To determine whether homeless patients experience suboptimal care in the emergency department (ED... more To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources. We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition. A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints. We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients. (Am J Public Health. Published online ahead of print March 17, 2016: e1-e6. doi:10.2105/AJPH.2015.303038).
Acute alcohol intake may be of potential hazard in anaesthesia emergency procedures because of co... more Acute alcohol intake may be of potential hazard in anaesthesia emergency procedures because of consciousness alterations. Alcohol ingestion alters indeed the functions of upper airway muscles and increases the risk of obstructive sleep apnea. However, no data are available on the effects of alcohol on the swallowing reflex (SR), which is a major protective mechanism against pulmonary inhalation and on upper airway resistances (UAR) following external inspiratory load application. This study was designed to investigate the effects of acute alcohol intake on SR and UAR in healthy volunteers. After informed consent, 8 male volunteers (29 +/- 3 years) were studied in the supine position. The tip of a catheter was placed through the naris at the epipharynx level for injection of 3 series of 2 volumes of distilled water (0.25 and 1 ml respectively). Swallows were identified by a submental electromyogram. SR efficiency was assessed by recording 1) the latency (L) between injection and the ...
Basic & clinical pharmacology & toxicology, Jan 22, 2014
Incidence of poisonings with serotonin reuptake inhibitors (SRIs) is growing. SRI toxicity is con... more Incidence of poisonings with serotonin reuptake inhibitors (SRIs) is growing. SRI toxicity is considered low, but its actual impact in multi-drug poisonings remains unclear. Our objective was to evaluate the consequences of SRI exposure in patients referred to the emergency department (ED) for deliberate multi-drug exposure. Patients admitted for multi-drug exposure involving at least one SRI were matched with patients who did not ingest any SRI, according to age, gender, type of drug and ingested doses. Features of serotonin syndrome according to Sternbach's criteria and Hunter's serotonin toxicity criteria were evaluated from records. In 4 years, 148 SRI-exposed patients were included and compared to 296 matched controls. The SRIs mainly involved were escitalopram (22%), venlafaxine (20%), fluoxetine (19%), citalopram (15%) and paroxetine (11%). Serotonin syndrome was diagnosed in one patient, but actually occurred in five SRI-exposed patients based on the retrospective ev...
Citalopram, a selective serotonin reuptake inhibitor, is generally considered to be of low toxici... more Citalopram, a selective serotonin reuptake inhibitor, is generally considered to be of low toxicity. However, serotonin syndrome, seizures, electrocardiographic abnormalities as well as respiratory failure and death have been described in patients with citalopram overdose. The mechanisms of severe toxicity remain unclear. Our objective was to study the mechanisms of death following high-dose citalopram administration in Sprague Dawley rats. The median lethal dose (MLD) of intraperitoneal (i.p.) citalopram was measured using Dixon & Bruce's up-and-down method at 102 mg/kg. Dose-effect relationships of citalopram-induced clinical features, alterations in arterial blood gas and plethysmography, and disturbances in blood lactate, plasma and platelet serotonin concentrations were studied. Seizures were significantly increased in rats receiving 80% and 120% of citalopram MLD versus controls (p < 0.05 and p < 0.01, respectively). A significant decrease in body temperature was observed after 90 min in rats treated with doses >60% MLD in comparison to controls (p < 0.05). The occurrence of serotonin behavioural syndrome was comparable in all groups. Citalopram administration did not result in significant hypoxemia, hypercapnia and lactate elevation. However, a significant moderate increase in the inspiratory time (p < 0.05) accompanied with an expiratory braking was observed. A significant dose-related linear decrease in platelet serotonin and increase in plasma serotonin concentrations were measured (p < 0.05). Pre-treatments of rats receiving 120% of citalopram MLD with diazepam (1.77 mg/kg) and cyproheptadine (17.1 mg/kg) prevented seizures and death, but propranolol pre-treatment was ineffective. Neuroprotection with diazepam and cyproheptadine was not associated with decreased serotonin plasma concentrations. In conclusion, citalopram-induced deaths resulted from seizures in relation to serotonin release, whilst respiratory and metabolic toxicity was mild. Our observations support the role of serotonin-induced neurotoxicity in citalopram overdose and suggest that cyproheptadine and benzodiazepines, but not beta-blockers, may have a role in the management of citalopram toxicity.
