med emergency / urgence - new health concept 21 online version.pdf · aziz koleilat, bruno...

Endorsed by

Trim

estr

iel

ISSN 2222-9442

December 2014 - N°21

Emergency responses in case of mass casualties’ different big bang incidents: the Paris Fire Department prehospital medical care approachLe télédiagnostic, un concept adapté à l’évaluation de la contamination accidentelle ou intentionnelle d’une ressource en eau

Chloroquine overdoseCoronary spasmIntérêt de l’échocardiographie en pré-hospitalierBrûlures et atteintes caustiques oculaires HIV and AIDS: global summary and basic facts

MED EMERGENCY / URGENCEMED EMERGENCY / URGENCE

NSEC offers exclusive courses accredited by the Lebanese Ministry of Education.Topics include:Emergency Medicine Techniques (EMT)Combat Medic Advanced Skills Training (CMAST)Combat LifeSaver (CLS)Demining Medics Advanced Life Support (DMALS)

Just because you are trained for something doesn't mean you are prepared for it…With the NSEC, direct your staff into the right path.

Fanar, P.O.Box: 90815 Jdeideh – Metn, Lebanon, T +961 1 888921, E [email protected], W www.newheathconcept.net

1Med Emergency, MJEM – 2014, No 21

E D I T O R ’ s N O T E

Man is not born to die but to innovate...

In her famous book “The Human Condition” published in1958, the philosopher Hannah Arendt summarizes the historical development of human existence. She introduces the concept of vita activa (active life) which comprises three basic conditions under which humans live – labor, work, and action – and explains how the Ancient Greeks positioned each activity in one of the four possible realms: the political, the social, the public, and the private.

Labor is repetitive, never-ending and only includes the activities that are necessary to the sustenance of life with nothing beyond that. Work on the other hand, has a clearly defined beginning and end. As for Action, it aims to create something immortal. In this same sense, Action is irreversible.

Arendt’s philosophy can be applied to our realm of Emergency medicine as well where labor is a repetition of acquired scientific knowledge through techniques that are more and more sophisticated. The only way for us to better deal with clinical or therapeutic difficulties we face in our daily practice, is to achieve our Work (care provision) in a manner which respects dignity and humanity. Emergency care is a good example of a set of actions and relationships which cannot be predictable. It is up to us to immortalize our actions through useful and beneficial acts that focus on the patient as a human being and not as a pathology. Such an attitude is the only guarantee of a better world.

Nagi Souaiby, MD, MPH, MHMChief Editor

MED Emergency, MJEM

Mediterranean Journal of Emergency Medicine Publication of the Lebanese Resuscitation Council

By New Health ConceptP.O.Box 90.815 Jdeideh - Lebanon

Tel: 00961.1.888921 Fax: 00.961.1.888922Email: [email protected]

Website: www.newhealthconcept.net

EDitoRiaL boaRD

EDitoR iN CHiEfNagi SOUAIBY

MaNagiNg EDitoRMaria FrANGIEH

RESEaRCH Abdo KHOUrY (France)Steve PHOTIOU (Italy)

Jean-Cyrille PITTELOUD (Switzerland)

CoNtiNuouS EDuCatioNElvis COrDIEr (France)

Daryl MACIAS (USA)Karim BEN MILOUD (Switzerland)

iNNovatioN, EDitiNg aND tRaNSLatioNGuillaume ALINIEr (Qatar / UK)

Karim FArAH (Lebanon)Hugues LEFOrT (France)

oNLiNE PubLiCatioN aND DESigNIsmaël HSSAIN (France)

Alec KAZANDJIANMireille SrOUr

NuRSiNg Lina AOUN CHOUEIrY

Chantal SAADEH KHALILMiDwivES

Sabine ABOU MALHAM (Canada)StuDENtS’ foRuMS aND CoNfERENCES

Ziad KHOUEIrY (France)

PaRaMEDiCS aND aMbuLaNCESFrédéric HOEPPLI (Switzerland)

Juerg LINIGEr (Switzerland)

aDMiNiStRatioN aND MaRkEtiNgGeorges KHALIL

aLLiaNCES

Fire Brigade of Paris – FranceGlobal Network Association of Emergency Medicine

Global Emergency Medicine Literature reviewLebanese Society for Quality and Patient Safety

aDviSoRy CoMMittEE

Pierre ABI HANNA, Georges ABI SAAD, Nayla ABOU MALHAM DOUGHANE, Arthur ATCHABAHIAN, Omar AYACH, Abdelouahab BELLOU, Maria Paula GOMEZ, Thierry GrOS, Maurice HADDAD, Berthe HACHEM, Mohamed HACHELAF,

Jamil HALABI, Chokri HAMOUDA, Khalil HELOU, Aziz KOLEILAT, Bruno MEGArBANE, Ahmad OSMAN, Alissar rADY, Wassim rAFFOUL, Sami rICHA, Abdul MOHSEN AL

SAAWI, Karim TAZArOUrTE, Youri YOrDANOV.

...In hommage to Dr Jean Claude Deslandes

When there is a will, there is a way ..

