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MED EMERGENCY / URGENCE
ISSN 2222-9442
Emergency responses in case of
mass casualties’ different big bang
incidents: the Paris Fire Department
prehospital medical care approach
Le télédiagnostic, un concept
adapté à l’évaluation de la
contamination accidentelle ou
intentionnelle d’une ressource en
eau
Trimestriel
Chloroquine overdose
Coronary spasm
Intérêt de l’échocardiographie en préhospitalier
Brûlures et atteintes caustiques oculaires
HIV and AIDS: global summary and basic
facts
Endorsed by
December 2014 - N°21
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Topics include:
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E D I T O R ’ s
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
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

Research
Abdo KHOURY (France)
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)
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.
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, 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.

Med Emergency, MJEM – 2014, No 21
Nagi Souaiby, MD, MPH, MHM
Chief Editor
...In hommage to Dr Jean Claude Deslandes
1
C O N T E N T S
Original Articles
Emergency responses in case of mass casualties’ different big bang incidents: the Paris Fire Department
prehospital medical care approach
Lefort 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 eau
Telediagnosis, an adapted concept for the accidental or intentional contamination water resource assessment
Baurès E, Adamy C, Brogat M, Cadière A, Roig B, Thomas O
Case Report
Chloroquine overdose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Maurin O, Arvis AM, Lefort H, Checinski A, Travers S, Mégarbane B, Tourtier JP
A patient with multiple sudden cardiac arrests due to coronary spasm
Corsia 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
préhospitalière
Pulmonary embolism masked by a myocardial infarction chart and revealed by prehospital echocardiography
p. 3
p. 10
p. 16
p. 20
p. 23
Kadji R, Laborne FX, Sapir D, Goube P, LAGADEC S, Desclefs JP, Briole N
Continuous Education
HIV and AIDS: global summary and basic facts
Rahal K, FRANGIEH M
.........................................................................................................................................................................
Continuous Education (French)
Conduite à tenir devant les brûlures et atteintes caustiques oculaires
What to do in case of burn and chemical eye burns and injuries
Castelbou M, Henriot C, Delbosc B, Saleh M
.................................................................................................................
General information
Recommendations for authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
p. 27
p. 32
p. 38
p. 40
Med Emergency, MJEM – 2014, No 21
ORIGINAL ARTICLE
Emergency responses in case of mass casualties’
different big bang incidents: the Paris Fire
Department prehospital medical care approach
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
ABSTRACT
Introduction: 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, MD
Emergency Medical Service, Fire Brigade of Paris, Paris, France
1 place Jules Renard, 75017, Paris
[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), France
2. SMPM, Military Health Services, Paris, France
3. Military Paramedics School, Toulon, France
Article history / info:
Category: Original article
Received: Nov 5, 2014
Revised: Nov 19, 2014
Accepted: Nov 26, 2014
Dr Hugues Lefort
Conflict of interest statement:
There is no conflict of interest to declare
Med Emergency, MJEM – 2014, No 21
3
ORIGINAL ARTICLE
in order to avoid the overcrowding of the nearby hospitals
already particularly flooded, in case of a disaster, by “walkingin” 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 RED ‘ALPHA’ PLAN
At least
- 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
4 emergency engins for each of
the multiple victims locations,
One of wich might need involvement of the CBRN means
Dedicated radio channel
Explosion and/or
terrorist attack with
multiple victims
IE
1 victim for
each medical
team
«I request
deploiment of the
Red Alpha
Plan ,TrocadéroSqua
re »
U1
AU
AU
3 -5 victims for each
medical team
RU
RU
U2
100 m
U3
Gathering
officer
Triage
officer
Evacuation Area Engins:
Gathering Area Engins:
2 first–aid engins and FBP
stretcher-bearersE
Evacuation
officer
Triage Area Engins :
1 van, 6 medical engins
1 radio-connection engin,
4 first-aid engins,10 associations engins and
engins for multiple victims transportation
Dessins : René Dosne
Figure 2: Modality of deployment of Red Alpha Plan. BSPP©
6
Med Emergency, MJEM – 2014, No 21
ORIGINAL ARTICLE
LE TÉLÉDIAGNOSTIC, UN CONCEPT ADAPTÉ À L’ÉVALUATION
DE LA CONTAMINATION ACCIDENTELLE OU INTENTIONNELLE
D’UNE RESSOURCE EN EAU
Telediagnosis, an adapted concept for the accidental or
intentional contamination water resource assessment
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
ABSTRACT
Introduction: 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, PhD
LERES, EHESP Rennes, Sorbonne Paris Cité
Avenue du Professeur Léon Bernard, 3500, Rennes, France
[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, France
2. INSERM, UMR Institut de recherche sur la santé l’environnement et le travail - 1085, LERES, Rennes, France
3. SDIS d’Ille-et-Vilaine (35), 2 rue du Moulin de Joué, 35000, Rennes, France
4. Université de Nîmes, EA7352 CHROME, rue du Dr Georges Salan, 30021, Nîmes, France
Article history / info:
Category: Original article
Received: July 9, 2014
Revised: August 13, 2014
Accepted: September 3, 2014
Dr Estelle Baurès
Conflict of interest statement:
There is no conflict of interest to declare
10
Med Emergency, MJEM – 2014, No 21
ORIGINAL ARTICLE
et permet donc un gain de temps très important.
