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Biomedical subjects

Frédéric Lapostolle

Publications and source records attributed to Frédéric Lapostolle.

At least 19 recordsLinked to original sources
PubMed2007

Emergency department visits caused by adverse drug events: results of a French survey.

BACKGROUND: Adverse drug events (ADEs) are a substantial cause of hospital admissions. However, little is known about the incidence, preventability and severity of ADEs resulting in emergency department visits. To address this issue, we conducted a prospective survey in emergency departments of French public hospitals. METHODS: This study was performed over two periods of 1 week each, one in June 1999 and one in December 1999, in emergency departments of five university hospitals and five general hospitals throughout France. All patients aged>or=15 years presenting with medical complaints were included in the study. Trauma patients, those with gynaecological conditions and those with alcohol intoxication or intentional drug poisoning were excluded from the study. Each patient was assessed by two local emergency physicians to determine whether the visit was the result of an ADE. All medical records were subsequently validated by an independent group of medical lecturers in iatrogenic disorders. RESULTS: Out of a total of 1937 patients consulting, 1562 were taking at least one drug during the previous week and were included for analysis; 328 (21%; 95% CI 19, 23) of these patients consulted an emergency physician because of an ADE. Patients with ADEs were older than those without (mean age 63.5 vs 54.8 years; p<0.0001). Furthermore, ADE patients were more likely to have a higher severity presentation than the non-ADE group (p=0.019). The number of drug exposures was significantly higher in patients with an ADE than in those without (mean number of medications 5.17 vs 3.82; p<0.0001). On multivariate analysis, only age and the number of medications taken were significantly associated with adverse events. In total, 410 drugs were incriminated in the occurrence of 328 ADEs. The most frequently incriminated drug classes were: (i) psychotropic agents (n=84; 20.5%); (ii) diuretics (n=48; 11.7%), anticoagulants (n=38; 9.3%) and other cardiovascular drugs (n=63; 15.4%); and (iii) analgesics, including NSAIDs (n=57; 13.9%). Preventability could be assessed in 280 of the 328 cases. In 106 cases (37.9%), the ADE was judged to be preventable. CONCLUSION: ADEs leading to emergency department visits are frequent, and many are preventable, confirming that there is a need to develop prevention strategies.

Adult↗
PubMed2006

Prehospital fibrinolysis with dual antiplatelet therapy in ST-elevation acute myocardial infarction: a substudy of the randomized double blind CLARITY-TIMI 28 trial.

BACKGROUND: Fibrinolytic therapy for acute ST-elevation myocardial infarction (STEMI) is frequently limited by delays in administration and by incomplete reperfusion or reocclusion of the infarct-related artery. Intensified prehospital management of STEMI may shorten time to treatment and improve outcomes. METHODS: We carried out a prospective substudy in 11 ambulance systems in 216 of the 3,491 patients with STEMI who were enrolled in the CLARITY-TIMI 28 trial. They were randomized in the ambulance to clopidogrel (n = 109) or placebo (n = 107) along with fibrinolysis, aspirin, and heparin. The primary endpoint was the composite of an occluded infarct-related artery (TIMI flow grade 0 or 1), or death or recurrent myocardial infarction before angiography. RESULTS: All patients received a fibrin-specific lytic and the baseline characteristics in both groups were comparable. The incidence of the primary endpoint was 16.5% in the clopidogrel-treated and 27.1% in the placebo patients (adj OR 0.62, 95% CI 0.31-1.21, p = 0.16), an effect that was consistent with the effects seen in the in-hospital patients in the main CLARITY-TIMI 28 trial. Prehospital clopidogrel therapy reduced the incidence of an occluded infarct-related artery on the predischarge angiogram (11.8% vs. 22.3%, adj OR 0.52, 95% CI 0.24-1.13, p = 0.10). The 30-day incidence of cardiovascular death, recurrent MI or recurrent myocardial ischemia requiring urgent revascularization was 12.8% vs. 14.0% (adj OR 1.07, 95% CI 0.48-2.39, p = 0.87). Early TIMI major bleeding occurred in no clopidogrel patients compared with two placebo patients (1.9%). CONCLUSIONS: Addition of clopidogrel to medical reperfusion of STEMI with fibrinolysis, heparin, and aspirin before reaching the hospital is feasible in medically equipped ambulances without an apparent increase in bleeding. Furthermore, prehospital clopidogrel tended to show better early coronary patency compared to placebo, a result consistent with that observed in patients randomized in-hospital in the CLARITY-TIMI 28 trial.

