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MED EMERGENCY / URGENCE
ISSN 2222-9442
Clinical care for sexual assault survivors: the
use of a multimedia training tool
Triple rule-out MDCT-angiography for chest
pain in emergency room
Analyse qualitative du conseil médical donné
par les médecins généralistes et urgentistes
du Service d’aide médicale urgente
A disconcerting leg: a case of deep vein
thrombosis with negative D-dimers
Cardiac arrest caused by torsades de pointes?
La médecine d’urgence et le droit au Liban
Les urgences médicales en ophtalmologie
Trimestriel
Toxicité des cathinones de synthèse
Endorsed by
June 2015 - N°23
When there is a will,
there is a way ..

MED Emergency, MJEM
Mediterranean Journal of Emergency Medicine
Publication of the Lebanese Resuscitation Council
By New Health Concept
P.O.Box 90.815 Jdeideh - Lebanon
Tel: 00961.1.888921 Fax: 00.961.1.888922
Email: [email protected]
Website: www.newhealthconcept.net

Editorial board
Editor in Chief
Nagi SOUAIBY
Managing editor
Maria Frangieh

International relations
Abdo KHOURY (France)

Research
Steve PHOTIOU (Italy)
Jean-Cyrille PITTELOUD (Switzerland)
Continuous Education
Elvis CORDIER (France)
Daryl MACIAS (USA)
Karim BEN MILOUD (Switzerland)
Innovation, Editing and Translation
Guillaume Alinier (Qatar / UK)
Karim FARAH (Lebanon)
Hugues LEFORT (France)
Online Publication and Design
Ismaël HSSAIN (France)
Alec KAZANDJIAN
Mireille SROUR
Nursing
Lina AOUN CHOUEIRY
Chantal SAADEH KHALIL
Midwives
Sabine Abou Malham (Canada)
Students’ Forums and conferences
Ziad KHOUEIRY (France)
Paramedics and Ambulances
Frédéric HOEPPLI (Switzerland)
Juerg LINIGER (Switzerland)
Administration and Marketing
Georges KHALIL

Alliances
Fire Brigade of Paris – France
Global Network Association of Emergency Medicine
Global Emergency Medicine Literature Review
Lebanese Society for Quality and Patient Safety

advisory Committee
Pierre ABI HANNA, Georges ABI SAAD,
Nayla Abou Malham Doughane, Arthur ATCHABAHIAN,
Omar AYACH, Abdelouahab BELLOU, Jean Claude DESLANDES,
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,
Elie SALAME, Karim TAZAROURTE, Youri YORDANOV.

Med Emergency, MJEM – 2015, No 23
E D I T O R I A L
Emergency medicine in the European and Arab Mediterranean countries would
benefit by coming even closer together.
The Mediterranean Journal of Emergency Medicine plays a role in this process of
building bridges of understanding between the European and Arab Mediterranean
countries.
I believe that the European Society of Emergency Medicine (EuSEM) can also help
physicians in all Mediterranean countries, whatever their culture, to achieve their
career goals and to help to improve emergency care for all patients.
We are a forum where everyone in the Mediterranean region can come together
and meet in peace and friendship. It is one of EuSEM’s aims to become a source
of information to answer any question raised about emergency medicine. We
want to become a matrix providing the answers to questions about clinical and
pre-clinical emergency medicine needed by physicians in training and undergoing
further training in their roles.
We want to provide answers about scientific medical questions but also to questions
about organisation and management of emergency medicine. This will include
working methods in emergency departments, personnel requirements, economics
and budgets.
To help achieve this aim we have set up a series of EuSEM working groups to
examine a range of themes such as research, education and training, professional
working methods, pre-hospital emergency medicine and young emergency doctors.
We hope that more physicians from the entire Mediterranean region will become
international members of EuSEM so enabling them to profit from this new source of
information, to achieve their personal goals and to improve the care of emergency
patients everywhere in the Mediterranean region.
EuSEM has also developed and implemented the European Board Examination
Emergency in Medicine (EBEEM) for physicians in emergency medicine. This exam
aims to create a uniform high standard in emergency medicine in every European
country, benefitting both physicians and patients.
The European specialty organisation UEMS is certifying this and undertaking the
final examinations in cooperation with EuSEM.
Physicians from all Mediterranean countries are invited to take part in the EBEEM
examination. EuSEM also organises education, training and preparation courses
for the EBEEM exam.
Physicians from both European and Arab Mediterranean countries can also take
part in these preparation courses. This will give them the opportunity to gain
Emergency medical training which may not be fully available in their own countries.
On a personal level, the examination board candidates will also gain a marvellous
personal opportunity to meet their European colleagues for a first hand exchange
of views about the answers to problems and challenges in their work.
EuSEM also now has its own annual congress. This event not only attracts delegates
from all over Europe, but also from America, Asia and the Middle East.
We have special congress tracks called "EuSEM meets..." in which a country or
region is explored in a special congress session.
In coming years I would hope that many Arab Mediterranean countries will be the
subject of an "EuSEM meets" congress session so that they can play an active role
in the congresses.
I hope many more physicians from both European and Arab Mediterranean
countries will attend EuSEM congresses. I also hope that more of them will
participate by making speeches and presentations.
Physicians can start this process by submitting abstracts for consideration by the
EuSEM congress reviewers.
Emergency physicians from both the European and Arab Mediterranean countries
can make a contribution to this cooperation by attending EuSEM’s congress in Torino
in October this year to gain the "truly European flavour of emergency medicine".
Europe and the Arab countries may have different cultures but I believe the values
of emergency physicians are the same all over the world: we share the goal that all
patients in emergency departments should get the best possible emergency care.
Dr. med. Barbara Hogan, MBA
President EuSEM
1
C O N T E N T S
Original Article
Clinical care for sexual assault survivors: the use of a multimedia training tool
​Souaiby N, Smith J, Naja L, MICHAEL S
..........................................................................................
Review Article
Triple rule-out MDCT-angiography for chest pain in emergency room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NADER L
Original Articles (French)
Analyse qualitative du conseil médical donné par les médecins généralistes et urgentistes du Service d’aide
médicale urgente
Qualitative analysis of medical consultation given by general practitioner and emergency physicians of the
emergency medical assistance system in France
Piednoir A, Foudi H, Foudi L, Cesareo E, Tazarourte K
................
