Zbrinjavanje hitnih stanja vezanih uz arterijsku hipertenziju u izvanbolničkoj hitnoj medicinskoj službi

SUMMARY Arterial hypertension is the most common cause of cardiovascular diseases and mortality. It significantly contributes to the incidence of other chronic diseases, the most frequent being myocardial infarction and stroke. Arterial hypertension, whether chronically uncontrolled or especially in case of hypertensive emergency, represents a complex state that must be adequately assessed and managed. Hypertensive emergencies are not common in the general population, but represent a serious health emergency that can rapidly lead to irreversible damage and loss of function of target organs if not treated adequately. Prompt and effective treatment in prehospital emergency care significantly contributes to the overall quality of the healthcare system.SAŽETAK Arterijska je hipertenzija najčešći uzrok kardiovaskularnih bolesti kao i smrtnosti. Znatno pridonosi učestalosti ostalih kroničnih bolesti, od kojih su najučestalije infarkt miokarda i moždani udar. Arterijska hipertenzija, bilo ona kronična neregulirana, a posebno u slučaju hipertenzivne hitnoće ili emergencije, kompleksno je stanje koje je potrebno odgovarajuće procijeniti i zbrinuti. Hipertenzivne emergencije nisu učestale u populaciji, ali su ozbiljna hitna stanja koja u kratkom vremenu, ako se odgovarajuće ne zbrinu, uzrokuju ireverzibilno oštećenje i gubitak funkcije ciljnih organa. Promptno i učinkovito postupanje u izvanbolničkoj hitnoj medicinskoj službi znatno doprinosi kvaliteti cjelokupnoga zdravstvenog sustava

Dijagnostika plućne embolije u Objedinjenom hitnom bolničkom prijamu

The aim of this study was to determine the association of clinical presentation, the Wells scoring system and D-dimer values with MSCT pulmonary angiography. A case control study was conducted in the Emergency Department of the Clinical Hospital Sveti Duh throughout 2019. Patients with a referral diagnosis of a pulmonary embolism were included in the study. Patients were divided into two groups. The first group consisted of patients diagnosed with pulmonary embolism by MSCT pulmonary angiography or postmortem, and the second group consisted of patients excluded from pulmonary embolisms. For the Wells score, D-dimers, troponin, respiratory rate and peripheral blood oxygen saturation, statistically significant differences were found between groups of patients with confirmed or excluded pulmonary embolism (p <0.001). For heart rate, chest pain, syncope, and hemoptysis, no statistically significant differences were found between these two groups of patients. Deep venous thrombosis of the lower extremities was found by ultrasound in > 70% of patients with massive a pulmonary embolism. Pulmonary embolism was confirmed in all patients for whom a high risk was calculated according to the Wells score. In conclusion, a low degree of clinical probability (according to the Wells score), along with a normal concentration of D-dimer, are a sure strategy in excluding pulmonary embolism.Cilj rada je bio utvrditi povezanost kliničke slike, Wellsovog bodovnog sustava i vrijednosti D-dimera s MSCT plućnom angiografijom. Provedena je studija istraživanja parova u Objedinjenom hitnom bolničkom prijamu Kliničke bolnice „Sveti Duh“ tijekom cijele 2019. godine. U istraživanje su bili uključeni bolesnici sa uputnom dijagnozom plućne embolije. Bolesnici su podijeljeni u dvije skupine. U prvoj su skupini bili bolesnici kojima je dijagnoza plućne embolije potvrđena MSCT plućnom angiografijom ili post mortem, a drugu skupinu su činili bolesnici kod kojih je isključena plućna embolija. Za Wellsov skor, D-dimere, troponin, frekvenciju disanja i perifernu zasićenost krvi kisikom nađene su statistički značajne razlike između skupina bolesnika s potvrđenom, odnosno isključenom plućnom embolijom (p<0,001). Za frekvenciju srca, bol u prsima, sinkopu i hemoptizu nije nađena statistički značajna razlika između ove dvije skupine bolesnika. U >70% bolesnika s masivnom plućnom embolijom ultrazvučno je nađena duboka venska tromboza donjih ekstremiteta. Kod svih bolesnika kojima je prema Wellsovom bodovnom skoru izračunat visok rizik potvrđena je plućna embolija. Zaključno, niski stupanj kliničke vjerojatnosti (prema Wellsovom bodovnom skoru) zajedno s normalnom koncentracijom D-dimera sigurna su strategija u isključenju plućne embolije

