severe multisystem defaillance. Nearly a century after the discovery of the causative agent, this zoonosis remains a public health problem, zoonosis priority in terms of virulence, its reporting is mandatory in our country. We report the case of a severe form of hepatonephritis due to water contaminated with Leptospira observed in Northern France.

Although transfusion practices have changed these last years, the neonatal period remains one period when the transfusion of blood components (in particular in red blood cells concentrates) is frequent, particularly for low birth weight premature babies. It is thus important to know well the pathophysiological characteristics specific to this age of life in order to reduce the risks of transfusion and to allow an optimal effectiveness of this treatment. Various studies on neonatal transfusion show that transfusion practices during the neonatal period are very heterogeneous from a team to another, and even within the same team. Therefore, we wanted to know the practices in France, by addressing a questionnaire to neonatology centres, in collaboration with the French Society Vigilance and Transfusion Therapy and the French Society of Neonatology (SFN). The results obtained confirm the heterogeneity of practices. To follow up on this study, we constituted a working group, in partnership with the SFN, the SFVTT and the EFS, with an aim of proposing good practice recommendations according to the methodology of the French "High Authority for Health", in order to homogenize at the national level transfusion practices of the new-born baby.

Le syndrome coronarien ou coronaire aigu (SCA) est constitue des manifestations cliniques, electrocardiographiques et biologiques liees a la rupture d’une plaque « vulnerable » d’atherome ayant induit la formation d’un thrombus limitant le flux sanguin dans le reseau arteriel coronaire [1,2] Merci de replacer ces appels de reference dans le texte. Les SCA sont classes en SCA avec elevation (ou sus-decalage) du segment ST (SCA ST+) et en SCA sans elevation du segment ST (SCA non ST+). Dans les SCA ST +, le thrombus est constitue principalement de fibrine entrainant une occlusion coronaire aigue totale responsable d’une necrose complete du tissu myocardique dans les six heures, tandis que dans les SCA non ST+, il est plutot de type plaquettaire n’obstruant pas completement la lumiere arterielle [3] Merci de replacer cet appel de reference dans le texte. La douleur thoracique est le signe d’appel le plus courant. Le facteur temps est l’element cle dans la prise en charge des SCA. Le role des Samu-Smur-Centre 15 est essentiel, permettant une prise en charge rapide. Quel que soit le type de SCA, le traitement comporte la prise d’aspirine, de clopidogrel ou de prasugrel, d’anticoagulant, une anxiolyse (si besoin) et un traitement antalgique. Dans les SCA non ST +, l’evaluation des marqueurs biologiques de souffrance myocardique (troponine) peut permettre une orientation diagnostique et therapeutique des la phase prehospitaliere. L’apport recent de nouvelles et puissantes molecules antiagregantes plaquettaires et anticoagulantes a modifie les strategies decisionnelles et de prise en charge des SCA en prehospitalier afin de garantir une reperfusion optimale et dans les meilleurs delais.

Au cours du sepsis severe, la presence d’elements membranaires bacteriens est responsable de l’activation et de la liberation de mediateurs de l’inflammation. Alors qu’une correlation entre la gravite de l’etat infectieux et l’activation de la coagulation est connue depuis plus de trente ans [1], l’interaction entre inflammation et coagulation a ete mise en evidence plus recemment. Plusieurs etudes ont demontre que le systeme de coagulation est active par les mediateurs inflammatoires, eux-memes actives par le systeme de coagulation [2]. L’endothelium est fortement implique dans ce processus [3]. Sous l’action d’une endotoxine, ses proprietes changent passant d’un etat normalement profibrinolytique et anticoagulant a un etat antifibrinolytique et procoagulant [2]. Le facteur tissulaire (FT) d’origine monocytaire et endotheliale est l’acteur principal du declenchement de la coagulation [4]. L’activation rapide et excessive de la coagulation est responsable de la formation de depots de fibrine dans la microcirculation, provoquant l’apparition de zones focales d’hypoperfusion, de necrose tissulaire et, au final, du developpement du syndrome de defaillance multiviscerale (SDMV) [5]. L’inhibiteur naturel du FT (tissue factor pathway inhibitor, TFPI) synthetise par l’endothelium, l’antithrombine (AT) et la proteine C (PC), elle-meme synthetisee par le foie et interagissant avec l’endothelium, jouent un role central dans la modulation de la coagulation.

