SPONTANA RUPTURA JETRE POVEZANA S PRIMJENOM HEPARINA NISKE MOLEKULARNE MASE

We present a rare case of a patient with spontaneous liver rupture, who was treated with anticoagulant therapy due to pulmonary embolism. The patient was diagnosed in the emergency department with deep vein thrombosis of his left leg and bilateral pulmonary embolism. He was admitted to the medical intensive care unit and low-molecular-weight heparin (enoxaparin) therapy was introduced. After the third dose, the patient started complaining of right shoulder and chest pain, and 3 hours later, when the patient was put in the sitting position, there was sharp drop of blood pressure, the patient lost consciousness, stopped breathing and pulse was impalpable. He was resuscitated for 4 minutes, after which he regained consciousness and complained of pain in the right shoulder, chest and right upper abdominal quadrant. Emergency abdominal ultrasonography showed free fl uid in the abdomen, and computed tomography showed liver hemorrhage and liver capsule rupture. The patient was transferred to the operating theater, where liver hemostasis and perihepatic packing were performed. This case report shows the extent of possible adverse effects of anticoagulant therapy, even in patients with short duration of therapy and with no prior blood clotting disorders. Prompt diagnosis and treatment of spontaneous liver rupture are crucial in favorable resolution of this complication.Prikazujemo slučaj bolesnika kod kojega je došlo do pojave spontane rupture jetre, a koji je bio liječen antikoagulacijskom terapijom zbog plućne embolije. Bolesniku je u hitnoj službi dijagnosticirana duboka venska tromboza lijeve noge te obostrana plućna embolija. Primljen je u Jedinicu intenzivne medicine te je započeto liječenje heparinom niske molekularne mase (enoksaparin). Nakon primljene treće doze bolesnik se počeo žaliti na bolove u desnom ramenu i prsnom košu te je 3 sata nakon toga, nakon postavljanja u sjedeći položaj, došlo do naglog pada tlaka, izgubio je svijest, prestao disati, a puls nije bio palpabilan. Nakon reanimiranja u trajanju od 4 minute došao je svijesti i žalio se na bolove u desnom ramenu, prsnom košu i gornjem desnom kvadrantu trbuha. Učinjenim ultrazvukom abdomena verifi cirana je slobodna tekućina u abdomenu, a kompjutoriziranom tomografi jom krvarenje iz jetre i ruptura jetrene čahure. Hitno je premješten u operacijsku dvoranu gdje je učinjena hemostaza i tamponada jetre. Prikaz ovoga bolesnika ukazuje na opseg mogućih neželjenih učinaka antikoagulacijske terapije, čak i kod bolesnika koji su kratkotrajno na antikoagulacijskoj terapiji i ne boluju od poremećaja zgrušavanja krvi. Pravodobno postavljanje dijagnoze spontane rupture jetre i primjena odgovarajuće terapije ključni su u poželjnom rješavanju navedene komplikacije

