Wells’ score for early prehospital screening of pulmonary embolism

Pulmonary embolism (PE) represents a significant health problem due to non-specific clinical features and a high risk of lethal outcome. PE diagnostics can sometimes be very difficult, especially at the prehospital level. We present a patient in whom early screening for PE at the prehospital level, performed using the Wells’ Score, was a life-saving event. Case scenario: the Emergency Medical Service (EMS) received a call regarding a male, aged 27 years, who was unconscious. Prior to losing consciousness, he complained of suffocation and tachycardia. Ten days earlier he sustained an injury to the knee which was immobilized with a splint, followed by bed rest. A year ago he was examined for chest pain, hypertension and tachycardia. On examination the patient was conscious, well oriented, eupneic, afebrile, with normal skin color. On pulmonary auscultation breath sounds were normal, and oxygen saturation was 90%. Findings on cardiac examination included: regular rate and rhythm, no murmur, blood pressure (BP) 120/85mmHg on both arms. ECG revealed sinus rhythm, rate of 100 beats/min, discreet signs of right heart strain (S1Q3T3 pattern), negative T wave from V1-V4, ST depression in D2, D3, AVF. A Wells’ score of 6 (most probably PE) was calculated: immobilization for 4 weeks – 1.5 points, tachycardia (pulse 120/min) – 1.5 points and alternative diagnosis less probable than PE – 3 points. The patient was suspected of PE and referred to a cardiologist. Conclusion. Pulmonary embolism often remains undiagnosed during a patient’s lifetime or is erroneously diagnosed. The significance of the scoring of each patient aimed at the recognition of pulmonary embolism at the prehospital level cannot be underestimated

Out-of-hospital cardiopulmonary resuscitation in four Serbian university cities: outcome follow-up according to the «Utstein style»

Aims. To investigate the return of spontaneous circulation (ROSC), survival to discharge, six-month and one-year survival of patients with out-of-hospital cardiac arrest in four university cities in Serbia. Methods. A prospective, two-year, multicentre study was designed. Using the Utstein template, we recorded out-of-hospital cardiopulmonary (CPR) and its outcomes, and analyzed the immediate survival (ROSC>20 min.), short-term survival (to discharge), long-term survival (one year after discharge), or death following out-of-hospital CPR. Results. During the study period, 591 patients met the inclusion criteria for enrollment and out-of-hospital CPR. The etiology of arrest was cardiac in 33.8% of patients. Cardiac arrest was witnessed by the advanced life support (ALS) team in 15.6% of cases. Asystole was the most frequent initial rhythm at time of arrest (46.4%). The highest survival rate (P<0,001) was observed in cases with initial VF and pulseless VT, while patients with asystole and pulseless electrical activity (PEA) had the least chance of survival. Within the whole group of patients, ROSC was detected with a frequency of 69.7%. The frequency of patients who died in the field or during admission to hospital was 58.9%, while 28.6% of admitted patients died before discharge. Thirteen percent of patients survived until discharge, and the overall six-month and one-year survival rates were 11.3% and 10%, respectively. No statistical difference in survival rates among the cities was found. Conclusion. The Utstein template should be implemented in the form of an official protocol for out-of-hospital CPR follow-up in all emergency medical services in Serbia