Case Report
p. 3
p. 10
p. 15
A disconcerting leg: a case of deep vein thrombosis with negative D-dimers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Thomas L, Sempere H
p. 21
Cardiac arrest caused by torsades de pointes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Franchin M, Frattini B, Luft A, Klein I, Tourtier JP
p. 24
Continuous Education (French)
La médecine d’urgence et le droit au Liban . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Emergency medicine and the law in Lebanon
DIAB n
p. 26
Urgences médicales en ophtalmologie - Conduite à tenir
How to manage medical emergencies in ophthalmology
HENRIOT C, Castelbou M, Delbosc B, Saleh M
p. 33
..................................................................................................................................................
Toxicité des cathinones de synthèse : un problème émergeant aux urgences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Toxicity of synthetic cathinones: an emerging concern in the emergency department
Mégarbane B
General information
Recommendations for authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
p. 42
p. 47
p. 48
Med Emergency, MJEM – 2015, No 23
O ri g inal article
​Souaiby N, Smith J, Naja L, MICHAEL S. Clinical care for sexual assault survivors: the use of a multimedia training tool.
Med Emergency, MJEM 2015; 23:3-9.
Key words: Multimedia training tool, sexual and gender based violence, sexual assault survivors, training of trainers
ABSTRACT
Introduction: Sexual assault rises as a global public health in conflict-affected populations where chaos prevails and gender
based violence becomes as a strategy of war. The health effects of sexual violence include unwanted pregnancy, unsafe
abortion, sexually transmitted infections (STIs), physical and psychological trauma, and social stigma. Training health care
providers (HCPs) has been prioritized by humanitarian actors globally to improve the quality clinical care to survivors of sexual
violence. However, few studies have evaluated the effectiveness of training interventions in refugee and post-conflict settings.
Methods: A four to five days “training of trainers” (ToT) was provided to relevant community health workers, nurses, midwives,
doctors and other relevant field workers working in conflict-affected environments in Jordan, Turkey, Syria and Lebanon using the
“Clinical care for sexual assault survivors (CCSAS) multimedia training tool” developed by International Rescue Committee (IRC).
Results: Overall, six ToTs took place; they included general practitioners, obstetrician/gynecologists, pediatricians, psychologist,
forensic physicians, nurses, social workers, midwifes, and program officers. In Jordan, 50 participants (two groups of 25) have
completed the training; the group improved by 142% on average at post-test in knowledge and attitudes to care for survivors (25%
on average of correct answers at pretest, 60.5% on average at posttest). A second ToT in Jordan included 22 participants who
have improved by 57.6% on average (50.3% vs. 79.3%). The third ToT in Turkey included 13 participants who have improved by
47% on average (38.5% vs. 56%). A forth ToT took place in Lebanon where 19 participants have improved by 62.5% on average
(56% vs. 91%). The fifth ToT in Syria, included 18 participants who have improved by 46.2% on average (52% vs. 76%). And the
sixth ToT took place in Turkey where nine participants have improved by 82.6% on average (46% on vs. 84%).
Discussion: All participants have successfully completed the training and showed improvement at the posttests. However,
key challenges and limitations identified included logistics at the preparation and recruitment stages, language barrier and
differences in cultural or religious views. Key barriers to quality care identified included poor or lack of access to services,
lack of trained staff, lack of privacy and confidentiality and lack of essential resources and treatment including emergency
contraception and HIV post-exposure prophylaxis (PEP) as well as unclear referral mechanism. Action plans were developed
by participants to address these barriers and follow-up to evaluate progress was planned.
Conclusion: The CCSAS multimedia training tool showed an initial positive impact and has demonstrated effectiveness in
promoting compassion and competence among trained HCPs and improving quality of clinical care for sexual assault survivors
in such humanitarian settings. On-going technical and psychosocial support, long-term behavior change interventions, supply
chain management, monitoring and evaluation, and interventions to raise awareness and identify survivors of sexual assault
are needed in addition to the training to ensure quality clinical care is delivered to sexual assault survivors.
Authors’ affiliation:
Correspondent author: Nagi SOUAIBY, MD, MPH, MHM
Faculty of Medicine, Saint Joseph University, USJ, Beirut, Lebanon
[email protected] [email protected]
Souaiby N, MD, MPH, MHM1, Smith J, MPH2, Naja L, MBA3​,
Michael S, MPH3​
​1. ​Faculty of Medicine, Saint Joseph University, USJ, Beirut, Lebanon
2. ICAP, Columbia University Mailman School of Public Health, New
York, USA
3. ABAAD-Resource Center for Gender Equality, Beirut, Lebanon
Med Emergency, MJEM – 2015, No 23
Article history / info:
Category: Original article
Received: Apr. 1, 2015
Revised: Apr. 22, 2015
Accepted: May 13, 2015
Conflict of interest statement:
The author declare a conflict of interest although
t he a rticle followed the regular reviewing
procedure
Dr Nagi Souaiby
3
R e V I E W article
NADER L. Triple rule-out MDCT-angiography for chest pain in emergency room. Med Emergency, MJEM 2015; 23:10-4.
Key words: Acute coronary syndrome, aortic dissection, chest pain, emergency department, pleural disease, pericardial disease,
pulmonary embolism, triple rule-out MDCT-angiography
ABSTRACT
One of the most common symptoms encountered in emergency rooms (ER) is chest pain. It does not only have cardiac
origin, differential diagnoses include vascular origin of pain as acute aortic dissection and pulmonary origin of pain such as
pulmonary embolism.
Several articles have demonstrated the importance and accuracy of a triple rule-out (TRO) multidetector computed tomography
angiography (MDCT-angiography) for managing chest pain in the ER. This article is a review of the “TRO” MDCT-angiography
for chest pain in ER.
While there are many exams for every clinical diagnosis, there is no diagnostic technique that can provide as comprehensive
evaluation and allow quick diagnostic orientation and targeted taking care for chest pain in the emergency department as
TRO MDCT-angiography.
TRO MDCT-angiography is the examination of choice to perform in the emergency department for patient with chest pain. It
can assess the coronary arteries, the pulmonary arteries, the thoracic aorta and other thoracic diseases.
Authors’ affiliation:
Correspondent author: Lucie NADER, MD, MHS, EMBA
Radiologist-Cardiovascular Imaging
Nawfal Medical Center, Byblos, Lebanon
El Arz Hospital, Beirut, Lebanon
[email protected]
Article history / info:
Category: Review article
Received: Apr. 8, 2015
Revised: Apr. 22, 2015
Accepted: May 6, 2015
Conflict of interest statement:
There is no conflict of interest to declare
INTRODUCTION
Chest pain is one of the most common symptoms encountered
in emergency rooms (ER) [1]. In the US, each year, more than six
million patients present to emergency departments (ED) for chest
pain suggestive of acute coronary syndrome (ACS). Over 40% of
these patients are hospitalized, and admissions are costly [2].