ACUTE DIABETIC COMPLICATIONS ATTENDED AT HOSPITAL EMERGENCY DEPARTMENT FROM 2010 TO 2018

Cilj rada: Šećerna bolest je veliki zdravstveni i socioekonomski problem u Republici Hrvatskoj. Prema podatcima Hrvatskog zavoda za javno zdravstvo registrirano je preko 300.000 bolesnika sa šećernom bolesti, uz daljnji rast broja oboljelih. U 2017. godini šećerna bolest nalazila se na petom mjestu vodećih uzroka smrti sa 3,7 % udjela u ukupnoj smrtnosti. Dijabetička ketoacidoza, hiperglikemijsko hiperosmolarno stanje i hipoglikemija su ozbiljne komplikacije šećerne bolesti tip 1 i tip 2, koje su ujedno i najčešća hitna stanja u endokrinologiji. Iako se dijabetička ketoacidoza najčešće javlja u osoba s tipom 1 šećerne bolesti, a hiperosmolarno stanje s tipom 2 sve je veća pojavnost dijabetičke ketoacidoze i u dijabetičara s tipom 2 šećerne bolesti. Glavni cilj istraživanja je analizirati hipoglikemijske i hiperglikemijske krize bolesnika u hitnoj medicinskoj službi u razdoblju od 2010. do 2018. godine u Kliničkoj bolnici Sveti Duh. Metode: Ispitivana populacija obuhvaćala je ukupno 175.446 odrasle osobe pregledane u hitnoj medicinskoj službi u razdoblju od 1. 1. 2010. do 31. 12. 2018., uz vrijednost glukoze u plazmi većoj od 13,9 mmol/L ili manjoj od 3,9 mmol/L. Ovisno o nalazu acidobaznog statusa, ketonuriji i osmolarnosti plazme bolesnici su podijeljeni u jednu od četiri skupine: neketotična hiperglikemija, hipoglikemija u šećernoj bolesti, dijabetička ketoacidoza ili hiperosmolarno hiperglikemijsko stanje. Bolesnici su također podijeljeni prema dobi i tipu šećerne bolesti. Rezultati: U 3.773 posjeta bila je zadovoljena defi nicija hiperglikemijske ili hipoglikemijske krize, od čega 180 epizoda dijabetičke ketoacidoze, 29 hiperosmolarna hiperglikemijska stanja, 359 hipoglikemijska stanja te 567 slučajeva novootkrivene šećerne bolesti. Broj epizoda hiperglikemijskih kriza bio je tijekom godina bez većih odstupanja. Samo 17,72 % slučajeva dijabetičke ketoacidoze zabilježeno je u bolesnika sa šećernom bolesti tip 1, dok su preostali bolesnici imali dijagnozu tip 2. Zabilježeno je da su infekcije bile najčešći čimbenik rizika dijabetičke ketoacidoze s 35,4 %, propuštanjem terapije inzulina kao drugim najčešćim uzrokom s 29,3 %. U 15 % bolesnika s akutnim komplikacijama šećerne bolesti zabilježen je ponovni prijam u razdoblju od 30 dana. Rasprava: Učestalost posjeta hitnom prijmu bolesnika sa šećernom bolesti bila je veća od očekivane s obzirom na učestalost dijagnoze u općoj populaciji. Zabilježeno je godišnje povećanje broja slučajeva dijabetičke ketoacidoze i hipoglikemija u bolesnika sa šećernom bolesti starijih od 60 godina. S obzirom na smjernice kliničke prakse, vrijeme započinjanja i volumen primjene kristaloidnih otopina bili su u preko dvije trećine slučajeva zadovoljavajući. Međutim, usporedbom sa smjernicama kliničke prakse o primjeni inzulina unutar prvih 60 minuta, u više od dvije trećine slučajeva dijabetičke ketoacidoze vrijeme prve primjene bilo je nakon 100 minuta. Mogući razlozi su nespecifi čnost kliničkih znakova i vrijeme potrebno do dostupnosti rezultata krvnih nalaza. Zaključak: Učestalost šećerne bolesti u bolesnika koji su zaprimljeni u hitnu medicinsku službu veća je od očekivane u općoj populaciji uz porast broja bolesnika sa šećernom bolesti tip 1 i tip 2. Većina bolesnika s dijabetičkom ketoacidozom imala su šećernu bolest tip 2, iako su se bolesnici s tipom 1 u hitnoj službi češće prezentirali s dijabetičkom ketoacidozom. Najčešći prepoznati čimbenici rizika za dijabetičku ketoacidozu bile su infekcije i neodgovarajuća terapija inzulina. Zabilježen je porast korištenja metformina i DPP-4 inhibitora u terapiji šećerne bolesti.Objective: Diabetes is one of the major health and socioeconomic problems in Croatia. According to data from the Croatian Institute of Public Health, over 300,000 patients with diabetes have been registered, with further increase in the number of patients. In 2017, diabetes was recognized as the fi fth leading cause of death, accounting for 3.7% of total mortality. Diabetic ketoacidosis, hyperglycemic hyperosmolar condition, and hypoglycemia are serious complications of type 1 and type 2 diabetes, which also are the most common emergency conditions in endocrinology. Although diabetic ketoacidosis most commonly occurs in people with type 1 diabetes and hyperosmolar condition in those with type 2 diabetes, there is an increasing incidence of diabetic ketoacidosis in subjects with type 2 diabetes. The main aim of the research was to analyze the hypoglycemic and hyperglycemic crisis patients at Department of Emergency Medicine, Sveti Duh University Hospital, during the 2010-2018 period. Methods: The study population included a total of 175,446 adults examined at Emergency Department from January 1, 2010 until December 31, 2018, with plasma glucose values greater than 13.9 mmol/L or less than 3.9 mmol/L. Depending on the acid-base status, ketonuria and plasma osmolarity, patients were divided into four groups as follows: non-ketotic hyperglycemia, hypoglycemia in diabetes, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. Patients were also divided according to age and type of diabetes. Results: At 3,773 visits, defi nitions of hyperglycemic or hypoglycemic crisis were met, of which 180 episodes of diabetic ketoacidosis, 29 hyperosmolar hyperglycemic conditions, 359 hypoglycemic conditions, and 567 cases of newly diagnosed diabetes. The number of episodes of hyperglycemic crisis was been without major fl uctuations over years. Only 17.72% of diabetic ketoacidosis cases were reported in patients with type 1 diabetes, whereas the remaining patients were diagnosed with type 2 diabetes. Infections were reported as the most common risk factor for diabetic ketoacidosis (35.4%), followed by missed insulin therapy as the second most common cause (29.3%). Repeated admission within 30 days was recorded in 15% of patients with acute complications of diabetes. Discussion: The frequency of visits of diabetic patients was higher than expected due to the frequency of diagnoses in the general population. There was an annual increase in the incidence of diabetic ketoacidosis and hypoglycemia in patients older than 60 years. Considering the guidelines for clinical practice, the starting time and volume of crystalloid solutions administered were satisfactory in more than two-thirds of cases. However, compared to clinical practice guidelines for insulin administration within the fi rst 60 minutes, the time of fi rst administration was after 100 minutes in more than two-thirds of diabetic ketoacidosis cases. The possible reasons were non-specifi city of the clinical signs and the time it took for blood test result reporting. Conclusion: The incidence of diabetes in patients admitted to the emergency department was higher than expected in the general population, with an increase in type 1 and type 2 diabetes patients. Most patients with diabetic ketoacidosis had already been diagnosed with type 2 diabetes, although patients with type 1 diabetes more often presented with diabetic ketoacidosis to the emergency department. The most commonly recognized risk factors for diabetic ketoacidosis were infection and inadequate insulin therapy. There was an increase in the use of metformin and DPP-4 inhibitors in diabetes therapy

