Biomedical subjects
Publications and source records attributed to F Lapostolle.
Prolonged air travel is associated with an increased incidence of thromboembolic events. The occurrence of stroke was studied in patients with pulmonary embolism after air travel in a review of all flights arriving at Charles de Gaulle Airport in Paris during an 8-year period. Thromboembolic stroke and patent foramen ovale were diagnosed in four patients with pulmonary embolus.
OBJECTIVE: We conducted a survey regarding the organization of medical rescue during major events (catastrophes with limited effects) occurring in urban areas (Paris and immediate suburbs). The goal of this work was to study the availability of on site medical help and the real needs.Study design - Retrospective survey. METHODS: Thirty-eight major events were analysed between 1988 and 2000. The median number (25th-75th percentiles) of victims per event was 42 (21-68) (range 8 to 424). RESULTS: The median percentage of true emergencies (TE) was 5% with regard to the total number of victims per event. Thirty minutes after the event, 92% of the sites had a number of physician-manned ambulances greater than the number of severe victims. The median time to first evacuation was 79 (62-102) min. CONCLUSION: Disasters with limited effect occurrence in Paris and its immediate suburbs are characterized by a small percentage of TE and by a constant oversupply of medical means onsite. These observations led us to propose a new organization of medical rescue during this type of catastrophe, abandoning the classical notion of forward medical command post (FMCP) for a collection point of medical services (CPMS) consisting all means of evacuation (physician-manned and other ambulances). Also, a new type of victim identification, based on hospital base-station medical direction is discussed in this paper.
Automated External Defibrillator (AED) during cardiopulmonary resuscitation should reduce mortality rate after out-of-hospital cardiac arrest. We report a case of defibrillation with AED during flight in a patient suffering cardiac arrest complicating an acute myocardial infarction. Two hours before landing, a 56-years-old man presented sudden cardiac arrest. Flight attendants performed basic cardiac life support, including AED. Five shocks were delivered. After landing, acute myocardial infarction was diagnosed and treated by prehospital thrombolysis and angioplasty with favorable outcome. AED is a crucial link of the chain of survival, especially where advance cardiac live support cannot be performed, like during flight. Despite an increasing AED availability, survival after cardiac arrest during flight remains exceptional.
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Ecstasy recreational use dramatically increased during the last decade in France. Multiples complications associated with ecstasy consumption have been reported. We describe an exceptional case of pneumomediastinum related to ecstasy recreational use. The patient was a 19-year old patient whose medical history was significant for asthma and was a moderate tobacco smoker. He reported regular ecstasy recreational use. He presented at the emergency unit for chest pain and cough, 48 hours after the ingestion of three tablets of ecstasy and the inhalation of three other tablets. Blood pressure was 90/60 mmHg, pulse rate was 120 per minute, respiratory rate was 32 per minute and pulse oximetry was 93%. Neck emphysema was noted. Chest radiograph and scanner diagnosed pneumomédiastinum. Outcome was favorable with symptomatic treatment and the patient was discharged home eight days later. Pneumomediastinum is an exceptional complication after ecstasy recreational use. Physician should be aware of the risk of such event.
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OBJECTIVE: To assess the characteristics and the incidence of morbidity of intubated asthmatic patients who received long-term paralysis. DESIGN: Retrospective cohort study. SETTING: Five intensive care units (ICUs) in Paris and the surrounding suburbs. PATIENTS AND PARTICIPANTS: The NMB group consisted of patients who received neuromuscular blocking agents for more than 12 h (NMB group) versus sedation alone (SED). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The incidence of post-extubation muscle weakness and/or myopathy was 18% in the NMB group compared to 2% in the SED group ( p=0.01). The occurrence of ventilator-associated pneumonia was higher in the NMB group (42% versus 4%; p<0.0001). The duration of ICU stay and of mechanical ventilation were significantly greater in the NMB group. Multiple logistic regression analysis showed that inclusion in the NMB group was the only independent predictor of the presence of the overall morbidity [odds ratio 6.4 (2.09; 19.64)]. CONCLUSION: While greater initial severity of respiratory compromise in the NMB group may explain part of the difference, use of NMB agents appears to be strongly related to the presence of significant complications among mechanically-ventilated asthmatic patients.