But in one hand, most of these patients do not have ACS [3] and
on other, despite diagnostic advances, 2% to 8% of ACS patients
are misdiagnosed and sent home, resulting in increased mortality
rate [4].
Chest pain in ER does not only have cardiac origin, differential
diagnoses include vascular origin of pain as acute aortic
10
dissection and pulmonary origin of pain such as pulmonary
embolism. Other etiologies may also be mentioned such as
pleural and pericardial pain, digestive or muscular pain [5;6].
In the ED, the management of a typical chest pain suggestive
of acute coronary syndrome has become well codified;
managing atypical chest pain remains more complex [7].
The proper diagnosis of the etiology of chest pain for patients
in the ER is still difficult and there is always a challenge to
differentiate patients with ACS, aortic dissection or pulmonary
embolism. Proper and timely treatment of aortic dissection or
pulmonary embolism depends on early etiologic diagnosis [8;9].
Med Emergency, MJEM – 2015, No 23
R e V I E W article
problem for doctors in the ER. The diagnosis of ACS includes
unstable angina (Figure 2), myocardial without ST segment
elevation, and myocardial infarction with ST segment elevation.
presence of coronary artery disease that can explain this chest
pain (Figure 5).
Among patients presenting to an ED with ACS symptoms, only
25% will have a confirmed diagnosis of ACS [4] (Figures 3 and 4).
Patients for whom the diagnosis of ACS is not diagnosed tend to
be younger, to have atypical chest pain and a normal ECG [11].
The uncertainty in the diagnosis of ACS leads to an increase in
the number of diagnostic tests and to an increase in hospital
admissions rate [12], therefore increasing the cost of diagnosis.
2- Pulmonary embolism
The TRO MDCT-angiography prescribed in the ED for chest pain,
allows the analysis of coronary arteries to confirm or deny the
The TRO MDCT-angiography can confirm or reject the diagnosis
of pulmonary embolism. A negative MDCT-angiography excludes
Figure 2: A 48-year-old man presented with atypical chest pain. He has a family
history of myocardial infarction. Electrocardiogram and troponin were normal.
TRO MDCT-angiography obtained one hour later shows calcified eccentric plaques
along the left anterior descending artery and the diagonal arteries. The aorta is
normal \LNader©
Figure 5: A 50-year-old man presented with chest discomfort. No family history
of coronary artery disease. He never smoked. There is no history of hypertension, diabetes or hyperlipidemia. He works at the stock exchange. The TRO
MDCT-angiography shows normal coronary arteries, normal pulmonary arteries,
normal aorta and no lung disease \LNader©
Pulmonary embolism must be raised before any chest pain
presenting to the ED. However, the diagnosis of pulmonary
embolism remains a challenge, especially when the final
outcome depends on the speed of starting a targeted treatment
(Figures 6 and 7).
an pulmonary embolism if the clinical probability is not high
or in combination with a negative lower limbs venous doppler
ultrasound if the clinical probability is high [13].
3- Aortic Dissection
3
Aortic dissection is the most common cause of aortic origin for
chest pain presenting to the ED. Aortic dissection can be deadly and
quick diagnosis can be life-saving for the patient (Figures 8 to 10).
In aortic dissection, the TRO MDCT-angiography during can:
confirm the diagnosis, locate the dissection, show its extent,
classify the dissection and analyze the involvement of all the
bifurcation of the aorta [14]. It can also quickly guide treatment
and prevent fatal death.
4- Other thoracic diseases
4
Figures 3 and 4: A 52-year-old man presented with unstable angina. His father
died of myocardial infarction at age 60. TRO MDCT-angiography shows severely
calcified coronary arteries with significant coronary artery stenosis involving the
left anterior descending artery and the right coronary artery \LNader©
12
TRO MDCT-angiography prescribed in the ER allows, besides
exploring thoracic vascular structures, the study of the lung
parenchyma, the myocardium, the pericardium, the chest wall,
etc. which in some cases may be of a remarkable utility for the
Med Emergency, MJEM – 2015, No 23
O ri g inal article
Analyse qualitative du conseil médical donné par
les médecins généralistes et urgentistes du Service
d’Aide médicale urgente
Qualitative analysis of medical consultation given by general
practitioner and emergency physicians of the Emergency
medical assistance system in France
Piednoir A, Foudi H, Foudi L, Cesareo E, Tazarourte K. Qualitative analysis of medical consultation given by general
practitioner and emergency physicians of the Emergency medical assistance system in France. Med Emergency, MJEM 2015; 23:15-20.
Mots clés : Conseil médical, médecin généraliste, médecin urgentiste, régulation médicale, SAMU
Keywords: Emergency medical assistance system, emergency physician, general practitioner, medical consultation, medical regulation
ABSTRACT
Introduction: The role of medical regulation of the Emergency Medical Assistance system in France (SAMU) in reducing the
use of health care services is suggested due to the possibility of giving medical consultation to applicants. Depending on the
type of initial call, a phone consultation is given by a general physician or an emergency physician. This work’s aim was to
characterize the consultation activity of medical regulation within a regional reception and dispatching center for emergency
calls (CRRA) and the impact of such consultation on the use of health care services.
Materials and method: The study is prospective, monocentric, describing the type of medical consultation given by general
practitioners or emergency physicians along with follow up within 48 hours from these consultations.
Results: Among medical regulation records randomly captured from CRRA over a period of one week, and after matching
the records, general practitioners mainly gave simple therapeutic consultation (69% vs. 22% for the emergency physicians,
p < 0.001), while emergency physicians advised the use of medical consultation. A follow up after 48 hours showed that
medical consultations were rather followed with a majority of patients satisfied with a simple therapeutic advice. No medical
complications related to consultation had been detected.
Discussion: This preliminary study confirms the significant number of calls to SAMU seeking medical consultation and the
crucial role of general practitioners in a SAMU medical regulation, to limit the use of health care services.
Authors’ affiliation:
Correspondent author: Karim TAZAROURTE, MD, PhD
Service des urgences, Centre hospitalier universitaire Edouard Herriot, Lyon, France
5 place d’Arsonval 69003 Lyon
[email protected]
Piednoir A1, Foudi H, MD1, Foudi L, MD1, Cesareo E, MD1,2, Tazarourte K MD, PhD1,2
1. Pôle Urgences-SAMU 77, centre hospitalier de Melun, 2 rue Fréteau de Peny 77000 Melun, France
2. Pôle Urgences-SAMU 69, centre hospitalier universitaire Edouard Herriot, place d’Arsonval 69003 Lyon, France
Article history / info:
Category: Original article
Received: April 15, 2015
Revised: May 6, 2015
Accepted: May 20, 2015
Pr Karim Tazarourte
Conflict of interest statement:
The authors declare no conflict of interest.