ACUTE DIABETIC COMPLICATIONS ATTENDED AT HOSPITAL EMERGENCY DEPARTMENT FROM 2010 TO 2018

Cilj rada: Šećerna bolest je veliki zdravstveni i socioekonomski problem u Republici Hrvatskoj. Prema podatcima Hrvatskog zavoda za javno zdravstvo registrirano je preko 300.000 bolesnika sa šećernom bolesti, uz daljnji rast broja oboljelih. U 2017. godini šećerna bolest nalazila se na petom mjestu vodećih uzroka smrti sa 3,7 % udjela u ukupnoj smrtnosti. Dijabetička ketoacidoza, hiperglikemijsko hiperosmolarno stanje i hipoglikemija su ozbiljne komplikacije šećerne bolesti tip 1 i tip 2, koje su ujedno i najčešća hitna stanja u endokrinologiji. Iako se dijabetička ketoacidoza najčešće javlja u osoba s tipom 1 šećerne bolesti, a hiperosmolarno stanje s tipom 2 sve je veća pojavnost dijabetičke ketoacidoze i u dijabetičara s tipom 2 šećerne bolesti. Glavni cilj istraživanja je analizirati hipoglikemijske i hiperglikemijske krize bolesnika u hitnoj medicinskoj službi u razdoblju od 2010. do 2018. godine u Kliničkoj bolnici Sveti Duh. Metode: Ispitivana populacija obuhvaćala je ukupno 175.446 odrasle osobe pregledane u hitnoj medicinskoj službi u razdoblju od 1. 1. 2010. do 31. 12. 2018., uz vrijednost glukoze u plazmi većoj od 13,9 mmol/L ili manjoj od 3,9 mmol/L. Ovisno o nalazu acidobaznog statusa, ketonuriji i osmolarnosti plazme bolesnici su podijeljeni u jednu od četiri skupine: neketotična hiperglikemija, hipoglikemija u šećernoj bolesti, dijabetička ketoacidoza ili hiperosmolarno hiperglikemijsko stanje. Bolesnici su također podijeljeni prema dobi i tipu šećerne bolesti. Rezultati: U 3.773 posjeta bila je zadovoljena defi nicija hiperglikemijske ili hipoglikemijske krize, od čega 180 epizoda dijabetičke ketoacidoze, 29 hiperosmolarna hiperglikemijska stanja, 359 hipoglikemijska stanja te 567 slučajeva novootkrivene šećerne bolesti. Broj epizoda hiperglikemijskih kriza bio je tijekom godina bez većih odstupanja. Samo 17,72 % slučajeva dijabetičke ketoacidoze zabilježeno je u bolesnika sa šećernom bolesti tip 1, dok su preostali bolesnici imali dijagnozu tip 2. Zabilježeno je da su infekcije bile najčešći čimbenik rizika dijabetičke ketoacidoze s 35,4 %, propuštanjem terapije inzulina kao drugim najčešćim uzrokom s 29,3 %. U 15 % bolesnika s akutnim komplikacijama šećerne bolesti zabilježen je ponovni prijam u razdoblju od 30 dana. Rasprava: Učestalost posjeta hitnom prijmu bolesnika sa šećernom bolesti bila je veća od očekivane s obzirom na učestalost dijagnoze u općoj populaciji. Zabilježeno je godišnje povećanje broja slučajeva dijabetičke ketoacidoze i hipoglikemija u bolesnika sa šećernom bolesti starijih od 60 godina. S obzirom na smjernice kliničke prakse, vrijeme započinjanja i volumen primjene kristaloidnih otopina bili su u preko dvije trećine slučajeva zadovoljavajući. Međutim, usporedbom sa smjernicama kliničke prakse o primjeni inzulina unutar prvih 60 minuta, u više od dvije trećine slučajeva dijabetičke ketoacidoze vrijeme prve primjene bilo je nakon 100 minuta. Mogući razlozi su nespecifi čnost kliničkih znakova i vrijeme potrebno do dostupnosti rezultata krvnih nalaza. Zaključak: Učestalost šećerne bolesti u bolesnika koji su zaprimljeni u hitnu medicinsku službu veća je od očekivane u općoj populaciji uz porast broja bolesnika sa šećernom bolesti tip 1 i tip 2. Većina bolesnika s dijabetičkom ketoacidozom imala su šećernu bolest tip 2, iako su se bolesnici s tipom 1 u hitnoj službi češće prezentirali s dijabetičkom ketoacidozom. Najčešći prepoznati čimbenici rizika za dijabetičku ketoacidozu bile su infekcije i neodgovarajuća terapija inzulina. Zabilježen je porast korištenja metformina i DPP-4 inhibitora u terapiji šećerne bolesti.Objective: Diabetes is