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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Recognition of ventricular fibrillation concomitant with pacing artifacts

Abstract

Introduction. In pre-hospital settings recognition of underlying rhythm in patients with ventricular stimulation can be difficult especially when a 3-lead electrocardiogram (ECG) is analyzed. This fact is particularly important in patients with life-threatening cardiac dysrhythmias. The pacing spikes in the ECG of a patient with cardiac arrest due to ventricular fibrillation may be misdiagnosed as QRS complexes.
Aim of the study. The aim of this study was to assess emergency medical care students’ accuracy in recognizing ventricular fibrillation when pacing spikes are present.
Material and methods. The study group consisted of 39 emergency medical care students, 16 males and 23 females, aged 21 – 23. Subjects were at the midpoint of their 3-year university healthcare professional education. Subjects were asked to interpret electrocardiograms presenting ventricular fibrillation with concomitant pacing artifacts, ventricular fibrillation and atrial fibrillation with ventricular pacing, respectively. Students were trained in recognition of ECG tracings presenting ventricular stimulation, atrial fibrillation and ventricular fibrillation. They were instructed that the duration of the QRS complex in adults is at least 0.06s and that pacemaker stimuli are shorter. Prior to the examination, an electrocardiogram similar to the abovementioned, with ventricular fibrillation and pacemaker stimuli, was not presented.
Results. Only one student (out of 39) recognized ventricular fibrillation with pacemaker stimuli present; the majority of students (92%) incorrectly interpreted the rhythm as atrial fibrillation or atrial flutter. The ECG with isolated ventricular fibrillation was correctly interpreted by all but two students who recognized polymorphic ventricular tachycardia and 62% of students correctly recognized ventricular pacing whereas none of them recognized atrial fibrillation.
Conclusions. 1. The skills of recognizing ventricular fibrillation in patients with concomitant ventricular pacing are poor among emergency medical care students.
2. The ECG tracing showing concomitant ventricular fibrillation and pacing stimuli should be included in teaching programs for emergency medical care students. An ongoing quality improvement program may reduce the rate of mistakes in ECG analysis in rare cases with life-threatening emergencies.

Key words: ventricular fibrillation, cardiopulmonary resuscitation, training, cardiac pacing

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Experience of Belgrade’s Emergency Medical Service in the implementation of cardiopulmonary resuscitation guidelines issued in 2010

Abstract

Introduction. Implementation of cardiopulmonary resuscitation (CPR) is defined by the unified 2010 Guidelines for CPR.
Objective. This paper presents the experience of Belgrade’s Emergency Medical Services (EMS) in the implementation of out-of-hospital (OH) CPR according to the new, 2010 Guidelines.
Methods. A retrospective study design was used. We recorded OH CPR and analyzed four variables: patient gender and age, arrest location, bystander witnessed arrest, and arrest rhythm (shockable – group I, non-shockable – group II). The study also looked at  implementation and follow-up of CPR, therapy, CPR duration, EMS reaction time, and patient outcome (Return of Spontaneous Circulation [ROSC] or death).
Results. Of 794 OH CPR attempts, 136 (17%) patients with field ROSC were transported to hospital admission (HA) (22% group I, 78% group II). ROSC at HA was sustained in 64 (47%), and unsustained in 72 (53%) patients. Among the patients with ROSC on HA, 47% had spontaneous breathing and 5% fully regained consciousness. The ROSC rate was higher after arrest occurring at home (P<0.001). No statistical significance between the groups regarding the following analyzed variables was found: patient gender, age, onset time (day or night shift), bystander witnessed arrest, ROSC, breathing and consciousness at HA. In all patients, intravenous (IV) access was established. Atropine was administered in 28 (21%) group II patients. Adrenaline was administered in 71% of patients and withheld in 29% of patients due to hospital closeness or sustained ROSC. By HA, 46% were successfully intubated. The average response time in group I was 8.1±4.0 minutes, in group II 6.8 ± 4.4 minutes. A highly significant association (p<0.01) was found between CPR duration and ROSC at HA (26.23 min – ROSC vs. 14.46 min – no ROSC).
Conclusion. Study results indicate the significance of the new Guidelines for CPR in the everyday practice of Belgrade’s EMS teams. Continual training increases the quality of administered CPR measures and the rate of patients with ROSC at HA. New studies would contribute to the disclosure of weak links in the survival chain after OH CPR in Belgrade.

