Réanimation Urgences最新文献

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  - Pharmacology of methadone

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  - Specific antagonist

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  - Toxicity of methadone in adults

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  - Therapeutic use in children

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  - Methadone poisoning in children

Endotracheal reintubation for post-extubation acute respiratory distress is sometimes difficult due to the presence of laryngeal edema. In the present study, a report was made on two patients with post-extubation acute respiratory distress syndrome, whose clinical condition deteriorated even with optimal medical treatment. The onset of acute respiratory acidosis and the progressive loss of consciousness could have justified intubation and the use of mechanical ventilation. However, noninvasive bilevel nasal positive pressure ventilation was introduced, thereby avoiding a more aggressive therapeutic option: a rapid positive response was obtained in both cases.

A case of recurrent hemothorax following accidental puncture of a normal aorta has been recorded. The patient was admitted for chronic bronchitis with subsequent dyspnea, and edema in the left lower leg. After clinical investigation, treatment included pleural drainage, during which arterial bleeding occurred. CT scan showed the absence of any aneurysm, but it revealed an accidental puncture of the descending aorta, which was directly in contact with the thoracic wall and situated very posteriorly. To the authors' knowledge, this is the only report in the literature on an accidental puncture of a normal aorta. However, one case of aneurysmal descending thoracic aorta and accidental puncture has already been reported.

Experts designated by the Société de réanimation de langue française had to audit the 1988 French consensus about upper gastrointestinal bleeding in critically ill patients. In the last decades the incidence of this nosocomial complication has dramatically decreased. A high-risk population has to be defined. H2 antagonists and sucralfate seemed to be more effective than antacids and prostaglandins. Proton pump inhibitors and enteral nutrition could be alternative prophylaxis. The cost-effectiveness ratio wasn't completely defined but implantation of clinical guidelines may reduce costs and limit such treatment for high-risk patients.

The ventral seat belt in the rear seats of motor vehicles is supposed to protect the passenger who uses it. In this study, however, the case is examined of a seat belt-associated injury involving a teenager. The ‘two-point’ seat belt held the teenager in place during a head-on collision between two vehicles travelling at high speed, and prevented him from being thrown forwards by the impact; but although the safety belt saved his life, he almost lost it afterwards due to the severe abdomino-rachidian injuries that it caused. In conclusion, it has been observed that the standard ‘three-point’ seat belt has significantly reduced the morbidity and mortality rate connected with road accidents; however, the ‘two-point’ version used in the middle part of the back seat can cause serious injury in accidents that occur at high speed. It is recommended that after the appropriate safety tests have been carried out, the ‘two-point’ seat belt should be replaced by an officially approved ‘four-point’ version.

Workload in emergency departments is known to be heavy, and may lead to “burn out” of the medical staff. Although the quantitative factors have been much studied, very few studies on qualitative factors interfering with medical activities are available.

Method: From April to June 1998, eight physicians working in five emergency departments of the south-east of France answered a self-7-day activity evaluation. Quantity of workload, duration and nature of necessary and unjustified breaks were registered.

Results: During the 631 hours of activity, these eight seniors saw 3,961 patients (21.2% of the emergency departments patients, two patients/hour/senior). Time for clinical work was 70%, for administrative work 6.5%, for authorized breaks 16.7%, and for unexpected breaks 6.2%. Unexpected breaks (UB) were justified in 66% and unjustified in 34%, and happened every 132 minutes. They are due to a resident (20.8% of UB), a secretary (14.7% of UB), another patient (13% of UB), a nurse (12.1% of UB), commercial representatives (12.3% of UB), and other people (21% of UB). Medical directors (two physicians) had a heavier administrative workload, and were more frequently interrupted than other physicians (p < 0.01, and p < 0.05).

Conclusion: Qualitative factors should be considered as important as quantitative ones in the evaluation of emergency department physician's workload.

Botulism is a rare but paralyzing disease caused by a neurotoxin produced by the anaerobic, spore-forming Gram-positive bacterium. Clostridium botulinum. Temperatures of over 120° C are required to kill the spores, while a one-minute exposure to 85° C is sufficient to inactivate the toxin. Although in most cases botulism is caused by eating contaminated food, experimental data and documented cases of botulism in laboratory workers clearly indicate that an aerosolized form of the toxin may also provoke botulism, i.e., that the bacterium can be inhaled. Moreover, according to experts, the use of aerosolized botullinum toxin could be one of the most frightening weapons in the context of biological warfare. We report one case of documented botulism probably secondary to the inhalation of serotype B toxin from contaminated food. This observation emphasizes that although the clinical diagnosis of botulism is fairly straighforward as it is based on highly indicative symptoms (multiple paralysis of the cranial nerves and atropinic signs), the route of acquisition is not always easy to determine.

The cost of intensive care is poorly documented in France, despite its contribution to the global hospital expenditures

Objectives: To assess the cost of intensive care in France.

Design: To calculate mean costs by type of patients, from the National Hospital Cost Survey (NHCS).

Patients: Patients hospitalized in an intensive care unit (ICU) in the public sector in 1997.

Results: The average cost of hospitalization in ICU is 20.532 ± 29.262 FF or 5.112 ± 3.256 FF per day (N = 23.029 after trimming). Intensive care represents 46% of medical costs per patient and 38% of their total costs. Daily cost varies according to the mode of hospital discharge and type of stay.

Discussion: The NHCS is the best available source of data on hospital costs, but it still underestimates the cost of ICU for sampling reasons, and does not yet include data to refine an analysis.

Conclusion: The study confirms that the costs of ICU are significant as compared to other hospital stays, and allows for the computation of plausible orders of magnitudes.