. . . . . . . . . . . . . . . . . . . . . . . . . . p. 3

. . . . . . . . . . . . . . . . . p. 10

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 16

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 20

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 23

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 27

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 32

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 38. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 40

Original Articles Emergency responses in case of mass casualties’ different big bang incidents: the Paris fire Department prehospital medical care approachLefort H, travers s, BIgnanD M, MIHaI I, BégueC f, CaLaMaI f, Hersan o, tourtIer JP, CarPentIer JP

Original Articles (French)Le télédiagnostic, un concept adapté à l’évaluation de la contamination accidentelle ou intentionnelle d’une ressource en eautelediagnosis, an adapted concept for the accidental or intentional contamination water resource assessmentBaurès e, aDaMy C, Brogat M, CaDIère a, roIg B, tHoMas o

Case ReportChloroquine overdoseMaurIn o, arvIs aM, Lefort H, CHeCInskI a, travers s, MégarBane B, tourtIer JP

a patient with multiple sudden cardiac arrests due to coronary spasmCorsIa a, DuBourDIeu s, Jost D, tourtIer JP, DoManskI L, segaL n

Case Report (French)une embolie pulmonaire masquée derrière un tableau d’infarctus et dévoilée par l’échographie préhospitalièrePulmonary embolism masked by a myocardial infarction chart and revealed by prehospital echocardiography

kaDJI r, LaBorne fX, saPIr D, gouBe P, LagaDeC s, DesCLefs JP, BrIoLe n

Continuous EducationHiv and aiDS: global summary and basic factsraHaL k, frangIeH M

Continuous Education (French)Conduite à tenir devant les brûlures et atteintes caustiques oculaireswhat to do in case of burn and chemical eye burns and injuriesCasteLBou M, HenrIot C, DeLBosC B, saLeH M

General informationRecommendations for authorsMembership

C O N T E N T s

2 Med Emergency, MJEM – 2014, No 21


ORIGINAL ARTICLE

LEFOrT H, TrAVErS S, BIGNAND M, MIHAI I, BéGUEC F, CALAMAI F, HErSAN O, TOUrTIEr JP, CArPENTIEr JP. Emergency responses in case of mass casualties’ different big bang incidents: the Paris Fire Department prehospital medical care approach. Med Emergency, MJEM 2014; 21:3-9.keywords: Big-bang, disaster preparedness, mass casualties, resuscitation, terrorist, toxic, triage

EmErgEncy rEsponsEs in casE of mass casualtiEs’ diffErEnt big bang incidEnts: thE paris firE dEpartmEnt prEhospital mEdical carE approach

abstractintroduction: Taking into consideration the natural disasters, the industrial and terrorist attacks had changed significantly with time. The idea of terrorist threats such as chemical biological radiologic or nuclear (CBrN) have determined the authorities to change and adjust their approach.

Methods: Through the experience of the Fire Brigade of Paris (BSPP), we focus on the emergency services organization during a major event and on the triage of the victims, whether of a natural disaster or exposed to the CBrN.

Results: The new approach is based on a very clear and very well organized emergency care support, a very well organized commanding network, and last but not least a very well prepared logistic support.

Conclusion: The willingness and the necessity to anticipate the occurrence of such risks is materialized by the systematic well organized and clearly assigned functions: transport, triage, medical care, and evacuation of the victims. All of which are coordinated by the medical rescue direction.

Authors’ affiliation:Correspondent author: Hugues LEFORT, MDEmergency Medical Service, Fire Brigade of Paris, Paris, France1 place Jules Renard, 75017, [email protected]

Lefort H, MD1, Travers S, MD1, Bignand M, MD1, Mihai I, MD1, Béguec F, RN1, Calamai F, MD1, Hersan O, MD2, Tourtier JP, MD1, Carpentier JP, MD3

1. Emergency Medical Service, Fire Brigade of Paris (BSPP), France2. SMPM, Military Health Services, Paris, France3. Military Paramedics School, Toulon, France

Article history / info: Category: Original articleReceived: Nov 5, 2014Revised: Nov 19, 2014Accepted: Nov 26, 2014

Conflict of interest statement: There is no conflict of interest to declare

Dr Hugues Lefort


in order to avoid the overcrowding of the nearby hospitals already particularly flooded, in case of a disaster, by “walking-in” patients that have not been filtered through the PMA [9-11]. This was the case after the explosion of the AZF factory in Toulouse in France on 21st September 2001.

The criteria to intervene depend on the actual or potential number of victims, type of disposed emergency services and the level of their possible involvement. When putting in action an OrSEC-NoVi plan, it is essential to corroborate the available medical means to the anticipated number of victims. Duncan et al., interviewed [12] a number of English experts in disaster medicine. Their goal was to establish, by using the Delphi method, whether there was a consensus concerning the 232 items involved when managing 100 victims. At the end, 23% of the interviewees reached an agreement on 54% of the questioned items (n-134). This anticipation can also avail the concept of multiplying coefficient following the retrospective experience of such situations: the ratio between the initial and the final number of victims. The number of casualties, being the unique variable, it should be completed by qualitative criteria:

- The deployment or organization difficulties.- The technical complexity of the intervention: incarceration contamination.- The vulnerability of the structure involved: a hotel, a hospital, a nursery, a nursing home, a school, or more generally, any place open to the public.- The potential evolution of the event.

The resources’ deployment is done in two stages:

- The first stage, available without delay in a predetermined manner: the deployment of means and personnel able to intervene promptly.

- The second stage, the volume and nature are based on information collected by the first responders. Predetermined groups and modules might be sent, depending on the needs (e.g. search and rescue, PMA, evacuation group, etc.)

The Red Plan Alpha: a Parisian specificity France has not yet been faced with what is called acts of hyper terrorism like the ones that took place in Tokyo in 1995 [13;14], Madrid in 2004, London in 2005 or Bombay in 2006 [15-17], targeting massive destruction, on multiple sites and with possible use of CBrN substances [1].

