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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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


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


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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Serum cortisol level as a useful predictor of surgical disease in patients with acute abdominal pain


Introduction. The immediate aim should be to identify potentially resuscitative acute abdominal pain that requires prompt investigation or early surgical intervention. We aimed to evaluate whether serum cortisol levels differentiate surgical and non-surgical disease in patients with acute abdominal pain.

Materials and methods. In this prospective cross-sectional study, the primary end-point was defined as differences in serum cortisol levels between surgically and non-surgically treated patients with non-traumatic acute abdominal pain. The secondary end-point was to compare the cortisol levels with defined complete blood count (CBC) parameters in those groups.

Results. One hundred eleven patients with acute abdominal pain were included in the study. Three most frequent diagnoses were nonspecific abdominal pain, acute appendicitis and dyspeptic complaints. Thirty patients were hospitalized and 22 of them were operated. The median cortisol level was 23.13 µg/dl in surgically treated patients and 13.94 µg/dl in non-surgically treated patients (p<0.001). The area under the ROC curve using cortisol to detect surgical disease was 0.750 (95% CI, 0.659-0.827) and the accuracy of cortisol to detect surgical disease was not inferior to defined CBC parameters. A cortisol value of 17.98 µg/dl had a sensitivity of 67.4% and a specificity of 77.3% for surgical disease.

Conclusion. Operated patients had higher serum cortisol levels. High serum cortisol levels may indicate surgical disease at the early stage on admission in ED patients with acute abdominal pain and may be used as a marker in the prediction of acute surgical abdomen.

Key words: abdominal pain, cortisol, emergency department, surgery

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Massive transfusion protocol: the reason it is necessary


Objective. The purpose of this study is to identify problems of emergency transfusion at the bedside and to determine need for massive transfusion protocol.

Methods. We included patients who met the criteria for “trauma team activation” and were admitted to division of trauma. The amount of blood product transfused in each unit was investigated for balanced transfusion. We also investigated the compliance with assessment of blood consumption score. The correlation between the time elapsed from patient visit to first transfusion order and time elapsed from first transfusion order to transfusion start was analyzed. Finally, we investigated various factors which serve to influence the decision-making process regarding early transfusion order.

Results. Ratio of packed Red blood cells (pRBC): Fresh frozen plasma (FFP) was well-balanced, but platelet transfusion done was much lower than pRBC and FFP in emergency room. The application of emergency blood release did not match the criteria of assessment of blood consumption (ABC) score. The time from the first transfusion order to the transfusion start was found to be constant irrespective of time from patient visit to first transfusion order. And, the time from the first transfusion order to transfusion start did not differ significantly among patients with early transfusion order and delayed transfusion order. Only systolic blood pressure of < 90 mmHg was identified as a major predictor for early transfusion order.

Conclusion. Balanced transfusion is not easy and emergency transfusion could be delayed at the bedside. Integrated and systematic structures for massive transfusion protocol would be invaluable and indispensable.

Key words: transfusion, emergency, protocol

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Contribution of Presepsin, Procalcitonin and C-reactive protein to the SOFA Score in Early Sepsis Diagnosis in Emergency Abdominal Surgical Patients


Purpose: This study examined whether the addition of biomarkers presepsin (PSEP), procalcitonin (PCT) and C-reactive protein (CRP) to the initial SOFA (iSOFA) score can improve diagnostic accuracy of early sepsis diagnosis in emergency abdominal surgery patients.

Materials and Methods: Seventy-two study subjects had diagnosis of acute abdomen due to gastrointestinal disturbances. The study evaluated diagnostic accuracy and predictive value of two models (iSOFA only and iSOFA combined with three biomarkers) for sepsis diagnosis.

Results: The AUC value for the iSOFA was highest, followed by the AUC value obtained for PSEP, PCT and CRP (0.989, 0.738, 0.694 and 0.606, respectively).The logistic regression analysis of the two models showed for the first model that patients with a higher iSOFA score are almost two times more likely to suffer from sepsis. In the second model, patients with a higher iSOFA score and a higher level of biomarkers are three times more likely to have sepsis.

Conclusions: Although the SOFA score is known to be the best diagnostic tool for sepsis diagnosis, it seems that among the three investigated markers PSEP and PCT– although not contributing to the iSOFA score– are good independent markers with significantly higher levels in septic than in non-septic patients. PSEP has the highest diagnostic accuracy for sepsis. Only the conventional marker CRP provides certain added value to the iSOFA score for sepsis prediction.

Further investigations should be performed to study the possible diagnostic value of dynamic changes of the three examined markers in prediction and early diagnosis of sepsis.

Keywords: Sepsis, SOFA, presepsin, procalcitonin, abdominal surgery

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