Cardiac Arrest in Special Circumstances-Recent Advances in Resuscitation.

BACKGROUND: Cardiopulmonary resuscitation (CPR) in special circumstances includes the emergency intervention for special causes, special environments, and special patients. Special causes cover the potential reversible causes of cardiac arrest that must be identified or excluded during any resuscitation act. The special environments section includes recommendations for the treatment of cardiac arrest occurring in specific locations: cardiac surgery, catheterization laboratory, dialysis unit, dental surgery, commercial airplanes or air ambulances, playing field, difficult environment (eg, drowning, high altitude, avalanche, and electrical injuries) or mass casualty incident. CPR for special patients gives guidance for the patients with severe comorbidities (asthma, heart failure with ventricular assist devices, neurological disease, and obesity) and pregnant women or older people. AREAS OF UNCERTAINTY: There are no generally worldwide accepted resuscitation guidelines for special circumstance, and there are still few studies investigating the safety and outcome of cardiac arrest in special circumstances. Applying standard advanced life support (ALS) guidelines in this situation is not enough to obtain better results from CPR, for example, cardiac arrest caused by electrolyte abnormalities require also the treatment of that electrolyte disturbance, not only standard CPR, or in the case of severe hypothermia, when standard ALS approach is not recommended until a temperature threshold is reached after warming measures. Data sources for this article are scientific articles describing retrospective studies conducted in CPR performed in special circumstances, experts' consensus, and related published opinion of experts in CPR. THERAPEUTIC ADVANCES: The newest advance in therapeutics applied to resuscitation field for these particular situations is the use of extracorporeal life support/extracorporeal membrane oxygenation devices during CPR. CONCLUSIONS: In special circumstances, ALS guidelines require modification and special attention for causes, environment, and patient particularities, with specific therapeutic intervention concomitant with standard ALS.

Translating training to medical practice in trauma care, a literature review.

Trauma, a global health challenge, remains a significant cause of mortality despite advances in trauma management. The establishment of trauma teams has revolutionized care in trauma resuscitation. The training of these teams is designed to promote self-trust and empower trainees in trauma care, enhance performance, and improve patient outcomes. Various training curricula have been developed, utilizing a plethora of teaching methods such as lectures, simulations, debriefings, skill workshops, and demonstrations. However, a universally accepted gold standard curriculum in trauma training is yet to be defined, and there is no standard method for delivering education in injury care teaching. In this review, we have examined relevant literature data on standard teaching programs, the educational delivery methods used, and their impact on adult trauma patients' outcomes and trained team-related outcomes. While most studies indicate improved trained team performance, they consistently show no improvement in patient-specific outcomes such as mortality, morbidity, and length of stay. However, data hints at optimal educational delivery and the role that technology may play in the future of trauma training development.

A Modern Diagnostic Procedure-The Introduction of Point-of-Care Ultrasound in Romanian Emergency Physicians' Daily Routine.

BACKGROUND: Emergency medicine in Romania has developed fast since inception. The need for faster diagnostic capabilities due to the high workload pre- and in-hospital made point-of-care ultrasound (POCUS) a logical next step. The advantages of POCUS are well known, but implementation presents challenges. Our goal was to study how a straightforward method of implementation would work locally. METHODS: Two prospective observational studies were conducted at 6 months (prehospital) and 4 months (in-hospital). The protocol used was extended focused assessment sonography in trauma (eFAST), and the shock index (SI) was used to stratify patients. Voluntary sampling was conducted by emergency physicians. The primary outcomes were patient numbers, type of case use, results, and accuracy. RESULTS: The prehospital study registered 34 patients: 41% traumas, 35% cardiac arrest, 18% shock, and 6% acute respiratory distress. The in-hospital study patients were 78: 36% traumas, 6% cardiac arrests, 41% shock, and 17% acute respiratory distress. A total of 88.5% of the cases were confirmed with definitive imagistic findings. CONCLUSION: The studies mark an increase in POCUS usage and use in complicated cases. Providing supervision and feedback into clinical practice resulted in a further increase in POCUS usage, the second study having an 88.5% accuracy when compared to the final diagnostic proving the increased efficiency of a longitudinal training approach.

Monitoring Perfusion Index in Patients Presenting to the Emergency Department Due to Drug Use.

