Neuroleptic malignant syndrome: a case report and discussion

Neuroleptic malignant syndrome (NMS) is an emergent, life threatening condition most often seen as an iatrogenic complication of neuroleptic or antipsychotic treatment. It is characterized by a tetrad of clinical features: mental status changes, fever, muscle rigidity and autonomic instability, although it is not necessary for all of them to be present at a same time for working diagnosis to be made. This paper will deal with the case of a 29-year old male patient diagnosed with schizophrenia who developed NMS, presented as a generalized tonic-clonic seizure and high fever, after 191 days of in-hospital treatment. After 13 days of hospital treatment in the Intensive Care Unit of Clinical Hospital Dubrava, the patient is in a hemodynamical and proper quantitative mental state and discharged for further psychiatric treatment at his parent hospital institution

SMJERNICE ZA OBRADU TRAUMATSKIH OZLJEDA GLAVE U ODRASLOJ POPULACIJI U HITNOJ SLUŽBI U KLINIČKOJ BOLNICI DUBRAVA

Head trauma is a common presentation in the Emergency Department (ED), ranging from skull fractures, minor traumatic brain injuries (TBIs) to severe TBIs in polytraumas. In moderate traumatic brain injuries, patient assessment and diagnostic work-ups can be ameliorated with the application of Clinical Decision Rules (CDRs) such as the Canadian CT Head Rule (CCHR) and the National Institute for Care and Excellence (NICE) guidelines. Optimal adherence to these CDRs greatly benefi ts patients, reduces waiting times, ED overcrowding, mortality and ED clinician pitfalls. The aim of this report is to provide the reader with a brief review of the CCHR and NICE guidelines, which are implemented in Dubrava University Hospital, with an overview as to how our ED collaborates with its neurosurgical team and other surgical specialists in situations of polytrauma and TBI patients, mainly focusing on TBI. In addition, we will introduce the Dubrava Model, one of the neurotrauma models implemented in fast treatment of TBIs in rural hospitals devoid of resident neurosurgeon.Trauma glave, sežući od prijeloma lubanje i manje traumatske ozljede mozga do teške traumatske ozljede mozga u politraumama, česta je prezentacija u hitnoj službi. Kod umjerenih/srednje teških traumatskih ozljeda mozga pristup bolesniku i dijagnostička obrada mogu se poboljšati primjenom kliničkih smjernica kao što su Canadian CT Head Rule (CCHR) i smjernice National Institute for Care and Excellence (NICE). Optimalno pridržavanje navedenih smjernica uvelike koristi bolesnicima, smanjuje vrijeme čekanja, prenapučenost hitne službe, smrtnost i pogreške liječnika u hitnoj službi. Cilj ovoga rada je pružiti čitatelju kratak pregled smjernica CCHR i NICE koje se primjenjuju u Kliničkoj bolnici Dubrava, s osvrtom na suradnju naše hitne službe i neurokirurškog tima te liječnika drugih kirurških grana u obradi politraumatiziranih bolesnika i bolesnika s traumatskim ozljedama mozga. Uz to, prikazujemo Model “Dubrava”, jedinstveni model pristupu neurotraumi koji se primjenjuje u brzom liječenju traumatskih ozljeda mozga u ruralnim bolnicama lišenim službujućeg neurokirurga

