Signa Vitae

Journal for Intensive Care and Emergency Medicine

CPR flow to prime the ischemic heart during cardiac arrest?


Cardiac arrest is unique among cardiac ischemic syndromes in that all circulation must be generated external to the heart. Although, chest compressions deliver limited blood flow, it may be possible to take advantage of this cardiopulmonary resuscitation (CPR) low-flow state to “prime” the heart in advance of return of restoration of spontaneous circulation. Prior investigation has demonstrated improved cardiac function after perfusing the globally ischemic heart with a cardioprotective agent under low-flow perfusion conditions (modeling CPR flow). These results raise the question as to whether CPR-generated flow can be utilized to induce pharmacological post-conditioning in the arrested heart.

Key words: low-flow, CPR, post-conditioning, cardioprotect

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Near infrared spectroscopy for evaluation of skeletal muscle tissue oxygenation in different types of shock


Clinical examination is non-invasive, but has well-recognized limitations in detecting compensated and uncompensated low flow states and their severity.

This paper describes the principles of near infra-red spectroscopy (NIRS) and the basis for its proposed use, in hypovolaemic, cardiogenic and septic shock, for assessing global and regional tissue oxygenation. The vascular occlusion test is explained. Limitations of NIRS, current controversies, and what is necessary in the future to make this technology a part of the initial and ongoing assessment of a patient, are discussed as well. The ultimate goal of such techniques is to prevent miss-assessment and inadequate resuscitation of patients, two major initiators in the development of multisystem organ failure and death.

Key words: shock, skeletal muscle, near-infrared spectroscopy

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The impact of changing work schedules on American firefighters’ sleep patterns and well-being


Across the nation, fire departments are adopting the 48/96 work schedule, in which firefighters work 48 consecutive hours with the following 96 hours off. Our study objective was to explain and quantify the impact of switching from the Kelly schedule to the 48/96 schedule by measuring changes in sleep, feelings of daytime function, as well as perceptions of professional and personal well-being for American firefighters. Sleep diaries and self-reported surveys were administered to firefighters at an urban fire department. Sleep diaries measuring the number of hours slept and feelings of refreshment were compared one month before and four months after implementation of the 48/96 schedule. The self-reported surveys measured sleepiness levels via the Epworth Sleepiness Scale. Secondary study objectives included changes in professional and personal well-being time for personal schedules, satisfaction, and health habits before and after the 48/96 schedule was implemented. The 59 firefighters included in the study reported an increase in sleep on-shift after the new schedule implementation (5.8 to 6.6 hours/night, p < 0.001). Participants also reported increased feelings of refreshment on days off (p < 0.001) and decreased daytime sleepiness (p < 0.001). We also found a general trend of improved perceptions of satisfaction, less shift interference with personal schedules and decreased feelings of burnout. American firefighters appeared to benefit from a 48/96 schedule, with short-term improvements in sleep patterns, feelings of burnout, and time for personal schedules.

Key words: firefighters, shift-work sleep disorder, emergency medical technicians, workplace, sleep, fatigue, burnout, professional, organizational culture

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Can we predict complications after elective carotid artery angioplasty and stenting with a simple Valsalva test?


Objectives. Arterial baroreflex plays a key role in short-term blood pressure balancing. It can also be quantified noninvasively with baroreceptor sensitivity during Valsalva manoeuver. The aim of the study was to evaluate the role of Valsalva manoeuver as a potential marker of possible autonomic dysfunction in patients after carotid artery angioplasty and stenting.

Materials and methods. We evaluated dynamic changes of blood pressure during Valsalva manoeuver (Valsalva ratio, adrenergic baroreceptor sensitivity) in 22 patients (11 male; 63.2 ± 6.7 years) with symptomatic, unilateral internal carotid artery stenosis, and compared results with age and sex matched control subjects.

Results. Valsalva ratio between baseline and post-procedural day (1.26 ± 0.13 vs 1.46 ± 0.31; p=0.002) was the only statistically significant parameter. All other tests (also between the study and the control group), cardiovagal and adrenergic, revealed no significant differences.

