BackgroundPulmonary embolism (PE) is a common diagnosis in an emergency department. It also represents a large share of patients admitted to hospital wards. Patients with PE can be risk-stratified ...and discharged early from the emergency department. This results in better availability of hospital beds for other patients and a significant reduction of treatment costs for the healthcare system. This paper aims to describe the protocols used in our emergency department, with special emphasis on risk stratification, for adverse events and bleeding risk, treatment strategies, and outcomes for this type of protocol. Materials and methodsThis paper is a retrospective analysis of patients discharged from the emergency department in a of two-year period (2020-2021) with a low-risk pulmonary embolism. ResultsWe have included in this study 42 patients discharged after a short-term observation from the emergency department (<24h) or short-term hospitalization; <24h). Ninety-one percent of patients were discharged with direct oral anticoagulant as a treatment for PE. We did not notice any adverse events (hemorrhage, progression of PE, or major cardiovascular issues). ConclusionIn the cohort of patients with PE, early discharge and outpatient treatment was safe and effective, with lower healthcare costs and almost no adverse events for patients.
Calcium channel blockers and beta-blockers toxicity/poisoning are one of the most common causes of poisoning. More importantly, they are among the deadliest types of poisoning caused by cardiac drugs ...that emergency physicians can encounter. Common toxidrome caused by these medications includes the following symptoms: hypotension, bradycardia, hypoglycemia/hyperglycemia, hypothermia, arrhythmia, and seizures. Treatment is usually complex, It consists of administration of various medications, such as crystalloids, intravenous calcium, glucagon, vasopressors/inotropes, and especially high-dose insulin euglycemic therapy. In this paper, we will review the mechanism for this type of treatment, propose a potential protocol for its application and address possible adverse effects. High-dose insulin euglycemic therapy should be an integral part of the treatment protocol for calcium channel blockers and beta-blockers toxicity.
The objective of this case report is to present a patient with acquired methemoglobinemia due to poisoning of an unknown cause. A 55-year-old man was brought to the Emergency Department, University ...Hospital Center Zagreb, with an unwell appearance, cyanotic, restless, and presented with a quantitative consciousness disorder. An initial assessment showed decreased oxygen saturation (SpO2 85 %), while point-of-care arterial blood gas (ABG) analysis assessed normal partial pressure of oxygen (pO2). Severe lactic acidosis with a compensatory drop in partial pressure of carbon dioxide (pCO2) and high rates of methemoglobin were found. Supportive oxygen therapy and crystalloid solutions were administered, which resulted in rapid clinical recovery within 40 minutes of the initial assessment. Clinical recovery was accompanied by normalized ABG test results taken serially. Typical antidotes, methylene blue and vitamin C, were not administered due to rapid clinical improvement. Methemoglobinemia can be congenital (hereditary) or acquired (toxic). Both conditions are rarely seen in emergency departments, nevertheless, they should be approached properly since methemoglobinemia can be a severe, and fatal, condition. Methemoglobinemia symptoms are the results of inadequate oxygen transport. The diagnosis was confirmed by co-oximetry, while three clinical entities suspected methemoglobinemia: refractory hypoxia, “cyanosis-saturation gap“ and dark brown blood. This paper reports our patient’s clinical presentation, discusses the causes and mechanisms of possible poisoning, and reviews recent guidelines for methemoglobinemia management.