Facing these new menaces, the authorities of the city of Paris have requested from the BSPP, in collaboration with the four EMS d’Ile de France, to be able to deploy simultaneously and on different locations the necessary means to ensure the command and control of at least four mass casualty sites, one of which may require the involvement of NrBC means, while maintaining a basic efficient operational activity. The red Plan Alpha (figure 2), put in place in 2007, aims to address the risk of mass influx of casualties, multi-site and terrorists attacks and bombings by restricting the initial rescue means involvement in order to be able to respond proportionately on several sites [18;19]. It also aims to preserve the operational services of emergency units and anticipate the potential risk of another attack on the original site. In this management of a large number of victims, the triage closest to the event must be conducted according to the principle of disaster medicine and the distribution of victims must be done to the proper hospitals. Thus, the term of “reinforcement” employed in the OrSEC-NoVi Zonal plan can then be implemented to enable the concerned area to benefit from all the necessary resources (means of interventions, hospital resources, etc.). Last, but not least, the patients vital signs monitoring must be registered, on-site and

Figure 2: Modality of deployment of Red Alpha Plan. BSPP©

At least 4 emergency engins for each of the multiple victims locations,One of wich might need involvement of the CBRN means

100 m

Explosion and/or terrorist attack with

multiple victims

Gathering Area Engins:

2 first–aid engins and FBP stretcher-bearersE

Triage Area Engins :

1 van, 6 medical engins

Evacuation Area Engins:

1 radio-connection engin,4 first-aid engins,10 associations engins and

engins for multiple victims transportation

U3

IE

U1

Dedicated radio channel

Gatheringofficer

Triage officer

Evacuation officer

1 victim for each medical

team

Dessins : René Dosne

U2

AU

RU

AU

RU

3 -5 victims for eachmedical team

«I requestdeploiment of the Red Alpha Plan ,TrocadéroSquare »

THE

RED

‘ALP

HA

’ P

LAN

ORIGINAL ARTICLE


BAUrèS E, ADAMY C, BrOGAT M, CADIèrE A, rOIG B, THOMAS O. Telediagnosis, an adapted concept for the accidental or intentional contamination water resource assessment. Med Emergency, MJEM 2014; 21:10-5.Mots clés : analyses in-situ, diagnostic rapide, mesure non paramétrique, pollution chimique des eaux, spectrophotométrie UV, téléassistance keywords: chemical pollution of water, fast diagnosis, in-situ analysis, non parametric measurement, remote support, spectrophotometry UV

lE tÉlÉdiagnostic, un concEpt adaptÉ À l’ÉValuationdE la contamination accidEntEllE ou intEntionnEllEd’unE rEssourcE En Eautelediagnosis, an adapted concept for the accidental or intentional contamination water resource assessment

abstractintroduction: In addition to existing approaches for the assessment of accidental or intentional contamination of water resource, the remote diagnosis has been developed to access quickly of relevant information.

Methods: Its implementation requires, on site, the use of a measurement and communication system enabling remote exchanges with an expert.

Results: This latter analyses the results of measures and establishes a first diagnosis about the presence of contamination and its nature, if possible. For this it has non-parametric data (including UV-visible spectra and fluorimetry) in addition to classical physico-chemical measurements (pH, conductivity, turbidity, temperature, dissolved O2, etc.).

Conclusion: Based on the results and required information, the expert can suggest conducting on site sampling and additional measures to better appreciate the temporal evolution of the contaminated water.

Authors’ affiliation:Correspondent author: Estelle BAURÈS, PhDLERES, EHESP Rennes, Sorbonne Paris Cité Avenue du Professeur Léon Bernard, 3500, Rennes, [email protected]

Baurès E, PhD1,2, Adamy C, MD3, Brogat M, PhD1,2, Cadière A, PhD4, Roig B, PhD4, Thomas O, PhD1,2

1. EHESP Rennes, Sorbonne Paris Cité, Avenue du Professeur Léon Bernard- CS 74312, 35000, Rennes, France2. INSERM, UMR Institut de recherche sur la santé l’environnement et le travail - 1085, LERES, Rennes, France3. SDIS d’Ille-et-Vilaine (35), 2 rue du Moulin de Joué, 35000, Rennes, France4. Université de Nîmes, EA7352 CHROME, rue du Dr Georges Salan, 30021, Nîmes, France

Article history / info: Category: Original articleReceived: July 9, 2014Revised: August 13, 2014Accepted: September 3, 2014


Dr Estelle Baurès

ORIGINAL ARTICLE


afin d’établir un diagnostic dans les plus brefs délais (quelques dizaines de minutes). Un point important est la possibilité de réaliser par le SMC des mesures non paramétriques [6] à l’aide de méthodes optiques simples et rapides comme la spectrophotométrie UV-visible ou la spectrofluorimétrie. Cette approche du diagnostic rapide consiste en l’identification d’un signal caractéristique d’une variation (dégradation) de la qualité de l’eau, sans chercher dans un premier temps à identifier un agent particulier. A titre d’exemple, une signature spectrale anormale (présence d’un pic au d’un épaulement) par rapport à celle d’une eau de surface non contaminée ou d’un échantillon de référence, permet de mettre en évidence une variation du milieu et peut amener à suspecter la présence d’un composé organique par exemple. Dans ce cas, cette substance peut être identifiée à partir d’une bibliothèque de spectres de composés purs [10], et dans un deuxième temps validée par les analyses en laboratoire.

Il ne s’agit donc plus, sur le terrain, de mesurer un paramètre, ou d’analyser une substance plus ou moins suspectée, mais de réaliser une mesure non paramétrique pertinente à partir des signaux optiques. Cette analyse spectrale est complétée par une série de mesure rapide renseignant sur la qualité globale de l’eau considérée (T°, turbidité, conductivité, pH, O2 dissous).

Dans un deuxième temps, une fonction de téléassistance permet d’envoyer à un expert les résultats par voie électronique (via le réseau internet ou satellitaire). L’expert alerté peut ainsi interpréter l’ensemble des éléments transmis (les signaux non paramétriques reçus, les spectres, les valeurs globales, les observations terrain) et fournir rapidement un avis sur la pollution suspectée ou survenue. Ce système communiquant permet à l’opérateur de recevoir rapidement les premières informations utiles pour une aide à la prise de décision (prélèvement et analyses complémentaires, fermeture d’un captage par exemple)

et permet donc un gain de temps très important.

