Intoxication accidentelle grave à l’hydrogène sulfuré : un cas pédiatrique de survie

We report a paediatric case of survival following severe hydrogen sulfide (H₂S) gas intoxication. A 13-year-old boy was found submerged to the neck in a manure tank. He was hypothermic, unresponsive with bilateral mydriasis, and had poor oxygen saturation. After intubation, he was transferred to the paediatric intensive care unit of a tertiary care children's hospital. He developed acute respiratory distress syndrome (ARDS) requiring high frequency percussive ventilation. Cardiac evaluation was significant for myocardial infarction and left ventricular function impairment. He completely recovered from the respiratory and cardiac failure. Neurological examinations showed abnormal signals on MRI in the semi-oval center and in the frontal cortex. Follow-up detected partial impairment of axonal fibers of the right external popliteal sciatic nerve. Paediatric cases of survival after H₂S intoxication have been rarely reported. Such exposures can evolve to severe ARDS and benefit from high frequency percussive ventilation. Hypothermia and other metabolic abnormalities are now better explained thanks to actual knowledge about endogenous H₂S function. Lessons learned from paediatric accidents should result in better information about this threat for farmers and families living in houses with septic tanks, reducing the risk to their own and their children's safety.     

Fatal outcome of an hydrogen sulfide poisoning

We report a case of fatal outcome poisoning by massive exposure to hydrogen sulfide of a sewer worker. This rare event was associated with a moderate intoxication of two members of the rescue team. The death was due to asystole and massive lung oedema. Autopsy analysis showed diffuse necrotic lesions in lungs. Hydrogen sulfide is a direct and systemic poison, produced by organic matter decomposition. The direct toxicity mechanism is still unclear. The systemic toxicity is due to an acute toxicity by oxygen depletion at cellular level. It is highly diffusable and potentially very dangerous. At low concentration, rotten egg smell must trigger hydrogen sulfide suspicion since at higher concentration it is undetectable, making intoxication possible. In case of acute intoxication, there is an almost instantaneous cardiovascular failure and a rapid death. Hydrogen sulfide exposure requires prevention measures and more specifically the use of respiratory equipment for members of the rescue team.     

Détresse respiratoire aiguë révélant une leptospirose

The respiratory manifestations of leptospirosis are usually begnin. A case is reported of anicteric leptospirosis with serious pulmonary affection. The clinical symptoms, the radiological manifestations and haemodynamic investigation were suggestive of an acute respiratory distress by non-haemodynamic pulmonary oedema. In accordance with other authors, one would be justified in including this acute respiratory failure as part of the acute respiratory distress syndrome of the adult (ARDS).     

L’œdème aigu du poumon à pression négative : illustration à partir d’un cas clinique inhabituel compliquant une paralysie récurrentielle postopératoire

Acute postoperative negative pressure pulmonary edema (NPPE) is a respiratory complication due to upper airway obstruction occurring most commonly in the postoperative period. Pathophysiologically, NPPE is explained by the abrupt generation of highly negative intrathoracic pressure that lead to fluid transudation from the pulmonary capillaries. This observation reports an unusual case of a young patient who has undergone total thyroidectomy for multinodular goiter. The postoperative period was marked by the occurrence of bilateral recurrent laryngeal nerve palsy that was complicated by a NPPE. The outcome was favorable after mechanical ventilation with reversal of NPPE and recovery of the recurrent laryngeal nerve function. This article stresses the importance of prevention of recurrent nerve palsy during thyroid surgery. It also highlights a little known respiratory complication: the NPPE. Understanding the pathophysiology of NPPE, rapid diagnosis and appropriate therapeutic measures could prevent its potential lethal consequences.     

Lung ultrasound‐guided management of acute breathlessness during pregnancy

Lung ultrasonography is a standard tool in the intensive care unit and in emergency medicine, but has not been described in the particular setting of the labour ward. During pregnancy, acute respiratory failure and pulmonary oedema are not uncommon life‐threatening events. We present two case reports outlining the potential of lung ultrasonography in parturients. In case 1, lung ultrasonography allowed early diagnosis and treatment of acute dyspnoea in a parturient admitted for suspected asthma exacerbation. Lung ultrasonography revealed a ‘B‐pattern’ of vertical lines radiating into the lung tissue, indicating severe pulmonary oedema complicating previously undiagnosed pre‐eclampsia. In case 2, a pre‐eclamptic patient was managed with combined transthoracic echocardiography and lung ultrasonography. The accuracy of lung ultrasonography in detecting interstitial oedema at a pre‐clinical stage allowed adequate fluid resuscitation in this patient who had a high risk of alveolar pulmonary oedema. We believe that these cases strongly support the prospective validation of lung ultrasound for management of lung disorders in pregnant women.     

Acute lung injury in fulminant hepatic failure following paracetamol poisoning.