Ticking time bomb: abdominal aortal aneurism detected at prehospital level

The cause of sudden death is increasingly more frequent due to abdominal aortal aneurism (AAA). This ticking “time bomb” in the abdomen is particularly inconvenient for diagnosis and treatment at the prehospital level. We present a rare case of prehospitally detected AAA that like the ticking time bomb threatened to rupture. Case scenario. A 66 years old male called Emergency Medical Services (EMS) due to unbearable pain (9/10 at the pain intensity scale) of crescendo type in the right gluteal region and the right hip. Four days before, due to a sudden feeling of pain within the above quoted region he underwent neurological, orthopedic and urological examinations. The diagnosis of coxarthrosis/coxalgia was made. He was treated with analgesics with suggested rest. Anamnestically, he was previously healthy, without family history of AAA. He is a several-year smoker and hypertonic. Physical findings: conscious, orientated, eupnoic, afebrile, normal skin color, with visible mucosa, excessive sweating and obesity. Auscultatory findings of the lungs and heart were also within normal limits. SaO2 = 99%. Blood pressure (BP) on both hands was 170/100 mmHg. ECG: sinus rhythm with a frequency of 80/min, without acute ST-T changes. The abdomen above the chest was with palpable pulsating tumefaction (size 5-6 cm) in the right inguinum that was respiratory immovable. Lazarević sign negative. Prehospital diagnosis was made: suspected AAA. On admission: treated as the emergency case, after multislice computed tomography (MSCT) and angiographic findings indication for emergency surgical intervention was made. He was of good general condition and satisfactory local status. Ten days after surgery the patient was released from hospital with prescribed antihypertensive and antiaggregant therapy, and was also forbidden smoking. Conclusion. The reported case is the confirmation that AAA represents a ticking “time bomb” in the organism that requires emergency prehospital recognition, emergency care and high emergency transport to a hospital

Wells’ score for early prehospital screening of pulmonary embolism

Pulmonary embolism (PE) represents a significant health problem due to non-specific clinical features and a high risk of lethal outcome. PE diagnostics can sometimes be very difficult, especially at the prehospital level. We present a patient in whom early screening for PE at the prehospital level, performed using the Wells’ Score, was a life-saving event. Case scenario: the Emergency Medical Service (EMS) received a call regarding a male, aged 27 years, who was unconscious. Prior to losing consciousness, he complained of suffocation and tachycardia. Ten days earlier he sustained an injury to the knee which was immobilized with a splint, followed by bed rest. A year ago he was examined for chest pain, hypertension and tachycardia. On examination the patient was conscious, well oriented, eupneic, afebrile, with normal skin color. On pulmonary auscultation breath sounds were normal, and oxygen saturation was 90%. Findings on cardiac examination included: regular rate and rhythm, no murmur, blood pressure (BP) 120/85mmHg on both arms. ECG revealed sinus rhythm, rate of 100 beats/min, discreet signs of right heart strain (S1Q3T3 pattern), negative T wave from V1-V4, ST depression in D2, D3, AVF. A Wells’ score of 6 (most probably PE) was calculated: immobilization for 4 weeks – 1.5 points, tachycardia (pulse 120/min) – 1.5 points and alternative diagnosis less probable than PE – 3 points. The patient was suspected of PE and referred to a cardiologist. Conclusion. Pulmonary embolism often remains undiagnosed during a patient’s lifetime or is erroneously diagnosed. The significance of the scoring of each patient aimed at the recognition of pulmonary embolism at the prehospital level cannot be underestimated

Assessment of the implementation of step-by-step adult basic life support sequence by emergency medical technicians and drivers during regular annual training

Objective. Evaluation of the efficiency of practicing step-by-step (SBS) BLS/AED (basic life support/automatic external defibrillator) sequence by emergency medical technicians (EMT) and ambulance drivers (AD) working in medical transport teams. Methods. A prospective two-month study was conducted in which EMTs and ADs working in medical transport teams performed their regular 4-hour annual training (1 h of lectures, 1.5 h of practical training and 1.5 h of testing). Each participant performed SBS of BLS/AED sequences in front of a three-member team of instructors. The implementation of BLS/AED sequence was evaluated by scoring from 0 to 2 (0 – not, 1 – partially, 2 – properly), separately for EMTs, ADs and in total. The final analysis compared a properly implemented SBS sequence (S1-S36) of actions: IA – initial assessment (S1-S10), BLS (S11-S18), AED (S19-S25), RP – recovery position (S26-S32) and FBAO – foreign body airway obstruction (S33-S36) for use by the BLS/AED between EMTs and ADs. The criterion for a completed regular training was at least 47 (65.0%) of the total number of points won for properly implemented procedures. Results. The study involved 31 EMTs and 63 Ads, regardless of gender and average age, with EMTs having slightly longer work experience (p>0.05). The results of our study show that EMTs are more skilled at IA, cardiopulmonary resuscitation (CPR) and AED, whereas ADs were better at implementing RP and performing the Heimlich maneuver (p<0.001). Conclusion. Although EMTs and ADs implement SBS BLS/AED procedures correctly and satisfactorily in more than 65.0%, future research should focus on finding more efficient, shorter and cheaper BLS/AED trainings

