Journal of the Accident and Medical Practitioners Association (JAMPA) 2006; Vol 3. (No. 2) Accident and Medical Practitioners Association, New Zealand ___________________________________________________________________________ Conference Report: Mediterranean Emergency Medicine Conference Nice, September 2005 Stephen Adams, MBChB, DipAnaes (UK), FAMPA
Goodfellow Unit, University of Auckland School of Medicine, Auckland
About the author:
Dr Stephen Adams, MBChB, DipAnaes (UK), FAMPA, is Senior Lecturer in Community
Emergency Medicine at the Goodfellow Unit, University of Auckland School of Medicine,
Auckland. He is also a member of the Editorial Board of the Journal of the Accident and
Medical Practitioners Association (JAMPA).
The Third Annual Joint Conference of the European Society of Emergency Medicine and
The American Academy of Emergency Medicine took place at the Acropolis Conference
Centre in Nice, France in September 2005. This meeting was designed to bring together
Emergency Medicine specialists from both sides of the Atlantic. Four AMPA members
attended this year along with about 1000 physicians from the USA, most countries of
Europe, and a few others from Australia and New Zealand. Approximately 10% of the
conference was conducted in French and the rest in English, but translating headphones
were available for those out of their linguistic depth. The stereotype of French chauvinism
towards language and disdain towards English speakers was not in evidence, either at the
Nice was originally a Greek trading settlement about 2500 years ago (hence the name of the
Conference Centre) but has since become part of the continuous urban area of the Cote
d’Azur that stretches several hundred kilometres across southern France and into Italy. It is
densely populated and congested, but 20 kilometres inland are rural areas that don’t seem
Fig. 1. The Acropolis Conference Centre, Nice.
The conference began at the time of Hurricane Katrina in the USA and a number of
delegates and speakers were not able to get to Nice or had to return home to assist.
Workshops prior to the conference included Ultrasound, Ventilation, Wound Care and
Paediatric Emergency Techniques. The main part of the conference started with a keynote
address by the very suave Mayor of Nice, and this was followed by a review of the history of
the Mediterranean Emergency Medicine Conference by the organizing committee.
Essentially, this joint conference of the American and European colleges arose from a desire
of US Emergency Physicians to be able to get away to the Mediterranean on conference
Fig 2. Local artist’s impression of a Doctor prior to attending the Conference.
The scientific and educational programmes included state-of-the-art lectures, workshops on
points of controversy in Emergency Medicine, paper presentations, and poster
presentations. This report summarises a few items that I thought might be of interest.
Infectious Diseases Tetanus
The workshops on infections were well attended by New Zealand delegates who had never
encountered most of these illnesses. Although tetanus is one infection that we see, its
occurrence is much lower than that described by speakers from India. The descriptions of
tetanus wards made rabies (the previous lecture) seem mild. An update of the
pathophysiology of the disease reminded us of the extraordinary resilience and ubiquity of
tetanus spores and their slow but inexorable progression, which may cause disease months
after the injury and death rates in the region of 50% to 85%. It was a timely reminder to
Once again, the urgency of antibiotic administration was emphasised with a reminder that
although the CSF may be sterile within 2 hours of antibiotic administration, the former
presence of meningococci may still be detected by PCR after this time. Newer therapies that
are showing promise include recombinant bactericidal/permeability-increasing protein (rBPI)
and recombinant human activated protein C. Predictably, the American speaker said the
Meningococcus B vaccine looked promising, but no trials had been completed to his
Cervical Spine Injuries
This perennial Emergency Medicine Topic was subtitled “How to never miss another
Cervical Spine Fracture”, but the hoped for infallible approach did not eventuate. The history
from the 1950s, when Rogers first described iatrogenic cervical spine injuries, up to the most
recent cervical spine rules was outlined. The generally accepted risk factors for significant
Highest risk accidents: Predisposing patient factors:
We were reminded of the downside of cervical immobilisation – aspiration risk, respiratory
limitation, pain, pressure necrosis and increased intracranial pressure.