Un prototype opérationnel de SMC a été développé pour le LErES par la société HOCEr. Le système, représenté schématiquement sur la figure 2 intègre plusieurs modules analytiques couplés au système de communication:

- Un module optique, composé d’un spectrophotomètre UV et fluorimètre permet la détection d’un ensemble des familles de substances comportant des groupements chromophores remarquables, ce qui permet de couvrir environ 95% des cas de contamination par substance organique, quelle soit intentionnelle ou accidentelle [10].

- Une sonde multi-paramètres robuste permet la mesure simultanée de six paramètres physico-chimiques (température, conductivité, turbidité, oxygène dissous, pH et potentiel redox). Outre la mesure de turbidité souvent associée à des contaminations microbiologiques [12], la mesure de conductivité différentielle (entre un échantillon contaminé et une référence en amont par exemple) permet de détecter une pollution minérale.

- Des kits colorimétriques complémentaires, de type « tests bandelettes », choisis pour leur facilité d’utilisation et leur rapidité de réponse complètent les mesures précédentes en cas de besoin. La sélection de ces tests est modulable [12].

- Un appareil photo numérique équipé d’un GPS intégré permet la géo-localisation de la contamination ou du (des) point(s) de prélèvement. Le géo référencement ainsi que les photos prises sur le terrain peuvent être également transmises à l’expert via internet.

L’ensemble a été développé pour répondre aux caractéristiques suivantes:

- Simplicité et facilité de transport et d’utilisation permettant un usage de ce système robuste par tout opérateur sur le terrain.- rapidité dans l’obtention des résultats, avec un délai réduit au minimum.- Communication par échange de données et d’information avec un expert.

Le tableau 1 synthétise les différents avantages et inconvénients des moyens disponibles en intégrant le SMC.

L’intérêt du concept de télédiagnostic et du système de mesure et de communication (SMC) associé, a été testé dans le cadre du

Sonde Spectro

KitsGPS Photo

Figure 2 : Concept technique et prototype du système de mesures et de communication

Positionnement

Moyens disponibles Délais Pertinence* Coûts**Prélèvements + analyses laboratoire +++ €€

Prélèvements + analyses sur site

Camion laboratoire ++ €€€€

Mesures et tests rapides sur site +/- €

télédiagnostic : Mesures + téléassistance ++ €

Tableau 1 : Comparaison des moyens disponibles

* par rapport à la réglementation et aux capacités analytiques** coût d’achat ou d’investissement

Evènements Alerte

Prélèvements Mesures sur site

Téléassistance(experts)

PrélèvementsMesures complémentaires

Rapport / conclusion

Figure 1 : Concept opérationnel du télédiagnostic

ORIGINAL ARTICLE


Authors’ affiliation:Correspondent author: Olga MAURIN, MDEmergency Medicine Department, Fire Brigade of Paris1 place Jules Renard, 75017, Paris, [email protected]

Maurin O, MD1, Arvis AM, MD1, Lefort H, MD1, Checinski A, MD, MSc2, Travers S, MD1, Mégarbane B, MD, PhD2, Tourtier JP, MD, PhD1

1. Emergency Medicine Department, Fire Brigade of Paris, France2. Department of Medical Critical Care Medicine, Lariboisière University Hospital, Paris, France

Article history / info: Category: Case reportReceived: Oct 2, 2014Revised: Nov 12, 2014Accepted: Nov 29, 2014

Conflict of interest statement: The authors declare no conflict of interest.

Dr Olga Maurin

introductionChloroquine has always been used as a treatment and prevention for malaria infection. In case of massive ingestion, intoxication can be harmful if not lethal. The first cases of chloroquine intoxication were reported in the literature in 1978 [1]. Additionally, there are few case-series from Africa including women who ingested higher dose as abortive measures [2]. In France, chloroquine overdose remains uncommon even though in the 80s, the number has increased following the publication of a book “suicide, instruction” which was rapidly withdrawn from publication.

Chloroquine overdose has a fast onset (1-3 hours) and high mortality (10% above 4 g). Being an over-the-counter medication (in several countries and in the past in France) and sold on

internet and some countries in boxes of 100 tablets of 100 mg made it easy to ingest a lethal dose. Conventional therapy did improve prognosis of the patient. However mortality is still elevated with severe overdose, hence triggering development of new unconventional therapies.

casE rEportWe report the case of a 45-year-old man with major depression, status post mitral valve replacement treated with fluindione (Previscan ®) who called the prehospital emergency services after the ingestion three hours prior of 100 tablets of 100 mg of chloroquine. A medical team was directed to his home. On arrival the patient was lying down with a Glasgow coma scale (GCS) of 11 (eye opening = 3, verbal response = 4 motor response = 4).

CAsE REpORT

MAUrIN O, ArVIS AM, LEFOrT H, CHECINSKI A, TrAVErS S, MéGArBANE B, TOUrTIEr JP. Chloroquine overdose. Med Emergency, MJEM 2014; 21:16-9.key words: chloroquine, ECMO, extracorporeal membrane oxygenation, mobil unit of cardiac assistance, overdose

chloroquinE oVErdosE

abstractChloroquine, a well-known anti-malarial drug may be lethal when ingested in large amount. We report the case of a 45 year-old patient who ingested 10 g of chloroquine in a suicidal attempt, 3 h prior to presentation. Despite aggressive management, the patient died on the third day. The ingested dose (> 4 g), the QrS duration (> 0.10 sec), and the onset of hypotension (systolic blood pressure < 100 mmHg) are the established prognosticators. The delay in management, the blood chloroquine concentration on admission, and the onset of cardiovascular complications also influence the final outcome. The treatment consists in tracheal intubation, mechanical ventilation, epinephrine and diazepam in the presence of any bad prognostic factor as well as 8.4% sodium bicarbonate in case of QrS complex enlargement on EKG. The chloroquine is not dialyzable nor hemofiltrated. extracorporeal membrane oxygenation (ECMO) might be helpful in the most severe case refractory to the pharmacological treatments.


