Emergency Medicine has come of age

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1 EDITORIAL When there is a will, there is a way.. MED Emergency Publication By New Health Concet P.O.Box Jdeideh - Lebanon Tel: Fax: Website: Editorial Board Editor in Chief Dr. Nagi SOUAIBY Managing Editor Chantal Saadeh Khalil, Georges Khalil, Georgina Maalouf Dany Matar Members Jean Claude DESLANDES (France) Chokri HAMOUDA A (Tunisia) Abdo KHOURY (France), Jean Yves Le Coz (France), Afif MUFARRIJ (Lebanon), Jean-Cyrille PITTELOUD (Switzerland), Alissar RADY (WHO), Ali RIAD AWAD (Jordan). AUTHORS OF THIS ISSUE JEAN CLAUDES DESLANDES, CARLOS NOUJEIM, ISMAEL HSSAIN, CHOKRI HAMOUDA, LOIC LAVAILL, AMAL TOHMY, SAID LARRIBI, RIM LAKHDAR, OLIVIER GALL, YANNICK GOTTWALLES. SCIENTIFIC COMMITTEE Pierre ABI HANNA, Georges ABI SAAD, Bahig ARBID, Chahine ASSI, Omar AYACH, Melhem AZZI, Charles BAD- DOURA, Martine BISSET, Nasri DIAB, Aziz GEAHCHAN, Regis GUARIGUES (France), Maurice HADDAD, Berthe HACHEM, Shady HAYEK, Mohamad HACHELAF (France), Jamil HALABI, Khalil HELOU, James MOISES (USA), Maurice KHOURY, Bruno MEGARBANE, Gladys MOURO, Ahmad OSMAN (Egyt), Joseh OTAYEK, Jamal Hussein Qunash (Jordan), Wassim RAFFOUL (Switzerland), Sami RICHA, Amal Tohmy, Claire GHAFARI ZABLIT IN PARTNERSHIP WITH Emergency Medicine has come of age From humble beginnings in an emergency room in the USA and a casualty station in the UK, SAMU in France and other models of care around the globe, the modern secialty of emergency medicine has come of age. Over 50 years of evolution have resulted in a secialty that is recognised internationally with a unique domain of skills and knowledge and a critical role in the rovision of emergency clinical services in many countries. Peter Cameron The develoment of treatments that are time sensitive such as treating AMI, trauma and sesis have necessitated a different way of managing emergency atients. The old aradigm of consultant rounds on a hosital ward on a daily or weekly basis, simly does not work. Patients need access to treatments within minutes or hours not days or weeks In addition, atient/community exectations have risen and the concet of being managed in a hahazard way by junior doctors on resentation to a hosital with a serious illness is simly not accetable. The cross fertilisation of management rocesses from industrial models, such as lean thinking have also contributed to the changes in emergency care. Ensuring that atients get the right treatments early in their hosital journey or even rior to arrival in hosital and that a coordinated management lan is instituted requires senior clinical decision making at the front door. The only feasible way of doing this across multile subsecialties is by having secialists with emergency training available 24 hours/7days er week. In the ast, there has been an argument that emergency medicine is only useful in rich countries as the marginal benefit comared with cost, for roviding this care is less than for other secialties such as ublic health, infectious diseases or obstetrics. This seems a surious argument, when the limiting factor in reducing reventable death and morbidity in most low income countries is an organised aroach to delivering good emergency care. This often extends to an organised system of medical care in general. Thus, access to any medical care is often as an emergency. Children dying of gastroenteritis need early assessment and good fluid management (not high technology), mothers dying of maternal haemorrhage need access to basic resuscitation and obstetric skills again not exensive. Trauma care can be massively imroved by analgesia, slinting and haemorrhage control without necessarily having access to a level one trauma centre. Creating an integrated emergency system that ensures access to simle emergency care for the majority of the community should be seen as a basic right globally. This should not be seen as a luxury for rich countries. Even in rich countries, good emergency care is frequently difficult (or imossible) to access because of cost or lack of organisation. The International Federation for Emergency Medicine (IFEM) is the global umbrella for emergency medicine societies. Its role is to romote the develoment of emergency medicine and suort countries with develoed emergency systems. Through full and affiliate membershi, it reresents more than 60 countries internationally. There is a lot to learn from each other in imroving emergency care and there is much to gain by collectively lobbying governments and other agencies to imrove outcomes for emergency atients. I welcome you to join our efforts in imroving emergency care internationally. Peter Cameron, MBBS, MD, FACEM President International Federation for Emergency Medicine, Academic Director Emergency and Trauma Centre, The Alfred hosital, Monash University, Melbourne Victoria, Australia 1

2 The NSEC is leased to announce its ucoming courses Accredited by Course Title Advanced Pediatric Life Suort APLS Target audience: This course, accredited by AAP and ACEP has been designed to meet the growing needs of emergency hysicians, ediatricians, nurses and all other health care rofessionals. It rovides them with a comlete body of knowledge in Pediatric Emergency Medicine. A textbook on Pediatric Emergencies will be delivered to the candidates rior to the course. Each chater or module of education of this textbook is case based and covers the key elements of assessment, diagnosis, testing, treatment, and disosition. Each chater also includes references, helful tables and charts, hotograhs and illustrations. The course is conducted in small grou discussion format. Date: June 7-8, 2012 Language: English Location: Beirut: TBA Course fee: 450 USD including the hardcover textbook Registration deadline: May 8, 2012 (limited laces) Alications of Ultrasound in Emergency Medicine This 1/2-day course introduces articiants to the concet of ultrasound use in emergency with live demo Date: June 6, 2012 (2-7m) Language: English Location: Beirut: TBA Course fee: 60 USD Registration deadline: June 1, 2012 Ultrasound-Enhanced life Suort USLS-BL1 This 2-day course introduces articiants to the concet of ultrasound use in ABCD assessment and management with extensive hands-on training as well Target audience: The course is relevant for hysicians and residents and Date: June 9-10, 2012 Language: English Location: Beirut: TBA Course fee: 500 USD Fees include: Registration deadline: May 10, 2012 (limited laces) didactic material and coffee / lunch breaks. For registration and information, lease contact us:

3 H O M A G E On the 12th of May of every year we celebrate the World Nurses Day. Med Emergency and Urgence Pratique ay them a secial tribute. The Curse of Kelvin By Dr Jean Claudes Deslandes Chief Editor of Urgence Pratique Journal In 1977, Alvin Feinstein, linked the curse of Kelvin to the difficulty that doctors had in assessing the quality of their work (1). Robert Wears reminds us of this in one of the editorials of Annals of Emergency Medicine (2). What are we talking about? Lord Kelvin, who was not interested in medicine, has noticed that if knowldege cannot be exressed and quantified by numbers, it remains worthless. Doctors have always considered themselves beyond the judgment of those who did not share the same knowledge. However, if many atients do not make it through a medical treatment without any reercussion on the doctor s aura, this is no longer the case. So for fear of being questioned or any attemt to wie out the malediction we have seen in the most recent years a roliferation of scores: Glasgow, ain scores etc.. In Emergency medicine, we are faced with the most difficult challenge of evaluating atients satisfaction. A coma atient will not seak, and an anxious atient suffering from resiratory distress does What is then the simlest indicator to measure whether we have erformed well our art? It is the look in the nurse s eyes.s not have the strength to comlain nor to thank. A voluntary intoxicated atient is being treated against his will. Most imortantly, medicine rergardless of the seciality is not and should not be marketing. Can you imagine billboards in town saying «99% of success rate for all coloscoies erformed at Beaucolon Clinic» or «all setic chocs treated at Deogracias hosital have been healed»? If we want to seek excellence it is because we have an ethical obligation to do so. What is then the most simle indicator to measure whether we have erformed well our art? It is the look in the nurse s eyes. Let us not fool ourselves. Our closest collaborators are our best judges. We have all felt it when we had a hesitant technical move or following a wrong osology. Let this be our motto «a satisfied nurse means a satisfied atient» and let us not hesitate to interrogate the look on her face when needed. (1). Feinstein AR. On exorcizing the ghost of Gauss and the curse of Kelvin. In: Clinical Biostatistics. St Louis, MO: C.V.Mosby; 1977: (2). Robert L. Wears. Patient satisfaction and the curse of Kelvin. Annals of Emergency Medicine. Vol. 46. N 1; S U M M A R Y EDITORIAL BY PETER CAMERON THE CURSE OF KELVIN NECROTIZING PANCREATITIS SIMULATION IN EMERGENCY MEDICINE INDICATIONS DU LAVAGE GASTRIQUE TU-BE OR NOT? TADPOLES IN MY STOOLS!!!! ACUTE HEART FAILURE ENDOCARDITE INFECTIEUSE SUR SONDE DE PACE MAKER PRISE EN CHARGE DE L ENFANT BRULÉ PÉDAGOGIE DE L ECG N