one of the major health and socioeconomic problems in Croatia. According to data from the Croatian Institute of Public Health, over 300,000 patients with diabetes have been registered, with further increase in the number of patients. In 2017, diabetes was recognized as the fi fth leading cause of death, accounting for 3.7% of total mortality. Diabetic ketoacidosis, hyperglycemic hyperosmolar condition, and hypoglycemia are serious complications of type 1 and type 2 diabetes, which also are the most common emergency conditions in endocrinology. Although diabetic ketoacidosis most commonly occurs in people with type 1 diabetes and hyperosmolar condition in those with type 2 diabetes, there is an increasing incidence of diabetic ketoacidosis in subjects with type 2 diabetes. The main aim of the research was to analyze the hypoglycemic and hyperglycemic crisis patients at Department of Emergency Medicine, Sveti Duh University Hospital, during the 2010-2018 period. Methods: The study population included a total of 175,446 adults examined at Emergency Department from January 1, 2010 until December 31, 2018, with plasma glucose values greater than 13.9 mmol/L or less than 3.9 mmol/L. Depending on the acid-base status, ketonuria and plasma osmolarity, patients were divided into four groups as follows: non-ketotic hyperglycemia, hypoglycemia in diabetes, diabetic ketoacidosis, and hyperosmolar hyperglycemic state. Patients were also divided according to age and type of diabetes. Results: At 3,773 visits, defi nitions of hyperglycemic or hypoglycemic crisis were met, of which 180 episodes of diabetic ketoacidosis, 29 hyperosmolar hyperglycemic conditions, 359 hypoglycemic conditions, and 567 cases of newly diagnosed diabetes. The number of episodes of hyperglycemic crisis was been without major fl uctuations over years. Only 17.72% of diabetic ketoacidosis cases were reported in patients with type 1 diabetes, whereas the remaining patients were diagnosed with type 2 diabetes. Infections were reported as the most common risk factor for diabetic ketoacidosis (35.4%), followed by missed insulin therapy as the second most common cause (29.3%). Repeated admission within 30 days was recorded in 15% of patients with acute complications of diabetes. Discussion: The frequency of visits of diabetic patients was higher than expected due to the frequency of diagnoses in the general population. There was an annual increase in the incidence of diabetic ketoacidosis and hypoglycemia in patients older than 60 years. Considering the guidelines for clinical practice, the starting time and volume of crystalloid solutions administered were satisfactory in more than two-thirds of cases. However, compared to clinical practice guidelines for insulin administration within the fi rst 60 minutes, the time of fi rst administration was after 100 minutes in more than two-thirds of diabetic ketoacidosis cases. The possible reasons were non-specifi city of the clinical signs and the time it took for blood test result reporting. Conclusion: The incidence of diabetes in patients admitted to the emergency department was higher than expected in the general population, with an increase in type 1 and type 2 diabetes patients. Most patients with diabetic ketoacidosis had already been diagnosed with type 2 diabetes, although patients with type 1 diabetes more often presented with diabetic ketoacidosis to the emergency department. The most commonly recognized risk factors for diabetic ketoacidosis were infection and inadequate insulin therapy. There was an increase in the use of metformin and DPP-4 inhibitors in diabetes therapy

Dijagnostička vrijednost ultrazvuka srca u procjeni trajanja arterijske hipertenzije

