Holinergični sindrom: prikaz primera zastrupitve z organofosfati in karbamati

Cholinergic syndrome is a common topic at western medical universities yet rarely observed in clinical practice. The treatment involves muscarinic antagonists, acetylcholinesterase reactivation, seizure control, and supportive measures. Here we report a case of a 52-year old Caucasian male who attempted suicide by ingesting a purple crystal powder that turned out to be a mixture of carbofuran and chlormephos. At clinical examination, the patient presented with salivation, perspiration, diarrhoea, bradypnoea, loss of consciousness, and epileptic seizures. Laboratory tests showed low plasma cholinesterase, and we started obidoxime along with supportive intensive care treatment. He was later transferred to the psychiatry department for further diagnostics and treatment.Holinergični sindrom je pogosta tema na medicinskih fakultetah v zahodnem svetu, ki pa ga redko obravnavamo v klinični praksi. Zdravljenje sestoji iz uporabe muskarinskih antagonistov, reaktivacije acetilholinesteraze, nadzora nad epileptičnimi napadi in podpornih ukrepov. Predstavljamo primer 52-letnega moškega, ki je poskušal storiti samomor z zaužitjem vijoličnega kristalnega prahu, ki se je izkazal za mešanico karbofurana in klormefosa. Ob pregledu smo opažali povečano slinjenje in potenje ter prisotnost driske, bradipneje, izgube zavesti in epileptičnih napadov. V laboratorijskih preiskavah smo beležili nizke vrednosti plazemske holinesteraze in pričeli zdravljenje z obidoksimom ob podpornem intenzivnem zdravljenju. Kasneje smo ga premestili na Oddelek za psihiatrijo za nadaljnjo diagnostiko in zdravljenje

Identification of lung sliding: a basic ultrasound technique with a steep learning curve

Introduction. One of the basic premises of sonographic lung imaging is the concept of lung sliding. Identification of clear lung sliding excludes pneumothorax (PTx) at that specific local point. Methods. Fifty-seven 4th year medical students were given a 20-minute lecture on sonographic identification of lung sliding and exclusion of PTx. After the lecture, students were asked to correctly position the probe, identify shown structures and on each attempt (six attempts in a row) state whether lung sliding is present or not. Results. There were 57 students in the sample. Fifty students (87.7%) successfully positioned the probe (all 4 positions) for PTx identification. All but five students (91.2%) recognized the anatomic structures of the thorax. Mean number of correctly identified cases per student was 5.1 ± 1.1. In 292 (85.4%) cases, the answer was correct. In 298 (87.1%) cases, students were confident in the correct answer. Students who were confident in the right answer gave the right answer significantly more often when compared to others (90.3% vs. 52.3%, p < 0.001). Sensitivity of this method for 4th year medical students was 82.6% and its specificity was 87.9%. For correct identification of lung sliding in the sixth attempt, students on average needed 4.5 correct attempts. Conclusion. Our study suggests that 4th year medical students with no prior experience in lung ultrasonography can easily acquire knowledge and skills needed to detect thoracic wall structures and identify lung sliding with a high degree of sensitivity and specificity

Impact of pre-hospital oxygenation and ventilation status on outcome in patients with isolated severe traumatic brain injury

Introduction. Hypoxia is one of the secondary insults and it worsens the outcome in patients with severe traumatic brain injury (TBI). On the other hand, there is some controversy about the impact of hyperoxia on the outcome in these patients. The aim of the study was to determine the impact of pre-hospital hypoxia, hyperoxia and pre-hospital ventilation status on outcome after isolated TBI. Methods. We retrospectively reviewed charts from patients with isolated severe TBI who underwent pre-hospital endotracheal intubation. The population was sorted into groups based on PaO2 (hypoxic, PaO2 <100 mmHg; normoxic, PaO2 100-200 mmHg; hyperoxic, PaO2 > 200 mmHg) and initial Glasgow Coma Scale (GCS) level (3-5 and ≥ 6). Ventilation status was defined as: hypocarbic (PaCO2 45 mmHg). Results. Oxygenation status had no significant impact on 24- and 48-hour survival, on the length of hospital stay or on neurological outcome (measured by the Glasgow Outcome Scale (GOS), Glasgow Pittsburgh Cerebral Performance Categories Scale (CPC), and GCS score at discharge) when all six groups were compared together. We were unable to prove a deleterious effect of hypoxia or hyperoxia compared to normoxia on rate of survival to hospital discharge (STHD) (0.38 (0.52) vs 0.50 (0.51) vs 0.65 (0.49), where 0 - no and 1 - yes; f = 1.246, p = 0.298). Ventilation status also failed to significantly affect survival and functional outcome in patients with isolated severe TBI. Conclusion. Pre-hospital oxygenation and ventilation status have no significant impact on outcome in patients with isolated severe TBI