Aged↗
PubMed2006

Reduction of paracetamol metabolism after hepatic resection.

INTRODUCTION: Paracetamol is often used as an analgesic following hepatic resection. During liver resection, vascular clamping is carried out to reduce blood loss. Previous studies have described transient postoperative rises in serum aminotransferase levels and decreases in prothrombin time and factor V levels. We have examined paracetamol metabolism after liver resection. METHODS: A prospective observational study was performed. All patients undergoing liver resection were included. Propacetamol was given every 6 h. Blood samples for plasma paracetamol concentrations were collected before, 1 h after the end of the first injection (T1), just before the second injection (6 h: T6), and just before the fifth injection (24 h: T24). RESULTS: 37 patients were recruited. 13 had hepatic vascular exclusion (HVE group), 13 had portal triad clamping (PTC group) and 11 had abdominal surgery with no liver resection (NLR group: control group). At T6, the plasma paracetamol concentration in the HVE group was significantly higher than in the NLR groups; at T24, this concentration was significantly higher in the HVE group than in the NLR and PTC groups, and was higher in the PTC group than in the NLR group. Prothrombin time and factor V was significantly lower in the HVE group than in the PTC group on the first postoperative day. DISCUSSION: This study showed a reduction of paracetamol metabolism in the liver resection group with significantly increased paracetamol levels. However, the maximum mean plasma concentration reached was not clinically or toxicologically significant. For these reasons, we cannot suggest that paracetamol should or should not be avoided in patients undergoing liver resection.

Acetaminophen↗
PubMed2006

Prehospital diagnosis of massive ethylene glycol poisoning and use of an early antidote.

We report the case of a patient suspected of voluntary massive poisoning by ethylene glycol. Prehospital diagnosis was established by portable blood analyser and an early antidote with 4 MP treatment initiated in out-of-hospital setting. Use of portable blood analyser in prehospital care should be considered in case of suspected massive poisoning by ethylene glycol.

Adult↗
PubMed2006

Survival of severely shocked patients who present with absent radial pulse and unrecordable blood pressure in the pre-hospital phase.

OBJECTIVES: To determine the mortality and clinical features of patients presenting with severe hypotension in the pre-hospital phase of care. DESIGN: A prospective observational study. The medical records of patients attended by a physician-led pre-hospital medical service were examined prospectively. Inclusion criteria were severe shock characterized by a non-palpable radial pulse and unrecordable blood pressure at clinical presentation. All consecutive records between September 2002 and September 2003 were included. SETTING: Seine Saint-Denis, an urban area with a population of 1.5 million located in the northern suburbs of Paris, France. INTERVENTIONS: None. RESULTS: One hundred and thirty one patients met the inclusion criteria. The overall mortality was 50% (66/131). Of the deaths, 20% (13/66) occurred in the pre-hospital phase and 80% (53/66) after arrival in hospital. Clinical features significantly associated with increased mortality were: more than one pre-existing co-morbidity, increased age, high Knaus score, a low Glasgow Coma Score, vasopressor administration, pre-hospital cardiac arrest and hypotension on arrival at hospital. The presence of anaphylactic shock was associated with low mortality. In multivariate analysis, occurrence of cardiac arrest (OR=13.5 [2.8; 64.5]), age (OR=1.03 [1.01; 1.05]) and low Glasgow Coma Scale score value (OR=1.15 [1.05; 1.29]) were independently associated with mortality. CONCLUSION: Patients presenting with profound hypotension in the pre-hospital phase have a high mortality. Patients who recover their blood pressure with interventions before hospital admission and those with anaphylactic shock have a better outcome than other patient sub-groups.