Background: Pulmonary embolism (PE) is a common diagnosis in an emergency department. It also represents a large share of patients admitted to hospital wards. Patients with PE can be risk-stratified ...and discharged early from the emergency department. This results in better availability of hospital beds for other patients and a significant reduction of treatment costs for the healthcare system. This paper aims to describe the protocols used in our emergency department, with special emphasis on risk stratification, for adverse events and bleeding risk, treatment strategies, and outcomes for this type of protocol. Materials and methods: This paper is a retrospective analysis of patients discharged from the emergency department in a of two-year period (2020-2021) with a low-risk pulmonary embolism. Results: We have included in this study 42 patients discharged after a short-term observation from the emergency department (<24h) or short-term hospitalization; <24h). Ninety-one percent of patients were discharged with direct oral anticoagulant as a treatment for PE. We did not notice any adverse events (hemorrhage, progression of PE, or major cardiovascular issues). Conclusion: In the cohort of patients with PE, early discharge and outpatient treatment was safe and effective, with lower healthcare costs and almost no adverse events for patients Key words: pulmonary embolism, emergency department, early discharge, outpatient treatment Uvod: Plucna embolija (PE) predstavlja jednu od cestih dijagnoza u svakodnevnom radu hitnog prijema i dovodi do velikog broja prijema u bolnicu, sto nije uvijek nuzno. Posto se pacijenti na temelju obrade i stratifikacije rizika mogu obraditi i otpustiti iz hitnog prijema, to moze dovesti do rasterecenja bolnickih odjela, te smanjenja troskova u sustavu zdravstva. Cilj ovog rada je opisati protokol koji se koristi u nasem centru, koji ukljucuje obradu stratifikaciju rizika za kompliciranu klinicku sliku i krvarenje, terapijske opcije i nezeljene dogadaje ovakve vrste lijecenja Materijali i metode: Ovo je retrospektivna analiza pacijenata koji su u razdoblju od dvije godine (2020 i 2021 godina) otpusteni iz hitnog prijema kao plucna embolija niskog rizika. Rezultati: U studiju je ukljuceno 42 pacijenata koja su otpustena iz OHBP KBC Zagreb nakon kratkotrajne opservacije (do 24h) ili su otpustena iz bolnice nakon kratkotrajne hospitalizacije (do 24h). U 91% slucaja je pacijentu u terapiju uveden direktni oralni antikoagulans. Kod niti jednog pacijenta nije bilo nezeljenih dogadaja (krvarenje, progresija tromboze ili veliki kardiovaskularni incident) Zakljucak: U ovoj kohorti jasno se vidi da je rani otpust pacijenata sa plucnom embolijom niskog rizika siguran nacin za lijecenje ove bolesti, te da dovodi do veceg zadovoljstva pacijenata, manjeg boja hospitalizacija, manjih troskova za bolnice, te zanemarivog broja nezeljenih ucinaka lijecenja. Kljucne rijeci: plucna embolija, hitni prijem, izvanbolnicko lijecenje, rani otpust
Calcium channel blockers and beta-blockers toxicity/poisoning are one of the most common causes of poisoning. More importantly, they are among the deadliest types of poisoning caused by cardiac drugs ...that emergency physicians can encounter. Common toxidrome caused by these medications includes the following symptoms: hypotension, bradycardia, hypoglycemia/hyperglycemia, hypothermia, arrhythmia, and seizures. Treatment is usually complex, It consists of administration of various medications, such as crystalloids, intravenous calcium, glucagon, vasopressors/inotropes, and especially high-dose insulin euglycemic therapy. In this paper, we will review the mechanism for this type of treatment, propose a potential protocol for its application and address possible adverse effects. High-dose insulin euglycemic therapy should be an integral part of the treatment protocol for calcium channel blockers and beta-blockers toxicity. Key words: calcium channel blockers, beta-blockers, toxicity, high-dose insulin euglycemic therapy Otrovanja sa blokatorima kalcijevih kanala i sa beta-blokatorima spadaju u jedne od cescih uzroka trovanja, ali jos i vaznije, jedne od najsmrtonosnijih trovanja sa kardioloskim lijekovima sa kojima se lijecnici u hitnoj medicini mogu susresti. Tipican toksidrom ukljucuje simptome poput hipotenzije, bradikardije, aritmije, hipoglikemije/hiperglikemije, hipotermije i epileptickih napada. Lijecenje je kompleksno, a samo specificno lijecenje ukljucuje primjenu kalcija, volumena, vazopresora/intropa, glukagona, te osobiti naglasak stavlja na primjenu hiperinzulinemija-euglikemija lijecenja. U ovom preglednom radu osvrnuti cu se na mehanizam ovog nacina lijecenja, protokol primjene te nuspojave koje se mogu javiti. Hiperinzulinemijaeuglikemija lijecenje trebao bi biti integralni dio protokola lijecenja trovanja sa beta-blokatorima i blokatorima kalcijevih kanala. Kljucne rijeci: blokatori kalcijevih kanala, beta-blokatori, toksicnost, hiperinzulinemija-euglikemija, lijecenje