Cervical Spine X-ray vs Computerised Tomography (CT)
Balancing the increased cost and radiation dose of CT against its greater sensitivity, it was
considered that CT should be reserved for high-energy injury mechanisms or when its use
had already been contemplated for another reason. Cervical spine x-rays are still cost
Flexion – Extension Views
These are suggested to still be useful in persistent neck pain despite apparent radiological
normality which has not settled with a semirigid collar. Of course, patients need to be able to
flex and extend 30 degrees, so there will be a significant group who are unable to have this
SCIWORA (Spinal Cord Injury Without Radiological Injury)
In the past, this has been regarded as mainly a paediatric injury. Profound or progressive
paralysis occurs in the first 48 hours. Magnetic resonance imaging (MRI) has shown this to
Motor Vehicle Entrapment
A European consultant in motor vehicle crashes covered MVA scene management and
discussed entrapment issues. Videos of airbags deploying, seatbelt pretensioners grabbing,
and anti-rollover devices extending during rescue were sobering reminders that the danger
is not over when the vehicle comes to a halt. There are increasing numbers of potentially
hazardous safety devices in newer vehicles. Some of the dangerous pieces of hardware are
located in areas remote from the area of deployment, so this possibility should be borne in
In addition, the equipment used in extraction such as the “Jaws of Life” is not without its
dangers, e.g. the cutting apparatus and the very high-pressure hydraulic lines which, if they
malfunction, have the potential to cause severe injury. The good news is that many crashes
that had a high likelihood of death as little as 20 years ago are now regarded
Anal fissures were highlighted as a problem where it may be worthwhile looking for an
underlying cause – in particular HIV infection, trauma, and high rectal pressures during
defecation. We were reminded that most anal fissures heal spontaneously and that sitz
baths aid comfort, though not necessarily healing. Stool softeners and a high-fibre diet will
reduce pressure. If topical glyceryl trinitrate (GTN) is used to relieve spasm, the patient
should be warned of the possibility of headache.
For internal haemorrhoids, a plea was made not to allow overuse of topical corticosteroids,
as skin atrophy has been reported. Surgical excision in the clinic was urged for external
haemorrhoids but not for paediatric, pregnant or immunocompromised patients. No particular
procedure (e.g. incision & drainage, window or X-shaped incision) was promoted as best.
For a pilonidal sinus/abscess, it was emphasised that a rectal examination is necessary to
exclude an anorectal abscess and that, if found, these patients should be hospitalised as
The current evidence on the treatment of bronchiolitis was reviewed. Key points made
• Ipratropium has generally not been shown to be useful in recent trials • β2-Adrenoceptor agonists such as salbutamol appear to decrease wheeze but do not
seem to be able to consistently produce clinical improvement 
• Nebulised adrenaline reduces hospital admissions and improves O2 saturation at 60
minutes, but recent studies have suggested this is a short-term effect only
• Corticosteroids have been shown to have no benefit for acute viral bronchiolitis in infants
and young children, according to a recent Cochrane review 
• Heliox (helium-oxygen mixture) appears to reduce the work of breathing in bronchiolitis
Two presentations were given on asthma. The first by a Saudi Emergency Medicine
specialist reviewed the evidence in paediatric asthma and, in general, was non-controversial.
The second, by Dr Richard Nowak, an Emergency Medicine specialist from the USA,
reviewed drugs in severe adult asthma with a skeptic’s eye. Medications discussed included:
• Oxygen: one trial that suggesting lower than maximal oxygen doses were beneficial was
• Intravenous β2-agonists: these drugs have not been shown to be additive to inhaled β2-
agonists in adults, and may reverse otherwise beneficial regional pulmonary hypoxic
• Ipratropium – this drug is considered to have a clear additive effect to inhaled β2-agonists • Corticosteroids reduce hospital admissions. Inhaled corticosteroids may work in 2 hours
as compared with the widely quoted 4 hours for oral and intrravenous corticosteroids
• Aminophylline’s effect is equivocal in adults, although it is beneficial in children • Magnesium was considered useful in a Cochrane review, but more recent studies have
• Heliox should, theoretically, be of benefit but no improvement in function has been
shown, and 30% oxygen in helium may produce hypoxia.