The aim of this study was to evaluate for the interest of realistic mannequin-based simulations as a tool to assess the knowledge of emergency medicine physicians in the field of difficult tracheal intubation.Prospective.Emergency physicians.Twenty-four emergency physicians were invited entering the study. The first step of the study consisted of an initial assessment of their knowledge in the field of difficult tracheal intubation. Then theoretical lectures on the tools and techniques of difficult tracheal intubation were given, followed by standard mannequin-based driven workshops. The second step was conducted six weeks later. Each physician's knowledge was re-evaluated and their ability to manage two difficult airway scenarios simulated on the AirMan simulator (Laerdal was assessed.Only one physician could not complete the program. Half of them worked at the University Hospital (UH) with half of them for less than three years. Lectures and standard mannequin-based driven workshops significantly improved physician's theoretical knowledge. Practical performance during difficult airway management scenarios was poor.We have demonstrated that theoretical lectures and standard mannequin-based driven workshops improved overall theoretical knowledge but did not translated to practical skill during of realistic mannequin-based simulations. Realistic mannequin-based simulations teaching programs in the field of difficult tracheal intubation should be considered.

Chondronecrosis of the cricoid cartilage is a rare complication of intubation. The records of two children were reviewed. An 8-month-old girl with myelomonocytic leukaemia developed chondronecrosis 10 days after a 2-day period of ventilation. A 4-year-old girl comatose after poisoning by the histamine antagonist, alimemazine, developed chondronecrosis after a 2-day period of intubation. The complication was suspected when extubation led to dyspnoea owing to laryngeal stridor and was confirmed by direct laryngoscopy. We review the development of the condition, the causative factors, treatment and prevention.

Resume L'avulsion partielle du cornet moyen est une complication inhabituelle de l'intubation nasotracheale, alors que le traumatisme de la muqueuse nasale est plus frequent. Nous rapportons le cas d'une patiente de 25 ans, sans antecedent particulier, qui apres une intubation nasotracheale pour extractions dentaires, a presente une obstruction nasale unilaterale en rapport avec un arrachement du cornet moyen sur toute sa longueur, avec bascule en arriere bloquant la choane.