Conclusion. We were not able to show that Valsalva manoeuver, as a simple, non-invasive and easy to perform test, could reliably confirm patients who are at a risk for postprocedural complications. It seems that most of the compensatory mechanisms, occurring after a revascularisation procedure, remain largely unclarified.

Key words: carotid stenosis, angioplasty, Valsalva manoeuver, baroreceptor sensitivity, Valsalva ratio

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Electrocardiography interpretation training in emergency medicine: methods, resources, competency assessment, and national standardization


Objective(s). The aim of this study was to evaluate the status of electrocardiography (ECG) training in emergency medicine residency programs in Turkey, and the attitude of the program representatives towards standardization of such training.

Methods. This investigation was planned as a cross-sectional study. An 18-item questionnaire was distributed to directors of residency programs. Responses were evaluated using SPSS (v.16.0), and analyzed using the chi-square test.

Results. Thirty-nine program directors (out of 42) responded to the questionnaire. Twenty-eight of them stated they did not have a formal ECG training curriculum. The most preferred ECG education method was clinical education in the Emergency Department; the most common education resource was ECG textbooks; and the most common evaluation method was case scenarios. Only thirteen of the programs had an obligation to prove competency. The most common competency-assessment method was obtaining a passing grade based on an instructor’s observation. The majority of program directors are of the opinion that there should be a formal ECG teaching curriculum, and that a national ECG training program and national ECG database should be formed.

Conclusions. The majority of programs do not have a formal ECG interpretation curriculum, which is an obligation to prove competency. As a result, their training methods, resources, and assessment tools were determined to be subjective.

Key words: emergency medicine, electrocardiography, education

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Extravascular lung water index as an indicator of lung injury in septic patients


Introduction. Transpulmonary thermodilution using PiCCO (Pulse-induced Contour Cardiac Output) is a standard minimally invasive method used for haemodynamic monitoring. Objectives. The goal of this paper is to examine the correlation and dynamics of the ExtraVascular Lung Water Index (EVLWI) as an indicator of acute lung injury in septic patients who underwent major abdominal surgery. Two groups of patients were selected: the ones with ALI (Acute Lung Injury): ALI patient group, and the ones without ALI: non-ALI patient group. A correlation between EVLWI and other haemodynamic and respiratory data in both groups were analyzed.

Materials and methods. The study included 48 patients. Throughout the seven-day period EVLWI, GEDVI (Global End-Diastolic Volume Index), ITBVI (IntraThoracic Blood Volume Index), CI (Cardiac Index), SVRI (Systemic Vascular Resistance Index) were measured in both groups using PiCCO monitoring over 8-hour intervals as well as heart rate, mean arterial pressure, serum albumin concentration, PaCO2 (arterial partial pressure of carbon dioxide), PaO2 (arterial partial pressure of oxygen), PaO2/FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio, lung compliance, lung resistance and ScvO2 (central venous oxygen saturation). All patients were analgosedated, intubated, mechanically ventilated, in sinus cardiac rhythm. Circulatory unstable patients had vasoactive support and Sequential Organ Failure Assessment (SOFA) scores calculated. Ventilator settings and dosage of vasoactive drugs were kept constant during the study.

Results. EVLWI was significantly higher in ALI patients group compared to non-ALI patients group. In patients with ALI group 11/22 patients died (50%), in the non-ALI patients group 6/26 patients died (23%). EVLWI was significantly higher in patients that died compared to ones who survived.

Conclusion. EVLWI is a good indicator of early acute lung injury in surgical patients with sepsis.

Key words: extravascular lung water index, acute lung injury, PiCCO monitoring, sepsis

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Predictors of neurological outcome in the emergency department for elderly patients following out-of-hospital restoration of spontaneous circulation


Aims. Survival rates for cardiac arrest in acute medicine are higher following out-of-hospital restoration of spontaneous circulation (OH-ROSC). However, data pertaining to OH-ROSC is limited in the elderly population. We aimed to assess the predictors of neurological outcome among elderly patients with OH-ROSC.

Methods. We retrospectively analyzed the data of patients 65 years and older who achieved OH-ROSC and who presented to the emergency department (ED) between 2009 and 2013. The following parameters were considered: age, sex, medical history, vital signs, blood values, initial electrical rhythm, witnessed cardiac arrest, bystander cardiopulmonary resuscitation, resuscitation duration, attempted defibrillation, and neurological outcome. Neurological outcomes were evaluated 3 months after cardiac arrest, using the cerebral performance category (CPC) score, and were classified into two groups: favorable outcome (CPC = 1–2) and unfavorable outcome (CPC = 3–5).

