Michel Baer

Automated external defibrillators in the workplace

Uptake must be supported by a detailed programme of implementation

Cardiac arrest in a patient with Brown-Vialetto-Van Laere syndrome

We report the case of a 22-y-old female with Brown-Vialetto-Van Laere syndrome who experienced sudden out-of-hospital cardiac arrest at night, witnessed by her mother. Healthcare professionals performed standard cardiopulmonary resuscitation while waiting for the arrival of the mobile emergency unit. Spontaneous circulation returned after 10 min. There was no spontaneous ventilation, and the mobile-unit physician performed endotracheal intubation without succinylcholine (suxamethonium), given the possibility of hyperkalaemia, and started an intravenous infusion of isotonic saline. The heart rate was then 110 beats/min, blood pressure 140/ 80 mmHg, and SpO2 was 99% with manual ventilation and 100% FiO2. No anaesthetic was needed. Bilateral mydriasis with abolition of the pupillary reflexes was noted. Corneal, orbicularis, oculocardiac, and oculocephalic reflexes were absent. The rest of the physical examination was normal. Electrocardiography showed tachycardia and sinus ectopy with a normal axis and no bundle branch block. The mother reported that her daughter had Brown-Vialetto-Van Laere syndrome, which had been diagnosed in Tunis 10 years earlier and caused bilateral weakness of the neck and trapezius muscles, as well as bilateral deafness. She had no known respiratory insufficiency and was not receiving treatment. The patient and her mother had arrived in France the day before after an uneventful trip. The patient had started experiencing dyspnoea on arrival about 10 hours earlier. There was no history of chest pain. Findings were normal from investigations for a cause carried out in the intensive care unit and including biochemistry, assays for toxic substances, and investigations for cardiovascular disease and pulmonary embolism. The diagnosis was acute respiratory failure with anoxic cardiac arrest complicating Brown-Vialetto-Van Laere syndrome. The electroencephalogram showed severely altered cerebral activity. Myoclonus developed within a few hours. Permissive hypothermia was initiated but stopped on the next day, given the poor neurological prognosis. She died one week later with pneumonia. This case not only illustrates the diagnostic challenges raised by Brown-Vialetto-Van Laere syndrome in the emergency setting, but also demonstrates that failure to prevent the complications of this orphan disease can cause death. Fewer than 50 cases of Brown-Vialetto-Van Laere syndrome have been reported. The first case was described in 1894. Features include bilateral severe hearing loss and palsies of the motor components of the 7th and 9th to 12th cranial nerves (1). Transmission is autosomal recessive, autosomal dominant, or X-linked, and sporadic cases occur (2). Respiratory failure develops slowly and is the main cause of death (3,4). Prevention of respiratory failure can be achieved using elective non-invasive ventilation (5). Introini et al. described the advantages of intensive treatment of respiratory failure and diaphragm paralysis in a patient with BrownVialetto-Van Laere syndrome at risk for ventilatory arrest (6). Our case is the first detailed report of Brown-Vialetto-Van Laere syndrome with sudden cardiac arrest. It shows that life-threatening respiratory failure can develop either at an early stage of Brown-Vialetto-Van Laere syndrome or after a period with unrecognized chronic respiratory failure. In our patient, the trip from Tunisia to France without medical assistance suggests a lack of effective medical management.

Difficulties encountered by physicians in interpreting focused echocardiography using a pocket ultrasound machine in prehospital emergencies.

Objective Pocket ultrasound devices (PUDs) increase the scope of transthoracic echocardiography. We assessed the ability of emergency physicians (EPs) to obtain and interpret views using PUDs in prehospital emergencies. Materials and methods Nine EPs underwent a 2-day training program focused on acquisition of four views and on evaluation of left ventricular function, right ventricular size, the inferior vena cava, and detection of pericardial effusion. Then, EPs used a PUD to perform transthoracic echocardiography in patients with shock or acute respiratory failure. The quality and interpretation of views were graded by an expert as not obtained/inadequate, adequate, or optimal. Agreement between the expert and the physicians was evaluated using Cohen’s &kgr; test. Results One hundred consecutive exams were evaluated in patients with shock or acute respiratory failure. Parasternal long-axis and short-axis views, and a subcostal view were not obtained or inadequate in 56, 54, and 54 patients, respectively. An apical four-chamber view was not obtained or inadequate in 33 patients. One, two, or three views were graded as adequate or optimal in 86, 65, and 35 patients. Agreement between physicians and experts for left ventricular systolic function, right ventricular size, and pericardial effusion was weak [&kgr; 0.37 (0.17; 0.59), 0.27 (0.023; 0.53), and 0.33 (−0.008; 0.67)]. Agreement for inferior vena cava evaluation was very weak [0.13 (−0.17; 0.43)]. Conclusion After a very short training program, echocardiography using a PUD in prehospital emergencies was feasible in half of patients. Acquisition of technical skills is reasonable, but accurate evaluation of cardiac function may require more extensive training.