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5 C A S E R E P O R T Carlos Noujeim Necrotizing Pancreatitis and Rhabdomyolysis (Pancréatite Nécrosante et Rhabdomyolyse) Dr. Carlos Noujeim Case reort We reort the case of a 29 year old male who resented with acute necrotizing ancreatitis and sustained severe rhabdomyolysis (with CPK levels exceeding IU/L) and multiorgan failure a few days later. Article history / info: Received: Jan. 16, 2012 Reviewed: Jan. 30, 2012 Received in revised form: Feb. 9, 2012 Acceted: Feb. 20, 2012 Abstract Patients with acute ancreatitis are frequently admitted to the emergency deartment, requiring romt intervention as ossibly resenting with life-threatening conditions. Patients may develo an associated systemic inflammatory resonse leading to multiorgan dysfunction, which is stratified into different scoring systems to describe severity and redict outcome. The finding of an associated rhabdomyolysis is rare. This clinical situation could be directly linked to the ancreatitis, as described in this article. Physicians should be aware of this otential comlication and its subsequent consequences. Key words Pancreatitis, Rhabdomyolysis Mr. X is a 29 year old male morbidly obese (BMI: 41.6) and known to suffer from oorly controlled diabetes mellitus tye-1, was admitted to our hosital with the diagnosis of acute necrotizing ancreatitis. On admission, he was oriented, hemodynamically stable with a relevant abdominal tenderness on hysical exam. Chemistry tests including electrolytes, lactate, and blood ketones were within normal ranges. Base deficit on arterial blood gas was 4 meq/l. An extremely elevated level of triglycerides was assessed at 7955 mg/dl. Patient s Ranson and BISAP scores on admission were 1 and 2, resectively. Abdominal CT scan showed Balthazar stage E acute necrotizing ancreatitis, which was directly attributed to hyertriglyceridemia. Total arental nutrition was started early through a central venous catheter. Two days after this initial diagnosis, he sustained acute kidney injury with anuria and significant metabolic acidosis requiring hemodialysis. High level of CPK (> 180,000 IU/L) with normal CK-MB and momentous hemoglobinuria were evidenced. He denied any history of trauma or illicit drug intake. The only medications the atient was taking were metformin and tolbutamide for his diabetes. Blood metformin concentration uon resentation was within the normal range (2.7 mg/l). Furthermore, his hosital stay was comlicated by acute lung injury and resiratory failure necessitating mechanical ventilation in addition to multile hosital-acquired infections necessitating broad sectrum antibiotics. Electromyograhy and nerve conduction studies showed acute severe motor fiber degeneration, comatible with acute necrotizing myositis and no evidence of olyneuroathy or neuromuscular transmission disorders. Follow-u laboratory tests after starting dialysis showed a steady decrease in CPK levels. However, refractory high-grade fever ersisted and reeated abdominal imaging showed two collections in the reheatic and aragastric saces whose ercutaneous draining found urulent fluid infected with Escherichia Coli sensitive to the rescribed antibiotic (imienem). This rocedure was followed by an oen surgical resection of necrotic ancreatic tissue due to ersistent fever and hemodynamic comromise. Desite all these measures, the atient died the day following the surgery. Discussion Rhabdomyolysis is a rare comlication of acute ancreatitis (1, 2). In a case series, Nakivell et al. reorted three out of 14 atients with severe ancreatitis develoing non traumatic rhabdomyolysis with CPK > 10,000 IU/L (1). A study conducted by Haraguchi et al. found a close relationshi between the severity of acute ancreatitis and rhabdomyolysis and suggested that renal failure that follows acute ancreatitis is artly due to rhabdomyolysis 5

6 C A S E R E P O R T REFERENCES 1-Nankivell BJ, Gillies AH. Acute ancreatitis and rhabdomyolysis: a new association. Aust N Z J Med 1991; 21: Pezzilli R, Billi P, Caelletti O, Barakat B, Miglio F. Rhabdomyolysis and acute ancreatitis. J Gastroenterol Heatol 1999; 14: Haraguchi Y, Hasegawa S, Ishihara T. Hyermyoglobinemia in severe acute ancreatitis. Gastroenterology 1990; 98: A Antons KA, Williams CD, Baker SK, Phillis PS. Clinical ersectives of statin-induced rhabdomyolysis. Am J Med May;119 (5): Sundar K, Suarez M, Banogon PE, Shairo JM. Zidovudine-induced fatal lactic acidosis and heatic failure in atients with acquired immunodeficiency syndrome: reort of two atients and review of the literature. Crit Care Med 1997; 25: Rosenberg H, Davis M, James D, Pollock N, Stowell K. Malignant hyerthermia. Orhanet J Rare Dis Ar 24; 2:21. 7-Zele I, De Tommaso I, Melandri R, Barakat B, Pezzilli R, Re G, Fontana G. Rhabdomyolysis during acute oisoning with drugs and nar cotics. Exerience with 7 clinical cases. Minerva Med Dec; 83(12): Yasumoto N, Hara M, Kitamoto Y, Nakayama M, Sato T. Cytomegalovirus infection associated with acute ancreatitis, rhabdomyolysis and renal failure. Intern Med 1992; 31: Abdulla AJ, Moorhead JF, Sweny P. Acute tubular necrosis due to rhabdomyolysis and ancreatitis associated with Salmonella enteritidis food oisoning. Nehrol Dial Translant 1993; 8: CT aearance of necrotizing ancreatitis: the image on the left is re-contrast. The image on the right is ost-contrast. The lack of contrast enhancement of most of the gland suggests areas of necrosis and elevated serum concentrations of myoglobin (3). However, these authors did not reort how the severity of acute ancreatitis was assessed. In contrast, a study conducted by Pezzilli et al., comaring serum myoglobin concentrations between healthy subjects versus atients with acute ancreatitis and between atients with mild versus severe acute ancreatitis did not find any significant difference (2). Both acute ancreatitis and rhabdomyolysis may result from side-effects of usual harmaceuticals including statins, fibrates, anti-retroviral theraies (4, 5), and anesthetic drugs like succinylcholine and halothane (6) as well as acute ethanol and cocaine oisonings (7) and infections like cytomegalovirus and salmonella (8, 9). In our case, no underlying secondary cause was assessed and rhabdomyolysis was directly attributed to ancreatitis, a comlication that occurs with delay from the diagnosis of ancreatitis, characteristically around one week (1). The athohysiology of ancreatitisassociated rhabdomyolysis is not well established. One otential mechanism would be ancreatitis-related release of digestive enzymes and inflammatory cytokines into the surrounding abdominal wall muscles resulting in cell lysis and a rise in CPK (1). This would be reflected by two clinical signs: Cullen s sign (i.e. eriumbilical ecchymotic discoloration, as an indicator of intraeritoneal hemorrhage) and Grey-Turner s sign (i.e. retroeritoneal leak of blood from the inflamed hemorrhagic ancreas, causing bruising or bluish discoloration of the flanks). In the resence of one of these two signs, the hysician should be aware of a ossible associated rhabdomyolysis. The rognostic value of rhabdomyolysis during acute ancreatitis is still debated. Nakivell et al. found a correlation between the eak serum CPK concentration and ancreatitis severity (1). However, this was not found in the rosective study done by Pezzilli et al. (2). Conclusion Acute rhabdomyolysis is a rare and ossibly a delayed comlication of acute severe necrotizing ancreatitis that should be considered in the setting of clinical deterioration and multile organ failure. In total, CPK has no diagnostic value for ancreatitis but may have a rognostic value that should be clarified in future rosective randomized studies. Abbreviations: CPK: Creatine PhoshoKinase CK-MB: Creatine Kinase-MB BMI: Body Mass Index BISAP: Bedside Index for Severity in Acute Pancreatitis Conflict of interest statement : There is no conflict of interest to declare Carlos Noujeim, MD Pulmonary and Critical Care Medicine