Results. Fifty-five patients were studied, of which 21 and 34 patients were classified as having favorable and unfavorable outcomes, respectively. The following values were associated with favorable outcomes: resuscitation duration, initial cardiac rhythm, base excess, pH, lactate levels, the motor response on the Glasgow Coma Scale (GCS), and the number of patients with GCS ≤8 (p < 0.01). Logistic regression analysis confirmed that motor response scores and lactate levels were independent predictors of neurological outcomes.

Conclusions. Lactate levels and GCS motor response measured immediately at ED arrival are likely to be useful to assess the neurological outcomes among elderly patients with OH-ROSC.

Key words: age, basic life support, cardiac arrest, prediction, resuscitation

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Serum levels of nitric oxide as a predictor of survival in acute respiratory distress syndrome caused by H1N1 pneumonia?


A large number of studies show elevated levels of nitric oxide (NO) in infective syndromes, but there is an insufficient number of studies which have investigated serum levels of NO in patients with acute respiratory distress syndrome (ARDS), especially in relation to survival. Hence, we created a study with the aim of determining the NO levels in relation to ARDS survival.

Serum levels of NO were measured by Griess reaction in 29 patients [16 men (55%), mean age years 52.72±18]. All data were statistically analyzed using one way ANOVA.

Our results show significantly higher serum NO levels in ARDS survivors compared to ARDS non-survivors, (p < 0.05). We conclude that higher serum levels of NO are strongly associated with better clinical outcomes, including increased survival.

Key words: acute respiratory distress syndrome, nitrogen oxide species, outcome

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Excessive anticoagulation identified by emergency medical service through point-of-care coagulometry


Bleeding because of excessive anticoagulation is a well-recognized complication of coumadin therapy. In cases of potentially life-threatening bleeding such as intracranial haemorrhage, reversal of anticoagulation should be carried out as soon as possible. Here we report the case of an emergency patient in whom excessive anticoagulation was diagnosed at the scene by emergency medical service personnel through the use of a point-of-care coagulometer. Following hospital admission, findings were confirmed by central laboratory assessment of prothrombin time. The time gained through the use of portable coagulometers may contribute to improved pre-hospital emergency management of anticoagulated patients.

Key words: anticoagulation, bedside testing, warfarin, haemorrhage

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A Giant Hydronephrotic Kidney with Ureteropelvic Junction Obstruction with Blunt Renal Trauma in a Boy


An 18-year-old male soccer player was transferred from the clinic to our emergency center with suspected blunt renal trauma. A giant ureteropelvic junction (UPJ) obstructed hydronephrosis in blunt renal trauma was revealed by enhanced computed tomography and angiography. The patient then underwent insertion of a double “J” stent and was placed under close observation in the intensive care unit. His improvement was rapid, and he subsequently underwent pyeloplasty. Although UPJ obstruction is one of the common pre-existing renal lesions (PERLs), hydronephrosis of such a giant size, associated with blunt trauma, is relatively rare. Hydronephrosis in the kidneys may easily lead to rupture, even with minor trauma.

Key words: injury, hydronephrosis, urine, angiography, pyeloplasty

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“Spontaneous” ping-pong fracture in newborns: case report and review of the literature


“Ping-pong” fractures (PPF) are depressed skull fractures typical of newborns. PPF usually result from head injury and, rarely, may cause severe long-term neurological sequelae. The management of PPF is still controversial. The goal of this paper is to present a case of “spontaneous” ping-pong fracture and to review the pertinent literature of the last 20 years. We report on a newborn who presented with a “spontaneous” parietal depressed skull fracture at birth. Preoperative computed tomography (CT) scan confirmed the PPF and excluded brain injuries. Neurosurgical intervention was performed on day 3 with immediate lifting of the fracture; the postoperative course was uneventful.

During the last 20 years, 22 cases of “spontaneous ping-pong” fractures in newborn have been reported, with different clinical pictures and management but, generally, with a good outcome.