Rôle du médecin du travail dans la préparation d’une situation de crise exceptionnelle

Resume Objectif La gestion de crise, quelle que soit son origine (sanitaire, accidentelle...), est devenue depuis plus d’une decennie un objectif prioritaire au niveau mondial. Ces crises sont caracterisees par l’imprevu et une destructuration des logiques habituelles de fonctionnement. L’objectif de ce travail est de synthetiser les differents roles que peut prendre le medecin du travail dans la gestion de ces crises et tout particulierement dans sa preparation. Methode Nous avons utilise les donnees de la litterature, avec un rappel des missions du medecin du travail en particulier dans la gestion de ces situations exceptionnelles (prevention primaire, secondaire), et des exemples pratiques issus de notre experience. Resultats Les roles du medecin du travail en cas de survenue d’un evenement exceptionnel sont multiples et dependent beaucoup de la structure de l’entreprise et des liens anterieurs tisses entre le medecin et sa direction. Ils peuvent se decliner dans le temps au cours d’une crise : role medical de soins sur le terrain, role d’expert sur les risques specifiques de l’entreprise, aussi bien sur le lieu de l’accident qu’en cellule de crise, et role de suivi de l’ensemble des personnes impliquees dans la crise. Neanmoins, le role le plus important du medecin du travail se situe avant la crise afin de la prevenir et d’en limiter les effets. Il peut ainsi apporter sa competence dans la preparation et la reflexion autour de la gestion des crises sanitaires, comme dans l’organisation d’exercices de simulation et de formation des salaries sur ce sujet. Conclusion L’anticipation, la preparation et la resolution d’une crise sont donc des domaines dans lesquels le medecin du travail doit pouvoir apporter sa competence et son expertise au service de l’entreprise.

Prise en charge préhospitalière de l’arrêt cardiaque de l’enfant et du nourrisson : enquête nationale de pratique

INTRODUCTION After the publication of new recommendations for cardiopulmonary resuscitation (2005 guidelines and 2006 French recommendations), we conducted a study amongst EMS teams concerning their approach with children and infants, nationwide. The objective was to measure the level of knowledge of guidelines and practice. METHODS The online questionnaire was offered to emergency physicians belonging to the French emergency database, between November 1st and December 15th 2007. Incomplete questionnaires were excluded from the study. We recorded: profile of personnel, knowledge of guidelines, basic CPR and advanced CPR parameters. RESULTS Four hundred and thirty-nine questionnaires were analyzed. Personnel was aged under 40 in 50.2 %, with 2-5 years experience in prehospital emergency care (57.6 %); 51,3 % declared having had training in pediatric CPR. A minority of subjects declared knowing the 2005 Guidelines (35 %), more the French 2006 recommendations (62.5 %). Basic CPR: transition age child/adult known in 30.3 %. Compression/ventilation ratio: 30/2 for one rescuer in 50.2 % (child), 46.5 % (infant); 15/2 for two or more rescuers in 57.6 % (child), 48 % (infant). AED age for use (1 year old) known in 59.8 %. Advanced CPR: epinephrine dose known in 89.3 % (intravenous) and 34.3 % (tracheal). External shock known in 57.2 %. CONCLUSION This study emphasizes the lack of knowledge, especially with regard to first aid. Formations will be developed.

Use of tabletop exercise in industrial training disaster.

Training exercises are now frequently used in health disaster and emergency medicine to train first responders,1 including the use of tabletops’ exercises.2–4 However, these kinds of drill are barely described in occupational and industrial safety and health. They represent an interesting alternative to real life disaster plans, considering the enormous human and technical resources that are required, and the disruptance of company’s daily business. We aimed at developing a special training for professionals of health and safety (occupational physicians, hygienists…) in case of health disaster in industrial settings, using a tabletop exercise. We organized a one day-session about disaster fundamentals for 28 occupational physicians included in a Master degree in emergency medicine training. A tabletop exercise was made based on a scenario of a fire in a plant with risk of chemical explosion - 22 victims and one dead (person). Three groups of 9/10 participants had 1h15 to discuss and « play » rescue operations from the initial accident to the discharge of the last victims from the triage centre. They were supervised by a physician and a nurse who are specialized in disaster training. We used a large tabletop representing the industrial plant and the figurines/vehicles (patients, industrial and emergency responders, firemen and police officers, journalist…). Satisfaction and cost were evaluated such as repeatability. The participants were largely satisfied by the training and believe, such as the teachers, that the exercise well illustrates the roles of occupational physicians, the triage centre, and intricate logistics during a health disaster. The direct cost was

Cardiac arrest in the workplace: Pilot study on the RéAC register

1,285 (975 euros), namely

Management of acute allergic reactions by dispatching physicians in a Medical Emergency Dispatch Centre

646 for the figurines and

221 Evaluation of stress and anxiety in a grimed population playing the role of victims in a live terrorist attack exercise

639 for the supervisors for the first year (

Emergency Preparedness and Response in Occupational Setting: A Position Statement

46 per participant). At the opposite of a real life exercise, we didn’t notice any impact on daily activities of the company/plant. One year later, the tabletop was performed again with other 28 participants with similar satisfaction and reduced cost (only