[Massive gas embolism following lung inflation for thoracic tomodensitometry in a multiple trauma patient with lung contusions]

We report a case of gas embolism into both right and left circulation in a polytrauma patient with lung contusions, revealed by thoracic CT scan showing the heart and aorta filled with gas. It followed a lung inflation with a O2/N2O mixture for about 30 seconds at a pressure of at least 40 cmH2O in order to obtain apnoea for CT scan and to recruit atelectatic territories. The presumed mechanism was the passage of the O2/N2O mixture during the lung inflation manoeuvre out of disrupted airways into torn pulmonary blood vessels and pushed back into the heart chambers. The patient recovered fully. Lung inflation manoeuvre to obtain a prolonged apnoea during CT scan examinations of thorax is contraindicated in case of thorax trauma, as it carries a risk of gas embolism.

Soybean oil, blackcurrant seed oil, medium-chain triglycerides, and plasma phospholipid fatty acids of stressed patients

Thirty-six adult severe head injury and cerebral stroke patients in four intensive-care units were randomized to receive one of three enteral diets for 21 days. These diets, which supplied 45% of calories from fat, differed only in lipid composition. Diet A was comprised of 100% soybean oil, diet B contained a 50:50 (wt/wt) mixture of soybean oil and medium-chain triglycerides (MCTs), and diet C contained 42.5% MCT, 50% soybean oil, and 7.5% blackcurrant seed oils. Plasma phosphatidylcholine and fatty acid composition of plasma total phospholipids were determined before initiating treatment (day 0) and weekly throughout the study. Results indicated that at the start of the study, all patients had low linoleic acid (18:2 omega 6) levels compared with healthy subjects. Emulsion A disturbed the balance between several fatty acids of the omega 6 series, as exemplified by the significant increase in 18:2 omega 6 proportions. In contrast, both emulsions B and C introduced a less-pronounced rise in 18:2 omega 6 associated for emulsion C with a significant increase in dihomo-gamma-linolenic acid (20:3 omega 6) and docosapentaenoic acid (22:5 omega 3) in plasma phospholipids. Furthermore, 18:3 omega 6 change was significantly different between groups A and C and that of 20:3 omega 6 between group A and both groups B and C. Throughout the study, arachidonic acid (20:4 omega 6) exhibited remarkable steady-state levels regardless of the diet. This study shows that providing the injured body with high amounts of 18:2 omega 6 does not lead to high levels of its upper derivatives in plasma phospholipids.(ABSTRACT TRUNCATED AT 250 WORDS)

Composition of phospholipid fatty acids in red blood cell membranes of patients in intensive care units: effects of different intakes of soybean oil, medium-chain triglycerides, and black-currant seed oil

Fatty acid composition of phospholipids in red blood cell membranes was studied in 32 severely head-injured or cerebral stroke patients receiving enteral nutrition for 3 weeks. During this study the effects of three diets differing only by their lipid composition were investigated. The daily energy intake of each patient amounted to 2950 kilocalories, of which the lipid fraction represented 45.7%. Diet A contained only soybean oil, diet B consisted of a 50% soybean oil and 50% medium-chain triglycerides mixture, and diet C was an emulsion of 50% soybean oil, 42.5% medium-chain triglycerides, and 7.5% black-currant seed oil. Our results showed no biochemical signs of fatty acid deficiency in red blood cell membranes for the patients at the beginning of the study, after a comparison with a control group of 20 healthy adults. Inhibition of delta 6-desaturase activity on linoleic acid (C18:2 omega 6) after diet A was suggested by an increase of linoleic acid without a corresponding increase of dihomo-gamma-linolenic acid (C20:3 omega 6). Replacing 50% of soybean oil by with medium-chain triglycerides (diet B) prevented this enzyme inhibition. Supply of black-currant seed oil rich in gamma-linolenic (C18:3 omega 6) and stearidonic (C18:4 omega 3) acids (diet C) induced significant increases of dihomo-gamma-linolenic and eicosapentaenoic (C20:5 omega 3) acids, without influencing arachidonic acid (C20:4 omega 6) levels. This balance was evaluated through the ratio (C20:3 omega 6 + C20:5 omega 3)/C20:4 omega 6.