The objective of this case report is to present a patient with acquired methemoglobinemia due to poisoning of an unknown cause. A 55-year-old man was brought to the Emergency Department, University ...Hospital Center Zagreb, with an unwell appearance, cyanotic, restless, and presented with a quantitative consciousness disorder. An initial assessment showed decreased oxygen saturation (SpO2 85 %), while point-of-care arterial blood gas (ABG) analysis assessed normal partial pressure of oxygen (pO2). Severe lactic acidosis with a compensatory drop in partial pressure of carbon dioxide (pCO2) and high rates of methemoglobin were found. Supportive oxygen therapy and crystalloid solutions were administered, which resulted in rapid clinical recovery within 40 minutes of the initial assessment. Clinical recovery was accompanied by normalized ABG test results taken serially. Typical antidotes, methylene blue and vitamin C, were not administered due to rapid clinical improvement. Methemoglobinemia can be congenital (hereditary) or acquired (toxic). Both conditions are rarely seen in emergency departments, nevertheless, they should be approached properly since methemoglobinemia can be a severe, and fatal, condition. Methemoglobinemia symptoms are the results of inadequate oxygen transport. The diagnosis was confirmed by co-oximetry, while three clinical entities suspected methemoglobinemia: refractory hypoxia, "cyanosis-saturation gap" and dark brown blood. This paper reports our patient's clinical presentation, discusses the causes and mechanisms of possible poisoning, and reviews recent guidelines for methemoglobinemia management. Key words: lactic acidosis, methemoglobinemia, poisoning Svrha ovog rada je prikaz slucaja pacijenta sa stecenom methemoglobinemijom uslijed trovanja nepoznatog uzroka. 55-godisnji muskarac zapustenog izgleda dovezen je u Objedinjeni hitni bolnicki prijem (OHBP) Klinickog bolnickog centra (KBC) Zagreb cijanotican, nemiran i kvalitativno promijenjenog stanja svijesti. U inicijalnoj obradi nadena je snizena saturacija kisikom (SaO2 85%), dok je plinska analiza arterijske krvi ukazivala na zadovoljavajuce vrijednosti parcijalnog tlaka kisika. Nadena je teska laktacidoza s kompenzatorno snizenim parcijalnim tlakom ugljikovog dioksida, a zamijecen je i visok postotak methemoglobina. Na primijenjenu suportivnu oksigenoterapiju te terapiju kristaloidnim otopinama, pacijentovo se klinicko stanje rapidno oporavlja unutar cetrdesetak minuta, sto se prati i normalizacijom serijski evaluiranog acidobaznog statusa. S obzirom na povoljan klinicki tijek, nije bilo potrebe za primjenom antidota--metilenskog modrila i vitamina C. Postoje urodena (genetska) i stecena (toksicna) methemoglobinemija. Oba stanja se rijetko vidaju na hitnom prijemu, a stecena methemoglobinemija moze biti zivotno ugrozavajuce stanje. Simptomi methemoglobinemije izravna su posljedica neadekvatnog transporta kisika. Dijagnoza se postavlja na temelju ko-oksimetrije, ali sama klinicka sumnja moze se postaviti na temelju sljedeca tri entiteta: refraktorne hipoksije, ,,cyanosis-saturation gap" i smede boje krvi. U ovom radu osvrnut cemo se na klinicki tijek naseg pacijenta, dotaci se potencijalnih mehanizama trovanja i uzroka toksicne methemoglobinemije te prikazati recentne preporuke za zbrinjavanje ovakvih slucaja. Kljucne rijeci: laktacidoza, methemoglobinemija, trovanje
U Hrvatskoj ne postoji razvijena subspecijalizacija iz kliničke toksikologije, a samim time nije razvijena ni strategija ni mreža toksikoloških centara. Činjenica je da se u svakodnevnom radu ...susrećemo s otrovanjima, a postoji nejednaka dostupnost antidotima u hitnim prijmovima ili centralnim bolničkim ljekarnama. Svrha ovog preglednog članka je upoznavanje s literaturom o dostupnosti antidota u akutnim bolnicama, vremenske i količinske, ali i vlastitih iskustava o izgradnji takve prakse u OHBP-u KBC-a Zagreb, a s nadom da će u budućnosti postojati strategija koja će dati preporuke o tome koje antidote moramo imati uvijek u hitnom prijmu, kada ih dajemo, u kojim dozama, i kakve zalihe bolnice moraju uvijek imati u centralnim ljekarnama.
