tag:blogger.com,1999:blog-3170326330372124202024-02-20T18:14:14.715-08:00VIBE-UrgenceVeille Iconographique, Bibliographique et Educationnelle en Médecine d'UrgenceVIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.comBlogger75125tag:blogger.com,1999:blog-317032633037212420.post-3583600497286640932021-03-29T08:38:00.005-07:002021-03-29T08:39:21.122-07:00Journal Club 4 (2020) - Une TAXE pour le TXA ?<p> </p><h1 _ngcontent-joh-c48="" class="ng-star-inserted" style="background-color: white; color: #005461; font-family: "Open Sans", Arial; font-size: 28px; line-height: 1.3; margin: 10px 0px;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7upiQQu53f4MoCiWqpRXIKvtEX7EviTdryh0PwhF79AgTi-N53bRryUbQSkMMITQQWslh2sztLr5HchjyqxNdJ81tdk4Ac-VOX7C4W_DUZGqsG3yD8VGkQgWyYYq5CS0vkcK_AyvkK6bH/s1448/image.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1242" data-original-width="1448" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7upiQQu53f4MoCiWqpRXIKvtEX7EviTdryh0PwhF79AgTi-N53bRryUbQSkMMITQQWslh2sztLr5HchjyqxNdJ81tdk4Ac-VOX7C4W_DUZGqsG3yD8VGkQgWyYYq5CS0vkcK_AyvkK6bH/s320/image.png" width="320" /></a></div><br />Un tampon pour l'acide tranexamique ?</h1><div _ngcontent-joh-c48="" class="annotation" style="background-color: white; color: #444444; font-family: "Open Sans", Arial; font-size: 15px;"><div _ngcontent-joh-c48="" class="picture ng-star-inserted" style="background-color: #ebebeb; height: 346px; margin: 0px -25px; position: relative;"><img _ngcontent-joh-c48="" alt="Un tampon pour l'acide tranexamique ?" height="300" src="https://s6.esanum.fr/backend/media/images/2021/3/19/15cf450c-a385-428b-bec3-2ac6e0df1e5d/renders/detailed@2x.jpg" style="background-color: #444444; border: 0px; display: block; height: 346px; max-width: 100%; width: 750px;" title="Un tampon pour l'acide tranexamique ?" width="642" /></div></div><div _ngcontent-joh-c48="" class="content ng-star-inserted" style="background-color: white; color: #444444; font-family: "Open Sans", Arial; font-size: 15px;"><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Nous publions ici, avec son accord, le Journal Club que le Pr Nicolas Peschanski * propose à ses étudiant.e.s afin de leur présenter certaines études relatives à sa spécialité. Nous l'en remercions chaleureusement.</em></h5><p style="margin: 10px 0px; text-align: center;"><img alt="MU Rennes nu.png" src="https://www.esanum.fr/images/292262" style="border: 0px; height: 169px; width: 300px;" /></p><h2 style="color: #005461; font-size: 22px; line-height: 1.2; text-align: center;">Journal Club n°4</h2><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br /><br />L’étude</h3><p style="margin: 10px 0px;"><strong>Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post-CRASH-2 Era</strong> <sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">1</sup></p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Pourquoi est-ce important ?</h3><p style="margin: 10px 0px;">L'étude CRASH-2 a montré une baisse de mortalité lorsque le TXA était administré à des patients adultes souffrant d'un traumatisme hémorragique grave. La plupart des sites de l'étude CRASH-2 se trouvaient dans des pays où les pratiques de transfusion et la capacité à identifier les événements indésirables étaient différentes de celles des centres de traumatologie américains ou européens. Cette étude se focalise justement sur l'utilisation du TXA dans le contexte d'un centre de traumatologie de haut niveau avec une filière de soins optimisée.</p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Un CRASH dans le monde réel ?</h3><p style="margin: 10px 0px;">Il s'agissait d'une étude rétrospective intéressant des patients :<br />- ayant reçu du TXA à l'U.C. à la dose de 1g en 10 minutes puis 1g en 8h,<br />- pris en charge dans les 3h du traumatisme,<br />- ayant présenté une hypotension ou bénéficié d'une transfusion massive<br />et ceux qui étaient allés directement des urgences au bloc opératoire. </p><ul style="list-style: square;"><li>Sur une période de trois ans, 273 patients ont reçu du TXA. </li><li>Le taux de mortalité était de 12,3% – similaire à la cohorte originale de l'étude CRASH-2 (14,5% de mortalité). </li><li>Dans 84% des cas, le TXA a été administré dans les trois heures.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Des différences notables</h3><ul style="list-style: square;"><li>Le résultat majeur de cette étude réside dans le taux d'événements thromboemboliques qui était beaucoup plus élevé (6,6%) comparé à la cohorte CRASH-2 (2%).</li><li>Par ailleurs, les patients de cette étude ont été plus souvent transfusés, ont subi plus de chirurgie, étaient plus âgés et comptaient un pourcentage plus élevé de femmes que la cohorte CRASH-2.</li><li>Ils présentaient également des blessures plus graves même si l'ISS (score de sévérité) n'était pas renseigné dans CRASH-2, ce qui empêche la comparaison directe. </li><li>En outre, le TXA a été administré plus tôt que dans CRASH-2. </li><li>Étonnamment, les auteurs ne relatent que 61% de patients ayant reçu à la fois la dose initiale TXA en bolus et celle d'entretien, alors que 94% ont reçu les deux doses de TXA dans l'essai CRASH-2. On pourrait donc penser que cela biaise les résultats en faveur d'un nombre réduit d'événements thromboemboliques. </li><li>La différence dans les événements thromboemboliques pourrait être due à l'âge plus avancé des patients, à des comorbidités plus importantes, à un taux plus élevé de chirurgie et de transfusion et à un meilleur dépistage des évènements thromboemboliques par rapport à l'essai CRASH-2.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />TXA or no-TXA, that is the question... (again)</h3>Cette étude montre que l'utilisation du TXA dans un contexte autre que celui de CRASH-2 – et semblable à nos filières françaises de traumatologie lourde – peut produire des résultats différents de ceux de la population de l'étude princeps.<p style="margin: 10px 0px;">D'autres travaux sont nécessaires pour déterminer le rapport bénéfice/risque du TXA dans une filière de traumatologie lourde.</p><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><em>Vous êtes médecin ?<br />Pour recevoir une sélection de nos articles ou les commenter, il vous suffit de vous inscrire.</em></h5><p style="margin: 10px 0px;"><br /><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Note :<br />1- <a href="https://pubmed.ncbi.nlm.nih.gov/32189440/" style="color: #005461; cursor: pointer; overflow-wrap: break-word;" target="_blank">Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post-CRASH-2 Era</a><br />Acad Emerg Med. 2020 May;27(5):358- 365. doi: 10.1111/acem.13883. Epub 2020 Mar 19</em></sup></p><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>* Nicolas Peschanski est professeur de médecine d'urgence et praticien hospitalier au CHU de Rennes. Membre actif de longue date de la SFMU – avec six années passées au sein de la commission scientifique – il siège depuis 2020 à la commission des référentiels.<br />Le parcours international du Pr Peschanski, notamment aux USA, lui a permis de devenir membre de la Commission Internationale de l'American College of Emergency Physicians ainsi que du comité de pilotage de l'EMCREG-International (Emergency Medicine Cardiac Research and Education Group). Il fait également partie de l'Eusem (</em>European Society for Emergency Medicine) et plus particulièrement de son comité «Web & social media».<br /><em>Le Pr Peschanski est très attaché au principe de la FOAMed (Free Open Access Meducation - Partage en libre accès des ressources éducatives médicales). Il utilise les réseaux sociaux (@DocNikko) à des fins pédagogiques et de partage des connaissances en médecine d’urgence.</em></h5><p style="margin: 10px 0px;"><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Liens d'intérêts<br />Le professeur Peschanski déclare les liens d'intérêts suivants :<br />- sur les trois dernières années : Vygon SA (consultant), Fisher&Paykel (symposium), AstraZeneca (symposium)<br />- sur les vingt dernières années :<br />Symposiums : Fisher&Paykel Healthcare , AstraZeneca, Lilly, Sanofi, Daiichi-Sankyo, HeartScape, The Medicine Company, Thermofisher, Roche Diagnostics<br />Boards : Bayer, AstraZeneca, Vygon SA, Portola USA, Sanofi, Boehringer Ingelheim<br />Congrès : Lilly, Sanofi, Vygon SA, Portola, Roche Diagnostics, Thermofisher<br />Fonds de recherche (non personnels) : Servier, Boehringer Ingelheim</em></sup></p></div>VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-14800068064502801532021-03-26T10:34:00.004-07:002021-03-26T10:40:37.164-07:00Journale Club 3 (2020) : Soyons un peu REBEL au sujet de l'oxygénation du COVID-19<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4dgNUuUJ9LeUWi-UOsSkluchpHqF-QBqXxlfuzx0eYisbVg4AMr_3v1KYa9NVDH9unq5K81ohGEQ9FhNkJG984UVa9BqOTUY2wKkEhloGC08x2ozi7qFUrHKNhrrZoYUk5s-vFZy9M7fo/" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="1242" data-original-width="1448" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj4dgNUuUJ9LeUWi-UOsSkluchpHqF-QBqXxlfuzx0eYisbVg4AMr_3v1KYa9NVDH9unq5K81ohGEQ9FhNkJG984UVa9BqOTUY2wKkEhloGC08x2ozi7qFUrHKNhrrZoYUk5s-vFZy9M7fo/" width="280" /></a></div><br /><p></p><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="background-color: white; color: #005461; font-family: "Open Sans", Arial; font-size: 28px; line-height: 1.3; margin: 10px 0px;">Ventilation non invasive et Covid-19 : Magnéto vs Batman... et Aquaman</h1><div><br /></div><div _ngcontent-nby-c46="" class="annotation" style="background-color: white; color: #444444; font-family: "Open Sans", Arial; font-size: 15px;"><div _ngcontent-nby-c46="" class="picture ng-star-inserted" style="background-color: #ebebeb; height: 346px; margin: 0px -25px; position: relative;"><img _ngcontent-nby-c46="" alt="Ventilation non invasive et Covid-19 : Magnéto vs Batman... et Aquaman" height="300" src="https://s3.esanum.fr/backend/media/images/2020/5/29/388cf26d-4919-4e1e-ab2f-8f1aeb021897/renders/detailed@2x.jpg" style="background-color: #444444; border: 0px; display: block; height: 346px; max-width: 100%; width: 750px;" title="Ventilation non invasive et Covid-19 : Magnéto vs Batman... et Aquaman" width="642" /></div></div><div _ngcontent-nby-c46="" class="content ng-star-inserted" style="background-color: white; color: #444444; font-family: "Open Sans", Arial; font-size: 15px;"><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Nicolas Peschanski est professeur de médecine d'urgence et praticien hospitalier au CHU de Rennes. Il est membre actif de longue date de la SFMU. Après avoir œuvré six ans au sein de la commission scientifique, il siège depuis 2020 à la commission des référentiels.<br />Son parcours international, notamment aux USA, lui a permis de devenir membre de la Commission Internationale de l'American College of Emergency Physicians ainsi que du comité de pilotage de l'EMCREG-International (Emergency Medicine Cardiac Research and Education Group).<br />Très attaché au principe de la FOAMed (Free Open Access Meducation - Partage en libre accès des ressources éducatives médicales), il utilise les réseaux sociaux (@DocNikko) à des fins pédagogiques et de partage des connaissances en médecine d’urgence.</em></h5><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><em>Le Pr Peschanski tient un journal club afin de présenter à ses étudiant.e.s certaines études relatives à sa spécialité. Il a accepté de le publier ici. Nous l'en remercions chaleureusement.</em></h5><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><em>(Cet article – publié initialement sur esanum.fr le 29 mai 2020 – est la version française et enrichie d’un article<sup style="font-size: 0.75em; line-height: 9.75px; position: unset; top: -0.5em;">1</sup> écrit par Salim Rezaie, publié sur son blog REBEL.EM le 1<sup style="font-size: 0.75em; line-height: 9.75px; position: unset; top: -0.5em;">er</sup> mai).</em></h5><div><em><br /></em></div><div><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="color: #005461; font-size: 28px; line-height: 1.3; margin: 10px 0px;">#Journal_Club</h1></div><p style="margin: 10px 0px; text-align: center;"><br /><em><img alt="MU Rennes nu.png" src="https://www.esanum.fr/images/292263" style="border: 0px; height: 169px; width: 300px;" /></em></p><h2 style="color: #005461; font-size: 22px; line-height: 1.2; text-align: center;">Journal Club n°3<br /> </h2><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Contexte</h3><ul style="list-style: square;"><li>Au cours des dernières semaines, la prise en charge des patients gravement malades atteints de COVID-19 a été modifiée. Nombre de praticiens semblent être passés d'une stratégie d'intubation précoce à l'utilisation de canules nasales à haut débit (HFNC) et à la ventilation non invasive (VNI). <strong>La HFNC et la VNI peuvent rendre inutile l'intubation endotrachéale chez les patients souffrant d'une insuffisance respiratoire aiguë.</strong></li><li>La ventilation mécanique n'est pas une intervention bénigne car elle s'accompagne d'un certain nombre de complications, notamment des pneumopathies acquises sous ventilation, une sédation excessive, une agitation, complications acquises en soins intensifs, ainsi que des lésions pulmonaires induites par la ventilation (IVL).</li><li>La VNI peut provoquer des lésions pulmonaires dues à des pressions négatives excessives. Cependant, la ventilation mécanique peut provoquer une IVL en raison de pressions positives excessives. <strong>Il existe un équilibre délicat entre le moment où il faut utiliser telle ou telle modalité de ventilation</strong> et celui où il faut passer d'une modalité à l'autre, ce qui nécessite une surveillance fréquente au chevet du patient. </li><li>La VNI a été utilisée avec succès pour les exacerbations de BPCO et l'œdème pulmonaire cardiogénique, mais son utilisation en cas d'insuffisance respiratoire hypoxémique aiguë est encore assez controversée. L'un des problèmes posés par la VNI au moyen d'un masque est que des niveaux plus élevés de pression expiratoire positive (PEP) sont souvent nécessaires dans les conditions d'hypoxémie et peuvent entraîner une intolérance au masque ainsi que des fuites d'air sur les côtés du masque.</li><li>La VNI par casque peut présenter plusieurs avantages par rapport aux masques faciaux, notamment une meilleure tolérance et moins de fuites d'air. Il n'existe pas beaucoup de données permettant de comparer ces avantages aux modalités de la VNI.</li></ul><h2 style="color: #005461; font-size: 22px; line-height: 1.2;"><br />La ventilation non invasive (VNI) délivrée par le casque est-elle meilleure que le masque pour prévenir le taux d'intubation chez les patients atteints de SDRA ?</h2><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />L’étude</h3><p style="margin: 10px 0px;"><strong>Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome:<br />A Randomized Clinical Trial</strong> <sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">1</sup><br /> </p><ul style="list-style: square;"><li>Essai clinique randomisé dans un seul centre sur 83 patients consécutifs atteints de SDRA nécessitant une VNI délivrée par un masque facial pendant au moins 8 heures pendant leur séjour aux soins intensifs à Chicago.</li><li>Prévision d'inscription de 206 patients.</li><li>L'essai s'est terminé prématurément en raison de critères d'efficacité prédéfinis. 44 patients ont été répartis au hasard dans le groupe des casques et 39 dans le groupe des masques.</li><li>Après 8 heures de VNI avec masque facial, les patients ont été répartis au hasard :<br />- VNI au masque facial (contrôle)<br />- VNI au casque (intervention)</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Résultats</h3><ul style="list-style: square;"><li>Primaires : proportion de patients nécessitant une intubation endotrachéale<br /> </li><li>Secondaires :<br />- 28 jours sans ventilation invasive (jours de vie sans ventilation mécanique)<br />- Durée du séjour en soins intensifs<br />- Durée du séjour à l’hôpital<br />- Mortalité à l'hôpital<br />- Mortalité à 90 jours</li><li>Événements indésirables : <br />- Ulcération de la peau au niveau du joint<br />- Intolérance des patients<br />- Complications des dispositifs (dégonflement du casque)</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Inclusion</h3><ul style="list-style: square;"><li>≥18 ans</li><li>Masque facial VNI obligatoire pendant au moins 8 heures pour la gestion du SDRA (SDRA défini par les critères de Berlin)</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Exclusion</h3><ul style="list-style: square;"><li>Arrêt cardiopulmonaire imminent</li><li>GCS < 8</li><li>Absence de réflexe de protection des voies respiratoires</li><li>Pression intracrânienne élevée</li><li>Trachéotomie</li><li>Obstruction des voies aériennes supérieures</li><li>Grossesse</li><li>Refus de l'intubation endotrachéale</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Résultats</h3><ul style="list-style: square;"><li>83 patients inscrits et inclus dans l'analyse<br />- 72% des patients avaient un rapport PaO2/FiO2 <200<br />- ≈50% des patients étaient immunodéprimés en raison d'un cancer ou d'une transplantation<br /> </li></ul><p style="margin: 10px 0px;"><img alt="Helmet-vs-Mask-Results-600x1.." src="https://www.esanum.fr/images/270234" style="border: 0px; width: 400px;" /><br /> </p><ul style="list-style: square;"><li>Raison la plus fréquente de l'intubation dans le groupe des masques faciaux : insuffisance respiratoire (c'est-à-dire tachypnée et hypoxémie)<br />- Masque facial : 83,3%<br />- Casque : 37.5%<br />- Différence absolue -45,3 ; 95 % IC -82,5 à -9,1 ; P = 0,01<br /> </li><li>Raison la plus fréquente d'intubation dans le groupe des casques : défaillance neurologique (c'est-à-dire troubles de la conscience et perte du réflexe de protection des voies aériennes)<br />- Masque facial : 4,2%<br />- Casque : 62.5%<br />- Différence absolue 58,3 ; 95 % IC 24,8 à 92,8 ; P = 0,001<br /> </li><li>Les événements indésirables comprenaient 3 ulcères cutanés liés à l'interface pour chaque groupe<br />- Masque facial : 7,6% (ulcères du nez)<br />- Casque : 6,8% (ulcères du cou)<br />- Pas statistiquement différent<br /> </li><li>Le titrage de la PEP à des niveaux plus élevés par protocole dans le groupe des masques faciaux a été limité en raison de l'intolérance des patients et de la fuite d'air excessive</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Points forts</h3><ul style="list-style: square;"><li>Cette étude randomisée et contrôlée répond à une question clinique importante.</li><li>Randomisation en aveugle.</li><li>Inscription consécutive.</li><li>Sur la base d'études antérieures montrant un taux d'intubation de 50% chez les patients atteints de SDRA traités par la VNI, les auteurs ont déterminé qu'un taux d'intubation de 30% (réduction de 20%) constituerait une amélioration cliniquement significative.</li><li>Utilisation d’une analyse de l'intention de traiter qui extrapolait à la pratique réelle.</li><li>Les patients décédés ont reçu un score de zéro pour les jours sans ventilateur.</li><li>Aucun patient n'a été perdu pour le suivi.</li><li>Les patients sont bien équilibrés entre les groupes en termes de caractéristiques de base.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Limites</h3><ul style="list-style: square;"><li>L’étude d'un seul centre avec un petit nombre de patients peut limiter la validité externe</li><li>L'essai s'est arrêté prématurément (un essai plus important aurait-il montré une aussi grande différence dans les résultats ?)</li><li>Impossible de rendre les médecins et les patients «aveugles» à cause de la VNI du casque par rapport au masque facial.<br />Cela peut avoir des impacts sur le résultat subjectif de la nécessité d'intuber.<br />Les patients ne sont pas traités exactement de la même manière :<br />- PEP soutenue médiane (Casque 8,0cmH20 contre Masque 5,1cmH20)<br />- FiO2 (Casque 50% vs Masque 60%)<br />- Le titrage de la PEP à des niveaux plus élevés dans le groupe des masques faciaux a été limité</li><li>Les résultats secondaires doivent être considérés comme exploratoires.</li><li>Essai non alimenté de manière appropriée. En supposant un taux d'intubation de 50% des patients souffrant d'une insuffisance respiratoire hypoxémique nécessitant une VNI, l'étude aurait nécessité 206 patients pour fournir une puissance de 90% afin de détecter une réduction absolue de 20% du résultat primaire.</li><li>Comme pour tout nouvel appareil, il y aura probablement une courbe d'apprentissage à mesure que les cliniciens se familiariseront avec l'appareil.<br />Cela nécessitera la formation de tous les médecins et du personnel (cf «Avis d’experts»)</li><li>Il s'agissait d'un éventail de maladies causant le SDRA, et non d'un diagnostic isolé.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Discussion</h3><ul style="list-style: square;"><li>Casque VNI :<br />- Pour éviter la réinhalation du dioxyde de carbone, le support de pression est réglé pour maintenir le débit inspiratoire du ventilateur > 100L/min.<br />- Pour minimiser l'effort inspiratoire et optimiser la synchronisation patient-ventilateur, le temps de pressurisation du ventilateur est fixé à 50 ms et le délai de désactivation du cycle est fixé à 50 % du débit inspiratoire maximal.<br /> </li><li>Décision d'intuber sur la base de critères prédéterminés :<br />- Détérioration neurologique<br />- Insuffisance respiratoire persistante ou aggravée (c'est-à-dire SpO2 <88%, Fréquence respiratoire > 36/min)<br />- Intolérance à l'égard du masque facial ou du casque<br />- Saignement des voies respiratoires<br />- Sécrétions respiratoires abondantes<br /> </li><li>Les auteurs ont choisi a priori une période de 8 heures de VNI de masque facial comme critère d'entrée dans l'étude pour éviter que les patients n'aient besoin de la VNI que pendant une courte période.<br /> </li><li>Étant donné que le risque d'aérosolisation est plus faible avec la VNI du casque, il est important de souligner que dans l'une des analyses exploratoires secondaires, les patients randomisés dans le groupe des casques avaient des niveaux de PEP nettement plus élevés, qui se sont maintenus tout au long de la VNI.<br />Cela a également été extrapolé à des réductions de la fréquence respiratoire et à des niveaux de saturation en oxygène similaires sur une FiO2 plus faible que celle obtenue avec le masque facial<br /> </li><li>Une mise en garde importante concernant le casque de VNI est qu'il a un grand volume interne et une compliance élevée qui peut conduire à la ré-inhalation du CO2. L’auteur se demande si c'est la raison pour laquelle nous voyons plus de problèmes neurologiques tels que les troubles de la conscience par rapport à la VNI du masque facial</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Clinical Take Home Point</h3><ul style="list-style: square;"><li>Bien qu'il s'agisse d'une étude à centre unique, <strong>il semble que la VNI avec casque réduise significativement le taux d'intubation chez les patients atteints de SDRA par rapport à la VNI avec masque facial</strong>.</li><li>De plus, la VNI avec casque est associée à une amélioration du nombre de jours sans ventilation, à une réduction de la durée du séjour en soins intensifs, ainsi qu'à une réduction de la mortalité à 90 jours, mais ces résultats ne sont qu'exploratoires pour le moment.</li><li>En attendant une étude plus large, il semble que la VNI avec casque soit une option viable et qu'elle devrait être explorée chez les patients atteints de SDRA.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Conclusion de l'auteur</h3><p style="margin: 10px 0px;"><strong>«Parmi les patients atteints de SDRA, le traitement par la VNI avec casque a entraîné une réduction significative des taux d'intubation. Il y a également eu une réduction statistiquement significative de la mortalité à 90 jours avec la VNI avec casque. Des études multicentriques sont nécessaires pour reproduire ces résultats.»</strong><br /> </p><p style="margin: 10px 0px;"><br /><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Notes :<br /><br />1- <a href="https://rebelem.com/covid-19-niv-helmet-vs-mask/" style="color: #005461; cursor: pointer; overflow-wrap: break-word;" target="_blank">COVID-19 NIV: Helmet vs Mask</a><br />Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)<br />2- Patel BK et al. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients with Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2016. PMID: 27179847</em></sup></p><h2 style="color: #005461; font-size: 22px; line-height: 1.2; text-align: center;"><br /><br />Avis d'experts : en Italie, Roberto Cosentini</h2><ul style="list-style: square;"><li>La VNI avec le casque est très difficile, car il faut pressuriser une énorme interface (volume de 15-20L) tout en maintenant une synchronisation optimale. Cela signifie qu'il est difficile de régler avec précision le ventilateur et la surveillance spécifique de la VNI (synchronisation et tension du casque).</li><li>De plus, le volume du casque est si grand qu'il est impossible de surveiller le volume courant, ce qui constitue une information importante sur l'évolution de la maladie.</li></ul><p style="margin: 10px 0px;"><img alt="" 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" style="border: 0px; height: 216px; width: 200px;" /></p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Équipement</h3><ul style="list-style: square;"><li>Le grand volume du casque nécessite un ventilateur à haute performance (réanimation), car la pressurisation doit être réalisée en quelques millisecondes.</li><li>À mon avis, cela limite la généralisabilité des résultats.</li></ul><p style="margin: 10px 0px; text-align: center;"><br /><br /><br /><img alt="Rebelem French Touch.jpeg" src="https://www.esanum.fr/images/270237" style="border: 0px; height: 200px; width: 300px;" /></p><h2 style="color: #005461; font-size: 22px; line-height: 1.2; text-align: center;"><br />Avis d'experts : en France, Nicolas Peschanski</h2><p style="margin: 10px 0px;">Depuis le début du mois de mars 2020, la pandémie de coronavirus 2019 (COVID-19) a causé plus de 120.000 décès en Europe. Les différents systèmes de santé européens ont connu une charge pressante, notamment en termes de recours aux systèmes d'assistance respiratoire aux soins intensifs et en réanimation.</p><p style="margin: 10px 0px;">En effet, la principale manifestation clinique des patients COVID-19 est représentée par une insuffisance respiratoire hypoxique aiguë secondaire à des infiltrats pulmonaires bilatéraux, qui dans de nombreux cas, entraîne un syndrome de détresse respiratoire aiguë (SDRA) et nécessite souvent une assistance respiratoire invasive.</p><p style="margin: 10px 0px;">Bien qu’exclue des recommandations de l’OMS initialement<sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">[1]</sup>,<strong> l’utilisation d’un support respiratoire précoce avec une ventilation non invasive ou de l'oxygène à haut débit ont été finalement intégrées aux recommandations de nombreuses sociétés savantes</strong> européennes et internationales au cours des mois de mars et avril 2020.<sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">[2,3]</sup></p><p style="margin: 10px 0px;">En effet, afin de limiter la dispersion des gouttelettes dans l'air et la contamination du personnel de santé, leur usage d’abord restreint a nécessité la validation de leur utilisation associée à des filtres anti-bactériens et/ou des mesures de protections renforcées.</p><p style="margin: 10px 0px;">L'expérience de l’Italie a montré que l’application d'une pression positive continue des voies respiratoires (CPAP) au moyen d'un casque peut représenter une alternative efficace pour recruter des unités alvéolaires malades et améliorer l'hypoxémie. Elle peut également limiter la contamination de la pièce, améliorer le confort des patients et permettre une meilleure assistance clinique avec une tolérance à long terme.</p><p style="margin: 10px 0px;">Cependant, <strong>le lancement d'une CPAP «Helmet» n'est pas sans écueils</strong>. Comme pour d’autres supports de ventilation non-invasive, elle nécessite un titrage et un suivi attentifs pour éviter un retard d'intubation. Dans cette analyse de Salim Rezaie, nous discutons de la comparaison de l’Helmet avec le masque facial et de certaines considérations importantes concernant le timing, les critères et les exigences de surveillance pour les patients atteints d'insuffisance respiratoire COVID-19 nécessitant un traitement CPAP.</p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Le casque en réanimation en France : des limitations supplémentaires et un manque d’expérience</h3><p style="margin: 10px 0px;">La première limite à l’utilisation des dispositifs «Helmet» est représentée par la régularité de son utilisation. Or,<strong> les réanimations italiennes ont une longue tradition de pratique avec ces dispositifs </strong>dont ils dominent parfaitement l’utilisation dans leurs services de soins continus et de réanimation.</p><p style="margin: 10px 0px;">Cependant, comme le précise nos collègues italiens interrogés par REBEL EM, la VNI (VS-AI ou CPAP) avec l’Helmet reste difficile. En effet, <strong>son utilisation nécessite un patient compliant, indemne de lésions aiguës ou chroniques de la face, mais également un respirateur performant</strong> <strong>compte-tenu de l’énorme espace mort à ventiler</strong> qui doit assurer l’absence d’accumulation de CO2.</p><p style="margin: 10px 0px;">Outre la surveillance spécifique de la VNI (synchronisation et tension interne de l’Helmet) qui est plus contraignante que le masque facial, <strong>il est impossible de surveiller le volume courant</strong>, comme le précise nos collègues italiens, ce qui constitue en effet une information importante sur l'évolution de la maladie. À mon avis, pour aller dans le sens de Roberto, <strong>cela limite l’application généralisée des résultats aux réanimations et USC françaises, et encore plus aux services d’urgence.</strong></p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Sortez équipé… Pas forcément casqué !</h3><p style="margin: 10px 0px;">La complexité du tableau clinique chez les patients atteints de pneumonie COVID-19 mérite une grande attention dans l'identification des patients présentant un risque élevé de détérioration rapide de la fonction respiratoire sous VNI.</p><p style="margin: 10px 0px;">L'application de la CPAP «Helmet» peut représenter un support respiratoire valable mais dans un environnement adapté et avec du personnel formé à son utilisation. Une titration de la PEP soigneuse doit être alors effectuée peut optimiser le recrutement alvéolaire et améliorer l'hypoxémie, ce qui en fait un dispositif à réserver aux soins intensifs ou un traitement temporaire pour améliorer les fonctions respiratoires des patients en attente d’un transfert.</p><p style="margin: 10px 0px;">Ses avantages sont une meilleure tolérance des appuis de l’interface et une contamination réduite de la pièce par rapport aux masques oro-nasaux. Quant à établir la supériorité de cette interface par rapport à la VNI avec les interfaces que nous utilisons habituellement, des études comparatives sont nécessaires et nous ne pouvons pas être aussi catégorique que les auteurs dans leur conclusion.</p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />À fond la forme ! Et si la solution ultime nous venait de l’océan ?</h3><p style="margin: 10px 0px;">Un masque de snorkeling (Easybreath Subea de Décathlon) adapté à un usage médical a été et reste utilisé pour protéger les professionnels de réanimation lors de gestes critiques sur les patients atteints ou suspects de COVID-19. Il est aussi proposé à des fins d’interface de ventilation par l’application d’un kit développé par plusieurs sociétés et start-up.</p><p style="margin: 10px 0px;"><br /><a href="https://www.youtube.com/watch?v=PkT7e3eUPW4&feature=emb_logo" style="color: #005461; cursor: pointer; overflow-wrap: break-word;" target="_blank"><img alt="Capture d’écran 2020-05-29 .." src="https://www.esanum.fr/images/270243" style="border: 0px; width: 400px;" /></a></p><p style="margin: 10px 0px;"><img alt="Capture d’écran 2020-05-29 .." src="https://www.esanum.fr/images/270244" style="border: 0px; height: 149px; width: 300px;" /></p><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><em><sup style="font-size: 0.75em; line-height: 9.75px; position: unset; top: -0.5em;">(Crédits : Icare Technologies)</sup></em></h5><p style="margin: 10px 0px;"><br />En effet, dans le cadre de la pandémie SARS-CoV-2, ce masque Easybreath a pu être adapté dans le but de se protéger contre l’aérosolisation du SRS-CoV-2 ou comme masque d’oxygénothérapie, de CPAP ou de VNI. Plusieurs entreprises, universités, hôpitaux s’y sont intéressés, au départ en Italie puis en Espagne et en France.</p><p style="margin: 10px 0px;">Ainsi,<strong> l’adaptation proposée par une société a été utilisée en Italie sur plus de 10.000 masques et d’autres versions dérivées sont actuellement expérimentées en Espagne, en Belgique ou aux Pays-Bas.</strong> Cependant, elles ont toutes comme point commun de remplacer le tuba par une valve qualifiée de «Charlotte» située sur l’orifice supérieur, d’où l’appellation de «voie haute».</p><p style="margin: 10px 0px;">En France, une société propose un kit d’adaptation double «voie haute et basse». À la différence des dispositifs proposés antérieurement, <strong>l’utilisation de la voie basse, placée en face de la cavité buccale, a pour but de faciliter la respiration et de réduire les volumes morts à fort taux de CO2</strong>. Par ailleurs, elle permet d’accroître les possibilités de raccordements et ainsi les possibilités d’utilisation et de traitements (oxygénothérapie, CPAP, VNI...).</p><p style="margin: 10px 0px;">Ce système correspond à une interface imaginée comme une solution d’urgence, dégradée, pour pallier la pénurie d’équipements liée à la crise du COVID-19. Cependant, <strong>on peut imaginer que ce système peut être destiné à devenir un substitut utilisable aux équipements classiques</strong> d’interface de support d’oxygénation avec support respiratoire mécanique ou non. Outre l’excellente protection à l’aérosolisation qu’il semble apporter, son cahier des charges correspond aux exigences réglementaires nécessaires à la validation des interfaces d’oxygénation/ventilation non-invasive usuelles (masques, «helmet», etc.).</p><p style="margin: 10px 0px;">Par ailleurs, la combinaison du masque Easybreath et d’un adaptateur validé, auquel un filtre antiviral est ajouté sur l’orifice supérieur, vise à permettre l’utilisation de cette interface tout en protégeant le personnel en milieu hospitalier contre le transfert de micro-organismes, de fluides corporels et de particules, lors de gestes critiques sur les patients atteints ou suspects de COVID-19.</p><p style="margin: 10px 0px;"><br /><a href="https://www.safran-group.com/fr/kit-easybreathtm-anticovid" style="color: #005461; cursor: pointer; overflow-wrap: break-word;" target="_blank"><img alt="safe_image.php.png" src="https://www.esanum.fr/images/270242" style="border: 0px; width: 400px;" /></a></p><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><em>Kit Easybreath™ Anticovid pour la protection des soignants (vidéo)<br />(Crédits Safran / Segula Technologies)</em></h5><p style="margin: 10px 0px;"><br />Enfin, <strong>la disponibilité du masque Easybreath en différentes tailles permet de s'adapter au plus grand nombre dès l’âge de 10 ans avec une efficacité garantie dans plus de 92% des conformations de visage.</strong> On peut donc envisager, au décours de la crise, l’usage médical de ce dispositif dans les indications proposées pour permettre une ventilation non invasive dans les USC et services d’urgence.</p><p style="margin: 10px 0px;">Il faudra cependant attendre quelques mois car il est nécessaire d’envisager la réalisation de tests en situation clinique sur des petites séries de malades avant de valider définitivement son utilisation dans l’un ou plusieurs des trois modes proposés (oxygénation, CPAP et VSAI-PEP), en particulier pour apprécier la tolérance du masque en utilisation prolongée chez les malades, sous réserve du choix des bons connecteurs (absence de fuite) et de la bonne configuration interne des valves des kits proposés.</p><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Vous êtes médecin ?<br />Pour recevoir une sélection de nos articles ou les commenter, il vous suffit de vous inscrire.</em></h5><p style="margin: 10px 0px;"><br /><br /><em><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">Références :<br />Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance V1.2 - WHO/2019-nCoV/Clinical/2020.4<br />Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19).<br />Crit Care Med. 2020 [Ahead of print] DOI: 10.1097/CCM.0000000000004363<br />Doctrine d’usage des dispositifs de ventilation et respirateurs pour les patients COVID-19<br />Préconisations du groupe d’experts « Ventilation » mandaté par le ministère des solidarités et de la santé – MARS. 2 avril 2020.</sup></em></p><p style="margin: 10px 0px;"><br /><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Liens d'intérêts<br />Le professeur Peschanski déclare les liens d'intérêts suivants :<br />- sur les trois dernières années : Vygon SA (consultant), Fisher&Paykel (symposium), AstraZeneca (symposium)<br />- sur les vingt dernières années :<br />Symposiums : Fisher&Paykel Healthcare , AstraZeneca, Lilly, Sanofi, Daiichi-Sankyo, HeartScape, The Medicine Company, Thermofisher, Roche Diagnostics<br />Boards : Bayer, AstraZeneca, Vygon SA, Portola USA, Sanofi, Boehringer Ingelheim<br />Congrès : Lilly, Sanofi, Vygon SA, Portola, Roche Diagnostics, Thermofisher<br />Fonds de recherche (non personnels) : Servier, Boehringer Ingelheim</em></sup></p></div>VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-91976075613671190682021-03-26T10:26:00.009-07:002021-03-26T10:44:56.284-07:00Journal Club 2 (2020) - YEARS, l'EP chez la femme enceinte n'est (presque) plus un casse-tête<p> </p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiL9a-YJQegcvsozyifTfyTc5SbaEjM4hgz3OZ7X36prkDABFR0tAseUB4g8wHC-h6N8ys3BNNbxwFmY3J21yfS54ZPcwy3S0SObhdstb_nIfvF_-kx7diOPBzXTIIbUc0HgtLv5L125_iw/s1448/Logo+MU.Rennes+nu.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1242" data-original-width="1448" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiL9a-YJQegcvsozyifTfyTc5SbaEjM4hgz3OZ7X36prkDABFR0tAseUB4g8wHC-h6N8ys3BNNbxwFmY3J21yfS54ZPcwy3S0SObhdstb_nIfvF_-kx7diOPBzXTIIbUc0HgtLv5L125_iw/s320/Logo+MU.Rennes+nu.jpg" width="320" /></a></div><br /><p></p><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="background-color: white; color: #005461; font-family: "Open Sans", Arial; font-size: 28px; line-height: 1.3; margin: 10px 0px;">Suspicion d'embolie pulmonaire et grossesse... Enfin du nouveau (et moins de scanners inutiles à la clé)</h1><div><br /></div><div _ngcontent-nby-c46="" class="annotation" style="background-color: white; color: #444444; font-family: "Open Sans", Arial; font-size: 15px;"><div _ngcontent-nby-c46="" class="picture ng-star-inserted" style="background-color: #ebebeb; height: 346px; margin: 0px -25px; position: relative;"><img _ngcontent-nby-c46="" alt="Suspicion d'embolie pulmonaire et grossesse... Enfin du nouveau (et moins de scanners inutiles à la clé)" height="300" src="https://s3.esanum.fr/backend/media/images/2021/3/19/54e73948-8fe0-4f93-876a-ca600158a0b4/renders/detailed@2x.jpg" style="background-color: #444444; border: 0px; display: block; height: 346px; max-width: 100%; width: 750px;" title="Suspicion d'embolie pulmonaire et grossesse... Enfin du nouveau (et moins de scanners inutiles à la clé)" width="642" /></div></div><div _ngcontent-nby-c46="" class="content ng-star-inserted" style="background-color: white; color: #444444; font-family: "Open Sans", Arial; font-size: 15px;"><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Nicolas Peschanski est professeur de médecine d'urgence et praticien hospitalier au CHU de Rennes. Il est membre actif de longue date de la SFMU. Après avoir œuvré six ans au sein de la commission scientifique, il siège depuis 2020 à la commission des référentiels.