Adolescent↗
PubMed2006

Usefulness of hand-held ultrasound devices in out-of-hospital diagnosis performed by emergency physicians.

OBJECTIVE: To evaluate the usefulness of ultrasonographic examinations as a diagnostic tool for emergency physicians in out-of-hospital settings. METHODS: Prospective study performed in a French teaching hospital. Eight emergency physicians given ultrasound training for out-of-hospital diagnosis of pleural, peritoneal, or pericardial effusion; deep venous thrombosis; and arterial flow interruption. After clinical examination, a probability of diagnosis ("clinical score") was assigned on visual analog scale from 0 (absent lesion) to 10 (present lesion). Clinical score between 3 and 7 was considered as clinically doubtful. After ultrasound examination, a second probability ("ultrasound score") was similarly determined. Potential usefulness of ultrasound examination was evaluated by calculating the absolute difference between clinical and ultrasound scores. Patients were followed up to determine final diagnosis: present or absent lesion. "Ultrasound usefulness score" (USS) was determined attributing a positive (when ultrasonography increased diagnostic accuracy) or a negative (when ultrasonography decreased diagnostic accuracy) value to the absolute difference between clinical and ultrasound scores. RESULTS: One hundred sixty-nine patients were included and 302 ultrasound examinations performed. Median duration of examination was 6 minutes (5-10 minutes). The suspected lesion was found in 45 cases (17%). Mean USS was +2 (0-4). Ultrasonographic examination improved diagnostic accuracy (ie, positive USS) in 181 (67%) cases, decreased it (ie, negative USS) in 22 (8%) cases, and was not contributive (ie, USS was 0) in 67 (25%) cases. When initial diagnosis was uncertain (n = 115), diagnostic performance reached +4 (3-5) and ultrasonographic examination improved diagnostic accuracy in 103 (90%) cases. CONCLUSION: Out-of-hospital ultrasonography increased diagnostic accuracy in out-of-hospital settings.

Ascitic Fluid↗
PubMed2006

Intravenous fluid temperature management by infrared thermometer.

BACKGROUND: The management of intravenous (IV) fluid temperature is a daily challenge in critical care, anesthesiology, and emergency medicine. Infusion of IV fluids at the right temperature partly influences clinical outcomes of critically ill patients. Nowadays, intravenous fluid temperature is poorly managed, as no suitable device is routinely available. Infrared (IR) thermometers have been recently developed for industrial, personal, or medical purposes. The aim of this study was to evaluate the accuracy of an IR thermometer in measuring temperature of warmed and cooled infusion fluids in fluid bags. METHODS: This study compared temperatures simultaneously recorded by an infrared thermometer and a temperature sensor. Temperatures of warmed (41 degrees C) and cooled (4 degrees C) infusion fluids in fluid bags were recorded by 2 independent operators every minute until IV bags' temperature reached ambient temperature. RESULTS: The relation curve was established with 576 measures. Temperature measures performed with an IR thermometer were perfectly linear and perfectly correlated with the reference method (R(2) = 0.995, P < 10(-5)). CONCLUSION: Infrared thermometers are efficient to measure IV fluid bag temperature in the range of temperatures used in clinical practice. As these devices are easy to use and inexpensive, they could be largely used in critical care, anesthesiology, or emergency medicine.

Humans↗
PubMed2005

Intracuff pressures of endotracheal tubes in the management of airway emergencies: the need for pressure monitoring.