Prehospital monitoring in resuscitation : today and the future

There is growing evidence that early detection and response to physiological deterioration can improve outcome for patients. Working out-of-hospital, we often find ourselves in diagnostic dilemmas, thus more reliable data could change our actions as well as give better assessment of patient\u27s condition. Therefore, we are always exploring new perspectives that could be transferred from experimental laboratory settings to our primary working area in the field to help us improve decision-making leading to better outcome. In the following sections, we represent our previous studies about the utility of continuous capnometry and the importance of point-of-care ultrasound in cardiopulmonary resuscitation (CPR), and discuss about the possible future use of transthoracic and transesophageal ultrasound, point-of-care biochemical monitoring, tissue oxygen saturation, pupillometry, and mixed and central venous oxygen saturation monitoring in the prehospital setting

Symptoms experienced by patients with acute myocardial infarction that the triage nurses should know in the emergency department: a systematic review

Brendan McCormack - ORCID: 0000-0001-8525-8905 https://orcid.org/0000-0001-8525-8905Background: Vascular and heart disease present a big problem in public health society. Acute myocardial infarction (AMI), which belongs under acute coronary syndromes, is one of the most common diseases and biggest causes of early death in developed countries. Symptoms in patients with myocardial infarction vary between typical and atypical symptoms. This review aims to identify different AMI symptoms of patients who seek medical attention in the emergency department (ED). Methods: A systematic review of the literature in CINAHL, MEDLINE, ScienceDirect, and SAGE was conducted to identify studies on detected symptoms in patients with myocardial infarction over 18 years in the ED. The search was limited to studies on this topic published up to December 2021. The data analysis was based on thematic analysis. Results: Out of 2,814 studies retrieved, 11 studies were included. The data analysis identified one main theme: clinical symptoms and three subcategories. Conclusion: The triage nurses need to pay attention to cardiovascular symptoms, such as chest pain, the most common symptom. Their focus also needs to be redirected to epigastric pain and cold sweating, which are abdominal and systemic symptoms, and anxiety and nausea/vomiting in patients with diabetes. Impact: AMI is one of the most common diseases and causes of early death in developed countries. The literature lacks knowledge about the different symptoms of AMI, which the triage nurses must be careful about. The knowledge and rapid identification of myocardial infarction helps triage nurses provide the best outcomes. ©2023 the author(s), published by De Gruyter. All rights reserved.https://doi.org/10.1515/9783110786088-002pubpu

Triage of patients with acute coronary syndrome at the emergency department: A retrospective study

Brendan McCormack - ORCID: 0000-0001-8525-8905 https://orcid.org/0000-0001-8525-8905Background: Acute coronary syndrome represents a considerable challenge worldwide as one of the causes of death; its diagnosis is often very complex. It includes acute myocardial infarction with ST-segment elevation, acute myocardial infarction without ST-segment elevation, unstable angina pectoris, and sudden cardiac arrest. Methods: This retrospective cohort study included 678 patients who were admitted to the emergency department between 2015 and 2019 with acute coronary syndrome. Triage data were reviewed for vital signs, baseline characteristics, chief complaints, demographic variables, mode and time of arrival, triage, diagnosis, and treatment. Regression was used to identify key symptoms and patient characteristics at triage encounter to predict acute coronary syndrome. Results: A total of 678 triage records were identified. The average age of the sample was 67 years old, 58.6% male, and 31.8% came by themselves to the emergency department. The most common diagnosis was acute myocardial infarctions without ST elevation (38.2%). Chest pain and difficulty in breathing were the two most common symptoms. Most patients were not assigned to the appropriate triage category, i.e., were diagnosed as less urgent. Discussion and conclusion: This study presents the triage of patients with acute coronary syndrome at the emergency department to provide a comprehensive insight into their care. By identifying patient symptoms at the emergency department, nurse triage recognizes patients with acute coronary syndrome on time, thus increasing the accuracy of determining the triage category, which will impact the treatment outcome of patients. ©2023 the author(s), published by De Gruyter. All rights reserved.https://doi.org/10.1515/9783110786088-009pubpu

Erythropoietin Facilitates the Return of Spontaneous Circulation, Survival and Neurological Outcome in Victims of Out-of-Hospital Cardiac Arrest