Authors contricution in this article:
Conducting the study, data analysis and draft writing: Piednoir A, Foudi H, Foudi L, Cesareo E and Tazarourte K
Med Emergency, MJEM – 2015, No 23
15
O ri g inal article
RÉSUMÉ
Introduction : Le rôle de la régulation médicale des Services d’aide médicale urgent (SAMU) pour réduire en France le recours
aux structures de soins est suggéré grâce à la possibilité de donner des conseils médicaux aux requérants. En fonction de la
nature initiale de l’appel, le conseil téléphonique est donné par un médecin généraliste ou un médecin urgentiste. Le but de
ce travail était de caractériser l’activité de ces conseils en régulation médicale au sein d’un centre régional de réception et
de régulation des appels (CRRA) en France et l’impact de ce conseil médical sur le recours aux structures de soins.
Matériels et méthode : Il s’agit d’une étude prospective, monocentrique, descriptive du type de conseils médicaux donnés
par les médecins généralistes ou urgentistes et le suivi à 48 heures de ces conseils.
Résultats : Parmi les dossiers de régulation médicale saisis au CRRA durant une période d’une semaine choisie au hasard,
et après appariement des dossiers, les médecins généralistes donnaient principalement des conseils thérapeutiques simples
(69% vs. 22% pour les urgentistes, p < 0,001), alors que les médecins urgentistes conseillaient le recours à une consultation
médicale. Le suivi à 48 heures montrait que les conseils étaient plutôt suivis avec une majorité de patients satisfaits par un
simple conseil thérapeutique. Aucune complication médicale liée aux conseils n’avait été objectivée.
Discussion : Cette étude préliminaire confirme le nombre important d’appel au SAMU pour conseils médicaux et le rôle
crucial des médecins généralistes au sein d’une régulation médicale du SAMU, pour limiter le recours aux soins.
Introduction
La permanence de soins (PDS) est devenue une activité majeure
des centres de réception et de régulation des appels (CRRA) –
centre 15 des Services d’aide médicale urgente (SAMU) français.
La part des conseils donnés aux requérants par la régulation
ne fait que croître : 30% du volume des dossiers en régulation
médicale du SAMU de Seine et Marne ont abouti à un conseil
en 2007 versus 12% en 2000 (données personnelles SAMU 77).
C’est une des raisons qui a conduit à proposer l’implantation
systématique de médecins régulateurs spécialistes en médecine
générale au sein de chaque SAMU. La proportion de conseil
donné est présumée être le garant d’une diminution de recours
à une consultation médicale physique. La définition du conseil
est vague. Il s’agit soit d’un conseil thérapeutique, soit du conseil
d’aller aux urgences, soit du conseil de voir un médecin. Peu
d’études ont été publiées en France, sur le type de conseil donné,
le suivi à 48 heures et la satisfaction du patient.
régulation médicale se composait en 2008 de 34 assistants de
régulation médicale (ARM), 50 médecins urgentistes hospitaliers,
et 20 médecins généralistes.
Notre étude se proposait de caractériser l’activité pour
conseil médical en régulation. Nous avons mené une étude
monocentrique, descriptive, prospective, au sein d’un SAMU
urbain et rural (SAMU 77 de Seine-et-Marne), en analysant le
type de conseil délivré par le médecin régulateur, la spécialité du
médecin (généraliste ou urgentiste), le devenir et la satisfaction
des patients à 48 heures du conseil. Le but principal de l’étude
était de caractériser l’activité de conseil (type de conseil donné
et son suivi à 48 heures). Les objectifs secondaires étaient de
déterminer si l’activité de conseil réduisait le recours à une
consultation aux urgences, et la raison pour laquelle les patients
appelaient le SAMU.
Deux groupes ont été défini :
Matériels et Méthode
L’étude était prospective, descriptive, non randomisée, du 21 avril
2008 au 27 avril 2008, soit une semaine tirée au sort parmi six
semaines au sein de l’année 2008. Cette étude s’était déroulée
au sein du SAMU de Seine-et-Marne (SAMU 77) qui est un SAMU
francilien avec une activité de 150 000 dossiers de régulation
annuels (données 2008). Au sein du SAMU 77, l’effectif de la
16
Le critère d’inclusion était un patient qui appelait directement le
SAMU avec un motif codé soit demande de conseil soit demande
de renseignement. La réponse du médecin régulateur était codée :
- Soit conseil médical : adaptation thérapeutique d’un traitement,
réassurance psychologique, etc.),
- Soit conseil de consulter le médecin traitant,
- Soit envoi de SOS médecin à domicile,
- Soit conseil d’aller aux Service d’accueil des urgences (SAU)
par ses propres moyens (CS SAU PM), par une ambulance privée
(CS SAU AP), par une ambulance des sapeurs-pompiers (CS
SAU VSAV).
1. Recours aux soins et envoi du patient au SAU, quel que soit le
moyen, ou l’envoi d’un médecin à domicile ;
2. Non recours aux soins avec conseil thérapeutique ou
consultation en différé du médecin traitant.
Les ARM transféraient les appels pour conseil médical au
médecin régulateur disponible. Deux types de médecins
régulateurs pouvaient répondre aux appels selon les horaires
de la journée :
1. Un médecin généraliste, de 20 heures à minuit du lundi au
samedi et de 8 heures à minuit le dimanche, définissant les
horaires de permanence des soins (PDS).
2. Un médecin urgentiste disponible en permanence.
Selon une procédure de service, aux heures de PDS, l’appel
pour conseil était passé prioritairement au médecin régulateur
généraliste. S’il y avait plus de cinq appels en attente, ou plus de
15 minutes d’attente prévisible, l’appel pour conseil était basculé
sur le régulateur urgentiste disponible.
Med Emergency, MJEM – 2015, No 23
case re p ort
A disconcerting leg: a case of deep vein
thrombosis with negative D-dimers
Thomas L, Sempere H. A disconcerting leg: a case of deep vein thrombosis with negative D-dimers. Med Emergency, MJEM 2015;
23:21-3.
Key words: D-dimers, deep vein thrombosis, false negative reactions, Wells score
ABSTRACT
The annual incidence of deep vein thrombosis (DVT) in the general population in France is about 1% to 1.6%. It can occur without
triggering factor identified or in patients with risk factors. We report an original case study of a patient with DVT of the lower
limb proven despite a negative D-dimers rate and low predictive score.