The aim of the study was to assess the correlation between the degree and duration of arterial hypertension and the hypertrophy of the left ventricle and the ejection fraction of the heart, with cardiac ultrasound. Our prospective study included 50 patients with arterial hypertension as leading diagnosis. All 50 patients were consecutively examined in the Emergency Department and then referred to the Cardiac clinic of the Clinical Hospital “Sveti Duh” for further evaluation. The inclusion criteria were male and female aged 18 and older and arterial hypertension as leading diagnosis during Emergency Department visit. Exclusion criteria were pathological conditions that alter myocardial architecture and impair contractility. Measurement of the left ventricle thickness based on the thickness of the intraventricular septum and the posterior wall of the left ventricle, and the ejection fraction was ultrasonically determined. The highest proportion of subjects was with the first degree of arterial hypertension, followed by subjects with a third degree. The average duration of arterial hypertension was 6.14 years. Of the total number of subjects, 28% did not take any antihypertensive drugs. A statistically significant association was found between the degree and duration of arterial hypertension with the development of left ventricular hypertrophy. Significant association wasn’t found between the degree or duration of arterial hypertension and the heart ejection fraction. Our study have shown strong correlation between the degree and duration of arterial hypertension and the development of left ventricular hypertrophy and ultrasound could be a useful method in the evaluation of some patients with arterial hypertension in the emergency department.Cilj istraživanja je bio uz pomoć ultrazvuka srca procijeniti povezanosti između stupnja i duljine trajanja arterijske hipertenzije te razvoja hipertrofije lijeve klijetke i istisne frakcije srca. Provedeno je prospektivno istraživanje koje je uključivalo 50 bolesnika sa arterijskom hipertenzijom kao vodećom dijagnozom. Svih 50 bolesnika je uzastopno pregledano u Objedinjenom hitnom bolničkom prijamu, a nakon toga upućeno u kardiološku ambulantu Kliničke bolnice „Sveti Duh“ na daljnju obradu. U istraživanje su bili uključeni bolesnici stariji od 18 godina, oba spola, s vodećom dijagnozom arterijske hipertenzije postavljene u Objedinjenom hitnom bolničkom prijamu dok su iz istraživanja bili isključeni bolesnici s patološkim stanjima koja mijenjaju arhitekturu i narušavaju kontraktilnost srca. Ultrazvučno se određivala debljina stijenke lijeve klijetke sačinjena od debljine intraventrikularnog septuma i stražnje stijenke lijeve klijetke te istisna frakcija. Najveći udio ispitanika bio je s prvim stupnjem, a slijedili su ih ispitanici s trećim stupnjem arterijske hipertenzije. Prosječno trajanje arterijske hipertenzije iznosilo je 6.14 godina. Od ukupnog broja ispitanika, 28% nije uzimalo nikakve antihipertenzivne lijekove. Pronađena je statistički značajna povezanost između stupnja i duljine trajanja arterijske hipertenzije s razvojem hipertrofije lijeve klijetke. Nije pronađena značajna povezanost stupnja niti duljine trajanja arterijske hipertenzije s istisnom frakcijom srca. Naša studija pokazala je snažnu povezanost između stupnja i duljine trajanja arterijske hipertenzije i razvoja hipertrofije lijeve klijetke, a ultrazvuk bi mogao biti korisna metoda u procjeni nekih bolesnika s arterijskom hipertenzijom u hitnoj službi