BACKGROUND--There is little information on the incidence of acute lung injury or changes in the pulmonary circulation in acute liver failure. The aim of this study was to record the incidence of acute lung injury in fulminant hepatic failure caused by paracetamol poisoning, to document the associated pulmonary circulatory changes, and to assess the impact of lung injury on patient outcome. METHODS--The degree of lung injury was retrospectively assessed by a standard scoring system (modified from Murray) in all patients with fulminant hepatic failure caused by paracetamol poisoning, admitted to the intensive care unit over a one year period. The severity of liver failure and illness, other organ system failure, and patient outcome were also analysed. RESULTS--Twenty four patients with paracetamol-induced liver failure were admitted and nine developed lung injury of whom eight (33%) had severe injury (Murray score > 2.5). In two patients hypoxaemia contributed to death. Patients with lung injury had higher median encephalopathy grades (4 v 2 in the non-injured group) and APACHE II scores (29 v 16). Circulatory failure, requiring vasoconstrictor support, occurred in all patients with lung injury but in only 40% of those without. Cerebral oedema, as detected by abnormal rises in intracranial pressure, also occurred in all patients with lung injury but in only 27% of the non-injured patients. The incidence of renal failure requiring renal replacement therapy was similar in both groups (67% and 47%). Pulmonary artery occlusion pressures were normal in the lung injury group. Cardiac output was high (median 11.2 1/min), systemic vascular resistance low (median 503 dynes/s/cm-5), and pulmonary vascular resistance low (median 70 dynes/s/cm-5), but not significantly different from the group without lung injury. Mortality was much higher in the lung injury group than in the non-injured group (89% v 13%). CONCLUSIONS--Acute lung injury was common in patients with paracetamol-induced fulminant hepatic failure and was associated with systemic circulatory failure and cerebral oedema. The development of acute lung injury was associated with high mortality.     

Tramadol overdose and serotonin syndrome manifesting as acute right heart dysfunction

Acute right heart failure in a young person is an unusual presentation and drug overdose is a rare cause. A case is described where the patient presented with striking clinical signs of acute pulmonary hypertension and right heart failure, which were confirmed by transthoracic echocardiography. The precipitating event appeared to be poisoning by tramadol. There were features in keeping with tramadol toxicity and serotonin syndrome. The possible pathophysiology behind the process is discussed.     

Intoxication à l’arsenic : une gastro-entérite un peu particulière…

Arsenic (As) intoxication is nowadays extremely rare. Two cases of acute and chronic As criminal poisoning leading to death of a couple of retired people, are reported. Clinical presentation was simulating a gastro-enteritidis with fast evolution to refractory shock. Toxicological analysis confirmed this diagnostic, with respectively blood As concentrations at 579 and 21 765 μg/l for our two patients.     

Minimal change disease with acute renal failure: a case against the nephrosarca hypothesis.

An unusual but well-documented presentation of minimal change disease is nephrotic proteinuria and acute renal failure. One pathophysiological mechanism proposed to explain this syndrome is nephrosarca, or severe oedema of the kidney. We describe a patient with minimal change disease who presented with heavy proteinuria and acute renal failure but had no evidence of renal interstitial oedema on biopsy. Aggressive fluid removal did not reverse the acute renal failure. Renal function slowly returned concomitant with resolution of the nephrotic syndrome following corticosteroid therapy. The time profile of the clinical events is not compatible with the nephrosarca hypothesis and suggests an alternative pathophysiological model for the diminished glomerular filtration rate seen in some cases of minimal change disease.     

Respiratory syndromes in acute poisoning

Respiratory syndromes in acute poisoning can refer to a wide range of specific clinical syndromes, from acute tracheobronchitis to acute pulmonary edema, chemical pneumonia, acute respiratory distress syndrome and respiratory failure, that occur as a result of direct or indirect effect of chemical substances, drugs and toxins on lungs and airways. Our study attempt to identify, during one-year retrospective study on patients diagnosed with acute poisoning, addressed to Medical Clinic of Emergency Clinic Hospital of Iasi, the respiratory syndromes commonly associated with acute poisoning. We found that the association of toxins, inhalation of gases or volatile substances have a high risk for appearance of respiratory syndromes. The outcome of these patients is influenced by the duration of exposure or the delay of presentation to the hospital after ingestion, and depends on the rapid and aggressive measures for basic life support and intensive care.     

Subarachnoidal haemorrhage and myocardial failure: interest of cardiac and cerebral monitoring

Spontaneous subarachnoidal haemorrhage can be associated with neurogenic pulmonary oedema and cardiogenic shock. The presentation is an ischemic myocardial dysfunction associated with normal coronary arteries. Hypoxaemia associated with arterial hypotension on patients with brain injury can worsen neurological outcome. The administration of norepinephrine associated with fluid expansion could be deleterious on cardiac function. We report the case of a patient with acute pulmonary oedema associated with post-aneurysmal subarachnoid haemorrhage managed with transoesophageal Doppler monitoring.     