(1) Background: The perfusion index (PI) represents the ratio between pulsatile blood flow and non-pulsatile blood flow in the peripheral tissue. (2) We aimed to investigate the blood pressure perfusion of tissues and organs in ethnobotanical, synthetic cannabinoid and cannabis derivative consumers through the value of perfusion index. (3) Results: The patients enrolled were divided into two groups: group A, which included all patients who presented in the ED within the first three hours after consumption, and group B, which included those patients who presented more than three hours and up to 12 h after drug consumption. The average values of the PI in the case of group A/group B were 1.51 ± 1.07/4.55 ± 3.66. Statistically significant correlations in both groups were recorded between the drug intake ED admission, respiratory rate, peripheral blood oxygen saturation and tissue perfusion index (p < 0.001). The average value of the PI measured in group A was significantly lower compared to that measured in patients in group B. Therefore, we concluded that the perfusion of peripheral organs and tissues was lower in the first 3 h after drug administration. (4) Conclusions: PI plays an important role in the early detection of impaired organ perfusion and in monitoring tissue hypoxia. A decreased PI value may be an early indication of decreased perfusion organ damage.

Pediatric Emergency Department Management in Acute Poisoning-A 2-Year Retrospective Study.

(1) Background: Poisonings in children are common reasons for addressing ED and can potentially have serious complications. Our research aims to review risk factors leading to poisoning in children. (2) Methods: A retrospective review of all pediatric poisoning cases addressing the Children's emergency department of St Mary Hospital over a two-year period was performed. (3) Results: We collected data on 797 children admitted for acute poisoning. The highest incidence identified was in the 12-18 and 1-3-year-old age groups. The distribution of voluntary versus unintentional poisonings was relatively balanced: 50.19% versus 47.43% (for some cases the type of intoxication remained unknown). Exposure to the toxic substance by ingestion was significant compared to the other routes, with an incidence of 87.1%. Acute poisoning happened at home in 70.4% of cases. A known risk factor before reaching the ED was present in 13.04%. (4) Conclusions: Our study showed a greater risk for acute poisoning in children between 1-3 years of age, and adolescents over 12 years. Identifying and documenting epidemiological aspects and other variables is important for establishing preventive measures and for therapeutic conduct. Adequate risk stratification and preventive measures involving closer supervision of minors or cognitive-behavioral programs can prevent voluntary intoxication.

The Beginning of an ECLS Center: First Successful ECPR in an Emergency Department in Romania-Case-Based Review.

According to the latest international resuscitation guidelines, extracorporeal cardiopulmonary resuscitation (ECPR) involves the utilization of extracorporeal membrane oxygenation (ECMO) in specific patients experiencing cardiac arrest, and it can be considered in situations where standard cardiopulmonary resuscitation efforts fail if they have a potentially reversible underlying cause, among which we can also find hypothermia. In cases of cardiac arrest, both witnessed and unwitnessed, hypothermic patients have higher chances of survival and favorable neurological outcomes compared to normothermic patients. ECPR is a multifaceted procedure that requires a proficient team, specialized equipment, and comprehensive multidisciplinary support within a healthcare system. However, it also carries the risk of severe, life-threatening complications. With the increasing use of ECPR in recent years and the growing number of centers implementing this technique outside the intensive care units, significant uncertainties persist in both prehospital and emergency department (ED) settings. Proper organization is crucial for an ECPR program in emergency settings, especially given the challenges and complexities of these treatments, which were previously not commonly used in ED. Therefore, within a narrative review, we have incorporated the initial case of ECPR in an ED in Romania, featuring a successful resuscitation in the context of severe hypothermia (20 °C) and a favorable neurological outcome (CPC score of 1).

Burnout Syndrome among Staff at an Emergency Department during the COVID-19 Pandemic.

OBJECTIVE: The aim of this current study was to identify the prevalence of burnout manifestation in a sample recruited from the emergency department of a hospital. Moreover, we aimed to assess the role of professional experience, age, and the professional category in shaping burnout manifestations. RESULTS: The results showed that higher proportions of burnout symptoms were reported by resident physicians, nurses, and physicians whereas lower proportions were encountered in the orderly group. Moreover, the results revealed a significant difference between men and women in the nurse group concerning depersonalization; men presented higher levels of depersonalization compared with women. Concerning emotional exhaustion and depersonalization, multiple comparisons showed differences among the professional categories. CONCLUSIONS: The implications of these results for preventing burnout syndrome are discussed.

Impact of Cardiopulmonary Resuscitation on Emergency Medical Staff-Romanian Perspective (IRESUS-EMS).