<br />Son parcours international, notamment aux USA, lui a permis de devenir membre de la Commission Internationale de l'American College of Emergency Physicians ainsi que du comité de pilotage de l'EMCREG-International (Emergency Medicine Cardiac Research and Education Group).<br />Très attaché au principe de la FOAMed (Free Open Access Meducation - Partage en libre accès des ressources éducatives médicales), il utilise les réseaux sociaux (@DocNikko) à des fins pédagogiques et de partage des connaissances en médecine d’urgence.</em></h5><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><em>Le Pr Peschanski tient un journal club afin de présenter à ses étudiant.e.s certaines études relatives à sa spécialité. Il a accepté de le publier ici. Nous l'en remercions chaleureusement.</em></h5><div><em><br /></em></div><div><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="color: #005461; font-size: 28px; line-height: 1.3; margin: 10px 0px;">#Journal_Club</h1></div><p style="margin: 10px 0px; text-align: center;"><img alt="MU Rennes nu.png" src="https://www.esanum.fr/images/292262" style="border: 0px; height: 169px; width: 300px;" /></p><h2 style="color: #005461; font-size: 22px; line-height: 1.2; text-align: center;">Journal Club n°2</h2><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br /><br />L’étude</h3><p style="margin: 10px 0px;"><br /><strong>Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism</strong> <sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">1</sup></p><p style="margin: 10px 0px;">L'algorithme YEARS adapté au risque d'embolie pulmonaire (EP) chez la femme enceinte a exclu de manière sensible et spécifique l'EP chez les femmes enceintes et a réduit le taux d'angioscanner et ceci à tous les stades de la grossesse.</p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Pourquoi est-ce important ?</h3><p style="margin: 10px 0px;">L'EP est l'une des principales causes de décès maternel pendant la grossesse. Cependant, il peut être difficile d'établir un diagnostic. En outre, le dosage des d-dimères associé à un algorithme utilisant le score de Wells ou de Genève modifié perd de sa spécificité et de sa sensibilité pendant la grossesse. </p><p style="margin: 10px 0px;">Comme les modalités d'imagerie telles que l'angioscanner et même la scintigraphie de ventilation-perfusion (VQ) exposent le fœtus et la mère à des radiations, il n'est pas toujours évident d'exclure ou de confirmer le diagnostic. La question à laquelle tente de répondre cet article est de proposer une règle de décision clinique permettant d'exclure sans risque l'EP chez les patientes enceintes et de réduire le taux d'imagerie. </p><p style="margin: 10px 0px;">Nous attendons cet algorithme depuis des ANNÉES. Il s'agit d'une étude prospective multicentrique internationale portant sur 498 femmes enceintes dont on soupçonnait l'EP. L'algorithme YEARS (figure ci-dessous) a été utilisé pour guider les tests de diagnostic et la prise en charge.</p><p style="margin: 10px 0px;"><br /><br /><img alt="blog urg 2.png" src="https://www.esanum.fr/images/292259" style="border: 0px; height: 425px; width: 600px;" /></p> <h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Des résultats probants</h3><ul style="list-style: square;"><li>Grâce à ce protocole, l'EP a été diagnostiquée chez 4% des patientes.</li><li>L'angioscanner a pu être évité chez 39% d’entre elles (N=195). </li><li>Une seule patiente n'ayant pas été initialement diagnostiquée a présenté une TVP au cours du suivi à trois mois.</li><li>Aucune autre patiente n'a été diagnostiquée pour une MTEV au cours du suivi. </li><li>L'efficience de l'algorithme était plus élevée au cours du premier trimestre (lorsque les radiations sont potentiellement les plus préjudiciables au fœtus en développement) et plus faible au cours du troisième trimestre. </li><li>Au total, l'angioscanner a pu être évité chez 65% des patientes au cours du premier trimestre, 46% au cours du deuxième et 32% au cours du troisième.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"> <br />Conclusion</h3>L'algorithme YEARS semble être un outil de décision clinique fiable et utilisable au quotidien pour exclure l'EP chez les patientes enceintes et réduire sans risque l'utilisation de l'angioscanner.<h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Vous êtes médecin ?<br />Pour recevoir une sélection de nos articles ou les commenter, il vous suffit de vous inscrire.</em></h5><p style="margin: 10px 0px;"><br /><br /><em><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">Référence :<br /><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1813865" style="color: #005461; cursor: pointer; overflow-wrap: break-word;" target="_blank">Pregnancy-Adapted YEARS Algorithm for Diagnosis of Suspected Pulmonary Embolism</a><br />March 21, 2019 – N Engl J Med 2019; 380:1139-1149<br />DOI: 10.1056/NEJMoa1813865</sup></em></p><p style="margin: 10px 0px;"><br /><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Liens d'intérêts<br />Le professeur Peschanski déclare les liens d'intérêts suivants :<br />- sur les trois dernières années : Vygon SA (consultant), Fisher&Paykel (symposium), AstraZeneca (symposium)<br />- sur les vingt dernières années :<br />Symposiums : Fisher&Paykel Healthcare , AstraZeneca, Lilly, Sanofi, Daiichi-Sankyo, HeartScape, The Medicine Company, Thermofisher, Roche Diagnostics<br />Boards : Bayer, AstraZeneca, Vygon SA, Portola USA, Sanofi, Boehringer Ingelheim<br />Congrès : Lilly, Sanofi, Vygon SA, Portola, Roche Diagnostics, Thermofisher<br />Fonds de recherche (non personnels) : Servier, Boehringer Ingelheim</em></sup></p></div>VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-36372181650198434312021-03-26T10:23:00.008-07:002021-03-26T10:45:32.889-07:00Journal Club 1 (2020) - De la pertinence des urgentistes dans l'indication d'hospitalisation<article _ngcontent-nby-c46="" class="panel-body ng-star-inserted" style="color: #444444; font-family: "Open Sans", Arial; font-size: 15px; padding: 25px;"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7upiQQu53f4MoCiWqpRXIKvtEX7EviTdryh0PwhF79AgTi-N53bRryUbQSkMMITQQWslh2sztLr5HchjyqxNdJ81tdk4Ac-VOX7C4W_DUZGqsG3yD8VGkQgWyYYq5CS0vkcK_AyvkK6bH/s1448/image.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1242" data-original-width="1448" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7upiQQu53f4MoCiWqpRXIKvtEX7EviTdryh0PwhF79AgTi-N53bRryUbQSkMMITQQWslh2sztLr5HchjyqxNdJ81tdk4Ac-VOX7C4W_DUZGqsG3yD8VGkQgWyYYq5CS0vkcK_AyvkK6bH/s320/image.png" width="320" /></a></div><br /><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="color: #005461; font-size: 28px; line-height: 1.3; margin: 10px 0px;"><br /></h1><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="color: #005461; font-size: 28px; line-height: 1.3; margin: 10px 0px;">Décisions d'admission par les urgentistes : leur pertinence réduit l'engorgement des urgences </h1><div><br /></div><div _ngcontent-nby-c46="" class="annotation"><div _ngcontent-nby-c46="" class="picture ng-star-inserted" style="background-color: #ebebeb; height: 346px; margin: 0px -25px; position: relative;"><img _ngcontent-nby-c46="" alt="Décisions d'admission par les urgentistes : leur pertinence réduit l'engorgement des urgences" height="300" src="https://s1.esanum.fr/backend/media/images/2021/3/10/527eff61-8f6c-4fbb-92c0-8fbb0969ff60/renders/detailed@2x.jpg" style="background-color: #444444; border: 0px; display: block; height: 346px; max-width: 100%; width: 750px;" title="Décisions d'admission par les urgentistes : leur pertinence réduit l'engorgement des urgences" width="642" /></div></div><div _ngcontent-nby-c46="" class="content ng-star-inserted"><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Nicolas Peschanski est professeur de médecine d'urgence et praticien hospitalier au CHU de Rennes. Il est membre actif de longue date de la SFMU. Après avoir œuvré six ans au sein de la commission scientifique, il siège depuis 2020 à la commission des référentiels.<br />Son parcours international, notamment aux USA, lui a permis de devenir membre de la Commission Internationale de l'American College of Emergency Physicians ainsi que du comité de pilotage de l'EMCREG-International (Emergency Medicine Cardiac Research and Education Group).<br />Très attaché au principe de la FOAMed (Free Open Access Meducation - Partage en libre accès des ressources éducatives médicales), il utilise les réseaux sociaux (@DocNikko) à des fins pédagogiques et de partage des connaissances en médecine d’urgence.</em></h5><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><em>Le Pr Peschanski tient un journal club afin de présenter à ses étudiant.e.s certaines études relatives à sa spécialité. Il a accepté de le publier ici. Nous l'en remercions chaleureusement.</em></h5><p style="margin: 10px 0px; text-align: center;"><br /></p><h1 _ngcontent-nby-c46="" class="ng-star-inserted" style="color: #005461; font-size: 28px; line-height: 1.3; margin: 10px 0px;">#Journal_Club</h1><p style="margin: 10px 0px; text-align: center;"><img alt="MU Rennes nu.png" src="https://www.esanum.fr/images/292261" style="border: 0px; height: 169px; width: 300px;" /></p><h2 style="color: #005461; font-size: 22px; line-height: 1.2; text-align: center;">Journal Club n°1</h2><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br /><br />L’étude</h3><p style="margin: 10px 0px;"><br /><strong>Using emergency physicians' abilities to predict patient admission to decrease admission delay time <sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;">1</sup></strong></p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Pourquoi est-ce important ?</h3><p style="margin: 10px 0px;">Dans certains systèmes hospitaliers – celui présenté dans cette étude est canadien –, lorsque l'urgentiste veut hospitaliser un patient il doit demander à un spécialiste de voir le patient et convenir avec lui de l’admission avant de pouvoir l’hospitaliser. </p><p style="margin: 10px 0px;">L'hypothèse de cette étude prospective était de mesurer la pertinence de l'urgentiste dans la décision d'hospitaliser un patient.</p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Méthode</h3><ul style="list-style: square;"><li>Il s'agit d'une étude prospective monocentrique menée à Ottawa sur une période de cinq mois. </li><li>On demandait aux urgentistes quelle décision ils prendraient juste avant que le spécialiste ne voie le patient. </li><li>L’échantillon excluait les patients graves et sévères (par exemple SCA, AVC, etc) ayant un besoin évident d'être hospitalisés.</li></ul><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Résultats</h3><ul style="list-style: square;"><li>Un urgentiste seul prend le plus souvent la bonne décision quelles que soient les spécialités.</li><li>Si l'urgentiste prenait la décision d'admission au lieu d'attendre le spécialiste,<strong> il évitait aux patients un total de 922 heures d'attente aux urgences sur cette période de cinq mois</strong>.</li><li>En termes de pertinence, <strong>les urgentistes ont correctement prédit 92,8% </strong>des admissions de patients. </li><li>La sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative étaient respectivement de 90,5%, 84,2%, 92,8% et 79,6%, toutes pathologies confondues.</li><li><strong>Seule la prédiction de l'admission en psychiatrie a un peu fait baisser les chiffres globaux</strong>. </li></ul> <h4 style="color: #005461; line-height: 1.1;">En détail :</h4><ul style="list-style: square;"><li>Concernant l’admission en chirurgie générale, l'indication était correcte (valeur prédictive positive – VPP) dans 90% des cas ; </li><li>pour la médecine interne, la VPP était de 95,7% ; </li><li>pour les autres types de chirurgie (c'est-à-dire ORL, neurochirurgie, plastique, traumatisme), la VPP était de 94,7% ; </li><li>pour les types de spécialités plus spécifiques (hématologie, gastro-entérologie, imagerie médicale, rénale), la VPP atteint même 100%. </li></ul><p style="margin: 10px 0px;">En outre, pour enfoncer le clou, l<strong>e rapport de concordance entre l'urgentiste et le spécialiste face à une même situation atteint un kappa 0,885</strong> (donc très reproductible) pour les indications d'hospitalisation.</p><h3 style="color: #005461; font-size: 18px; line-height: 1.1;"><br />Conclusions</h3><p style="margin: 10px 0px;">Cette étude suggère que la simple décision de l'urgentiste pour l'indication d'hospitalisation pourrait largement suffire et permettrait de réduire une part de l'encombrement et les temps d'attente aux urgences.<br /><br />À répéter en multicentrique (et en France là où ce n'est pas encore le cas). </p><h5 style="color: #005461; font-size: 13px; line-height: 1.1;"><br /><br /><em>Vous êtes médecin ?<br />Pour recevoir une sélection de nos articles ou les commenter, il vous suffit de vous inscrire.</em></h5><p style="margin: 10px 0px;"><br /><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Note :<br />1- <a href="http://emj.bmj.com/content/37/7/417.long" style="color: #005461; cursor: pointer; overflow-wrap: break-word;" target="_blank">Using emergency physicians' abilities to predict patient admission to decrease admission delay time</a><br />Emerg Med J – 2020 Jul;37(7):417-422.<br />doi: 10.1136/emermed-2019-208859. Epub 2020 Mar 5</em></sup></p><p style="margin: 10px 0px;"><br /><br /><sup style="font-size: 0.75em; line-height: 11.25px; position: unset; top: -0.5em;"><em>Liens d'intérêts<br />Le professeur Peschanski déclare les liens d'intérêts suivants :<br />- sur les trois dernières années : Vygon SA (consultant), Fisher&Paykel (symposium), AstraZeneca (symposium)<br />- sur les vingt dernières années :<br />Symposiums : Fisher&Paykel Healthcare , AstraZeneca, Lilly, Sanofi, Daiichi-Sankyo, HeartScape, The Medicine Company, Thermofisher, Roche Diagnostics<br />Boards : Bayer, AstraZeneca, Vygon SA, Portola USA, Sanofi, Boehringer Ingelheim<br />Congrès : Lilly, Sanofi, Vygon SA, Portola, Roche Diagnostics, Thermofisher<br />Fonds de recherche (non personnels) : Servier, Boehringer Ingelheim</em></sup></p></div><div _ngcontent-nby-c46="" class="bottom" style="-webkit-box-align: end; -webkit-box-flex: 0; -webkit-box-pack: justify; align-items: flex-end; display: flex; flex: 0 1 auto; justify-content: space-between;"><esn-share-link _ngcontent-nby-c46="" _nghost-nby-c51="" class="share ng-star-inserted" data-owner-type="platform" style="-webkit-box-flex: 0; 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-webkit-box-flex: 0; -webkit-box-pack: justify; align-items: flex-start; border-color: rgb(0, 84, 97); box-sizing: border-box; color: #444444; display: flex; flex: 0 1 auto; font-family: "Open Sans", Arial; font-size: 15px; justify-content: space-between; padding: 0px 25px 15px;"><esn-copyrights _ngcontent-nby-c46="" _nghost-nby-c57="" class="ng-star-inserted" data-layout-position="copyrights" style="display: inline-flex; font-size: 13px; margin: 5px 0px;"><ul _ngcontent-nby-c57="" class="ng-star-inserted" style="list-style: none; margin: 0px; opacity: 0.7; padding: 0px;"></ul></esn-copyrights></footer>VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-22688617437425048382019-05-09T09:24:00.001-07:002019-05-09T09:24:51.312-07:00#FrenchFOAMed Millésime 2019<header class="entry-header" style="box-sizing: inherit;"><h1 class="entry-title" style="box-sizing: inherit; clear: both; color: #495762; font-family: Montserrat, Tahoma, sans-serif; font-size: 38px; line-height: 1.3; margin: 0px 0px 15px;">
#frenchFOAMed: cuvée 2019 – ou en sommes nous?</h1>
</header><div class="entry-content" style="box-sizing: inherit; margin: 1.6em 0px 0px;">
<div style="background-color: white; box-sizing: inherit; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin-bottom: 1.6em;">
<img height="180" src="https://i1.wp.com/www.abcmed.ch/wp-content/uploads/2019/04/Screenshot-2019-04-30-at-10.45.24.png?zoom=2&resize=1409%2C403" style="background-color: transparent;" width="640" /></div>
<div style="background-color: white; box-sizing: inherit; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin-bottom: 1.6em;">
Une récente discussion avec nos confrères de <a href="https://lifeinthefastlane.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">LITFL </a>a relancé la discussion du #frenchFOAMed et où nous en sommes. </div>
<div style="background-color: white; box-sizing: inherit; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin-bottom: 1.6em;">
S’en est suivi un <a href="https://twitter.com/SwissCEM/status/1121688372815073282" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">twitterchat</a> avec plusieurs consœurs et confrères afin de mettre à jour la liste des blogs <a href="https://twitter.com/search?vertical=default&q=%23frenchFOAMed&src=typd" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">#frenchFOAMed</a>. </div>
<div style="background-color: white; box-sizing: inherit; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin-bottom: 1.6em;">
Voici donc la liste mise à jour en Avril 2019 des sites de FOAMed en français. </div>
<div style="background-color: white; box-sizing: inherit; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin-bottom: 1.6em;">
Un grand merci donc à tous ceux ayant participé à la discussion !</div>
<div style="background-color: white; box-sizing: inherit; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin-bottom: 1.6em;">
Absent de cette liste, vous souhaiteriez y paraitre ? Prenez <a href="http://www.abcmed.ch/contact/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">contact</a> avec nous !</div>
<hr class="wp-block-separator" style="background-color: #cccccc; border: 0px; box-sizing: content-box; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; height: 1px; margin-bottom: 1.6em;" />
<table class="wp-block-table aligncenter is-style-stripes" style="background-color: white; border-collapse: inherit; border-color: rgb(238, 238, 238) rgb(238, 238, 238) rgb(243, 244, 245); border-image: initial; border-spacing: 0px; border-style: solid; border-width: 1px; box-sizing: inherit; clear: both; color: #495762; font-family: Karla, Tahoma, sans-serif; font-size: 16px; margin: 0.8em auto; width: auto;"><tbody style="box-sizing: inherit;">
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><strong style="box-sizing: inherit;">Nom</strong></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><strong style="box-sizing: inherit;">URL</strong></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><strong style="box-sizing: inherit;">Twitter</strong></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><strong style="box-sizing: inherit;">Pays</strong></td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Airway, Breathing and Continuous Medical Education</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://www.abcmed.ch/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://www.abcmed.ch</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@SwissCEM</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">Switzerland</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Organisation des Urgences</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://saturg.blogspot.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://saturg.blogspot.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@wargonm</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">La Mine: Médecine d’urgence hospitalière et préhospitalière</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://la-mine.net/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://la-mine.net</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@Rhazelovitch</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Emergency medicine: a young doc’s mood</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://docadrenaline.wordpress.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://docadrenaline.wordpress.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@DocAdrenalin</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Journal d’un médecin urgentiste</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://gkierzek.blog.lemonde.fr/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://gkierzek.blog.lemonde.fr</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@gkierzek</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Veille Iconographique, Bibliographique et Educationnelle en Médecine d’Urgence</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://vibe-urgence.blogspot.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://vibe-urgence.blogspot.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@DocNikko</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Il ne sert à rien de diagnostiquer trop vite, il faut échographier à point…</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://echo-urgences.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://echo-urgences.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@echo_urg</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Site de formation à la lecture de l’ElectroCardioGramme.</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://e-cardiogram.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://e-cardiogram.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Le réseau nord alpin des urgences</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://www.renau.org/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://www.renau.org</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Le Gazier</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://legazier.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://legazier.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@LeGazier</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Hic et Nunc</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://www.nfkb0.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://www.nfkb0.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@nfkb</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">De l’insuffisance cardiaque surtout, de la cardiologie évidemment, et un peu d’autres choses</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://insuffisantcardiologue.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://insuffisantcardiologue.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@FZore</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Ecoute la MEUF</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://www.lameuf.ca/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://www.lameuf.ca</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@EcouteLaMEUF</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">Canada</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Chronique dans l’Actualite</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://lactualite.com/auteur/alainvadeboncoeur" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://lactualite.com/auteur/alainvadeboncoeur</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@Vadeboncoeur_Al</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Transfert Optimisé des Publications en Médecine d’Urgence</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://topmu.ca/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://topmu.ca</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@TopMU</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">Canada</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">ECG & Co</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://ecgandco.wordpress.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://ecgandco.wordpress.com</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Docs d’urgence</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://facebook.com/docsdurgence/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">facebook.com/docsdurgence</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@Docsdurgence</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">Pas sur ma garde</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="http://%20http//blockchoc.org/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">http://blockchoc.org</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">@BLOCKCHOC1</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">Switzerland</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><em style="box-sizing: inherit;">SAMU – Urgences Bobigny</em></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://samuurgencesreanim.wixsite.com/emu93-medicalurgence" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://samuurgencesreanim.wixsite.com/emu93-medicalurgence</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"> </td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background-color: #f3f4f5; box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">Traumedic</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://traumedic.wordpress.com/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://traumedic.wordpress.com/</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">France</td></tr>
<tr style="background: rgb(249, 249, 249); box-sizing: inherit;"><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">ECG France-Québec</td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"><a href="https://www.facebook.com/ECG-France-Qu%C3%A9bec-613253038774764/" style="background-color: transparent; border-bottom: 2px solid transparent; box-sizing: inherit; color: #495762; font-weight: bold; overflow-wrap: break-word; text-decoration-line: none; transition: all 0.1s ease 0s;">https://www.facebook.com/ECG-France-Qu%C3%A9bec-613253038774764/</a></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;"></td><td style="border-color: transparent; box-sizing: inherit; padding: 0.8em 5px;">Canada, France<br /></td></tr>
</tbody></table>
</div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com1tag:blogger.com,1999:blog-317032633037212420.post-77239594111734163572018-06-21T02:55:00.006-07:002018-06-21T02:57:59.090-07:00Être et (surtout) rester heureux en médecine d'urgence<header id="reader-article-header" style="background: 0px 0px rgb(255, 255, 255); border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.9); font-family: -apple-system, system-ui, system-ui, "Segoe UI", Roboto, "Helvetica Neue", "Fira Sans", Ubuntu, Oxygen, "Oxygen Sans", Cantarell, "Droid Sans", "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Emoji", "Segoe UI Symbol", "Lucida Grande", Helvetica, Arial, sans-serif; font-size: 16px; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><h1 class="reader-article-header__title Sans-42px-black-85%-regular pt6 pb4" style="background: 0px 0px; border: 0px; box-sizing: inherit; font-family: -apple-system, system-ui, BlinkMacSystemFont, "Segoe UI", Roboto, "Helvetica Neue", "Fira Sans", Ubuntu, Oxygen, "Oxygen Sans", Cantarell, "Droid Sans", "Apple Color Emoji", "Segoe UI Emoji", "Segoe UI Emoji", "Segoe UI Symbol", "Lucida Grande", Helvetica, Arial, sans-serif; font-size: 40px; line-height: 48px; margin: 0px; outline: 0px; padding: 32px 0px 16px; vertical-align: baseline;">
Être et (surtout) rester heureux en médecine d'urgence</h1>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Il y a quelques jours, lors de la session commune SFMU/SUdF (Société Française de Médecine d'Urgence / SAMU et Urgences de France) pour le congrès #Urgences2018, on m'a demandé de venir exposer ma vision de l'urgentiste heureux sous forme d'une présentation façon TED. Défi oh combien intéressant en cette période de #SAMU bashing et de "problèmes" des urgences hospitalières. En tout cas, l'occasion de tordre le cou à beaucoup d'idées reçues qui arrivent à décourager certains d'entre-nous, en particulier les plus jeunes dans nos rangs. Le diaporama est disponible <a href="https://www.slideshare.net/NicolasPeschanski/urgentiste-et-heureux-tedx-sfmu-sudf-urgences-2018" style="background: 0px 0px transparent; border: 0px; box-sizing: inherit; color: #665ed0; margin: 0px; padding: 0px; text-decoration-line: none; touch-action: manipulation; vertical-align: baseline; word-wrap: break-word;" target="_blank">ici</a>.</span></div>
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<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">Alors, Heureux ?</span></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQEZnVCTLNeYwQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=ll2eV9VJGsVg5sgewAXlGWEdlcP3GDJAexZxvIceFdo" data-media-urn="urn:li:digitalmediaAsset:C4E12AQEZnVCTLNeYwQ" src="https://media.licdn.com/dms/image/C4E12AQEZnVCTLNeYwQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=ll2eV9VJGsVg5sgewAXlGWEdlcP3GDJAexZxvIceFdo" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Il est vrai que nous vivons, nous urgentistes, sur le fil, entre urgences vitales et "petits bobos", entre la nuit et le jour, la semaine et le week-end, entre la population (dont quand même plus de 20 millions d'individus qui nous font confiance chaque année) et l'institution hospitalière et au-delà, entre la naissance, la vie, ses accidents de parcours, la maladie et la mort. Alors "heureux" l'urgentiste que je suis ? Comme souvent, je me suis tourné vers mes amis d'outre-océans, américains et australiens pour la plupart, à qui j'ai posé la question afin de trouver des réponses à exposer à mes collègues urgentistes français. Parallèlement, j'ai effectué un petit sondage sur la Twittosphère pour prendre l'ambiance de la profession... Voici le récit de mes réflexions, parfois empruntées à d'autres, de ma vision (qui n'est pas inscrite dans le marbre) et de ma quête perpétuelle du bonheur en tant qu'urgentiste.</span></div>
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<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">Un constat : même parmi les plus motivés, les temps sont durs...!</span></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQHPi2SYf4wihg/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=oYhayv95ynK0ZiuxA7l79ktJ8WMfN2P3yvzw6DmW074" data-media-urn="urn:li:digitalmediaAsset:C4E12AQHPi2SYf4wihg" src="https://media.licdn.com/dms/image/C4E12AQHPi2SYf4wihg/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=oYhayv95ynK0ZiuxA7l79ktJ8WMfN2P3yvzw6DmW074" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">On peut facilement concevoir que dans un corps de métier, les professionnels les plus ouverts et les plus dynamiques aient adopté les réseaux sociaux et leurs usages. Il convient de faire un constat inquiétant (à défaut d'alarmant) en regardant les réponses à mon sondage qui a tout de même touché 132 professionnels en 4 jours : plus de la moitié des médecins qui ont répondu à cette simple dichotomie ne sont pas heureux dans leur profession d'urgentiste.</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQETfgNyw53b-g/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=qSZaRPbzAoM7N-mNrl4LsWPkryE0bL_tZd96q3ehhI4" data-media-urn="urn:li:digitalmediaAsset:C4E12AQETfgNyw53b-g" src="https://media.licdn.com/dms/image/C4E12AQETfgNyw53b-g/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=qSZaRPbzAoM7N-mNrl4LsWPkryE0bL_tZd96q3ehhI4" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Est-ce dû à cette pression intense des flux de malades à gérer depuis plusieurs hivers ? A l'absence de généralistes disponibles ? Au faible numerus clausus ?... J'en passe, tant les raisons invoquées par les médias, les institutions, les organes étatiques etc... sont souvent faussées par une vision étroite et étriquée de nos problématiques et malheureusement, une culpabilisation des patients qui n'ont rien demandé à personne sauf d'avoir le juste droit aux justes soins.</span></div>
<h3 style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">La médecine d'urgence est une équation simple</span></span></h3>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQHZAVA8cZwj1A/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=9Mxu2J1IWsAxdbS5cSC0MELkALKoKimNdT_2RugmM3s" data-media-urn="urn:li:digitalmediaAsset:C4E12AQHZAVA8cZwj1A" src="https://media.licdn.com/dms/image/C4E12AQHZAVA8cZwj1A/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=9Mxu2J1IWsAxdbS5cSC0MELkALKoKimNdT_2RugmM3s" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Si on veut bien se donner la peine de regarder objectivement notre métier et ce à quoi il nous confronte, il est relativement simple d'en appeler aux mathématiques. L'urgence réelle ou ressentie représente une somme de contraintes et d'incertitude qui démultiplient les risques. Ainsi, chaque décision diagnostique, thérapeutique, d'orientation s'inscrit dans cette équation qu'il faut multiplier par autant de patients que l'on a, à un instant t, sous notre responsabilité.</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Alors, comment répondre à cette (sur)charge cognitive sans pour autant être déstabilisé, voire en ressentir du bien-être et de la fierté ?</span></div>
<h3 style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">L'âme de l'urgentiste... et le développement de son 6ème sens</span></span></h3>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQHRtNTcYydTnA/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=0fKXGPMfLNmlpOSSAHDmIDNaOl7wmGWTwas8HsYE2ak" data-media-urn="urn:li:digitalmediaAsset:C4E12AQHRtNTcYydTnA" src="https://media.licdn.com/dms/image/C4E12AQHRtNTcYydTnA/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=0fKXGPMfLNmlpOSSAHDmIDNaOl7wmGWTwas8HsYE2ak" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Savoir que l'on est urgentiste, c'est trouver les moyens de répondre à l'équation et de saisir que seuls vos collègues urgentistes peuvent comprendre votre boulot car aucun autre médecin ne fait le même job que vous. Certains de nos confrères d'autres spécialités, parfois très proches, peuvent imaginer, peuvent écouter, peuvent sympathiser, mais ils ne font pas ce que vous faites. Ne vous attendez pas à ce qu'ils en soient capables même s'ils vous disent le contraire. Ce que vous faites si bien, personne d'autre que vos semblables peut le faire. Ainsi, notre état d'esprit diffère de beaucoup de nos collègues car nous abordons tout symptôme, toute pathologie par ce que mes confrères anglo-saxons appellent "the dangerous condition wheel", la "roue des situations graves potentielles".</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">En effet, notre cerveau d'urgentiste est conditionné à imaginer et, surtout, à anticiper le pire de toute situation qui se présente à nous... Et nous sommes devenus des experts dans cette pratique, des urgentologues comme diraient mes amis québécois. Cette fierté à être celui ou celle qui va faire basculer du bon côté une situation potentiellement catastrophique est très bien représentée par le logo de l'ACEP (American College of Emergency Medicine). En effet, vous disposez devant vous de 64 malades symbolisés par 64 carrés.</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4D12AQGP8dXVwf4DYQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=xhIVbSAHH3hKwTm3vWiKUsPIDRDrE4eZTAkW2ZUVlQs" data-media-urn="urn:li:digitalmediaAsset:C4D12AQGP8dXVwf4DYQ" src="https://media.licdn.com/dms/image/C4D12AQGP8dXVwf4DYQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=xhIVbSAHH3hKwTm3vWiKUsPIDRDrE4eZTAkW2ZUVlQs" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Parmi eux, 63 patients vont présenter des situations cliniques caricaturales que votre cerveau "automatique" va interpréter pour vous permettre de proposer une prise en charge standardisée et protocolisée... C'est sur le 64ème malade (symbolisé par le carré blanc) que votre 6ème sens d'urgentiste va faire la différence, celui pour lequel vous allez vous battre, donner tout ce que vous avez dans les tripes parce que vous avez "senti" que sans vous, sa prise en charge va être incomplète, inappropriée, voire le lit d'erreurs médicales.</span></div>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">Les MacGyver de la médecine... dans l'Amazon(ie) de la santé</span></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Non seulement nous sommes devenus experts mais nous avons la capacité unique à offrir des réponses (graduées) à tout ce qui nous est demandé. Nous prenons environ 10000 décisions par garde et avons une sensibilité diagnostique très élevée, en particulier pour les situations critiques et graves (jetez un coup d'oeil à la présentation de @yordayou à ce sujet <a href="https://www.slideshare.net/NicolasPeschanski/dcision-diagnostique-apprendre-de-ses-erreurs-journe-mdecine-durgence-normande-sanofi-2018" style="background: 0px 0px transparent; border: 0px; box-sizing: inherit; color: #665ed0; margin: 0px; padding: 0px; text-decoration-line: none; touch-action: manipulation; vertical-align: baseline; word-wrap: break-word;" target="_blank">ici</a>). Comme le disait Osler, <u style="box-sizing: inherit;">la médecine est une science de l'incertitude et un art de la probabilité</u>. Connaissez-vous une seule spécialité médicale où cette diversité des situations et des présentations cliniques existe ? Bien évidemment, il n'en existe pas puisque c'est le cœur même de notre spécificité, de ce qui fait de l'urgentiste un médecin unique. Nous sommes par essence les meilleurs probabilisticiens de la médecine aiguë car il n'y a pas de limites au champs des possibles et des explorations. Cela fait notre force, notre dynamisme et notre fierté.</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4D12AQG7H1L99DOuuQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=pZg5D8ABQAfL7dtln4TYFPRgI3Um-7NDiAj4DNHGVXc" data-media-urn="urn:li:digitalmediaAsset:C4D12AQG7H1L99DOuuQ" src="https://media.licdn.com/dms/image/C4D12AQG7H1L99DOuuQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=pZg5D8ABQAfL7dtln4TYFPRgI3Um-7NDiAj4DNHGVXc" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Comme l'a dit récemment Judith Tintinalli (<a href="https://feminem.org/author/judith-tintinalli-md-ms/" rel="nofollow noopener" style="background: 0px 0px transparent; border: 0px; box-sizing: inherit; color: #665ed0; margin: 0px; padding: 0px; text-decoration-line: none; touch-action: manipulation; vertical-align: baseline; word-wrap: break-word;" target="_blank">https://feminem.org/author/judith-tintinalli-md-ms/</a>) lors de l'ICEM (International Conference on Emergency Medicine), la médecine d'urgence est l'Amazon de la santé : une demande = une réponse rapide et adaptée à toute heure de la journée et de la nuit, en tout point du territoire, tous les jours, week-ends et vacances compris.</span></div>
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<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">Les particularités du bonheur en médecine d'urgence</span></span></h3>
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<img data-li-src="https://media.licdn.com/dms/image/C4D12AQGfLlAiul2cRg/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=PnOB139mmXTCHKXc-9aTjRiz-hF3Gzbka8C1HkFZ9oI" data-media-urn="urn:li:digitalmediaAsset:C4D12AQGfLlAiul2cRg" src="https://media.licdn.com/dms/image/C4D12AQGfLlAiul2cRg/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=PnOB139mmXTCHKXc-9aTjRiz-hF3Gzbka8C1HkFZ9oI" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">En médecine d'urgence, la <u style="box-sizing: inherit;">reconnaissance</u> revêt une importance toute particulière. En effet, il est facile pour certains de tomber dans un mode insatisfait et de se plaindre (d'ailleurs, on entend bien trop souvent ces litanies). Comme il est simple, voire simpliste, de se plaindre du système, des patients, du manque de moyens, de la pression, du temps. Il faut se rappeler à quel point d'autres jobs (médicaux ou non) sont difficiles. Prenez par exemple le métier d'avocat : avez-vous réfléchi une seconde combien il peut être stressant et prenant ? Avez-vous encore pensé à tous ces emplois qui peuvent être ingrats voire insignifiants ?</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4D12AQG0P11ftGWUrQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=RmUuT_C1S1-SQrv1FZwy3G6y2xjXbu8ljZ1tKe3OCA8" data-media-urn="urn:li:digitalmediaAsset:C4D12AQG0P11ftGWUrQ" src="https://media.licdn.com/dms/image/C4D12AQG0P11ftGWUrQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=RmUuT_C1S1-SQrv1FZwy3G6y2xjXbu8ljZ1tKe3OCA8" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Nous avons un job qui a du sens, du cœur et, si ce n'est pas le cas, nous pouvons toujours nous améliorer en nous connectant davantage aux patients. Même si nous souffrons souvent de l'absence de reconnaissance de nos pairs d'autres spécialités (pour ne pas dire du dédain voire du mépris) ou des administrations, nous pouvons nous sentir fier d'avoir un tel rendement professionnel, de rendre une telle qualité de service à la population toute entière. Soyez d'abord reconnaissant envers vous-même car si ce que nous faisons peut parfois vous sembler un fardeau, il faut le ressentir comme un privilège et ceci dépend principalement de son propre état d'esprit et de sa mentalité. En effet, plutôt que de vous plaindre, soyez reconnaissant de vivre ces situations qui vous mettent sous pression car elles vous motivent, vous rendent inventif et vous poussent à toujours faire mieux.</span></div>
