After a short review on pathophysiologic mechanisms of comatose states and their complications, a cohort of 392 comatose patients (Glasgow Coma Scale < or = 8) hospitalized in intensive care is analyzed in order to estimate the relative frequency of the different causes of nontraumatic coma. Depending on pathology, the following practical, sequential procedure is recommended: at first, identification and treatment of disorders of vital functions, objective estimate of the severity of the coma and rapid diagnostic orientation with a targeted neurologic investigation; then, simple therapeutic interventions in order to treat reversible causes of a metabolic encephalopathy as well as immediate measures for neuroprotection (anticonvulsive and antihypotensive therapy, oxygen, etc.). An initial, adequate control of the comatose patient is mandatory in order to limit disabling cerebral complications.

Brain Diseases, Metabolic↗

PubMed1993

[Esophageal perforation in a fruitless attempt at endotracheal intubation].

Esophageal perforation is a rare but potentially serious complication of endotracheal intubation, often leading to mediastinitis. The diagnosis should be performed rapidly, based on suggestive clinical signs as well as on plain chest roentgenograms and contrast esophagogram. The usual treatment consists of broad spectrum antibiotherapy, prompt surgical closure of the perforation and adequate drainage of the area. The overall mortality rate of about 50% is significantly reduced if therapy is begun within the first 12 hours. A number of ancillary tests and clinical criteria have been proposed in order to assess difficult intubations. The authors report a case of esophageal perforation following a difficult intubation, resulting in acute respiratory distress, subcutaneous emphysema and bilateral pneumothorax. An early diagnosis and prompt surgical treatment facilitated a successful outcome.

Esophageal Perforation↗

PubMed1993

[Late post-traumatic pericardial effusion. Identification of promoting conditions and literature review apropos of 2 cases].

The authors report two cases of post traumatic haemopericardium discovered 18 days after a iatrogenic penetrating trauma (sternal puncture) for the first one, and 102 days after a fall with blunt thoracic trauma and multiple associated injuries, for the second one. After admission, the first case rapidly developed a severe tamponade requiring a pericardial drainage, of 420 ml of non coagulated blood. The second case, in spite of a volume of liquid of more than 1000 ml, showed only a fatigue and a dyspnea, without any sign of haemodynamic failure. A literature review allows to be more specific about the characteristics of the tamponade and the different mechanisms responsible for cardiac injuries connected to thoracic traumas. For many reasons, the cardiac damages and/or their complications are often misjudged, particularly in thoracic traumas associated with multiple lesions. Among the sequelae, pericarditis, with or without effusion, is particularly frequent and it is essential to systematically look for it before dismissing a patient who went through a thoracic trauma. As for the bone marrow sampling, the sternal puncture generates a great number of injuries and must be proscribed. The iliac crest puncture should take its place.

Aged↗

PubMed1993

[Myocardial lesion secondary to defibrillation. Literature review and practical implications].

A 39 years old patient was defibrillated during the acute stage of an inferior myocardial infarction. He presented an elevation of the ST segment in the right precordial leads immediately after resuscitation. The evolution of the electrocardiographic changes were characterised by the development of a septo-apical subepicardial necrosis, whose sequelae remained nine months after the initial event. In the absence of any stenosing lesion of the anterior interventricular coronary artery, this necrosis can be attributed to the electrical shocks. The close position of the defibrillator paddles on the thorax certainly played a determining role, exposing the underlying myocardial tissue to an excessive electrical intensity. The authors point out the importance of the technical modalities of defibrillation that are likely to ensure the best chances of success with a minimum of secondary myocardial damage.

Adult↗