Key words: out-of-hospital resuscitation, experience, Belgrade Emergency Medical Service, new guidelines for CPR

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Rapid-response extracorporeal membrane oxygenation to support failed conventional cardiopulmonary resuscitation (E-CPR) in children – case reports and literature review

Abstract

The use of extracorporeal membrane oxygenation (ECMO) to support failed conventional cardiopulmonary resuscitation e.g. ECMO cardiopulmonary resuscitation (E-CPR) in children has been increasing. We report on the first three patients in whom E-CPR was used at our institution, a low volume surgical centre. Patient’s diagnoses were: influenza B myocarditis, truncus arteriosus two days after complete surgical repair and cardiogenic shock during adenovirus infection with a discovered recoarctation of the aorta. The use of E-CPR rescued 1 patient (33%) out of three. Apart from high volume surgical centres, E-CPR can also be implemented in low volume centres with a trained in-house ECMO team, in selected cases.

Key words: cardiopulmonary resuscitation, child, extracorporeal membrane oxygenation, refractory cardiac arrest

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Migraine due to intraparenchymal hemorrhage during a blast crisis

Abstract

Background. Hyperleukocytosis is defined as a white blood cell (WBC) count in excess of 100,000 per mm3. Hyperleukocytosis can cause leukostasis syndrome, the accumulation of leukemic blast cells within the capillary lumen, resulting in neurologic and pulmonary manifestations that can lead to intracranial haemorrhage and respiratory failure.
Objective. Identify a correct diagnostic approach, as the diagnosis of leukostasis in a patient suffering from acute leukemia with hyperleukocytosis is made only clinically. A full blood cell count and a peripheral blood smear are essential for diagnosing leukostasis.
Case report. A 19 year old girl presented to the emergency department reporting onset of headache, absence of regression of symptoms after taking painkillers (non steroidal anti inflammatory drugs (NSAIDs)), intense fatigue and absence of fever. On examination, modest hypotension and anisocoria (with reactive pupils) were evidenced. A brain computed tomography (CT) scan was performed. Several, large areas of parenchymal haemorrhage were identified. A chest and abdomen CT scan was requested. The images demonstrated the presence of splenomegaly. The laboratory findings confirmed the suspected diagnosis, with a leukocyte count equal to 980,000 units per mm3 and a platelet count of 24,000 units per mm3.
Conclusion. Given the clinical case and its evolution, no report of recent onset of headache, especially in young patients, should be underestimated.

Key words: intraparenchymal hemorrhage, hyperleukocytosis, leukostasis, leukaemia, emergency department

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Suspected chyle leak during complex spine surgery A unique case of propofol infusion resulting in lipid emulsion pooling in the surgical field

Abstract

The authors report a case of propofol infusion being mistaken for chyle during a two stage thoracic spinal fusion. Propofol is commonly used during spine surgery to facilitate neuromonitoring and there are no reported cases of these observations in the spine literature. We describe the positioning, timing, and treatment in a patient that required prolonged care to rule out a chylothorax.  Chyle and the pharmacologic and physiologic effects of propofol are discussed. This review outlines our reasoning and steps used to rule out a chyle leak in the setting of propofol-based anesthesia.

Key words: chest tube, chylothorax, motor evoked potential monitoring, neuromonitoring, propofol infusion syndrome, PRIS, thoracic duct, thoracotomy, total intravenous anesthesia, TIVA

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