BACKGROUND: Unnecessary resuscitation is defined as putting in a disproportionate amount of effort compared to the patients' prognosis and chance of survival. The primary objective of this study was to determine the number of resuscitations perceived as unnecessary by emergency medical personnel and to correlate it with the characteristics of resuscitation team members, patient particularities and organizational factors related to the professional environment. METHODS: This was a prospective cross-sectional study carried out in the emergency department of a university hospital, exploring the perception of the uselessness of cardiopulmonary resuscitation (CPR) through the completion of a questionnaire. RESULTS: In total, 70.37% of respondents are often involved in CPR attempts in which the efforts made are disproportionate compared to the patients' expected prognosis, in terms of survival or quality of life. The presence of a non-shockable rhythm increased, by two times, the chances of medical staff finding it unnecessary to initiate CPR. CONCLUSIONS: The current study was the first in Romania to investigate the perception of unnecessary CPR, based on the recollection of the last resuscitation performed by the emergency medical staff. The objective criteria related to the patient were the most important predictors for assessing the adequacy of the decision to initiate CPR.

Outcomes of death and prolonged renal insufficiency in ethylene glycol poisoned patients.

BACKGROUND: Despite the severity of ethylene glycol intoxication, there is a paucity of studies that analyze prognostic factors. This study aims to determine prognostic factors with impact on core outcomes like death and prolonged kidney injury (KI) in ethylene glycol poisoned patients. METHODS: We retrospectively assessed prevalence, clinical and biochemical features in one large data set from two regional hospitals from the North-East region of Romania, between January 2012 and October 2017. Secondly, we compared prognostic factors of cases treated with dialysis plus antidote (N = 28 patients) with cases who received antidote only and supportive therapy (N = 28 patients). RESULTS: Of the 56 cases included, 16 deaths (28.57%) were recorded. The symptomatology at admission was more severe among patients requiring hemodialysis: a lower mean value for initial pH, lower initial alkaline reserve (AR) and higher mean values for initial serum creatinine (Cr1). The data analysis (survivors/deceased) showed a correlation between pH, Glasgow Coma Score (GCS), and increased mortality. In addition, we found a correlation between initial mean values for pH, AR (mmol/L), Cr1 (mg/dL), and peak Cr24 (mg/dL) with outcomes of RI or death. CONCLUSIONS: Compared with survivors, patients who died or had prolonged kidney injury were more likely to exhibit clinical signs such as coma, seizures, and acidosis. Hemodialysis and antidote should be started early and continued until acidosis is corrected.

Attempted Suicide: A Cross-Sectional Survey 2015.

Aim: Suicide is a global health problem with an increasing incidence among young adults and teenagers. The study was aimed at analyzing the profile and identifying the frequency, nature, and contributing factors of suicides. Material and Methods: This retrospective study included all patients who attempted suicide admitted to the Emergency Department (ED) of 'St Spiridon' Hospital Iasi - Romania, during 2015. They were analyzed by sex, age, residence, suicide method, associated pathology, potential risk factors and interventions. Results and Discussion: The study included 368 patients (53.81% female and 46.19% male). 63.58% were admitted to ED for drug ingestion, 14.13% for ingestion of organophosphorus compounds, rat poison, herbicide and corrosive substances and 22.28% for traumatic suicide attempts. Drug ingestion (42.11%) was preferred by women while self-inflicted cut injuries (14.94%) and corrosive substance ingestion (8.42%) were more common in males. Benzodiazepines ingestion (20.10%) followed by self-inflicted cut injuries (13.85%) and corrosive substance ingestion (6.52%) were the most frequently used suicide methods. At the time of admission to ED31.52% of patients were on psychiatric treatment and 65.48% were at the first suicide attempt. The admission rate was 57% and mortality rate 0.27%. Conclusions: Suicidal behavior can be prevented by psychotherapeutic, pharmacological or neuromodulatory treatments for mental disorders. Also, regular follow-up of people who attempted suicide by mental health services is key to preventing future suicide attempts.

Ethnobotanical and Cannabis Drug Use: A Step Between Danger and Pleasure.