Svrha ovog rada je prikaz neobičnog slučaja otrovanja metforminom s razvojem laktacidoze, koji je uspješno liječen u hitnom prijmu. Dijabetičar u dobi od 65 godina koji je u terapiji imao metformin ...dovezen je u noćnim satima u hitni prijam zbog traume glave. Nađene su niske vrijednosti glukoze u kapilarnoj krvi, koje su se normalizirale nakon primjene glukoze intravenski. Nakon udarca u glavu zaostao je nejasan kvalitativni poremećaj svijesti, a u acidobaznom statusu smo našli tešku acidozu s proširenim anionskim zjapom i povišenim laktatima. Na agresivne potporne mjere došlo je do stabilizacije acidobaznog statusa, a nakon dugotrajne opservacije pacijent je otpušten iz hitnog prijma. Ovakvo otrovanje metforminom je neobična i atipična klinička prezentacija koja je mogla lako završiti smrtnim ishodom. U prikazu slučaja dajemo recentne preporuke o prepoznavanju, obradi i liječenju ovog za život opasnog stanja.
Svrha ovog rada je prikaz slučaja pacijenta sa stečenom methemoglobinemijom uslijed trovanja nepoznatog uzroka.
55-godišnji muškarac zapuštenog izgleda dovežen je u Objedinjeni hitni bolnički prijem ...(OHBP ) Kliničkog bolničkog
centra (KBC) Zagreb cijanotičan, nemiran i kvalitativno promijenjenog stanja svijesti. U inicijalnoj obradi nađena je snižena
saturacija kisikom (SaO2 85%), dok je plinska analiza arterijske krvi ukazivala na zadovoljavajuće vrijednosti parcijalnog
tlaka kisika. Nađena je teška laktacidoza s kompenzatorno sniženim parcijalnim tlakom ugljikovog dioksida, a zamijećen je i
visok postotak methemoglobina. Na primijenjenu suportivnu oksigenoterapiju te terapiju kristaloidnim otopinama, pacijentovo
se kliničko stanje rapidno oporavlja unutar četrdesetak minuta, što se prati i normalizacijom serijski evaluiranog acidobaznog
statusa. S obzirom na povoljan klinički tijek, nije bilo potrebe za primjenom antidota – metilenskog modrila i vitamina
C. Postoje urođena (genetska) i stečena (toksična) methemoglobinemija. Oba stanja se rijetko viđaju na hitnom prijemu,
a stečena methemoglobinemija može biti životno ugrožavajuće stanje. Simptomi methemoglobinemije izravna su posljedica
neadekvatnog transporta kisika. Dijagnoza se postavlja na temelju ko-oksimetrije, ali sama klinička sumnja može se
postaviti na temelju sljedeća tri entiteta: refraktorne hipoksije, „cyanosis-saturation gap“ i smeđe boje krvi. U ovom radu
osvrnut ćemo se na klinički tijek našeg pacijenta, dotaći se potencijalnih mehanizama trovanja i uzroka toksične methemoglobinemije
te prikazati recentne preporuke za zbrinjavanje ovakvih slučaja.