Fracture of the Duromedics mitral valve housing with leaflet escape

We report a case of leaflet embolisation consequent upon a hemicircumferential fracture of the pyrolytic valve housing of a 29 mm mitral Duromedics Valve implanted for seven months. The clinical presentation is discussed and the literature on mechanical valve failure compared. Unlike pivoting disc valves where absent valve clicks equate with serious occluder dysfunction, valve sounds may persist with bileaflet valve malfunction due to the unimpeded movement of the normally functioning second leaflet. Whilst intrinsic structural failure is increasingly uncommon constant clinical awareness of its occurrence in a patient with a mechanical valve presenting with unexplained acute heart failure and pulmonary oedema, and prompt surgical intervention offers the best chance of survival. The aetiology of the primary fracture in this case remains unclear.     

Acute pulmonary oedema in pregnant women

Acute pulmonary oedema in pregnant women is an uncommon but life-threatening event. The aims of this review are to address why pulmonary oedema occurs in pregnant women and to discuss immediate management. We performed a systematic literature search of electronic databases including MEDLINE, EMBASE and the Cochrane Library, using the key words obstetrics, pregnancy, acute pulmonary oedema, pregnancy complications, maternal, cardiac function and haemodynamics. We present a simple clinical classification of acute pulmonary oedema in pregnancy into pulmonary oedema occurring in normotensive or hypotensive women (i.e. without hypertension), and acute pulmonary oedema occurring in hypertensive women, which allows focused management. Pre-eclampsia remains an important cause of hypertensive acute pulmonary oedema in pregnancy and preventive strategies include close clinical monitoring and restricted fluid administration. Immediate management of acute pulmonary oedema includes oxygenation, ventilation and circulation control with venodilators. Pregnancy-specific issues include consideration of the physiological changes of pregnancy, the risk of aspiration and difficult airway, reduced respiratory and metabolic reserve, avoidance of aortocaval compression and delivery of the fetus.     

Chloroquine poisoning with respiratory distress and fatal outcome]

Chloroquine poisoning can cause life threatening cardiovascular disturbances. We report three cases of suicide with chloroquine causing acute respiratory insufficiency from pulmonary oedema with lethal outcome, despite a treatment with diazepam, epinephrine and mechanical ventilation.     

Étiologie des œdèmes pulmonaires lésionnels transfusionnels. À propos d’un cas

Acute lung injury is a common adverse effect of massive blood transfusion, responsible for 17% of the deaths due to transfusion in France. A cardiac origin is often suspected. We report a case of post-transfusional pulmonary oedema in a cirrhotic patient, which could be related to a non-cardiac and underdiagnosed aetiology: the so-called transfusion related acute lung injury (TRALI).     

ADULT RESPIRATORY DISTRESS SYNDROME AFTER ATTEMPTED STRANGULATION

We describe a case of severe acute lung injury after attemptedstrangulation. The patient presented initially with cerebralirritability and florid, non-cardiogenic pulmonary oedema whichwere followed by a prolonged period of the adult respiratorydistress syndrome, severe sepsis and multiple system organ failure,a/though the patient eventually survived. The pulmonary injuryfollowing strangulation is proposed to be a result of the generationof marked subatmospheric pressures within the lungs during vigorousinspiration against an obstructed airway, although the processesinvolved in the so-called neurogenic pulmonary oedema are difficultto exclude. (Br. J. Anaesth. 1993; 70: 583–586)     

Rare immune-mediated pneumonitis in association with post-streptococcal glomerulonephritis

We describe the case of a 48-year-old man with an acute nephritis and respiratory failure. Clinical history, streptococcal antibody titres and renal biopsy led to a diagnosis of post-streptococcal glomerulonephritis. Respiratory investigations excluded pulmonary oedema and infection. We hypothesize that this man had a co-existing post-streptococcal glomerulonephritis and an immune-mediated pneumonitis. This is a very rare association, which was last described in 1982.     

Acute respiratory distress disclosing leptospirosis

The respiratory manifestations of leptospirosis are usually benign. A case is reported of anicteric leptospirosis with serious pulmonary affection. The clinical symptoms, the radiological manifestations and haemodynamic investigation were suggestive of an acute respiratory distress by non-haemodynamic pulmonary oedema. In accordance with other authors, one would be justified in including this acute respiratory failure as part of the acute respiratory distress syndrome of the adult (ARDS).     

Épiglottite aiguë obstructive en réanimation : stratégie pour une intubation à haut risque

Acute epiglottitis is an infection of supraglottic structures, with a high risk of life-threatening respiratory obstruction. We report a case of a 52-year-old patient who presented with a prehospital hypoxic respiratory arrest caused by obstructive oedema with a successful resuscitation. Laryngoscopy after a sudden unplanned extubation permits diagnosis of acute obstructive epiglottitis. The growing threat of laryngeal dyspnea prompts emergency tracheal airway protection, by means of the combined preparation of transtracheal oxygenation access and the use of fiber-optic laryngoscopy. This case report emphasises the airway management strategy successfully used in this patient.     

Peripartum presentation of an acute aortic dissection

We report the case of an acute type A aortic dissection occurringin a 35-year-old parturient. The initial diagnosis was missed;a subsequent emergency Caesarean section 3 weeks after presentationwas followed by the development of left ventricular failureand pulmonary oedema in the early postoperative period. Echocardiographyconfirmed the diagnosis of aortic dissection and the patientunderwent a successful surgical repair.