USE OF TRANSPORT VENTILATOR AT THE INSTITUTE OF EMERGENCY MEDICINE OF VARAŽDIN COUNTY

Svaki liječnički tim izvanbolničkih zavoda za hitnu medicinu - Tim 1 opremljen je transportnim ventilatorom. Cilj rada bio je utvrditi razinu edukacije i osposobljenost zdravstvenih radnika Tima 1 Zavoda za hitnu medicinu Varaždinske županije (ZHM VŽ) iz područja mehaničke ventilacije te koliko se transportni ventilator upotrebljava u svakodnevnom radu. Ispitanici su dobili zadatak da na transportnom ventilatoru namjeste postavke za dva načina ventilacije: invazivni, tijekom reanimacije (Volume Controlled Continuous Mandatory Ventilation) i neinvazivni (Spontaneous Continuous Positive Airway Pressure). Od ukupno 21 ispitanika 7 (33 %) ih je uspješno namjestilo postavke transportnog ventilatora za oba zadana scenarija, 6 (29 %) samo u scenariju reanimacije, a 8 (38 %) ispitanika nije uspjelo ni u jednom scenariju. Bolje rezultate postigli su ispitanici koji su završili tečaj „Održavanje dišnog puta i mehanička ventilacija u hitnoj medicini“ te koji su neku od edukacija završili prošle ili ove go dine. Čak 19 (90 %) ispitanika izrazilo je potrebu za dodatnom edukacijom. Broj radnih sati transportnih ventilatora u posljednje dvije godine iznosio je prosječno 2 sata i 10 minuta po uređaju, što je nedovoljno. Međutim, s obzirom na velik udio zdravstvenih radnika koji su naveli potrebu za dodatnom edukacijom, postoji velik prostor za poboljšanje upotrebe transportnog ventilatora u ZHM VŽ s ciljem što bolje skrbi za hitne bolesnike.The objective of this study conducted at the Institute of Emergency Medicine of Varaždin County (IEM VC) was to investigate the emergency medicine service (EMS) healthcare workers’ education and capability regarding mechanical ventilation and to explore the use of transport ventilator in daily practice. To quantify EMS healthcare workers’ capability for use of transport ventilator, we developed two clinical scenarios with emphasis on emergency management of ventilated patients, i.e. one during resuscitation (VC CMV mode) and the other for noninvasive mechanical ventilation (SpnCPAP mode). The following data were collected: profession, years of work in the EMS, and year and type of education in the fi eld of mechanical ventilation. Years of work in the EMS were 1-21 years in both scenarios solved, 2 months to 25 years in the fi rst scenario solved, and 1-27 years in neither scenario solved. The number of operating hours of each transport mechanical ventilator was obtained from the memory of the device at regular service, which is carried out every two years. Out of 21 respondents, 7 (33%) had successfully adjusted the transport mechanical ventilator settings in both scenarios, 6 (29%) only in the scenario of resuscitation, and 8 (38%) failed in both scenarios. Distribution by profession was as follows: 3 out of 8 doctors and 4 out of 13 nurses/technicians successfully solved both scenarios, 3 doctors and 3 nurses/technicians successfully solved first scenario, and 2 doctors and 6 medical nurses/technicians failed to solve both scenarios. Better results were achieved by respondents who had completed the Respiratory and Mechanical Ventilation in Emergency Medicine course or other education in the last two years. Even 19 (90%) respondents expressed the need for additional education. The number of operating hours of transport mechanical ventilator in the last two years was 2 hours and 10 minutes per device. The medical teams of IEM VC often take care of patients who could benefit from the use of transport ventilator because of their condition. The results suggest that the knowledge about the use of transport mechanical ventilator is not dependent on the years in work in the EMS, being a physician or a nurse/technician. However, this knowledge was found to greatly depend on the type and time of education. Literature data show that even though mechanical ventilation is considered a standard in emergency medicine, the exact time of training required for its use has not been established, and the number of studies investigating the use of mechanical ventilator in the fi ld of emergency medicine is limited. The limitations of this study were a relatively small number of respondents and the fact that each subject was individually tested about working with transport ventilator, whereas teamwork is used in daily work, so that a physician and nurse/ technician together with educated driver provide care of emergency patients. In conclusion, transport ventilator is not used enough in daily care of patients in IEM VC. Much better ability to work with transport ventilator was demonstrated by physicians and nurses/technicians with a higher level of education in mechanical ventilation, regardless of years of work in the EMS. Considering the large proportion of healthcare workers who have identifi ed the need for additional education, there is a great opportunity to improve the use of mechanical ventilator, with the aim of providing better care for emergency patients

Blokovi perifernih živaca u bolesnika s prijelomom kuka

Hip fractures represent a major public health issue with increasing incidence as a population ages. The aim of this review is to describe peripheral nerve block techniques (the fascia iliaca compartment block and the pericapsular nerve group block) as pain management for hip fractures in emergency medicine, and to emphasize their benefits. Hip fractures are extremely painful injuries. The pain itself is unpleasant for patients and if left untreated it can lead to multiple complications during preoperative, operative and postoperative patient management. Pain management for elderly hip fracture patients is often challenging. Non-steroidal anti-inflammatory drugs are not recommended due to their side effects, the increased risk of gastrointestinal bleeding, renal function impairment and platelet aggregation inhibition. Paracetamol alone is often insufficient, and opioids have many potentially harmful side effects, such as delirium development. Peripheral nerve blocks for hip fractures are safe and effective, also in emergency medicine settings. The benefits for patients are greater pain relief, especially during movement, less opioid requirements and decreased incidence of delirium. Regional analgesia should be routinely used in hip fracture pain management.Prijelom kuka predstavlja značajan javno zdravstveni problem čija će incidencija rasti sa starenjem populacije. Cilj ovog preglednog članka je opisati blokove perifernih živaca u liječenju boli kod bolesnika s prijelomom kuka, (bloka ilijakalne fascije i bloka perikapsularnih živaca), te naglasiti prednosti njihove primjene. Prijelom kuka je izrazito bolna ozljeda. Bol sama po sebi je neugodna za bolesnika, a ukoliko je neodgovarajuće liječena može dovesti do višestrukih komplikacija tijekom prijeoperacijskog, operacijskog i poslijeoperacijskog zbrinjavanja bolesnika. Unatoč postojanju brojnih analgetika, liječenje boli u starijih bolesnika s prijelomom kuka često je zahtjevno. Nesteroidni protuupalni lijekovi se ne preporučuju radi svojih neželjenih učinaka, paracetamol je često nedovoljan, a opioidi također mogu imati brojne neželjene učinke, uključujući razvoj akutnog smetenog stanja. Primjena blokova perifernih živaca je sigurna i učinkovita, također u uvjetima hitne medicine. Koristi za bolesnike su bolje ublažavanje boli, osobito prilikom pomicanja, smanjena potreba za primjenom opioida i smanjena incidencija akutnog smetenog stanja. Primjena blokova perifenih živaca u liječenju boli kod bolesnika s prijelomom kuka trebala bi postati svakodnevnica u kliničkoj praksi