Acute myocardial infarction (AMI) is the prototype of a real emergency, and both efficacy and speed are necessary for effective management. The advent of thrombolysis therapy has transformed the care of these patients. In fact, the most frequent complication of AMI is sudden death which still occurs within the first hour after symptom onset. Thrombolytic therapy has been shown to reduce early and long term mortality about 20%. The mortality gain is dependent on the delay time of early reperfusion. A large number of studies have shown that this relationship is best described as exponential: in the first 1 to 2 hours after the onset of chest pain, the benefit of thrombolysis is greater. Reducing the time to thrombolysis must therefore be the main objective of prehospital treatment of AMI. In the last 10 years, a large number of strategies to reduce the time to reperfusion have been evaluated, including initiation of thrombolytic therapy prior to arrival to hospital. In France, prehospital emergency medicine is an integral part of the medical care system. The SAMU is a hospital department whose function is to centralize emergency medical calls and organise an appropriate response with the intention of ensuring the shortest delay between the initial call and the appropriate treatment. In the event of an emergency medical call concerning chest pain, the medical dispatcher of SAMU may decide to send a MICU (mobile intensive care unit). If a diagnosis of AMI is confirmed, clinical ECG criteria, prehospital thrombolysis is currently seen as the best treatment strategy. The SAMU experience has proven that prehospital thrombolysis is both safe and effective. During the last ten years to fifteen years the field of reperfusion during acute myocardial infarction was a real battlefield between the proponents of thrombolysis and those of primary percutaneous interventions. Nowadays there is a growing number of physicians who will consider that the best way forward is not to oppose these two effective methods but to find the most appropriate niche for each or even better to combine them to achieve reperfusion. In this respect, the concept of facilitated percutaneous intervention is a very attractive one which shows promising results. A large number of studies are now ongoing to demonstrate its efficacy and to help us to choosing the ideal combination of anti-thrombotic agents to be used. That is one of the main interests of the CAPTIM study. French trial comparing prehospital thrombolysis to primary angioplasty. There is no difference between the two strategies in term of primary end points. That could be the real life for acute myocardial infarction. We have to consider in this study the fact than 33% of the patients had a pre hospital thrombolysis followed by a fast angioplasty. The results are impressing: the 30 day mortality in the pre hospital thrombolysis arm is only 3.8%. But if the delay between pain to pre hospital thrombolysis is under 2 hours this 30 day mortality fall down to 2.2%. This is betterThan il all the recent trials published comparing on site thrombolysis to primary angioplasty (DANAM II, C Port, PRAGUE II). These good results in the CAPTIM study when the delay pain to treatment is less than 2 hours include also the occurrence of cardiogenic shock in favour of pre hospital thrombolysis (1.3%). The good strategy in a next future could be the association of pre hospital thrombolysis and angioplasty. In a recent French register (USIC 2000) including all the patients arriving in CICU during a month and regarding the one month mortality this strategy seems to be the best (3.6%). The arrival of TNK-tPA is now changing the general management of prehospital AMI by reducing the time to treatment. This is clearly now the new standard of prehospital treatment. The reduction of UHF dose is recommended and the LWMH is considered as the next step as recently demonstrated in the ASSENT 3 and 3+ trials. Several recent registries have shown than we offer reperfusion to only half of the patients and even more important, when we do not offer it, this is unjustified in nearly half of the cases and these patients , forgotten for reperfusion have all a very poor prognosis. The other major problem is that patients are treated too late mainly because the call the emergency system too late. The are several ways to improve the time to treatment : information of the patients , shortening of the intra-hospital delays by better organisation and finally and perhaps more importantly , pre hospital triage and treatment. The efficacy and safety of the pre hospital strategy is now recognised worldwide. The best strategy for acute myocardial infarction should involve emergency physicians and cardiologist in a real local task-force to join and coordinate their efforts. That is the way to open more arteries earlier, that is to say save myocardium and more lives.

To assess the perioperative evolution of the nutritional status of head and neck surgical patients.Prospective, descriptive case series.Fifty-four patients candidates for total or partial laryngectomy for malignancy of the neck tract without a past of neck surgery. The nutritional status of all patients hospitalized for total pharyngolaryngectomy, total or partial laryngectomy was assessed by 1) clinical parameters including weight (W), weight variation (WV, percentage of loss), Body Mass Index (BMI), triceps skin fold measurement (T), midarm circumference (M), and 2) biological parameters such as serum albumin (SA), transthyretin (TTR), lymphocytes (Ly). These parameters were noted at the time of diagnostic laryngoscopy (T1), the day before surgery (T2), and 10 days afterward (T3) when patients were authorized to eat normally. All patients had enteral nutrition (EN) support (35 kcal/kg/day) starting at D1 and for 10 days afterward. Only complete data per patient were analyzed.24 patients were excluded. During the 21 days [7-53] preoperative period (T1-T2), WV was (6.6% [-8,1-+20.0] [T2] vs. 4.7% [-12,9-+20.0] [T1], p0.05) without difference in T and M. In the postoperative period (T2-T3), all parameters worsened, except T, with: WV (8.2% [-8,1-+20.0] [T3], p0.05 vs T2), M (27.4 cm [20.0-37.0] [T3] vs 28.3 cm [20.5-39.0] [T2], p0.05) et TTR (0.21 mg/l [0.09-0.36] [T3] vs. 0.27 mg/l [0.08-0.45] [T2], p0.05). BMI was 22.9 [15.2-36.7] (T1) vs 22.9 [15.2-35.3] (T2), NS and 22.1 [15.0-34.9] (T3), p0.05 vs (T2).The nutritional status in malignancy head and neck surgical patients seems to be best assessed by loss weight. It worsened mainly during the postoperative period even if a well-conducted EN was performed as defined by the French consensus conference.