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9 E D U C A T I O N HSSAIN Ismaël, SOUAIBY Nagi, BENMILOUD Karim, ZUMBIEHL Frédéric, SCHOETTKER Patrick, BELLOU Abdelouahab. BENEFITS & LIMITATIONS OF MEDICAL SIMULATION IN EMERGENCY MEDICINE Introduction Dr Ismaël Hssain Article history / info: Received: Jan. 29, 2012 Reviewed: Feb. 15, 2012 Received in revised form: Feb. 27, 2012 Acceted: Feb. 29, 2012 Abstract Background: The concet of simulation as an educational tool in Emergency Medicine is becoming commonly used. Aims: Develoing a simulation-based course aears to be the best way for EM learning and imroving atient safety. Teachers should know why simulation techniques are useful in adult learning and at what stage they should be included in the curriculum. This highlights the need for a clear statement of benefits and limitations of medical simulation. Method: This aer is the outcome of the medical simulation and education worksho that was designed for the 1st Global Network in EM Conference held in Dubai in January Results: This aer resents a clear classification of educational scheme in adult medical learning and its benefits in understanding the need for EM in training using teamwork for risk reduction and better health care. There are different ways to teach in simulated environment and it should be in combination with traditional methods. Essential factors for the success of simulation-based education include roviding feedback and staff training, integrating simulation into beginning and continuing training and roviding reeated ractical situations with variable levels of difficulty and setting. Conclusion: In emergency medicine context, Simulation is helful for guiding Emergency Medicine (EM) is always confronted with the dilemma of how to rovide excellent medical education while imroving atient safety. Learning EM is difficult in an inhositable environment where the main objective is saving lives. In life threatening situations such as cardiac arrest or trauma management, multidiscilinary collaboration and teamwork are required. To otimize atient outcomes, decisions should be taken immediately and treatment should be administered aroriately. Training in a realistic simulated environment to take charge of scenario imroves the quality and the effectiveness of health care. Simulation resents a number of advantages for EM learning and is gaining in oularity. Adult Learning Theory Adult learning theory first focused on distinguishing adult learning from that of children in a formal education system. The early sychological models including behaviorism, cognitivism, cognitive constructivism, and humanistic sychology determined that learning was an individual rocess of changing behavioral atterns, or increasing or altering mental models and rocesses (1). Knowles Princiles Knowles theories, based on humanistic theory, focus on the adult learner as one being indeendent with a need to understand how this new learning exerience will benefit them, how it fits into their existing knowledge, and reinforces their autonomy to learn in a way that works for them. Adult s exerience should be used in their new learning and the technique should include ways to include the adult s knowledge. It should be a tool that they can draw uon and also rovide engagement by recognizing them for their exeriences. Internal motivators are more imortant than the external motivators that adults may receive for more learning. These internal motivators can come in the form of increased job satisfaction, self-esteem, and quality of life (2). However, all of the early sychological learning models still focus on the individual learning rocess that occurs without consideration of context: learning is seen as being indeendent of the erson s social setting, osition or culture. Three models of learning Other models show how to teach adults while learning in a comlex and changing environment. Three domains of learning are outlined: cognitive, affective, and sychomotor. The traditional focus of learning has been on cognitive (mental caacities and rocesses), while in the behavioral health field, affective (values and attitudes) may be the most challenging to change. Psychomotor (ercetual skills) are also imortant in develoing the clinical skills (3). 9

10 E D U C A T I O N Context-secific Learning Knowledge acquisition and alication should referably occur at the same time. Exercises in the alication of knowledge should be reeated in numerous and varied situations. Teachers should focus on Problem Based Learning (PBL) since acquiring knowledge through a rofessional roblem or situation leads to more accessible knowledge. PBL is listed as a comonent of evidence based-teaching. But, the most imortant concet is context-secific Learning that means that the learning and the alication environments should be as similar as ossible (4). Interactive session and feedback Continuing education strategies show efficacy towards changing healthcare rovider s behavior and sometimes have ositive effects on the status of the atient s health. Interactive sessions encourage the active involvement of the healthcare rovider in the educational rocess. The audit and feedback aroach involves giving feedback to roviders after conducting reviews of a rovider s rofessional ractice. Feedback is often given in the form of eer comarison or as a rovider rofile, which may be accomanied by recommendations to hel guide future clinical ractice (5). Staff training and coaching rinciles Training by itself is ineffective. Some functional comonents includes that the learner gathers knowledge of the rogram and ractice, demonstrates key skills, and conforms to ractice criteria of key skills. The knowledge and skills are not just for the clinician, but also for all rofessionals working in the infrastructure including trainers, chiefs, evaluators, and administrators. Part of the training includes staff training and coaching rinciles to assist in the training rocess. The core comonents of staff coaching are teaching and reinforcing evidence-based skill develoment and learning how to adat and craft skills to the ersonal style of the ractitioner. Suort during stress times may also be imortant (6). Finally, what kind of interactive rogram is based on exeriential learning that involves a grou in a secific context, working together to resolve roblems, conducting suervised activities and discussing best ractices? Simulation, of course! Best Education Program for EM Crisis Resource Management (CRM) Abstract educators and trainees to realize the otential learning outcomes in rofessional develoment. Simulation imroves EM quality of care. High-risk enterrises such as aviation have recognized the contribution of human error to accidents and catastrohic events. Training in teamwork and communication, known as CRM training, has been imlemented in aviation industry to reduce the risk of such error (7). Anesthesiology was one of the first secialties demonstrating the imact of human factors. An increased interest in learning from incidents was observed and resulted in considerable imrovements to atient safety during anesthesia and later in emergency context (8). The rinciles of CRM are intended to hel revent and manage difficulties during medical care and they highlight the human factors related to the team like the social asects or to the individual like the cognitive asect (9). Medical Errors and Human Factors Key words Simulation, Emergency medicine, Education 10 Over the ast decade, it has become aarent that medical errors are ervasive in health care and that many of these errors occur in oerating room setting, esecially during emergencies (10, 11). There were four recurring exlanations in errors related to cardiac arrest management:

11 E D U C A T I O N Lack of good organization Equiment issues Inability to use equiment Lack of sace to work safely. Organizational roblems related to team dynamics are: Poor communication Unclear leadershi Peole interruting one another Lack of knowledge of guidelines When looking secifically at communication roblems, common factors identified include: Dynamics (including team membershi and leadershi behavior), Influence of stress Debriefing Conflict within teams (12) The mergency environment includes a number of factors that render it more rone to communication and teamwork failure. These include: time ressure, frequent rotation of ER ersonnel, resence of multiles actors and multiles atients. Team leadershi and Team working A resuscitation team is not simly a grou of eole working together, it has a collective goal and members of the team are deendent on one another. Individuals have a resonsibility to take art in teamwork whether they act as a team leader or member. Motivation of a team is more effective if the team leader knows the names of team members, can commit eole to work at something they erceive as imortant, and can give each team member a role suitable to their exerience (13). But in emergencies, colleagues come together and may not know one another s name, skills, background and exerience. The team should familiarize itself with local guidelines, rotocols and equiment. Risk reduction can be achieved at local level only if team training. Stress Emergencies can give rise to extreme stress and fear, which in turn can affect erformance. Stress reduces concentration and involves difficulties in decision-making. Fear to harm atient reduces the time to initiate treatment (14). Practice in a simulation setting reduces stress over a short eriod of one-day training course (15). 11

12 E D U C A T I O N Debriefing Successful teams become more effective with on going training, reflection, audit and feedback focused on erformance as debriefing aids learning. The main art of a simulation course is the time of debriefing. Benefits of Simulation in EM Simulation based training has been recommended as a method to train teams on learning skills for edagogical and atient safety reasons, and the use of this tool is increasing across the world. Simulation exlores the imortance of human factors training in order to imrove quality of care and safety of atients. It also constitutes the final level to hel health care rovider avoid, recognize and recover from errors (16). Simulation exlores the three key markers of teamwork (communication, management, leadershi) that are intrinsically related to quality of resuscitation (17). Full-scale simulation includes a realistic manikin and monitor laced in a realistic clinical environment, such as an Emergency Room or an ambulance. Monitors and manikin interface with a comuter rogram to roject and dislay vital signs, voice and sometimes movements. Team members articiate in a scenario: a atient case develos according to a set of learning objectives and the articiants actions, while the instructors adat to articiants actions. The scenario is audio and video recorded and clis from the recordings are used in debriefing session (18). The relationshi between articiants and trainers is different from a classic classroom. In simulation based training, the simulation instructors role is not to teach but to facilitate learning. For the articiants to grow rofessionally they must develo meta- cognitive skills and among these is the ability to analyze critically ones own erformance. In debriefing session, the facilitator use small sequences from the recording to illustrate learning objectives and oen discussion (19). Simulation seems to be an ideal way of learning without causing harm, inconvenience or utting atients at risk (20). By varying arameters of scenarios it is ossible to exose trainees to a wider range of ossible behaviors and outcomes than they could encounter in clinical ractice over the same or much longer eriod of time. It is a totally different teaching aroach that is about facilitation rather than demonstrating or lecturing. In Simulation, instead of teaching secific technical skills, articiants receive instructions in human factors associated with otimal team erformance in delivery of efficient and safe atient care in combination with traditional methods (21). Limitations of Simulation in EM Change of attitudes and working mode is difficult for adults. Simulation aears to be a romising tool to facilitate it. But Simulation should be used when aroriate and in combination with traditional methods. To be most beneficial, the aroriate tye of simulation tool needs to be used correctly and at the right stage in the educational curriculum. There are six tyes of educational simulation tools or levels that have been identified cover a wide range of degrees of authenticity. In high level of simulation, the most advanced and exensive tyes of atient simulators are used. They are driven by hysiological models to reroduce all the vital signs that can normally be monitored on a atient. Unless real atients could be used, even the best actors cannot control their auscultation Sounds, temerature or blood ressure. But, they can however be suerior in realism to the most advanced atient simulators for some scenarios (22). 12

13 E D U C A T I O N Proosed tyology of simulation methodologies and characteristics. With the kind ermission of Prof Guillaume Alinier & Medical Teacher (22) Technological S i mulation Level S i mulation technique LEVEL 0 LEVEL 1 LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5 W r i t t e n s i mulation includes en a n d a er s i mulations or «ati ent m anagement roblems» and latent images 3D models which can be a basic m anneq u i n, l ow f idelity s i mulation models or art task simulators Screen based s i mulators, com u t e r s i mulati on, v i d e o s, software or virtual reality and surgical simulators S t andardi zed atients, real or si mulat ed (trained actors) role lay I n t ermedi a t e fidelity simulator, c o m u t e r controlled, rogrammable full body size atient simulators not fully interactive H igh f idelity s i mulation latf orms I n t eractive atient simulators or com u t er controlled model dr iven atient simulators Tye Passive Interactive Partly interactive Interactive S k i l l s Cognitive Psychomotor Cognitive Psychomotor, P s y chomotor, P s y chomotor, addressed cogni t i ve & cogni t i ve & cogni t i ve & interersonal interersonal interersonal F aci l i t y Classroom Clinical skills Multimedi a D e e n d s Clinical skills room Same as LEVEL required room o r com u t e r o n sc enario or si mulation 4 + usually set classroom laboratory or classroom requirements center realistic setting (ex: ER) u with audio & video recording equiment Tyical use Disadvantages P a t i e n t m anagement roblems, diagnosi s & assessment Unrealistic Poor feed back Demonstration & ractical skills Little interactivity Cogni t i ve skills, clinical management U n r e a l i s t i c setting Difficulty to use comuter Same as LEVEL 2 For small grous of student only Patients & actors trained No i nvasi ve ractice Clinical skills room or si mulation center realistic setting (ex: ER) P rogrammi ng scenario required Fami l i ar with equiment Small grou Same as LEVEL 4 C o s t o f m anneq u i n & facility Not very ortable Same as LEVEL 4 Advantages Low cost Large number of student Same as LEVEL 1 + eq u iment mobile S ame as LEV EL 2 + self learning & feedback on erformance Very realistic Communication skills Multi rofessional training R e a l i s t i c exerience Multi rofessional training R e a l i s t i c exerience P erformanc e r e cor d e d for debriefing Multi rofessional training High fidelity simulation mostly relies on sace, time, hysical and human resources, so it has inevitable shortcomings. Setting u and running a simulation center can be very exensive as it requires clinical, technical, and administrative staffing, a atient simulator or simulated atient in a simulated oerational clinical or community area, a control room, a debriefing room, and an integrated Audio/Visual system. That s why the word simulation should be used more concisely and in context to revent confusion (22). Conclusion Whether it is acquired under simulated condition, accumulated and reeated exerience often imroves erformance and confidence. This is very imortant in healthcare where saving lives and ensuring atients well-being is a riority. 13