Aim: The study aimed to identify the risk factors and the particularities of ethnobotanicals and cannabis users who needed medical care in the Emergency Department of the "Sf. Spiridon" County Hospital. Material and Methods: Retrospective study conducted over a period of 18 months (January 1, 2015- June 30, 2016). This study included all patients who presented to the E.D. after drug (cannabis and ethnobotanicals) consumption. The variables studied for creating the consumer profile were sex, age, social background, method of consumption, clinical and laboratory changes. Results and Discussion: The study included 153 patients brought to hospital by ambulance (71.89%) for cannabis or ethnobotanical poisoning. Most patients were males (92.15%) from urban areas (75.97%), aged between 18 and 24 years (52.28%). At the time of admission to ED 96.07% of them needed medical care for consumption of ethnobotanicals through various methods and only 3.92% were brought to hospital for cannabis or marijuana use. For 61.70% of patients, curiosity was the reason behind their addiction. Toxicology testing (qualitative urine analysis) was useful in identifying the presence of tetrahydrocannabinol(THC) or a combination of THC and barbiturates, benzodiazepines, opioids in 26.53% of ethnobotanical and 66.67% of cannabis users. Conclusions: In Romania, the most commonly used drugs are cannabis followed by ethnobotanical products. For a while, ethnobotanical products were falsely considered as risk-free, but they contain dangerous substances with devastating effects, which, unless treatment is initiated immediately, can lead to death.

[Issues on the use of ethnobotanicals]. / Aspecte privind consumul de produse etnobotanice.

AIM: To identify the risk factors for the use of ethnobotanicals and the people at risk to becoming users. MATERIAL AND METHODS: This questionnaire basez objective population study included 89 subjects aged 14 to 42 years. RESULTS: 19.10% of the subjects admitted using ethnobotanicals, most of them being 20-25 years old (35.29%), males (82.35%), with an average educational level, and unmarried. It should be noted that 23.52% of the users were underage. 85.15% of the subjects first used ehnobotanicals out of curiosity, 29,41% under the influence of friends (94.11% of them having friends that use these products). 11.76% of the respondents stated that they did not know what they used, the product being offered to them by friends as a cigarette or candy. Favorite places for consumption were: at home (64.70%), parks and public areas (23.52%), coffee shops and night clubs (11.76%). Cigarette was the preferred method of use (70.58%), followed by joint (23.52%) and "salt bath" (5.88%). The described effects were: hallucinogen (35.29%), aphrodisiac (29.41%) and relaxing (23.52%). To strengthen these effects, most users associated alcohol and tabacco (70.58%), or other illegal drugs (7.14%). According to this study all users were familiar with the risks associated with the use of these products, but only 64.70% agree with closing the weed-shops. CONCLUSIONS: The obtained data are of help in initiating prevention and rehabilitation programs in school and colleges.

[Oncological emergencies in the emergency department]. / Urgente oncologice în departamentul de urgenta.

AIMS: to assess the profile and the characteristic of oncological patients, establishing management in patients with neoplasia presented in the emergency department (ED), the analysis of short-term movements in patients with neoplasia whilst in the ED. MATERIAL AND METHODS: we performed a retrospective study on nonrandomized consecutive cases. The lot analysis included 1315 oncological patients admitted in the Emergency Department of the Clinical Emergency Hospital "St. Spiridon" Iasi, in the period June 1st, 2009 - May 31st, 2010. 23.12% of the patients had high suspicion of neoplasia at the first visit to the ED. RESULTS: 67.07% of patients were in metastatic stage disease located as follows: liver metastasis 37.59%, lung metastasis 18.36%, lymph node metastasis 13, 29%. After processing the data there were found statistically significant correlations between the age of patients and the documented/suspected diagnosis of neoplasia (p = 0.01) in the sense that a neoplasia diagnosis in emergency was more frequent in people of young age. It should be mentioned that other studies rarely mention first diagnosis of neoplasia in emergency department with presence of complications. CONCLUSION: 1315 oncological patients presented in ED, almost a quarter of which presented high suspicion of neoplasia (still without histopathological confirmation) when in ED (23.12%). Most of them were aged male patients (over 65 years old), with tumors of the digestive system. A significant proportion (almost 60%) of these patients ended up in emergency due to complications and the therapy intended life support and pain management. Some of these patients were directed to further exploring and emergency outpatient therapy while 75% of patients were hospitalized after stabilization. Although we expected that the frequency of complications to be higher in patients previously diagnosed with cancer, data analysis showed no statistically significant differences (p = NS) between the rate of complications in patients previously diagnosed with neoplasia and those with high-suspicion neoplasia first diagnosed in the ED.