Ozadje: Eritropoetin aktivira znotrajcelične poti, ki delujejo zaščitno in preprečijo propad celice, tudi miokarda. Aplikacija eritropoetina med srčnim zastojem ohrani podajnost miokarda in omogoči hemodinamsko bolj učinkovito zunanjo masažo srca. Namen: Namen študije je bil raziskati učinek eritropoetina, ki ga apliciramo znotraj 2 minut od začetka oživljanja pri bolnikih zaradi srčnega zastoja izven bolnišnice. Metode: Primerjali smo skupino bolnikov, ki so med oživljanjem prejeli eritropoetin (90.000 enot eritropoetina beta, n = 24), s kontrolno skupino bolnikov, ki so med oživljanjem prejeli fiziološko raztopino (0,9% NaCl, n = 30) in retrospektivno z enakovredno skupino bolnikov, ki smo jih oživljali po enakem protokolu kot prejšnji skupini, vendar v času pred začetkom te študije (n = 48). Rezultati: V primerjavi s kontrolno skupino, ima skupina bolnikov, ki je med oživljanjem prejela eritropoetin, višji odstotek sprejema na oddelek za intenzivno interno medicino (OIIM) (92% vs 50%, p = 0.004), povratek spontanega krvnega obtoka na terenu (92% vs 53%, p = 0.006), 24-urno preživetje (83% vs 47%, p = 0.008) in odpust iz bolnišnice (54% vs 20%, p = 0.011). Po multivariantni analizi spremenljivk, ki vplivajo na razplet oživljanja, sta statistično značilni razliki le pri sprejemu na OIIM in pri povratku spontanega krvnega obtoka na terenu. V primerjavi skupine bolnikov, ki je med oživljanjem prejela eritropoetin, z enakovredno skupino z enakovrednimi izhodiščnimi spremenljivkami, ima skupina bolnikov, ki je prejela eritropoetin, višji odstotek sprejema na OIIM (92% vs 65%, p = 0.024) in 24-urno preživetje (83% vs 52%, p = 0.014) ter statično neznačilno razliko pri povrnitvi spontanega krvnega obtoka na terenu (92% vs 71%, p = 0.060) in odpustu iz bolnišnice (54% vs 31%, p = 0.063). Po multivariantni analizi spremenljivk, ki vplivajo na razplet oživljanja, so vsi štirje izhodi statistično značilno različni med skupinama. Vrednosti delnega tlaka ogljikovega dioksida (PCO2) na koncu izdiha, ki so pokazatelj zadostnosti krvnega obtoka med oživljanjem in s tem kvalitete zunanje masaže srca, so bile višje v skupini bolnikov, ki so med oživljanjem prejeli eritropoetin. Zaključek: Uporaba eritropoetina med oživljanjem poveča odstotek povrnitve spontanega krvnega obtoka na terenu, sprejem na OIIM, 24-urno preživetje in odpust iz bolnišnice. Ta učinek eritropoetina gre pripisati zaščitnemu delovanju na miokard in posledično hemodinamsko bolj učinkoviti zunanji masaži srca.Background: Erythropoietin activates potent protective mechanisms in non -hematopoietic tissues including the myocardium. In a rat model of ventricular fibrillation, erythropoietin preserved myocardial compliance enabling hemodynamically more effective CPR. Objective: To investigate the effects of intravenous erythropoietin given within 2 minutes of physician-led CPR in out-of-hospital cardiac arrest victims. Methods: Erythropoietin (90,000 IU of beta-epoetin, n = 24) was compared prospectively with 0.9% NaCl (concurrent controls = 30) and retrospectively with a preceding group treated with similar protocol (matched controls = 48). Results: Compared with concurrent controls, the erythropoietin group had higher rates of intensive care unit (ICU) admission (92% vs 50%, p = 0.004), return of spontaneous circulation (ROSC) (92% vs 53%, p = 0.006), 24-hour survival (83% vs 47%, p = 0.008), and hospital survival (54% vs 20%, p = 0.011). However, after adjusting for pretreatment covariates only ICU admission and ROSC remained statistically significant. Compared with matched controls, the erythropoietin group had higher rates of ICU admission (92% vs 65%, p = 0.024) and 24-hour survival (83% vs 52%, p = 0.014) with statistically insignificant higher ROSC (92% vs 71%, p = 0.060) and hospital survival (54% vs 31%, p = 0.063). However, after adjusting for pretreatment covariates all four outcomes were statistically significant. End-tidal PCO2 (an estimate of forward blood flow during chest compression) was higher in the erythropoietin group. Conclusions: Erythropoietin given during CPR facilitates ROSC, ICU admission, 24-hour survival, and hospital survival. This effect was consistent with myocardial protection leading to hemodynamically more effective CPR