Alerte
Evènements
Prélèvements
Prélèvements
Mesures complémentaires
Mesures sur site
Téléassistance
(experts)
Rapport / conclusion
Figure 1 : Concept opérationnel du télédiagnostic
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)
Sonde
GPS
Spectro
Kits
Photo
Figure 2 : Concept technique et prototype du système de mesures et de
communication
Med Emergency, MJEM – 2014, No 21
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
Positionnement
Moyens disponibles
Délais
Prélèvements + Analyses
laboratoire
Prélèvements + Analyses
sur site
Camion laboratoire
Mesures et tests rapides
sur site
Télédiagnostic : Mesures
+ téléassistance
Pertinence* Coûts**
+++
€€
++
€€€€
+/-
€
++
€
* par rapport à la réglementation et aux capacités analytiques
** coût d’achat ou d’investissement
Tableau 1 : Comparaison des moyens disponibles
13
ca s e re p ort
Chloroquine overdose
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
ABSTRACT
Chloroquine, 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.
Authors’ affiliation:
Correspondent author: Olga MAURIN, MD
Emergency Medicine Department, Fire Brigade of Paris
1 place Jules Renard, 75017, Paris, France
[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, France
2. Department of Medical Critical Care Medicine, Lariboisière University Hospital, Paris, France
Article history / info:
Category: Case report
Received: Oct 2, 2014
Revised: Nov 12, 2014
Accepted: Nov 29, 2014
Dr Olga Maurin
Conflict of interest statement:
The authors declare no conflict of interest.
Introduction
Chloroquine 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
16
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 Report
We 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).
Med Emergency, MJEM – 2014, No 21
ca s e re p ort
A PATIENT WITH MULTIPLE SUDDEN CARDIAC ARRESTS
DUE TO CORONARY SPASM
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
ABSTRACT
Aim: To report the case of a patient suffering multiple cardiac arrests due to coronary spasm. Prinzmetal’s angina which is underdiagnosed 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.
Authors’ affiliation:
Correspondent author: Nicolas SEGAL, MD, PhD
Department of Emergency Medicine, Lariboisière University Hospital
2, rue Ambroise Paré, 75010, Paris, France
[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, France
2. Emergency Medicine Department, Robert Boulin hospital, 33500, Libourne, France
3. Emergency Medicine Department, Fire Brigade of Paris, France
Dr Nicolas Segal
Article history / info:
Category: Case report
Received: Oct 1, 2014
Revised: Oct 22, 2014
Accepted: Nov 5, 2014
Conflict of interest statement:
There is no conflict of interest to declare
20
Med Emergency, MJEM – 2014, No 21
C o n t ica
n uso
s E
u c at i o n
eure
pd
ort
Une embolie pulmonaire masquée derrière un
tableau d’infarctus et dévoilée par l’échographie préhospitalière
Pulmonary 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. 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, urgences
Keywords: acute coronary syndrome, Emergency Medical Assistance Services, emergency room, malaise, Mobile Emergency and
Intensive Care Services, prehospital echocardiography, pulmonary embolism, thoracic angioscan
ABSTRACT
Pulmonary 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 Francilien
F-91108, Corbeil Cedex Essonne, France
[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, France
2. Service de cardiologie, Centre Hospitalier Sud-Francilien, Corbeil-Essonnes, France
Article history / info:
Category: Case report
Received: Sept 10
Revised: Oct 29
Accepted: Nov 19
Dr Roger Kadji
Conflict of interest statement:
There is no conflict of interest to declare
Med Emergency, MJEM – 2014, No 21
23
Co
n t i n u o u s education
E d u c at i o n
continuous
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-moon
United Nations Secretary-General
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
ABSTRACT
Investing 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, MS
HIV training officer
HIV/AIDS Unit, UNIFIL, Naqoura, Lebanon
[email protected]
Rahal K, MS1, Frangieh M, MS2
1. HIV/AIDS Unit, UNIFIL, Naqoura, Lebanon
2. Managing editor, Med Emergency, Fanar, Lebanon
Article history / info:
Category: Continuous education
Received: Oct 8, 2014
Revised: Oct 29, 2014
Accepted: Nov 12, 2014
Kinana Rahal
Conflict of interest statement:
There is no conflict of interest to declare
INTRODUCTION
Investing 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
Med Emergency, MJEM – 2014, No 21
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.