COrSIA A, DUBOUrDIEU S, JOST D, TOUrTIEr JP, DOMANSKI L, SEGAL N. A patient with multiple sudden cardiac arrests due to coronary spasm. Med Emergency, MJEM 2014; 21:20-2.key words: cardiac arrest, cardiopulmonary resuscitation, coronary circulation, Prinzmetal’s angina, resuscitation

a patiEnt With multiplE suddEn cardiac arrEsts duE to coronary spasm

Authors’ affiliation:Correspondent author: Nicolas SEGAL, MD, PHDDepartment of Emergency Medicine, Lariboisière University Hospital2, rue Ambroise Paré, 75010, Paris, [email protected]

Corsia A, MD2, Dubourdieu S, MD3, Jost D ,MD3, Tourtier JP, MD, PhD3, Domanski L, MD3, Segal N, MD, PhD1

1. Emergency Medicine Department, AP-HP, Lariboisière University Hospital, F-75018, Paris, France2. Emergency Medicine Department, Robert Boulin hospital, 33500, Libourne, France3. Emergency Medicine Department, Fire Brigade of Paris, France

Article history / info: Category: Case reportReceived: Oct 1, 2014Revised: Oct 22, 2014Accepted: Nov 5, 2014


Dr Nicolas Segal

CAsE REpORT

abstractaim: To report the case of a patient suffering multiple cardiac arrests due to coronary spasm. Prinzmetal’s angina which is under-diagnosed can be responsible for myocardial ischemia with all its resulting complications, the most severe being conductive and ventricular rhythm disorders and asystole.

Methods: The Paris fire brigade’s basic life support and mobile intensive care unit team’s records as well as inpatient hospital records were the data sources for this report. The patient’s consent was obtained before any data was utilized.

Case Report: A 66-year-old man with a long history (years) of undiagnosed fainting spells suffered four cardiac arrests the same morning. After two successful returns of spontaneous circulation resuscitative efforts, the patient exhibited a completely normal cardiovascular and neurological profile. After the second cardiac arrest, he complained of typical chest pain. Initially his ECG showed atrial fibrillation without any heart block or repolarisation abnormalities. After the cardiac arrest it changed to an inferior and lateral ST depression and then to an inferior ST elevation.

His coronarography showed no acute coronary lesion. Nonetheless, the Methergin® test confirmed a Prinzmetal’s angina diagnosis.

Conclusion: The Prinzmetal’s angina or angina inversa are terms used to indicate a clinical and physiopathological entity different from traditional angina. The guideline for resuscitation should discuss the use of adrenaline (epinephrine) in this particular setting where its alpha effects may worsen the spasms.


Continuous EduCation

KADJI r, LABOrNE FX, SAPIr D, GOUBE P, LAGADEC S, DESCLEFS JP, BrIOLE N. Pulmonary embolism masked by a myocardial infarction chart and revealed by prehospital echocardiography. Med Emergency, MJEM 2014; 21:23-6.Mots clés : angioscanner thoracique, échocardiographie préhospitalière, embolie pulmonaire, malaise, service d’aide médicale urgente SAMU, service mobile d’urgence et de réanimation SMUr, syndrome coronarien aigu, urgenceskeywords: acute coronary syndrome, Emergency Medical Assistance Services, emergency room, malaise, Mobile Emergency and Intensive Care Services, prehospital echocardiography, pulmonary embolism, thoracic angioscan

unE EmboliE pulmonairE masquÉE dErrièrE un tablEau d’infarctus Et dÉVoilÉE par l’Échogra-phiE prÉhospitalièrEpulmonary embolism masked by a myocardial infarction chart and revealed by prehospital echocardiography

abstractPulmonary embolism is a frequent cardiovascular emergency, but the clinical diagnosis is often difficult. Confusion with acute coronary syndrome can be possible; an echocardiography at the prehospital care could enable to discriminate these two pathologies.

We report the case of a 54 years old woman, with dyslipidaemia and overweight, examined by a prehospital medicalized team in Paris region for chest pain. The electrocardiogram found a depressed ST-segment in the inferolateral and apical segments. A prehospital echocardiography rectified the initial diagnosis of acute coronary syndrome in favor of a pulmonary embolism with signs of acute cor pulmonale and the absence of left ventricular dysfunction. These arguments had allowed initiating the appropriate treatment and guiding the patient to the adequate service.

With the advent of compact and portable devices, ultrasound is now transportable in prehospital medicine. The echography seems simple, non-invasive, extremely informative and discriminating; in prehospital setting, it must help answering questions without delaying the standard care.

Authors’ affiliation:Correspondent author: Roger KADJI, MD SAMU 91 – SMUR Corbeil, Centre Hospitalier Sud FrancilienF-91108, Corbeil Cedex Essonne, [email protected]

Kadji R, MD1, Laborne FX, MD1, Sapir D, MD1, Goube P, MD2, Lagadec S, MD1, Desclefs JP, MD1, Briole N, MD1

1. SAMU 91 – SMUR Corbeil, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France2. Service de cardiologie, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France

Article history / info: Category: Case reportReceived: Sept 10Revised: Oct 29Accepted: Nov 19


Dr Roger Kadji

CAsE REpORT


Continuous EduCation

rAHAL K, FrANGIEH M. HIV and AIDS: global summary and basic facts. Med Emergency, MJEM 2014; 21:27-31.keywords: AIDS, HIV, MArPs, Post exposure prophylaxis, prevalence rate

hiV and aids: global summary and basic facts

“Our mission is to build a better world, to leave no one behind, to stand for the poorest and the most vulnerable in the name of global peace and social justice.”