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

EFFICIENCY OF TRIAGE SYSTEM AT UNIVERSITY HOSPITAL DUBRAVA - RETROSPECTIVE STUDY

U ovom retrospektivnom istraživanju sakupili smo podatke o učinkovitosti trijažnog sustava Kliničke bolnice Dubrava (KBD) u razdoblju od 1. prosinca 2014. do 30. studenog 2019. godine. Cilj istraživanja je ustanoviti učinkovitost i maksimalno vrijeme čekanja pacijenata u hitnoj internističkoj služni (HIS) i hitnoj kirurškoj službi (HKS) u KBD tijekom navedenog petogodišnjeg razdoblja, te rezultate usporediti sa standardima Australazijskog trijažnog sustava (ATS). U cilju nam je i ustanoviti dinamiku broja pacijenata u svim trijažnim kategorijama te korelirati rezultate s promjenama u ustroju hitne službe KBD koje su se dogodile u 2019. godini (smanjenje opsega teritorijalnog pokrivanja hitne službe KBD i uvođenje dodatnog liječnika na radilište HKS). Iz službenog bolničkog informatičkog sustava (BIS) dobiveni su podatci o 217.567 pacijenata koji su trijažirani i obrađeni u HIS i HKS od 1. prosinca 2014. do 30. studenog 2019. godine. Pacijenti su raspodijeljeni prema trijažnim kategorijama, maksimalnom vremenu čekanja na početak pregleda i prema učinkovitosti. Iz naših rezultata je vidljivo da je smanjenje broja pacijenata u 2019. godini zbog smanjenja opsega teritorijalnog pokrivanja hitne službe KBD i uvođenja dodatnog liječnika na radilište HKS doprinijelo smanjenju vremena čekanja na pregled te povećanju učinkovitosti u svim trijažnim kategorijama, a posebno u kategorijama 2 i 3 gdje je učinkovitost inicijalno bila najniža. Navedeno ukazuje da smanjenje opsega teritorijalnog pokrivanja hitne službe, kao i uvođenje dodatnog medicinskog osoblja povećava učinkovitost, odnosno rezultira bržim zbrinjavanjem pacijenata. Potrebno je provesti dodatna istraživanja i analize prostorne iskoristivosti, potrebe za većim brojem osoblja i opreme s obzirom na dnevni protok pacijenata u hitnoj službi, a sve u svrhu poboljšanja učinkovitosti trijažnog sustava, sigurnosti i kvalitete liječenja pregledanih pacijenata.This retrospective study addresses the effi cacy of a triage system at University Hospital Dubrava (UHD), from December 1st, 2014 to November 30th, 2019. The aim of this study is to determine the effectiveness and maximum waiting time of patients at the Internal Medicine Emergency Department (IMED) and Surgery Emergency Department (SED) in UHD over fi ve-year period, and to compare the results with Australasian triage system (ATS) standards. We also aim to establish the dynamics of the quantity of patients in all triage categories and to correlate the results with the changes in the structure of the UHD emergency service that occurred in 2019 (reduction of the territorial coverage of the UHD emergency department and an additional doctor at the SED site). Information on 217,567 patients triaged and treated at IMED and SED from December 1st, 2014 to November 30th, 2019 were enabled from the offi cial Hospital Information System (HIS). The distribution of patients is by triage category, maximum waiting time for the start of the examination and effi ciency. From our results it is evident that the decrease in the number of patients in 2019 due to the decrease in the scope of territorial coverage of the UHD emergency service and an additional doctor at the SED site contributed to the reduction of waiting time for examination and increase of effi ciency in all triage categories, especially in categories 2 and 3 where effi ciency was initially the lowest. This suggests that reducing the scope of territorial emergency coverage as well as introducing additional medical staff increases effi ciency, that is, results in faster patient care. Additional research and analysis of spatial usability, staffi ng and other resources needs to be done regarding the daily fl ow of patients through the emergency room, all with the aim of improving the effi ciency of triage, safety and treatment quality of the patients examined

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

ALGORITHMS FOR PERIPROCEDURAL MANAGEMENT AND MANAGEMENT OF BLEEDING IN PATIENTS TREATED WITH NON-VITAMIN K ORAL ANTICOAGULANTS