When the predictive score of venous thromboembolic disease is low, the diagnostic strategy is that D-dimers are assayed for
eliminating DVT, the negative predictive value being very high, around 94% to 100%. The use of Doppler ultrasound is then
recommended. The cases of false negatives reported in the literature are few and question the false negative D-dimers etiologies.
Authors’ affiliation:
Correspondent author: Léa THOMAS, MD
Centre médical des armées (CMA) de Vincennes, antenne médicale en gendarmerie de Maisons-Alfort
4 avenue Busteau 94700 Maisons-Alfort
[email protected]
Thomas L, MD1, Sempere H, MD2
1. CMA de Vincennes, antenne médicale de Maisons-Alfort, 4 avenue Busteau 94700 Maisons-Alfort
2. CMA de Vincennes, antenne médicale de Rosny-sous-bois, 1 boulevard Théophile Sueur 93111
Rosny-sous-bois
Article history / info:
Category: Case report
Received: Apr. 29, 2015
Revised: May 20, 2015
Accepted: May 27, 2015
Dr Léa Thomas
Conflict of interest statement:
There is no conflict of interest to declare
Clinical case
We report the case of a 32 year old athletic man, presenting
himself to medical consultation in general practice for pain in
the right calf lasting for one week. The only medical history he
presented was a meniscectomy of the right knee six months
ago without prolonged immobilization and an episode of left
cervical-brachial neuralgia.
The clinical examination revealed a hemodynamically stable
patient, his blood pressure was 123/68 mmHg, with a heart rate of
66 beats per minute, a respiratory rate of 14 cycles per minute and
a temperature of 36.3° Celsius. Examination of the lower limbs
area highlighted soft calves with no loss of lateral movement or
increase in circumference. Pain on palpation of the internal right
gastrocnemius muscle, exquisite and consistently reproducible
Med Emergency, MJEM – 2015, No 23
was present with a negative Homans’ sign. The rest of the routine
general examination was normal especially the cardiorespiratory
exam (no right or left signs).
A venous echo-doppler of lower limbs was performed despite
the low probability of DVT (Wells score = -2) [1] (Table 1) as well
as a negative D Dimers blood level equal to 443 ng.mL-1 using
immune-enzymatic assay (negativity < 500 ng.mL-1 according
to laboratory standards).
Echo-Doppler revealed an internal gastrocnemius muscle
thrombosis in the right leg. A conventional treatment [2] was then
set up by low molecular weight heparin (LMWH) then relayed
by oral anticoagulants anti-vitamin K type (AVK).
21
case re p ort
Cardiac arrest caused by torsades de pointes?
Franchin M, Frattini B, Luft A, Klein I, Tourtier JP. Cardiac arrest caused by torsades de pointes?. Med Emergency, MJEM
2015; 23:24-5.
Key words: torsade de pointes, pre-hospital, treatment
ABSTRACT
Torsade de pointes (TdP) are a rare cause of cardiac arrest with very specific management. We report the case of an 82 years
old patient, suffering a syncopal episode by torsades de pointes initially considered as cardiorespiratory arrest. The first line
therapy treatment is based on intravenous magnesium administration to correct the consistently prolonged QT interval. In case
of persistence of torsades and bradycardia, it is followed by an acceleration of the heart rate by means of atropine, an electrosystolic pacing or isoproterenol. Cessation of all QT-prolonging drugs and correction of electrolyte disturbances (frequent
hypokalemia) are also essential.
Authors’ affiliation:
Correspondent author: Benoit Frattini, MD, MSc
Emergency Medicine Department, Fire Brigade of Paris
1 place Jules Renard, 75017, Paris, France
[email protected]
Franchin M, MD, Frattini B, MD, MSc, Luft A, MD, Klein I, MD, Tourtier JP, MD, PhD
Emergency Medicine Department, Fire Brigade of Paris, France
Authors’ contibution:
Management, co-writers: Frattini B, Franchin M, Luft A
Reviewers: Klein I, Tourtier JP
Article history / info:
Dr Marilyn Franchin
Category: Case report
Received: Apr. 15, 2015
Revised: May 06, 2015
Accepted: May 20, 2015
Conflict of interest statement:
There is no conflict of interest to declare
Clinical case
First aid was called for an 82 years old woman suffering from
a syncopal episode. At the prompt arrival of first aid, cardiopulmonary resuscitation (CPR) was undertaken since the patient
was unconscious and had no carotid pulse. After two cycles
of CPR, and before the first analysis of the automated external
defibrillator (AED), the first aid team noted the presence of a
carotid pulse and a gradual recovery of consciousness.
When the medical team arrived, the patient was conscious
and several electrocardiogram tracings objectified torsade de
pointes (Figure 1) interspersed with periods of sinus rhythm with
narrow QRS complexes and a very long corrected QT interval
(QTc) (Figure 2). Electrolyte panel was normal (Na: 136 mmol.L-1;
K: 4.6 mmol.L-1).
24
An intravenous (IV) injection of 3 g magnesium sulfate is
administered over 15 minutes with a syringe pump, which
allowed preventing TdP and transporting the patient to cardiac
intensive care unit.
Interrogating the entourage revealed a history of diabetes, atrial
fibrillation, heart failure, Alzheimer’s disease and hypothyroidism
treated with insulin, Previscan®, Cordarone®, Lasilix®, Deroxat®,
and Levothyrox®.
During her hospitalization, the patient presented sustained episode
of TdP with syncope requiring an external shock. The etiologic
assessment concluded the accountability of the association
of Cordarone® and Deroxat®. Discontinuation of these two
treatments resulted in the standardization of the QT interval.
Med Emergency, MJEM – 2015, No 23
C ontin u o u s E d u cation
La médecine d’urgence et le droit au Liban
Emergency medicine and the law in Lebanon
DIAB n. Emergency medicine and the law in Lebanon. Med Emergency, MJEM 2015; 23:26-32.
Mots clés : Droit, médecine d’urgence, responsabilité médicale, urgentiste
Keywords: Emergency medicine, emergency room physician, law, medical responsibility
ABSTRACT
The Emergency physician always acts in an atmosphere perceived as dramatic by the patient and his family. He has to act
quickly in line with the principle of the “Golden Hour” where every single minute counts. In this context of unplanned activity
where one tries to predict the unpredictable some good management rules become a must and a set of responsibilities lies
with the Emergency room (ER) physician as well as with Emergency departments (ED) in hospitals. This article attempts to
review the Lebanese rules and regulations (with some punctual reference to the French Law) applicable to ED in general
and ER physicians in particular.