Ban Ki-moonUnited Nations Secretary-General

abstractInvesting in AIDS is leading to concrete outcomes with an optimistic view to end this epidemic. Unfortunately, achievement and progress related to this disease are not fairly disseminated among high risk populations. There is a need to reform policies and punitive laws, in addition to ensuring adequate access to treatment without forgetting the importance of addressing stigma and discrimination, implementing an efficient awareness campaign and prevention program and services taking into consideration specificities of each region. HIV program must be integrated within the national disaster preparedness and response plans. International and national efforts need to rise, especially from the government side along with the civil society to efficiently overcome health threatening conditions facing vulnerable populations. This article addresses main findings and limitations in the region and serves as a reminder on basic facts versus myths and a global summary on HIV/AIDS.

Authors’ affiliation:Correspondent author: Kinana RAHAL, MSHIV training officerHIV/AIDS Unit, UNIFIL, Naqoura, [email protected]

Rahal K, MS1, Frangieh M, MS2

1. HIV/AIDS Unit, UNIFIL, Naqoura, Lebanon2. Managing editor, Med Emergency, Fanar, Lebanon

Article history / info: Category: Continuous educationReceived: Oct 8, 2014Revised: Oct 29, 2014Accepted: Nov 12, 2014


Kinana Rahal

CONTINuOus EDuCATION

introductionInvesting in Acquired Immunodeficiency Syndrome (AIDS) is leading to concrete outcomes with an optimistic view to end this epidemic.

In 2013, Human Immunodeficiency Virus (HIV) cases worldwide have reached 35 million. New infections in that same year were 38% lower rate than that in 2001 with

approximately 2.1 million new HIV cases.

Moreover, after reaching a peak in 2005, a 35% decline in death rate from AIDS related causes was observed in 2013. However, it is worth noting that antiretroviral therapy is not equally covered between children (24%) and adults (38%); those rates increased respectively by 3% and 6% by mid 2014.


CASTELBOU M, HENrIOT C, DELBOSC B, SALEH M. What to do in case of burn and chemical eye burns and injuries. Med Emergency, MJEM 2014; 21:32-7.Mots clés : brûlures oculaires, brûlures caustiques, thermiques, rayonnementkeywords: ocular burn, chemical burn, thermic, radiation

conduitE a tEnir dEVant lEs brulurEs Et attEintEs caustiquEs oculairEsWhat to do in case of burn and chemical eye burns and injuries

abstractOcular burns are a common emergency situation where the cooperation between the emergency physician and ophthalmologist is essential for evaluation and for optimum treatment of patient. A prompt and appropriate management will allow minim functional sequelae that can be very disabling. Knowledge of the causative agents, well-performed clinical examination and efficient eyewash are needed before more specialized treatments are considered.

Authors’ affiliation:Correspondent author: Maher SALEH, MD, PhDDépartement d’ophtalmologie-Centre Hospitalo-Universitaire de Besançon, France3 boulevard Fleming, Besançon 25030, [email protected]

Castelbou M, MD, Henriot C, MD, Delbosc B, MD, Saleh M, MD, PhDDépartement ophtalmologie, Centre Hospitalo-Universitaire de Besançon, France

Article history / info: Category: Continuous educationReceived: Nov 4, 2014Revised: Nov 19, 2014Accepted: Nov 26, 2014


Photo credit:The iconography of this article is original, owned by the ophthalmology department of the University Hospital of Besançon.

Dr Marie Castelbou

rÉsumÉLes brûlures oculaires sont une situation d’urgence fréquente où la coopération urgentiste-ophtalmologiste est primordiale afin d’évaluer et de traiter au mieux le patient. Une prise en charge rapide et adaptée permettra de minimiser les séquelles fonctionnelles qui peuvent être très invalidantes. La connaissance des agents causaux, un examen clinique bien conduit et un lavage oculaire bien réalisé sont nécessaires avant que des traitements plus spécialisés ne soient envisagés.



Le grade iv est défini par une atteinte de 6 à 9 heures de limbe et 50% à 75% de la conjonctive. Le pronostic va de bon à réservé.

Le grade v est synonyme de mauvais pronostic. Il se définit par une destruction subtotale du limbe supérieure à 9 heures mais inférieure à 12 heures et de 75% à 99,9% de la conjonctive.

Le grade vi implique une atteinte limbique sur 360° ainsi qu’une destruction de 100% de la conjonctive. Le pronostic est très mauvais quel que soit le traitement utilisé.

traitEmEntsLes traitements spécifiques seront prescrits par l’ophtalmologiste :

Traitements médicaux [7]- Lubrifiants locaux: les larmes artificielles sans conservateurs diminueront la kératite superficielle due à la brûlure et au lavage intensif [11].

Les pommades ophtalmiques sont à éviter.

- Les antibiotiques locaux à larges spectres éviteront une surinfection bactérienne secondaire. (ex : collyre à la tobramycine ou au chloramphénicol, rifamycine, azythromycine).

- Collyres cycloplégiques : diminuent l’inflammation des corps ciliaires, limitent les synéchies, effet antalgique.

- Antalgiques per os à la demande.

- Corticoïdes locaux pendant les 10 premiers jours. Ces derniers seront à manier avec précaution, ils peuvent retarder la cicatrisation et favoriser l’infection. Ils seront indispensables en présence d’un Tyndall de chambre antérieure (inflammation) [11].

- Prévention des symblépharons par passage régulier d’un écouvillon dans les culs de sac conjonctivaux, ou mise en place d’anneaux scléraux. Dans les formes les plus sévères, les adhésions (symblépharons) peuvent être responsables de malposition palpébrale et d’ulcère par exposition à distance de la brûlure.

Traitements chirurgicauxL’intervention chirurgicale se fait le plus souvent sous anesthésie générale. Dans l’urgence, le but est de prévenir la perforation oculaire et d’éviter la constitution de synéchies et de symblépharons. Dans un deuxième temps, le but de la chirurgie sera de préserver la transparence des milieux, en particulier de la cornée par autogreffe de limbe ou par kératoplastie transfixiante (greffe de cornée) dans les formes les plus évoluées.