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<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">Des recettes pour être heureux (et le rester)</span></span></div>
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<img data-li-src="https://media.licdn.com/dms/image/C4D12AQEBXmQ3xl2GdA/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=s0HEdeVP2sSjpSFMXMjVHH-YDspmbkhtBUc-ZU8ENR4" data-media-urn="urn:li:digitalmediaAsset:C4D12AQEBXmQ3xl2GdA" src="https://media.licdn.com/dms/image/C4D12AQEBXmQ3xl2GdA/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=s0HEdeVP2sSjpSFMXMjVHH-YDspmbkhtBUc-ZU8ENR4" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
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<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Toutes les gardes ont une fin. </span>Peu importe combien de temps elle a duré, de quelle intensité elle a été, ou à quelle pression vous avez été soumis, vous quitterez l'hôpital lorsque votre garde s'est achevée et vous retournerez à la vraie vie. Assurez des <u style="box-sizing: inherit;">transmissions de qualité</u> et laissez quelqu'un d'autre porter la charge de ce qui va suivre aux urgences et surtout, ne repartez pas avec à la maison !</span></li>
</ul>
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<img data-li-src="https://media.licdn.com/dms/image/C4D12AQEzrCk5Da2gMw/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=96Jq4JQbVG7c4VfswRfuLZE1_E06tNudxiZQ7qWgEVw" data-media-urn="urn:li:digitalmediaAsset:C4D12AQEzrCk5Da2gMw" src="https://media.licdn.com/dms/image/C4D12AQEzrCk5Da2gMw/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=96Jq4JQbVG7c4VfswRfuLZE1_E06tNudxiZQ7qWgEVw" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
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<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">L’après</span>. Assurez-vous que lorsque votre garde, votre quart de travail se termine, vous avez quelque chose de prévu : sport, randonnée, cinéma, sieste, musée, pêche au gros, café en terrasse... Peu importe ce que c'est, faites-le !</span></li>
</ul>
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<img data-li-src="https://media.licdn.com/dms/image/C4D12AQFQ-SYjI7n-cg/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=aZg3kexiJRGJQIza-UBv6BQQ4rhceRlqAjl3g4umWWs" data-media-urn="urn:li:digitalmediaAsset:C4D12AQFQ-SYjI7n-cg" src="https://media.licdn.com/dms/image/C4D12AQFQ-SYjI7n-cg/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=aZg3kexiJRGJQIza-UBv6BQQ4rhceRlqAjl3g4umWWs" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
<ul style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Soyez bons. </span>Appréciez-vous, aimez les gens en général et les malades en particulier ! Cela vous rendra meilleur dans vos interrogatoires, meilleur dans votre relation avec le patient et son entourage et donc, meilleur dans vos décisions diagnostiques et thérapeutiques. Vous éviterez bien des erreurs surtout si vous êtes jeunes (et même si vous êtes plus âgés ; ce n'est pas moi mais la science qui le dit : <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858850/" rel="nofollow noopener" style="background: 0px 0px transparent; border: 0px; box-sizing: inherit; color: #665ed0; margin: 0px; padding: 0px; text-decoration-line: none; touch-action: manipulation; vertical-align: baseline; word-wrap: break-word;" target="_blank">PMC5858850</a>)</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Appréciez les ainés. </span>Il n'y a rien d'autre de plus horripilant, voire de plus insultant et insupportable, que d'entendre "encore un vieux 'pourri' à voir" dans un service d'urgence. Comment juger et préjuger de ces longues vies pleines d'expériences, de rencontres, de joies et de peines..., et de biaiser <u style="box-sizing: inherit;">a priori </u>votre relation avec un patient qui a bien des choses à vous apprendre (même s'il est dément !). Les vieux méritent amplement notre respect et notre intérêt de médecin mais surtout d'être humain. Ils sont une source infinie de bon sens, de bons mots... et de symptômes essentiels à leur bonne prise en charge.</span></li>
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<img data-li-src="https://media.licdn.com/dms/image/C4E12AQGfsqQgihBEXw/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=H5jSJtPHNyP74vrjt5hG2OJ6h94AqEMeNYfJrh8Ckl8" data-media-urn="urn:li:digitalmediaAsset:C4E12AQGfsqQgihBEXw" src="https://media.licdn.com/dms/image/C4E12AQGfsqQgihBEXw/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=H5jSJtPHNyP74vrjt5hG2OJ6h94AqEMeNYfJrh8Ckl8" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
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<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Ayez de l'empathie. </span>Rappelez-vous toujours que le patient, c'est celui qui est malade. L'empathie est assurément une bonne chose, mais la maladie est la leur, elle leur appartient et il faut la respecter. Aider nos patients est notre crédo et nous devons nous efforcer de soulager la souffrance chaque fois que nous le pouvons. N'essayez pas de souffrir avec eux, cela vous entrainera inexorablement vers le bas.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Calme est mère de sûreté.</span> La frustration, la déception et la colère font partie intégrante de votre job. Ce sont toutes des réponses normales à la pratique de votre métier dans un système de santé dont les ressources sont limitées tout en essayant de faire face à une demande croissante et parfois écrasante. Ressentir ces émotions signifie que vous vous souciez des malades et des conditions de leur prise en charge. L'affect est une bonne chose mais il faut apprendre à le canaliser et à l'exprimer avec calme.</span></li>
</ul>
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<img data-li-src="https://media.licdn.com/dms/image/C4E12AQFel6TlpL26FQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=D46ERrWr1hjLrSIjm0jQBl5Lk2S52r_qtWsqRW0iODI" data-media-urn="urn:li:digitalmediaAsset:C4E12AQFel6TlpL26FQ" src="https://media.licdn.com/dms/image/C4E12AQFel6TlpL26FQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=D46ERrWr1hjLrSIjm0jQBl5Lk2S52r_qtWsqRW0iODI" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></div>
<div class="slate-resizable-image-embed slate-image-embed__resize-right" style="background: 0px 0px; border: 0px; box-sizing: inherit; clear: both; color: rgba(0, 0, 0, 0.75); float: right; font-family: "Source Serif Pro", serif; font-size: 20px; line-height: 3.2rem; margin: 0px 0px 0px 32px; max-width: 432px; outline: 0px; padding: 0px; position: relative; vertical-align: baseline;">
<img data-li-src="https://media.licdn.com/dms/image/C4E12AQHooq1-Ch19Jg/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=dvP9maZt_hJNKEVaOdeb56YCrm8Wkgkdfi11yUA0LbQ" data-media-urn="urn:li:digitalmediaAsset:C4E12AQHooq1-Ch19Jg" src="https://media.licdn.com/dms/image/C4E12AQHooq1-Ch19Jg/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=dvP9maZt_hJNKEVaOdeb56YCrm8Wkgkdfi11yUA0LbQ" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
<ul style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Prévenir le burn-out et le bore-out.</span> Apprenez à repérer vos propres alarmes. Lorsque vous arrêtez de vous soucier de vos patients, de votre équipe, de vos projets professionnels comme personnels, c'est que vous êtes en burn-out. De même, si vous ressentez moins la souffrance et la douleur des patients, c'est que vous devenez insensible à tout, même à vous-même. Pensez "communication". Parlez-en à la maison - un peu - (sans faire porter le poids de votre malaise à vos proches : vous voir peu ou pas épanouis les atteint déjà), mais surtout trouvez un collègue en qui vous avez confiance car il y a presque toujours un moyen de prévenir le burn-out et de se remettre en selle auprès de ceux qui connaissent votre travail.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Addiction(s). </span>Ne faites confiance à aucun substitutif chimique pour vous aider dans votre travail. L'alcool ou tout autre supplétif (psychostimulants - légaux ou non -, psychotropes, …) sont l'un des moyens les plus rapides pour se sentir détendu après une garde, une semaine ou une journée difficile. Cela vous apaisera - momentanément -, vous rassurera - peut-être -, mais surtout vous détruira doucement - ou plus rapidement -, rendant votre job dépendant d'une addiction. Utilisez-les avec prudence et modération après votre boulot, voire pas du tout. Gardez les moyens de vous détendre pour les périodes de repos et le temps passé en famille et/ou avec les amis.</span></li>
</ul>
<div class="slate-resizable-image-embed slate-image-embed__resize-full-width" style="background: 0px 0px; border: 0px; box-sizing: inherit; clear: both; color: rgba(0, 0, 0, 0.75); font-family: "Source Serif Pro", serif; font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; position: relative; vertical-align: baseline;">
<img data-li-src="https://media.licdn.com/dms/image/C4E12AQEYVFYvxjqmAw/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=AU0O-a7pHFElhC77Sr-uZo4XZ3Y5mhwaJhAYPpcgReg" data-media-urn="urn:li:digitalmediaAsset:C4E12AQEYVFYvxjqmAw" src="https://media.licdn.com/dms/image/C4E12AQEYVFYvxjqmAw/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=AU0O-a7pHFElhC77Sr-uZo4XZ3Y5mhwaJhAYPpcgReg" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></div>
<div class="slate-resizable-image-embed slate-image-embed__resize-left" style="background: 0px 0px; border: 0px; box-sizing: inherit; clear: both; color: rgba(0, 0, 0, 0.75); float: left; font-family: "Source Serif Pro", serif; font-size: 20px; line-height: 3.2rem; margin: 0px 32px 0px 0px; max-width: 432px; outline: 0px; padding: 0px; position: relative; vertical-align: baseline;">
<img data-li-src="https://media.licdn.com/dms/image/C4E12AQE1TiQbH_uvgQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=WgMrs66_KsQlCxdrOP3kKVL3AxlwytD_HsGT2aGkxu8" data-media-urn="urn:li:digitalmediaAsset:C4E12AQE1TiQbH_uvgQ" src="https://media.licdn.com/dms/image/C4E12AQE1TiQbH_uvgQ/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=WgMrs66_KsQlCxdrOP3kKVL3AxlwytD_HsGT2aGkxu8" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
<ul style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Apprenez tout le temps... et surtout de vos erreurs & échecs. </span>La médecine, en général, et l'urgentologie en particulier, nécessitent de se tenir continuellement informé tant notre spécialité est diversifiée et transversale. Trouvez les moyens de vous faire plaisir en apprenant, les possibilités sont infinies surtout depuis l'avènement d'internet. Plus encore, lorsque vous ressentez un échec, lorsque vous pensez avoir laissé tomber un patient, un collègue car vous étiez démuni, lorsque encore vous pensez que vous n'êtes pas bon et que vous ne le serez jamais, prenez du recul et <u style="box-sizing: inherit;">regardez objectivement</u> ce qui vous a mis mal à l'aise. Pensez alors à quelqu'un que vous avez aidé, quelque chose de difficile que vous avez particulièrement bien réussi, à une personne à qui vous avez sauvé la vie, à ce petit mieux qui vous a fait avancer dans votre pratique, avant de vous concentrer sur vous-même et le problème auquel vous avez eu à faire face. Si vous travaillez correctement, il y a beaucoup plus de leçons à tirer d'une erreur ou d'un cas qui a mal tourné que la routine que vous maîtrisez. </span></li>
</ul>
<div class="slate-resizable-image-embed slate-image-embed__resize-right" style="background: 0px 0px; border: 0px; box-sizing: inherit; clear: both; color: rgba(0, 0, 0, 0.75); float: right; font-size: 20px; line-height: 3.2rem; margin: 0px 0px 0px 32px; max-width: 432px; outline: 0px; padding: 0px; position: relative; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQHojUnyQvd6HQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=zdgtcTQI1-jEktIR44MwNyK0lyiEI3osSh89ZIurz6I" data-media-urn="urn:li:digitalmediaAsset:C4E12AQHojUnyQvd6HQ" src="https://media.licdn.com/dms/image/C4E12AQHojUnyQvd6HQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=zdgtcTQI1-jEktIR44MwNyK0lyiEI3osSh89ZIurz6I" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
<ul style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Prenez des pauses régulièrement. </span>Je ne parle pas ici de vos congés mais bien de vos journées et nuits de travail. En effet, en vous posant, en sortant ces quelques 5 à 10 minutes du flux, vous allez penser mieux, travailler mieux et être plus heureux. Vous ferez moins d'erreurs. Vous serez plus efficace et plus rapide. Vous vous souviendrez des choses importantes qui doivent être faites plutôt que d'être noyé par des demandes multiples qui détournent votre attention. Personne ne sait quoi que ce soit de ce que vous ressentez au moment de prendre une pause. Laissez les sceptiques pensez ce qu'ils veulent, les urgentistes intelligents vous assureront qu'il faut le faire régulièrement.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Soyez Zen... respirez. </span>Sans aucune connotation philosophique ou religieuse, rester (ou apprendre à rester) zen lorsque des pensées indésirables dérangent votre esprit, lorsque vous vous attardez sur ce qui a mal tourné, lorsque vous craignez de ne pas y arriver, est fondamental dans notre pratique. En effet, dans ces situations de stress "négatif", faites ceci : arrêtez tout, apprenez à reconnaître les pensées indésirables et concentrez-vous plutôt sur votre respiration. Elle va finir par être le centre de vos pensées. Ainsi, quand ces pensées indésirables vont finir par disparaitre, vous allez pouvoir reprendre votre job bien plus relâché et surtout efficace. Cela prend en général moins d'une minute et vous pouvez le faire n'importe-où et presque n'importe quand. Répétez cette "gymnastique" le cas échéant.</span></li>
</ul>
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<img data-li-src="https://media.licdn.com/dms/image/C4E12AQG8nS7rh9Vt2g/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=0RqmgdBaa478MZqMsLymIT25zYL5ItQArdB4VWnP65c" data-media-urn="urn:li:digitalmediaAsset:C4E12AQG8nS7rh9Vt2g" src="https://media.licdn.com/dms/image/C4E12AQG8nS7rh9Vt2g/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=0RqmgdBaa478MZqMsLymIT25zYL5ItQArdB4VWnP65c" style="background: 0px 0px; border: 0px; box-sizing: inherit; display: block; height: auto; margin: 0px auto; max-width: 432px; outline: 0px; padding: 0px; vertical-align: baseline;" /></div>
<div class="slate-resizable-image-embed slate-image-embed__resize-right" style="background: 0px 0px; border: 0px; box-sizing: inherit; clear: both; color: rgba(0, 0, 0, 0.75); float: right; font-size: 20px; line-height: 3.2rem; margin: 0px 0px 0px 32px; max-width: 432px; outline: 0px; padding: 0px; position: relative; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQEqC3qQvORW5w/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=0PKhdWmzW8QA2oEHDZqTrVy88hqPMqjZ8a1fvhBeSUo" data-media-urn="urn:li:digitalmediaAsset:C4E12AQEqC3qQvORW5w" src="https://media.licdn.com/dms/image/C4E12AQEqC3qQvORW5w/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=0PKhdWmzW8QA2oEHDZqTrVy88hqPMqjZ8a1fvhBeSUo" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline;" /></span></div>
<ul style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Les bonus.</span> Trouvez des bonus à votre métier, à votre pratique. Au-delà de la nécessaire formation initiale et continue à travers les D.U., les séminaires, les congrès, essayez de trouver un intérêt à vivre votre job différemment. Pour certains, cela peut être la médecine humanitaire, pour d'autres médicaliser une expédition polaire, un trek en haute montagne, des secours maritimes ou encore un safari. Nous sommes très polyvalents et très demandés par nombre de structures comme les ONG, les organisations sportives, les agences de voyages, etc. Profitez-en, c'est souvent riche d'enseignements et d'idées qui sont autant d'éléments à l'amélioration de votre pratique quotidienne.</span></li>
</ul>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">S'améliorer encore et toujours en 10 points</span></span></div>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Au-delà de votre pratique professionnelle, gardez comme objectif d'être meilleur dans votre vie car cela retentira sur votre métier. Pour cela, adoptez une recette simple et éprouvée.</span></div>
<div class="slate-resizable-image-embed slate-image-embed__resize-full-width" style="background: 0px 0px; border: 0px; box-sizing: inherit; clear: both; color: rgba(0, 0, 0, 0.75); font-family: "Source Serif Pro", serif; font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; position: relative; vertical-align: baseline;">
<img data-li-src="https://media.licdn.com/dms/image/C4E12AQHnUSEQXsZQOg/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=Agc4hEmkB01xTgBBZdQ5L6snb2Bo06LRv4ed1UyEb_A" data-media-urn="urn:li:digitalmediaAsset:C4E12AQHnUSEQXsZQOg" src="https://media.licdn.com/dms/image/C4E12AQHnUSEQXsZQOg/article-inline_image-shrink_1500_2232/0?e=2128896000&v=beta&t=Agc4hEmkB01xTgBBZdQ5L6snb2Bo06LRv4ed1UyEb_A" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></div>
<ol style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Apprenez et découvrez-vous : </span>n'attendez pas que cela vienne d'autrui</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Sortez de votre zone de confort :</span> c'est ce qui vous apportera la satisfaction</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Recherchez sans relâche les défis et apprenez de vos erreurs : </span>vous en sortirez grandi</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Demandez des retours, des commentaires sur vos actes et pratiques</span></span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Apprenez de ceux qui vous inspirent :</span> trouvez-vous un mentor</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">Quitter vos mauvaises habitudes : </span>tabac, alcool, psychotropes,... choisissez plutôt voyages, activité physique, sauna, ballades,...</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Trouvez votre voie avec des gens bienveillants</span></span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Méditez et respirez</span></span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Soyez gentil et attentionné avec autrui</span></span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Faites des pauses</span></span></li>
</ol>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><br style="box-sizing: inherit;" /></span></div>
<h3 style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Trebuchet MS, sans-serif; font-size: large;">Heureux en général (et donc, en médecine d'urgence)</span></span></h3>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Le bonheur est rarement dû aux circonstances extérieures mais beaucoup plus au ressenti interne. Si vous n'êtes pas content, ne pensez pas que déménager, changer de job, gagner plus d'argent, bouleverser votre vie de famille, etc. va faire la différence, à moins que ces choses ne soient déjà mal engagées. Nous pensons toujours que l'herbe est plus verte de l'autre côté mais c'est en réalité rarement le cas. Pour le bonheur, vous devez changer votre façon d'interagir avec votre environnement et avec les autres, vos propres attentes, ainsi que votre propre état d'esprit. Changer la façon dont vous êtes lié à votre travail mais ne changez pas de travail. C'est comme dans la vie de couple, le plus souvent il vaut mieux changer votre relation avec votre conjoint plutôt que de changer de conjoint. Changez qui vous êtes, pas ce que vous avez (encore une fois, la richesse matérielle ne vous rendra pas heureux).</span></div>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Finalement, être un urgentiste heureux correspond à une équation assez simple :</span></div>
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<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><img data-li-src="https://media.licdn.com/dms/image/C4E12AQFyYeW_mClIPg/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=6CobaeyY9rPcSdlLjyX4t4bOm4KCVewv4tu8Ml2xMPQ" data-media-urn="urn:li:digitalmediaAsset:C4E12AQFyYeW_mClIPg" src="https://media.licdn.com/dms/image/C4E12AQFyYeW_mClIPg/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=6CobaeyY9rPcSdlLjyX4t4bOm4KCVewv4tu8Ml2xMPQ" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></span></div>
<div style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin-bottom: 3.2rem; margin-top: 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;">
<span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">Ainsi, trouver les éléments de réponses à cette simple équation correspond-il à appliquer des recettes simples à son quotidien tant professionnel que privé :</span></div>
<ul style="background: 0px 0px; border: 0px; box-sizing: inherit; color: rgba(0, 0, 0, 0.75); font-size: 20px; line-height: 3.2rem; margin: 3.2rem 0px; outline: 0px; padding: 0px; vertical-align: baseline;">
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">1. Avoir une activité sociale soutenue. </span>Être avec les autres dans le travail comme dans la vie.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">2. Être reconnaissant tous les jours. </span>Il y a toujours des bénéfices à être reconnaissant même si les choses semblent parfois mal engagées. Vous pourriez vivre en Corée du Nord, ce n'est pas le cas, soyez-en reconnaissant et, en général, soyez le pour ce vous ne faites pas sous la contrainte.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">3. Faites de l'exercice. </span>La science a depuis longtemps prouvé que c'est bénéfique même au travail.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">4. Rester conscient de notre environnement. </span>Restez dans le moment présent.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">5. Avoir des objectifs, agir avec sens. </span>Chercher un but ou une signification à vos actes, parfois, simplement améliorer le bien-être des autres.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">6. Soyez indulgent et ayez de l'amour-propre (sans narcissisme ni ego démesuré). </span>Accordez-vous des pauses, ne soyez pas dur envers vous-même. Faites ce que vous pouvez pour vous améliorer et pardonnez-vous pour les choses que vous ne pouvez pas changer. Vous ne serez jamais parfait mais si vous faites une erreur, cherchez pourquoi et apprenez. Ne vous flagellez pas pour ça. Il y en aura toujours d'autres pour vous rappeler qu'ils sont meilleurs ou plus intelligents. Félicitez-les car ils sont voués à rencontrer beaucoup de succès (mais aussi à recevoir beaucoup de coups et finir par s'isoler eux-mêmes). Montrez que vous êtes sincèrement heureux pour eux et aidez-les à avoir encore plus de succès. Ne soyez pas jaloux du succès des autres et, si vous avez du succès vous-même, entraînez les autres avec vous. Aidez-les à avoir plus de réussites.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;">7. Sachez que le bonheur ne vient jamais de plus de richesse matérielle. </span>Des études montrent que la richesse fait une différence dans le bonheur jusqu'à un certain point. Au-delà de ce 'cut-off', le revenu et la richesse ne correspondent pas au bonheur. Si vous n'êtes pas satisfait de vos revenus, il est peu probable que gagner plus ou avoir plus va faire la différence.</span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">8. Le bonheur est surtout lié à votre état d'esprit et non aux circonstances extérieures.</span></span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">9. Soyez fier d'être urgentiste.</span></span></li>
<li style="background: 0px 0px; border: 0px; box-sizing: inherit; margin: 2.4rem 0px 2.4rem 3.2rem; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="background: 0px 0px; border: 0px; box-sizing: inherit; font-weight: 700; margin: 0px; outline: 0px; padding: 0px; vertical-align: baseline;"><span style="font-family: Helvetica Neue, Arial, Helvetica, sans-serif;">10. Vivez-le avec passion !</span></span></li>
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<img data-li-src="https://media.licdn.com/dms/image/C4E12AQEEijN9XcGxzQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=yVeMTDThDakrzOQgVki9pKODHL-hDB85GKprAu7uA-8" data-media-urn="urn:li:digitalmediaAsset:C4E12AQEEijN9XcGxzQ" src="https://media.licdn.com/dms/image/C4E12AQEEijN9XcGxzQ/article-inline_image-shrink_1000_1488/0?e=2128896000&v=beta&t=yVeMTDThDakrzOQgVki9pKODHL-hDB85GKprAu7uA-8" style="background: 0px 0px; border: 0px; box-sizing: inherit; height: auto; margin: 0px; max-width: 100%; outline: 0px; padding: 0px; vertical-align: baseline; width: 744px;" /></div>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-61026653052815279512018-02-28T00:48:00.001-08:002018-02-28T00:49:20.324-08:00Nous ne sommes pas vendredi... Mais c'est déjà le n°13 de e-triage<div id="access-shortcuts-wrapper" style="background-color: white; box-sizing: border-box; color: #6c6c71; font-family: "Lucida Sans", verdana, sans-serif; font-size: 13px; position: relative; z-index: 999000;">
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Newsletter e-triage #13 – Février 2018</div>
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Février 2018</div>
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<article class="article ttl-dotted etriage" style="box-sizing: border-box; padding: 0px 50px;"><header class="article-header" style="box-sizing: border-box; position: relative;"><h2 class="edito" style="-webkit-font-smoothing: subpixel-antialiased; background: url("../img/title-dot.png") 0px 3px no-repeat transparent; box-sizing: border-box; color: #009d4e; font-size: 3.333em; font-weight: 400; line-height: 38.4px; margin: 0px 0px 1em -50px; padding: 0px 0px 0px 50px; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.004) 1px 1px 1px;">
Edito</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><em style="box-sizing: border-box;">Ce n’est pas parce que les choses sont difficiles que nous n’osons pas. C’est parce que nous n’osons pas qu’elles sont difficiles.</em><br style="box-sizing: border-box;" />Sénèque<br style="box-sizing: border-box;" /><br style="box-sizing: border-box;" />Lorsque James Elam fit du bouche à bouche à des patients poliomyélitiques apnéiques, ses collègues le regardèrent avec effroi. Faisant fi du risque de contagion, le Dr Elam initia un geste qui bouleversait la réanimation d’urgence. <a class="more-link" href="http://news.vygon.com/fr/newsletter-e-triage-13-fevrier-2018/edito/" style="-webkit-font-smoothing: subpixel-antialiased; box-sizing: border-box; color: black; font-weight: 700; text-decoration-line: none; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.004) 1px 1px 1px; transition: all 160ms;">[…]</a></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Jean-Claude Deslandes</strong><br style="box-sizing: border-box;" /><strong style="box-sizing: border-box;">Rédacteur en Chef</strong></span></div>
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Revue de presse</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Annales françaises de Médecine d’urgence</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Cricothyroïdotomie par technique SMS (Scalpel, Mandrin long béquillé, Sonde d’intubation)<br style="box-sizing: border-box;" />- Prise en charge des plaies en structure d’urgence</span></div>
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<a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-13-fevrier-2018/annales-francaises-de-medecine-durgence/" style="-webkit-font-smoothing: subpixel-antialiased; box-sizing: border-box; color: black; display: block; float: left; font-weight: 700; margin-left: -147px; position: absolute; right: 0px; text-align: center; text-decoration-line: none; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.004) 1px 1px 1px; top: 0px; transition: all 160ms; width: 147px;"><img alt="" border="0" height="51" src="http://news.vygon.com/wp-content/themes/vyg-news/img/gamme/btn-etriage-more.png" style="border: 0px; box-sizing: border-box; height: auto; max-width: 100%; vertical-align: middle;" width="49" /><br style="box-sizing: border-box;" /><span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif; font-size: 16px;">Lire la suite</span></a></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Annals of Emergency Medicine</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Ropivacaine en injections intramusculaires paracervicales pour chépalées chez l’enfant<br style="box-sizing: border-box;" />- Arrêt de la réanimation après un arrêt cardiaque extrahospitalier<br style="box-sizing: border-box;" />- Intérêt de l’intubation trachéale dans l’arrêt cardiaque<br style="box-sizing: border-box;" />- Intérêt de la bougie dès la première tentative d’intubation<br style="box-sizing: border-box;" />- Hypotension artérielle en préhospitalier et mortalité des traumatismes crâniens</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Journal Européen des Urgences et de Réanimation</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- L’utilisation des défibrillateurs semi-automatiques par le grand public améliore la survie immédiate des arrêts cardiaques survenant dans les aéroports internationaux.<br style="box-sizing: border-box;" />- Place de l’assistance respiratoire et circulatoire extracorporelle de courte durée (ECMO), post-cardiotomie exclue, dans la prise en charge des défaillances graves du nouveau-né et de l’enfant<br style="box-sizing: border-box;" />- Pneumomédiastin et consommation de cocaïne<br style="box-sizing: border-box;" />- Etats de mal épileptiques (EME) de l’adulte et de l’enfant</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">The American Journal of Emergency Medicine – partie 1</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- L’injection de Shenfu améliore t-elle l’immunité cellulaire et le devenir des patients en choc septique ?<br style="box-sizing: border-box;" />- Evaluation des infections bactériennes chez l’enfant<br style="box-sizing: border-box;" />- Thérapies complémentaires aux traitements médicaux d’une lombalgie aiguë non radiculaire<br style="box-sizing: border-box;" />- Prise en charge des hypoglycémies aux urgences<br style="box-sizing: border-box;" />- Intérêt de compressions automatisées dans la prise en charge d’un arrêt cardiaque<br style="box-sizing: border-box;" />- Lésions parenchymateuses en relation avec des manœuvres de RCP<br style="box-sizing: border-box;" />- Glucagon et exacerbations réfractaires d’asthme</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">The American Journal of Emergency Medicine – partie 2</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Accès IV versus intra-osseux et reprise d’une activité circulatoire spontanée dans les arrêts cardiaques extrahospitaliers (ACEH)<br style="box-sizing: border-box;" />- Concentration plasmatique d’acide tranexamique après administration IV ou IO<br style="box-sizing: border-box;" />- Plasma-lyte A, ringer lactate et soluté salé isotonique dans le traitement des chocs hémorragiques chez le rat<br style="box-sizing: border-box;" />- Kétamine intra nasale (IN) versus morphine IV dans le traitement des coliques néphrétiques<br style="box-sizing: border-box;" />- Décompression thoracique en préhospitalier après traumatisme sévère du thorax</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">The American Journal of Emergency Medicine – partie 3</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Effets secondaires de la morphine aux urgences<br style="box-sizing: border-box;" />- Pincement inspiratoire des ailes du nez comme signe marquant d’une acidose respiratoire<br style="box-sizing: border-box;" />- RCP assistée par téléphone : est-elle pertinente ?<br style="box-sizing: border-box;" />- Intérêt de l’échographie chez les enfants présentant une exacerbation aiguë de leur asthme</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">The American Journal of Emergency Medicine – partie 4</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Défibrillation avant l’arrivée des secours médicaux<br style="box-sizing: border-box;" />- Sédation procédurale pour fracture des os longs chez l’enfant obèse<br style="box-sizing: border-box;" />- Effet cardioprotecteur du nicorandil en post arrêt cardiaque, chez le cochon<br style="box-sizing: border-box;" />- Pré-oxygénation et gestion des voies aériennes en urgence.<br style="box-sizing: border-box;" />- Réduction du paraphimosis<br style="box-sizing: border-box;" />- RCP chez l’enfant : quelle méthode de compression thoracique ?<br style="box-sizing: border-box;" />- Rôle pronostique de la copeptine après un traumatisme crânien<br style="box-sizing: border-box;" />- Propofol versus alfentanil pour sédation procédurale aux urgences<br style="box-sizing: border-box;" />- Epinéphrine et arrêt cardiaque<br style="box-sizing: border-box;" />- Choc septique : évaluation de la mortalité<br style="box-sizing: border-box;" />- Oxygénation apnéique durant l’intubation</span></div>
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Actualité de l'Arrêt Cardiaque</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Revue exhaustive de la littérature</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Actualité dans la réanimation cardio-pulmonaire et cardio-cérébrale</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">American Heart Association (AHA)</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Bag-mask ventilation fails to improve on endotracheal intubation in cardiac arrest (CAAM)</strong></span></div>
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Retour sur congrès</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">EUSEM – European Society for Emergency Medicine</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">23-27 septembre 2017 , Athènes</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">European Resuscitation Council</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">28-30 septembre 2017, Freiburg</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">AMUQ – Association des Médecins d’Urgence du Québec</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">16-19 octobre 2017, Montréal</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Remarquable premier congrès Espagnol sur l’arrêt cardiaque</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">20-21 octobre 2017, Madrid</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">ACEP – American College of Emergency Physicians</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">30 octobre-1er novembre 2017, Washington (DC)</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">SOFCOT – Société Française de Chirurgie Orthopédique et Traumatologie</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">6-9 novembre 2017, Paris</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">A retenir du dernier congrès de l’AHA 2017</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">11-15 novembre, Anaheim (CA)</span></div>
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Agenda</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Congrès – Réunions – Formations</strong></span></div>
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Formation</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Test de connaissances</strong></span></div>
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Nouveaux ouvrages</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">La clinique fondée sur les valeurs</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">Depuis longtemps, déjà, Fulford et son équipe reprochent à la pratique de l ‘Evidence-Based Medicine une déshumanisation de la relation entre soignants et soignés.</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Le blessé par attentat terroriste</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">Trois médecins de formation militaire et au cœur des attentats parisiens, se sont entourés d’experts pour écrire un ouvrage de référence.</span></div>
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Cas cliniques</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Cas cliniques</strong></span></div>
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Témoignage</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Ils ont fait l’histoire de la médecine d’urgence</strong></span></div>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com1tag:blogger.com,1999:blog-317032633037212420.post-90827050445404181522018-02-16T02:16:00.000-08:002018-02-16T02:16:28.182-08:00Où la bienveillance devient un priorité de santé publique !<h2 style="clear: both; text-align: center;">
Il y a Urgence !!!</h2>
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Aujourd'hui, ce n'est pas scientifique, c'est un coup de gueule humaniste !</div>
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Il nous incombe de développer la bientraitance au sein de nos hôpitaux pour qu'à leur tour les internes en médecine deviennent de bons médecins et de valeureux collègues.</div>