Remifentanil and alfentanil are opioids often used during direct laryngoscopy (DL). This prospective, randomized study compared these agents with respect to haemodynamic and Bispectral Index (BIS) responses, glottic visualization, and rapidity of recovery (spontaneous ventilation, eye opening) in DL without intubation.A total of 60 patients undergoing DL were randomized into two groups: remifentanil (R) and alfentanil (A). Anaesthesia was induced with propofol 2.5 mg kg(-1) and the opioid was administered 1 min later (R=2 microg kg(-1) or A=30 microg kg(-1) over 30 s). DL was commenced 1 min after (corresponding to 3 min after the beginning of induction). Glottic visualization, opioid and/or propofol re-injection, spontaneous ventilation recovery, and eye opening were recorded.During DL, mean arterial pressure (MAP) increased by 6% in the R group vs 20% in the A group (P0.05) when compared with post-induction values without affecting heart rate or BIS. No significant difference was observed between groups with respect to glottic exposure, opioid and/or propofol re-injection, and spontaneous ventilation recovery (mean (SEM) 3.8 (0.6) min, R group vs 3.2 (0.7) min, A group, NS) or eye opening (7.1 (1.1) min, R group vs 7.4 (0.9) min, A group, NS). Thirty minutes after postanaesthesia care unit (PACU) admission, MAP returned to its pre-induction value in the R group (104 (3) vs 109 (3) at baseline, NS), whereas in the A group MAP remained significantly lower at this time point (96 (4) vs 106 (3) at baseline, P0.05).This study showed that only remifentanil prevented MAP increase without adverse effects such as bradycardia during DL, and prevented MAP decrease 30 min after PACU admission.

In the United Kingdom, a recent analysis of an intensive care unit (ICU) database reported that surgical patients represented 45% of total ICU admissions with an important mortality rate since 20.1% of them died [1]. A surgical patient is considered at high risk if their preoperative status is altered or if the surgical procedure is prolonged and/or associated with heavy blood loss. Many attempts have been made to identify such patients early and to evaluate the impact of perioperative therapeutic optimization on outcome. In 1979, Shoemaker et al. [2] defined criteria for high surgical risk. These included: patient history: age more than 70 years with evidence of limited major physiologic function, previous severe cardiopulmonary or vascular illness, severe nutritional disorders critical factors: severe multiple trauma, massive acute blood loss, shock, septicemia or septic shock, respiratory failure, acute abdominal catastrophe, acute intestinal or renal failure surgical procedure factors: extensive surgery for cancer or prolonged surgery more than 8 hours.

We report the case of a 64-year-old man without hemorrhagic history experiencing epistaxis. The standard hemostasis assessment including prothrombin index, activated partial thromboplastin time (APTT) and platelet count found an isolated abnormal APTT (105 sec vs 33 sec). Therefore, coagulation factors were explored. An acquired factor VIII deficiency (5%) with anti-FVIII antibody (4.5 Bethesda unit.mL-1) was recognised. This anti-FVIII antibody was related to a Chlamydia pneumoniae pulmonary infection. Treatment consisted of: i) Four successive anterior packing and activated factor VII infusion (Novoseven); ii) steroids injection and bi-antibiotherapy. The time course of the epistaxis was favourable under treatment.

Septic shock develops when specific microbial components gain access to the circulation and are recognized by the immune system, generating exaggerated mediator and cytokine production. The main microbial components responsible for this recognition are lipopolysaccharide (LPS) in Gram-negative bacteria, or peptidoglycan and teichoic acid in Gram-positive bacteria. Microbial compounds display molecular pattern recognition receptors (PRR) — such as LPS receptors (Toll-like receptor [TLR]4 and CD 14) which are expressed constitutively on innate immune system cells (macrophages and dendritics cells) [1].

The vascular endothelium is a highly specialized tissue involved in modulating immune responses and vascular cell growth, and in regulating the level of hemostatic, inflammatory, and vasoactive agents in the blood (Table 1). Endothelial cells line vessels in every organ system and regulate the flow of nutrient substances, diverse biologically active molecules, and the blood cells themselves. This ‘gate-keeping’ role of the endothelium is effected through the presence of membrane-bound receptors for numerous molecules including proteins, lipid transporting particles, metabolites and hormones, as well as through specific junction proteins and receptors that govern cell-to-cell and cell-tomatrix interactions [1]. This feature explains why endothelium dysfunction and/or injury with subendothelium exposure facilitates leukocyte and platelet aggregation and aggravation of coagulopathy. Therefore, endothelial dysfunction and/or injury should favor impaired perfusion, tissue hypoxia and subsequent organ dysfunction.