STUDY OBJECTIVE: Excessive pressure exerted on the tracheal mucosa is an avoidable factor implicated as a cause of damage after intubation of the trachea with cuffed tubes. Many patients are intubated in the out-of-hospital setting by emergency medical teams. The time spent in the out-of-hospital setting could very well be long enough for tracheal mucosal damage to occur if cuff pressure is not controlled. The objective of this study is to assess the incidence of intracuff excessive pressure in the out-of-hospital setting. METHODS: We performed an observational prospective study. Every patient who required tracheal intubation was included in the study, regardless of indication. When the patient was stabilized, the cuff was connected to a manometer, and pressure was systematically recorded. Corrections to inflation were performed if necessary to achieve a cuff pressure of 14 to 27 cm H2O. RESULTS: One hundred seven patients were included. Eighty-five were out-of-hospital patients and 22 were transfers between 2 hospitals who had been previously intubated when the mobile intensive care unit team arrived. The first recorded cuff pressures were greater than 27 cm H2O among 79% of patients (85/107), with a mean pressure of 56 cm H2O (SD+/-34 cm H2O) in out-of-hospital patients and 69 cm H2O (SD+/-37 cm H2O) for transferred patients. Pressure correction was made in 72% of patients (77/107). There were corrections in 69% (59/85) of out-of-hospital patients and 82% (18/22) of transferred patients. CONCLUSION: This study revealed that the majority of cuff pressures exceeded safe pressure and required correction. Frequent measurement and adjustment of cuff pressure has been recommended, but this method requires a specific manometer.

Emergency Medical Services↗
PubMed2005

Is primary angioplasty more effective than prehospital fibrinolysis in diabetics with acute myocardial infarction? Data from the CAPTIM randomized clinical trial.

AIMS: The CAPTIM study randomized patients managed within 6 h of acute ST-segment elevation myocardial infarction to primary angioplasty or prehospital fibrinolysis (rt-PA), with immediate transfer to a centre with interventional facilities. It found a similar incidence of the primary endpoint of death, recurrent MI, or stroke at 30 days with both strategies. We report here the outcome in the diabetic subgroup. METHODS AND RESULTS: The relationship of diabetic status (diabetics, n=103, non-diabetics, n=731) and treatment strategy with the occurrence of the primary endpoint and of death was analysed. Compared with non-diabetics, diabetics had a higher baseline risk profile, a higher rate of the primary endpoint (14.6 vs. 5.6%; P=0.002), and a high rate of mortality (8.7 vs. 3.1%; P=0.01) at 30 days. The incidence of the primary endpoint tended to be higher in diabetics randomized to prehospital fibrinolysis compared with those randomized to primary angioplasty [21.7 vs. 8.8% (10/46 vs. 5/57); RR: 2.47 (0.91-6.74); P=0.09]. This difference was driven by the higher mortality in the fibrinolysis group [13.0 vs. 5.3% (6/46 vs. 3/57); RR: 2.47 (0.7-9.4); P=0.29]. For non-diabetics, no such trend was observed. Compared with non-diabetics, diabetics had a much higher rate of rescue angioplasty (41.4 vs. 23.5%; P=0.01) and a higher mortality after rescue angioplasty [17.4 vs. 0% (4/23 vs. 0/90); P=0.001]. CONCLUSION: These results suggest that diabetic patients presenting within 6 h of an acute myocardial infarction may derive particular benefit from a strategy of primary angioplasty. However, the small number of diabetic patients in this subgroup analysis does not allow a final conclusion and a specifically designed study is warranted.

Aged↗
PubMed2005

[Determination of early markers of a sanitary event. The example of the heat wave of August 2003 at the Samu 93-centre 15 in France].