AIRWAY MANAGEMENT IN OUT OF HOSPITAL CARDIAC ARREST – CURRENT SITUATION AND OUTCOMES

Iznenadni srčani zastoj (ISZ) je značajan javnozdravstveni problem. Procijenjena učestalost ISZ-a prema podatcima Hrvatskog kardiološkog društva u Hrvatskoj je 9.000 godišnje, jedna osoba svakog sata. Postotak preživljenja nakon ISZ-a u Europi kreće se oko 10 %. Cilj ovog rada je ustanoviti postotak bolesnika koji su nakon IZS-a sa znakovima života doveženi u bolnicu u Varaždinskoj županiji te povezanost IZS-a s metodom osiguranja dišnog puta. Provedeno je retrospektivno istraživanje svih kardiopulmonalnih reanimacija (KPR) tijekom dvije godine, (od 1. 1. 2014 do 31.12. 2015.) u Zavodu za hitnu medicinu Varaždinske županije u dvije ispostave: Varaždin i Novi Marof. Djelatnost Zavoda je izvanbolnička hitna medicinska skrb, te su analizirani podatci o izvanbolničkoj KPR nakon srčanog zastoja koji su prikupljeni iz obrazaca Utstein koji je uniformirani propisani obrazac za praćenje ishoda KPR-a, a ispunjava se nakon provedene reanimacije. U promatranom dvogodišnjem razdoblju zabilježeno je 168 reanimacija: 61 osobe ženskog (36,3 %) i 107 muškog spola (63,7 %). Najmlađa osoba imala je 24 godine, a najstarija 100, dok je prosječna dob bolesnika iznosila 67,5±13,87 godina. Od 168 reanimacija u 45 (26,8 %) bolesnika došlo je do uspostave spontane cirkulacije te su bolesnici prevezeni u bolnicu sa znakovima života. Tijekom postupaka reanimacije svi bolesnici imali su osiguran dišni put, endotrahealnom intubacijom ili uz pomoć supraglotičkog pomagala (SGP)- u velikoj većini slučajeva i-gel. Od 168 reanimacija u 22 (13,1 %) bolesnika provedena je endotrahealna intubacija, dok je u preostalih 146 (86,9 %) bolesnika postavljen SGP. U skupini preživjelih 13,3 % bilo je endotrahealno intubirano (6 od 45 bolesnika, AR=0,13), a u skupini preminulih bolesnika 13 % (16 od 123, AR= 0,13) Omjer šansi (OR) je 1,03, relativni rizik (RR) 1,00, pripisivi rizik (PR) 0,00. Iz rezultata provedenog istraživanja vidljivo je da se u većini izvanbolnički provedenih postupaka kardiopulmonalne reanimacije za osiguranje dišnog puta zbog jednostavnosti primjene koristi supraglotičko pomagalo, a kao posljedica nedostatka stalnog liječničkog osoblja. U našim rezultatima nema značajne razlike u preživljenju s obzirom na metodu osiguranja dišnog puta.Sudden cardiac arrest (SCA) is a major public health problem. The estimated incidence of SCA in Croatia is 9000, which means one person every hour. The survival rate after SCA in Europe is about 10%. The goal of this research was to determine the rate of patients who, after SCA, have been transported to a hospital in Varaždin County with signs of life and how this rate was connected to airway management. A retrospective study of cardiopulmonary resuscitation (CPR) was conducted over two years, from January 1, 2014 to December 31, 2015 at the Varaždin County Institute of Emergency Medicine at two locations, in Varaždin and Novi Marof. The Institute provides pre-hospital emergency medical care and data on CPR were collected from the Utstein forms, i.e. uniformed CPR outcome monitoring forms that are fulfi lled after every resuscitation. There were a total 168 of resuscitations in the observed two-year period. There were 61 (36.3%) female and 107 (63.7%) male patients. The youngest person was aged 24 and the oldest 100 years, mean age 67.5±13.87 years. Spontaneous circulation was reestablished in 45 out of 168 resuscitated patients (26.8%) and those patients were transported to a hospital with signs of life. Airway management techniques used during resuscitation were endotracheal intubation (ETI) or supraglottic airway (SGA), in the majority i-gel. Twenty-two of 168 patients (13.1% ) were intubated, whereas in the remaining 146 (86.9%) patients SGA was used (145 i-gel, 1 LMA). In the group of surviving patients, 13.3% (6 out of 45 patients, absolute risk (AR) 0.13) were intubated, and in the group of deceased patients 13.0 % were intubated (16 out of 123 patients, AR 0.13). Odds ratio was 1.03, relative risk 1.00 and attributable risk 0.00. Study results revealed that in most cases of pre-hospital CPR the airway management technique was supraglottic airway, while ETI was much less frequent. Such choice of airway management should probably be ascribed to the lack of permanent medical staff in emergency medical service, a large number of doctors who had recently completed internship, their limited clinical experience and limited experience in ETI. A recently published randomized clinical study has shown that there is no difference between ventilation with a mask with self-infl ating ventilation bag and ETI in terms of survival, with a more favorable neurological outcome during pre-hospital CPR. The benefi t of advanced airway management in CPR lies in the fact that there is less interruption of chest compression due to asynchronous ventilation. On the other hand, the reasons for poor neurological outcome in patients with ETI may be hyperventilation during CPR, absence of previous satisfactory oxygenation, but also too much interruption of chest compression during the intubation. In our study, there was no signifi cant difference in survival in terms of different airway management techniques, however, most recent studies are in favor of ETI. In conclusion, in the research of cardiopulmonary resuscitation after SCA in Varaždin County, the rate of patients with signs of life transported to the hospital was 26.8%. The most frequently used airway management in pre-hospital CPR was supraglottic airway (I-gel)