Introduction – objectifs Le diagnostic des bacteriemies et le traitement des patients reposent sur le resultat d’hemocultures (HC). Le volume de sang preleve est considere comme essentiel pour la detection des microorganismes alors que la repetition des HC accroit les contaminations. Nous avons compare les performances d’une technique de ponction unique (PU) de 40 ml de sang et d’une technique de ponction multiple (PM). Materiels et methodes Une etude multicentrique, prospective, a ete menee en 2012 aux urgences adultes de 3 hopitaux universitaires francais. La PU recueillait 40 ml de sang repartis dans 2 paires de flacons numerotes [aerobie (FA1), anaerobie (FN1), FA2, FN2]. FA1 et FN1 etaient considerees comme la premiere paire d’HC de PM et suivies de 1 a 3 autres paires d’HC dans les 24 heures suivantes permettant ainsi que chaque patient soit son propre temoin pour les comparaisons. La performance de detection d’un microorganisme et le taux de contamination etaient compares pour les 2 techniques. Resultats Parmi 2 314 patients inclus, 300 patients ont ete positifs pour un pathogene (n = 245) ou un contaminant (n = 55). Un pathogene etait isole avec PU vs PM dans 97,4 % vs 95,5 % des cas. Parmi les 245 patients avec pathogene, 11 etaient positifs avec PU mais negatifs avec PM et 7 negatifs avec PU mais positifs avec PM (P = 0,480). La performance de PU vs PM chez les 137 patients ayant eu une PM avec seulement 2 ponctions etait superieure (10 vs 2 ; P = 0,044). Trente et une contaminations ont ete revelees par PU et PM, 7 uniquement par PU et 17 uniquement par PM (P = 0,062). Considerant la somme des pathogenes manques et des contaminants, la performance de PU est superieure a celle de PM (P = 0,043). Conclusion Dans la volonte d’ameliorer le diagnostic des bacteriemies et de diminuer les depenses induites par les contaminations, la PU offre une alternative interessante a la PM.

Larvae of the hawkmoth, Manduca sexta, exhibit a defensive proleg withdrawal reflex in which deflection of mechanosensory hairs on the proleg tip (the planta) evokes retraction of the proleg. A previous behavioral study showed that this reflex habituates in response to repeated planta hair deflection and exhibits several other defining features of habituation. In a semi-intact preparation consisting of a proleg and its associated segmental ganglion, repeated deflection of a planta hair or electrical stimulation of its sensory neuron causes a neural correlate of habituation, manifested as a decrease in the number of action potentials evoked in the proleg motor nerve. Monosynaptic connections from planta hair sensory neurons to the principal planta retractor motoneuron exhibit several forms of activity-dependent plasticity. In the present study we recorded intracellularly from this motoneuron during repetitive electrical stimulation of a planta hair sensory neuron. The number of action potentials evoked in the motoneuron decreased significantly, representing a neural correlate of habituation. The motoneuron's resting membrane potential, input resistance, and spike threshold measured before and after repetitive stimulation did not differ between the stimulated group and a control group. Furthermore, the amplitude of the monosynaptic excitatory postsynaptic potential, as well as the magnitude of paired-pulse facilitation, evoked in the motoneuron by the sensory neuron did not change after repetitive stimulation. These results suggest that depression at the sensorimotor synapse does not contribute to reflex habituation. Rather, other mechanisms in the ganglion of the stimulated segment, such as changes in polysynaptic reflex pathways, appear to be responsible.