“Ping-pong” fractures can occur in uneventful pregnancies and after uncomplicated vaginal or cesarean deliveries. CT scan, with low-dose protocol for infants, is the gold standard examination to evaluate the fracture and any associated brain lesions. Treatment is selected according to fracture characteristics.

Key words: ping-pong fracture, newborns, CT scan, delivery, neurosurgery

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Treatment of near-fatal beta blocker and calcium channel blocker intoxication with hyperinsulinemic euglycemia, intravenous lipid emulsions and high doses of norepinephrine


Background. Treatment of combined beta blocker and calcium channel blocker intoxication remains challenging due to a profound and treatment-resistant circulatory collapse. Along with standard therapy (calcium, glucagon, mechanical ventilation, vasopressors), two novel approaches are increasingly being reported as successful: hyperinsulinemic euglycemia and intravenous lipid emulsion.

Case Report. Our patient: a 66-year-old Caucasian male who ingested approximately 450 mg of bisoprolol, 300 mg of amlodipine, 200 mg of doxazosin and smaller amounts of nifedipine, torasemide, acetysaliclic acid and ibuprofen in a suicide attempt. The patient was hypotensive and bradycardic on admission with left-ventricular ejection fraction estimated at 10-15%. By combining standard therapy (intubation, mechanical ventilation, vasopressors, calcium and glucagon) and new therapies (hyperinsulinemic euglycemia and intravenous lipid emulsions) in a stepwise approach we normalized systolic function and treated bradycardia within 2 hours of admission. However, severe hypotension persisted requiring extremely high doses of norepinephrine (14 mcg/kg/min) and vasopressin (0.03 U/min) to maintain his blood pressure over the following three days. He was discharged home after prolonged in-hospital treatment and rehabilitation (62 days) and extensive physical and psychiatric rehabilitation.

Why should an emergency physician be aware of this? Aggressive medical therapy including hyperinsulinemic euglycemia, intravenous lipid emulsions and high doses of norepinephrine could be considered for multidrug intoxication with a predominant clinical picture of beta blocker and calcium channel blocker intoxication in patients presenting with severe hemodynamic compromise.

Key words: poisoning, emergency treatment, complementary therapies

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A case of concurrent deep venous thrombosis, pseudoaneurysm, and extremity abscess in an intravenous methamphetamine abuser


Introduction. Intravenous drug abuse is a global concern with an estimated 16 million people engaging in this behavior worldwide. (1) In addition, Methamphetamine abuse is widely reported with 1.2 million Americans declaring its use in 2012. (2)

Case description. The patient presented to the Emergency Department for “right groin pain” at a site she had been injecting methamphetamine. She had a palpable, non-pulsatile mass of her right groin, diffuse erythema and tenderness of her right leg, and several ecchymotic areas on multiple toes. She was found to have an extensive deep vein thrombosis of the right lower extremity, right femoral pseudoaneurysm, septic emboli, and deep space infection of her right groin. The pseudoaneurysm was removed surgically, an extra-anatomical arterial bypass was placed, an inferior vena caval filter was inserted, anticoagulants were initiated, the groin abscess was debrided and washed out, and the patient was started on antibiotics.

Discussion. Emergency physicians practicing clinically should be aware of the potential adverse outcomes of intravenous drug abuse. This patient encounter details nearly all of the significant adverse outcomes patients could experience: cellulitis, deep space infection/abscess, deep venous thrombosis, arterial pseudoaneurysm, and septic emboli.

Key words: abscess, venous thrombosis, false aneurysm, pseudoaneurysm, methamphetamine, intravenous substance abuse, intravenous drug abuse

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A comparison of the effectiveness of intubation using a McGrath Series 5 videolaryngoscope with either a Truflex articulating stylet or a standard intubation stylet in a group of medical students


Background. Intubation is the optimal method for opening the airway and effective ventilation of the patient. However, there are occasional problems with intubation, especially in patients with injuries under pre-hospital conditions. Therefore, it is important to identify devices, e.g., videolaryngoscopes or guides, which may facilitate and shorten the procedure. This study addresses the use of a Truflex articulated guide with a videolaryngoscope.