- Débridement avec excision économique des tissus nécrosés

- Greffe de membrane amniotique [12-14] (figure 4)

- Autogreffe de limbe en cas d’insuffisance limbique dans les brûlures unilatérales après excision du pannus fibrovasculaire,

ou de cellules épithéliales limbiques mises en culture sur une membrane amniotique [15-18]

- Plastie ténonienne ou conjonctivale par autogreffe conjonctivale ou de muqueuse buccale ou nasale selon l’étendue [19]

- Greffe de cornée (figure 5)

L’arbre décisionnel suivant [7] permet d’optimiser la prise en charge des brûlures oculaires (tableau 1).

cas particuliEr dEs brûlurEs par

Figure 4: Greffe de membrane amniotique. Photographies à la lampe fente (gros-sissement x 7,5). La membrane amniotique est un composant du placenta qui accélère la cicatri-sation cornéenne et évite la perforation. Elle se délite spontanément au bout de 3 à 4 semaines.

Figure 5: Greffe de cornée par kératoplastie transfixiante gauche. Photographies à la lampe fente (grossissement x10). Le greffon est prélevé sur un donneur cadavérique et préparé par la banque d’organes (dans ce cas l’établissement français du sang). Notez au centre le greffon transparent de 8 mm entouré par un surjet intracornéen non résorbable. Le tissu du receveur est souvent ischémié en cas de brûlures oculaires ce qui augmente les risques de rejet.



Med Emergency, MJEM the Mediterranean Journal of Emergency Medicine The Journal publishes articles in English and/or French pertai-ning to Emergency Medicine from its scientific aspect (research, case studies, clinical articles, orientation and practical conduct), administrative (Management and organization of Emergency Me-dicine), medical-legal and social aspects. It also accepts articles that deal with prevention of emergencies. Although it focuses more on practical issues of emergency medicine, the Journal accepts theoretical, methodological and analytical articles. It is also interested in communications, letters, commentaries and critiques of issues related to emergency. Authors can submit their original articles and the accompanying references to the editor: New Health Concept B.P. 90.815 Jdeideh- Lebanon or via email. The article should be accompanied by a letter by the author/s that clearly states that joint authors of the article are aware of the application to publish and have agreed to allow free accessing of texts by New Health Concept Edition publication. Please create a separate file (indicating the name of the author) for all the photographs, tables and graphs you would like to be included in the article and send them to the following address: [email protected] All submissions will undergo a preliminary evaluation and an ethical revision by the editorial board to determine whether it will be allowed to appear in the journal. Articles that pass this preliminary evaluation will also be anonymously reviewed by two members of a scientific committee. Once the article has been approved for publication, a biography of 10 lines should be developed.

manuscript prEparation Articles are to be submitted in a typewritten format. Paragraphs are double spaced. Font size should be 12. The submitting author should send his contact details with the article such as telephone number or an email address. The original text of the article should be sent without illustrations in its original format (e.g. Microsoft Word). Pages should be numbered. Titles and subtitles of equal importance should be marked identically. Abbreviations should be explained when first encountered in the text. The articles should not exceed 2500 words or not more than 10 pages. Abstracts and Key Words: Each article should include an abstract In English (and in French for French articles) no longer than 300 words. Keywords (not more than 6 words) and the title of the article should also be presented in both languages. Text: The author needs to respect the following formatting pro-cedures when submitting the article: • On the front page- the author’s name, affiliations, complete mai-ling address, telephone number and email address. The names and the affiliations of collaborators should be clearly indicated. Please ensure that this information is only presented on the front page and does not appear on the other pages of the article. • Bibliographic references need to appear in order of appea-rance in the text. They must be identified in the text by Arabic numbers in brackets. There should be about 10-30 references. They must conform to presentation norms applied in the scien-tific editing world (vancouver style). • Photographs, figures, graphs and tables: these should be sent in separate files and need to be numbered and marked with the author’s name and commentary. They need to be numbered in chronological ordered when they are to be referred to in the text. The term “graph/table/figure/photo number x” should be used in order to avoid confusion with bibliographical references. • End notes should be listed separately at the end of the text and not at the end of each page. Ps: It’s strongly recommended to add photography of the author who can also allow us to communicate his e-mail address.

for research original articles and review articles authors should clearly note the following: • If the study was approved by a local or international IRB (insti-tutional review board), a government ministry, or a community group. • The design of a study: a randomized controlled trial or an observational study that includes a control group.• Discuss attempts to limit bias in the article.• The design of a review: formal meta-analysis or a systematic review that only includes studies with a control group how the review articles are selected.• Which statistical tests are used to analyze the data?

addEndumconflict-of-interest statement* Conflict of interest exists when an author (or the author’s institution), reviewer, or editor has financial or personal relationships that inappropriately influence (bias) his or her actions (such relationships are also known as dual commitments, competing interests, or competing loyalties). These relationships vary from those with negligible potential to those with great potential to influence judgment, and not all relationships represent true conflict of interest. The potential for conflict of interest can exist whether or not an individual believes that the relationship affects his or her scientific judgment. Financial relationships (such as employment, consultancies, stock ownership, honoraria, paid expert testimony) are the most easily identifiable conflicts of interest and the most likely to undermine the credibility of the journal, the authors, and of science itself. However, conflicts can occur for other reasons, such as personal relationships, academic competition, and intellectual passion. statement of informed consent* Patients have a right to privacy that should not be infringed without informed consent. Identifying information, including patients’ names, initials, or hospital numbers, should not be published in written descriptions, photographs, and pedigrees unless the information is essential for scientific purposes and the patient (or parent or guardian) gives written informed consent for publication. Informed consent for this purpose requires that a patient who is identifiable be shown the manuscript to be published. Authors should identify Individuals who provide writing assistance and disclose the funding source for this assistance. Identifying details should be omitted if they are not essential. Complete anonymity is difficult to achieve, however, and informed consent should be obtained if there is any doubt. For example, masking the eye region in photographs of patients is inadequate protection of anonymity. If identifying characteristics are altered to protect anonymity, such as in genetic pedigrees, authors should provide assurance that alterations do not distort scientific meaning and editors should so note. statement of human and animal rights* When reporting experiments on human subjects, authors should indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach, and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should be asked to indicate whether the institutional and national guide for the care and use of laboratory animals was followed.