RETROPERITONEAL GAS GANGRENE

Plinska gangrena ili klostridijska mionekroza smrtonosna je infekcija i destrukcija zdravog mišićnog tkiva koja se razvija nakon traume (traumatska) ili hematogenim širenjem iz gastrointestinalnog trakta (spontana). Rano prepoznavanje i agresivno liječenje od najveće su važnosti. Bol na mjestu traumatske ozljede u kombinaciji sa znakovima sistemske toksičnosti te prisutnost plina u mekim tkivima podupiru dijagnozu plinske gangrene. Prigodom kliničkog pregleda najosjetljiviji i najspecifi čniji znak su krepitacije u mekim tkivima pri čemu je radiološko snimanje također koristan dijagnostički alat. Prikazujemo slučaj 44-godišnje žene koja se javlja u hitnu službu s bolovima u lijevom kuku i koljenu koje ima unatrag nekoliko dana. Bolesnica je izričito negirala traumu ili druge značajne tegobe za vrijeme pregleda. Iz njezine povijesti bolesti poznato je da je prije devet godina liječena od raka dojke zbog čega je bila podvrgnuta operaciji i kemoterapiji. Učinjen je rendgenski snimak lijevog kuka i koljena koji je opisao lijevostranu koksartrozu. Pacijentica je na koncu otpuštena kući nakon intramuskularno primljenog analgetika, s uputom da se javi u redovnu ortopedsku ambulantu, a u slučaju pogoršanja u hitnu službu. Sedam dana kasnije pacijentica se javila u hitnu službu zbog otežanog disanja, povišene tjelesne temperature do 39° C, lošeg općeg stanja i otekline lijevog gležnja i potkoljenice. Nakon dijagnostičke obrade verifi cirani su izrazito povišeni upalni parametri te je na MSCT-u abdomena opisana plinska gangrena lijevog retroperitoneja i mišića lijeve strane zdjelice te lijevog proksimalnog femura. Promptno su konzultirani abdominalni kirurg i traumatolog koji su indicirali empirijsku antibiotsku terapiju i hitno kirurško liječenje u općoj anesteziji. Postoperacijski tijek je protekao uredno te se pacijentica godinu dana nakon zahvata osjeća dobro. U ovom radu prikazano je kako od jedne naizgled uobičajene kliničke prezentacije može u samo nekoliko dana doći do komplikacije opasne za život i kliničkog pogoršanja. Pravovremena i adekvatna reakcija liječnika u hitnoj službi bila je presudna pri čemu je pacijentica ubrzo nakon dijagnoze podvrgnuta radikalnom i agresivnom kirurškom liječenju i antibiotskoj terapiji čime je spriječen i izbjegnut značajan štetan ili čak smrtonosan ishod.Gas gangrene or clostridial myonecrosis is a life-threatening infection and destruction of healthy muscle tissue that develops after trauma (traumatic) or by hematogenous spread from the gastrointestinal tract (spontaneous). Early recognition and aggressive treatment are of utmost importance. Pain at the site of traumatic injury combined with signs of systemic toxicity and the presence of gas in the soft tissue support the diagnosis of gas gangrene. On clinical examination, crepitations in soft tissues are the most sensitive and specifi c sign, and radiological imaging is also a useful diagnostic tool. On differential diagnosis, polymicrobial necrotizing soft tissue infection should be distinguished from gas gangrene. We present a case of a 44-year-old female who presented to the emergency department with pain in her left hip and knee, felt for several days back. She explicitly denied trauma or other signifi cant illness at the time of examination. Her personal history revealed that she had been treated for breast cancer 9 years before, had undergone surgery and chemotherapy. The x-ray of her left hip and knee showed left coxarthrosis. Eventually, the patient was discharged home after receiving intramuscular diclofenac 75 mg in the left gluteus, with instructions to report to the orthopedic outpatient clinic, and in case of deterioration, to the emergency room. Seven days later, the patient presented to our emergency room because of diffi culty breathing, fever up to 39 °C, poor general condition, and swelling of the left ankle and lower leg. After diagnostic workup, highly elevated infl ammatory parameters were verifi ed and multi-slice computed tomography of the abdomen showed gas gangrene of the left retroperitoneum and muscles of the left side of the pelvis and left proximal femur. Abdominal surgeon and traumatologist were promptly consulted and empirical parenteral antibiotic therapy and emergency surgery under general anesthesia were indicated. The postoperative course was without major complications and one year after the procedure, the patient felt well. This case report shows that a seemingly benign clinical presentation can lead to life-threatening complications and clinical deterioration in just a few days. The timely and appropriate response of the emergency room physician was crucial, where soon after the diagnosis, the patient underwent radical and aggressive surgical treatment and antibiotic therapy, thus preventing and avoiding a signifi cant adverse or even lethal outcome

The role of hyperbaric oxygenotherapy (HBOT) in the treatment of COVID-19 patients

Pandemija COVID-19 postavila je velik izazov suvremenoj medicini. Unatoč značajnim naporima medicinske i znanstvene zajednice, do trenutka pisanja ovog članka i dalje ne postoji ciljano etiološko liječenje bolesnika akutno oboljelih od COVID-19, kao i bolesnika s post-COVID sindromom. Hiperbarična oksigenoterapija (HBOT) jest medicinski i znanstveno priznat terapijski postupak u liječenju brojnih akutnih i kroničnih stanja u kojima je nedostatak kisika osnovni patofiziološki poremećaj. S obzirom na nekoliko publiciranih serija slučajeva koji su pokazali značajan povoljni učinak primjene HBOT-a u liječenju pacijenata oboljelih od infekcije COVID-19 te na osnovi višedesetljetnog iskustva u primjeni HBOT-a u drugim poljima, rodila se potreba za provođenjem kvalitetnih i dobro strukturiranih studija kojima je cilj jasno ispitati utjecaj primjene HBOT-a u liječenju oboljelih od COVID-19. Prema dostupnim izvorima trenutno se u svijetu provodi 9 takvih istraživanja. Mehanizmi učinka primjene HBOT-a u liječenju oboljelih od COVID-19 zasnivaju se na korekciji hipoksije, atenuaciji upalnog odgovora te „otplate duga kisika“ u kratkom vremenskom razdoblju, na taj način osiguravajući prozor aerobnom metabolizmu u duboko hipoksičnim tkivima i važnim organima.The COVID-19 pandemic has posed a major challenge to modern medicine. Despite significant efforts by the medical and scientific community, at the time of writing, there is still no targeted etiological treatment for acutely ill COVID-19 patients as well as patients with post-COVID syndrome. Hyperbaric oxygen therapy (HBOT) is a medically and scientifically recognized therapeutic procedure in the treatment of a number of acute and chronic conditions in which oxygen deficiency is pathophysiologically primary disorder. Given the several published series of cases that have shown a significant beneficial effect of HBOT in the treatment of patients with COVID-19 infection, and based on decades of experience in the use of HBOT in other fields, the need to conduct quality and well-structured studies arose with the aim to clearly examine the impact of HBOT use in the treatment of COVID-19 patients. According to available sources, nine such studies are being conducted worldwide.The mechanisms of the effect of HBOT in the treatment of COVID-19 patients are based on the correction of hypoxia, attenuation of the inflammatory response and “repayment of oxygen debt” in a short period of time, thus providing a window to aerobic metabolism in deeply hypoxic tissues and important organs