Objectives. The main objective of the study is to evaluate the effectiveness of intubation using a Truflex articulating stylet with a McGrath videolaryngoscope, and to determine whether the average time of intubation using a Truflex articulating stylet is shorter than that using a standard intubation stylet.

Materials and methods. The study involved 43 full-time 5th year medical students. All tests were performed on training manikins with a difficult airway in January 2013. Chi-square test was used for statistical analysis with a significance level of p < 0.01. Calculations were performed using the Statistica package.

Results. Intubation using a McGrath videolaryngoscope with a Truflex articulating stylet was more effective than that using a standard intubation stylet with the same laryngoscope: 71% as compared to 40%. The mean time of successful intubation using a Truflex articulating stylet was shorter than that using a standard intubation stylet guide (31.1 ± 12.8 s and 39.8 ± 12.4 s, respectively).

Conclusions. The mean time of tracheal intubation using a Truflex articulating stylet is shorter than that using a standard intubation stylet. Intubation is also more effective when a Truflex articulating stylet is used together with a McGrath videolaryngoscope.

Key words: Truflex articulating stylet, Truflex, intubation, McGrath

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Be careful what you eat and drink; Coprinic and Kounis syndrome in a patient with the Samter`s triad


Allergic reactions to chemicals, food products or even insect bites are encountered all over the world with a variety of manifestations. Symptoms range from the development of a minor rash to life threatening anaphylactic reactions. Sometimes, acute coronary syndrome (ACS) can be registered in such patients, which may have a serious impact on the course and management of the allergic reaction. Mushroom poisoning constitutes the main portion of plant toxicities in Spain. Depending on the type of mushroom, the adverse effects range from mild gastrointestinal (GI) symptoms to major cytotoxic effects resulting in organ failure and death. Coprinopsis atramentaria poisoning is rare but with serious consequences. We report a case of a 27 year old patient with a previous history of mild persistent asthma, nasal polyps and aspirin allergy that arrived to the Emergency Department with dizziness and temor after consuming beer at a party. On arrival to the hospital, the patient suddenly collapsed, with an electrocardiogram (ECG) showing ST elevation in the inferior leads and 3rd degree atrioventricular (AV) block accompanied by urticarial-like lesions. After administration of treatment, the patient and ECG abnormalities improved. A detailed medical history showed that the patient had eaten scrambled mushrooms and beer. Expert analysis demonstrated that the combined consumption of Coprinopsis atramentaria and alcoholic beverages produced a disulfiram-like reaction (Coprinic syndrome) and type I Kounis syndrome. No case like this has been previously reported.

Key words: Kounis syndrome, Coreopsis atramentaria, acute coronary syndrome

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When ˝clinician˝ does not rhyme with ˝communication˝

It is sad to say that communication skills, whether needed by a clinician to give a prognosis to a terrified patient or required by a petrified speaker during a congress presentation, are very often lacking from the modern-day biomedical professional’s armamentarium.

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Chronic fatigue after a night of work in Serbia (our experience)

Working during the night, especially with geriatric patients, has a detrimental effect on the circadian rhythm. (1) This study was approved by the Ethics Committee and Commission for Examining Ethics. The sample was randomly formed and consisted of 1200 nurses. In order to meet ethical standards in research, subjects voluntarily signed the consent form to join the study. The study group consisted of 600 nurses working the night shift with geriatric patients. The control group consisted of 600 nurses working the eight-hour day shift. As a survey instrument, two questionnaires were used.

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NTpro-BNP – diagnostic significance and recommended clinical applications


Brain natriuretic peptides are elevated in circulation in proportion to a decrease in myocardial function. They have been uniformly shown to have excellent negative predictive value in differential diagnosis of dyspnoea. They can also be used in diagnosing heart failure and have been recently shown as possible prognostic markers in acute coronary syndrome and pulmonary embolism. It is important to note that brain natriuretic peptide values rise with age and are inversely proportional to body mass index and glomerular filtration rate.