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<span style="font-style: italic;">Le Figaro </span><br /><img class="CToWUd" height="13" src="https://blogger.googleusercontent.com/img/proxy/AVvXsEgV8j7Q3-THk9BWZv0hlSt7ucNyc5chAh6ki3A9Yo-2fl-0SdYJceAlll7XJKCjKOX-0EgR2gsvrNnfLh9tWDKvoBv_Kdltdci_O3j1Lj0kQ3vkdQmq_WGQIPfdKJsHa97hIiEU5uPf8-x4AMB0rAOzuWEHfB-xgiWvdGveHmneTmaqHA=s0-d-e1-ft" width="430" /><br /><span style="color: #536887; font-size: 20px; font-weight: bold;">« Le grand malaise des internes en médecine »</span><br /><br /><span style="color: #3d3d3d;">Le Figaro remarque en effet :<em> « Anxiété, mal-être, suicides… Les étudiants en médecine ploient sous la charge de travail et le poids des responsabilités, avec un encadrement défaillant. La situation est telle, avec dix suicides en un an, que leurs syndicats ont interpellé la ministre de la Santé, Agnès Buzyn, dans une lettre ouverte ».</em><br />Le journal observe que <em>« consciente de «la souffrance des futurs soignants», qui est «une préoccupation majeure», elle s’est engagée à les recevoir d’ici à la fin février, après la remise d’un rapport qu’elle a confié à une psychiatre spécialisée dans les risques psychosociaux chez les étudiants en médecine ».</em><br />Le quotidien souligne que <em>« pour Jean-Baptiste Bonnet, président de l’Intersyndicale nationale des internes (Isni), «il y a urgence». Selon son organisation, une dizaine d’internes se sont suicidés au cours des 12 derniers mois ».</em><br />Le Figaro relève que <em>« l’Isni, aidé de trois autres syndicats d’étudiants en médecine, d’internes et de praticiens des hôpitaux, avait déjà tenté d’alerter l’opinion publique en publiant, en juin dernier, une enquête aux résultats préoccupants ».<br />« Selon l’étude, menée auprès de 22.000 futurs médecins, plus de 66% des étudiants en médecine souffriraient d’anxiété, contre 26% de la population française. Ils seraient près de 28 % à être atteints de troubles dépressifs, contre seulement 10% des Français. Près d’un sur quatre déclare avoir déjà eu des idées suicidaires », </em>indique le journal.<br />Leslie Grichy, ancienne vice-présidente de l’Isni et responsable de l’enquête, remarque cependant qu’aucune <em>« prise de conscience réelle [n’a eu lieu]. Objectivement, il ne s’est rien passé derrière ».</em><br />Le Figaro note que <em>« désormais psychiatre, elle explique le mal-être des internes par «de multiples facteurs professionnels» », </em>évoquant <em>« la surcharge de travail – de futurs médecins «travaillent parfois 60, 80 voire 100 heures par semaine» ; le management «par des médecins qui ne sont pas formés à gérer des équipes, qui sont souvent maladroits et créent de la souffrance» ; et la réalité du métier, «la confrontation permanente à la maladie et la mort, à la souffrance», à laquelle les jeunes étudiants «ne sont pas bien préparés» ».</em><br />Emanuel Loeb, président de l’Inter Syndicat national des chefs de clinique et assistants, observe ainsi que <em>« les établissements fonctionnent majoritairement sur le travail abattu par les internes, qui servent de chevilles ouvrières ».</em><br />Le directeur adjoint d’un grand CHU note quant à lui : <em>« On charge les internes de façon disproportionnée. Ils tiennent l’ensemble des hôpitaux, sont très peu encadrés - par manque de seniors - et sont nos pions quand on est en situation d’urgence. Mais, à l’inverse, nous n’avons aucune tolérance sur leurs absences ou leurs limites ».</em><br />Le Figaro relève que <em>« parfois seuls pendant une garde, ceux qui sont encore étudiants peuvent être amenés à prendre des décisions aux conséquences lourdes pour leurs patients ».</em><br />Le quotidien ajoute que <em>« dans sa lettre ouverte à Agnès Buzyn, [Jean-Baptiste Bonnet] insiste sur l’importance de mieux «anticiper les risques avant que le mal-être ne survienne» et de «contrôler les abus sur le temps de travail». Pour accompagner les étudiants en détresse, il cite en exemple les dispositifs «SOS», avec un numéro de téléphone ou une adresse mail destinés à recueillir les confidences des internes, des supports qui «marchent malheureusement très bien» ».</em><br />Le journal conclut qu’Agnès Buzyn <em>« s’est saisie du sujet. La ministre a commandé un rapport à la psychiatre Donata Marra, spécialisée dans les risques psychosociaux chez les étudiants en médecine. […] La ministre de la Santé s’est engagée à recevoir «dès la remise du rapport», les différentes organisations des étudiants en médecine ».</em><br />Agnès Buzyn appelle ainsi à <em>« une discussion constructive sur le dépistage, la prévention et l’amélioration des conditions de formation ».</em></span>VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-75797972660036536772017-12-11T03:58:00.001-08:002017-12-11T04:26:38.792-08:00Syndrome aortique aigu - Ma dissection vaut bien un score prédictif et une pincée de biomarqueurs<h2>
<span style="font-family: Trebuchet MS, sans-serif;">Un "ADvISED" éclairé grace aux D-dimères dans la dissection aortique ?</span></h2>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1jECzi3J0xPZcciEuzp3ytCCQ4Ilgh-HCDZDMa-MFQVegySbXhDFIhZZEZWEWJGLJ8rvdciD6hB-VwE233yHtt7p492da5dL-x4HDG2nu4ibsPEjqsoMTlBxe9s2xBVPf7XL_J3FXSGoc/s1600/Rosbeef.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em; text-align: center;"><img border="0" data-original-height="1125" data-original-width="1500" height="480" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1jECzi3J0xPZcciEuzp3ytCCQ4Ilgh-HCDZDMa-MFQVegySbXhDFIhZZEZWEWJGLJ8rvdciD6hB-VwE233yHtt7p492da5dL-x4HDG2nu4ibsPEjqsoMTlBxe9s2xBVPf7XL_J3FXSGoc/s640/Rosbeef.png" width="640" /></a></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Dans cet article paru dans Circulation en octobre dernier, la combinaison d'un dosage des D-dimères négatif (avec un seuil fixé à <500 ng/ml) et d'un score de risque de détection de dissection aortique (TDA) ≤ 1 a permis le diagnostic de 99,7% des dissections aortiques... Peut-on supporter d'avoir manqué 0,3% des patients présentant un syndrome aortique aigu ? Telle est la question...</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">L'article</span></h4>
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<span style="font-family: Trebuchet MS, sans-serif;"><a data-saferedirecturl="https://www.google.com/url?hl=fr&q=https://journalfeed.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D2f0caea0dc%26e%3Df721cda332&source=gmail&ust=1512825759170000&usg=AFQjCNG12IdPPHIX188-IZVtvJUBuk2kiQ" href="https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=2f0caea0dc&e=f721cda332" style="background-color: white; color: #6dc6dd; font-size: 15px; word-wrap: break-word;" target="_blank">Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes: The ADvISED Prospective Multicenter Study.</a><span style="background-color: white; color: #606060; font-size: 15px;"> Circulation. 2017 Oct 13. pii: CIRCULATIONAHA.117.029457. doi: 10.1161/CIRCULATIONAHA.117.</span><wbr style="background-color: white; color: #606060; font-size: 15px;"></wbr><span style="background-color: white; color: #606060; font-size: 15px;">029457. [Epub ahead of print]</span></span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Pourquoi cette question est importante ?</span></h4>
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<span style="font-family: Trebuchet MS, sans-serif;">Les syndromes aortiques aigus (SAA) comprennent la dissection aortique, l'hématome aortique intramural, l'ulcération aortique pénétrante et la rupture de l'isthme aortique. Ces situations cliniques rares mais exceptionnellement graves occupent une place particulières dans nos pratiques et leur simple évocation nous provoquent des sueurs froides rien qu'à l'idée d'avoir pu louper le diagnostic lors d'une de nos gardes. En effet, les SAA sont à la fois rares et difficiles à diagnostiquer, ce qui entraîne un nombre important de surestimations et d'examens parfois coûteux, inutiles et non dénués de risques. Ainsi, dans leur introduction, les auteurs de cet article mentionnent que seuls 2,7% des examens scannographiques effectués en urgence pour suspicion de SAA ont été positifs. C'est un très mauvais coup pour votre temps, votre capacité diagnostique (votre égo de clinicien)... et votre argent.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1eYHd5-sa01ctcoZPirkg7_f9-QSA32kBxtysf4whZ45yMEQic3H-PMZGJTxnzScugSGR1tFvFHznukearizxmq7C7b3fKRbV49bEdg28yqEZ-Wy8t6VTLwG2_RRDdkbO1DxXELFHc9B8/s1600/grenade_6343_w560.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="399" data-original-width="560" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1eYHd5-sa01ctcoZPirkg7_f9-QSA32kBxtysf4whZ45yMEQic3H-PMZGJTxnzScugSGR1tFvFHznukearizxmq7C7b3fKRbV49bEdg28yqEZ-Wy8t6VTLwG2_RRDdkbO1DxXELFHc9B8/s1600/grenade_6343_w560.jpg" /></a></div>
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<span style="font-family: Trebuchet MS, sans-serif;">L'étude de nos collègues peut-elle nous aider dans notre démarche diagnostique ?</span></h3>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjBbtb2NIHT5XgmLFnhcFzroGqv_c05w88LSTiTcae90kujsrGW-2vq3Dj4WTFrYX_wcekdrOTkysNGhGrgHtyv5uhPVFHFSm-BcZAk4eTPhsHnBlKhrRG_8oyheferyGh51nb2JL2y0mZ/s1600/Marphanoid.png" imageanchor="1" style="font-weight: 400; margin-left: auto; margin-right: auto; text-align: center;"><img border="0" data-original-height="809" data-original-width="750" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjBbtb2NIHT5XgmLFnhcFzroGqv_c05w88LSTiTcae90kujsrGW-2vq3Dj4WTFrYX_wcekdrOTkysNGhGrgHtyv5uhPVFHFSm-BcZAk4eTPhsHnBlKhrRG_8oyheferyGh51nb2JL2y0mZ/s400/Marphanoid.png" width="370" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Il ne serait pas un peut marphanoïde delui-là ?</td></tr>
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<span style="font-family: Trebuchet MS, sans-serif;">Je voudrais un scanner multi-barettes avec une pincée de D-dimères...</span></h4>
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<span style="font-family: Trebuchet MS, sans-serif;">Cette étude observationnelle, internationale, multicentrique et prospective a eu le grand mérite de recruter 1 850 patients. </span><span style="font-family: "Trebuchet MS", sans-serif;">Fait important, les patients étaient seulement inclus si le diagnostic de SAA était évoqué par le clinicien dans sa demande d'examens complémentaires.</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Les critères d'inclusion étaient des adultes présentant une douleur aiguë (moins de 14 jours) pouvant évoquer un SSA avec au moins 1 des symptômes suivants : </span></div>
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<li><span style="font-family: Trebuchet MS, sans-serif;">douleur thoracique non traumatique, </span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">douleur abdominale, </span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">douleur dorsale, </span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">syncope ou hypotension. </span></li>
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<span style="font-family: Trebuchet MS, sans-serif;">Le score utilisé était le score ADD (pour Aortic Dissection Risk Score)</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2mE3oKUCurxUXp6ubDDJLwRIE9NkDpI8s7jqX19j4KJQ99voXtARdMLfa_Jc3f9euscoZ4HD7Z0KWdKCLmr0SIbJvB7GCJHD5xssDumMq2MiFZ5Ka6ye-hpfWOUd9NDjgMtxjKysutVM0/s1600/Score+ADD.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="521" data-original-width="975" height="212" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2mE3oKUCurxUXp6ubDDJLwRIE9NkDpI8s7jqX19j4KJQ99voXtARdMLfa_Jc3f9euscoZ4HD7Z0KWdKCLmr0SIbJvB7GCJHD5xssDumMq2MiFZ5Ka6ye-hpfWOUd9NDjgMtxjKysutVM0/s400/Score+ADD.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Rogers et al., Sensitivity of the Aortic Dissection Detection Risk Score, a Novel Guideline-Based Tool for Identification of Acute Aortic Dissection at Initial Presentation. <span style="font-family: Times, Times New Roman, serif;"><em style="background-color: white; color: #606060; font-size: 15px; text-align: left;">Circulation. </em><span style="background-color: white; color: #606060; font-size: 15px; text-align: left;">201</span><wbr style="background-color: white; color: #606060; font-size: 15px; text-align: left;"></wbr><span style="background-color: white; color: #606060; font-size: 15px; text-align: left;">1.</span></span></td></tr>
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<b style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;">Résultats</span></b></h2>
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<span style="font-family: "Trebuchet MS", sans-serif;">Sur l'ensemble de l'échantillon, 3 patients (0,3%) avaient un résultats de D-dimères négatif avec un score de risque ADD ≤ 1.</span></div>
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<span style="font-family: "Trebuchet MS", sans-serif;">On obtenait ainsi une sensibilité 99,6% avec une valeur prédictive négative VPN de 99,7%. </span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJj1APXMv94XIMday5qcL5TTaNlEDfSIXXS3iDRQM9bS-SdQPy2lb4apJmY5nC8SPsCJrcWd1D0AESJ6fFKGrZMCLN7nUYTH2KdRRGwlEe24EGRv3sjqIIO7vhI9olXLea_LPEli1IFPkA/s1600/ch50-d9.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="399" data-original-width="400" height="397" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhJj1APXMv94XIMday5qcL5TTaNlEDfSIXXS3iDRQM9bS-SdQPy2lb4apJmY5nC8SPsCJrcWd1D0AESJ6fFKGrZMCLN7nUYTH2KdRRGwlEe24EGRv3sjqIIO7vhI9olXLea_LPEli1IFPkA/s400/ch50-d9.jpg" width="400" /></a></div>
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<span style="font-family: "Trebuchet MS", sans-serif;"><span style="font-size: small;">Limites & perspectives</span></span></h2>
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<span style="font-family: "Trebuchet MS", sans-serif;">Ce qui est intéressant dans la description des faux-négatifs, voire bien utile, chez ces 3 patients, c'est qu'on </span><span style="font-family: "Trebuchet MS", sans-serif;">retrouvait soit un médiastin élargi sur la radiographie de thorax, soit l'évocation d'une une douleur thoracique soudaine, sévère, et transfixiante qui nous aurait fait pratiquer le TDM thoracique. </span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Ensuite, l'une des principales critiques à cette étude était que la détermination de la suspicion de SAA était déterminée par le clinicien prescripteur de l'examen, situation qui est difficile à normaliser et qui logiquement introduit un biais de sélection. Fait intéressant, les biais de sélections atteignent une incidence de 13% pour le SAA dans cet échantillon, ce qui était assez élevé. </span><span style="font-family: "Trebuchet MS", sans-serif;">Cela signifie probablement que les promoteurs de l'étude ont choisi leur population très soigneusement afin d'ajouter plus de validité à leurs résultats. </span></div>
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<span style="font-family: "Trebuchet MS", sans-serif;">Cependant, ces données nous prouvent qu'un algorithme diagnostique associant un score </span><span style="font-family: "Trebuchet MS", sans-serif;">ADD au dosage des </span><span style="font-family: Trebuchet MS, sans-serif;">D-dimères pourrait être envisageable dans notre pratique clinique. Mais paradoxalement, son application à une population de douleur thoracique plus hétérogène et moins sélectionnée, pourrait augmenter de façon drastique le taux de réalisation de scanner thoracique en raison d'une dépendance accrue au dosage du biomarqueur en l'occurence le test aux D-dimères.</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">En conclusion...</span></h2>
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<span style="font-family: Trebuchet MS, sans-serif;">Il nous reste la bonne parole de Michael DeBakey himself! (ayant lui-même souffert d'une dissection aortique, opéré en urgence à l'âge de 97 ans, ce qui lui a permis de pratiquer son art médical jusqu'à ses 99 ans)</span></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Pour faire de la bonne médecine, il faut récolter les bonnes informations...</span></div>
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<li><span style="font-family: Trebuchet MS, sans-serif;">La notion d'une douleur extrêmement vive (thoracique, dorsale et/ou abdominale)</span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">La notion d'irradiation</span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">La notion de survenue extrêmement brutale (l'hémorragie méningée du thorax/abdomen)... mais qui peut avoir disparu au moment de votre examen (17% des cas)</span></li>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-48322374762053543372017-11-15T06:36:00.002-08:002017-11-15T06:57:59.368-08:00Oedème Pulmonaire Aigu - On achève bien les pavots...<h2 style="background-color: white; color: #606060; font-family: Arial, "Helvetica Neue", Helvetica, sans-serif; line-height: 22.5px; margin-bottom: 1em; margin-top: 1em; padding: 0px; text-align: center;">
<span style="font-size: large;">MORPHINE KILLS!</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;">Depuis quelques temps déjà, elle était sur la sellette... la voilà associée à une augmentation de mortalité à court terme dans le traitement de l'insuffisance cardiaque aiguë. En effet, la morphine est responsable d'une surmortalité dans le <a href="https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=1f396b2094&e=f721cda332" style="background-color: transparent; color: #6dc6dd; word-wrap: break-word;" target="_blank">Registre EAHFE</a>, contrairement à toutes les autres variables étudiées : 20% contre 12,7%. Donc, il n'y a plus photo ! Fini la morphine dans l'OAP ?</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><strong>L'article paru dans CHEST</strong> </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-size: small;">Miró Ò, Gil V, Martín-Sánchez FJ, et al. Morphine use in </span><span style="font-size: small;">the emergency department and outcomes of patients with </span><span style="font-size: small;">acute heart failure: A propensity score-matching analysis </span><span style="font-size: small;">based on the EAHFE Registry. </span><span style="font-size: small;">CHEST. 2017;152(4):821-832. doi:10.1016/j.chest.2017.03.037. <a href="https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=1f396b2094&e=f721cda332" target="_blank">Epub 2017 12 avril</a>.</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><strong>Pourquoi cette question?</strong> </span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;">Des études déjà anciennes ont montré que la morphine pouvait avoir un effet favorable sur la dyspnée et entrainait une diminution modérée de la précharge.(1) Même si ces effets sont connus, elle peut également impacter l'effort respiratoire et nuire à l'hémodynamique. La morphine est utilisée depuis longtemps pour traiter les patients souffrant d'insuffisance cardiaque aiguë sévère. Ainsi, l'AHA recommande officiellement que la morphine soit utilisé dans le cadre des soins palliatifs, mais elle relève l'absence de données de qualité appuyant ou réfutant son utilisation.(2) Le fait est qu'il n'existe pas à ce jour d'étude randomisée contrôlée. Certaines études observationnelles avaient déjà révélé des inquiétudes quand à son utilisation, ainsi qu'elle pouvait augmenter la mortalité. Le blog </span><span style="background-color: transparent; font-family: "trebuchet ms" , sans-serif;">REBEL EM avait fait </span><a href="https://journalfeed.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=7931ca9c71&e=f721cda332" style="background-color: transparent; color: #6dc6dd; font-family: "Trebuchet MS", sans-serif; word-wrap: break-word;" target="_blank">cet excellent post sur le registre ADHERE</a><span style="background-color: transparent; font-family: "trebuchet ms" , sans-serif;"> et les résultats </span><span style="font-family: "trebuchet ms" , sans-serif;">d'autres</span><span style="font-family: "trebuchet ms" , sans-serif;"> </span><span style="background-color: transparent; font-family: "trebuchet ms" , sans-serif;">études rétrospectives avait également révélé les dommages associés à la morphine.(3,4,5) </span><span style="font-family: "trebuchet ms" , sans-serif;">Dans ce contexte, cette </span><span style="font-family: "trebuchet ms" , sans-serif;">rigoureuse</span><span style="font-family: "trebuchet ms" , sans-serif;"> analyse de registre permet de nous fournir davantage d'arguments avec un critère "dur" de mortalité. </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><strong>OAPc = Je vais prendre un coup de nitrés,</strong> <strong>un peu de BiPAP, mais la morphine</strong> ?<br />Ce fut la question posée dans cette étude </span><span style="font-family: "trebuchet ms" , sans-serif;">rétrospective </span><span style="font-family: "trebuchet ms" , sans-serif;">du registre EAHFE comprenant plus de 6000 patients pour lesquels les données ont été collectées dans 34 services d'</span><span style="font-family: "trebuchet ms" , sans-serif;">urgences </span><span style="font-family: "trebuchet ms" , sans-serif;">en Espagne. La méthodologie a utilisé les scores de propension afin d'appareiller 275 paires de patients, l'une ayant reçu de la morphine, l'autre non. Les auteurs ont constaté que la mortalité à 30 jours était beaucoup plus élevé chez les patients ayant reçu la morphine que celle dans le groupe de ceux n'en ayant pas reçu : 20% contre 12,7%, avec un risque relatif de 1,66 ! Par ailleurs, les résultats sur les critères secondaires de la mortalité à court terme étaient également pire dans tous les domaines chez ceux ayant reçu la morphine. Bien entendu, il convient d'interpréter ces résultats avec prudence et ne pas établir trop vite un rapport de causalité directe étant donné la conception de l'étude. Cependant, ces résultats amènent à la prudence pour celles et ceux qui utilisent la morphine dans leurs protocoles. En effet, ces nouveaux résultats soulèvent à nouveau des préoccupations importantes sur la sécurité concernant l'usage de la morphine dans le traitement de l'OAPc en particulier et de la décompensation aiguë d'insuffisance cardiaque en général.(6,7)</span></div>
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<li><span style="font-family: "trebuchet ms" , sans-serif;">Pugsley MK. The diverse molecular mechanisms <span style="background-color: white;">responsible for the actions of opioids on the cardiovascular </span><span style="background-color: white;">system. Pharmacol Ther 2002;93:51-75. </span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;">Jessup M, Abraham WT, Casey DE, et al. <span style="background-color: white;">2009 focused update: ACCF/</span><span class="highlight">AHA</span><span style="background-color: white;"> </span><span class="highlight">Guidelines</span><span style="background-color: white;"> </span><span style="background-color: white;">for the</span><span style="background-color: white;"> </span><span class="highlight">Diagnosis</span><span style="background-color: white;"> </span><span style="background-color: white;">and</span><span style="background-color: white;"> </span><span class="highlight">Management</span><span style="background-color: white;"> </span><span style="background-color: white;">of</span><span style="background-color: white;"> </span><span class="highlight">Heart Failure </span><span style="background-color: white;">in Adults: a report of the American College of Cardiology Foundation/American</span><span style="background-color: white;"> </span><span class="highlight">Heart</span><span style="background-color: white;"> </span><span style="background-color: white;">Association Task Force on Practice</span><span style="background-color: white;"> </span><span class="highlight">Guidelines</span><span style="background-color: white;">: developed in collaboration with the International Society for</span><span style="background-color: white;"> </span><span class="highlight">Heart</span><span style="background-color: white;"> </span><span style="background-color: white;">and Lung Transplantation. </span><span role="menubar" style="background-color: white;"><a abstractlink="yes" alsec="jour" alterm="Circulation." aria-expanded="false" aria-haspopup="true" href="https://www-ncbi-nlm-nih-gov.gate2.inist.fr/pubmed/19324967#" role="menuitem" style="border-bottom: 0px; color: #660066;" title="Circulation.">Circulation</a></span><span style="background-color: white;"> 2009 Apr 14;119(14):1977-2016.</span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;">Peacock WF, Hollander JE, Diercks DB, et al. Morphine <span style="background-color: white;">and outcomes in acute decompensated heart failure: an </span><span style="background-color: white;">ADHERE analysis. Emerg Med J 2008;25:205-9.</span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;">Ellingsrud C, Agewall S. Morphine in the treatment <span style="background-color: white;">of acute pulmonary oedema--Why? Int J Cardiol </span><span style="background-color: white;">2016;202:870-3.</span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;">Gray A, Goodacre S, Seah M, et al. Diuretic, opiate <span style="background-color: white;">and nitrate use in severe acidotic acute cardiogenic </span><span style="background-color: white;">pulmonary oedema: analysis from the 3CPO trial. QJM </span><span style="background-color: white;">2010;103:573-81.</span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;">Iakobishvili Z, Cohen E, Garty M, et al. Use of intravenous <span style="background-color: white;">morphine for acute decompensated heart failure in patients </span><span style="background-color: white;">with and without acute coronary syndromes. Acute Card </span><span style="background-color: white;">Care 2011;13:76-80. </span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;">Sosnowski MA. Review article: lack of effect of opiates in <span style="background-color: white;">the treatment of acute cardiogenic pulmonary oedema. </span><span style="background-color: white;">Emerg Med Australas 2008;20:384-90.</span></span></li>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-14771392188441330132017-11-12T08:00:00.002-08:002017-11-12T08:06:24.153-08:00Quelques nouvelles de Washington DC<div class="separator" style="clear: both; text-align: center;">
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Trebuchet MS, sans-serif; font-size: 18.0pt; line-height: 115%;">Congrès de l'ACEP 2017, Washington DC<o:p></o:p></span></b></h1>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Cette 49<sup>ème</sup>
édition de l'ACEP Scientific Assembly a eu lieu cette année du 29 octobre au 1<sup>er</sup>
novembre au Walter E. Convention Center de la capitale américaine. A nouveau,
plus de 7000 participants urgentistes, paramedics, infirmiers ont pris
rendez-vous pour mettre à niveau leurs connaissances et échanger leurs
expériences. Que retenir de quelques-unes des 360 sessions qui ont eu lieu lors
du plus grand rassemblement dédié à la médecine d'urgence.<o:p></o:p></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Trebuchet MS, sans-serif; font-size: 14.0pt; line-height: 115%; mso-bidi-font-size: 13.0pt;">Pour les fans de l'ECG… et les autres<o:p></o:p></span></b></h2>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Le Pr Amal
Mattu (University of Maryland School of Medicine), a délivré comme chaque
année, deux sessions extraordinaires sur la nécessaire expertise de
l'urgentiste dans la lecture de l'ECG. La première rappelle qu'il ne faut pas
se fier à l'interprétation automatisée de l'ECG par l'appareil telle qu'elle
apparaît sur nos tracés. A travers de nombreux exemples et une revue de la
bibliographie<sup>1</sup>, il a rappelé la nécessaire rigueur de
l'interprétation de l'ECG aux urgences. <o:p></o:p></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Lors d'un
autre opus consacré aux "mimiques" du syndrome coronarien aigu, il a
rappelé à quel point l'hyperkaliémie pouvait être source de piège dans de
nombreuses situations aux urgences au-delà des clichés habituels des
modifications "dose-dépendantes" traditionnellement enseignées. Il a
très justement désigné l'hyperkaliémie comme la "Syphilis de l'ECG"
tant les aspects ECG peuvent être confondants mais essentiels dans la prise en
charge des patients victimes d'hyperkaliémie.<sup>2</sup> Il a rappelé à juste
titre que lorsqu'un tracé avait un aspect très atypique, en particulier en
présence d'une bradycardie, il fallait suspecter une hyperkaliémie et/ou une
intoxication médicamenteuse à effet cardiotrope et traiter par un sel de
calcium sans attendre le résultat de la kaliémie.<o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSEcUJ4WFzt9nynFJ6Va6knKOVnatWQzUiQw5kGUPSLP7Rx7Exukz8wvkiVAGk-aMEKgKnCiyXLW3jp8FurEkzg5JZBA3gtWcSoPbH_VJpSd-oF_EfCpOgvigMuhZxHWnq2aIU6Gx9u5O1/s1600/syphilis-2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: Trebuchet MS, sans-serif;"><img border="0" data-original-height="456" data-original-width="760" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSEcUJ4WFzt9nynFJ6Va6knKOVnatWQzUiQw5kGUPSLP7Rx7Exukz8wvkiVAGk-aMEKgKnCiyXLW3jp8FurEkzg5JZBA3gtWcSoPbH_VJpSd-oF_EfCpOgvigMuhZxHWnq2aIU6Gx9u5O1/s400/syphilis-2.jpg" width="400" /></span></a></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Trebuchet MS, sans-serif; font-size: 14.0pt; line-height: 115%; mso-bidi-font-size: 13.0pt;">Quelques perles issues des sessions "Critical Care Emergency
Medicine"<o:p></o:p></span></b></h2>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Le Pr
Michael Winters (University of Maryland) a rappelé que lorsqu'on réglait les
paramètres d'une ventilation mécanique chez le patient obèse il fallait
calculer les volumes en fonction du poids idéal et non du poids réel.<sup>3</sup><o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBSJoJfW3v2pf-p5us3Gc94gOciFJ7YCadjFk6ZczA-4KHMJRiAuuN-D2Qeb2DM8cAoZ0T-9YTTnsZHZgR_nEDsZFapzgcLcWiXpJonECufTcKk0__T_tI_sTAY9o67-mnhJFM7PzKhGho/s1600/Obese.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: Trebuchet MS, sans-serif;"><img border="0" data-original-height="369" data-original-width="581" height="254" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiBSJoJfW3v2pf-p5us3Gc94gOciFJ7YCadjFk6ZczA-4KHMJRiAuuN-D2Qeb2DM8cAoZ0T-9YTTnsZHZgR_nEDsZFapzgcLcWiXpJonECufTcKk0__T_tI_sTAY9o67-mnhJFM7PzKhGho/s400/Obese.png" width="400" /></span></a></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Le Dr Sean
Kivlehan (Brigham and Women's Hospital, Boston), lors d'une session consacrée
aux urgences vitales, nous rappelle que la voie intra-osseuse est utile voire
prioritaire dans certaines conditions et que son usage doit être élargi.<sup>4,5<o:p></o:p></sup></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzoLkdTRK10TOcmC41Y-TTInMuM82TjDxk73_LS4ABgmz66huJbsYRQOrKNS1zD5hE5g4iALfBAAPi90Hwn6u4H4O7uKiXRUgddFutXjSHJYegRw8xdBAC8wPCGzlf5NhHmm8u-F8cyzW9/s1600/IO+in+obese+patients.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: Trebuchet MS, sans-serif;"><img border="0" data-original-height="653" data-original-width="1200" height="217" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzoLkdTRK10TOcmC41Y-TTInMuM82TjDxk73_LS4ABgmz66huJbsYRQOrKNS1zD5hE5g4iALfBAAPi90Hwn6u4H4O7uKiXRUgddFutXjSHJYegRw8xdBAC8wPCGzlf5NhHmm8u-F8cyzW9/s400/IO+in+obese+patients.jpg" width="400" /></span></a></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Au cours
d'une autre session consacrée à l'urgence vitale, le Pr Michael A. Gibbs
(Carolinas Medical Center, Caroline du Nord) a abordé une problématique
passionnante sur l'intubation difficile aux urgences, attendue ou non. Cette
thématique a abordé de nouveaux aspects sur l'importance de la séquence de
pré-oxygénation avec l'oxygénation d'apnée et l'intubation en séquence
retardée, concept développé aux urgences et dont les résultats sont
encourageants.<sup>6,7,8</sup> Par ailleurs, il a rappelé la règle des
"15" utile pour la pratique de la pré-oxygénation afin de minimiser
les risques de désaturation "NO-DESAT Rules of 15" :<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-hansi-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Tête
proclive à 15° x 2 = 30° (comme dans l'intubation de l'obèse)<o:p></o:p></span></span></div>
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<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><v:shape alt="Positioning the Morbidly Obese Patient" id="_x0000_i1025" style="height: 180pt; width: 315pt;" type="#_x0000_t75">
<v:imagedata o:href="http://www.airwayelearning.com/Files/Billeder/Airway%20ELearning/Newsletters/reverse-trendelenberg-r3-FINAL-with-text.png" src="file:////Users/DocNikko1/Library/Group%20Containers/UBF8T346G9.Office/msoclip1/01/clip_image002.png">
</v:imagedata></v:shape></span><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 115%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-hansi-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Si
utilisation du masque à haute concentration : débit au maximum du manomètre
> 15 L/min<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpMiddle" style="line-height: 115%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-hansi-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Pré-oxygénation
par VNI (ou CPAP !) : PEEP réglée à 15 cmH<sub>2</sub>O<o:p></o:p></span></span></div>
<div class="MsoListParagraphCxSpLast" style="line-height: 115%; mso-list: l1 level1 lfo2; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%; mso-ascii-font-family: Calibri; mso-bidi-font-family: Calibri; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Calibri; mso-hansi-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;"> </span></span></span><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Oxygénation
per-procédure par canule nasale : débit à 15 L/min (permet l'oxygénation
d'apnée)<o:p></o:p></span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimbFf5ENtWd96hweXU4hmuGJf8ik4n4-XrvuyDIfheR5JYNALaw2BP0yLe1vN6zIEoTqCd55Ia_5NlKFyhHUQ1yOAHHbCdMcgtu-dN-Urmi5baIicfJOdYXY1pWeGOKHr-f3HYzFJfQmFB/s1600/Rule+of+15%2527s+in+Pre-Ox.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: Trebuchet MS, sans-serif;"><img border="0" data-original-height="900" data-original-width="1600" height="223" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEimbFf5ENtWd96hweXU4hmuGJf8ik4n4-XrvuyDIfheR5JYNALaw2BP0yLe1vN6zIEoTqCd55Ia_5NlKFyhHUQ1yOAHHbCdMcgtu-dN-Urmi5baIicfJOdYXY1pWeGOKHr-f3HYzFJfQmFB/s400/Rule+of+15%2527s+in+Pre-Ox.jpg" width="400" /></span></a></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: Trebuchet MS, sans-serif; font-size: 14.0pt; line-height: 115%; mso-bidi-font-size: 13.0pt;">Repenser la prise en charge thérapeutique de première ligne dans l'OAP<o:p></o:p></span></b></h2>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Le Pr Amal
Mattu encore lui, (University of Maryland) a abordé la prise en charge
thérapeutique de l'OAP cardiogénique et enfoncé le clou concernant l'abandon
des diurétiques en première ligne. En effet, les objectifs du traitement de
l'œdème pulmonaire cardiogénique sont :<o:p></o:p></span></div>
<div class="MsoListParagraphCxSpFirst" style="line-height: 115%; mso-list: l0 level1 lfo3; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%;"><span style="mso-list: Ignore;">·<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Diminuer la précharge<o:p></o:p></span></span></div>
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<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%;"><span style="mso-list: Ignore;">·<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Diminuer la post-charge<o:p></o:p></span></span></div>
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<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-size: 12.0pt; line-height: 115%;"><span style="mso-list: Ignore;">·<span style="font-size: 7pt; font-stretch: normal; font-style: normal; font-variant: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Améliorer la fonction VG<o:p></o:p></span></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Le
traitement initial doit donc être axé sur la redistribution des fluides et non
sur l'élimination des fluides. En effet, plus de 50% des patients atteints
d'œdème pulmonaire cardiogénique sont euvolémiques. Dans ce contexte, les
dérivés nitrés apportent une diminution rapide de la précharge ainsi qu'une
réduction efficace de la postcharge à des doses plus élevées. Pour lui, il faut
savoir être "agressif" avec cette thérapeutique.<sup>9</sup> </span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><br /></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">En outre, ce qui est relativement récent pour nos collègues américains, l'usage
de la VNI à deux niveaux de pression est fortement recommandé en première ligne
car il est maintenant clairement établi qu'elle permet une diminution de la
précharge et de la post-charge, contribuant ainsi à augmenter le débit
cardiaque. </span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><br /></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Par ailleurs, l'orateur s'est attaqué aux dogmes entourant la prise
en charge de l'OAP. Il a ainsi montré que l'usage de la morphine était associé
à une augmentation du nombre d'intubation, de l'admission en soins intensifs et
ainsi qu'à une augmentation de la mortalité. Elle n'a donc plus aucun rôle dans
le traitement de l'œdème pulmonaire cardiogénique.<sup>11</sup> </span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><br /></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">Même chose pour
les diurétiques, réduits à une thérapeutique de 3<sup>ème</sup> ligne selon lui
en raison de l'augmentation de la post-charge, des effets sont souvent retardés
de 30 à 120 minutes, d'une phase initiale de vasoconstriction et de l'absence
d'efficacité chez les patients insuffisants rénaux anuriques. Par ailleurs, ils
peuvent également diminuer le débit cardiaque au cours des 90 premières minutes.<sup>12</sup><o:p></o:p></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;"><br /></span></div>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 12.0pt; line-height: 115%; mso-bidi-font-size: 11.0pt;">En résumé,
les options thérapeutiques dans l'œdème pulmonaire cardiogénique inteviennent
dans cet ordre :<o:p></o:p></span></div>
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<br />
<ul>
<li><span style="font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -18pt;"><span style="mso-list: Ignore;"><span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span></span><span style="font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -18pt;">VNI/CPAP -
Traitement de première ligne</span></li>
<li><span style="font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -18pt;"><span style="mso-list: Ignore;"><span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span></span><span style="font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -18pt;">Dérivés
nitrés - Agents de première ligne</span></li>
<li><span style="font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -18pt;"><span style="mso-list: Ignore;"><span style="font-size: 7pt; font-stretch: normal; line-height: normal;"> </span></span></span><span style="font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -18pt;">Furosémide
- Agent de troisième ligne uniquement en cas de tableau congestif avec une dose
unique correspondant à la dose habituelle quotidienne du patient.</span></li>
</ul>
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<span style="font-family: Trebuchet MS, sans-serif; font-size: 18.0pt; line-height: 115%; mso-bidi-font-size: 12.0pt;"><o:p> </o:p></span></h3>
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<h3 style="line-height: 115%;">
<b><span style="font-family: Trebuchet MS, sans-serif; font-size: 18.0pt; line-height: 115%; mso-bidi-font-size: 12.0pt;">Références<o:p></o:p></span></b></h3>
<div class="MsoListParagraph" style="line-height: 115%; margin-left: 53.0pt; mso-add-space: auto; mso-list: l2 level1 lfo1; text-indent: -35.0pt;">
<br />
<ul><ul>
<li><span style="font-family: Trebuchet MS, sans-serif;">1. Hughes KE et al. Safety of Computer Interpretation of
Normal Triage Electrocardiograms. Acad Emerg Med 2017;24(1):120-24.</span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;"><br /></span></li>
<li><span lang="EN-US" style="background-color: white; font-family: "Trebuchet MS", sans-serif; line-height: 115%; text-indent: -35pt;">2. </span><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">Durfey N et al. Severe Hyperkalemia: Can
the Electrocardiogram Risk Stratify for Short-term adverse Events? West J Emerg
Med 2017</span><span style="background-color: white; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">;</span><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">18(5):963-71. </span><span lang="EN-US" style="background-color: white; border: 1pt none; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; padding: 0cm; text-indent: -35pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/28874951" style="background-color: white; font-family: "Trebuchet MS", sans-serif; text-indent: -35pt;" target="_blank">PMID:
28874951</a></span></li>
<li><br /></li>
<li><span style="font-family: Trebuchet MS, sans-serif;"><span style="color: #242424;">3. </span>Richard JCM. Tables donnant les valeurs d’un volume
courant (VT) de 6 ml/kg en fonction du poids idéal théorique. Réanimation 2006;1:87.</span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;"><br /></span></li>
<li><span lang="EN-US" style="background-color: white; font-family: "Trebuchet MS", sans-serif; line-height: 115%; text-indent: -35pt;">4. </span><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">Pasley J et al. Intraosseous Infusion
Rates Under High Pressure: A Cadaveric Comparison of Anatomic Sites. J Trauma
Acute Care Surg 2015. </span><span lang="EN-US" style="background-color: white; border: 1pt none; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; padding: 0cm; text-indent: -35pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/25757113" style="background-color: white; font-family: "Trebuchet MS", sans-serif; text-indent: -35pt;" target="_blank">PMID:
25757113</a></span></li>
<li><br /></li>
<li><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">5. Moayedi S et al. Safety and Efficacy of
the “Easy Internal Jugular (IJ)”: An Approach to Difficult Intravenous Access.