Whilst the practitioner is under the obligation to provide care in line with the rules of the profession and the most recent
scientific progress, he needs however to have the required skills to perform this polyvalent specialty and be able to manage
complex cases. What is the legal nature of the emergency physician-patient relationship (that is different from the traditional
physician-patient relationship) and what are the obligations of the ER physician? We shall try to answer these questions in
the light of the Lebanese law and the French comparative Law.
Authors’ affiliation:
Correspondent author: Nasri Antoine DIAB, PhD, LLM
Avocat au Barreau de Paris et de Beyrouth
Professeur des Facultés de Droit
website: www.nad-lawfirm.com
Article history / info:
Category: Continuous education
Previously published: Diab N. Emergency medicine and the law in Lebanon.
Med Emergency, MJEM 2009; 1:53-6.
Revised and Reedited: May 15, 2015
Pr Nasri Diab
Conflict of interest statement:
There is no conflict of interest to declare
RÉSUMÉ
Le médecin urgentiste opère presque toujours dans une ambiance vécue comme dramatique par le patient et sa famille. Il
doit agir rapidement, selon le principe de la “Golden hour” dans laquelle chaque minute compte. Dans ce contexte d’activité
non programmée, où l’on tente de prévoir l’imprévu, des règles de bonne gestion s’imposent et des responsabilités pèsent
aussi bien sur le médecin des urgences que sur les services d’urgences des hôpitaux. Cet article se propose d’exposer la
réglementation libanaise (avec renvoi ponctuel aux droit français) applicable au service des urgences en général et au médecin
urgentiste en particulier.
Si le praticien est soumis à une obligation de prodiguer des soins conformes aux règles de l’art et des données récentes de la
science, encore faut-il qu’il ait les compétences requises par cette spécialité polyvalente pour pouvoir gérer les cas complexes.
Quelle est la nature juridique de la relation malade-médecin des urgences (qui est différente de la relation traditionnelle liant
le patient à son médecin traitant) et quelles sont les obligations qui pèsent sur ce dernier ? Nous allons tenter de répondre à
ces questions à la lumière du droit libanais et du droit comparé français.
26
Med Emergency, MJEM – 2015, No 23
C ontin u o u s E d u cation
Urgences médicales en ophtalmologie
Conduite à tenir
How to manage medical emergencies in ophthalmology
HENRIOT C, Castelbou M, Delbosc B, Saleh M. How to manage medical emergencies in ophthalmology. Med Emergency,
MJEM 2015; 23:33-41.
Mots clés : baisse visuelle, douleur oculaire, rougeur oculaire, urgences
Keywords: dimmed vision, emergencies, eye redness, eye pain
ABSTRACT
Ophthalmological emergencies are of diverse etiology and severity while warning signs are less diverse. In front of cardinal
signs that are redness, pain and impaired vision, it is necessary for emergency physician to structure the diagnostic process.
Some of these situations require an urgent ophthalmologic care as in acute angle-closure glaucoma or endophthalmitis.
The neuro-ophtalmic emergencies, in turn, must be imperatively identified because of the vital risk involved. The emergency
physician will be able to, through appropriate interrogation, optimize patient care and to refer him to the ophthalmologist
based on level of appropriate emergency. In case of experience and suitable equipment, he will also carry out a slit-lamp
examination that will help him detect the most obvious defects and in some cases to achieve an adapted treatment such as
extraction of a foreign body from cornea or under eyelid.
Authors’ affiliation:
Correspondent author: Maher SALEH, MD, PhD
Département d’ophtalmologie, centre hospitalo-universitaire de Besançon
3 boulevard Fleming, Besançon 25030, France
[email protected] ; www.ophtalmobesancon.fr
Henriot C, MD, Castelbou M, MD, Delbosc B, MD, PhD, Saleh M, MD, PhD
Département d’ophtalmologie, Centre Hospitalo-Universitaire de Besançon, France
Authors contribution in this article:
Writing, literature review: Henriot C
Collection of iconography: Castelbou M, Henriot C
Supervision and editing: Bernard D, Saleh M
Photos taken with the consent of patients.
Article history / info:
Category: Continuous education
Received: Apr. 22, 2015
Revised: May 13, 2015
Accepted: May 20, 2015
Conflict of intrest statement:
There is no conflict of interest to declare
Dr Christophe Henriot
Photos credit:
Photos taken with the consent of patients \CHUBesançon\Opht©
RÉSUMÉ
Les urgences ophtalmologiques sont d’étiologie et de gravité diverses alors que les signes d’appels sont peu variés. Devant
les signes cardinaux que sont la rougeur, douleur et baisse de vision, il est nécessaire pour l’urgentiste de structurer la
démarche diagnostique. Certaines de ces situations nécessitent une prise en charge ophtalmologique urgente comme en cas
de glaucome aigu par fermeture de l’angle ou d’endophtalmie. Les urgences neurophtalmologiques, quant à elles, doivent
impérativement être identifiées devant le risque vital qu’elles comportent. L’urgentiste pourra ainsi, grâce à un interrogatoire
approprié, optimiser la prise en charge du patient et le référer à l’ophtalmologiste selon le niveau d’urgence adapté. En cas
d’expérience et d’équipement adapté, il pourra également réaliser un examen à la lampe à fente qui l’aidera à détecter les
anomalies les plus évidentes et dans certains cas à réaliser un traitement adapté comme l’extraction d’un corps étranger
cornéen ou sous palpébral.
Med Emergency, MJEM – 2015, No 23
33
C ontin u o u s E d u cation
INTRODUCTION
La proportion de pathologies ophtalmologiques dans le
service des urgences générales serait de 1 à 6% [1-3]. Devant
un nombre limité de signes d’appel cliniques (baisse de vision,
rougeur et douleur oculaire notamment) peut se cacher une
variété de pathologies parmi lesquelles certaines doivent être
identifiées par l’urgentiste, le pronostic visuel dépendant de
la rapidité de leur prise en charge. Ces pathologies peuvent
nécessiter une prise en charge purement ophtalmologique
ou au contraire pluridisciplinaire. Les urgences neuroophtalmologiques doivent impérativement être reconnues à
temps, le pronostic vital pouvant être engagé.
Plus qu’une longue liste de pathologies, il est important de
structurer la démarche diagnostique en s’appuyant sur les
signes cardinaux que sont la rougeur oculaire, la présence d’une
douleur et la présence d’une baisse de l’acuité visuelle [4-5].