When managing airways in a prehospital setting, emergency physicians have to deal with difficult ... more When managing airways in a prehospital setting, emergency physicians have to deal with difficult intubation (DI), which increases morbidity and mortality. The primary goal of this study was to determine predictors of DI in the out-of-hospital field faced by the French physician-staffed Emergency Medical Service. The study was a prospective, observational study, including all consecutive patients intubated during a 30-month period. Patients having experienced standard intubation (two attempts or less) or DI (more than two attempts) were compared. Six hundred and ninety-four patients were included: 70 (11%) were classified as DI and 583 as standard intubations. Logistic regression showed that airways obstruction [odds ratio (OR), 4.1; 95% confidence interval (CI), 1.71-14.4], intubation on the floor (OR, 2.6; 95% CI, 1.04-6.6), and a hyoid-mental distance less than three fingers (OR, 2.3; 95% CI, 1.2-4.7) were independent predictors of DI. Immediate complications occurred in 89 patients (16%): 66 (11%) in the standard intubation group and 23 (31%) in the DI group (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01). For prehospital orotracheal intubation, independent risk factors of DI are a mental-thyroid distance less than three fingers, a patient on the floor, and a superior airways obstruction. Anticipation of DI could result in fewer attempts, and fewer complications, as the rate of complication increases with the difficulty of intubation.
Objective To evaluate the possible place of noninvasive positive pressure ventilation (NPPV) as a... more Objective To evaluate the possible place of noninvasive positive pressure ventilation (NPPV) as a reversible and adjustable option offering the possibility of sustaining life until the hospital stay for patients with advanced life-support limitations and life-threatening respiratory distress in the prehospital setting.
To determine whether homeless patients experience suboptimal care in the emergency department (ED... more To determine whether homeless patients experience suboptimal care in the emergency department (ED) by the provision of fewer health care resources. We conducted a prospective multicenter cohort study in 30 EDs in France. During 72 hours in March 2015, all homeless patients that visited the participating EDs were included in the study. The primary health care service measure was the order by the physician of a diagnostic investigation or provision of a treatment in the ED. Secondary measures of health care services included ED waiting time, number and type of investigations per patient, treatment in the ED, and discharge disposition. A total of 254 homeless patients and 254 nonhomeless patients were included. After excluding homeless patients that attended the ED for the sole purpose of housing, we analyzed 214 homeless and 214 nonhomeless. We found no significant difference between the 2 groups in terms of health care resource consumption, and for our secondary endpoints. We did not find significant differences in the level of medical care delivered in French EDs to homeless patients compared with matched nonhomeless patients. (Am J Public Health. Published online ahead of print March 17, 2016: e1-e6. doi:10.2105/AJPH.2015.303038).
Acute alcohol intake may be of potential hazard in anaesthesia emergency procedures because of co... more Acute alcohol intake may be of potential hazard in anaesthesia emergency procedures because of consciousness alterations. Alcohol ingestion alters indeed the functions of upper airway muscles and increases the risk of obstructive sleep apnea. However, no data are available on the effects of alcohol on the swallowing reflex (SR), which is a major protective mechanism against pulmonary inhalation and on upper airway resistances (UAR) following external inspiratory load application. This study was designed to investigate the effects of acute alcohol intake on SR and UAR in healthy volunteers. After informed consent, 8 male volunteers (29 +/- 3 years) were studied in the supine position. The tip of a catheter was placed through the naris at the epipharynx level for injection of 3 series of 2 volumes of distilled water (0.25 and 1 ml respectively). Swallows were identified by a submental electromyogram. SR efficiency was assessed by recording 1) the latency (L) between injection and the ...
Basic & clinical pharmacology & toxicology, Jan 22, 2014
Incidence of poisonings with serotonin reuptake inhibitors (SRIs) is growing. SRI toxicity is con... more Incidence of poisonings with serotonin reuptake inhibitors (SRIs) is growing. SRI toxicity is considered low, but its actual impact in multi-drug poisonings remains unclear. Our objective was to evaluate the consequences of SRI exposure in patients referred to the emergency department (ED) for deliberate multi-drug exposure. Patients admitted for multi-drug exposure involving at least one SRI were matched with patients who did not ingest any SRI, according to age, gender, type of drug and ingested doses. Features of serotonin syndrome according to Sternbach's criteria and Hunter's serotonin toxicity criteria were evaluated from records. In 4 years, 148 SRI-exposed patients were included and compared to 296 matched controls. The SRIs mainly involved were escitalopram (22%), venlafaxine (20%), fluoxetine (19%), citalopram (15%) and paroxetine (11%). Serotonin syndrome was diagnosed in one patient, but actually occurred in five SRI-exposed patients based on the retrospective ev...