*International Committee of Medical Journal editors ("uniform requirements for Manuscripts submitted to Biomedical Journals") -- february 2006

RECOMMENDATIONs FOR AuTHORs

EDitoR iN CHiEf aND DiRECtoR Nagi SOUAIBY

MaNagiNg EDitoRMaria FrANGIEH

ExECutivE boaRDIsmaël HSSAIN Abdo KHOUrY

Hugues LEFOrT

CovER PiCtuRE PréfecturePolice\BSPP\BurnerP©

DESigN

Mireille SrOUr: Creative Couple

wEbMaStERAlec KAZANDJIAN: Web Sart

PRiNtiNgMELKI PrINT INTErNATIONAL S.A.L.

Quarterly Journal ISSN No 2222-9442Printed in Lebanon

All rights reserved. Please note Med Emergency Publication copyright in all reprints.

the advertising organizations:

NSEC – cover page 2. Karl-Storz – page 39. Med Emergency MJEM – cover page 3. ECG book – back cover.

ONLINE SUBSCRIPTIONhttp://www.newhealthconcept.net/subscribe.asp

Kindly fill and send by email to:Med Emergency, MJEM Publications, New Health Concept,Email: [email protected]

MED EMERGENCY Publications - P.O. Box 90.815 - Jdeideh - Lebanon Tel: +961-1-888921, Fax: +961-1-888922

Membership

Individual

Student

Institution

110

90

200

180

130

350

4 Issues1 Year(USD)

8 Issues2 Year(USD)

E-copy Printed copy

NameSurnameAddress

P.O.Box CityCountryTel EmailProfession Affiliation

ELECTROCaRdiOGRaMME SiMPLiFiÉUn guide pratique pour tousGOTTWALLES Y - Président du Collège de Médecine d’Urgence du Nord-Est Chef de Pôle, Chef de Service, Praticien Hospitalier, Pôle Urgences Pasteur - Hôpitaux civils de Colmar et 39, avenue de la Liberté 68024 COLMAR Cedex - FranceKEMPF N - Assistant spécialiste, Pôle Urgences Pasteur - Hôpitaux civils de Colmar - 39, Avenue de la Liberté. 68024 COLMAR Cedex – FranceSAVINEAU-RAETH JR. Assistant spécialiste, Pôle Urgences PasteurHôpitaux civils de Colmar - 39, Avenue de la Liberté. 68024 COLMAR Cedex - FranceLEFORT H - Urgentiste, - Brigade de sapeurs-pompiers de Paris, Service de santé des arméesSOUAIBY N - Urgentiste réanimateur, des universités de Montpellier et de Paris Éditeur en Chef de la revue Méditerranéenne de Médecine d’urgence (MJEM).

La cardiologie est une discipline qui effraie souvent les étudiants du fait de la lecture des électrocardiogrammes qu’elle impose. Et malgré les extraordinaires développements technologiques que la discipline a connus avec en premier lieu l’apport de l’échocardiographie, l’électrocardiographie demeure un élément fondamental de sa pratique quotidienne.

Un nouveau livre sur l’électrocardiographie s’imposait-il ? Oui bien sûr, quand on discute quotidiennement avec les étudiants en médecine qui ont conscience des difficultés imposées par le déchiffrage de ces tracés, pour l’exercice futur de leur profession comme pour l’obtention des examens préalables à l’obtention du diplôme.

Ce livre « pour les nuls » ne doit pas être déconsidéré par son titre. Il est extrêmement fourni, parfaitement didactique et complet pour tout médecin qui veut être performant dans la lecture de l’électrocardiogramme, autant l’étudiant que le médecin généraliste ou spécialiste.

Le Docteur Yannick GOTTWALLES est « tombé dedans quand il était petit », en tous cas au moins très prématurément dans sa pratique de médecin. Il a su comprendre les attentes de ses confrères dans ce domaine et s’est attelé, après des années d’enseignement pratique, à rédiger ce livre pour offrir au plus grand nombre l’opportunité d’accéder à toute l’expérience qu’il a accumulée.

En tant qu’Universitaire en Cardiologie et Maladies Vasculaires pour la formation initiale des étudiants, mais aussi Président de la Société Française de Cardiologie pour la formation continue des praticiens, je ne peux qu’encourager une telle entreprise dont le succès ne me semble faire aucun doute !

Professeur Yves JuillièrePrésident de la Société Française de Cardiologie

Sarl Dominique TORREILLES - 11, Boulevard Henri IV - CS 79525 - 34960 Montpellier Cedex 2 - Tél. : 04.67.63.68.80 - Fax : 04.67.52.59.05E-mail : [email protected]

Succursale : 8, rue de Primatice - 75013 Paris - Tél. : 01.40.09.27.71 - Fax : 01.40.09.80.71Comptabilité : Tél. : 04.67.63.68.82 - Fax : 04.67.63.68.84

L’essentiel de la librairie médicale et paramédicale disponible en ligne

www. livres-medicaux.com

Ouvrage indispensable et accessible

Isbn : 978 284023 955 0 154 pages - Format 15x21 cm

Pub ECG.indd 1 20/01/15 12:21

med emergency / urgence - new health concept 21 online version.pdf · aziz koleilat, bruno...

Documents