Conduite à tenir devant un œil
rouge (Tableau 1)
En présence d’un œil rouge, il faut rechercher la présence
d’une douleur
En effet, les hyperhémies oculaires non douloureuses
orientent vers des pathologies bénignes comme l’hémorragie
sous conjonctivale ou la conjonctivite. Ces deux pathologies
n’entrainent pas, dans la majorité des cas, de baisse
d’acuité visuelle. Pour s’aider, le terrain et la localisation de
l’hémorragie sont utiles.
L’hémorragie sous conjonctivale (Figure 1) fait consulter
le patient, qui ne présente, par ailleurs, aucune autre plainte
fonctionnelle. Elle survient de manière spontanée chez un
patient volontiers hypertendu parfois sous anticoagulant ou
anti-agrégant plaquettaire.
Elle est « en nappe » et peut prendre l’aspect de sang vieilli
de couleur changeante. Il est important d’éliminer la survenue
d’un traumatisme oculaire, l’hémorragie pouvant dans ce cas
masquer la présence d’une plaie perforante oculaire [4].
La conjonctivite (Figure 2), associe à une hyperhémie
oculaire plus diffuse, des symptômes plus gênants que
douloureux : sensation de corps étranger oculaire,
photophobie, larmoiement, sécrétions et prurit oculaire [5].
Le terrain est souvent évocateur : un contage récent avec
une personne porteuse d’une conjonctivite ou d’une rhinopharyngite, la présence d’une adénopathie pré-tragienne
oriente vers une origine virale. La présence d’un terrain
atopique et d’allergies multiples associés à une rhinite claire et
un prurit au premier plan font suspecter une origine allergique.
Des sécrétions purulentes, orientent vers une origine
bactérienne en particulier chez l’enfant ou le nourrisson.
Devant un œil rouge et douloureux, et en absence d’une
baisse de vision, il faut évoquer :
L’épisclérite (Figure 3). Il s’agit d’une inflammation des
vaisseaux épiscléraux qui peut être diffuse ou nodulaire. En
plus de la rougeur localisée, il existe une douleur localisée. Elle
34
est idiopathique dans 70 % des cas mais peut parfois être liée à
des étiologies inflammatoires ou infectieuses [5].
La sclérite (Figure 4). L’inflammation est dans ce cas plus
profonde et les symptômes accentués: la rougeur est marquée,
la douleur est intense, profonde, insomniante et non calmée
par des antalgiques. Un bilan étiologique est dans ce cas
nécessaire en consultation spécialisée.
Si la triade est complète (rougeur, douleur et baisse de
vision), il faut évoquer :
La kératite aigüe (Figure 5) [6]. Elle est caractérisée par des
douleurs importantes, une photophobie et un blépharospasme.
L’œil est rouge et larmoyant. Le contexte est primordial pour
orienter le diagnostic : Le port de lentilles de contact doit
faire évoquer l’abcès de cornée parfois visible à l’œil nu s’il
est de grand diamètre. La survenue d’un traumatisme récent
ou de brûlures chimiques ou thermiques oriente vers une
érosion ou un ulcère de cornée. L’instillation d’une goutte de
fluorescéine et l’examen à la lumière bleue met en évidence
une prise de fluorescéine bien délimitée correspondant à la
zone d’épithélium manquante. Un aspect dendritique (feuille
de fougère) oriente vers une kératite herpétique (Figure 6).
Une kératite ponctuée superficielle est une cause fréquente
de consultation en urgence. Les causes sont là aussi très
nombreuses et il faut veiller à éverser la paupière supérieure
à la recherche d’un corps étranger sous palpébral. Une
malocclusion palpébrale peut être responsable d’une
kératite d’exposition, tandis que la kératite à adénovirus ou la
sècheresse oculaire sont également fréquemment en cause [6].
Si la triade est persistante et si le test à la fluorescéine est
négatif, il faut évoquer :
Le glaucome aigu par fermeture de l’angle (Figure 7) [7],
constitue une autre urgence fonctionnelle qu’il est
indispensable d’identifier à temps, l’hypertonie oculaire
pouvant provoquer une neuropathie optique irréversible au
bout de quelques heures. L’œil est rouge, très douloureux avec
céphalées ou douleurs rétro orbitaires intenses, résistantes
aux antalgiques classiques et parfois émétisantes. A l’examen,
la baisse de vision est sévère et associée à une semi-mydriase
aréactive, la cornée est œdématiée et classiquement au
toucher bi-digital, l’œil est dur « en bille de bois ». A l’anamnèse
il est utile de rechercher un facteur déclencheur comme
un changement de traitement récent (médicament à effet
parasympatholytique comme l’atropine et ses dérivés, ou
sympathomimétique notamment), ou une hypermétropie
forte. La survenue d’épisode antérieur complet ou à minima
(halo coloré) est à rechercher. Le diagnostic sera confirmé
par l’ophtalmologiste à l’examen biomicroscopique où il
retrouve une athalamie (chambre antérieure effondrée) et une
hypertonie oculaire souvent importante (70 mmHg au lieu de
9-21 mmHg habituel).
Dans les suites d’une occlusion veineuse rétinienne ou chez
un patient diabétique, un tableau quasi identique en dehors
de la semi-mydriase aréflective orientera vers un glaucome
néo-vasculaire (Figure 8) qui sera confirmé par une rubéose à
l’examen biomicroscopique [5].
Med Emergency, MJEM – 2015, No 23
C ontin u o u s E d u cation
Toxicité des cathinones de synthèse : un problème
émergeant aux urgences
Toxicity of synthetic cathinones: an emerging concern in the
emergency department
Mégarbane B. Toxicity of synthetic cathinones: an emerging concern in the emergency department. Med Emergency, MJEM 2015;
23:42-6.
Mots clés : agitation, cathinone de synthèse, convulsion, effet de type amphétaminique, intoxication, nouvelle substance psychoactive
Keywords: amphetamine-like, agitation, intoxication, new psychoactive substance, seizure, synthetic cathinone
ABSTRACT
The new psychoactive substances including synthetic cathinones have changed the landscape of recreational drugs since
2005. Mainly sold on internet, they represent a “legal” alternative to controlled and regulated psychoactive substances. The
new technologies, their attractive lower prices and legal marketing contributed to make the new psychoactive substances
become increasingly popular. However, significant physical, psychical, and addictive consequences of their unique or repeated
use seem to represent a growing health concern with remaining uncertainties for the future. Emergency departments in the
occidental countries admit increasing numbers of poisoned patents in relation to the use of synthetic cathinones, referred
for excessive psychomotor stimulation and delirium. Cases of coma, seizures, cardiovascular compromise, organ failure and
even fatalities have been recently reported.