14 E D U C A T I O N Corresondant author: Ismaël HSSAIN, MD Emergency & Disaster Medicine Teaching Director, Center for EMS Education, CESU 68 Emergency & Disaster Medicine, Pre Hosital & Critical Care Deartment Mulhouse General Hosital - France Conflict of interest statement : There is no conflict of interest to declare Emergencies involve comlex hysiology and require interaction among multile care roviders, including Emergency Doctors, Nurses, others medical secialties, Pre-hosital EMS, in-hosital staff and administration. To otimize atient outcomes, roviders must be able to erform secific technical and cognitive skills as well as share in efficient coordination and communication. To facilitate and romote excellence in teamwork while reinforcing care secific to ER, Simulation should be more imlemented in Emergency Medicine rogram from beginning to continuing education. All of these simulation rograms would have ositive effects on comfort and confidence levels among rofessional involved in Emergency events and on risk reduction for atient safety. HSSAIN Ismaël, MD (1), SOUAIBY Nagi, MD (2), BENMILOUD Karim, MD (3), ZUM- BIEHL Frédéric (1), SCHOETTKER Patrick, MD (4), BELLOUAbdelouahab, MD(5) (1) Center for EMS Education, CESU 68, Emergency & Disaster Medicine - Pre Hosital & Critical Care Deartment, Mulhouse General Hosital, France (2) National School for Emergency Care, Beirut, Lebanon (3) Anesthesiology Deartment, Sital Wallis, Switzerland (4) Anesthesiology Deartment, Lausanne University Hosital, Switzerland (5) Euroean Society for Emergency Medicine (Eusem), Emergency Deartment, Rennes University Hosital, France REFERENCES (1) Jacqueline Yannacci, MPP, Kristin Roberts, BBA, and Vijay Ganju, Ph.D. Princiles from Adult Learning Theory, Evidence-Based Teaching, and Visual Marketing: What are the Imlications for Toolkit Develoment? Center for Mental Health Quality and Accountability NRI, Inc. February 2006 (2) Fidishun, Dolores (n.d). Andragogy and technology: integrating adult learning theory as we teach with technology [Electronic version]. Retrieved Setember 16, htt://www.mtsu.edu/~itconf/roceed00/fidishun.htm. (3) Tusting, Karin & Barton, David Models of adult learning: a literature review. [Electronic version]. National Research and Develoment Centre for Adult Literacy and Numeracy (2003). (4) Stuart, Gail et al. Evidence-based teaching ractice: imlications for behavioral health. Administration and Policy in Mental Health. 32(2), 112 (2004) (5) Hammick, M. Interrofessional education: evidence from the ast to guide the future. Medical Teacher, 22(5), (2000) (6) Fixsen, D., Naoom, S.F., Blase, D.A., Friedman, R.M., Wallace, F. (2005) Imlementation Research: A Synthesis of the Literature. University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Imlementation Research Network (2005) (7) Billings CE, Reynard WD: Human factor in aircraft incidents. Aviation Sace Environnement medicine, 1984; 55:960-5 (8) Gaba DM, Fish KJ, Howard SK: Crisis management in anesthesiology. Philadelhia. Elsevier. Livingston.1994 (9) Rall M, Gaba DM, Howard SK, Dieckmann P. Human erformance and atient safety. In Miller RD Anesthesia. Philadelhia. Elsevier. Livingston. 2009, (10) Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on Quality of healthcare in America, Institute of Medicine, Washington DC, National Academic Press, 1999 (11) Gawande AA, Zimmer MJ, Studdert DM, Brennan TA. Analysis of errors reorted by surgeons at three teaching hositals. Surgery. 2003, 133: (12) Andersen PO & al: Critical incidents related to cardiac arrests reorted to the Danish Patient Safety database. 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15 T O X I C O L O G I E Dr. Chokri Hamouda Article history / info: Received: Feb. 4, 2012 Reviewed: Feb. 26, 2012 Received in revised form: Feb 27, 2012 Acceted: Feb. 29, 2012 Résumé Selon les recommandations récentes des sociétés savantes le LG ne doit as être emloyé our les intoxications aiguës ordinaires. Par ailleurs le LG ne s adresse qu aux toxiques non carbo-adsorbables ingérés à quantité massive otentiellement mortelle et ce durant la remière heure de rise en charge en resectant les contre-indications. Nous asserons en revue les suorts de ces recommandations. Mots clés Lavage gastrique, Intoxication HAMOUDA Chokri, ZAOUCH Khadija, MAJED Kamel, FALFOUL BORSALI Nèbiha LAVAGE GASTRIQUE, QUELLES INDICATIONS EN 2012? GASTRIC LAVAGE, WHAT RECOMMANDATIONS IN 2012? INTRODUCTION Certes les intoxications aiguës ne constituent as un motif assez fréquent de consultation dans une urgence olyvalente, ceendant la gravité otentielle du tableau clinique ainsi que l efficience de l intervention de l urgentiste, aussi bien en termes de gestes à ratiquer qu en actes à éviter, justifient le choix du thème. En 2010 l association américaine des centres anti oison (AAPCC) a raorté la récetion de 2,4 millions aels our intoxication aiguë. De son coté, soit en 2001, l institut américain de médecine avance le chiffre de 4 millions intoxications aiguës avec hositalisations et décès [1, 2]. Les urgences toxicologiques du centre d assistance médicale urgente de Tunis drainent annuellement 4000 malades. La rise en charge de ces malades reose sur 3 axes théraeutiques comlémentaires : un traitement symtomatique fondamental, un traitement évacuateur et/ou éurateur et un traitement antidotique dans certaines situations (rise de toxique lésionnel). Nous asserons en revue les recommandations actuelles du lavage gastrique (LG) comme moy en de décontamination digestive chez les victimes d intoxication aiguë ar ingestion. En même tems nous insisterons sur le bon sens clinique de l urgentiste quant à l aort de cette rocédure invasive chez un atient qui consulte souvent audelà des deux remières heures d ingestion. Le lavage gastrique (LG) est-il une anacée en toxicologie? Durant les 25 dernières années, la décontamination digestive au cours des intoxications aiguës a manifestement évolué d une aroche agressive vers une stratégie moins agressive. Cette évolution des ratiques a été soutenue ar les recommandations de l Académie Américaine de Toxicologie Clinique (AACT) et de l Association Euroéenne des Centres Anti- Poison et des Toxicologues Cliniciens (EAPCCT) ubliées conjointement de 1997 à 2005 [3-8]. Ceendant l adhésion des raticiens à ces recommandations reste Le LG s adresse aux toxiques non carboadsorbables rotéger les voies aériennes lorsque les réflexes de rotection sont absents loin des attentes [9], d autant lus que les conseils rodigués ar les centres anti-oisons ne sont as uniformes à ce sujet [10]. Le recours au LG lors des intoxications aiguës symtomatiques était de mise jusqu aux remières décades du 20ème siècle. Ce n est qu à artir des années 1950 qu on commençait à mettre en doute l efficacité du LG en milieu édiatrique [11]. En 1966 Matthew et coll., arès une étude ortant sur 259 atients adultes victimes d une intoxication barbiturique, considérée comme intoxication symtomatique ar excellence, remarquaient qu au-delà de 4h ost ingestion l efficacité du LG, en terme de récuération des comrimés ingérés, était faible [12]. Cette attitude controversée s est oursuivie même arès la ublication des remières recommandations de 1997 [4, 13]. Quelles évidences dans les études générales? Dans deux études randomisées comarant l association Lavage Gastrique-Charbon Activé au Charbon Activé (CA) seul, aucun gain en termes de devenir n a été démontré [14, 15]. Dans une autre étude [16], les auteurs ont constaté que le LG récoce, ratiqué dans l heure qui suit l ingestion, associé au CA avait un imact favorable (<0.05) en termes d amendement du toxidrome en comaraison au CA seul. Ceendant la combinaison (LG-CA) s associait à une majoration de l incidence de la neumoathie d inhalation (=0,0001) en comaraison au CA seul (8,5% vs 0%) [14]. Qu en est-il our les toxiques lésionnels tye aracétamol? Dans une revue de quatre études randomisées comarant le LG au CA lors des intoxications aiguës au aracétamol, aucune reuve n a été démontrée en faveur du LG [17]. Ceendant dans une autre étude menée aurès de 34 volontaires sains, ce qui ne reroduit as la vraie vie, le LG ratiqué dans l heure qui suit l ingestion a ermis une réduction significative de la aracétamolémie [18]. Dans une autre étude, menée chez des atients qui se sont résentés 15

