Les techniques dˈassistance circulatoire mécanique ont été rarement utilisées au cours des intoxications. Leur efficacité a été démontrée par cinq études chez lˈanimal au cours dˈintoxications par des cardiotropes ou des antidépresseurs tricycliques. Vingt-cinq cas dˈintoxications humaines par des antiarythmiques ou dˈautres substances cardiotoxiques et traités par une assistance circulatoire (ECMO ou CPBIA) ont été rapportés. Lˈassistance circulatoire a permis la survie de 80 % de ces patients qui présentaient un choc (sept fois) ou un arrêt cardiaque (18 fois) réfractaires aux mesures thérapeutiques conventionnelles maximales. Bien que les indications soient rares, ces techniques peuvent être salutaires lorsque les conditions médicotechniques sont favorables. Lˈassistance respiratoire par ECMO a été utilisée dans quelques cas de syndromes de détresse respiratoire secondaires à des pneumopathies aux solvants mais nˈa pas fait la preuve de son utilité.Circulatory assist devices have rarely been used in poisonings. Their efficacy has been demonstrated in five animal studies of intoxication by cardiotropic drugs or tricyclic antidepressants. Twenty-five cases of human poisonings by antiarrhythmic drugs or other cardiotoxic products and treated by circulatory support (ECMO or IABP) have been reported. The use of circulatory assist devices allowed the recovery in 80% of those patients who presented shock (seven times) or cardiac arrest (18 times) refractory to maximal therapy. Although the indications are rare, these techniques may be life-saving if the medical and technical conditions are fulfilled. Respiratory support by ECMO has been used in some cases of acute respiratory distress syndrome due to hydrocarbons but their usefulness has not been demonstrated.

Background-The outcome of resuscitated patients after cardiac arrest complicating acute myocardial infarction remains poor, primarily because of the relatively low success rates of cardiopulmonary resuscitation management. Existing data suggest potential beneficial effects of early myocardial reperfusion, but the predictors of survival in these patients remain unknown.Methods and Results-From 1995 to 2005, 186 patients (78% men; mean age, 60.4 +/- 13.8 years) underwent immediate percutaneous coronary intervention after successful resuscitation for cardiac arrest complicating acute myocardial infarction. Prompt prehospital management was performed by mobile medical care units in 154 of 186 patients, whereas 32 had in-hospital cardiac arrest. Infarct location was anterior in 105 patients (56%), and shock was present on admission in 96 (52%). Percutaneous coronary intervention (stenting rate 90%) was successful in 161 of 186 patients (87%). Six-month survival rate was 100 of 186 (54%), and 6-month survival free of neurological sequelae was 46%. By multivariate analysis, predictors of 6-month survival were a shorter interval between the onset of cardiac arrest and arrival of a first responder (odds ratio, 0.67; 95% CI, 0.54 to 0.84), a shorter interval between the onset of cardiac arrest and return of spontaneous circulation (odds ratio, 0.91; 95% CI, 0.87 to 0.96), and absence of diabetes (odds ratio, 7.30; 95% CI, 1.80 to 29.41).Conclusions-In patients with resuscitated cardiac arrest complicating acute myocardial infarction, prompt prehospital management and early revascularization were associated with a 54% survival rate at 6 months. A strategy including adequate prehospital management, early revascularization, and specific care in dedicated intensive care units should be strongly considered in resuscitated patients after cardiac arrest complicating acute myocardial infarction.

BACKGROUND:Primary therapies in acute myocardial infarction (thrombolysis and angioplasty) have inherent limitations which may be overcome by combining them. So far, no trial has demonstrated a clinical benefit in combining mechanical and pharmacological treatment strategies.METHODS:From January 1995 to December 1999, out of 1010 patients admitted to our institution for acute myocardial infarction, 148 had received pre-hospital full dose thrombolysis within 12 h of onset. One hundred and thirty-one patients were included and underwent immediate angioplasty and stenting when suitable, independent of the infarct-artery patency (TIMI grade flow 0-3). In-hospital outcome was assessed and clinical information was collected for a mean (+/-SD) of 2+/-1 years.RESULTS:Ninety-minute angiography revealed a patent (TIMI grade 3) infarct artery in 65 patients (49%). Immediate angioplasty was performed in 119 patients (91%) with stent implantation in 114 (96%). Angioplasty achieved TIMI 2, 3 flow in 98%, and complete patency (TIMI 3 flow) in 92%. Six other patients underwent deferred revascularization (surgery in one patient, angioplasty in five) and six received medical treatment. Stent thrombosis and reinfarction occurred in three patients (2.3%). In-hospital death occurred in six patients (4.6%), including four patients presenting with cardiogenic shock. Major bleeding was observed in 2.3% of cases. No patient had emergency surgery. Freedom from death and reinfarction at 2 years was 90% and freedom from death, reinfarction and target vessel revascularization was 83%.CONCLUSION:A strategy of combined reperfusion using full dose pre-hospital thrombolysis and immediate angioplasty with stent implantation in a non-selected acute myocardial infarction population is safe and achieves high and early patency rates. This preliminary experience suggests that a combined strategy in acute myocardial infarction may have a significant impact on both early and long-term outcomes.

The Essonne region of France is situated to the south of Paris. A population of more than 1 million, heavy commercial traffic, and industrial centers mandate first-rate prehospital and hospital emergency medicine. Medical education in France comprises 3 years of basic medical science, followed by 3 years of hospital rotations and a residency of variable length. Emergency medicine is struggling for recognition as a specialty. The ED at the hospital center in Corbeil-Essonnes, France, has 21,000 visits per year, accounting for 30% of hospital admissions. The physical plant is modern and well-organized, with 13 beds. Attention is paid to quality improvement. Prehospital emergency care also receives due attention. A two-tiered system of BLS ambulances run by the fire department and ALS ambulances run by hospitals provide 24-hour emergency coverage. Because of aggressive triage, only 65% of requests for service result in dispatch of an ambulance. Tasks for physicians involved in emergency medicine in France today include further development of firemen's medical skills, development and use of telemedicine, and accreditation of emergency medicine as a recognized specialty.