PREHOSPITAL PAIN MANAGEMENT IN PATIENTS WITH HIP FRACTURE

Cilj rada: Prijelom kuka je značajan javnozdravstveni problem, osobito u bolesnika starije životne dobi, kod kojih predstavlja drugu dijagnozu po učestalosti tijekom stacionarnog bolničkog liječenja u Hrvatskoj. Iako su brojna istraživanja pokazala važnost što ranije procjene i liječenja boli u bolesnika s prijelomom kuka, a s ciljem smanjenja komplikacija i smrtnosti u kasnijem tijeku bolesti, liječenje boli tijekom hitnog medicinskog zbrinjavanja ove skupine bolesnika još uvijek se ne provodi sustavno, a literaturni podaci o primjeni analgetika i načinu transportne imobilizacije su ograničeni. Cilj ovog rada je utvrditi učinkovitost liječenja boli tijekom izvanbolničkog hitnog zbrinjavanja bolesnika s prijelomom kuka, te utvrditi učestalost primjene analgetika. Metode: Provedeno je analitičko presječno istraživanje u Zavodu za hitnu medicinu Varaždinske županije u razdoblju od 1. siječnja do 31. prosinca 2018. godine a koje je uključivalo bolesnike s kliničkom sumnjom na prijelom kuka. Rezultati: Tijekom 2018. godine ukupno je zbrinuto 187 bolesnika s kliničkom sumnjom na prijelom kuka. Bol je procijenjena u ukupno 92 % bolesnika. Jaka bol (NRS 7-10) zabilježena je u 19,8 % bolesnika, umjerena bol (NRS 4-6) u 57 %, blaga bol (NRS 1-3) u 19,8 %, dok je 3,5 % bolesnika bilo bez boli (NRS 0). Ukupno 90,4 % bolesnika nije dobilo analgeziju. U skupini bolesnika s jakom boli 67,6 % bolesnika nije primilo analgetik, dok je kod preostalih najčešće primjenjivan tramadol. Transportna imobilizacija primijenjena je u 43,9 % bolesnika. Najčešće su korištena rasklopna nosila ili vakuum madrac. Zaključak: Unatoč visokom postotku procjene boli dobiveni rezultati ukazuju na neodgovarajuću analgeziju i transportnu imobilizaciju u bolesnika s prijelomom kuka. Budući da se radi o bolesnicima starije životne dobi, od iznimne je važnosti uvesti analgetske protokole kako bi se poboljšalo liječenje i izbjegle negativne posljedice neliječene boli.Objective: Hip fracture is a signifi cant public health and personal issue, especially for elderly patients, where it is the second most common diagnosis in stationary hospitalization in Croatia. Although numerous research studies have revealed the importance of early assessment and pain management during emergency care of such patients, it is still not applied systematically, and literature data on the use of analgesics and immobilization during transport are limited. The objective of this study was to research prehospital pain management in patients with hip fracture, primarily the frequency of prehospital analgesic administration. Methods: We conducted a cross-sectional analytical study of patients with clinically diagnosed hip fractures at the Institute of Emergency Medicine of Varaždin County during a one-year period (from January 1, 2018 to December 31, 2018). Results: In 2018, a total of 187 patients with hip fracture were treated, 133 (71.1%) women, mean age 80.8±8.3 (median 79, mod 84) years. Level of pain was assessed in 92% of patients; strong pain (NRS 7-10) was present in 19.8%, medium pain (NRS 4-6) in 57%, mild pain (NRS 1-3) in 19.8% and no pain (NRS 0) in 3.5% of patients. Analgesics were not administered in 90.4% of all cases, specifi cally in 67.6% of the strong pain group. In the rest of cases, the most frequently applied analgesic was tramadol. Application of analgesics was somewhat more frequent in male patients but the difference was not statistically signifi cant. Immobilization during transport was not applied in 56.1% of cases, whereas in the remainder it was mostly done by use of scoop stretcher or vacuum mattress. Discussion: This study showed insuffi cient use of analgesics in spite of general recognition of the importance of pain treatment. The most frequently applied analgesic was tramadol, which is no longer recommended as a fi rst choice medication. There are limited research data on prehospital pain management in this group of patients, but also point out the inadequate use of analgesics in patients with hip fracture, as well in other trauma patients. Various factors infl uence the frequency and method of analgesic application and one of these is certainly emergency medical service staff education, which has a well-established benefi cial effect on the emergency patient care. Limitations of this study were retrospective data collection and the high likelihood that some of the patients were transported by ordinary patient transport service upon initial physician assessment. Therefore, the number of cases presented does not cover the total of all hip fracture cases in the Varaždin County in 2018. Conclusion: The great majority of patients with hip fracture did not receive analgesics during prehospital emergency care and in more than half of all cases there was no immobilization during transport. Although there was a tendency of more frequent application of analgesics in male patients, the difference was not statistically signifi cant. As the condition is mostly affecting elderly patients, it is very important to improve prehospital pain management during their emergency care, which could be achieved by better education of emergency medical service team members