Cilj terapije antagonistima vitamina K (varfarin) i novim oralnim antikoagulantnim lijekovima (NOAK-ima) jesu prevencija moždanog udara i drugih embolija kod bolesnika s nevalvularnom fibrilacijom atrija te liječenje i prevencija venske tromboembolije. Kod svih bolesnika potrebno je odrediti bubrežnu funkciju klirensom kreatina jer o tome ovise izbor i doziranje NOAK-a. Izuzetno je važno obratiti pozornost na starije bolesnike s brojnim pridruženim stanjima i interakcijama lijekova zbog velike učestalosti neuroloških simptoma i lošijeg ishoda. Oralno antikoagulantno liječenje izazov je, posebno u stanjima nenamjernog predoziranja lijeka, u krvarenjima ili u stanjima hitnoga prijeoperacijskog zbrinjavanja. Zbog sve većeg broja bolesnika koji uzimaju NOAK-e osnovana je 2015. godine ekspertna grupa specijalista hitne medicine koja je u listopadu 2015. održala u Zagrebu Konsenzusnu konferenciju radi donošenja postupnika za prijeoperacijsko zbrinjavanje i zbrinjavanje bolesnika u hitnim stanjima koji uzimaju NOAK-e u Hrvatskoj.The goal of therapy with vitamin K antagonists (warfarin), and new direct oral anticoagulant drugs (NOAC or DOAC) is the prevention of stroke and embolic events in patients with non-valvular atrial fibrillation and treatment and prevention of venous thromboembolism. In all cases it is necessary to determine renal function with creatinine clearance because it determines the choice and dosage of NOAC’s. It is extremely important to pay attention to older patients with a number of associated conditions and drug interactions, with a high incidence of neurological symptoms and worse outcomes. Oral anticoagulation can represent a challenge, especially in cases of drug overdose or emergencies such as bleeding and need for urgent surgery. The need for the guidelines has emerged during the last years because of new classes of oral anticoagulants being prescribed more frequently. The expert working group of emergency specialists was formed and gathered on Consensus Conference in October 2015 in Zagreb, to design guidelines for the patients with NOAC therapy and provides details of preoperative management and managements in emergency conditions

Postupnici za periproceduralno zbrinjavanje i zbrinjavanje krvarenja u bolesnika liječenih novim oralnim antikoagulantnim lijekovima [Algorithms for periprocedural management and management of bleeding in patients treated with non-vitamin K oral anticoagulants]

The goal of therapy with vitamin K antagonists (warfarin), and new direct oral anticoagulant drugs (NOAC or DOAC) is the prevention of stroke and embolic events in patients with non-valvular atrial fibrillation and treatment and prevention of venous thromboembolism. In all cases it is necessary to determine renal function with creatinine clearance because it determines the choice and dosage of NOAC’s. It is extremely important to pay attention to older patients with a number of associated conditions and drug interactions, with a high incidence of neurological symptoms and worse outcomes. Oral anticoagulation can represent a challenge, especially in cases of drug overdose or emergencies such as bleeding and need for urgent surgery. The need for the guidelines has emerged during the last years because of new classes of oral anticoagulants being prescribed more frequently. The expert working group of emergency specialists was formed and gathered on Consensus Conference in October 2015 in Zagreb, to design guidelines for the patients with NOAC therapy and provides details of preoperative management and managements in emergency conditions

Characteristics and Outcomes of Patients With Deep Vein Thrombosis Diagnosed in Emergency Department of Clinical Hospital Dubrava During 2019

Aim: Deep vein thrombosis (DVT) is a common clinical condition encountered in the emergency department (ED). The aim of this study was to compare the characteristics and outcomes of patients with respect to treatment using novel oral anticoagulants (NOAC). Materials and Methods: In this retrospective observational study, we analyzed medical records of patients diagnosed with DVT during 2019 in the ED of the Clinical Hospital Dubrava. We identified 295 patients, who comprised 1.2% of all patients examined in the ED. Results: Women were more frequently diagnosed with DVT (59%) and they were older than the men (median age 69 vs. 62 years, respectively). Patients with proximal deep vein thrombosis (71%) were admitted to the hospital. Two thirds of all patients were treated with NOAC. Rivaroxaban was the most commonly prescribed drug (52% of patients). Control Doppler ultrasound was performed in 58% of the patients, and complete resolution was observed in 63% of the cases. NOACs caused significantly fewer bleeding events than warfarin (3.2% vs. 13.6%, p < 0.05). Conclusion: Our results demonstrate that patients with DVT can be safely treated with NOACs in an outpatient setting