16 T O X I C O L O G I E Key Words Gastric Lavage, Intoxication 16 Abstract According to recent recommendations of scientific societies Gastric Lavage should not be used for common acute oisonings. Also GL is only indicating for otentially fatal intoxication in the first hour of care by resecting contraindications. We will review suorts of these recommendations. à 4h ost-ingestion de aracétamol à doses lors de l ingestion de roduits caustiques ou sura théraeutiques, l évacuation digestive d hydrocarbures. Les rinciales comlications (LG, Siro IPECA et CA) randomisée à de cette manœuvre à visée théraeutique sont aucune intervention du médecin d accueil la erforation de l œsohage et de l estomac, aux urgences ermettait une réduction l inhalation et la neumoathie d inhalation. significative de la aracétamolémie [19]. Dans une étude observationnelle traitant de 14 Dans le sous-groue CA la aracétamolémie LG réalisés d une façon consécutive dans quatre était manifestement lus réduite en hôitaux Sri-lankais, les auteurs raortent cinq comaraison aux deux autres sous-groues inhalations et deux comlications cardiaques : LG (=0,013) et Siro IPECA (=0,027). à tye de troubles du rythme majeurs [26]. Ceendant aucune différence en termes Dans une revue indienne récente, traitant de de manifestations cliniques n a 98 cas d intoxications aiguës été constatée entre les différents aux esticides, l incidence de sous-groues (LG, Siro IPECA la neumoathie d inhalation et CA) [19]. Pourquoi faire Eviter le LG lors varie de 2,2 à 13,2% selon que le comliquer lorsqu on eut faire simle! de l ingestion malade soit traité en structure de roximité ou en centre hositalo- de roduits Dans une revue de deux études universitaire [27]. Comme autres caustiques ou traitant d intoxication à l asirine comlications de la manœuvre, les menées chez des volontaires d hydrocarbures. auteurs raortent une désaturation sains, aucun avantage n a été érihérique en oxygène dans démontré en faveur de l utilisation 13,3% ; un laryngosasme, une du LG ar raort au CA seul [20]. tachycardie et un désordre électrolytique dans 2,2% our chacune de ces comlications [27]. Quant Qu en est-il au sujet de l effet à l effet de chasse ylorique du LG et de la stabilisant de membrane? ossibilité de majoration de la symtomatologie, nous n avons as trouvé dans la littérature de Dans une étude traitant d intoxications données corroborant ce ostula [28]. Toutes ces aiguës aux antidéresseurs tricycliques, la comlications rendent le LG une manœuvre à comaraison LG vs CA n avait as montré haut risque de iatrogénie [26]. de différence statistiquement significative en termes de devenir. De même la combinaison du LG au CA n avait as démontré de suériorité ar raort au CA seul [21]. Les inhibiteurs des cholinestérases font-ils l excetion? Quel est l indication du LG au cours des intoxications aiguës ar ingestion d un inhibiteur des cholinestérases? Le LG doit être ratiqué récocement, dans un délai d une heure, en raison de l absortion raide des inhibiteurs des cholinestérases [22]. Un lavage gastrique tardif au-delà de 12 heures, voire réété serait utile our certains auteurs [23] ; mais son intérêt reste controversé [24, 25]. En effet dans une revue systématique d essais contrôlés traitant de l utilité du LG au cours des intoxications aiguës aux esters organohoshorés aucune reuve de forte uissance n a u être aortée quant à l utilité du LG dans le traitement de ces intoxications aiguës [25]. Qu en est-il au sujet du bon sens clinique de l urgentiste? Les contre-indications du LG doivent être resectées. Il s agit d intuber le atient, avant la ratique du LG, en vue de rotéger les voies aériennes lorsque les réflexes de rotection sont absents et d éviter le LG La survenue d une neumoathie d inhalation est loin d être négligeable. Que eut-on retenir au terme de cette «randonnée»? Au terme de cette revue confrontant le bon sens clinique de l urgentiste aux résultats des études exérimentales et cliniques au sujet du LG, nous mettons l accent sur l hétérogénéité des différentes séries ubliées. Ce qui constitue un véritable handica quant à l extraolation des différents résultats. Le caractère oly médicamenteux est souvent résent. La variabilité des quantités suosées ingérées d une étude à l autre et la résence de co- morbidités contribuent aux difficultés d interrétation des résultats des études traitant de l efficacité du LG en termes de décontamination digestive au décours d une intoxication aiguë ar ingestion. Dans une revue récente de Timothy yubliée 2011[29], les auteurs corroborent les recommandations l AACT/EPCCT ubliés en 1997 à savoir : Le LG ne doit as être emloyé our les intoxications aiguës ordinaires Le LG ne s adresse qu aux toxiques non carbo-adsorbables ingérés à quantité massive otentiellement mortelle et ce durant la remière heure de rise en charge en resectant les contre-indications. Les résultats de cette activité de recherche clinique commencent à avoir un imact dans la vraie vie uisque sur les 2,4 millions de cas d intoxications raortées ar l AAPCC, seulement MED EMERGENCY N o 10

17 T O X I C O L O G I E HAMOUDA Chokri, ZAOUCH Khadija, MAJED Kamel, FALFOUL BORSALI Nèbiha Service des Urgences, CHU la Rabta, Faculté de Médecine de Tunis Université Tunis El Manar 6093 atient (0,25%) et 238 (0,02%) enfants âgés de moins de 5 ans avaient eu un LG [30]. Conclusion De nos jours le recours au LG comme moyen de décontamination digestive est de moins en moins réalisé au cours de la rise en charge des intoxications aiguës ar ingestion. Cette ratique à effet très aléatoire n est as dénuée de risques iatrogènes ouvant déasser les effets des intoxications aiguës otentiellement redoutés. Conflict of interest statement : There is no conflict of interest to declare RÉFÉRENCES 1. Bronstein AC, Syker DA, Cantilena LR Jr, Green J, Rumack BH, DART RC: 2010 Annual Reort of the American Association of Poison Control Centers National Poison Data System (NPDS): 28th Annual Reort. 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Lancet 2008; 371: Gu YL, Wan WG, Xu ML, Zou HJ. Gastric lavage for organohoshate esticide oisoned atients in Chinese. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi 2004;22: Li Y, Yu X, Wang Z, Wang H, Zhao X, Cao YP, et al. Gastric lavage in acute organohoshorus esticide oisoning: a randomized controlled trial of multile vs single gastric lavage in unselected acute organohoshoshorus esticide oisoning. BMC Emerg Med 2006;6: Li Y, Tse ML, Gawarammana I, Buckley N, Eddleston M: Systematic review of controlled clinical trials of gastric lavage in acute organohoshorus esticide oisoning. Clin Toxicol (Phila) 2009, 47: Eddleston M, Haggalla S, Reginald K, Sudarshan K, Senthilkumaran M, Karalliedde L, Ariaratnam A, Sheriff MH, Warrell DA, Buckley NA: The hazards of gastric lavage for intentional self-oisoning in a resource oor location. Clin Toxicol (Phila) 2007, 45: Bhardwaj UB, Subramaniyan A, Bhalla A, Sharma N, Singh S: Safety of gastric lavage using nasogastric ryle s tube inesticide oisoning. Health (London) 2011, 3: Eddleston M, Juszczak E, Buckley N: Does gastric lavage really ush oisons beyond the ylorus? A systematic review of the evidence. Ann Emerg Med 2003, 42: Timothy E Albertson, Kelly P Owen, Mark E Sutter and Andrew L Chan: Gastrointestinal decontamination in the acutely oisoned atient. Inter J Emerg Med 2011, 4: Bond GR: The role of activated charcoal and gastric emtying in gastrointestinal decontamination: a state-of-the-art review. Ann Emerg Med 2002, 39: Bronstein AC, Syker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL: 2009 Annual Reort of the American Association of Poison Control Centers National Poison Data System (NPDS): 27th Annual Reort. Clin Toxicol (Phila) 2010, 48: MED EMERGENCY N o 10 17