OBJECTIVE: The aim of this study was to determine, a posteriori, the parameters detecting an event in a French medical emergency dispatching centre (SAMU). METHODS: Six parameters were retained: total number of medical requests received by the Samu 93-centre 15: the number of decisions to send a mobile intensive care unit (MICU), number of decisions to send a non-medical unit, number of decisions to send a general practitioner and number of deaths observed by the physicians of the MICU. For each parameter, a daily referential was established over the five previous years (1998 to 2002) and compared with the results of August 2003 RESULTS: The number of decisions to send a non-medical unit and the number of decisions to send a general practitioner were unchanged. The number of deaths on the 8th of August observed by the MICU physician should have led to an alert being given: 5.0 deaths for a referential of 1.7 (+ 194%). The number of decisions to send an MICU on the 7th of August should have led to an alert being given: 41 interventions for a referential of 25 (+64%). The number of medical interventions on the 6th of August should have led to an alert being given: 351 interventions for a referential of 299 (+17%). CONCLUSION: The total number of medical interventions treated by the SAMU 93-centre 15 is a the most sensitive and earliest marker of a sanitary event, such as that observed in August 2003 with the heat wave.

Disaster Planning↗
PubMed2005

A randomized, double-blind study comparing morphine with fentanyl in prehospital analgesia.

STUDY OBJECTIVE: The aim of this study was to compare, by a randomized double-blind method, morphine (M) and fentanyl (F) in a prehospital setting. METHODS: Consecutive patients with severe, acute pain defined as a visual analog scale score (VASS) of 60/100 or higher were included. The M group received an initial intravenous M injection of 0.1 mg/kg then of 3 mg every 5 minutes. The F group received an initial intravenous F injection of 1 microg/kg then of 30 microg every 5 minutes. The goal of analgesia was a VASS of 30/100 or lower. The end point was the VASS measured 30 minutes after initial administration (VAS [T30]). RESULTS: There were 26 patients included in the M group and 28 in the F group. Initial VASS(T0) and VASS(T30), mean (95% CI), were 83 (78-88) and 40 (28-52) in the M group and 77 (72-82) and 35 (27-43) in the F group (P=NS). Sixty-two percent of patients in the M group described analgesia as excellent or good vs 76% of those in the F group who did (P=NS). There were no differences in the incidence of side effects in the 2 groups. CONCLUSION: This study demonstrates that M and F were comparable in treating severe, acute pain in a prehospital setting during the first 30 minutes in spontaneous breathing patients.

Acute Disease↗
PubMed2005

Prognostic factors in victims of falls from height.

OBJECTIVE: Falls from height cause significant mortality in the urban environment, but reliable prognostic factors have not been identified. Even the intuitive relation between the distance fallen and mortality rate has been questioned. Our objective was to determine factors predictive of increased mortality rate in victims of falls from height. DESIGN: Clinical observational study, retrospective for January 1998 to May 1999 and prospective from June 1999 to September 2000. SETTING: The study population was drawn from Seine-Saint-Denis, an urban region near Paris with 1.3 million inhabitants treated by a French out-of-hospital medical emergencies unit. PATIENTS: Patients were victims of falls from height >3 m, age >12 yrs. Study entry was performed on the scene by an emergency physician from the medical emergencies unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Studied data included age, gender, circumstances of fall, height of fall, nature of the impact surface (soft or hard), transient impact preceding final impact, and part of the body touching the ground first. The primary end point was mortality. The study included 287 patients, 116 (40%) during the retrospective phase and 171 (60%) during the prospective phase. Ninety-seven patients (34%) ultimately died. In multivariate analysis, age (mean, 41.6 +/- 16.6 yrs in patients who died vs. 34.9 +/- 14.9 in survivors; odds ratio, 1.05; p < .0005); height of fall (median, 5.0; 3.8-8.0 vs. 2.0; 1.2-3.0 floors; odds ratio, 1.24; p < .0001); nature of the impact surface (hard in 39% vs. soft in 22%; odds ratio, 2.7; p < .05); and head, anterior, and lateral body surfaces touching the ground first (with respectively mortality rates of 44%, odds ratio, 16.7, p = .0001; 57%, odds ratio, 10.6, p < 0.005; 32%, odds ratio, 11.1, p < .001) were independently correlated with the final mortality rate. CONCLUSIONS: Patient age, height of fall, impact surface nature, and body part first touching the ground are independent prognostic factors in victims of falls from height.

Accidental Falls↗