Endotracheal intubation is widely used for airway management in a prehospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome in adult patients. The benefits, in term of outcomes of invasive airway management before reaching hospital, remain controversial. However, inadequate airway management in this patient population is the primary cause of preventable mortality. An increase in intubation failures and in the rate of complications in trauma patients should induce us to improve airway management skills at the scene of trauma. If the addition of emergency physicians to a prehospital setting is to have any influence on outcome, further studies are merited. However, it has been established that sedation with rapid sequence intubation is superior in terms of success, complications and rates of intubation difficulty. Orotracheal intubation with planned neuromuscular blockade and in-line cervical alignment remains the safest and most effective method for airway control in patients who are severely injured.
BACKGROUND: Air travel is believed to be a risk factor for pulmonary embolism, but the relation between pulmonary embolism and distance flown has not been documented. The aim of this study was to investigate whether the duration of air travel is related to the risk of pulmonary embolism. METHODS: From November 1993 to December 2000, we systematically reviewed all cases of pulmonary embolism requiring medical care on arrival at France's busiest international airport. Data on the geographic origins of all flights and the numbers of passengers were collected in order to evaluate the incidence of pulmonary embolism per 1 million passenger arrivals as a function of the distance traveled. RESULTS: A total of 135.29 million passengers from 145 countries or other areas arrived at Charles de Gaulle Airport during the period of the study, of whom 56 had confirmed pulmonary embolism. The incidence of pulmonary embolism was much higher among passengers traveling more than 5000 km (3000 mi) (1.5 cases per million, as compared with 0.01 case per million among those traveling less than 5000 km). The incidence of pulmonary embolism was 4.8 cases per million for those traveling more than 10,000 km (6000 mi). CONCLUSIONS: A greater distance traveled is a significant contributing risk factor for pulmonary embolism associated with air travel.
OBJECTIVE: To study the availability of antidotes in French emergency medical aid units (SAMU). METHODS: The physicians or nurses responsible for antidotes in French emergency medical aid units (SAMU) were interviewed by phone. The study involved 102 SAMU in metropolitan France. Four answers on availability of 37 antidotes were possible: the antidote was available in the emergency vehicle used for interventions; the antidote was available in the hospital-located SAMU; the antidote was available in the referral hospital (emergency unit, intensive care unit, operating room, pharmacy); the antidote was not available or not known to be available. RESULTS: Adrenaline and atropine were available in all the intervention vehicles. Nine other antidotes were available in more than two-thirds of the vehicles: 30% glucose (101/102), isoprenaline (100/102), dobutamine (98/112), sodium bicarbonate (97/102), naloxone (95/102), calcium chloride or bicarbonate (89/102), flumazénil (83/102), sodium lactate (77/102), and magnesium sulfate (66/102). Among the other antidotes, hydroxocobalamine and propranolol were available in 24/102 intervention vehicles and activated charcoal in 22/102. Antidigitalic antibodies and 4-methylpyrazole were not available in any vehicle, and were available in less than 25% of the hospitals. CONCLUSION: There is a great disparity of antidote availability. Certain essential antidotes, for which there is no alternative, are not available in emergency intervention vehicles and even in the hospital. The SAMU should develop an economically acceptable departmental management scheme for exceptional-use antidotes.
INTRODUCTION: Carbon monoxide detectors are currently used by the French prehospital medical teams. These detectors can also be used to measure expired breath carbon monoxide concentration. The interest of this measurement has never been studied. OBJECTIVE: To evaluate interest of expired breath carbon monoxide concentration measurement in the management of prehospital carbon monoxide intoxication. STUDY DESIGN: Patients with carbon monoxide poisoning were included during 1998. PATIENTS AND METHODS: Four levels of clinical severity: no symptom, minor, medium or severe intoxication were defined. Carbon monoxide concentration were measured in the expired breath (COHbe) at the place of the intoxication and in blood samples collected at the place of the intoxication (COHbs) and at the hospital (COHbh). RESULTS: 209 patients were included, 144 had no symptom (55%), the value of COHbe was 11.6 +/- 7.5% (mean +/- DS) and the value of COHbh was 4.9 +/- 3.3%. 91 patients had minor intoxication (35%), the value of COHbe was 16.4 +/- 7.9% and the value of COHbh was 7.1 +/- 4.5%, 21 patients had sever or medium intoxication (8%) the value of COHbe was 26.4 +/- 17.7% and the the value of COHbh was 12.8 +/- 9.3%. Results for COHbh were obtained for only three patients. Relationship between symptoms and expired breath carbon monoxide and relationship between symptoms and carbon monoxide blood concentration on arrival at the hospital were significant (p < 0.05). CONCLUSION: Measurement of expired carbon monoxide concentration, easy and quick to perform is correlated with clinical severity in carbon monoxide poisoning.
