Respiratory manifestations of near-drowning in adult immersion victims are often severe. Nevertheless, in noncomatose patients at least, intubation can often be avoided and quick improvement is the rule while a good outcome is usually expected even in elderly patients.

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IntroductionInfections with resistant organisms represent a serious menace in critically ill patients. As options for effective chemotherapy diminish, intensive care unit (ICU) mortality will increase. Mortality rates as high as 60% have been reported for serious infections (ventilator-associated pneumonia [VAP], bloodstream infections) with inappropriate initial treatment [1][2][3][4][5][6]. In a recent study [7], inadequate antimicrobial treatment of infection was an important and independent determinant of mortality in critically ill patients. In that series patients receiving inadequate treatment had an in-hospital mortality rate of 52.1%, as compared with 12.2% in those patients who were adequately treated. APACHE = Acute Physiology and Chronic Health Evaluation; CVVHD = continuous venovenous hemodiafiltration; ICU = intensive care unit; VAP = ventilator-associated pneumonia. AbstractIntroduction The increasing prevalence of multiresistant Gram-negative strains in intensive care units (ICUs) has recently rekindled interest in colistin, a bactericidal antibiotic that was used in the 1960s for treatment of infections caused by Gram-negative bacilli. We conducted the present observational study to evaluate the efficacy of intravenous colistin in the treatment of critically ill patients with sepsis caused by Gram-negative bacilli resistant to all other antibiotics. Patients and method Critically ill patients with sepsis caused by Gram-negative bacilli resistant to all antibiotics with the exception of colistin were treated in the six-bed ICU of a trauma hospital. Diagnosis of infection was based on clinical data and isolation of bacteria, and the bacteria were tested with respect to their susceptibility to colistin. Clinical response to colistin was evaluated. Results Twenty-four patients (mean age 44.3 years, mean Acute Physiology and Chronic Health Evaluation II score 20.6) received 26 courses of colistin. Clinical response was observed for 73% of the treatments. Survival at 30 days was 57.7%. Deterioration in renal function was observed in 14.3% of 21 patients who were not already receiving renal replacement therapy, but in only one case did this deterioration have serious clinical consequences. Conclusion The lack of a control group in the present study does not allow any definite conclusions to be drawn regarding the clinical effectiveness of colistin. On the other hand, this drug has an acceptable safety profile and its use should be considered in severe infections with multiresistant Gram-negative bacilli.

A case of domestic violence is reported. The patient presented with the triad of injuries associated with the shaking of infants: retinal haemorrhages, subdural haematoma, and patterned bruising; this has been described as the shaken adult syndrome. This case report reflects the diYculties in diagnosing domestic violence in the accident and emergency setting.

Background: Varicella pneumonia is a serious complication of primary varicella infection in adults that often results in respiratory failure and death. Objective: To analyze the clinical and laboratory manifestations of primary varicella pneumonia in patients admitted to our intensive care unit (ICU). Methods: Retrospective study on patients treated in our ICU with a diagnosis of primary varicella pneumonia during a period of 15 years. We recorded age, gender, smoking habits, clinical and laboratory findings, arterial blood gases, chest radiograph, illness severity (SAPS II), length of stay, necessity for mechanical ventilation, complications, therapy and survival. We examined the influence of the duration of respiratory symptoms and rash prior to admission, and the influence of illness severity on outcome. Results: There was a statistically significant difference in duration of respiratory symptoms, duration of rash and SAPS II on admission between: (a) mechanically ventilated patients vs. spontaneously breathing patients (p < 0.007, p < 0.00, p < 0.00), (b) patients who survived vs. patients with poor outcome (p < 0.001, p < 0.000, p < 0.000), and (c) mechanically ventilated patients with poor outcome vs. mechanically ventilated patients who survived (p < 0.001, p < 0.00, p < 0.000). Overall mortality was 13.6%; death occurred only in mechanically ventilated patients (mortality 33.3%). Conclusions: Primary varicella pneumonia remains a critical problem with significant mortality. When recognized before respiratory failure ensues and mechanical ventilation becomes mandatory, patients could have an excellent outcome. Adult patients who delay asking for medical support, the disease may lead to the need for mechanical ventilation and severe complications with a fatal outcome.

These results suggest that clonidine is effective in the treatment of blood pressure instability in severe tetanus.

Hydrogen sulfide poisoning is a rare but devastating injury. Four of 8 cases of toxic inhalation of hydrogen sulfide are presented with special attention to the life-threatening complications. Four patients died at the scene of the accident and the remaining 4 had been hospitalized in the Intensive Care Unit (ICU). One patient died in the hospital from cardiogenic pulmonary edema and circulatory failure (pulmonary wedge pressure > 30 mmHg) and 3 patients left the hospital in good health although they presented serious complications. One of them left the hospital with a temporary pacemaker, and 1 of the 2 others died after two months owing to myocardial infarction. The authors discuss in detail the clinical features of this condition and emphasize the need for urgent and appropriate therapy as well as the need for safe environmental conditions.

Troponin is frequently elevated in critically ill patients. More research is needed on the diagnostic and prognostic significance and possible clinical applications of troponin measurements in patients with sepsis and critical illness.