EuReCa ONE—27 Nations, ONE Europe, ONE Registry A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe

AbstractIntroductionThe aim of the EuReCa ONE study was to determine the incidence, process, and outcome for out of hospital cardiac arrest (OHCA) throughout Europe.MethodsThis was an international, prospective, multi-centre one-month study. Patients who suffered an OHCA during October 2014 who were attended and/or treated by an Emergency Medical Service (EMS) were eligible for inclusion in the study. Data were extracted from national, regional or local registries.ResultsData on 10,682 confirmed OHCAs from 248 regions in 27 countries, covering an estimated population of 174 million. In 7146 (66%) cases, CPR was started by a bystander or by the EMS. The incidence of CPR attempts ranged from 19.0 to 104.0 per 100,000 population per year. 1735 had ROSC on arrival at hospital (25.2%), Overall, 662/6414 (10.3%) in all cases with CPR attempted survived for at least 30 days or to hospital discharge.ConclusionThe results of EuReCa ONE highlight that OHCA is still a major public health problem accounting for a substantial number of deaths in Europe.EuReCa ONE very clearly demonstrates marked differences in the processes for data collection and reported outcomes following OHCA all over Europe. Using these data and analyses, different countries, regions, systems, and concepts can benchmark themselves and may learn from each other to further improve survival following one of our major health care events

WHEN “BRUGADA HEART” STOPS BEATING

The typical Brugada patient is young, otherwise healthy male with normal general medical and cardiovascular physical findings. A present a case of successful resuscitation following “Brugada heart” arrest, where diagnosis of type 2 Brugada syndrome was made after cardiopulmonary resuscitation (CPR)

Recent treatment of postischaemic anoxic brain damage after cardiac arrest by using therapeutic hypothermia

Organ injury caused by ischemia and anoxia during prolonged cardiac arrest is compounded by reperfusion injury that occurs when spontaneous circulation is restored. Mild hypothermia (32-35ºC) is neuroprotective through several mechanisms, including suppression of apoptosis, reduced production of excitotoxins and free radicals, and anti-inflammatory actions. Experimental studies show that hypothermia is more effective the earlier it is started after return of spontaneous circulation (ROSC). Two randomized clinical trials show improved survival and neurological outcome in adults who remained comatose after initial resuscitation from prehospital VF cardiac arrest, and who were cooled after ROSC. Different strategies can be used to induce hypothermia. Optimal timing of therapeutic hypothermia for cardiac ischemia is unknown. In patients who failed to respond to standard cardiopulmonary resuscitation, intra-arrest cooling using ice-cold intravenous (i.v.) fluid improved the chance of survival. Recently, fasudil, a Rho kinase inhibitor, was reported to prevent cerebral ischaemia in vivo by increasing cerebral blood flow and inhibiting inflammatory responses. In future, two different kinds of protective therapies, BCL-2 overexpression and hypothermia, will both inhibit aspects of apoptotic cell death cascades, and that combination treatment can prolong the temporal 'therapeutic window' for gene therapy

Not to declare dead someone still alive: Case reports

Introduction. Diagnosing death represents an activity that carries a great deal of public responsibility for medical professionals and is continually exposed to the control of citizens and media. Although this is a taboo subject in medical circles, unfortunately in medical practice there are situations when the physician issues a death diagnosis form without even examining the person or for an already buried person. Such physician’s action is impermissible and it leads to the possibility of professional and criminal law punishment. Case Outline. By giving examples from practice, we wish to point out the need for exceptional caution when confirming and diagnosing death in order to diagnose the true, i.e. rule out apparent death and consequently avoid the mistake of declaring dead someone still alive. Conclusion. When confirming and declaring death, exceptional caution of the physician is necessary so as not to declare dead someone still alive