The management of femur shaft fracture associated with severe traumatic brain injury

The aim of this article is to describe the management of femoral shaft fractures in patients with severe traumatic brain injury (TBI). This is a major problem and two questions remain currently of interest: When and how to perform orthopedic surgery in severe TBI patients? The main point of perioperative management remains the prevention of secondary brain insults and the monitoring of intracranial pressure is essential especially in patients with intracranial lesions on the CT-scan. The “double hit” concept, suggesting that surgery by itself might increase the preexisting systemic inflammatory response, gives argument for very early or delayed surgery. Early definitive femoral osteosynthesis, if requires lengthy surgical procedure, does not seem appropriate in this context and “damage-control orthopedics” with external fixation seems to be a good alternative.     

Haemophagocytic lymphohistiocytosis syndrome: a possible cause of multi-organ failure in severe head trauma?

We report the case of a 26-year-old patient who was victim of severe head trauma following a trafic road accident. Two days after trauma, she had fever, pancytopenia and multi-organ failure. The haemophagocytic lymphohistiocytosis syndrome was suspected. This diagnosis was confirmed by biologic findings (elevated serum levels of ferritin and triglycerid) and histological findings (examination of bone marrow smears showing histiocytes phagocytosing blood cells). The evolution was unfavorable despite of corticotherapy and symptomatic measures.     

Penile Doppler ultrasound: contribution to the management of erectile dysfunction

Erectile dysfunction (ED) is a common multifactorial disease, in most situations arising from an organic or mixed cause. Most cases of ED classified as arterial are linked to endothelial dysfunction in relation to the key factors of cardiovascular risk. ED is an indicator of vascular health in general. It is also a predictor of cardiovascular events, including coronary heart disease. It has also been associated with lower peripheral arterial disease and stroke. At the present time, penile Doppler ultrasound examination is relatively little used in the management of ED, knowledge of the etiologic factors being most often not necessary for therapeutic management, but also because of the absence of standardization. Nonetheless, recent large-scale studies have shown that the vascular nature of ED, based on Doppler parameters recorded after intracavernous injection of vasoactive drugs, was also predictive of cardiovascular events and cardiovascular mortality, warranting greater interest in this test.     

Audit of the prehospital management of severe head injured patients in the "Pays-de-la-Loire" region

Objective

To study severe head injured patients (SHIP) during prehospital emergency care (Samu) and the first day in the French Pays-de-la-Loire area, in 2005.

Study design

Prospective and multicenter.

Patients and methods

All patients managed by Samu with GCS ≤ 8 on the field, starting from a GCS ≤ 10.

Results

We report on 125 patients (88% of all SHIP managed in 2005), including 114 with a GCS less or equal to eight on which analysis was performed: age: 37 ± 20 years, men: 4/1, road accident: 73%, fall: 20%, (polytrauma: 53%, artificial ventilation: 92%). Delays: field medical care 54 ± 28 min, transportation: 32 ± 29 min, total time to hospital: 1 h 55 ± 48 min. Direct admission in a center with neurosurgery on site: 68%; 47% of patients admitted in general hospitals were transferred to a tertiary hospital (71% to neurosurgery). Mortality before 24th hour (23%) was associated (p < 0.05) with shorter transfer time, older patient, persistent shock, fluid loading greater than 1500 ml, continuous infusion of vasopressors, focal neurological deficit. Problems were reported by Samu teams (21% of cases): medical care (32%), emergency ambulance availability (20%), alerting process (16%), on field care before Samu (12%). Of note, mannitol was never used, despite a mydriasis.

Conclusion

We observed a delayed referral of patients to a tertiary hospital, a limited use of CT image transmission and the absence of mannitol administration but also organisational problems reported in 21% of cases problems are main target for quality improvement.     

Reconstruction of the nasal alar defect with the superiorly based nasolabial flap described by Burget: report of seven cases

Background

The reconstitution of a nasal alar rim and lobule defect represent a difficult challenge in consideration of his situation, anatomy and function. This article describes the technique and the interest of the nasolabial flap when used to cover the entire alar subunit.

Methods

We present 7 cases of alar rim and lobule defect after skin cancer excision. In the series, there are two full-thickness with lining defect. The patients were reconstructed with a superiorly based nasolabial flap, according to the subunit principle as introduced by Burget. A free cartilage graft was used to restore structural support with marginal skin flaps were turned over for intranasal lining when necessary.

Results

The cosmetic and functional outcomes of each repair were judged from good to excellent by patients and surgeons. No case of flap infection or necrosis occurred.

Conclusion

The superiorly based nasolabial flap, describe by Burget, provides an excellent choice for cosmetic and functional reconstruction of the nasal alar defect.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Lésions ischémiques secondaires : comment les prévenir ?

In addition to the initial lesions related to the brain injury, the final outcome depends also largely on the secondary ischaemic lesions. These lesions result from hypoperfusion whatever the mechanisms. It is then essential to detect early the conditions at risk of ischaemia, to be treated aggressively since the initial care. The multimodal monitoring is the only way to diagnose these conditions, to provide information about the mechanisms, and then to better adapt the treatment. Such an early detection helps to limit the consequences of the initial trauma, and may improve outcome.     

Cerebral salt wasting syndrome: experimental study in rats

Introduction

The cerebral salt wasting syndrome (CSWS) is characterized by hyponatraemia secondary to excessive natriuesis with osmotic duiresis. This syndrome, frequently, occurs after subarachnoid haemorrhage (SAH), but may occur after any acute cerebral aggression.

Objectives

The aim of the study was to assess the frequency of the CSWS in animal models with, SAH, cerebral ischemia (CI), and cranial trauma (CT), and its correlation with the secretion of brain natriuretic peptide (BNP).

Method

Four groups of rats were selected: group SAH (n = 7) consisted of SAH induced by perforation of the carotid artery in its intracerebral part; group CI (n = 7) consisted of CI induced by ligature of the carotid artery; group CT (n = 7) consisted of induced CT; and a control group Sham (n = 7). Weight, serum sodium, BNP, and urinary sodium, were measured at baseline and 24 hours after.

Results

Rats with SAH had significant natriuresis and diuresis with negative sodium balance (–95.9 ± 447.4 μmol) with a significant difference (P < 0.05) compared to the rats of the CI and the Sham groups. There was no difference in the 24 hours level of BNP between the four different groups.

Conclusion

We conclude that SAH, in animal models, induced high diuresis with negative sodium balance in the first 24 hours. These findings were absents in the others groups. This was independent of the BNP secretion and may correspond to the early occurrence of a CSWS.     

Oxygénothérapie hyperbare et gaz inertes dans l’ischémie cérébrale et le traumatisme crânien

Cerebral ischemia is a common thread of acute cerebral lesions, whether vascular or traumatic origin. Hyperbaric oxygen (HBO) improves tissue oxygenation and may prevent impairment of reversible lesions. In experimental models of cerebral ischemia or traumatic brain injury, HBO has neuroprotective effects which are related to various mechanisms such as modulation of oxidative stress, neuro-inflammation or cerebral and mitochondrial metabolism. However, results of clinical trials failed to prove any neuroprotective effects for cerebral ischemia and remained to be confirmed for traumatic brain injury despite preliminary encouraging results. The addition of inert gases to HBO sessions, especially argon or xenon which show neuroprotective experimental effects, may provide an additional improvement of cerebral lesions. Further multicentric studies with a strict methodology and a better targeted definition are required before drawing definitive conclusions about the efficiency of combined therapy with HBO and inert gases in acute cerebral lesions.