[Early informing of patients with spinal cord injuries]

Early information to patients on the prognosis of acute spinal injuries is an important and uneasy task. This retrospective study was undertaken to assess the consequences of this information. It appears that early information involves easier and more confident relationships between patient, nurses and medical staff in the ICU. This early information, despite its difficulty, seems beneficial.

[Cardiac arrest caused by pericardial heart dislocation]

A case is reported of a 33-year-old multiple injured patient with closed chest trauma and an unknown rupture of left pericardium and hemidiaphragm. A peroperative cardiac arrest, one year later, was related to dislocation of the heart. Thoracotomy for internal cardiac massage was responsible for a successful outcome.

[Physical dependence on benzodiazepines in traumatology]

During the last years, there have been more and more observations of physical dependence on the benzodiazepines. This paper emphasizes the seriousness of this syndrome, its similarity with delirium tremens and its optimal treatment by high doses of benzodiazepines. This article shows also the misuse of drugs lowering the epileptogenic threshold and suggests in replacement the peranaesthesic administration of benzodiazepines or barbiturates. Finally the treatment should be started with a gradual and slow withdrawal so as to avoid undesirable neurological signs.

Prognostic value of combined data on enzymes and inflammation markers in plasma in cases of severe head injury

We measured certain enzyme activities (aldolase, aspartate aminotransferase, creatine kinase, and lactate dehydrogenase) and inflammation markers (alpha 1-antitrypsin, C-reactive protein, fibrinogen, and leukocytes) each day for four days in plasma of patients with severe head injury. The univariate prognostic efficiency of each biochemical parameter was assessed 24, 48, 72, and 96 h after trauma. By stepwise multivariate analysis applied every day, we found that (a) four variables, two enzymes (lactate dehydrogenase and aspartate aminotransferase) and two inflammation markers (C-reactive protein and leukocytes), sufficed to reliably predict the patient's outcome and (b) data recorded at 72 h best discriminated between survivors and nonsurvivors. A risk index based on the four selected variables and validated on a large control sample allowed the correct allocation of, respectively, 90% of survivors and 88% of nonsurvivors at 72 h. We discuss why results obtained at 72 h are more predictive than those obtained at any other of the times considered.

Prognostic value of combined data on enzymes and inflammation markers in plasma in cases of severe head injury

We measured certain enzyme activities (aldolase, aspartate aminotransferase, creatine kinase, and lactate dehydrogenase) and inflammation markers (alpha 1-antitrypsin, C-reactive protein, fibrinogen, and leukocytes) each day for four days in plasma of patients with severe head injury. The univariate prognostic efficiency of each biochemical parameter was assessed 24, 48, 72, and 96 h after trauma. By stepwise multivariate analysis applied every day, we found that (a) four variables, two enzymes (lactate dehydrogenase and aspartate aminotransferase) and two inflammation markers (C-reactive protein and leukocytes), sufficed to reliably predict the patient's outcome and (b) data recorded at 72 h best discriminated between survivors and nonsurvivors. A risk index based on the four selected variables and validated on a large control sample allowed the correct allocation of, respectively, 90% of survivors and 88% of nonsurvivors at 72 h. We discuss why results obtained at 72 h are more predictive than those obtained at any other of the times considered.

[Hypertensive accident in a surgical patient with unsuspected pheochromocytoma (author's transl)]

Death may follow anesthetic incident in unsuspected pheochromocytoma. They may lead to hypertensive crisis with cerebrovascular accident and severe arythmias or acute left heart failure with pulmonary edema. We report a case illustrating these problems and in which death has followed. Analysis of the 18 cases recorded in world litterature demonstrates a mortality rate of 85 p. cent. The accident can occur in association with surgery, anesthesia and certain, even minor, investigatory procedures. However if the crisis is recognized and appropriatly treated, the patient may recover before irreversible shock occurs.