18 MÉDECINE D URGENCE PRÉ-HOSPITALIÈRE LAVAILL Loic, NGUYEN Sohie, HSSAIN Ismaël Tu-be or not? Dr Loic Lavaill Article history / info: Received: Jan. 30, 2012 Reviewed: Feb. 10, 2012 Received in revised form: Feb. 27, 2012 Acceted: Mar. 7, Abstract When managing a major trauma in a rehosital setting, one of the riorities, facing a decreased level of conscientiousness, is the uer airway management to assure atient s oxygenation. In case of thoracic trauma, the first diagnosis to rule out is a tension neumothorax. In this case, a needle decomression or even a chest tube is a must. We are reorting a osttraumatic neumothorax case with a left diahragmatic ruture and ascension of the abdominal organs into the thoracic cavity. The question is: to what extent should we rely on the clinical examination that reveals a re-hosital resiratory distress and what imortance should we give to a leural TM mode ultrasound exam in re-hosital setting to refine the diagnosis and avoid iatrogenic comlications? Key Words Thoracic trauma, diahragmatic ruture, ultrasound, chest tube, re-hosital management. Cas clinique Il s agit d une intervention ré hositalière sur un accident de la voie ublique (AVP) entre deux véhicules légers qui se sont ercutés à haute énergie cinétique lors d un choc frontal sur une route déartementale. La victime est un homme de 51 ans, incarcéré dans son véhicule. Il résente des difficultés resiratoires et des troubles de la conscience avec un Glasgow coma scale (GCS) qui asse de 14 à 7 durant les manœuvres de désincarcération. Il est considéré, arès le bilan initial, comme critique avec une menace sur la erméabilité des voies aériennes suérieures (A : Airway) et la resiration (B : Breathing) liée à un traumatisme crânien grave (GCS 8), vomissements et laie du scal (D : Disability), et une disarition des murmures vésiculaires dans l hémi thorax gauche. L hémodynamique du atient est restée stable durant les manœuvres de désincarcération et d extraction de la victime du véhicule (C : Circulation). Etant donné le traumatisme crânien grave et la forte susicion de neumothorax gauche, une indication d intubation, endobronchique sélective droite, est retenue afin de rivilégier le oumon suosé sain. La sonde d intubation orotrachéale (IOT) utilisée est alors fixée à 30cm des arcades dentaires. La météorologie défavorable ce jour là ne ermettant as une évacuation ar voie héliortée, celle-ci est réalisée ar voie routière vers le centre de traumatologie le lus roche dans de bonnes conditions hémodynamiques. Il est décidé de ne as drainer l hémithorax gauche «à l aveugle» étant donné la stabilité du atient, aussi bien sur le lan resiratoire que circulatoire arès intubation. Arès imagerie ar tomodensitométrie cors entier, le bilan lésionnel révèle une ruture diahragmatique gauche associée à une ascension des viscères abdominaux et une fracture de rate dans l hémithorax gauche. Par ailleurs, il existe quelques foyers de contusions cérébrales mineures. Le atient est transféré raidement au bloc de chirurgie viscérale et thoracique our rise en charge de cette hernie diahragmatique avec une évolution favorable et des suites oératoires simles. RX Thorax de face: ruture diahragmatique gauche Discussion Les critères consensuels d intubation d un traumatisme thoracique sont les suivants (1): - défaillances circulatoires et/ou neurologiques associées ; - difficultés techniques associées à une éventuelle indication d intubation orotrachéale lors du transfert (our un transfert secondaire) ; - contrôle analgésique non satisfaisant avec imossibilité de cooération du atient ; - hyoxémie < 60 mmhg malgré une oxygénothéraie bien conduite ; - hyercanie > 45 mmhg ; - détresse resiratoire en relation avec une neumoathie hyoxémiante. L intubation endobronchique (IEB) sélective en usage réhositalier ne fait as encore l objet de recommandations de sociétés savantes. Elle a été ar contre citée comme une éventualité théraeutique (2). La difficulté de reroduire le geste à bon escient exlique robablement cela. La réalisation d une IEB sélective nécessite, en anesthésie rogrammée, l emloi de sondes articulières, calibrées et réformées, destinées à faciliter la cathéterisation de la bronche cible (3). Dans le cas résent l IEB a été réalisée avec une sonde d intubation orotrachéale classique, en rofitant des disositions anatomiques classiques our cathétériser la bronche souche droite (en oussant la sonde d IOT au-delà des reères habituels de l IOT) (2). On eut imaginer qu en cas de variation anatomique et/ou de neumothorax infra clinique à droite cette décision n aurait as ermis la mise en sécurité du atient (4).

19 MÉDECINE D URGENCE PRÉ-HOSPITALIÈRE LAVAILL Loic, MD, NGUYEN Sohie, MD, HSSAIN Ismaël, MD Center for EMS Education Emergency & Disaster Medicine Pre Hosital & Critical Care Deartment Mulhouse General Hosital, France Centre d Enseignement et de Soins d Urgence, CESU 68 Pôle SAMU 68 SMUR Urgences Réanimation Médicale Centre Hositalier de Mulhouse, France Conflict of interest statement : There is no conflict of interest to declare Résumé Lors de la rise en charge d un traumatisé grave en médecine d urgence ré hositalière, une des riorités face à des troubles de la conscience est la libération des voies aériennes suérieures et l oxygénothéraie. Si on évoque un traumatisme du thorax, le diagnostic à éliminer en remier est celui du neumothorax comressif. Auquel cas l exsufflation voir le drainage thoracique à l aveugle s imosent. Nous raortons un cas de neumothorax ost traumatique associé à une ruture diahragmatique gauche et ascension de viscères abdominaux. La question que nous nous osons : jusqu à quel limite faut-il se fier aux données de l examen clinique de détresse resiratoire en réhositalier et quel lace doit-on donner à l échograhie leurale en mode TM en réhositalier our affiner le diagnostic et éviter la iatrogénie? Mots clés Trauma thoracique, ruture diahragmatique, échograhie thoracique, drain thoracique, rise en charge ré-hositalière La réalisation d un rotocole de recherche clinique à ce roos résente de lus quelques difficultés inhérentes à la rareté des indications otentielles d IEB en contexte réhositalier. La mise à disosition de sondes d IEB aux équies médicales ré hositalières est enfin difficilement envisageable étant donné leur coût largement suérieur à celui des sondes d IOT classiques, et la rareté de leur utilisation d autant lus que leur utilisation nécessiterait un arentissage sécifique. Le drainage d un neumothorax ar une équie réhositalière est mieux documenté (1,5 10). La luart des équies et des recommandations réconisent une tentative d exsufflation rimaire à l aiguille en cas de neumothorax comressif avec distension thoracique (7,9). C est notamment le cas des recommandations nord-américaines, dont celles des équies ré hositalières comosées de aramedics. L ATLS (Advanced Trauma Life Suort) recommande l utilisation d une aiguille d une longueur minimale de 3cm, introduite sur la ligne médio claviculaire sur le 2ème esace intercostal de l hémithorax concerné (11). Ce site de onction allie efficacité (en regard de l aex ulmonaire, drainage essentiellement aérique) et sécurité (eu de structures vasculaires intra thoraciques en regard). La luart des atients ont une éaisseur de aroi musculo-adio-cutanée comrise entre 3 et 4,5cm en regard de ce site de onction, ce qui a conduit à réviser la recommandation de longueur en 1996, soit désormais 5cm (7,12). L évacuation de l éanchement leural, sous quelque modalité que ce soit, ne eut raisonnablement s envisager que sur un atient intubé et ventilé en ression ositive, avec une sédation et une analgésie convenable (1). La réalisation de cet acte ne saurait s envisager si l éanchement (aérique et/ou hématique) est bien toléré (5). La mauvaise tolérance d un neumothorax se mesure sur des aramètres hémodynamiques en cas de comression médiastinale et/ ou éricardique externe. Ce geste devra généralement être accomagné d une tentative de récuération de la masse sanguine sortante (et donc d un drainage en milieu stérile) our tenter de alier la soliation sanguine issue des grandes quantités de sang que eut contenir un hémothorax (6). En règle donc, il est licite de recommander face à un hémo et/ou neumothorax mal toléré la réalisation d un drainage à l aide d un disositif stérile (13), en circuit fermé, ermettant la récuération de la masse sanguine intra thoracique et la réalisation d une autotransfusion ar la suite (14,15). Le sang issu du drainage d un hémothorax résente en effet la articularité de ne ouvoir coaguler, et ce grâce à l activation de facteurs fibrinolytiques sanguins (16). Des disositifs stériles à usage unique, tye ConstaVac Stryker ou Snyder Hemovac, existent à ces fins. Ces disositifs disosent d une ome autonome, alimentée ar un bloc batterie inclus dans le disositif, et d une caacité de dérivation du flux our l autotransfusion (17,18). En cas d absence de ce matériel l on eut aussi utiliser une oche collecteur d urine, stérile, ermettant ar l une des extrémités la connexion au drain et ar l autre l abouchement à une ligne de erfusion disosant d un filtre (19). Ce geste devra être réalisé arès un toucher leural et via un guidage digital our éviter les lésions ouvant être causées ar un mandrin ou un guide (6,10). Les critères de réalisation de cet acte en cas d absence de lateau de radiologie sont les suivants (10) : - SO2 < 92% sous 100% de FiO2 ; - PA systolique < 90 mm Hg ; - fréquence resiratoire sontanée < 10 cm ; - altération de la vigilance (sur l échelle de Glasgow), sous 100% de FiO2 ; - arrêt cardiaque. L échograhie leuro-ulmonaire fait désormais artie du bilan échograhique réalisé à l accueil du olytraumatisé en service d urgences (20). Elle recherche les éanchements liquidiens et/ou aériens dans les hyochondres, et eut s envisager aussi bien au lit du malade qu en situation réhositalière our aider au diagnostic devant un traumatisé grave (21). S envisageant sur un atient couché, l échograhie ostérieure recherche les éanchements liquidiens avec une sensibilité de 84 à 97% our une sécificité roche de 100% (22,23). L échograhie antérieure recherche quant à elle des éanchements aériques (20,24), avec une sensibilité de 59 à 87% et une sécificité de rès de 100% (25,26). Ces valeurs diagnostiques ne s entendent bien entendu que our des oérateurs formés à l utilisation des matériels ultrasonores. Conclusion L intubation endobronchique sélective en réhositalier est une alternative théraeutique instrumentale en situation de forte susicion de neumothorax. L usage de sondes classiques eut s avérer ratique et efficace. Par ailleurs, le drainage thoracique en situation réhositalière n est as recommandé chez un atient résentant un traumatisme diahragmatique et une ascension des viscères abdominaux (27 29). Ceendant et lorsque l état clinique de la victime l oblige, un toucher leural et un guidage digital rudent ermettraient d assurer une sécurité satisfaisante lors du drainage. 19

