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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Vasoactive-inotropic score as a predictor of in-hospital mortality in out-of-hospital cardiac arrest

Abstract

Background: The Vasoactive-Inotropic Score (VIS) is an objective clinical tool used to quantify the need for cardiovascular support in children and adolescents after surgery and to predict prognosis of pediatric septic shock. Considering the post-cardiac arrest syndrome (PCAS) is a sepsis-like syndrome, we aimed to investigate the correlation between VIS and in-hospital mortality in out-of-hospital cardiac arrest (OHCA) patients who achieved a sustained return of spontaneous circulation (ROSC) and admitted to the intensive care unit (ICU).

Methods: A retrospective chart review of 504 OHCA patients who were admitted to the emergency room with OHCA from Jan 2015 to Dec 2016 was done. VIS was calculated with the recorded administration rate of the drugs on electronic medical record at the same time during the first 24 hours in ICU. The highest value of VIS in 24 hours (24hr-peak VIS) was used for investigating the correlation between VIS and in-hospital mortality.

Results: Among 504 OHCA patients, 166 patients were admitted to the intensive care unit and 116 patients died during hospital stay. The probability of in-hospital mortality was significantly higher when 24hr-peak VIS was higher than 33.3 [Odds ratio (OR) = 3.18, 95% CI = 1.22 – 8.29, p value = 0.018].

Conclusion: 24hr-Peak VIS could be a good scoring system for predicting in-hospital mortality in OHCA patients who admitted to ICU. The AUC was 0.762 (95% CI = 0.690 to 0.825) and the optimal cut-off values were 33.3 (sensitivity 0.764, specificity 0.610).

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Atypical Cerebral Infarction in a Patient Suspected Ingestion of Synthetic Cannabinoids

Abstract

Background: Synthetic cannabinoids are recreational street drugs with many known adverse effects.

Case presentation: Here we present the case of an atypical cerebral infarction in a patient with a suspected ingestion of synthetic cannabinoids.

Conclusion: Although synthetic cannabinoids use is not conventionally associated with stroke, some case reports describe cerebral infarction and myocardial infarction with significant synthetic cannabinoids intake. Emergency physicians should know the association of synthetic cannabinoids with seizures, myocardial infarction, and now possibly ischemic stroke.

Key words: stroke, cannabinoids, synthetic cannabinoids, case report

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Misleading presentation of ruptured abdominal aortic aneurysm and the role of point-of-care ultrasound for diagnosis

Abstract

If not recognized and treated early enough, the rupture of abdominal aortic aneurysm (rAAA) embodies a devastating medical emergency. It is associated with high morbidity and mortality which can reach up to 100 % in untreated individuals. Patients are usually hypotensive, shocked, complain of pain in the abdomen or back, and can have a palpable pulsatile abdominal mass. rAAA can be misdiagnosed due to patient’s comorbidities, site of rupture, or unusual presentations. Unusual clinical presentations include transient lower limb paralysis, right hypochondrial pain, groin pain, testicular pain, iliofemoral venous thrombosis, and others. When ruptured abdominal aneurysm is suspected an emergency ultrasound should be performed. In this article we are going to present a patient with unusual presentation of ruptured abdominal aneurysm and the importance of point-of-care ultrasound in similar cases.

Key words: abdominal aortic aneurysm, rupture, point-of-care ultrasound

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Assessment of the implementation of step-by-step adult basic life support sequence by emergency medical technicians and drivers during regular annual training

Abstract

Objective. Evaluation of the efficiency of practicing step-by-step (SBS) BLS/AED (basic life support/automatic external defibrillator) sequence by emergency medical technicians (EMT) and ambulance drivers (AD) working in medical transport teams.

Methods. A prospective two-month study was conducted in which EMTs and ADs working in medical transport teams performed their regular 4-hour annual training (1 h of lectures, 1.5 h of practical training and 1.5 h of testing). Each participant performed SBS of BLS/AED sequences in front of a three-member team of instructors. The implementation of BLS/AED sequence was evaluated by scoring from 0 to 2 (0 – not, 1 – partially, 2 – properly), separately for EMTs, ADs and in total. The final analysis compared a properly implemented SBS sequence (S1-S36) of actions: IA – initial assessment (S1-S10), BLS (S11-S18), AED (S19-S25), RP – recovery position (S26-S32) and FBAO – foreign body airway obstruction (S33-S36) for use by the BLS/AED between EMTs and ADs. The criterion for a completed regular training was at least 47 (65.0%) of the total number of points won for properly implemented procedures.

Results. The study involved 31 EMTs and 63 Ads, regardless of gender and average age, with EMTs having slightly longer work experience (p>0.05). The results of our study show that EMTs are more skilled at IA, cardiopulmonary resuscitation (CPR) and AED, whereas ADs were better at implementing RP and performing the Heimlich maneuver (p<0.001).

Conclusion. Although EMTs and ADs implement SBS BLS/AED procedures correctly and satisfactorily in more than 65.0%, future research should focus on finding more efficient, shorter and cheaper BLS/AED trainings.

Key words: basic life support, step-by-step, sequence, emergency medical technicians, ambulance drivers

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Diagnostic markers of serious bacterial infections in infants aged 29 to 90 days

Abstract

Objectives: The diagnosis of serious bacterial infection (SBI) is difficult due to a lack of clinical evidence. The purpose of this study was to determine which inflammatory markers can be used to detect SBI in febrile infants.

Methods: This retrospective cohort study included infants aged 29 to 90 days who visited a tertiary hospital emergency department in Korea between July 2016 and June 2018. The diagnostic characteristics of the neutrophil-to-lymphocyte ratio (NLR), procalcitonin (PCT), C-reactive protein (CRP), white blood cell (WBC) count, and absolute neutrophil cell (ANC) count for detecting SBI were described. Their cutoff values were calculated based on receiver operating characteristic (ROC) curve analysis.

Results: Among 528 infants, 199 were finally enrolled. SBI was detected in 68 (34.2%) of these infants. The median values of all investigated diagnostic markers were significantly higher in infants with SBI than the values in those without: WBC (12.72 vs. 9.91 k/μL), ANC (6.28 vs. 3.14 k/μL), CRP (26.6 vs. 2.8 mg/L), NLR (1.29 vs. 0.78), and PCT (0.5 vs. 0 ng/mL). The areas under the ROC curves for discriminating SBI were: 0.705 (95% confidence interval [CI], 0.629-0.781), 0.793 (95% CI, 0.731-0.856), 0.832 (95% CI, 0.775-0.889), 0.722 (95% CI, 0.651-0.792), and 0.695 (95% CI, 0.611-0.780) for WBC, ANC, CRP, NLR, and PCT, respectively. Using a cutoff value of 0.67 for NLR, the negative predictive value was 90.8% for identifying SBI.

Conclusions: CRP was the best single discriminatory marker of SBI, while NLR was the best parameter for considering discharge.

Key words: bacterial infection, urinary tract infection, clinical marker, discharge planning

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