JEM 2016. </span><span lang="EN-US" style="background-color: white; border: 1pt none; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; padding: 0cm; text-indent: -35pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/27658558" style="background-color: white; font-family: "Trebuchet MS", sans-serif; text-indent: -35pt;" target="_blank">PMID: 27658558</a></span></li>
<li><br /></li>
<li><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">6. Driver BE et al. Flush Rate Oxygen for
Emergency Airway Preoxygenation. Ann Emerg Med 2017. </span><span lang="EN-US" style="background-color: white; border: 1pt none; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; padding: 0cm; text-indent: -35pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/27522310" style="background-color: white; font-family: "Trebuchet MS", sans-serif; text-indent: -35pt;" target="_blank">PMID:
27522310</a></span></li>
<li><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;"><br /></span></li>
<li><span lang="EN-US" style="background-color: white; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; text-indent: -35pt;">7. Caputo N et al. EmergeNcy Department use
of Apneic Oxygenation Versus Usual Care During Rapid Sequence Intubation: A
Randomized Controlled Trial (The ENDAO Trial). Acad Emerg Med 2017. </span><span lang="EN-US" style="background-color: white; border: 1pt none; color: #242424; font-family: "Trebuchet MS", sans-serif; font-size: 12pt; line-height: 115%; padding: 0cm; text-indent: -35pt;"><a href="https://www.ncbi.nlm.nih.gov/pubmed/28791755" style="background-color: white; font-family: "Trebuchet MS", sans-serif; text-indent: -35pt;" target="_blank">PMID:
28791755</a></span></li>
<li><br /></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">8. Weingart SD. Preoxygenation,
reoxygenation, and delayed sequence intubation in the emergency department. J
Emerg Med. 2011;40(6):661-7.</span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;"><br /></span></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">9. Chaudry SI et al. Patterns of Weight
Change Preceding Hospitalization for Heart Failure. Circulation 2007. <u style="background-color: white; color: #242424; font-size: 12pt; text-indent: -35pt;">PMID:
17846286</u></span></li>
<li><br /></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">10. Wilson SS et al. Use of Nitroglycerin by
Bolus Prevents Intensive Care Unit Admission in Patients with Acute
Hypertensive Heart Failure. Am J Emerg Med 2017. <u style="background-color: white; color: #242424; font-size: 12pt; text-indent: -35pt;">PMID: 27825693</u></span></li>
<li><br /></li>
<li><span style="font-family: Trebuchet MS, sans-serif;"><span style="color: #242424;"><span style="background-color: white;">11. </span></span>Peacock WF et al. Morphine and Outcomes in
Acute Decompensated Heart Failure: An ADHERE Analysis. Emerg Med J 2008. <span style="background-color: white; color: #242424; font-size: 12pt; text-indent: -35pt;">PMID:
18356349</span></span></li>
<li><br /></li>
<li><span style="font-family: Trebuchet MS, sans-serif;">12. ter Maaten JM et al. Renal tubular
resistance is the primary driver for loop diuretic resistance in acute heart
failure. Eur J Heart Fail 2017. doi:10.1002/ejhf.757</span></li>
</ul>
</ul>
</div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-17901015207517226412017-09-23T06:01:00.002-07:002017-09-23T06:15:12.106-07:00e-Triage n°12 est de sortie... Partagez sans modération ! <iframe id="sidekick" src="chrome-extension://padcapdkhelngdelppbbjmkmkfceoikg/content/infobar/infobar.html" style="-webkit-text-stroke-width: 0px; background: none !important; border: none !important; bottom: auto !important; box-shadow: none !important; box-sizing: content-box !important; color: #6c6c71; display: none; font-family: "Lucida Sans", verdana, sans-serif; font-size: 13px; font-style: normal; font-variant-caps: normal; font-variant-ligatures: normal; font-weight: normal; height: 1032px; left: auto !important; letter-spacing: normal; margin: 0px !important; max-height: none !important; max-width: none !important; min-height: 0px !important; min-width: 0px !important; orphans: 2; padding: 0px !important; position: fixed; resize: none !important; right: 0px !important; text-align: start; text-decoration-color: initial; text-decoration-style: initial; text-indent: 0px; text-transform: none; top: 0px !important; transform: translate3d(1020px, 0px, 0px) !important; transition: all 0.25s ease-in-out; user-select: none !important; vertical-align: baseline !important; white-space: normal; widows: 2; width: 1020px !important; word-spacing: 0px; z-index: 2147483647 !important;"></iframe><br />
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Newsletter e-triage n°12 – Septembre 2017</div>
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Septembre 2017</div>
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Edito</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;"><em style="box-sizing: border-box;">Les personnes animées d’une passion peuvent rendre le monde meilleur.</em></span><br />
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;"><em style="box-sizing: border-box;">Steve Jobs</em></span></div>
<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;"><br style="box-sizing: border-box;" />Rien n’est plus vrai en ce qui concerne les femmes et les hommes qui œuvrent dans le domaine de la santé, et plus particulièrement dans celui de l’urgence, là où le besoin est le plus pressant.<br style="box-sizing: border-box;" />C’est vrai pour les soignants directs ou indirects, du secouriste premier répondant à l’enseignant universitaire élaborant les protocoles scientifiques, en passant par les infirmiers et médecins du préhospitalier. <a class="more-link" href="http://news.vygon.com/fr/newsletter-e-triage-n12-septembre-2017/edito/" style="-webkit-font-smoothing: subpixel-antialiased; box-sizing: border-box; color: black; font-weight: 700; text-decoration: none; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.004) 1px 1px 1px; transition: all 160ms;">[…]</a></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;"><strong style="box-sizing: border-box; font-weight: bold;">Dr Jean-Claude Deslandes</strong><br style="box-sizing: border-box;" /><strong style="box-sizing: border-box; font-weight: bold;">Rédacteur en Chef</strong></span></div>
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Actualité de l'urgence</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Le rêve réaliste de Lars Wik au congrès Urgences 2017</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Connaissez-vous le signe de Frank ?</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Stratégie analgésique devant des fractures de côtes douloureuses</strong></span></div>
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Revue de presse</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Annales françaises de médecine d’urgence</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">- Thrombolyse intraveineuse dans les infarctus cérébraux aigus dans un centre sans unité neuro-vasculaire.<br style="box-sizing: border-box;" />- Physiopathologie et prise en charge de l’hypotension post-intubation (HPI) en séquence rapide.<br style="box-sizing: border-box;" />- Prise en charge de la dyspnée aiguë suspecte d’insuffisance cardiaque.</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Annals of Emergency Medicine</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">- Prise en charge des évènements hémorragiques chez les patients traités par du dabigatran pour une FA.<br style="box-sizing: border-box;" />- Prise en charge aux urgences des fibrillations et flutters auriculaires.<br style="box-sizing: border-box;" />- Lésion rénale aiguë après injection intra-veineuse de produit de contraste.<br style="box-sizing: border-box;" />- Volume optimal de midazolam intra-nasal chez l’enfant.<br style="box-sizing: border-box;" />- Prédiction des effets indésirables de la morphine aux urgences. Etude internationale.<br style="box-sizing: border-box;" />- Le nitrite de sodium et le thiosulfate de sodium sont actifs dans les intoxications cyanés lorsqu’ils sont injectés en intra-musculaire.<br style="box-sizing: border-box;" />- Devenir des sujets ayant ingéré de hautes concentrations de peroxide.<br style="box-sizing: border-box;" />- Lidocaïne intra-nasale dans le traitement en urgence de la migraine.<br style="box-sizing: border-box;" />- Antibiotiques en première intention versus chirurgie pour les appendicites. Etude pilote.<br style="box-sizing: border-box;" />- Faut-il réaliser une ponction lombaire chez les enfants présentant des convulsions fébriles marquées ?</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">The American Journal of Emergency Medicine</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">- Propofol ou midazolam pour la sédation procédurale ?<br style="box-sizing: border-box;" />- Fentanyl intranasal et protoxyde d’azote pour la réduction des fractures.<br style="box-sizing: border-box;" />- Intérêt de la création d’une Unité de Soins Intensifs.<br style="box-sizing: border-box;" />- Variations saisonnières de l’hypotranémie chez les personnes âgées.<br style="box-sizing: border-box;" />- Intoxication salicylée et hémodialyse<br style="box-sizing: border-box;" />- Evaluation du pronostic des traumatismes cérébraux inconscients : Intérêt de l’électro-encéphalogramme.<br style="box-sizing: border-box;" />- Intubation trachéale et position proclive.<br style="box-sizing: border-box;" />- Kétamine en première intention chez les patients agités aux urgences.<br style="box-sizing: border-box;" />- Kétamine intranasal versus morphine IV, pour la prise en charge des coliques néphrétiques.<br style="box-sizing: border-box;" />- Traumatisme thoracique sévère : échecs des drainages pleuraux décompressifs.<br style="box-sizing: border-box;" />- Intubation trachéale avec un laryngoscope Macintosh ou utilisation d’un dispositif supra-glottique type i-GEL lorsqu’une immobilisation du rachis cervical est en place.</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Journal Européen des Urgences et de Réanimation</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">- Le damage control pré-hospitalier n’est pas le scoop and run.<br style="box-sizing: border-box;" />- Le garrot hémostatique<br style="box-sizing: border-box;" />- Analgésie locorégionale en urgence chez l’adulte.<br style="box-sizing: border-box;" />- Prise en charge d’un patient ayant des fractures de côtes.<br style="box-sizing: border-box;" />- Prise en charge de la syncope.<br style="box-sizing: border-box;" />- Les complications thromboemboliques post-traumatiques.<br style="box-sizing: border-box;" />- Urgences en neuro-ophtalmologie.</span></div>
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Actualité de l'Arrêt Cardiaque</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Arrêt Cardiaque</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">- Reducing Brain Injury After Cardiac Arrest<br style="box-sizing: border-box;" />- Comment améliorer la survie !<br style="box-sizing: border-box;" />- Nouvelle compression thoracique à deux pouces chez l’enfant<br style="box-sizing: border-box;" />- Moment optimal pour injecter l’épinéphrine dans le cadre d’un arrêt cardiaque<br style="box-sizing: border-box;" />- Intubation trachéale durant les compressions thoraciques.<br style="box-sizing: border-box;" />- Intérêt d’un ballon occlusif aortique lors d’une RCP pour arrêt cardiaque non traumatique.</span></div>
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Retour sur les congrès</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">2ème Journée de Traumatologie</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">9 juin 2017, Marseille</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Secours Santé</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">23 au 25 mars 2017, Vannes</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">SFMU et SAMU de France</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">31 mai - 2 juin, Porte Maillot</span></div>
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Agenda</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Congrès – Réunions – Formations</strong></span></div>
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Formation</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Test de connaissances</strong></span></div>
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Nouveaux ouvrages</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Urgences Médicales</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">S’il est un ouvrage d’urgence connu, c’est bien « l’Axel Ellrodt ». Il a demandé, pour cette 6e (!) édition, à Nicolas Peschanski d’en assurer la coordination ...</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Anesthésie Réanimation en chirurgie thoracique</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif;">Cet ouvrage, très spécialisé, concerne en premier chef les anesthésistes réanimateurs. Cependant, la richesse des informations fournies sur la physiologie...</span></div>
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Nouveauté</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">LUCAS 3</strong></span></div>
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Cas clinique</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Intubation facilitée par un smart-phone</strong></span></div>
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Témoignage</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong style="box-sizing: border-box; font-weight: bold;">Il y a un héros en chacun de nous</strong></span></div>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-3164128092469715892017-07-05T00:45:00.000-07:002017-07-05T00:46:02.508-07:00Vous l'attendiez tous, la voilà : e-Triage n°11, la Newsletter de l'Urgence et des Urgentistes<header class="header header-wrapper" style="background-color: white; box-sizing: border-box; color: #6c6c71; font-family: 'Lucida Sans', verdana, sans-serif; font-size: 13px; font-variant-ligatures: normal; margin-top: 24px; orphans: 2; widows: 2;"><div align="center" style="-webkit-font-smoothing: subpixel-antialiased; box-sizing: border-box; margin-bottom: 1em; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.00392157) 1px 1px 1px;">
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Mai 2017</div>
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<article class="article ttl-dotted etriage" style="box-sizing: border-box; padding: 0px 30px 0px 40px;"><h2 class="edito" style="-webkit-font-smoothing: subpixel-antialiased; background-color: transparent; background-image: url(https://www.blogger.com/img/title-dot.png); background-position: 0px 3px; background-repeat: no-repeat no-repeat; box-sizing: border-box; color: #009d4e; font-size: 3.333em; font-weight: 400; line-height: 38.4px; margin: 0px 0px 1em -40px; padding: 0px 0px 0px 40px; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.00392157) 1px 1px 1px;">
Edito</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><em style="box-sizing: border-box;">Ce qui fait la valeur de la science, c’est qu’elle est communicable.</em><br style="box-sizing: border-box;" /><em style="box-sizing: border-box;">Arthur Schopenhauer</em><br style="box-sizing: border-box;" /><br style="box-sizing: border-box;" />La médecine d’urgence est une spécialité « jeune » qui a su s’imposer en quelques décennies comme une entité à part entière. Elle apporte une solution scientifiquement validée et cliniquement concrète à certaines situations médicales ou traumatiques demandant une réponse rapide et pertinente. En périphérie des autres spécialités, elle s’en différencie par un temps de réflexion et d’action court. <a class="more-link" href="http://news.vygon.com/fr/newsletter-e-triage-n11-mai-2017/edito/" style="-webkit-font-smoothing: subpixel-antialiased; box-sizing: border-box; color: black; font-weight: 700; text-decoration: none; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.004) 1px 1px 1px; transition: all 160ms;">[…]</a></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Jean-Claude Deslandes</strong><br style="box-sizing: border-box;" />Rédacteur en Chef</span></div>
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Actualité de l'urgence</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Seringues électriques</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">La rubrique « actualité de l’urgence » de ce numéro est consacrée à un article paru dans « Critical Care Nurse » en août dernier et dont Bruno Garrigue est un des auteurs principaux.</span></div>
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Revue de Presse</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Anesthésie et Réanimation</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Prise en charge des traumatisés graves à la phase précoce.</span></div>
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<a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-n11-mai-2017/anesthesie-et-reanimation/" style="-webkit-font-smoothing: subpixel-antialiased; box-sizing: border-box; color: black; display: block; float: left; font-weight: 700; margin-left: -147px; position: absolute; right: 0px; text-align: center; text-decoration: none; text-rendering: optimizeLegibility; text-shadow: rgba(0, 0, 0, 0.004) 1px 1px 1px; top: 0px; transition: all 160ms; width: 147px;"><img alt="" border="0" height="51" src="http://news.vygon.com/wp-content/themes/vyg-news/img/gamme/btn-etriage-more.png" style="border: 0px; box-sizing: border-box; height: auto; max-width: 100%; vertical-align: middle;" width="49" /><br style="box-sizing: border-box;" /><span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif; font-size: 16px;">Lire la suite</span></a></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Annals of Emergency Medicine</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Préoxygénation aux urgences.<br style="box-sizing: border-box;" />- Etomidate versus kétamine pour l’intubation à séquence rapide.<br style="box-sizing: border-box;" />- Lopéramide, un médicament qui n’est pas innocent.<br style="box-sizing: border-box;" />- Ingestion accidentelle par un enfant du liquide d’une cigarette électronique.<br style="box-sizing: border-box;" />- Effets combinés de l’hypoxie et de l’hypotension sur la mortalité des traumatismes crâniens graves.<br style="box-sizing: border-box;" />-Epilepsie primaire aux urgences : intérêt d’un encéphalogramme (EEG) précoce.<br style="box-sizing: border-box;" />- Pour les sujets âgés, une visite aux urgences, sans hospitalisation en suivant, est souvent associée à une régression fonctionnelle.</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">The American Journal of Emergency Medicine</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Score prédictif d’une insuffisance cardiaque congestive : le score de Brest<br style="box-sizing: border-box;" />- Intérêt d’un entraînement fréquent à la pose d’un garrot tourniquet.<br style="box-sizing: border-box;" />- Doses cumulatives de radiations chez les sujets souffrant d’un traumatisme fermé.</span></div>
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Actualité de l'arrêt cardiaque</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Dernières publications</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">- Contrôle de la température et durée du coma chez les survivants d’un arrêt cardiaque (AC).<br style="box-sizing: border-box;" />- Intérêt d’une administration précoce d’épinéphrine dans les arrêts cardiaques préhospitaliers.<br style="box-sizing: border-box;" />- Arrêt cardiaque extra hospitalier en relation avec une hémorragie intracrânienne.<br style="box-sizing: border-box;" />- EtCO2 initial et devenir des arrêt cardiaques intra-hospitaliers.</span></div>
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Retour sur les congrès</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">NAEMSP – National Association of Emergency Physicians</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">21 - 26 janvier 2017</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">1ère Session de Formation de Médecine d’Urgence et de Catastrophe Héliportée</strong></span></div>
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Agenda</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Congrès – Réunions – Formations</strong></span></div>
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Formation</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Test de connaissances</strong></span></div>
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Nouveaux ouvrages</h2>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Guide de poche d’échographie cardiaque</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">Un échographiste cardiologue et un anesthésiste ont partagé leur expérience pour nous proposer un ouvrage de formation qui sera apprécié des spécialistes ...</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Manuel de médecine de catastrophe</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">Les services médicaux de secours français, adaptant avec bonheur dans le domaine civil la riche expérience du service de santé des armées, a été pionnier dans l’élaboration ...</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">Urgences absolues</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">Peu d’ouvrages traitent spécifiquement des urgences absolues. Ces urgences mettant en péril immédiat la victime nécessitent une prise en charge optimale ...</span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;"><strong style="box-sizing: border-box;">UR’G de garde</strong></span></div>
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<span style="box-sizing: border-box; color: #6c6c71; font-family: Lucida Sans, sans-serif;">Dans cette 4ème édition, les protocoles d’Avicenne proposent des conduites pratiques et validées à tenir face à 144 pathologies. C’est peu de dire que les principales situations...</span></div>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-17466601880740858072017-04-12T08:11:00.002-07:002017-04-25T09:21:28.920-07:00RINSE - L'hypothermie se prend une douche froide... dans l'arrêt cardiaque pré-hospitalier.<div style="text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf6VQqzJW7D_gjYH174eoPgILF6YyRD2JlNGUtECbTaDZtxVFc7GVN6fyZCsOKmw91b-JUKhH61Ygm7vsdGclpfA2ebg1mtrvqRa6eUMNniP5pHLWkst8bzno2S5VdWObC9eRkt_dn46qo/s1600/shower.with_.essay_.image1_.jpg" imageanchor="1"><img border="0" height="426" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf6VQqzJW7D_gjYH174eoPgILF6YyRD2JlNGUtECbTaDZtxVFc7GVN6fyZCsOKmw91b-JUKhH61Ygm7vsdGclpfA2ebg1mtrvqRa6eUMNniP5pHLWkst8bzno2S5VdWObC9eRkt_dn46qo/s640/shower.with_.essay_.image1_.jpg" width="640" /></a></div>
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<h4>
<span style="font-family: Trebuchet MS, sans-serif;">Hypothermie et arrêt cardiaque extra-hospitalier</span></h4>
<span style="font-family: Trebuchet MS, sans-serif;">L'hypothermie thérapeutique après un arrêt cardiaque a été presque généralisée à partir de 2002, après que deux essais randomisés [mais avec de faibles cohortes et en non-aveugle (n = 77 et n = 273)] ont montré un bénéfice significatif de l'hypothermie après un arrêt cardiaque en fibrillation ventriculaire en dehors de l'hôpital. Les unités de soins intensifs ont rapidement adopté des protocoles agressifs nécessitant une forte contrainte en ressources pour gérer les besoins liés au refroidissement à 33°C.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<h4>
<span style="font-family: Trebuchet MS, sans-serif;">TTM</span></h4>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgh0i-ln68jOzJ7luzEEjEG_9kpDZOXqO7TBPibXHZkN8wujANx2-eqzPiKW4dRnZ2sXkx92D690iGa0cpSCAI6srIcvEssXKFcL9Qo7ry5T3LYR74cUVlA-Xywe6WMlhiQQQWP-j5DmABM/s1600/TTM+vs+2002gr1_lrg.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgh0i-ln68jOzJ7luzEEjEG_9kpDZOXqO7TBPibXHZkN8wujANx2-eqzPiKW4dRnZ2sXkx92D690iGa0cpSCAI6srIcvEssXKFcL9Qo7ry5T3LYR74cUVlA-Xywe6WMlhiQQQWP-j5DmABM/s400/TTM+vs+2002gr1_lrg.jpg" width="400" /></a><span style="font-family: Trebuchet MS, sans-serif;">En 2014, un essai beaucoup plus large et randomisé "Targeted Temperature Management" (TTM) avec 950 patients contredit les deux études initiales sur hypothermie, ne montrant aucun bénéfice du refroidissement à 33°C par rapport à un maintien stricte de la température à 36°C (essentiellement en assurant l'absence d'hyperthermie). Ainsi, pour les médecins et les centres qui ont accepté ces données plus convaincantes, les soins après arrêt cardiaque pourraient être devenus beaucoup plus simples.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Cependant, les contradicteurs de cette étude qui a fait le "buzz" en 2014 ont soutenu avec une certaine justesse scientifique que l'absence de bénéfices observés dans TTM ne résultait pas de l'absence d'efficacité de l'hypothermie car les patients n'avaient pas été suffisamment refroidis dans TTM. </span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Et, voici que l'essai RINSE, publié dans Circulation en août 2016, semble aller dans le sens des résultats de TTM.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Les auteurs ont randomisé ~1200 patients en arrêt cardiaque hospitalisés en Australie, et soit soumis à une hypothermie thérapeutique initiale préhospitalière à l'aide de 2 litres de perfusion de NaCl 0,9% refroidie à 3°C, soit soumis aux soins préhospitaliers habituels. Tous les patients ont ensuite été transportés vers des centres de références où l'hypothermie thérapeutique correspondait au traitement standardisé post-arrêt cardiaque. Les températures cibles dans ces services de réanimation ont changé en cours d'essai suite à la publication de TTM, de nombreux centres passant d'une cible de 33°C à 36°C.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1310519" target="_blank"><br /></a></span>
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<strong style="border: 0px; font-size: 13.92px; margin: 0px; outline: 0px; padding: 0px;"><a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1310519" target="_blank">Niklas Nielsen <em style="border: 0px; font-size: 13.92px; margin: 0px; outline: 0px; padding: 0px;">et al,</em> for the TTM investigators. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. <em style="border: 0px; color: #455d8f; font-size: 13.92px; margin: 0px; outline: 0px; padding: 0px; text-decoration: none;">N Engl J Med</em><span style="color: #455d8f; font-size: x-small;"><span> November 17, 2013.</span></span> DOI: 10.1056/NEJMoa1310519</a></strong></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Que s'est-il passé dans RINSE ? </span></h4>
<span style="font-family: Trebuchet MS, sans-serif;">Les patients en arrêt cardiaque présentant un rythme chocable et recevant la solution de sérum salé isotonique refroidie ont présenté un RACS dans 41% des cas alors que ceux bénéficiant d'un traitement standard atteignaient le retour de la circulation spontanée dans 50% des cas (p = 0,03).</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Cependant, au décours de l'hospitalisation, des proportions équivalentes de patients ont survécu (10% contre 11% - p = 0,71).</span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">Que peut-on en tirer comme enseignement ?</span></h4>
<span style="font-family: Trebuchet MS, sans-serif;">Tout le monde s'accorde à dire que l'hyperthermie doit être empêchée après un arrêt cardiaque car elle est associée à un mauvais pronostic neurologique. On estime également que les épisodes d'hyperthermie antérieurs à l'admission hospitalière sont particulièrement néfastes (par rapport aux épisodes survenant pendant le séjour en réanimation). Ainsi, tout le monde (détracteurs et promoteurs de l'étude TTM) s'accorde à dire qu'un contrôle de la température est souhaitable quelque soit le niveau d'hypothermie choisi. Par ailleurs, aucune preuve n'est assez forte pour suggérer qu'une méthode de refroidissement (soluté refroidi, hypothermie de surface par "couverture", bains froids ou combinaison) est meilleure qu'un autre.</span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">L'essai RINSE n'apporte pas de réponse définitive. Cependant, compte tenu des contraintes représentées par la conservation et la stabilité thermique des solutés de perfusion en extra-hospitalier, plus de résultats d'essais cliniques sont nécessaires à l'établissement de recommandations concernant l'hypothermie thérapeutique pré-hospitalière.</span><br />
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<span style="font-family: Trebuchet MS, sans-serif;">L'article</span></h4>
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<span style="font-family: Trebuchet MS, sans-serif;"><span style="background-color: white; font-variant-ligatures: normal; orphans: 2; widows: 2;">Induction of Therapeutic Hypothermia During Out-of-Hospital Cardiac Arrest Using a Rapid Infusion of Cold Saline (The RINSE Trial). </span><i style="background-color: white; border: 0px; font-variant-ligatures: normal; margin: 0px; orphans: 2; outline: 0px; padding: 0px; widows: 2;">Circulation</i><span style="background-color: white; font-variant-ligatures: normal; orphans: 2; widows: 2;">. August 2016. [</span><a href="http://www.ncbi.nlm.nih.gov/pubmed/27562972" style="background-color: white; border: 0px; color: #455d8f; font-variant-ligatures: normal; margin: 0px; orphans: 2; outline: 0px; padding: 0px; text-decoration: none; widows: 2;" target="_blank">PubMed</a><span style="background-color: white; font-variant-ligatures: normal; orphans: 2; widows: 2;">]</span></span></div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-46640606265271147242017-04-12T05:15:00.001-07:002017-04-12T05:22:03.289-07:00Et si être méchant n'était qu'un problème de peau... au cinéma !<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhi8JYK-BypH5wBZxKAuy3Fu3DJTszje8QTyyuaGoOGqe_8BBoG2XHzWSc7rCNrpsX3LgI-8UyuR2J7bhRq4bRUFVnuSKCDIN1QzI2_seJ3pXstZPl0fl1j20mUgMVuMaVubRcbptYuY13B/s1600/IMG_1782.PNG" imageanchor="1" style="clear: left; display: inline !important; font-family: 'source sans pro semi bold', helvetica, arial, sans-serif; font-size: 2.28571em; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="388" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhi8JYK-BypH5wBZxKAuy3Fu3DJTszje8QTyyuaGoOGqe_8BBoG2XHzWSc7rCNrpsX3LgI-8UyuR2J7bhRq4bRUFVnuSKCDIN1QzI2_seJ3pXstZPl0fl1j20mUgMVuMaVubRcbptYuY13B/s640/IMG_1782.PNG" width="640" /></a></div>
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<span style="font-family: "georgia" , "times new roman" , serif; font-size: x-large;">Quel est le point commun entre Dark Vador et Hannibal Lecter ?</span></h2>
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<time class="article-date" style="display: block; font-size: 12px; line-height: 1.3;">12 avr. 2017</time><span class="publisher-name" style="box-sizing: border-box; color: #b0b0b0; font-family: "source sans pro" , "helvetica" , "arial" , sans-serif; font-size: 12px; line-height: 1.3;">Univadis Résumés Cliniques</span></div>
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<span style="box-sizing: border-box; color: #b0b0b0; font-size: 12px; line-height: 1.3;"><span style="box-sizing: border-box; display: block; font-family: "source sans pro semi bold" , "helvetica" , "arial" , sans-serif; font-size: 14px; line-height: 1.3; text-transform: uppercase;">RÉSUMÉ PAR</span><a class="author" href="https://www.univadis.fr/page/who-we-are#caroline-guignot" style="box-sizing: border-box; color: #b0b0b0; line-height: 1.3; text-decoration: none;">Caroline Guignot</a></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2Ot61Ots-42C3cqRFL34CekuRXy3Ew6f0kArllZmYArE4CRJ-1JJ-Ou5E_VY-fxeklSC6h9hyJwrn61aTNSVIrjlDTzy0x-fDQ0DzN6uS8giJuzmoyHgIpQf4Zag9pxOkFyuBxrBAM2u0/s1600/anigif_enhanced-32245-1399224278-6.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2Ot61Ots-42C3cqRFL34CekuRXy3Ew6f0kArllZmYArE4CRJ-1JJ-Ou5E_VY-fxeklSC6h9hyJwrn61aTNSVIrjlDTzy0x-fDQ0DzN6uS8giJuzmoyHgIpQf4Zag9pxOkFyuBxrBAM2u0/s640/anigif_enhanced-32245-1399224278-6.gif" width="432" /></a></div>
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<span style="font-size: 17.9999px;">Les atteintes dermatologiques affectent souvent les personnages de méchants dans les films américains, notamment au niveau du visage. Or, l'amalgame entre maladie de peau et morale, bien évidemment non fondé, favorise la stigmatisation des personnes qui en sont atteintes dans la 'vraie vie'. C'est la raison pour laquelle certains groupes de défense de patients, à l'image de la </span><em style="box-sizing: border-box; font-size: 17.9999px;">National Organization for Albinism and Hypopigmentation</em><span style="font-size: 17.9999px;"> </span><span style="font-size: 17.9999px;">(NOAH), se sont constitués aux Etats-Unis afin de combattre le recours à ce type d'imagerie par l'industrie hollywoodienne. Des chercheurs américains viennent de dresser un état des lieux des stéréotypes utilisés dans les grands films américains.</span></div>
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<strong style="box-sizing: border-box; font-size: 18px; width: auto;">Méthodologie</strong></div>
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Les auteurs ont sélectionné les 10 premiers méchants et les ont comparé aux 10 premiers héros déterminés à partir de la liste des 100 plus grands héros et méchants de tous les temps qui a été établie en 2003 par les 1.500 membres de l'Institut du Film Américain (AFI).</div>
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Un héros était défini comme un personnage démontrant un sens moral, du courage et une aptitude au sacrifice dans des situations extrêmes, en donnant le meilleur de soi. Un méchant était défini comme un personnage exprimant méchanceté, égoïsme et volonté de puissance, que ces caractéristiques soient ou non dévoilées.</div>
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Les 10 principaux héros de la liste étaient : Atticus Finch (<em style="box-sizing: border-box;">Du silence et des ombres</em>), Indiana Jones (<em style="box-sizing: border-box;">Les Aventuriers de l'Arche perdue</em>), James Bond (<em style="box-sizing: border-box;">James Bond 007 contre Dr. No</em>), Richard Blaine (<em style="box-sizing: border-box;">Casablanca</em>), Will Kane (<em style="box-sizing: border-box;">Le Train sifflera trois fois</em>), Clarice Starling (<em style="box-sizing: border-box;">Le Silence des agneaux</em>), Rocky Balboa (<em style="box-sizing: border-box;">Rocky</em>), Ellen Ripley (<em style="box-sizing: border-box;">Aliens le retour</em>), George Bailey (<em style="box-sizing: border-box;">La Vie est belle</em>) et T.E. Lawrence (<em style="box-sizing: border-box;">Lawrence d'Arabie</em>).</div>
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Les 10 principaux méchants étaient : Hannibal Lecter (<em style="box-sizing: border-box;">Le Silence des agneaux</em>), Norman Bate (<em style="box-sizing: border-box;">Psychose</em>), Dark Vador (<em style="box-sizing: border-box;">La Guerre des Étoiles</em>), la méchante sorcière de l'ouest (<em style="box-sizing: border-box;">Le Magicien d'Oz</em>), l'infirmière Ratched (<em style="box-sizing: border-box;">Vol au-dessus d'un nid de coucou</em>), Mr. Potter (<em style="box-sizing: border-box;">La Vie est belle</em>), Alex Forrest (<em style="box-sizing: border-box;">Liaison fatale</em>), Phyllis Dietrichson (<em style="box-sizing: border-box;">Assurance sur la mort</em>), Regan MacNeil (<em style="box-sizing: border-box;">L'Exorciste</em>), la Reine (<em style="box-sizing: border-box;">Blanche-Neige et les sept nains</em>).</div>
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Pour chacun des 20 personnages, les lésions de la peau et les atteintes dermatologiques ont été recensées : type, couleur, localisation…</div>
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<strong style="box-sizing: border-box; font-size: 18px; width: auto;">Résultats</strong></div>
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Au total, 60% des méchants retenus pour l'analyse avaient des atteintes dermatologiques, toutes localisées sur le visage ou sur le crâne. Il s'agissait d'alopécie, d'hyperpigmentation péri-orbitaire, de profondes rides, de cicatrices multiples, de verrues sur le visage et de rhinophyma.</div>
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Aucun des héros n'avait, en revanche, de signes dermatologiques de cette nature, une fois exclus les calvities modérées (Norwood-Hamilton ≤2), les cicatrices uniques et les marques temporaires (ecchymoses, blessures durant l'intrigue).</div>
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La peau des méchants avait souvent un teint grisâtre ou une couleur anormale, au contraire des héros dont la peau avait un aspect normal.</div>
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<strong style="box-sizing: border-box; font-size: 18px; width: auto;">À retenir</strong></div>
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Dans les films hollywoodiens, les personnages méchants présentent plus souvent des maladies et lésions de la peau que les héros. La présence de cicatrices, illustrant un passé ponctué de violences, est souvent largement utilisée, mais aussi suggérée par le nom même des personnages (Scarface, Scar dans le Roi Lion…). Si elles peuvent exister chez les héros (Indiana Jones, Richard Blaine), elles sont moins nombreuses, plus discrètes, et sont propres à l'acteur et non créées pour le personnage. Parallèlement, la représentation de la vieille femme ridée a souvent été utilisée pour évoquer la face du mal, au-delà même du seul cinéma américain. Enfin, outre ceux qui ont été rapportés parmi ce top 20, d'autres atteintes ont été fréquemment stigmatisées dans les films, comme l'albinisme (68 films présentant des méchants albinos entre 1960 et 2006). La sensibilisation des professionnels du cinéma sur cette stigmatisation doit être accentuée pour réduire le préjudice ressenti par les personnes qui en sont réellement atteintes.</div>
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<span style="font-family: "georgia" , "times new roman" , serif;"><a href="http://jamanetwork.com/journals/jamadermatology/fullarticle/2614259" target="_blank"><span style="background-color: #f6f6f6; font-variant-ligatures: normal;">Amthor-Croley J </span><em style="background-color: #f6f6f6; box-sizing: border-box; font-variant-ligatures: normal;">et al.</em><span style="background-color: #f6f6f6; font-variant-ligatures: normal;"> Dermatologic Features of Classic Movie Villains - The Face of Evil. </span></a></span></h4>
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<span style="font-family: "georgia" , "times new roman" , serif;"><a href="http://jamanetwork.com/journals/jamadermatology/fullarticle/2614259" target="_blank"><em style="background-color: #f6f6f6; box-sizing: border-box; font-variant-ligatures: normal;">JAMA Dermatol.</em><span style="background-color: #f6f6f6; font-variant-ligatures: normal;"> Published online April 5, 2017. doi:10.1001/jamadermatol.2016.5979</span></a></span></h4>
</header>VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-57487439298104824232017-04-04T05:47:00.001-07:002017-04-04T21:13:35.704-07:00Burn-Out de l'urgentiste<div class="separator" style="clear: both; text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBk_iCCDdYSj9uXnG96qppoo3H_mPcLeYvLV9gU34C7AyF2Tj9cokTRgESTiAG8En2Y4lsKguyxZcLq03BA_gRqVrPvcAXeTSNaujdR62WeJoLhZ9oeRe4NMaNr44WQ46RbLb9pkO0RK1e/s1600/Burn-out+jauge.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: "trebuchet ms" , sans-serif;"><img border="0" height="235" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBk_iCCDdYSj9uXnG96qppoo3H_mPcLeYvLV9gU34C7AyF2Tj9cokTRgESTiAG8En2Y4lsKguyxZcLq03BA_gRqVrPvcAXeTSNaujdR62WeJoLhZ9oeRe4NMaNr44WQ46RbLb9pkO0RK1e/s400/Burn-out+jauge.jpg" width="400" /></span></a></div>
<h2>
<span style="font-family: Trebuchet MS, sans-serif;">Burn-Out de l'urgentiste</span></h2>
<h3>
<span style="font-family: Trebuchet MS, sans-serif; font-weight: normal;">Suite aux nombreuses réactions suscitées par mon post d'hier, je vous livre </span></h3>
<h3>
<a href="https://www.blogger.com/blogger.g?blogID=317032633037212420" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><a href="https://www.blogger.com/blogger.g?blogID=317032633037212420" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><span style="font-family: Trebuchet MS, sans-serif; font-weight: normal;">mes réflexions écrites suite à l'invitation de SAMU et Urgences de France </span></h3>
<h3>
<span style="font-family: Trebuchet MS, sans-serif; font-weight: normal;">pour les 3èmes assises de l'urgences en septembre 2014.</span></h3>
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<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
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<!--StartFragment-->
<br />
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Comme nombre d'entre-vous, j'ai connu l'évolution
de mon temps de travail en même temps que l'évolution de notre pratique. J'ai
connu les "gardes" de Week-end où pendant 48 à 64 heures, nous
restions postés aux urgences et/ou en SMUR. Pire, encore non-thésé, j'ai