27
continuous education
CONDUITE A TENIR DEVANT LES BRULURES ET ATTEINTES
CAUSTIQUES OCULAIRES
What to do in case of burn and chemical eye burns and injuries
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, rayonnement
Keywords: ocular burn, chemical burn, thermic, radiation
ABSTRACT
Ocular 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, PhD
Département d’ophtalmologie-Centre Hospitalo-Universitaire de Besançon, France
3 boulevard Fleming, Besançon 25030, France
[email protected]
Castelbou M, MD, Henriot C, MD, Delbosc B, MD, Saleh M, MD, PhD
Département ophtalmologie, Centre Hospitalo-Universitaire de Besançon, France
Article history / info:
Category: Continuous education
Received: Nov 4, 2014
Revised: Nov 19, 2014
Accepted: Nov 26, 2014
Dr Marie Castelbou
Conflict of interest statement:
There is no conflict of interest to declare
Photo credit:
The iconography of this article is original, owned by the ophthalmology department of the University Hospital of Besançon.
RÉSUMÉ
Les 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.
32
Med Emergency, MJEM – 2014, No 21
continuous education
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.
- 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
Traitements
Les traitements
l’ophtalmologiste :
ou de cellules épithéliales limbiques mises en culture sur une
membrane amniotique [15-18]
spécifiques
seront
prescrits
par
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.
Figure 4: Greffe de membrane amniotique. Photographies à la lampe fente (grossissement x 7,5).
La membrane amniotique est un composant du placenta qui accélère la cicatrisation cornéenne et évite la perforation. Elle se délite spontanément au bout de
3 à 4 semaines.
- 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 chirurgicaux
L’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,
Med Emergency, MJEM – 2014, No 21
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.
35
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
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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
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The term “graph/table/figure/photo number x” should be used in
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PS: It’s strongly recommended to add photography of the author
who can also allow us to communicate his E-mail address.
38
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
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authors should provide assurance that alterations do not distort
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with the ethical standards of the responsible committee on
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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
Med Emergency, MJEM – 2014, No 21
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ELECTROCaRdiOGRaMME
SiMPLiFiÉ
Un guide pratique pour tous
Isbn : 978 284023 955 0
154 pages - Format 15x21 cm
GOTTWALLES 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 France
KEMPF N - Assistant spécialiste, Pôle Urgences Pasteur - Hôpitaux civils de
Colmar - 39, Avenue de la Liberté. 68024 COLMAR Cedex – France
SAVINEAU-RAETH JR. Assistant spécialiste, Pôle Urgences Pasteur
Hôpitaux civils de Colmar - 39, Avenue de la Liberté. 68024 COLMAR Cedex France
LEFORT H - Urgentiste, - Brigade de sapeurs-pompiers de Paris, Service de
santé des armées
SOUAIBY N - Urgentiste réanimateur, des universités de Montpellier et de Paris
Éditeur en Chef de la revue Méditerranéenne de Médecine d’urgence (MJEM).
Ouvrage indispensable et accessible
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 Juillière
Président 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 : 04.67.52.59.05
E-mail : [email protected]
Succursale : 8, rue de Primatice - 75013 Paris - Tél. : 01.40.09.27.71 - Fax : 01.40.09.80.71
Comptabilité : Tél. : 04.67.63.68.82 - Fax : 04.67.63.68.84
Pub ECG.indd 1
20/01/15 12:21