Dr Nowak’s harshest judgment was reserved for the manufacturers of β2-agonists, including
salbutamol (albuterol), which are produced as racemic mixtures. It is known that the R-
isomer of salbutamol is therapeutic while the S-isomer is not. Studies were cited to show that
the S-isomer is pro-inflammatory and causes both smooth muscle constriction and chronic
changes in airways. His view on the role of inhaled corticosteroids is that they are necessary
to minimise the injury caused by the S-isomer, and that the epidemic of deaths prior to the
global use of inhaled corticosteroids was due to the effect of the S-isomer. Dr Nowak
supported the use of R-salbutamol (levalbuterol; available in the USA) for which he produced
data showing it to be more effective. He denied any conflict of interest in this drug’s
This topic was covered by an American physician from a high lightning-strike area. There are
• Direct strike (usually to the head) • Contact with an object conducting a lightning strike • Side flash from a strike • Ground current from a nearby strike • Blunt trauma secondary to sudden expansion of heated air and falls.
The differences from electric shock and electrical burn were highlighted:
• Cardiac arrest is usually asystole • Dysrhythmias are common and may include a prolonged QT segment • A secondary vasospasm may occur in the extremities • CNS depression may result in loss of consciousness, prolonged apnoea and amnesia • A secondary iridocyclitis may mimic blown pupils • There may be fractures and dislocations from blunt trauma and muscle contraction • Tympanic membrane rupture is quite common • Skin burns are of the direct “rosette” configuration around the entry point or may have a
tree-like shape. In appearance and depth, they are like a liquid that was burnt or
evaporated by heat. They seldom involve deep tissues.
Treatment follows the usual ABCs, with consideration of the following:
• Patients in cardiorespiratory arrest should be resuscitated first • Fixed dilated pupils may not signify brain death • Asystole is more likely to be convertible to a rhythm with output than in other scenarios • Internal injury is more likely to be due to blunt trauma rather than electricity.
In the long term, residual disability is quite common and the most common post-acute
treatment is ENT or ophthalmology referral.
Whitcomb D, Martinez JA, Daberkow D. Lightning injuries. South Med J 2002;95(11):1331-4.
In summary, the Mediterranean Conference was useful in bridging the differences between
North American and European Emergency Medicine specialists and in giving a more
balanced view than the conferences of the two sponsoring organisations (albeit without
Asian/Australasian input). Future conferences will take place at sites of great touristic or
cultural significance. In 2007, the conference will be held on September 14-18 at Sorrento in
Italy, which will offer the opportunity of visiting Pompeii and Capri.
Fig 3. An evening on the Promenade des Anglais, Nice. References
Flores G, Horwitz RI. Efficacy of beta2-agonists in bronchiolitis: a reappraisal and
meta-analysis. Pediatrics 1997;100(2 Pt 1):233-9.
Patel H, Platt R, Lozano JM, Wang EE. Glucocorticoids for acute viral bronchiolitis in
infants and young children. Cochrane Database Syst Rev 2004;(3):CD004878.
Gupta VK, Cheifetz IM. Heliox administration in the pediatric intensive care unit: an
evidence-based review. Pediatr Crit Care Med 2005;6(2):204-11.
doi: 10.1146/annurev.med.54.101601.152421Copyright c 2003 by Annual Reviews. All rights reserved FUNCTIONAL GENOMICS OF THE PARAOXONASE (PON1) POLYMORPHISMS: Effects on Pesticide Sensitivity, Cardiovascular Disease, and Drug Metabolism Lucio G. Costa,1 Toby B. Cole,1,2 Gail P. Jarvik,2 andClement E. Furlong2 Departments of 1Environmental Health and 2Genome Sciences and Medicine, Divisionof Med
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