EFFICIENCY OF TRIAGE SYSTEM AT UNIVERSITY HOSPITAL DUBRAVA - RETROSPECTIVE STUDY

U ovom retrospektivnom istraživanju sakupili smo podatke o učinkovitosti trijažnog sustava Kliničke bolnice Dubrava (KBD) u razdoblju od 1. prosinca 2014. do 30. studenog 2019. godine. Cilj istraživanja je ustanoviti učinkovitost i maksimalno vrijeme čekanja pacijenata u hitnoj internističkoj služni (HIS) i hitnoj kirurškoj službi (HKS) u KBD tijekom navedenog petogodišnjeg razdoblja, te rezultate usporediti sa standardima Australazijskog trijažnog sustava (ATS). U cilju nam je i ustanoviti dinamiku broja pacijenata u svim trijažnim kategorijama te korelirati rezultate s promjenama u ustroju hitne službe KBD koje su se dogodile u 2019. godini (smanjenje opsega teritorijalnog pokrivanja hitne službe KBD i uvođenje dodatnog liječnika na radilište HKS). Iz službenog bolničkog informatičkog sustava (BIS) dobiveni su podatci o 217.567 pacijenata koji su trijažirani i obrađeni u HIS i HKS od 1. prosinca 2014. do 30. studenog 2019. godine. Pacijenti su raspodijeljeni prema trijažnim kategorijama, maksimalnom vremenu čekanja na početak pregleda i prema učinkovitosti. Iz naših rezultata je vidljivo da je smanjenje broja pacijenata u 2019. godini zbog smanjenja opsega teritorijalnog pokrivanja hitne službe KBD i uvođenja dodatnog liječnika na radilište HKS doprinijelo smanjenju vremena čekanja na pregled te povećanju učinkovitosti u svim trijažnim kategorijama, a posebno u kategorijama 2 i 3 gdje je učinkovitost inicijalno bila najniža. Navedeno ukazuje da smanjenje opsega teritorijalnog pokrivanja hitne službe, kao i uvođenje dodatnog medicinskog osoblja povećava učinkovitost, odnosno rezultira bržim zbrinjavanjem pacijenata. Potrebno je provesti dodatna istraživanja i analize prostorne iskoristivosti, potrebe za većim brojem osoblja i opreme s obzirom na dnevni protok pacijenata u hitnoj službi, a sve u svrhu poboljšanja učinkovitosti trijažnog sustava, sigurnosti i kvalitete liječenja pregledanih pacijenata.This retrospective study addresses the effi cacy of a triage system at University Hospital Dubrava (UHD), from December 1st, 2014 to November 30th, 2019. The aim of this study is to determine the effectiveness and maximum waiting time of patients at the Internal Medicine Emergency Department (IMED) and Surgery Emergency Department (SED) in UHD over fi ve-year period, and to compare the results with Australasian triage system (ATS) standards. We also aim to establish the dynamics of the quantity of patients in all triage categories and to correlate the results with the changes in the structure of the UHD emergency service that occurred in 2019 (reduction of the territorial coverage of the UHD emergency department and an additional doctor at the SED site). Information on 217,567 patients triaged and treated at IMED and SED from December 1st, 2014 to November 30th, 2019 were enabled from the offi cial Hospital Information System (HIS). The distribution of patients is by triage category, maximum waiting time for the start of the examination and effi ciency. From our results it is evident that the decrease in the number of patients in 2019 due to the decrease in the scope of territorial coverage of the UHD emergency service and an additional doctor at the SED site contributed to the reduction of waiting time for examination and increase of effi ciency in all triage categories, especially in categories 2 and 3 where effi ciency was initially the lowest. This suggests that reducing the scope of territorial emergency coverage as well as introducing additional medical staff increases effi ciency, that is, results in faster patient care. Additional research and analysis of spatial usability, staffi ng and other resources needs to be done regarding the daily fl ow of patients through the emergency room, all with the aim of improving the effi ciency of triage, safety and treatment quality of the patients examined