Citalopram, a selective serotonin reuptake inhibitor, is generally considered to be of low toxici... more Citalopram, a selective serotonin reuptake inhibitor, is generally considered to be of low toxicity. However, serotonin syndrome, seizures, electrocardiographic abnormalities as well as respiratory failure and death have been described in patients with citalopram overdose. The mechanisms of severe toxicity remain unclear. Our objective was to study the mechanisms of death following high-dose citalopram administration in Sprague Dawley rats. The median lethal dose (MLD) of intraperitoneal (i.p.) citalopram was measured using Dixon & Bruce's up-and-down method at 102 mg/kg. Dose-effect relationships of citalopram-induced clinical features, alterations in arterial blood gas and plethysmography, and disturbances in blood lactate, plasma and platelet serotonin concentrations were studied. Seizures were significantly increased in rats receiving 80% and 120% of citalopram MLD versus controls (p < 0.05 and p < 0.01, respectively). A significant decrease in body temperature was observed after 90 min in rats treated with doses >60% MLD in comparison to controls (p < 0.05). The occurrence of serotonin behavioural syndrome was comparable in all groups. Citalopram administration did not result in significant hypoxemia, hypercapnia and lactate elevation. However, a significant moderate increase in the inspiratory time (p < 0.05) accompanied with an expiratory braking was observed. A significant dose-related linear decrease in platelet serotonin and increase in plasma serotonin concentrations were measured (p < 0.05). Pre-treatments of rats receiving 120% of citalopram MLD with diazepam (1.77 mg/kg) and cyproheptadine (17.1 mg/kg) prevented seizures and death, but propranolol pre-treatment was ineffective. Neuroprotection with diazepam and cyproheptadine was not associated with decreased serotonin plasma concentrations. In conclusion, citalopram-induced deaths resulted from seizures in relation to serotonin release, whilst respiratory and metabolic toxicity was mild. Our observations support the role of serotonin-induced neurotoxicity in citalopram overdose and suggest that cyproheptadine and benzodiazepines, but not beta-blockers, may have a role in the management of citalopram toxicity.
When managing airways in a prehospital setting, emergency physicians have to deal with difficult ... more When managing airways in a prehospital setting, emergency physicians have to deal with difficult intubation (DI), which increases morbidity and mortality. The primary goal of this study was to determine predictors of DI in the out-of-hospital field faced by the French physician-staffed Emergency Medical Service. The study was a prospective, observational study, including all consecutive patients intubated during a 30-month period. Patients having experienced standard intubation (two attempts or less) or DI (more than two attempts) were compared. Six hundred and ninety-four patients were included: 70 (11%) were classified as DI and 583 as standard intubations. Logistic regression showed that airways obstruction [odds ratio (OR), 4.1; 95% confidence interval (CI), 1.71-14.4], intubation on the floor (OR, 2.6; 95% CI, 1.04-6.6), and a hyoid-mental distance less than three fingers (OR, 2.3; 95% CI, 1.2-4.7) were independent predictors of DI. Immediate complications occurred in 89 patients (16%): 66 (11%) in the standard intubation group and 23 (31%) in the DI group (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.01). For prehospital orotracheal intubation, independent risk factors of DI are a mental-thyroid distance less than three fingers, a patient on the floor, and a superior airways obstruction. Anticipation of DI could result in fewer attempts, and fewer complications, as the rate of complication increases with the difficulty of intubation.
Objective To evaluate the possible place of noninvasive positive pressure ventilation (NPPV) as a... more Objective To evaluate the possible place of noninvasive positive pressure ventilation (NPPV) as a reversible and adjustable option offering the possibility of sustaining life until the hospital stay for patients with advanced life-support limitations and life-threatening respiratory distress in the prehospital setting.
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