Dangerous misuse of anaesthetic drugs is illustrated in a case of gamma-hydroxybutyrate (gamma-OH) poisoning. A 36-year-old patient, coming from USA ingested approximately 200 mL of a liquid. He presented a non reactive coma (Glasgow coma scale at 3), abnormal movements, hypotension and bradycardia. Outcome was favorable with symptomatic treatment including tracheal intubation and ventilation. The patient was discharged 24 hours later. This case was a typical gamma OH poisoning. Its consumption is current in the United States for body-builders. Poisoning was involuntary, due to a dilution mistake. Toxicological analysis assessed this diagnostic. Such poisoning is exceptional in France.
BACKGROUND: The purpose of this study is to describe all degrees of endotracheal intubation difficulty among patients attended by eight anesthesiologists during routine surgery over a six-month period. Airway characteristics were routinely assessed preoperatively, according to the anesthesiologists' usual practice. METHODS: Difficult tracheal intubation was evaluated by the Intubation Difficulty Scale (IDS), a quantitative score based on seven variables. An IDS value of 0 is consistent with a procedure without difficulty, and an IDS > 5 with a procedure involving moderate to major difficulty. RESULTS: For 1171 patients undergoing tracheal intubation, IDS was 0 in 55%, and greater than 5 in 8% of cases. External laryngeal pressure, repositioning the patient and added use of a stylet were the most frequent methods chosen to facilitate tracheal intubation. CONCLUSION: There was a high incidence (37%) of minor difficulties encountered during routine surgery.
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BACKGROUND: The "sniffing position" is widely considered essential to the performance of orotracheal intubation and has become the cornerstone of training in anesthesiology. However, the anatomic superiority of this patient head position has not been established. METHODS: Eight healthy young adult volunteers underwent magnetic resonance imaging scanning in three anatomic positions: head in neutral position, in simple extension, and in the "sniffing position" (neck flexed and head extended by means of a pillow). The following measurements were made on each scan: (1) the axis of the mouth (MA); (2) the pharyngeal axis (PA); (3) the laryngeal axis (LA); and (4) the line of vision. The various angles between these axes were defined: alpha angle between the MA and PA, beta angle between PA and LA, and delta angle between line of vision and LA. RESULTS: Both simple extension and sniffing positions significantly improved (P < 0.05) the delta angle associated with best laryngoscopic view. Our results show that the beta value increases significantly (P < 0.05) when the head position is shifted from the neutral position (beta = 7 +/- 6 degrees ) to the sniffing position (beta = 13 +/- 6 degrees ), and the alpha value slightly (but significantly) decreases (from 87 +/- 10 degrees to 63 +/- 11 degrees; P < 0.05). Anatomic alignment of the LA, PA, and MA axes is impossible to achieve in any of the three positions tested. There were no significant differences between angles observed in simple extension and sniffing positions. CONCLUSIONS: The sniffing position does not achieve alignment of the three important axes (MA, PA, and LA) in awake patients with normal airway anatomy.
BACKGROUND: The "sniffing position" is recommended for optimization of glottic visualization under direct laryngoscopy. However, no study to date has confirmed its superiority over simple head extension. In a prospective, randomized study, the authors compared the sniffing position with simple head extension in orotracheal intubation. METHODS: The study included 456 consecutive patients. The sniffing position was obtained by placement of a 7-cm cushion under the head of the patient. The extension position was obtained by simple head extension. The anesthetic procedure included two Laryngoscopies without paralysis: the first was used for topical glottic anesthesia. During the second direct laryngoscopy, intubation of the trachea was performed. The head position was randomized as follows: group A was in the sniffing position during the first Laryngoscopy and the extension position during the second, group B was in the extension position during the first laryngoscopy and the sniffing position during the second. Glottic exposure was assessed by the Cormack scale. RESULTS: The sniffing position improved glottic exposure (decreased the Cormack grade) in 18% of patients and worsened it (increased the Cormack grade) in 11% of patients, in comparison with simple extension. The Cormack grade distribution was not significantly modified between the two groups. Multivariate analysis showed that reduced neck mobility and obesity were independently related to improvement in laryngoscopic view with application of the sniffing position. CONCLUSIONS: Routine use of the sniffing position appears to provide no significant advantage over simple head extension for tracheal intubation in this setting. The sniffing position appears to be advantageous in obese and head extension-limited patients.