parfois enchainé des périodes de 72 heures au sein d'un SAMU/SMUR pour laisser
partir des collègues en vacances au mois d'août. Heureusement, ce temps est
révolu et il n'est plus concevable de redevenir les "galériens" de la
médecine hospitalière de premiers recours.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">En juillet 2011, en l'espace de 10 jours, je perds
2 collègues et amis, tous deux décédés de mort violente. L'un expérimenté, avec
qui j'ai travaillé 8 ans au sein d'un CHG, se noie accidentellement. L'autre,
l'un de nos plus brillants éléments parmi les DESC, qui devait être thésé au
mois d'octobre 2011 et rejoindre notre équipe, se suicide au retour d'une
intervention SMUR mal vécue, ce malgré un débriefing de mes collègues de garde au
SAMU ce jour là. Nous avons tous été bouleversés.<o:p></o:p></span></div>
<!--EndFragment--></div>
<div>
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6mvaCBukoOc1xmMDVsBsxOyUy9cYZHtwoLKs-U39zshLu-MD7KX72PSWFY3oNxUkCRZ4LR-HobXtll8_H81aAWVs9q85fS0YU5kV94HJITREBH_Xj98c7RPF3TmYcBF6PRnKxsig8hSyl/s1600/allumage-potentiel-croissance.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: Trebuchet MS, sans-serif;"><img border="0" height="265" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6mvaCBukoOc1xmMDVsBsxOyUy9cYZHtwoLKs-U39zshLu-MD7KX72PSWFY3oNxUkCRZ4LR-HobXtll8_H81aAWVs9q85fS0YU5kV94HJITREBH_Xj98c7RPF3TmYcBF6PRnKxsig8hSyl/s400/allumage-potentiel-croissance.jpg" width="400" /></span></a></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Je ne pouvais en rester là et je me suis posé cette
question : ont-ils été victimes du burn-out de l'urgentiste ? Voilà ce à quoi
j'ai voulu réfléchir pour répondre à mes propres interrogations. <o:p></o:p></span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="page number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote reference"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="endnote text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="table of authorities"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="macro"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="toa heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Bullet 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Number 5"/>
<w:LsdException Locked="false" Priority="10" QFormat="true" Name="Title"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Closing"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Signature"/>
<w:LsdException Locked="false" Priority="0" SemiHidden="true"
UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
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<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">En effet, nous sommes tous victimes d'une sensation
de surmenage professionnel, à des degrés divers, dans notre pratique très
exposée. Mais comment se préserver de cette descente vers l'enfer que
représente le <i style="mso-bidi-font-style: normal;">burn-out</i> et comment apprendre
à gérer les périodes difficiles inhérentes à notre métier ?<o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Voici quelques éléments de réflexion que j'ai déjà
pu partager avec vous sur la liste de diffusion de SUdF. Ils sont le fruit de mes
rencontres avec nos collègues américains que je côtoie régulièrement depuis
2008.<o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><img src="webkit-fake-url://ea01951d-4433-4afd-a2c8-eff267f4e383/image.tiff" /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><img src="webkit-fake-url://8a5cf576-8db9-4b08-837e-2dae6a7eb85e/image.tiff" /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
</div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">J'ai eu le privilège d'être reçu lors du Congrès de
l'<i style="mso-bidi-font-style: normal;">ACEP</i> 2011 (American College of
Emergency Physicians) chez le <i style="mso-bidi-font-style: normal;">Dr Larry
Bedard</i> à San Francisco. Cet ancien président de <i style="mso-bidi-font-style: normal;">l'ACEP</i> de 1997 à 1998, <span style="mso-spacerun: yes;"> </span>jeune
retraité de 69 ans, avait invité nombre de ses amis urgentistes des premières
heures. Surpris du nombre de sexa- et septuagénaires dans l'assemblée, j'ai
évoqué avec certains leur carrière. En effet, j'étais pour le moins surpris de
leur très bonne forme physique et morale apparente... certains exerçaient
encore et avaient plus de 70 ans ! J'ai interpelé le plus connu d'entre-eux, le
<i style="mso-bidi-font-style: normal;">Dr Peter Rosen, </i>79 ans, Professeur de
Médecine d'Urgence à l'Université de Californie San Diego et qui exerce encore
! Considéré à juste titre comme l'un des pères de la Médecine d'Urgence aux USA,
il a écrit un article en août 1979 intitulé "The Biology of Emergency
Medicine" qui représente pour nombre de nos collègues américains le
fondement de notre spécialité.</span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri";">L</span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">es réponses de Peter Rosen à mes questions ont été
comme la confirmation de ce que je pense. Voici <span style="color: red;">ses
propos </span>relatés le plus précisément possible et qui sont, à mon sens, autant
de pistes "anti-bur-nout" :<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: Trebuchet MS, sans-serif;"></span><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<div style="text-align: right;">
</div>
<span style="font-family: Trebuchet MS, sans-serif;"><b style="mso-bidi-font-weight: normal;"><span style="color: red; font-family: "calibri"; mso-bidi-font-family: Arial;">"La médecine d'urgence est un choix</span></b><span style="color: red; font-family: "calibri"; mso-bidi-font-family: Arial;"> et non une
voie de recours lorsqu'on a échoué à telle ou telle spécialité."</span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;"> <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><i style="mso-bidi-font-style: normal;"><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Cette affirmation me conforte dans mon engagement
de médecin urgentiste mais, d'après lui, elle a un prix </span></i><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">: <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="color: red; font-family: "calibri"; mso-bidi-font-family: Arial;">"Il
ne faut s'engager dans cette voie que lorsqu'on pense pouvoir y faire
l'ensemble de sa carrière, donc accepter d'avoir une vie décalée avec une
activité de nuit et de WE. Bref, il faut comprendre <b style="mso-bidi-font-weight: normal;">qu'on ne vivra pas comme tout le monde</b>, ce qui est passionnant mais
peut être dérangeant, voire décourageant." "Pour cela, <b style="mso-bidi-font-weight: normal;">il faut être reconnu de ses pairs</b>, des
autres spécialités, des organismes et tutelles, et surtout du gouvernement."</span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;"> <o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Notons que l'ACEP dispose d'un groupe de 51
lobbyistes (médecins urgentistes) qui s'activent auprès du Congrès à
temps-plein à Washington DC !!!<o:p></o:p></span></i></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;"><span style="mso-spacerun: yes;"> </span><span style="color: red;">"Il faut <b style="mso-bidi-font-weight: normal;">préserver sa vie de famille et ses amis</b>,
donc se battre pour que cela soit possible au sein du service et de l'hôpital
dans lequel on travaille. Sinon, il faut en changer."</span> <i style="mso-bidi-font-style: normal;">(si tant est que ce soit possible).<o:p></o:p></i></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="color: red; font-family: "calibri"; mso-bidi-font-family: Arial;">"<b style="mso-bidi-font-weight: normal;"> Acquérir de l'expérience et des
compétences </b>lors de sa formation spécialisée pendant ses années de <i style="mso-bidi-font-style: normal;">Resident</i> </span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">(internes de spécialité aux USA),<span style="color: red;"> puis les développer par une activité clinique soutenue
pendant les premières années de pratique senior (Attending)". <o:p></o:p></span></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Pour Peter
Rosen, et je partage son analyse, <span style="color: red;">"on acquiert
plus d'expérience lors d'une garde de WE ou de nuit que pendant une semaine de
cours académiques."<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 18.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 14.2pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="color: red; font-family: "calibri"; mso-bidi-font-family: Arial;">"A
l'approche de la quarantaine, il faut <b style="mso-bidi-font-weight: normal;">développer
une ou plusieurs compétences particulières</b> : l'enseignement, le
management, certaines pathologies ou un autre domaine en rapport avec la
médecine d'urgence."</span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;"> <i style="mso-bidi-font-style: normal;">En d'autres termes, ce qui est
important pour la suite de sa carrière, c'est de se trouver une
"niche" qui nous passionne et de développer ses compétences et connaissances
dans ce domaine... devenir un expert afin de les diffuser auprès des autres urgentistes,
les plus jeunes comme les autres.<o:p></o:p></i></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 14.2pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; margin-left: 14.2pt; margin-right: 0cm; margin-top: 0cm; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Après le développement de cet argumentaire,
il m'a précisé que si l'on ne se projetait pas dans sa carrière d'urgentiste, <span style="mso-spacerun: yes;"> </span><span style="color: red;">"le risque était
de décrocher, de faire un <span class="il"><i style="mso-bidi-font-style: normal;">burn</i></span><i style="mso-bidi-font-style: normal;">-<span class="il">out,</span></i> et au final</span>
<span style="color: red;">de perdre des médecins compétents et expérimentés, y
compris parmi les meilleurs cliniciens/enseignants d'entre-nous."</span></span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Pour éviter cela, il m'a
décrit certaines des recettes que l'<i style="mso-bidi-font-style: normal;">ACEP</i>
a développées depuis les années 70 (p</span><span style="font-family: "calibri";">our
rappel, aux USA, la sous-spécialité date de 1974 avec une reconnaissance fédérale
en 1979, un Board (collège d'enseignant) datant de 1984, et la spécialité
pleine et entière reconnue en 1989) </span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">:</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 36.0pt; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Une activité clinique adaptée au type d'hôpital et au type de service
d'urgence : </span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 72.0pt; mso-list: l2 level2 lfo1; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "courier new"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">pas de gardes (shifts) de 24 h sauf dans les centres primaires (nombre
moyen de passages entre minuit et 6 h = 3/h maximum)</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 72.0pt; mso-list: l2 level2 lfo1; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "courier new"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">gardes de 12 h possible dans les secondary centers, équivalent CHG (sauf
si trauma center et > 50 000 passages) </span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 72.0pt; mso-list: l2 level2 lfo1; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "courier new"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Partout ailleurs, CHU et gros CHG, organisation en 3 shifts sur 24 h.</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 72.0pt; mso-list: l2 level2 lfo1; tab-stops: list 72.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "courier new"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">gardes de nuits (night-shift) non-obligatoires pour les > 50 ans dans
les tertiary centers (équivalent CHU)</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 36.0pt; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Pas plus de 4 shifts de 9 heures chacun par semaine pour les > 50
ans.</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 36.0pt; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Encouragement, formations, bourses destinées à promouvoir certaines
"sur-spécialités" en médecine d'urgence.</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 36.0pt; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Accompagnement juridique, de santé du travail, programmes de fitness, de
gestion de l'alimentation et du sommeil, etc...</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-left: 36.0pt; mso-list: l2 level1 lfo1; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;">
<!--[if !supportLists]--><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Calibri; mso-fareast-font-family: Calibri;"><span style="mso-list: Ignore;">-<span style="font-size: 7pt; font-style: normal; font-variant-caps: normal; font-weight: normal; line-height: normal;">
</span></span></span><!--[endif]--><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Détachement possible tout les 7 ans, pendant une durée d'un an maximum,
encouragé et financé par l'état fédéral lorsqu'il s'agît d'un programme
humanitaire (y compris à l'étranger) ou à vocation sociale.</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 6.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Je ne peux hélas pas me souvenir de toute
cette conversation qui m'a profondément marquée. Mais ce qui est certain, c'est
que nos collègues américains semblent avoir pris très sérieusement ces
problèmes de carrière d'urgentistes et de risque de <i style="mso-bidi-font-style: normal;">burn-out</i> en considération. Le résultat est manifestement très
encourageant et ils m'ont semblé aborder leur vie professionnelle sereinement.</span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Une autre expérience m'a également
beaucoup apporté dans cette réflexion sur notre métier.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Lors d'une mission humanitaire en 2000,
j'ai eu le privilège de travailler 6 mois avec les Drs William ("Rick")
et Jean <span class="il">ABBOTT</span>, un couple d'urgentistes américains. Depuis,
nous sommes restés amis et très régulièrement en contact. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
</div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">J'ai eu l'occasion de les retrouver à
Denver lors du congrès de l'<i style="mso-bidi-font-style: normal;">ACEP</i> 2012.
Rick a aujourd'hui 65 ans et il est urgentiste depuis 1973. Le décompte est
simple, 41 ans de pratique de la médecine d'urgences (dont 4 à temps-partiel),
dans plusieurs types de structures : 25 ans en hôpital privé de taille moyenne,
régulièrement en sites isolés (réserve Navajo, Tasmanie, haute-montagne), 10
ans en clinique privée et enfin, depuis 6 ans, en CHU avec une activité
d'enseignement à 20%. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri";">Surpris de le retrouver toujours aussi
fringuant, j'ai longuement évoqué leur carrière à tous les 2 car j'étais étonné
de leur très bonne forme physique et morale. Lorsque j'ai abordé les conditions
de pratique,</span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">
les réponses de Rick ont été comme une nouvelle confirmation des propos de
Peter Rosen :</span><span style="font-family: "calibri";"> le risque de travailler
à flux tendu est de décrocher, de faire un "burn-out" et de perdre
des médecins expérimentés à la fois en clinique et aussi sur les plannings. Des
témoignages récents le prouve hélas dans l'hexagone.</span><span style="font-family: "calibri"; mso-bidi-font-family: Arial;"> </span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">J'ai suivi mon ami Rick lors
de 2 shifts de 9 h de pendant mon séjour à Denver, l'un de jour (7h-16h),
l'autre de nuit (23h-7h).</span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Premier constat pour moi
qui travaille en 10-14-24h : ce rythme m'a semblé beaucoup plus physiologique,
même en prenant la garde à 23 h. Je n'ai pas ressenti les "longueurs"
d'une garde de 24 h, voire celles d'une nuit de 14 h. Surtout, j'ai trouvé que
ma concentration, même à 4 h du matin, était intacte. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Il m'a précisé également
que ses temps de formation, de cours de "M & M's" (Morbidity
& Mortality) et de congrès n'étaient pas en sus mais inclus dans ces 36
heures hebdomadaires lissées sur 3 mois (sauf dérogations exceptionnelles
rarement accordées). <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Le reste de sa semaine, activité
supplémentaire, était plutôt consacrée à sa récente activité académique
(universitaire) et à sa sur-spécialité de "Wilderness Medicine".
Ainsi, à Aurora où il officie, ils sont 37 ETP pour 55000 passages annuels et
un trauma center de niveau 2. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Ceci explique peut-être
cela, mais pas seulement. Force est de constater que personne, à l'hôpital
d'Aurora (qui est un des hôpitaux universitaires de Denver), ni l'administration,
ni les praticiens des autres spécialités, ne remet en cause ce nombre d'ETP aux
urgences, le plus élevé de l'établissement.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Je ne peux pas
énumérer tous les éléments qui m'ont semblé permettre à de nombreux collègues
américains d'arriver à une fin de carrière médicale "normale" vers 65
ans, et parfois après 70 ans (pas de limites d'âge aux USA). Mais l'expérience
de mon ami Rick m'a marquée</span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Lorsque, à
son tour, il est venu me rendre visite au CHU de Rouen l'année dernière, il a
pu se faire une idée de notre pratique et son résultat a été sans appel.</span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Pour lui, nous
sommes "malades" de travailler autant, même si le nombre de jour de congés
lui a semblé important comparativement à ses 4 à 6 semaines annuelles. Nous
souffrons d'un grave problème démographique, d'un réel manque de reconnaissance
de notre spécialité et de ses spécificités, en particulier sur le travail posté
et de WE ! En effet, savoir que nous pouvions faire des shifts de 24 h dans une
structure hospitalo-universitaire qui accueille 100 000 passages annuels pour
les urgences adultes, avec une moyenne hebdomadaire de travail à 55 h, l'a
rendu dubitatif sur notre avenir et notre capacité à éviter les <i style="mso-bidi-font-style: normal;">burn-out</i>. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif; mso-bidi-font-family: Arial;">Ces
expériences et les éléments de réponses qu'elles ont pu m'apporter ne sont peut
être que le reflet d'une vision partielle, voire partiale ou trop
"pro-américaine". Ce qui est certain, c'est que le constat m'a semblé
très encourageant pour aborder la question de la carrière d'urgentiste. D'ailleurs,
lors du congrès de l'ACEP, des sessions sont consacrées chaque année au <i style="mso-bidi-font-style: normal;">burn-out</i>, au fitness, à l'alimentation,
à la gestion du sommeil avant, pendant et après les gardes… A chaque fois, les
salles sont remplies, des "recettes" sont proposées mais surtout,
elles sont soutenues et promues par des commissions officielles et
recommandations des sociétés savantes de médecine d'urgence. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 200%; margin-bottom: 12.0pt; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">J'espère que
notre spécialité atteindra ce degré de maturité avant que ne vienne l'heure de
prendre ma retraite… d'urgentiste. </span></span><span style="font-family: 'Trebuchet MS', sans-serif;">Je vous
remercie d'avoir écouté ces quelques mots. Je salue mes amis Rick et Jean <span class="il">Abbott</span> qui m'ont montré la voie et me conforte dans ma vision
de la médecine d'urgence. Merci également à nos collègues d'outre-Atlantique,
en particulier à Peter Rosen et Larry Bedard, </span><span style="font-family: 'Trebuchet MS', sans-serif;">qui ont su élever cette spécialité au rang qu'elle a atteint
aujourd'hui : la 3<sup>ème</sup> spécialité la plus prisée à la sortie des facs
de médecine américaines !</span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: "calibri"; mso-bidi-font-family: Arial;">Amitiés à toutes et
tous.</span><span style="font-family: "calibri";"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;">Nicolas PESCHANSKI</span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<span style="font-family: Trebuchet MS, sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Trebuchet MS, sans-serif;">Bibliographie<o:p></o:p></span></b></div>
<ol start="1" style="margin-top: 0cm;" type="1">
<li class="MsoNormal" style="line-height: 200%; mso-list: l1 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-family: Trebuchet MS, sans-serif; mso-ansi-language: EN-GB;">Rosen P. The biology of emergency medicine.
JACEP. 1979; 8:280–3.<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: 200%; mso-list: l1 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-family: Trebuchet MS, sans-serif; mso-ansi-language: EN-GB;">Zink B. Anyone, Anything, Anytime: A History of
Emergency Medicine. Philadelphia, PA: Mosby, Elsevier, 2006.<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: 200%; mso-list: l1 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-family: Trebuchet MS, sans-serif; mso-ansi-language: EN-GB;">Zink BJ. The Biology of Emergency Medicine: What
Have 30 Years Meant for Rosen’s Original Concepts? Academic Emerg Med
2011;18:301–304<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: 200%; mso-list: l1 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-family: Trebuchet MS, sans-serif; mso-ansi-language: EN-GB;">Institute of Medicine. Hospital-Based Emergency
Care: At the Breaking Point. Washington, DC: National Academies Press,
2006<o:p></o:p></span></li>
<li class="MsoNormal" style="line-height: 200%; mso-list: l1 level1 lfo2; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: Trebuchet MS, sans-serif;"><span lang="EN-GB" style="font-family: "calibri"; mso-ansi-language: EN-GB;">American College of Emergency Physicians.
Definition of Emergency Medicine. </span><span style="font-family: "calibri";"><a href="http://www.acep.org/content.aspx?id=29164&terms=%20definition%20of%20Emergency%20medicine." target="_blank">http://www.acep.org/content.aspx?id=29164&terms=definition%20of%20Emergency%20medicine</a>.<o:p></o:p></span></span></li>
</ol>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<span style="font-family: Trebuchet MS, sans-serif;"><span style="font-family: Trebuchet MS, sans-serif;"></span><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;"></span></div>
<div class="MsoNormal" style="line-height: 200%; text-align: justify;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: Trebuchet MS, sans-serif;">Filmographie<o:p></o:p></span></b></div>
<div class="separator" style="clear: both; text-align: center;">
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UnhideWhenUsed="true" Name="Default Paragraph Font"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="List Continue 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Message Header"/>
<w:LsdException Locked="false" Priority="11" QFormat="true" Name="Subtitle"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Salutation"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Date"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text First Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Heading"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Body Text Indent 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Block Text"/>
<w:LsdException Locked="false" Priority="0" SemiHidden="true"
UnhideWhenUsed="true" Name="Hyperlink"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="FollowedHyperlink"/>
<w:LsdException Locked="false" Priority="22" QFormat="true" Name="Strong"/>
<w:LsdException Locked="false" Priority="20" QFormat="true" Name="Emphasis"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Document Map"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Plain Text"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="E-mail Signature"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
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<li class="MsoNormal" style="line-height: 200%; text-align: left;"><span style="font-family: Trebuchet MS, sans-serif;"><span lang="EN-GB" style="font-family: "calibri"; mso-ansi-language: EN-GB;">Film documentaire de l'Emergency Medicine
Residency Association 2013 : <i style="mso-bidi-font-style: normal;">24|7|365:
The Evolution of Emergency Medicine.</i></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;"> </span><u><span lang="EN-GB" style="font-family: "calibri"; mso-ansi-language: EN-GB;"><a href="http://www.emra.org/publications/legacy-documentary/"><span lang="FR" style="mso-ansi-language: FR;">http://www.emra.org/publications/legacy-documentary/</span></a></span></u><span style="font-family: "calibri";">. Visible gratuitement en suivant ce lien : <a href="https://vimeo.com/99666716">https://vimeo.com/99666716</a><o:p></o:p></span></span></li>
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<li class="MsoNormal" style="line-height: 200%; mso-list: l0 level1 lfo3; tab-stops: list 36.0pt; text-align: justify;"><span style="font-family: Trebuchet MS, sans-serif;">Film documentaire
sorti aux USA en juin 2014 : <i style="mso-bidi-font-style: normal;">Code
Black: A look into America's busiest ER.</i> (Sortie non prevue en France.)
Bande annonce visible en suivant ce lien : <a href="http://codeblackmovie.com/">http://codeblackmovie.com/</a> et film ci-dessous.<o:p></o:p></span></li>
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<i style="text-align: justify;"><span style="font-family: Trebuchet MS, sans-serif;">24|7|365: The Evolution of Emergency Medicine Trailer</span></i></div>
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<span style="font-family: Trebuchet MS, sans-serif;">Code Black (2013)</span></div>
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<br />VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com1tag:blogger.com,1999:blog-317032633037212420.post-5979880012023779502017-04-03T05:47:00.001-07:002017-04-03T06:24:36.415-07:00 Lettre à un(e) jeune médecin urgentiste<h2>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfS2rQ7VZDQCuTEL3hgtjici4F5fUg7aaSK2xlJQ-uTZSBJkevZC7IjFJRTz_UiniqljC-OzO_G1zwaMtKT2yMI6xWWrBwPzbO00DU4AENBmDSaL2KESwKZl3ZhLO62G1yv6lO06X2pmHl/s1600/227va.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="387" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfS2rQ7VZDQCuTEL3hgtjici4F5fUg7aaSK2xlJQ-uTZSBJkevZC7IjFJRTz_UiniqljC-OzO_G1zwaMtKT2yMI6xWWrBwPzbO00DU4AENBmDSaL2KESwKZl3ZhLO62G1yv6lO06X2pmHl/s400/227va.jpg" width="400" /></a><span style="font-family: "trebuchet ms" , sans-serif;">Lettre à un(e) jeune médecin urgentiste</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;">... inspirée d'un message de Mike Cameron (Australie) à ses jeunes collègues...</span></h3>
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<span style="font-family: "trebuchet ms" , sans-serif;">Quand j'ai commencé en 1995, il existait trois stéréotypes de médecins qui pratiquaient la médecine d'urgence : des médecins en mission qui sauvent le monde, des accros à l'adrénaline et des imbéciles. En fait, au départ, on est souvent les trois en même temps.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Maintenant que j'aborde un autre pan de ma carrière, j'ai quelques conseils à partager avec les plus jeunes de mes collègues (et les autres) que j'espère vous trouverez utiles.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">1. Toutes les gardes ont une fin. Peu importe combien de temps elle a duré, de quelle intensité elle a été, ou à quelle pression vous avez été soumis, vous quitterez l'hôpital lorsque votre garde s'est achevée et vous retournerez à la vraie vie. Assurez des transmissions de qualité et laissez quelqu'un d'autre porter la charge de ce qui va suivre aux urgences, ne repartez pas avec à la maison.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizAUV0Ygli3puodnIwDmge5oBIoEz4G41zNFtzfsYPS5kWTyfGnhRCefQbzO3O191gT7PaajE3KgDeUFPM3tiKyrNhjdibEJUzgGHs2Xb3FYnsbrhtrD5-XiroHI13OVzwygTK9SyqoCnB/s1600/1366990806429142_IMG_104177_HR.jpg" imageanchor="1" style="background-color: transparent; margin-left: 1em; margin-right: 1em; text-align: center;"><span style="font-family: "trebuchet ms" , sans-serif;"><img border="0" height="296" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizAUV0Ygli3puodnIwDmge5oBIoEz4G41zNFtzfsYPS5kWTyfGnhRCefQbzO3O191gT7PaajE3KgDeUFPM3tiKyrNhjdibEJUzgGHs2Xb3FYnsbrhtrD5-XiroHI13OVzwygTK9SyqoCnB/s400/1366990806429142_IMG_104177_HR.jpg" width="400" /></span></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">2. Assurez-vous que lorsque votre quart de travail se termine, vous avez quelque chose de prévu : sport, cinéma, sieste, musée, terrasse... Peu importe ce que c'est, faites-le !</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixK-r60K1q6rfA5MGBl1iRLxVYBuhkAtlQB0Hu_a6PgnSbwOZ0hCTT9pShMkUoAx4a4SeECJy3envxCivZoWRPLGlCuRkQV4SU4V8WB9yvp8zzG1yJExEyqALNUBfOkiYXRPEApHf1jHtM/s1600/Herosquadbackground.jpg" imageanchor="1" style="font-family: -webkit-standard; letter-spacing: normal; margin-left: 1em; margin-right: 1em; orphans: auto; text-align: center; widows: auto;"><span style="font-family: "trebuchet ms" , sans-serif;"><img border="0" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixK-r60K1q6rfA5MGBl1iRLxVYBuhkAtlQB0Hu_a6PgnSbwOZ0hCTT9pShMkUoAx4a4SeECJy3envxCivZoWRPLGlCuRkQV4SU4V8WB9yvp8zzG1yJExEyqALNUBfOkiYXRPEApHf1jHtM/s400/Herosquadbackground.jpg" width="400" /></span></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">3. Rappelez-vous, le patient, c'est celui qui est malade. L'empathie est assurément une bonne chose, mais la souffrance est la leur, elle leur appartient et il faut la respecter. Aider nos patients est notre crédo et nous devons nous efforcer de soulager la souffrance chaque fois que nous le pouvons. N'essayez pas de souffrir avec eux, cela vous entrainera inexorablement vers le bas.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">4. La frustration, la déception et la colère font partie intégrante de votre job. Ce sont toutes des réponses normales à la pratique de votre métier dans un système de santé à ressources limitées essayant de faire face à une demande croissante et parfois écrasante. Sentir ces émotions signifie que vous vous souciez des malades et des conditions de leur prise en charge. L'affect est une bonne chose mais il faut apprendre à le canaliser et à l'exprimer avec calme.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">5. Lorsque vous arrêtez de vous soucier de vos patients, c'est que vous êtes en burn-out. Si vous ressentez moins la souffrance et la douleur des patients, c'est que vous devenez insensible à tout, même à vous-même. Parlez à un collègue en qui vous avez confiance car il y a presque toujours un moyen de prévenir le burn-out et de se remettre en selle.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">6. L'alcool (ou tout autre supplétif : psychostimulant, psychotrope, …) est l'un des moyens les plus rapides pour se sentir détendu après une garde, une semaine ou une journée difficile. Certes, cela vous apaisera, vous rassurera peut-être, mais surtout vous détruira, rendant votre job dépendant d'une addiction. Utilisez-le avec prudence et modération après votre boulot, voire pas du tout. Gardez le pour les périodes de repos et le temps passé en famille et avec les amis. Ne faites confiance à aucun substitutif chimique pour vous aider dans votre travail.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">7. Seuls vos collègues urgentistes peuvent comprendre votre boulot car aucun autre médecin ne fait le même job que vous. Certains peuvent imaginer, peuvent écouter, peuvent sympathiser, mais ils ne font pas ce que vous faites si bien. Ne vous attendez pas à ce qu'ils en soient capables même s'ils vous disent le contraire.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">8. Lorsque vous ressentez un échec, lorsque vous pensez avoir laissé tomber un patient, lorsque vous pensez que vous n'êtes pas bon et que vous ne le serez jamais, prenez du recul et regardez objectivement ce qui vous a mis mal à l'aise. Pensez alors à quelqu'un que vous avez aidé, quelque chose de difficile que vous avez particulièrement bien réussi, à une personne dont vous avez sauvé la vie, à ce petit mieux qui vous a fait avancer dans votre pratique, avant de vous concentrer sur vous-même et le problème auquel vous avez eu à faire face. Si vous travaillez correctement, il y a beaucoup plus de leçons à tirer d'une erreur ou d'un cas qui a mal tourné que la routine que vous maîtrisez.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">9. Prenez des pauses régulièrement. Vous allez penser mieux, travailler mieux et être plus heureux. Vous ferez moins d'erreurs. Vous serez plus efficace et plus rapide. Vous vous souviendrez des choses importantes qui doivent être faites plutôt que d'être noyé par des demandes multiples qui détournent votre attention. Personne ne sait quoi que ce soit de ce que vous ressentez au moment de prendre une pause. Laissez les sceptiques penser ce qu'ils veulent, les urgentistes intelligents vous assureront de le faire régulièrement.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">10. Zen. Lorsque des pensées indésirables dérangent votre esprit, lorsque vous vous attardez sur ce qui a mal tourné, lorsque vous craignez de ne pas y arriver, faites ceci : arrêtez tout, apprenez à reconnaître les pensées indésirables et concentrez-vous plutôt sur votre respiration. Quand ces pensées indésirables disparaissent, reprenez votre job. Cela prend moins d'une minute et vous pouvez le faire n'importe où et presque n'importe quand. Répétez cette "gymnastique" le cas échéant.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span><span style="font-family: "trebuchet ms" , sans-serif;">Vous vous êtes embarqué dans l'une des carrières les plus difficiles et les plus enrichissantes de la planète médecine. Vous avez des ressources insoupçonnées et serez projeté bien au-delà de vos capacités à réfléchir simultanément à tous les cas que vous allez prendre en charge, encore et encore. Vous ferez bien plus pour vos concitoyens sur une semaine que beaucoup d'entre eux durant leur vie entière. Vous êtes privilégié, vous possédez un pouvoir inégalé (surtout la nuit et les week-ends) et malgré tout, votre salaire est assez bon. De plus, pour les soirées entre copains, il y a beaucoup d'histoires à raconter pour rire… ou pleurer.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Vous cherchez à être parfait. Vous échouerez comme nous l'avons tous fait. Apprenez à vous connaître, améliorez tout ce que vous pouvez, rappelez-vous que nous sommes tous faillibles et qu'avec de grands pouvoirs viennent de grandes responsabilités. Pardonnez-vous régulièrement mais apprenez toujours de vos erreurs.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Demandez-vous ceci quand vous prenez votre garde : le monde de l'urgence est-il un endroit meilleur ou pire qu'un autre pour qu'il vaille le coup d'en faire partie ? Si c'est le cas, alors félicitations, c'est que vous avez la force de continuer. S'il vous semble pire, c'est que vous êtes en difficulté. Parlez-en immédiatement à quelqu'un de confiance. Il vous aidera à avoir confiance en vous, à obtenir ce que vous souhaitez, et, en vous aidant à définir votre chemin de vie professionnelle ainsi que dans votre pratique, non seulement il vous maintiendra loin de l'abîme, mais plus encore, il vous permettra d'entretenir la flamme de la passion de l'autre qui vous anime.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Dédicace toute particulière à mes amis et collègues des Urgences Adultes et du SAMU 76A du <a class="profileLink" data-hovercard-prefer-more-content-show="1" data-hovercard="/ajax/hovercard/user.php?id=1671553451" href="https://www.facebook.com/chu.rouen.7" style="color: #365899; cursor: pointer; text-decoration: none;">Chu Rouen</a> que je quitte dans quelques jours...</span></div>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-79188775923799158602017-03-27T14:25:00.000-07:002017-03-27T15:37:41.353-07:00Et si notre sens clinique était meilleur que les scores ?<div style="text-align: center;">
<span id="result_box" lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtW2G04Ko1_BYopT3EU8K6NRejGjOeUPPGtKWp1uhxfY8YyKe8gRhrxWtob7X2vvubWGQpYYm74R3OBbeMK82Z1arnwakOzHkuzFWQhK39qJBfql1X7Ky1DufY-5z_WCwGKya4vCht0-72/s1600/non-fico-credit-scores.jpg" imageanchor="1"><img border="0" height="255" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtW2G04Ko1_BYopT3EU8K6NRejGjOeUPPGtKWp1uhxfY8YyKe8gRhrxWtob7X2vvubWGQpYYm74R3OBbeMK82Z1arnwakOzHkuzFWQhK39qJBfql1X7Ky1DufY-5z_WCwGKya4vCht0-72/s400/non-fico-credit-scores.jpg" width="400" /></a></span></span></span></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"></span></span></span><br />
<div>
</div>
<h2>
<span style="font-family: "trebuchet ms" , sans-serif;">Man vs. Numbers</span></h2>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"></span></span></span><br />
<div>
</div>
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?">Les
instruments d'aide à la décision clinique sont à la mode, surtout aux urgences ! Lorsqu'en plus, ils
sont incorporés à l'arbre décisionnel électronique de votre logiciel, ils deviennent (presque) incontournables. Alors pourquoi laisser
le clinicien, faillible par définition, prendre des décisions de vie
ou de mort lorsque le "concierge numérique", incontournable et impartial,
peut assurer une évaluation objective de la situation clinique ? </span><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
">Pensez à votre prochaine garde et imaginez à quelle fréquence vous allez, consciemment ou intuitivement, utiliser ou citer un score d'aide à la décision dans votre pratique clinique.</span></span></span></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"></span></span></span><br />
<div style="text-align: justify;">
<br /></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
">
</span></span></span><br />
<div style="text-align: center;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"><span id="result_box" lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtW2G04Ko1_BYopT3EU8K6NRejGjOeUPPGtKWp1uhxfY8YyKe8gRhrxWtob7X2vvubWGQpYYm74R3OBbeMK82Z1arnwakOzHkuzFWQhK39qJBfql1X7Ky1DufY-5z_WCwGKya4vCht0-72/s1600/non-fico-credit-scores.jpg" imageanchor="1"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMPlctUujWfO4qGgvw5Ba9CCAcfh11HbiLIwGEDBLSh5ZuJA4PTf5IWNT4HiSV9dSlhQ42XtHP5Z9jEQ5NXhNiVfXHVRgHLPmk5NUpmbzDqFc4Q_Y-VfByJnh8k7j1mz713CESaIvoz-S7/s1600/Upgrade_3_to_X-1.png" imageanchor="1"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMPlctUujWfO4qGgvw5Ba9CCAcfh11HbiLIwGEDBLSh5ZuJA4PTf5IWNT4HiSV9dSlhQ42XtHP5Z9jEQ5NXhNiVfXHVRgHLPmk5NUpmbzDqFc4Q_Y-VfByJnh8k7j1mz713CESaIvoz-S7/s400/Upgrade_3_to_X-1.png" /></a></a></span></span></span></span></span></span></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"></span></span></span><br />
<div style="text-align: justify;">
<br /></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
">
</span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
">Et oui, vous allez utiliser le PERC et le score de Wells (ou le score de Genève modifié) devant la prochaine suspicion d'embolie pulmonaire, sans aucun doute les critères d'Ottawa pour votre prochain traumatisme de la cheville, ou encore, si comme moi vous l'adoptez, le Score HEART pour évaluer la douleur thoracique chez un patient à bas risque de SCA... la
liste est sans fin et vous auriez raison d'utiliser ces outils.</span></span></span></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"></span></span></span><br />
<div>
</div>
<div style="text-align: center;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"></span></span></span><br />
<div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"><span id="result_box" lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRuT0Ayh094gzJkhcv3rlYkXWLicagfD3rXN4GnL7nDXKupS2cioVq7UpJ2Y_wGr7aiUIPIX-c2HsGvpAR03yYR22JX1ga6i_VurU48YG5Ni5t7tmDZRIlp2EiAQcWusU3MIJh_ENB49nX/s1600/macgpic-1435330928-98442196932226-op.jpg" imageanchor="1"><img border="0" height="231" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiRuT0Ayh094gzJkhcv3rlYkXWLicagfD3rXN4GnL7nDXKupS2cioVq7UpJ2Y_wGr7aiUIPIX-c2HsGvpAR03yYR22JX1ga6i_VurU48YG5Ni5t7tmDZRIlp2EiAQcWusU3MIJh_ENB49nX/s400/macgpic-1435330928-98442196932226-op.jpg" width="400" /></a></span></span></span></span></span></span> </div>
</div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"></span></span></span></span></span></span><br />
<div>
</div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Clinical decision instruments are all the rage, especially when incorporated into the electronic health record – why let the fallible clinician’s electrical Jello make life-or-death decisions when the untiring, unbiased digital concierge can be similarly equipped?"></span></span></span></span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Think about your next shift, and how frequently you consciously or unconsciously use or cite a decision instrument in your practice – HEART, NEXUS, PERC, Well’s, PECARN, the list is endless.