20 MÉDECINE D URGENCE PRÉ-HOSPITALIÈRE BIBLIOGRAPHIE 1. Michelet P, Jacquin L, Bessereau J, Couret D. Les traumatismes thoraciques : Comment je les ventile - Quand faut-il les drainer? Traumatologie vitale - le traumatisme thoracique. Paris: SFMU SUdF; Carli P, Incagnoli P. Traumatismes ouverts thoraco-abdominaux : l avis du médecin du SAMU et du SMUR. Paris: Elsevier Masson SAS; Fischler M. Anesthésie en chirurgie thoracique. Enycl Med Chir - Anesthésie-Réanimation. 2002;( A-10): Vazel L, Potard G, Martins-Carvalho C, LeGuyader M, Marchadour N, Marianowski R. Intubation : technique, indication, surveillance, comlications. EMC - Oto-rhino-laryngologie Feb;1(1): Schmidt U, Stal M, Gerich T, Blauth M, Maull KI, Tscherne H. Chest tube decomression of blunt chest injuries by hysicians in the field: effectiveness and comlications. J Trauma Jan;44(1): Moritz F, Dominique S, Lenoir F, Veber B. Drainage thoracique aux urgences. EMC - Médecine Ar;1(2): Blaivas M. Inadequate needle thoracostomy rate in the rehosital setting for resumed neumothorax: an ultrasound study. J Ultrasound Med Se;29(9): Aylwin CJ, Brohi K, Davies GD, Walsh MS. Pre-Hosital and In-Hosital Thoracostomy: Indications and Comlications. Ann R Coll Surg Engl Jan;90(1): Barton ED, Eerson M, Hoyt DB, Fortlage D, Rosen P. Prehosital needle asiration and tube thoracostomy in trauma victims: A six-year exerience with aeromedical crews. The Journal of Emergency Medicine Ar;13(2): Leigh-Smith S, Harris T. Tension neumothorax time for a re-think? Emerg Med J Jan;22(1): American Colege of Surgeons. Committee on Trauma. Advanced Trauma Life Suort for Doctors. Chicago, IL: American College of Surgeons; Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension neumothorax: insufficient cannula length and otential failure. Injury Jun;27(5): Barriot P, Riou B, Viars P. Prehosital Autotransfusion in Life-Threatening Hemothorax. Chest Mar 1;93(3): FERRARA BE. Autotransfusion: its use in acute hemothorax. Southern medical journal. 1957;50(4): Symbas PN. Autotransfusion from hemothorax: exerimental and clinical studies. Journal of Trauma. 1972;12(8): Schved JF, Gris JC, Gilly D, Joubert P, Eledjam JJ, d Athis F. Etude de l activité fibrinolytique dans les liquides de onction d hémothorax traumatique. Annales Françaises d Anesthésie et de Réanimation. 1991;10(2): Ritter MA, Fechtman RW. Closed wound drainage systems: the Stryker Constavac versus the Snyder Hemovac. Ortho Rev May;17(5): Trammell TR, Fisher D, Brueckmann FR, Haines N. Closed-wound drainage systems. The Solcotrans Plus versus the Stryker- CBC ConstaVAC. Ortho Rev Jun;20(6): Baumann MH. What size chest tube? What drainage system is ideal? And other chest tube management questions. Curr Oin Pulm Med Jul;9(4): Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out neumothorax in the critically ill. Lung sliding. Chest Nov;108(5): Le P. Langlois S. Training in Emergency Ultrasound for Civilian and Military Use. Prehos Disast Med. 2002;17(s2):S Ma OJ, Mateer JR, Ogata M, Kefer MP, Wittmann D, Arahamian C. Prosective analysis of a raid trauma ultrasound examination erformed by emergency hysicians. J Trauma Jun;38(6): Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J Jan;21(1): Lichtenstein D, Mezière G, Biderman P, Gener A. The comet-tail artifact: an ultrasound sign ruling out neumothorax. Intensive Care Med Ar;25(4): Dulchavsky SA, Schwarz KL, Kirkatrick AW, Billica RD, Williams DR, Diebel LN, et al. Prosective evaluation of thoracic ultrasound in the detection of neumothorax. J Trauma Feb;50(2): Neff MA, Monk JS Jr, Peters K, Nikhilesh A. Detection of occult neumothoraces on abdominal comuted tomograhic scans in trauma atients. J Trauma Aug;49(2): Rashid F, Chakrabarty MM, Singh R, Iftikhar SY. A review on delayed resentation of diahragmatic ruture. World J Emerg Surg Aug 21;4: Genotelle N, Lherm T, Gontier O, Le Gall C, Caen D. Hémothorax droit intarissable révélateur d une laie héatique avec ruture diahragmatique. Annales Françaises d Anesthésie et de Réanimation Aug;23(8): Gunn JM, Savola J, Isotalo K. Left-sided diahragmatic and ericardial rutures with subluxation of the heart after blunt trauma. Ann. Thorac. Surg Jan;93(1):

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