[Blue baby syndrome: the source of the truth]

Methemoglobinemia is a rare disorder preferentially affecting children. The outcome may be dramatic when the disorder remains unidentified, however early recognition using unspecific exams allows prompt therapy. We report the case of a 14-month-old baby who presented with a sudden access of cyanosis resulting from acute methemoglobinemia. Careful investigation identified contamination of familial food by an excess of nitrates related to the use of well water from rural location.

[How I treat ... out-of-hospital cardiac arrest. The role of the emergency medical dispatcher]

Sudden cardiac arrest is an event associated with a very low survival rate. The latter is inversely proportional to the duration of the cardiovascular arrest. The chain of survival concept is a sequence of 4 events to be carried out as fast as possible with a view to ensure the patient's survival. This sequence consists of early access to and activation of the emergency medical system, early initiation of basic cardiopulmonary resuscitation, early defibrillation and early specialized care. The number of potential witnesses trained in Basic Life Support (BLS) does not guarantee an adequate basic resuscitation before the arrival of medical aid. In order to optimize the management of victims and callers, the concept of dispatching-assisted cardiopulmonary resuscitation based on a structured protocol has been implemented. The implementation of this plan to improve the quality of call handling required training and assessment of impacts on beneficiaries. The research datashow a reduction of the duration of cardiac arrest, an increase in resuscitation initiated by a witness, an improved survival rate, and a decreased stress and unanimous approval of dispatchers. Currently, the process is being improved and sustained.

[The current state of simulation in medical education]

Training methodology having emerged primarily over the last two decades, simulation in health care has arisen from the idea that students should never practice on the patient for their "first time". Simulation makes it possible to try out the errors and to repeat the skills over and over, in a reproducible way and in the most realistic possible environment, but with no harm to the patients, a risk socially intolerable. Simulation implies multiple methods from simple role-playing schemes to most powerful experiments on high-fidelity mannequins. In all cases, simulation implies a strictly codified structure: briefing, scenario, then debriefing. Indeed, debriefing represents the cornerstone of the teaching process allowing, both technical and non-technical skills acquisition through a work based on self-criticism. It should be noticed however that, although medical simulation has very clearly provided evidence of its effectiveness in skills acquisition, appropriate behaviours or application of algorithms, it has not demonstrated any benefit in terms of patients' care quality. Further research is therefore needed to validate this last assumption, which represents the very objective of any evolution in medicine.

[The alert algorithm: why, for whom, how, and when?]

Phone cardiopulmonary resuscitation (CPR) assists any cardiac arrest witness, previously trained or not, through standardized instructions given by phone. These instructions are intended to guide the bystander in checking for responsiveness, opening the airway and checking for adequate breathing, and to initiate chest compressions in case of apparent death. The "Algorithme Liégeois d'Encadrement à la Réanimation par Té1éphone" (ALERT) is an original phone CPR protocol helping the dispatchers to guide callers during the dispatcher's time window, between the beginning of the call and the Emergency Medical Services (EMS) arrival on scene. Its use has been demonstrated to increase the frequency and performance of bystanders' initial CPR efforts. Such improvement might increase the survival chances of out-of-hospital cardiac arrest victims (OOHCA).

[Presentation of ELISA: a new triage algorithm suitable for emergency department]

Emergency departments are frequently overcrowded due to the imbalance between need and availability of care. It results that influx patients should be regulated by using a triage tool located at the entrance area. This process has been in development for almost 15 years.We propose a new algorithm of triage (ELISA or Liège Scale of severity index at admission) based on a five-score level of emergency from U1 (emergent) to U5 (non urgent). Such a stratification of the state of emergency is associated with a time-delay for the first medical contact (immediate to 120 min) and a corresponding track for providing optimal care (emergency care unit, B sector or bed, A sector or ambulatory and waiting room) which together fit the sorting for the right patient to the right resources in the right place at the right time. Our algorithm has a confident efficiency as evidenced by the comparison between initial score of emergency and patient's follow up (intensive care, hospital recovery and discharge).

[Hemolytic uremic syndrome with an atypical presentation]

The hemolytic uremic syndrome (HUS) is rare and of guarded prognosis in adults. It expresses a renal thrombotic microangiopathy. We report the case of a young patient whose clinical presentation and exploration make a diagnosis of HUS likely. The atypical presentation provides an opportunity not only to discuss all diagnostic elements based on recent pathophysiological hypotheses, but also to highlight recommendations for the management of this severe disease.

[The long QT syndrome]

The congenital long QT syndrome (LQTS) is a hereditary cardiac disease characterized by a prolongation of the QT interval > 440 ms at rest ECG associated with a high risk of ventricular arrhythmias (torsade de pointe). Clinical manifestations are syncope and sudden cardiac death. The implicated genes encode cardiac ion channel subunits or proteins involved in modulating ionic currents. The diagnosis of LQTS can be complex in borderline cases. Etiology, pathogenesis, diagnosis and treatment are discussed.

[Epiploic appendagitis, an ignored diagnosis]

Epiploic appendagitis is the term used to describe the inflammation of an epiploic appendage. These small masses of fat distributed along the colon, from the caecum to the recto-sigmoid junction can inflammate by torsion, spontaneously or secondarily with the inflammation of an anatomical structure in the neighbourhood. Symptomatology may mimic retro-caecal appendicitis or diverticulitis and the diagnosis by CT avoids unnecessary surgery or hospitalization. Indeed, under conservative treatment by AINS and analgesics, symptomatology regresses in about five days. In this article, we relate the case of a patient with a typical clinical presentation, to remind the elements of this pathological entity.

[Acute exacerbation of asthma: a disease that still remains life-threatening]

Severe exacerbations of asthma can be life-threatening if not aggressively treated. Despite the publication of therapeutic guidelines developed by experts in this field and people education programs, early recognition and characterization of patients at risk for fatal asthma remain scarce. We report the case of a young lady suffering from acute exacerbation of asthma responsible for intensive care admission with long term mechanical ventilation due to the lack in initial appropriate care.

[Aortic pseudo-aneurysm after coarctation repair]

Aortic pseudo-aneurysm is a well-known late complication after surgical repair of aortic coarctation. We report two cases of pseudo-aneurysm of the aortic isthmus evidenced after previous surgical repair of congenital aortic coarctation. These clinical observations give us the opportunity to underline the importance of a specific lifelong medical follow-up for patients who have undergone such surgery.

[How I treat... paracetamol poisoning]

Drug self-poisoning is a common cause of admission in ED. Among various incriminated substances, paracetamol is often implicated and presents a severe toxicity. We briefly describe the epidemiology and physiopathology of paracetamol self-poisoning. We then clarify the diagnostic elements, thresholds of toxicity, indications for treatment and different available therapeutic guidelines.