"></span></span></span><br />
<div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
">Justement, nous passons beaucoup de temps à dériver, à valider et à comparer ces
instruments d'aide à la décision - par exemple en opposant le score HEART au sore TIMI ou au score GRACE - mais, comme
l'indique l'article qui nous intéresse, nous passons en fait très peu de temps à évaluer leur
performance par rapport au jugement et à l'intuition du clinicien.</span></span></span></div>
</div>
<br />
<br />
<div style="text-align: center;">
<span style="font-family: "trebuchet ms" , sans-serif;"></span><br />
<div>
</div>
</div>
<h3>
<span style="font-family: "trebuchet ms" , sans-serif;">L'article qui vous dévoile avec objectivité que l'homme n'est pas (encore) vaincu par la machine</span></h3>
<span lang="fr" tabindex="-1"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
"></span></span><br />
<h3 style="text-align: justify;">
<span lang="fr" tabindex="-1"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
">
</span></span></h3>
<span lang="fr" tabindex="-1"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
">
</span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
"><span style="font-family: "trebuchet ms" , sans-serif;">"Structured Clinical Decision Aids Are Seldom Compared With Subjective Physician Judgment, and are Seldom Superior"</span></span></span><br />
<span lang="fr" tabindex="-1"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
"><a href="http://www.annemergmed.com/article/S0196-0644(16)31520-7/fulltext"><span style="font-family: "trebuchet ms" , sans-serif;">http://www.annemergmed.com/article/S0196-0644(16)31520-7/fulltext</span></a></span></span></div>
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span title="We spend a great deal of time deriving, validating, and comparing decision instruments – think HEART vs. TIMI vs. GRACE – but, as this article points out, very little time actually examining their performance compared to clinician judgment.
"></span></span><br />
<div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="These authors reviewed all publications in Annals of Emergency Medicine concerned with the performance characteristics of a decision instrument.">Les
auteurs de cet article ont donc examiné toutes les publications parues dans Annals of Emergency
Medicine concernant les performances d'un score, d'une règle ou d'un outil d'aide à la décision. </span><span title="They identified 171 articles to this effect, 131 of which performed a prospective evaluation.">Ils ont pu sélectionner 171 articles, dont 131 proposaient une évaluation prospective de ces scores. </span><span title="Of these, the authors were able to find only 15 which actually bothered to compare the performance of the objective rule with unstructured physician assessment.">Parmi
eux, seuls 15 comparent la performance du score ou de la règle objective avec l'évaluation clinique intuitive et non structurée des
médecins. Une recherche bibliographique comp</span></span><span style="font-family: "trebuchet ms" , sans-serif;"><span title="With a little extra digging, these authors then identified 6 additional studies evaluating physician assessment in other journals relevant to their original 171.
">lémentaire, réalisée dans d'autres revues de médecine d'urgence, a permis ensuite d'
identifier 6 études supplémentaires évaluant l'intuition clinique des médecins (gestalt) à un score ou une règle définis par les critères de sélection des 171 études originelles.</span><span title="Then, of these 21 articles, two favored the decision instrument: a 2003 assessment of the Canadian C-Spine Rule, and a 2002 neural network for chest pain.">A partir de ces 21 articles, l'analyse effectuée a permis d'obtenir les résultats suivants :</span></span></span></div>
</div>
<ul>
</ul>
<div style="text-align: justify;">
<ul>
<li><span lang="fr" tabindex="-1"><span title="Then, of these 21 articles, two favored the decision instrument: a 2003 assessment of the Canadian C-Spine Rule, and a 2002 neural network for chest pain."><span style="font-family: "trebuchet ms" , sans-serif;">deux articles donnent l'avantage aux outils d'aide à la décision clinique : une évaluation de 2003 de la règle canadienne C-Spine Rule, et un raisonnement algorithmique de 2002 pour l'évaluation de la douleur thoracique.</span></span></span></li>
<li><span lang="fr" tabindex="-1"><span title="In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
"><span style="font-family: "trebuchet ms" , sans-serif;">dans les 19 articles restant, la comparaison était en faveur du jugement du clinicien ou a été neutre. En effet, les caractéristiques de performance étaient similaires dans les deux groupes et le gagnant dépendait d'une pondération de la sensibilité ou de la spécificité. </span></span></span></li>
</ul>
<span lang="fr" tabindex="-1"><span title="In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
"><span style="font-family: "trebuchet ms" , sans-serif;"></span></span></span><br />
<div style="text-align: center;">
<span lang="fr" tabindex="-1"><span title="In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
"><span style="font-family: "trebuchet ms" , sans-serif;"><br /></span></span></span><br />
<span lang="fr" tabindex="-1"><span title="In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
"><span style="font-family: "trebuchet ms" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjX2vOnhRCT-hLAjOO5NPsc7bqW9mP38mf5l1SLYml2PwTPR4xiT5E8dQ6CwIfavp6mPs9zFd2WN47QwTF0vajt24KddVmtBcHDwA8SvYs35iE1kc-LSOiIT1BEDPU27YXNVAEmXGaQoO-/s1600/FINGERTIP.jpg" imageanchor="1"><img border="0" height="215" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgjX2vOnhRCT-hLAjOO5NPsc7bqW9mP38mf5l1SLYml2PwTPR4xiT5E8dQ6CwIfavp6mPs9zFd2WN47QwTF0vajt24KddVmtBcHDwA8SvYs35iE1kc-LSOiIT1BEDPU27YXNVAEmXGaQoO-/s400/FINGERTIP.jpg" width="400" /></a></span></span></span></div>
<span lang="fr" tabindex="-1"><span title="In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
"><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span><br />
<div style="text-align: center;">
<br /></div>
<span lang="fr" tabindex="-1"><span title="In the remainder, the comparison either favored clinician judgment or was a “toss up” in the sense the performance characteristics were similar and the winner depended on a value-weighting of sensitivity or specificity.
"><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span><span lang="fr" tabindex="-1"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."></span></span><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."></span></span></span><br />
<div>
</div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."></span></span></span><br />
<h3>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns.">
<span style="font-family: "trebuchet ms" , sans-serif;">Alors, homme ou machine, faites vos jeux !</span></span></span></span></h3>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns.">
</span></span></span><br />
<div style="text-align: justify;">
<br /></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;">Malgré ces résultats qui laissent penser que Big Brother n'est pas encore la panacée pour la démarche diagnostique, il ne faut pas se décourager. En effet, l'évaluation et la dérivation de nouveaux scores et autres outils d'aide à la décision a quand même un bel avenir devant lui<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns.">, car oui, les préjugés conscients et inconscients des êtres humains sont des préoccupations de tous les jours aux urgences, surtout qu'ils sont sujets à variation. </span></span></span></span></span></span></span><br />
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."></span></span></span></span></span></span></span><br />
<div>
</div>
</div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns.">Par ailleurs, o</span><span title="Neither should it be construed from these data that many common decision instruments are of lesser value than our current usage places in them, only that they have not yet been tested adequately.">n ne doit pas non plus interpréter ces données comme le chant du cygne pour de nombreux scores et algorithmes de décision communément utilisés dans notre pratique clinique. Ce n'est pas qu'ils soient de moindre valeur que notre jugement clinique ou que d'autres ceux que nous utilisons actuellement, mais seulement qu'ils n'ont pas encore été testés objectivement en les comparant les uns aux autres et à l'intuition clinique moyenne d'un échantillon représentatif de cliniciens. </span></span></span></span></span></span></span></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Neither should it be construed from these data that many common decision instruments are of lesser value than our current usage places in them, only that they have not yet been tested adequately."></span></span></span></span></span></span></span><br />
<div>
</div>
</div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Neither should it be construed from these data that many common decision instruments are of lesser value than our current usage places in them, only that they have not yet been tested adequately."></span></span><span title="However, many of these simple models are simply that – and the complexity of many clinical questions will at least favor the more information-rich approach of practicing clinicians.
"><span style="font-family: "trebuchet ms" , sans-serif;">Cependant, nombre de ces modèles simples correspondent tout simplement à des situations standardisées et la complexité de nombreuses présentations cliniques favorisera, au moins pour un moment encore, l'approche plus riche en information des praticiens humains.</span></span></span></span></span></span></span></div>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="This should not discourage the derivation and evaluation of further decision instruments, as yes, the conscious and unconscious biases of human beings are valid concerns."><span style="font-family: "trebuchet ms" , sans-serif;">
</span></span></span></span><br />
<div style="text-align: justify;">
<span lang="fr" tabindex="-1"><span title="However, many of these simple models are simply that – and the complexity of many clinical questions will at least favor the more information-rich approach of practicing clinicians.
"></span></span><br />
<div>
</div>
</div>
</div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-17907639473693035752017-03-27T06:12:00.002-07:002017-03-28T03:22:17.283-07:00Hot Stuff! Et si l'hyperthermie du sepsis était bénéfique ?<div style="text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRgtIt88EtaAewka0JBvxMrChqZcbmrbg-pw5LwDsjlHLKdwiEzEFAv5ePIPH7SW5iCWYUN67Z_JB_gF0EQLbUESPkgJMNVTNqrWLUZpWM8WquRakQ69YsMmIt06zVX1b8kN5o8xDnWuhO/s1600/worlds-smallest-thermometer-dna-nanothermometer.jpg" imageanchor="1"><img border="0" height="387" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjRgtIt88EtaAewka0JBvxMrChqZcbmrbg-pw5LwDsjlHLKdwiEzEFAv5ePIPH7SW5iCWYUN67Z_JB_gF0EQLbUESPkgJMNVTNqrWLUZpWM8WquRakQ69YsMmIt06zVX1b8kN5o8xDnWuhO/s640/worlds-smallest-thermometer-dna-nanothermometer.jpg" width="640" /></a></div>
<span id="result_box" lang="fr"><span title="IS FEVER THE NORMAL TEMPERATURE OF SEPSIS?
"><br /></span></span>
<h2>
<span lang="fr"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Posted on March 25, 2017 by K
"><span lang="fr"><span title="IS FEVER THE NORMAL TEMPERATURE OF SEPSIS?
">La fièvre est-elle la température normale du sepsis ?</span></span></span><span title="imagesWe know that hypothermia in sepsis is associated with increased mortality but other than that we tend to see fever in sepsis as something bad."></span></span></span></h2>
<span lang="fr"><span title="imagesWe know that hypothermia in sepsis is associated with increased mortality but other than that we tend to see fever in sepsis as something bad."><span style="font-family: "trebuchet ms" , sans-serif;">Depuis quelques années, la littérature abondante sur le sepsis nous a convaincu que l'hypothermie est associée à une augmentation de la morbi-mortalité. Par ailleurs, nous avons tendance à
voir l'hyperthermie comme un facteur au mieux à contrôler, voire péjoratif dans la prise en charge des dans le sepsis et les choc septiques aux urgences et en réanimation ? En effet, n</span></span></span><span lang="fr"><span title="We tend to perceive sepsis patients as more sick the more the temperature is elevated."><span style="font-family: "trebuchet ms" , sans-serif;">ous avons tendance à percevoir naturellement les patients dont la température est la plus élevée comme ceux qui sont les plus gravement atteints. D'ailleurs, la tendance des protocoles de prise en charge est </span></span><span style="font-family: "trebuchet ms" , sans-serif;"><span title="We then tend to treat that hyperthermia with paracetamol, ibuprofen or external cooling.
">à traiter cette hyperthermie avec différents moyens thérapeutiques médicamenteux (paracétamol, ibuprofène,...) ou adjuvants tel le refroidissement externe.</span><span title="A large Swedish study in Crit Care Med suggests that increasing temperatures might actually be a good thing.">Or, une large étude suédoise, dont les résultats sont parus dans la revue Critical Care Médicine cette semaine, suggère que la présence de températures élevées à la prise en charge pourrait être une bonne chose. En effet, l</span><span title="Increasing body temperatures on sepsis recognition is associated with improved outcomes.
">'augmentation des températures corporelles est associée à une amélioration de la survie selon une relation linéaire.</span></span></span><br />
<div style="text-align: center;">
<span lang="fr"><span title="Increasing body temperatures on sepsis recognition is associated with improved outcomes.
"><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNhmmScr32QpxyUgCq_qU_7tUaqE2y57BR7M7oromPDK6G6kODIsezVJbKtVijlUZbc37cdvzKcltEbA02RVLq2jwj0Q_tPQtmX751tT3fyhorLjxyRBASShCJ7dm8C1LnQWI0JVGqkqy5/s1600/temp+sepsis.png" imageanchor="1"><span style="font-family: "trebuchet ms" , sans-serif;"><img border="0" height="361" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjNhmmScr32QpxyUgCq_qU_7tUaqE2y57BR7M7oromPDK6G6kODIsezVJbKtVijlUZbc37cdvzKcltEbA02RVLq2jwj0Q_tPQtmX751tT3fyhorLjxyRBASShCJ7dm8C1LnQWI0JVGqkqy5/s400/temp+sepsis.png" width="400" /></span></a></span></span></div>
<h3 style="text-align: left;">
<span lang="fr"><span title="Increasing body temperatures on sepsis recognition is associated with improved outcomes.
"><br /></span><span style="font-family: "trebuchet ms" , sans-serif;"><span title="The study
">L'étude</span><span title="A large Swedish multicenter cohort study of data compiled in a national sepsis register."></span></span></span></h3>
<div style="text-align: left;">
<span style="font-family: "trebuchet ms" , sans-serif;">Il s'agît d'une grande étude de cohorte multicentrique suédoise réalisée à partir de données compilées dans un registre national du sepsis. L'étude
a inclus 2225 patients adultes qui ont été admis dans l'une des 30 structures de réanimation suédoises avec un diagnostic de sepsis ou de choc septique entre
2007 et 2015. 56% étaient des hommes et l'âge médian était de 68 ans. La mortalité globale était de 24,7% et la durée médiane du séjour en soins intensifs était de 13 jours. L'objectif principal était d'évaluer la mortalité hospitalière à partir de des données initiales à partir du moment où le diagnostic de sepsis ou de choc septique était posé. Seuls les états septiques ayant bénéficié d'un traitement optimal défini par la mise en place du protocole de prise en charge thérapeutique dans l'heure qui suit le diagnostic.</span><br />
<span lang="fr"><span title="Results
"><span style="font-family: "trebuchet ms" , sans-serif;"></span></span></span><br /></div>
<h4 style="text-align: left;">
<span lang="fr"><span title="Results
"><span style="font-family: "trebuchet ms" , sans-serif;">Résultats</span></span></span></h4>
<div style="text-align: left;">
<span lang="fr"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Screen Shot 2017-03-25 at 14.39.16Mortality was, as expected, highest in the hypothermic (<35°C) group at 36.3%.">La mortalité était, comme prévu, la plus
élevée (36,3%) dans le groupe hypothermie (<35°C). </span><span title="But then the authors could demonstrate an almost linear reverse association between hyperthermia and mortality in the interval from 35°C up to greater than 41°C.
">Mais, alors que les auteurs s'attendaient à retrouver une association semblable dans le groupe hyperthermie (>39°C), ils ont constater un relation
presque linéaire entre l'hyperthermie et la mortalité dans l'intervalle
des patients compris entre >35° C et <41°C. Ainsi, e</span><span title="On average, mortality decreased by almost 5% for every increase of C°.">n moyenne, la mortalité a diminué de près de 5% pour chaque augmentation de +1C°. L</span><span title="As did ICU length of stay.">a durée de séjour en soins intensifs suivait la même tendance favorable. </span><span title="As for clinical signs on presentation to ED, body temperature was the strongest predictor of mortality followed by respiratory rate, heart rate, saturation and then blood pressure.
">En ce qui concerne les signes cliniques présents à la prise en charge initiale aux urgences, la
température corporelle était le plus fort prédicteur de la mortalité,
suivie par la fréquence respiratoire, le rythme cardiaque, la saturation, puis la tension artérielle.</span></span></span></div>
<div style="text-align: center;">
<span lang="fr"><span title="As for clinical signs on presentation to ED, body temperature was the strongest predictor of mortality followed by respiratory rate, heart rate, saturation and then blood pressure.
"><br /><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkozYoLmzaUuws8VcaiYRdDdUBlWj17yj6hkW5bNZCPlFcb56yCD3ptp3lYkDUaxoSx5i6G59T9asKdvBwbke4t2579Rn5KWppd2UnVxl2mulXpq5d6gS5urO2H9_mN76GHAgAuiNKOT4N/s1600/thermometer.JPG" imageanchor="1"><span style="font-family: "trebuchet ms" , sans-serif;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjkozYoLmzaUuws8VcaiYRdDdUBlWj17yj6hkW5bNZCPlFcb56yCD3ptp3lYkDUaxoSx5i6G59T9asKdvBwbke4t2579Rn5KWppd2UnVxl2mulXpq5d6gS5urO2H9_mN76GHAgAuiNKOT4N/s400/thermometer.JPG" /></span></a></span></span></div>
<div style="text-align: left;">
<span lang="fr"><span title="As for clinical signs on presentation to ED, body temperature was the strongest predictor of mortality followed by respiratory rate, heart rate, saturation and then blood pressure.
"><br /></span><span title="One would suspect patients with higher body temperatures would be detected earlier and receive better treatment as more of them would have received bundle treatment within the first hour."><span style="font-family: "trebuchet ms" , sans-serif;">On
aurait pu s'attendre à ce que les patients ayant les températures corporelles
les plus élevées soient détectés précocement et reçoivent ainsi un
traitement adapté plus rapidement. </span></span><span title="However, sub-group analysis could demonstrate that the relationship between body temperature and survival remained intact whether stratified by age, lactate level, bacterial etiology, or sepsis bundle achievement.
"><span style="font-family: "trebuchet ms" , sans-serif;">Or, l'analyse des sous-groupes a montré que la
relation linéaire entre la température corporelle et la survie est demeurée
intacte, que ce soit en fonction de l'âge, du taux de lactate, de
l'étiologie bactérienne ou de la mise en route du traitement adapté de l'infection grave.</span></span><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Take-home message
"></span></span></span></div>
<div style="text-align: left;">
<span lang="fr"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Take-home message
"><br /></span></span></span></div>
<h3 style="text-align: left;">
<span lang="fr"><span title="Take-home message
"><span style="font-family: "trebuchet ms" , sans-serif;">Que peut-on en déduire ?</span></span></span></h3>
<div style="text-align: left;">
<span lang="fr"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="There was a stronger and and inversely linear association between increasing temperatures at ED arrival and mortality as well as length of stay.">Il
y a manifestement une association forte et inversement proportionnelle entre
des températures élevées à l'arrivée aux urgences chez les patients septiques et la mortalité
(ainsi que pour la durée du séjour). Par ailleurs, u</span><span title="Better quality of care in febrile patients did not explain this association.">ne qualité des soins plus précoce et de meilleure qualité chez les patients fébriles n'a pas permis d'expliquer cette association. </span></span><span title="Of the vital signs, temperature was the best predictor of death.
"><span style="font-family: "trebuchet ms" , sans-serif;">Enfin, de tous les signes vitaux, la température était le meilleur prédictif de la mort.</span></span><span title="In an editorial in the same issue, the editors Laupland and Niven write that:
"><span style="font-family: "trebuchet ms" , sans-serif;">Ce papier doit nous sensibiliser encore plus à la prise de température dès que le diagnostic d'infection sévère est évoqué aux urgences. Bien que ces données aient été obtenues à partir d'un registre, les résultats sont largement convaincants pour changer notre point de vue. C'est un sentiment partagé par certains experts qui, dans un excellent éditorial du même numéro, écrivent : </span></span><span title="¨Although we must continue to use fever as a sentinel sign for detecting patients with serious infections, it is the absence of that sign that calls for our greatest attention among patients with severe sepsis and septic shock.¨
"><span style="font-family: "trebuchet ms" , sans-serif;">«Bien que nous devons continuer à utiliser la fièvre comme un symptôme
sentinelle pour détecter les patients atteints d'infections graves,
c'est l'absence de ce signe qui doit appeler à notre plus grande attention chez
les patients atteints de sepsis sévère et de choc septique».</span></span></span></div>
<div style="text-align: left;">
<span lang="fr"><span title="¨Although we must continue to use fever as a sentinel sign for detecting patients with serious infections, it is the absence of that sign that calls for our greatest attention among patients with severe sepsis and septic shock.¨
"><span style="font-family: "trebuchet ms";"><br /></span></span></span></div>
<div style="text-align: left;">
<span lang="fr"><span title="¨Although we must continue to use fever as a sentinel sign for detecting patients with serious infections, it is the absence of that sign that calls for our greatest attention among patients with severe sepsis and septic shock.¨
"><span style="font-family: "trebuchet ms";">Drs Laupland et Niven </span></span></span></div>
<span lang="fr"></span><br />
<div style="text-align: left;">
<br /></div>
<span lang="fr">
<span title="¨Although we must continue to use fever as a sentinel sign for detecting patients with serious infections, it is the absence of that sign that calls for our greatest attention among patients with severe sepsis and septic shock.¨
"></span></span>
<h3>
<span lang="fr"><span title="¨Although we must continue to use fever as a sentinel sign for detecting patients with serious infections, it is the absence of that sign that calls for our greatest attention among patients with severe sepsis and septic shock.¨
">
<span style="font-family: "trebuchet ms" , sans-serif;"><span lang="fr"><span title="Take-home message
">Le papier</span></span></span></span></span></h3>
<span lang="fr"><span title="¨Although we must continue to use fever as a sentinel sign for detecting patients with serious infections, it is the absence of that sign that calls for our greatest attention among patients with severe sepsis and septic shock.¨
">
</span><span style="font-family: "trebuchet ms" , sans-serif;"><span title="The paper lives here:
"><br /></span></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"><span title="The paper lives here:
"><a href="http://ovidsp.tx.ovid.com.gate2.inist.fr/sp-3.24.1b/ovidweb.cgi?T=JS&PAGE=fulltext&D=ovft&AN=00003246-201704000-00004&NEWS=N&CSC=Y&CHANNEL=PubMed" target="_blank">Crit Care Med. 2017 Apr;45(4):591-599. Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU. Sundén-Cullberg J, Rylance R, Svefors J, Norrby-Teglund A, Björk J, Inghammar M.</a></span></span></span><br />
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
<span lang="fr"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="The paper lives here:
"><br /></span></span></span></div>
<h3 style="text-align: left;">
<span lang="fr"><span title="The paper lives here:
"><span style="font-family: "trebuchet ms" , sans-serif;">L'éditorial</span></span></span></h3>
<div style="text-align: left;">
<span lang="fr"><span style="font-family: "trebuchet ms" , sans-serif;"><span title="The paper lives here:
"><a href="https://www-ncbi-nlm-nih-gov.gate2.inist.fr/pubmed/28291100" target="_blank">Crit Care Med. 2017 Apr;45(4):747-748. The Normal Abnormal Vital Sign of Sepsis. Laupland KB, Niven DJ.</a></span></span></span></div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-2811633741421923632017-03-24T09:26:00.003-07:002017-03-25T00:00:51.477-07:00Ne vous couchez plus devant la difficulté ! Intubez-les demi-assis !<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHkH2EiCrkURHR1bYX4T9VcT64CdEc3a5Y1w-eWg0JxYJvv25TE5ak7hMurmcGlFB99_rZI6STzfJJe7xbnXN05M0rMsVCTgdaiOkBxxxh0HSdeeGu07CtP7XUGiXLqny4x2ytNoW64FEz/s1600/unnamed.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="385" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjHkH2EiCrkURHR1bYX4T9VcT64CdEc3a5Y1w-eWg0JxYJvv25TE5ak7hMurmcGlFB99_rZI6STzfJJe7xbnXN05M0rMsVCTgdaiOkBxxxh0HSdeeGu07CtP7XUGiXLqny4x2ytNoW64FEz/s400/unnamed.png" width="400" /></a></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 16.0pt; line-height: 150%; mso-bidi-font-size: 11.0pt;"><span style="font-family: "trebuchet ms" , sans-serif;"><br /></span></span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 16.0pt; line-height: 150%; mso-bidi-font-size: 11.0pt;"><span style="font-family: "trebuchet ms" , sans-serif;">L'intubation demi-assise (Head-Up) améliore le taux de succès<o:p></o:p></span></span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 12.0pt; line-height: 150%; mso-bidi-font-size: 11.0pt;"><span style="font-family: "trebuchet ms" , sans-serif;">Mettez-les tête haute !<o:p></o:p></span></span></b></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Plusieurs études suggèrent que l'intubation
avec la tête du lit surélevée peut aider à faciliter la procédure, en
particulier chez l'obèse en anesthésie. Mais qu'en est-il aux urgences ?<o:p></o:p></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZD0yT7V0dlYYNNwgZX-VHbyboluGMbEI3l0LKcnEaMgeT4fpPaM6I8Yl2i_CXCrkKvqz5a_F4ATVIG8nON6PXvY0lvnBdK0qrW6pdKMme19JsgP3ssxCDlofiesyuGvgoNNgZMFlC-tG5/s1600/reverse-trendelenberg-r3-FINAL-with-text.png" imageanchor="1"><img border="0" height="365" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZD0yT7V0dlYYNNwgZX-VHbyboluGMbEI3l0LKcnEaMgeT4fpPaM6I8Yl2i_CXCrkKvqz5a_F4ATVIG8nON6PXvY0lvnBdK0qrW6pdKMme19JsgP3ssxCDlofiesyuGvgoNNgZMFlC-tG5/s640/reverse-trendelenberg-r3-FINAL-with-text.png" width="640" /></a></span></div>
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<br /></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Les responsables du programme de
formation des résidents de médecine d'urgence de plusieurs états des USA ont
réalisé une étude observationnelle prospective sur 231 intubations effectuées par
58 résidents pendant 5 ans. Ils ont enregistré le nombre de réussite à la
première tentative selon la position du malade enregistrée en 3 groupes selon l'inclinaison
de l'axe tête-cou-tronc. Les résultats ont montré les taux de succès à la
première tentative suivants :<o:p></o:p></span></div>
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<ul>
<li><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -18pt;"><span style="font-size: 7pt; line-height: normal;"> </span></span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -18pt;">position quasi-verticale (> 45°) : 86% de
réussite,</span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -18pt;"><span style="font-size: 7pt; line-height: normal;"> </span></span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -18pt;">inclinaison de 11 à 44° : 78% de réussite,</span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -18pt;"><span style="font-size: 7pt; line-height: normal;"> </span></span><span style="font-family: "trebuchet ms" , sans-serif; text-indent: -18pt;">décubitus dorsal (0 à 10°) : seulement 66% de
réussite.</span></li>
</ul>
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<div class="MsoListParagraphCxSpLast" style="line-height: 150%;">
<span style="font-family: "trebuchet ms" , sans-serif;">Donc, non seulement le taux de
réussite était plus élevé dans le groupe avec l'inclinaison la plus forte mais
les chances de succès à la première tentative ont augmenté de 11% pour chaque 5°
suplémentaires d'élévation. Par ailleurs, il faut noter que la laryngoscopie
directe a été utilisée dans 79% des cas et la vidéo-laryngoscopie dans les 21%
restants.</span></div>
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<br /></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-size: 12.0pt; line-height: 150%; mso-bidi-font-size: 11.0pt;"><span style="font-family: "trebuchet ms" , sans-serif;">Que faut-il en conclure ?<o:p></o:p></span></span></b></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Il est possible que l'élévation de
la tête du lit pour une inclinaison de l'axe tête-cou-tronc > 45° facilité
la réussite à la première tentative pour l'intubation endotrachéale aux
urgences. Cela reste néanmoins à prouver par la réalisation d'une étude
multicentrique randomisée comparant par exemple cette position
"Head-Up" au décubitus dorsal. A vos lettres d'intentions les amis !<o:p></o:p></span></div>
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<br /></div>
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<o:p><span style="font-family: "trebuchet ms" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjm9J3I6u6xXa6IZ5H2NsCzavS3F6oN3mHFIq5CCzJbn9eG657Qieks3l6onePLgqdelKbg2Xe9W8PZ0VfrCaF0mfOZpCVwpGEduRADgy5DIkN-fe20GST1KQfqG6GRRWJ1cvwQufDCRmQ0/s1600/93_A70_i105_L.gif" imageanchor="1"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjm9J3I6u6xXa6IZ5H2NsCzavS3F6oN3mHFIq5CCzJbn9eG657Qieks3l6onePLgqdelKbg2Xe9W8PZ0VfrCaF0mfOZpCVwpGEduRADgy5DIkN-fe20GST1KQfqG6GRRWJ1cvwQufDCRmQ0/s1600/93_A70_i105_L.gif" /></a></span></o:p></div>
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<o:p><br /></o:p></div>
<div class="MsoNormal" style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-size: 12.0pt; line-height: 150%; mso-bidi-font-size: 11.0pt;"><span style="font-family: "trebuchet ms" , sans-serif;">Référence<o:p></o:p></span></span></b></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">Turner JS, et al. Feasibility of
upright patient positioning and intubation success rates at two academic
emergency departments, American Journal of Emergency Medicine (2017) <a href="http://dx.doi.org/10.1016/j.ajem.2017.02.011">http://dx.doi.org/10.1016/j.ajem.2017.02.011</a></span><o:p></o:p></div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-81573385899899584072017-03-20T09:04:00.002-07:002017-03-20T09:07:37.696-07:00Un remède de cheval pour le patient agité aux urgences ?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBwaE05tExQLiMr0NZ5In4t6NaStnSb5uLXJ7O_27PjgB3nOGCGYdMQ7cI1iNdG1TGTIHMFK7oJYDC543bF-H5nu7TF32r2L1tG1Ig-7QY0YJQytC6bu2WEvnjXIYNY21bUeEiAZ9vBy8q/s1600/horse-02.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjBwaE05tExQLiMr0NZ5In4t6NaStnSb5uLXJ7O_27PjgB3nOGCGYdMQ7cI1iNdG1TGTIHMFK7oJYDC543bF-H5nu7TF32r2L1tG1Ig-7QY0YJQytC6bu2WEvnjXIYNY21bUeEiAZ9vBy8q/s640/horse-02.jpg" width="640" /></a></div>
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<span class="Titre1Car"><span style="font-size: 16pt;"><span style="font-family: "trebuchet ms" , sans-serif;">A-t-on l’idée
saugrenue d’utiliser un tranquillisant vétérinaire chez les patients agités aux
urgences ?<o:p></o:p></span></span></span></h2>
<span style="font-family: "trebuchet ms" , sans-serif;">
</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij9qvFZniCjfGDvkrEgKp4f3QARhDwqzYHZoy7fShsxn1a98MLyzCpUe5SJNKLBUfJTKRJqUoHxUq_HpP9koj0D_oOVLsEaw5BFuIPrMT3luIeL7QeSxFdq3qIfa4RYfuJ23MSb-CNKGnd/s1600/Special+K.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a> </div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span class="Titre1Car"><span style="font-size: 16pt;"><strong>
</strong></span></span>Il y a peu de publications sur l’utilisation de la kétamine en
première intention pour les patients agités. <span title="This observational study found that a median dose of 1 mg/kg IV or 3 mg/kg IM ketamine (compared to midazolam 3mg IV/2.2mg IM, lorazepam 2mg IV/2.4mg IM, haloperidol 6mg IM, or haloperidol/lorazepam 5mg/">L’American
Journal of Emergency Medicine publie ce mois-ci une étude observationnelle
prospective dont les conclusions sont intéressantes. Celle-ci a en effet révélé
qu'une dose médiane de 1 mg/kg IV ou 3 mg/kg IM de ketamine (comparée au
midazolam 3 mg IV / 2,2 mg IM, lorazépam 2 mg IV / 2,4 mg IM, halopéridol 6 mg
IM ou halopéridol / lorazépam 5 mg / </span><span title="2mg) was far more effective at reducing agitation at 5, 10, and 15 minutes.">2
mg) a été beaucoup plus efficace pour traitée l'agitation à 5, 10 et 15
minutes. </span><span title="And there was no increase in adverse effects.">Par
ailleurs, il n'y avait pas d'augmentation du nombre d’effets indésirables dans
le groupe traité par kétamine. </span><span title="Ketamine was surprisingly hemodynamically neutral, given its intrinsic sympathomimetic properties.">En
particulier, son usage n’a entrainé aucun retentissement hémodynamique
contrairement aux autres médicaments utilisés dans les autres bras de l’étude. La
kétamine semble donc être un médicament de première ligne très efficace et sûr
pour les patients agités aux urgences. </span></span><span title="PharmERToxGuy has an outstanding summary of this article.