Key words: Brain natriuretic peptide N-terminal brain natriuretic peptide, heart failure

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Porphyrias – diagnostic challenge in Emergency room


Porphyrias form a heterogeneous group of disorders of haem biosynthesis. They are often missed or wrongly diagnosed in the emergency department. Acute porphyrias present most commonly as abdominal pain or as neurological or atypical psychiatric symptoms. The variety of clinical features may delay diagnosis, and unrecognized disease is potentially life-threatening. The frequency and severity of attacks vary widely. In some people, this disease remains latent throughout life, even in the presence of precipitating factors. Other people experience frequent and sometimes life-threatening attacks even in the apparent absence of exogenous precipitating factors.

Laboratory diagnosis of acute porphyria includes porphyrin precursors delta aminolevulic acid and porphobilinogen. Patients presenting with acute crises often have several-fold increases in PBG above the reference interval, usually > 10 times the upper reference limit. Hyponatremia and rabdomyolysis are relatively common manifestation accompanying acute attack.

Key words: porphyria, laboratory diagnostic, emergency room

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Procalcitonin – potential, limitations and availability


Bacterial infections and sepsis are major problems in critically ill patients. Timely diagnosis and therapy reduce morbidity and mortality. Many studies have included the investigation of various biomarkers whose elevated concentrations can indicate sepsis; among them, PCT proved to be most useful.

PCT is synthesized in the thyroid gland as a prohormone of calcitonin. In healthy individuals the PCT concentration is <0.1 ng/mL.

The advantage of the PCT is a high negative predictive value for the exclusion of sepsis, with the cut-off value of 0.5 ng/ml. A concentration between 2 and 10 ng/ml indicates strong sepsis, whereas a value ≥10 ng/ml is associated with septic shock. In addition to the diagnosis of sepsis, the measurement of PCT concentration is useful for the introduction and monitoring of antibiotic therapy, which is performed according to an algorithm based on the cut-off value for PCT.

Immunoassays are used to measure PCT concentrations in serum or plasma. It is possible to determine the concentration in whole blood by using point-of-care testing.

In pathological conditions that are not associated with sepsis, PCT is useful as a prognostic indicator of disease complications. Some studies suggest that PCT is a potential early indicator of acute coronary syndrome.

Key words: procalcitonin, bacterial infection, sepsis, intensive care unit

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Laboratory utilization in the emergency department – are the requested tests patient-oriented?


Emergency laboratory services are essential for the efficient management of critically ill patients admitted to the emergency department. Characterised by their high priority of processing, analysing and reporting, they serve as a discriminating tool in the triage of medical emergencies, rather than as a diagnostic tool. Optimal and adequate utilisation of laboratory testing greatly contributes to the overall quality and efficiency of laboratory services. From our experience gained through monitoring the ordering habits among physicians at the Emergency Medical Service of the University Hospital Centre Zagreb, non-selective overuse of laboratory tests occurs in practice. The most commonly used laboratory tests are often ordered together and at a negligible variation between physicians, regardless of a widely varied patient population. Patient-oriented laboratory diagnostics can be achieved through limiting the availability of test ordering, an application of test panels based on relevant guidelines and protocols and upkeep of continuous close interaction between clinicians and laboratory experts.

Key words: emergency laboratory tests, laboratory utilization

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Gestational trophoblastic disease with multisistemic complications


Gestational trophoblastic disease (GTD) is a condition of uncertain etiology, comprised of a hydatidiform mole (complete and partial), invasive mole, choriocarcinoma, epithelioid trophoblastic tumour and placental site trophoblastic tumour.
A partial hydatidiform mole develops when dispermy occurs, and the resulting conceptus is triploidy.
A 26-year-old woman (Gravida 2, Para 1, with one previous vaginal delivery of a normal female infant) was 16 weeks pregnant and was scheduled for emergency surgical treatment. She was diagnosed with a hydatidiform mole and eclampsia in our hospital for further treatment.
Her pre-treatment beta human chorionic gonadotropin (β-HCG) level was extremely high at 1,082,900 mIU/ml. The obstetricians considered septic complications from the hydatidiform mole and we decided to perform an emergency Sectio parva.
Two weeks after delivery, the serum β-hCG level was 16,341 mlU/mL and normalized gradually within two months without any cytotoxic therapy.
Partial mole hydatidosa (PMH), as a milder form of GTD, can go along with malignant complications with fatal consequences.

Key words: gestational trophoblastic disease, eclampsia, chorionic gonadotropin beta subunit.

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