Aim and Background The stroke network is organised around the Stroke Unit (SU) which is known to be effective to reduce mortality and handicap in all types of strokes. However, most of patients do not receive imaging in a timely manner, only 40% of patients admitted in a hospital with SU are hospitalised in this unit and less than 1% of patients are thrombolysed. The aim of our study was to evaluate the efficacy of the stroke network before the stroke unit for improving. Programme We conducted a prospective study during 2 months to evaluate the intra-hospital management of patients admitted for suspected stroke in emergency department (ED) before the SUof our University Hospital in terms of delay, imaging and orientation. We compared the length of stay in ED for patients admitted for suspected stroke and for patients hospitalised for other neurological reasons. Results 258 patients were admitted for suspected stroke. This diagnosis was confirmed in 225 patients, including 44 transient ischaemic attack, 155 ischaemic stroke, 26 hemorrhagic stroke; 13 patients received intravenous thrombolysis. 27% were admitted within 3 h after symptom onset, 8% between 3 and 4 h 30 and 20% awaked with stroke. The delay of admission was significantly shorter in patients with hemorrhagic stroke and in patients for whom the emergency telephone system have been used. Median delay for imaging was1 h 59 min in the all population and was 53 min for patients admitted within 3 h. Only 12% of patients received CT scan within 25 min of hospital admission. Two third of the patients were admitted in stroke unit. The mean length of stay at the ED was 25 min for thrombolysis patients, 5 h 20 for the others admitted in stroke unit and 5 h 57 for all the population hospitalised for stroke, which did not differ from the length of stay for the other neurological hospitalisations. Discussion The impact of the stroke network is proved by the high percentage of patients admitted in stroke unit and the shorter delay of management for patients who are thrombolysed. However, the benefit is not observed for all patients with stroke. Conclusion These data suggest areas for improvement in hospital-level stroke system of care which could increase patient access to stroke unit and therefore potentially reduce stroke related morbidity and mortality. It should be recommended for all patients admitted for stroke and not only for patients who can be thrombolysed. Objectif(s), Contexte Les autorites sanitaires francaises ont favorise la mise en place d9une filiere d9organisation des soins, structuree autour de l9unite neurovasculaire (UNV) dont le benefice est attendu quel que soit l9âge du patient, le type et la severite de l9AVC. Malgre cette organisation, l9acces rapide a l9imagerie est reserve a une minorite de patients, 40% des patients admis dans un etablissement avec UNV y sont admis et moins de 1% des patients victimes d9AVC sont actuellement thrombolyses. L9objectif de notre travail est d9analyser le fonctionnement de la filiere neurovasculaire (fNV) en amont de l9UNV afin de l9optimiser. Programme Nous avons mene une etude prospective sur une periode de 2 mois en analysant les modalites de prise en charge intra-hospistaliere (delais d9admission, acces a l9imagerie, duree de sejour, orientation) des patients admis pour AVC dans le SAU du CHU de Lille en amont de l9UNV. Nous avons compare, dans un deuxieme temps, le delai de sejour des patients admis pour AVC a celui des patients hospitalises pour un autre motif neurologique. Resultats 250 patients suspects d9AVC ont ete admis, ce diagnostic a ete retenu chez 225 d9entre eux. Il s9agissait de 44 accidents transitoires et 181 accidents constitues dont 155 d9origine ischemique ; parmi eux 13 ont ete thrombolyses. 27% des patients etaient admis dans les 3h ; 8% entre 3-4h30 et 20% avaient un AVC du reveil. Les delais d9admission sont plus courts chez les patients ayant beneficie d9une regulation et chez ceux dont l9accident est de nature hemorragique. Tous les patients ont eu un scanner cerebral dont le delai median de realisation etait de 1h59. Pour les patients admis dans les 3 heures le delai median etait de 53 minutes. Au total, seuls 12% des patients ont eu leur imagerie dans les 25 minutes apres leur admission conformement aux recommandations. Au terme de la prise en charge, 2 patients sur 3 ont ete admis en UNV. Le duree de sejour au SAU pour les patients admis en UNV etait de 5h20 apres exclusion des patients thrombolyses (pour qui le delai etait de 25 minutes), ce delai etait de 5h57 pour l9ensemble des admissions pour AVC, il ne differait pas significativement des autres motifs d9admission en neurologie. Discussion Il existe un effet filiere avec plus de 60% des patients admis en UNV et des delais plus courts pour les patients eligibles pour une thrombolyse. Cependant, ce benefice en termes de delai ne se repercute pas sur l9AVC « standard » dont les delais de prise en charge et de duree de sejour restent prolonges au SAU alors que les premieres heures de l9AVC sont decisives tant sur le plan physiopathologique que therapeutique. Conclusion Le developpement d9une prise en charge structuree des AVC doit maintenant s9etendre a tous les AVC et non pas aux seuls patients susceptibles de beneficier d9une thrombolyse.