"><span style="font-family: "trebuchet ms" , sans-serif;">Pour
les anglophiles, <a href="https://pharmertoxguy.com/2017/02/27/ketamine-as-a-first-line-treatment-for-severe-agitation-in-the-ed/" target="_blank">PharmERToxGuy</a> a remarquablement résumé les résultats de cet
article.<br style="mso-special-character: line-break;" />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij9qvFZniCjfGDvkrEgKp4f3QARhDwqzYHZoy7fShsxn1a98MLyzCpUe5SJNKLBUfJTKRJqUoHxUq_HpP9koj0D_oOVLsEaw5BFuIPrMT3luIeL7QeSxFdq3qIfa4RYfuJ23MSb-CNKGnd/s1600/Special+K.jpeg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEij9qvFZniCjfGDvkrEgKp4f3QARhDwqzYHZoy7fShsxn1a98MLyzCpUe5SJNKLBUfJTKRJqUoHxUq_HpP9koj0D_oOVLsEaw5BFuIPrMT3luIeL7QeSxFdq3qIfa4RYfuJ23MSb-CNKGnd/s400/Special+K.jpeg" width="400" /></a><span title="PharmERToxGuy has an outstanding summary of this article.
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</span><span title="Am J Emerg Med."><span style="font-family: "trebuchet ms" , sans-serif;"><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Riddell J,
Tran A, Bengiamin R, Hendey GW, Armenian P.
<b style="mso-bidi-font-weight: normal;">Ketamine as a first-line treatment for
severely agitated emergency department patients. </b></span><span lang="EN-GB" style="mso-ansi-language: EN-GB;">Am J Emerg
Med. </span><span title="2017 Feb 13. pii: S0735-6757(17)30114-6.">2017 Feb 13.
pii: S0735-6757 (17) 30114-6. </span><span title="doi: 10.1016/j.ajem.2017.02.026.">Doi: 10.1016 / j.ajem.2017.02.026. </span><span title="[Epub ahead of print]
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<a href="http://www.ncbi.nlm.nih.gov/pubmed/28237385"><span style="font-family: "trebuchet ms" , sans-serif;">http://www.ncbi.nlm.nih.gov/pubmed/28237385</span></a><br /><span style="font-family: "trebuchet ms" , sans-serif;">
</span><span style="font-family: "trebuchet ms" , sans-serif;"><span title="Ketamine as a first-line treatment for severely agitated emergency department patients.
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</span><span title="Riddell J1, Tran A2, Bengiamin R3, Hendey GW4, Armenian P3.
"><span class="Titre3Car"></span><span lang="EN-GB" style="font-size: 13pt; mso-ansi-language: EN-GB;"><span title="Author information:
">Abstract<o:p></o:p></span></span></span></span></h3>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">OBJECTIVE:<o:p></o:p></span></span></div>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">Emergency
physicians often need to control agitated patients who present a danger to
themselves and hospital personnel. Commonly used medications have limitations.
Our primary objective was to compare the time to a defined reduction in
agitation scores for ketamine versus benzodiazepines and haloperidol, alone or
in combination. Our secondary objectives were to compare rates of medication
redosing, vital sign changes, and adverse events in the different treatment
groups.<o:p></o:p></span></span></div>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">We
conducted a single-center, prospective, observational study examining agitation
levels in acutely agitated emergency department patients between the ages of 18
and 65 who required sedation medication for acute agitation. Providers measured
agitation levels on a previously validated 6-point sedation scale at 0-, 5-,
10-, and 15-min after receiving sedation. We also assessed the incidence of
adverse events, repeat or rescue medication dosing, and changes in vital signs.<o:p></o:p></span></span></div>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">RESULTS:<o:p></o:p></span></span></div>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">106
patients were enrolled and 98 met eligibility criteria. There was no
significant difference between groups in initial agitation scores. Based on
agitation scores, more patients in the ketamine group were no longer agitated
than the other medication groups at 5-, 10-, and 15-min after receiving
medication. Patients receiving ketamine had similar rates of redosing, changes
in vital signs, and adverse events to the other groups.<o:p></o:p></span></span></div>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">In highly
agitated and violent emergency department patients, significantly fewer
patients receiving ketamine as a first line sedating agent were agitated at 5-,
10-, and 15-min. Ketamine appears to be faster at controlling agitation than
standard emergency department medications.<o:p></o:p></span></span></div>
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<span lang="EN-GB" style="mso-ansi-language: EN-GB;"><span style="font-family: "trebuchet ms" , sans-serif;">Copyright ©
2017 Elsevier Inc. All rights reserved.<o:p></o:p></span></span></div>
</span><br />VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-62408822742462500422017-03-13T16:09:00.002-07:002017-03-13T16:17:35.026-07:00And the Beat Goes On ! Et si on ne massait pas assez vite ?<div class="separator" style="clear: both; text-align: center;">
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">"Stayin 'Alive" ou "La Marche de l'Empereur de StarWars"... Vous connaissez ?</span></span></h3>
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"></span></span><br />
<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;"><br />L'objectif "cible" du nombre de compressions thoraciques pour la RCP dans l'arrêt cardiaque est de 100 -120 battements par minute. Tous ces "tubes" ont un tempo régulier compris dans cet intervalle. A défaut de métronome, on peut s'aider de l'un de ces morceaux durant la RCP. D'ailleurs l'AHA en a fait le symbole de sa campagne grand public de sensibilisation de la population à la réalisation du massage cardiaque externe.</span></span></div>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms";"><br /></span></span></div>
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/n5hP4DIBCEE/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/n5hP4DIBCEE?feature=player_embedded" width="320"></iframe></div>
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<span style="font-family: "verdana" , sans-serif;">Régalez-vous avec ce tempo définitivement disco !</span></div>
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<h3 style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">"And The Beat Goes On!"</span></span></span></h3>
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<span lang="fr" tabindex="-1"><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms";"><br /></span></span></span></div>
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<span lang="fr" tabindex="-1"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhqf0Q-nSBh8wXD33Eiqc-j1ESi7sh2QTjRsFNmD2sGslC5WulaYE1venJcg-L12n0Elr9YGo9bREQZsiNNiy0XHkzYODVvTH-RzTP7kfo35UvAFqmc_yrUj4Ax3FJc003E6VVVxa5sLZgE/s1600/the-beat-goes-on.png" /></span></div>
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<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"></span><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Dans
une étude récente portant sur la prise en charge de l'arrêt cardiaque intra-hospitalier, on a étudié le taux de RACS selon 3 groupes de mesures de la fréquence des compressions thoraciques. Cela donne :</span></span></div>
<ul>
<li><div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Groupe 100-120/min : 29% de RACS</span></span></div>
</li>
<li><div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Groupe
121-140/min : 64% de RACS</span></span></div>
</li>
<li><div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Groupe > 140 compressions/min : RACS 49%</span></span></div>
</li>
</ul>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Bref, le taux de RACS dans le groupe </span></span><span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">121-140 semblait être le meilleur ! </span></span></div>
<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Et... même > 140/min on reste largement meilleur que ce qui est recommandé.</span></span></div>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Que faut-il en penser ?</span></span></h3>
<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Peut-être qu'une fréquence de compression plus rapides que les 100-120 recommandés peut entraîner une amélioration du nombre de RACS ?</span></span></div>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms";"><br /></span></span></div>
<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Cependant, il reste à savoir si cela améliore les résultats à long terme et si ces résultats sont retrouvés dans une étude randomisée extra-hospitalière...</span></span></div>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms";"><br /></span></span></div>
<h3 style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Changer de tempo ou changer de partition ?</span></span></h3>
<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Pour
vous donner une idée de la rapidité, Bee Gees "Stayin 'Alive" a un tempo de
103/min.</span></span></div>
<div style="border-image: none; text-align: left;">
<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Passer à "Shake It Off" de Taylor Swift (160/min) on plutôt à "Hot Blooded" de Foreigner qui frappe le 'sweet spot' à 130 battements par
minute</span>.</span></div>
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<span lang="fr" tabindex="-1"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/oQwNN-0AgWc/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/oQwNN-0AgWc?feature=player_embedded" width="320"></iframe></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: "verdana" , sans-serif;">Stayin' Alive (1977)</span></div>
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<span style="font-family: "verdana";"><br /></span></div>
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<span style="font-family: "verdana";"></span><iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/nfWlot6h_JM/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/nfWlot6h_JM?feature=player_embedded" width="320"></iframe></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: "trebuchet ms" , sans-serif;">Shake It Off (2014)</span></div>
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<span style="font-family: "trebuchet ms";"><br /></span></div>
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<span style="font-family: "trebuchet ms";"></span><iframe allowfullscreen="" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/Z6yOHh3np10/0.jpg" frameborder="0" height="266" src="https://www.youtube.com/embed/Z6yOHh3np10?feature=player_embedded" width="320"></iframe></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: "trebuchet ms" , sans-serif;">Hot Blooded (1978)</span></div>
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<span lang="fr" tabindex="-1"><br /></span></div>
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<span lang="fr" tabindex="-1"><span style="font-family: "verdana" , sans-serif;">A vos iPod</span></span><span lang="fr" tabindex="-1"><span style="font-family: "verdana" , sans-serif;"> !!!</span></span></h2>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoMisTjfT9BtttxhsumrieMzufHu81yfowZFXK8X2e4n1ZwPvu88rU9P6bFlms46GK_zJ5N7x_dchn0GlspJxEA4aVXvb23sd9PFDM73WVGtCwDqdYfsRNnl3FPHKCQgEQP-LDERVDcSyY/s1600/iPod.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="241" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoMisTjfT9BtttxhsumrieMzufHu81yfowZFXK8X2e4n1ZwPvu88rU9P6bFlms46GK_zJ5N7x_dchn0GlspJxEA4aVXvb23sd9PFDM73WVGtCwDqdYfsRNnl3FPHKCQgEQP-LDERVDcSyY/s320/iPod.jpg" width="320" /></a></div>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms" , sans-serif;">Référence</span></span></h2>
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<span lang="fr" tabindex="-1"><span style="font-family: "trebuchet ms";"><div style="color: #606060; font-size: 15px; line-height: 150%; margin: 1em 0px; padding: 0px; text-align: left;">
<a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3De8e67266bc%26e%3Df721cda332&source=gmail&ust=1489531015070000&usg=AFQjCNEkVpbVGb9VBHenD6RA2-duLxOj7g" href="https://www.ncbi.nlm.nih.gov/pubmed/27666168" style="-ms-word-wrap: break-word; color: #17377f;" target="_blank"><span style="font-family: "trebuchet ms" , sans-serif;">Association between chest compression rates and clinical outcomes following in-hospital cardiac arrest at an academic tertiary hospital.</span></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3Db4fa04da42%26e%3Df721cda332&source=gmail&ust=1489531015070000&usg=AFQjCNH2pNEG47QevjKQJ9ALYypwYS-XrQ" href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=b4fa04da42&e=f721cda332" style="-ms-word-wrap: break-word; color: #17377f; font-weight: normal;" target="_blank"><span style="font-family: "trebuchet ms" , sans-serif;"><strong>Kilgannon JH</strong></span></a><span style="font-family: "trebuchet ms" , sans-serif;"> et al. </span><a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3De8e67266bc%26e%3Df721cda332&source=gmail&ust=1489531015070000&usg=AFQjCNEkVpbVGb9VBHenD6RA2-duLxOj7g" href="https://www.ncbi.nlm.nih.gov/pubmed/27666168" style="-ms-word-wrap: break-word; color: #17377f;" target="_blank"><span style="font-family: "trebuchet ms" , sans-serif;"></span></a>Resuscitation. 2017 Jan;110:154-161. doi: 10.1016/j.resuscitation.2016.<wbr></wbr>09.015. Epub 2016 Sep 22.</span></div>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-5548662992410404522017-03-03T03:23:00.002-08:002017-03-03T03:24:15.499-08:00Intuber les arrêts cardiaques... mais pas trop vite !<div class="separator" style="clear: both; text-align: center;">
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<h1 style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "trebuchet ms" , sans-serif; font-size: 18.0pt; line-height: 150%;"><br /></span></b></h1>
<h1 style="line-height: 150%;">
<b style="mso-bidi-font-weight: normal;"><span style="font-family: "trebuchet ms" , sans-serif; font-size: 18.0pt; line-height: 150%;">Peut-être
faut-il patienter pour intuber les patients en arrêt cardiaque ?<o:p></o:p></span></b></h1>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "trebuchet ms" , sans-serif; font-size: 12.0pt; line-height: 150%;">Le mois
dernier, un article du JAMA publie les résultats d'une étude sur l'intubation
des patients hospitalisés en arrêt cardiaque. Dans ce travail bien construit, l'intubation
dans le premier ¼ d'heure de la RCP était associée à une morbi-mortalité plus
élevée. Le résultat le plus marquant était que la survie avec un bon pronostic
neurologique était bien meilleure chez les patients non intubés (NNT = 33). Par
ailleurs, la survie globale et le RACS étaient également plus faibles chez les
patients intubés. Bien que la méthodologie de cette vaste étude soit complexe,
on peut se demander pourquoi les patients intubés dans les 15 premières minutes
de la RCP spécialisée ont-ils un moins bon pronostic ? L'intubation a-t-elle
provoqué une pause dans les compressions ou un retard dans d'autres aspects de
la réanimation ? Les patients intubés ont-ils subi une hyperventilation
délétère ? Il reste difficile de pouvoir en tirer une leçon simple. Cette étude
observationnelle ne permet pas de conclure définitivement et peut être sujette à
confusion en dépit du score de propension utilisé dans les deux bras. Cependant,
on est en droit de s'interroger sur l'utilité de l'intubation précoce dans la
prise en charge de la ventilation de l'arrêt cardiaque.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span></div>
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<b style="mso-bidi-font-weight: normal;"><span style="font-family: "trebuchet ms" , sans-serif; font-size: 12.0pt; line-height: 150%;">Que peut-on alors tirer de cette étude ?<o:p></o:p></span></b></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "trebuchet ms" , sans-serif; font-size: 12.0pt; line-height: 150%;">L'intubation
précoce (< 15') lors de l'arrêt cardiaque de l'adulte hospitalisé a été
associée à des résultats plus médiocres en termes de morbi-mortalité et à une survie
neurologiquement intacte diminuée. Encore une fois, plutôt que de se focaliser
sur l'intubation, il faut avant tout assurer une RCP de haute qualité et mettre
l'accent sur la défibrillation précoce tout en continuant à étudier l'intérêt
de l'intubation et la ventilation de l'arrêt cardiaque.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span></div>
<div style="background: white; line-height: 115%; margin-bottom: 12.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt;">
<span style="color: #606060; font-family: "trebuchet ms" , sans-serif; font-size: 14.0pt; line-height: 115%;">JAMA. 2017 Jan 24. doi: 10.1001/jama.2016.20165. [Epub ahead of
print]<o:p></o:p></span></div>
<div style="-webkit-text-stroke-width: 0px; background: white; font-variant-caps: normal; font-variant-ligatures: normal; line-height: 115%; margin-bottom: 12.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; orphans: 2; widows: 2; word-spacing: 0px;">
<span style="color: #606060; font-family: "trebuchet ms" , sans-serif; line-height: 115%;"><a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage1.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3Da2cfd9b7c5%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNFr99cXHDoZG6qGYGNgEKv5DbboqA" href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=a2cfd9b7c5&e=f721cda332" style="word-wrap: break-word;" target="_blank"><strong><span style="color: #17377f; font-family: "calibri"; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-hansi-theme-font: minor-latin;">Association Between Tracheal Intubation During Adult
In-Hospital Cardiac Arrest and Survival.</span></strong></a><o:p></o:p></span></div>
<div style="-webkit-text-stroke-width: 0px; background: white; font-variant-caps: normal; font-variant-ligatures: normal; line-height: 115%; margin-bottom: 12.0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 12.0pt; orphans: 2; widows: 2; word-spacing: 0px;">
<span style="color: #606060; font-family: "trebuchet ms" , sans-serif; line-height: 115%;"><a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D9d70919c95%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNHsKO5kCtyM6fWuxttdeLZJbyKEQw" href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=9d70919c95&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Andersen LW</span></a>1, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage2.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D2ae89147a2%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNFZbDlBXxRx20tqcBufVA7qw6AFjQ" href="http://emtopics.us3.list-manage2.com/track/click?u=827fa052009e49f904cc3c386&id=2ae89147a2&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Granfeldt A</span></a>2, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage2.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D587e458e49%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNG6jw092TN4ZU-8_JvXBjW6jmKXVw" href="http://emtopics.us3.list-manage2.com/track/click?u=827fa052009e49f904cc3c386&id=587e458e49&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Callaway CW</span></a>3, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D222c34321f%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNEepb3-2OL0PCaWfYlFW7JKaRnyZg" href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=222c34321f&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Bradley SM</span></a>4, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage1.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D14eb1799a4%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNEC0n_Shg1GYHMHMia5y5Fo-j76CA" href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=14eb1799a4&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Soar J</span></a>5, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage1.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D4e2feb1980%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNHV1wlKKgXQdQgbhyjYSIX_-DdTnQ" href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=4e2feb1980&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Nolan JP</span></a>6, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3Daa3a94b269%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNHfc29ywlKSsiakGPNNoUBz9aJhAg" href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=aa3a94b269&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Kurth T</span></a>7, <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage2.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D39175bbe76%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNFIPEKa3ACR4sjucqETtphXHy4Rcg" href="http://emtopics.us3.list-manage2.com/track/click?u=827fa052009e49f904cc3c386&id=39175bbe76&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">Donnino MW</span></a>8; <a data-saferedirecturl="https://www.google.com/url?hl=fr&q=http://emtopics.us3.list-manage1.com/track/click?u%3D827fa052009e49f904cc3c386%26id%3D296da27039%26e%3Df721cda332&source=gmail&ust=1488559353033000&usg=AFQjCNF2i0bhEBnxvVdQKaF_1CXKJ7rS0g" href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=296da27039&e=f721cda332" style="word-wrap: break-word;" target="_blank"><span style="color: #17377f;">American Heart
Association’s Get With The Guidelines–Resuscitation Investigators</span></a>.<o:p></o:p></span></div>
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<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Top of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Bottom of Form"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal (Web)"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Acronym"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Address"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Cite"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Code"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Definition"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Keyboard"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Preformatted"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Sample"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Typewriter"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="HTML Variable"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Normal Table"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="annotation subject"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="No List"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Outline List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Simple 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Classic 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Colorful 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Columns 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Grid 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table List 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table 3D effects 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Contemporary"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Elegant"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Professional"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Subtle 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Web 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Balloon Text"/>
<w:LsdException Locked="false" Priority="39" Name="Table Grid"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Table Theme"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 1"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 2"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 3"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 4"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 5"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 6"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 7"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 8"/>
<w:LsdException Locked="false" SemiHidden="true" UnhideWhenUsed="true"
Name="Note Level 9"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Placeholder Text"/>
<w:LsdException Locked="false" Priority="1" QFormat="true" Name="No Spacing"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading"/>
<w:LsdException Locked="false" Priority="61" Name="Light List"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 1"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 1"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 1"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 1"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 1"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 1"/>
<w:LsdException Locked="false" SemiHidden="true" Name="Revision"/>
<w:LsdException Locked="false" Priority="34" QFormat="true"
Name="List Paragraph"/>
<w:LsdException Locked="false" Priority="29" QFormat="true" Name="Quote"/>
<w:LsdException Locked="false" Priority="30" QFormat="true"
Name="Intense Quote"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 1"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 1"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 1"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 1"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 1"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 1"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 1"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 1"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 2"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 2"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 2"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 2"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 2"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 2"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 2"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 2"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 2"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 2"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 2"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 2"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 2"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 2"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 3"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 3"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 3"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 3"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 3"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 3"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 3"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 3"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 3"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 3"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 3"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 3"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 3"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 3"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 4"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 4"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 4"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 4"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 4"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 4"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 4"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 4"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 4"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 4"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 4"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 4"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 4"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 4"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 5"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 5"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 5"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 5"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 5"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 5"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 5"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 5"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 5"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 5"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 5"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 5"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 5"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 5"/>
<w:LsdException Locked="false" Priority="60" Name="Light Shading Accent 6"/>
<w:LsdException Locked="false" Priority="61" Name="Light List Accent 6"/>
<w:LsdException Locked="false" Priority="62" Name="Light Grid Accent 6"/>
<w:LsdException Locked="false" Priority="63" Name="Medium Shading 1 Accent 6"/>
<w:LsdException Locked="false" Priority="64" Name="Medium Shading 2 Accent 6"/>
<w:LsdException Locked="false" Priority="65" Name="Medium List 1 Accent 6"/>
<w:LsdException Locked="false" Priority="66" Name="Medium List 2 Accent 6"/>
<w:LsdException Locked="false" Priority="67" Name="Medium Grid 1 Accent 6"/>
<w:LsdException Locked="false" Priority="68" Name="Medium Grid 2 Accent 6"/>
<w:LsdException Locked="false" Priority="69" Name="Medium Grid 3 Accent 6"/>
<w:LsdException Locked="false" Priority="70" Name="Dark List Accent 6"/>
<w:LsdException Locked="false" Priority="71" Name="Colorful Shading Accent 6"/>
<w:LsdException Locked="false" Priority="72" Name="Colorful List Accent 6"/>
<w:LsdException Locked="false" Priority="73" Name="Colorful Grid Accent 6"/>
<w:LsdException Locked="false" Priority="19" QFormat="true"
Name="Subtle Emphasis"/>
<w:LsdException Locked="false" Priority="21" QFormat="true"
Name="Intense Emphasis"/>
<w:LsdException Locked="false" Priority="31" QFormat="true"
Name="Subtle Reference"/>
<w:LsdException Locked="false" Priority="32" QFormat="true"
Name="Intense Reference"/>
<w:LsdException Locked="false" Priority="33" QFormat="true" Name="Book Title"/>
<w:LsdException Locked="false" Priority="37" SemiHidden="true"
UnhideWhenUsed="true" Name="Bibliography"/>
<w:LsdException Locked="false" Priority="39" SemiHidden="true"
UnhideWhenUsed="true" QFormat="true" Name="TOC Heading"/>
<w:LsdException Locked="false" Priority="41" Name="Plain Table 1"/>
<w:LsdException Locked="false" Priority="42" Name="Plain Table 2"/>
<w:LsdException Locked="false" Priority="43" Name="Plain Table 3"/>
<w:LsdException Locked="false" Priority="44" Name="Plain Table 4"/>
<w:LsdException Locked="false" Priority="45" Name="Plain Table 5"/>
<w:LsdException Locked="false" Priority="40" Name="Grid Table Light"/>
<w:LsdException Locked="false" Priority="46" Name="Grid Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="Grid Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="Grid Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="Grid Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="Grid Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="Grid Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="Grid Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="Grid Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="Grid Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="Grid Table 7 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="46" Name="List Table 1 Light"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark"/>
<w:LsdException Locked="false" Priority="51" Name="List Table 6 Colorful"/>
<w:LsdException Locked="false" Priority="52" Name="List Table 7 Colorful"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 1"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 1"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 1"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 1"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 1"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 1"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 2"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 2"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 2"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 2"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 2"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 2"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 3"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 3"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 3"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 3"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 3"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 3"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 4"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 4"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 4"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 4"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 4"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 4"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 5"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 5"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 5"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 5"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 5"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 5"/>
<w:LsdException Locked="false" Priority="46"
Name="List Table 1 Light Accent 6"/>
<w:LsdException Locked="false" Priority="47" Name="List Table 2 Accent 6"/>
<w:LsdException Locked="false" Priority="48" Name="List Table 3 Accent 6"/>
<w:LsdException Locked="false" Priority="49" Name="List Table 4 Accent 6"/>
<w:LsdException Locked="false" Priority="50" Name="List Table 5 Dark Accent 6"/>
<w:LsdException Locked="false" Priority="51"
Name="List Table 6 Colorful Accent 6"/>
<w:LsdException Locked="false" Priority="52"
Name="List Table 7 Colorful Accent 6"/>
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VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com0tag:blogger.com,1999:blog-317032633037212420.post-821677227514218462017-03-01T07:01:00.007-08:002017-03-03T03:33:38.857-08:00Pulmonary Embolism: Keep It Simple!<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<div style="margin: 0cm 0cm 0pt; text-align: center;">
<span style="font-family: Trebuchet MS, sans-serif; font-size: 14pt;"><strong><br style="mso-special-character: line-break;" />
</strong><img alt="Résultat de recherche d'images pour "pulmnary embolism"" class="irc_mi" height="297" onload="google.aft&&google.aft(this)" src="https://www.danintranet.org/media/adimg/12310.jpg" style="margin-top: 6px;" width="400" /><br style="mso-special-character: line-break;" /><strong>
</strong></span></div>
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Trebuchet MS, sans-serif;"><strong style="font-size: 18.66666603088379px;">Embolie pulmonaire – Utilisez des scores simplifiés et un dosage de D-dimères ajusté à l'âge</strong></span><br />
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<span style="font-family: Trebuchet MS, sans-serif;">Il faut parfois savoir
rester simple !</span></div>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Trebuchet MS, sans-serif;"><br />
Je suis un grand fan des scores de probabilités d’EP qui doit s’appliquer à
toute évocation de ce diagnostic parfois difficile. Le score Wells simplifié
pour l’EP utilise 1 ou 0 et fournit un résultat dichotomique : EP probable ou
EP improbable. Ce qui est intéressant, c’est qu’il est aussi bon que la version
standard, bien plus complexe. L’étude ci-dessous a examiné la performance du
score de Wells original versus simplifié pour le diagnostic d’EP et le dosage
des D-dimère (ELISA) ajusté en fonction de l'âge. Elle a conclu que les
résultats étaient identiques (0,9% de faux négatif avec le score de Wells
original + D-dimères ajustés à l'âge vs 0,8% de faux négatif avec le score
simplifié + D-dimères ajustés à l'âge). </span></div>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span></div>
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Trebuchet MS, sans-serif;">En conclusion, si la
version simplifiée est plus facile à utiliser, fournit un résultat
dichotomique, et est aussi performante que l'original, pourquoi ne pas l’intégrer
à nos algorithme ?<br />
<br />
<b style="mso-bidi-font-weight: normal;">J Thromb Haemost. 2017 Jan 20. doi:
10.1111/jth.13630. [Epub ahead of print]</b></span></div>
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Calibri;"><a href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=5d5f3074c5&e=f721cda332" target="_blank"><b><span style="color: blue; font-family: Trebuchet MS, sans-serif;">The original and simplified Wells rules and age-adjusted
D-dimer testing to rule out pulmonary embolism: an individual patient data
meta-analysis.</span></b></a></span></div>
<span style="font-family: Trebuchet MS, sans-serif;"><br /></span>
<div style="margin: 0cm 0cm 0pt;">
<span style="font-family: Trebuchet MS, sans-serif;"><a href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=273b7b768b&e=f721cda332" target="_blank"><span style="color: blue;">van Es N</span></a>1, <a href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=d7836bf039&e=f721cda332" target="_blank"><span style="color: blue;">Kraaijpoel N</span></a>1, <a href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=6b47093473&e=f721cda332" target="_blank"><span style="color: blue;">Klok FA</span></a>2, <a href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=02c92983a8&e=f721cda332" target="_blank"><span style="color: blue;">Huisman MV</span></a>2, <a href="http://emtopics.us3.list-manage2.com/track/click?u=827fa052009e49f904cc3c386&id=dd7492b074&e=f721cda332" target="_blank"><span style="color: blue;">Den Exter PL</span></a>2, <a href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=9a8ea0f73e&e=f721cda332" target="_blank"><span style="color: blue;">Mos IC</span></a>2, <a href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=d209c76810&e=f721cda332" target="_blank"><span style="color: blue;">Galipienzo J</span></a>3, <a href="http://emtopics.us3.list-manage.com/track/click?u=827fa052009e49f904cc3c386&id=2f2c618a64&e=f721cda332" target="_blank"><span style="color: blue;">Büller HR</span></a>1, <a href="http://emtopics.us3.list-manage1.com/track/click?u=827fa052009e49f904cc3c386&id=ba1226f341&e=f721cda332" target="_blank"><span style="color: blue;">Bossuyt PM</span></a>4.</span></div>
VIBE Urgencehttp://www.blogger.com/profile/03444877497075082714noreply@blogger.com1tag:blogger.com,1999:blog-317032633037212420.post-39025053054902814362017-03-01T06:57:00.001-08:002017-03-03T03:35:09.139-08:00Le premier e-Triage de l'année et 10ème du nom est en ligne<div class="container-fluid" id="site-wrapper">
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<span style="font-family: "trebuchet ms" , sans-serif;">Février 2017</span></div>
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Edito</span></h2>
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<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;"><em>Si la démarche qualité avait été appliquée à la musique, le jazz n‘aurait jamais été inventé.</em><br />
Frank Barrett<br />
<br />
En médecine, la démarche qualité a pour mantra l’<em>evidence based medecine</em>.
C’est une méthodologie de raisonnement permettant de réduire les aléas
thérapeutiques en s’appuyant sur des preuves scientifiques validées par
la communauté médicale. Proposée au début des années quatre-vingt par
des épidémiologistes canadiens, elle est devenue le garant des bonnes
pratiques. <a class="more-link" href="http://news.vygon.com/fr/newsletter-e-triage-n10-fevrier-2017/edito/">[…]</a></span><br />
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;"><strong>Jean-Claude Deslandes</strong><br />
<strong>Rédacteur en Chef</strong></span></div>
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Actualité de l'urgence</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Annales Françaises de Médecine d’Urgence</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">Les
auteurs ont souhaité tester la non infériorité de la cryothérapie par
un dispositif spécialisé (Alkantis) utilisé seul ou avec un
antalgique...</span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-n10-fevrier-2017/annales-francaises-de-medecine-durgence-2/" style="text-decoration: none;">
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>La famille Ecureuil fête ses 30 millions d’heures de vol !</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">Le
premier Ecureuil a été livré en 1977. Baptisé aujourd’hui H 125, il a
été très vite adopté par les acteurs du transport médical, et ce, sur
tous les continents...</span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-n10-fevrier-2017/famille-ecureuil-fete-30-millions-dheures-de-vol/" style="text-decoration: none;">
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Un centre de formation unique et performant</strong></span>
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<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">Ce
Centre de Pédagogie et de Simulation, inauguré en décembre dernier, est
unique en France de par la qualité et l’importance de l’outil...</span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-n10-fevrier-2017/centre-de-formation-unique-performant/" style="text-decoration: none;">
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Algorithme thérapeutique</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">Protocole Clinique SEPSIS</span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-n10-fevrier-2017/protocole-clinique-sepsis/" style="text-decoration: none;">
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Vu sur le web</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">- Pulmonary Embolism in Syncope Italian Trial (PESIT)<br />
- Blood transfusion guidelines « online October 12 in JAMA »<br />
- Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis<br />
- NACIAM: N-Acetylcysteine Reduces Infarct Size<br />
- IV Amiodarone for Wide Complex Tachycardia: Time to Say Goodbye?<br />
- Fluid Resuscitation Management in Patients With Burns: Update</span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><a class="btn-more" href="http://news.vygon.com/fr/newsletter-e-triage-n10-fevrier-2017/website/" style="text-decoration: none;">
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Grands témoins</strong></span>
</span></div>
</div>
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<span style="font-family: "trebuchet ms" , sans-serif;">
Revue de Presse</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>American Journal of Emergency Medicine</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">- Position de la tête et réussite d’une intubation à l’aveugle à l’aide d’un dispositif supra-glottique.<br />
- Réponse cardio vasculaire aux drogues énergisantes dans une population saine.<br />
- Le volume et la rapidité d’administration de solutés IV
influencent-ils la restauration de la pression artérielle moyenne durant
une hémorragie ?<br />
- Validation de la lecture d’une angiographie coronaire numérisée par un téléphone portable.<br />
- Pathologies vues aux urgences et associées à un trouble électrolytique.<br />
- Colique néphrétique : approche comparée aux USA et en France.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Annales Françaises de Médecine d’Urgence</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">- Complications obstétricales des traumatismes de la femme enceinte.<br />
- Lunettes connectées en médecine pré-hospitalière.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Annals of Emergency Medicine</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">-Diagnostic d’une dysfonction ventriculaire droite dans le cadre d’une embolie pulmonaire.<br />
- Réanimation liquidienne précoce dans les chocs septiques.<br />
- Fracture de la base du crâne chez l’enfant après un traumatisme crânien fermé.<br />
- Etude POKER : propofol ou ketofol pour sédation procédurale.<br />
- Asthme aigü de l’adulte : dose orale unique de dexamethasone ou 5 jours de prednisone ?<br />
- Efficacité d’une échelle de Glasgow réduite à ses composantes motrices.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Wilderness & Environmental Medicine</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">- Hypothermie thérapeutique dans le cadre d’un arrêt cardiaque du à la foudre.</span></div>
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Actualité de l'Arrêt Cardiaque</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Arrêt cardiaque</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">- Utilisation des défibrillateurs par le grand public pour les arrêts cardiaques survenant dans les lieux publics.<br />
- Intérêt d’un dispositif d’aide à la RCP.<br />
- Activité électrique sans pouls des embolies pulmonaires traitées par thrombolyse (PEAPETT study)<br />
- Amélioration de la survie et de l’état neurologique de rats par
Edaravone injectée après une fibrillation ventriculaire chez des rats.</span></div>
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Retour sur les congrès</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>European Resuscitation Council – ERC</strong></span>
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<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">24-25 septembre 2016, Reykjavik</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>European Society for Emergency Medicine – EUSEM</strong></span>
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<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">1-4 octobre 2016, Vienne</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Association des Médecins d’Urgence du Québec – AMUQ</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">25-28 octobre 2016, Québec</span></div>
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Agenda</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Congrès – Réunions – Formations</strong></span>
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Formation</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Test de connaissances</strong></span>
</span></div>
</div>
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Nouveaux ouvrages</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Les essentiels de la recherche bibliographique en santé</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">Soigner,
préparer un cours, élaborer un article, se lancer dans une étude
clinique, mettre à jour ses connaissances, rien de tout cela ne saurait
se faire sans une recherche bibliographique. Oui mais comment aller à
l’essentiel ? ...</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Méga-guide pratique des urgences</strong></span>
</span></div>
<span style="color: #6c6c71; font-family: "trebuchet ms" , sans-serif; font-size: x-small;">Comme
l’annoncent les auteurs, c’est en adaptant l’evidence based medicine à
la pratique que 145 situations pathologiques sont explorées, analysées
et se voient proposer des solutions pathologiques...</span></div>
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Nouveauté</span></h2>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Easy Pulse de Schiller</strong></span>
</span></div>
</div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Seringue pré-remplie d’adrénaline</strong></span>
</span></div>
</div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="color: #6c6c71; font-family: "lucida sans" , sans-serif; font-size: small;"><strong>Moniteur multi-paramètre de poche</strong></span>
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