Authors’ affiliation:
Correspondent author: Bruno Mégarbane, MD, PhD
Réanimation Médicale et Toxicologique, Hôpital Lariboisière, INSERM
1144, Université Paris-Diderot, 2 Rue Ambroise Paré, 75010 Paris
[email protected]
Article history / info:
Category: Continuous Education
Received: April 15, 2015
Accepted: April 29, 2015
Conflict of interest statement:
Pr Bruno Mégarbane
There is no conflict of interest to declare
RÉSUMÉ
Les nouveaux produits de synthèse dont font partie les cathinones, ont totalement modifié le paysage des drogues festives
depuis 2005. Vendus essentiellement sur internet, ils constituent généralement une alternative « légale » aux substances
psychoactives contrôlées et réglementées. Les nouvelles technologies, leur coût plus réduit, et leur image pseudo-légale
ont fortement contribué à les populariser. Néanmoins, les conséquences somatiques, psychiques et addictologiques de leur
consommation, unique ou répétée, semblent croissantes avec de nombreuses inconnues pour l’avenir. Ainsi, le nombre de
patients adressés dans les services d’urgence des pays occidentaux à la suite de la consommation de cathinones de synthèse
augmente régulièrement, avec essentiellement des tableaux de stimulation psychomotrice et de délire aigu. Des cas de coma,
de convulsions, de complications cardiovasculaires, de défaillance d’organe voire de décès ont aussi été récemment rapportés.
42
Med Emergency, MJEM – 2015, No 23
C ontin u o u s E d u cation
Apparus depuis une décennie sur le marché des drogues festives, les nouveaux produits de synthèse (NPS) rassemblent un éventail
très vaste de substances (Figure 1), parmi lesquels les cathinones de synthèse constituent l’une des familles de molécules les plus
consommées en Europe et en Amérique du Nord, après les cannabinoïdes de synthèse [1]. Les cathinones que l’on peut se procurer
sur de nombreux sites en ligne, sont vendus sous des noms aussi divers que « bath salts » (sels de bain), « plant food » (engrais),
« legal highs » (stimulants légaux), « designer drugs », « party pills » ou « jewelry cleaners ». Ces molécules produisent des effets de
type amphétaminiques, mimant aussi pour certains, les effets psychostimulants de la cocaïne. Parmi les cathinones de synthèse,
on peut citer la méphédrone (4-MMC), la plus connue, la méthylènedioxypyrovalérone (MDPV), la plus répandue actuellement,
la butylone, la méthylone, l’éthylone, la méthédrone, la 3-methylmethcathinone (3-MMC) et la 4-methylethylcathinone (4-MEC)
(Figure 2). Dans une enquête menée par le magazine britannique Mixmag dès 2009, la méphédrone arrivait en quatrième position
des drogues les plus consommées, derrière le cannabis, l’ecstasy et la cocaïne, expérimentée par environ un tiers des personnes
interrogées. Aujourd’hui, toutes les cathinones de synthèse sont classées en France depuis l’arrêté du 27 juillet 2012 ainsi que dans
plusieurs autres pays européens, alors que seules la cathinone, la methcathinone, l’amfépramone et la pyrovalérone, sont sous
contrôle à l’échelle internationale [2].
Cannabinoides de synthèse
Cathinones
Pipérazines
Tryptamines
Phénéthylamines
Autres (substances chimiques,
plantes, médicaments)
Figure 1 : Principaux groupes de nouveaux produits de synthèse signalés via le système d’alerte précoce (EWS) de l’Union européenne entre 2005 et 2012 (source :
Observatoire Européens des Drogues et des Toxicomanies. Rapport européen
sur les drogues 2013 : tendances et évolutions)
Figure 3 : Sachet energy-1 retrouvé sur le patient et contenant un mélange de
cathinones de synthèse
Figure 2 : Structure chimique des cathinones les plus communes
Figure 4 : Feuilles de khat cultivés en péninsule arabique et en Corne d’Afrique\
AOstojic©
Cas clinique
Un homme est amené aux urgences pour agitation et propos
incohérents. Il était retrouvé vers trois heure du matin, errant
dans une rue d’un quartier branché, incapable de donner son
nom et de fournir des explications sur ce qu’il y faisait. Il était
confus, semblait halluciné, comme poursuivi par des tueurs
et répétait de façon machinale des phrases incantatoires.
Son examen clinique montrait : une température à 38,5°C,
une fréquence cardiaque à 170 battements par minute, une
pression artérielle à 195/85 mmHg, une fréquence respiratoire à
22 cycles par minute et une saturation en air ambiant à 98%.
L’examen neurologique ne retrouvait aucun signe de localisation
ni syndrome méningé. Les réflexes ostéotendineux étaient
vifs sans signes pyramidaux francs, l’auscultation pulmonaire
normale et l’abdomen souple. Dans sa poche, était retrouvé un
sachet contenant une poudre blanche avec un étiquetage portant
la mention de « Energy-1, Research compound » (Figure 3).
Med Emergency, MJEM – 2015, No 23
Rapidement, vous consultez un site encyclopédique sur internet
qui vous révèle que ce composé est en fait un mélange de
cathinones de synthèse. Vous suspectez donc une intoxication
aiguë par ces cathinones.
QCM 1 – Parmi les propriétés suivantes, lesquelles caractérisent
les cathinones de synthèse ?
A- Ces molécules possèdent une structure chimique voisine
des opioïdes
B- Ces molécules sont des analogues structuraux de la cocaïne
C- Ces molécules sont des dérivés β-cétone de l’amphétamine
D- Ces molécules sont des dérivés de synthèse d’un alcaloïde
contenu dans la feuille de coca
E- Ces molécules sont utilisées par voie inhalée ou injectée
43
R E C O M M E N D AT I O N S F O R A U T H O R S
Med Emergency, MJEM
The Mediterranean Journal of Emergency Medicine
The Journal publishes articles in English and/or French pertaining to Emergency Medicine from its scientific aspect (research,
case studies, clinical articles, orientation and practical conduct),
administrative (Management and organization of Emergency Medicine), 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 JdeidehLebanon 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 procedures when submitting the article:
• On the front page- the author’s name, affiliations, complete mailing 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 appearance 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 scientific 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.
Med Emergency, MJEM – 2015, No 23
For research original articles and review articles
authors should clearly note the following:
• If the study was approved by a local or international IRB (institutional 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?
ADDENDUM
Conflict-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
47
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