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.

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.

Bio-electrical impedance analysis for perioperative fluid evaluation in open major abdominal surgery.

Water retention and intercompartmental redistribution occur frequently in association with adverse postoperative outcomes, yet the available strategies for non-invasive assessment are limited. One such approach for evaluating body water composition in various circumstances is bio-electrical impedance analysis (BIA). This study aims to appraise the usefulness of the Body Composition Monitor (BCM, Fresenius Medical Care, Germany) in assessing body fluid composition and intercompartmental shifts before and after open major abdominal surgery. This prospective, clinician blinded observational study enrolled all the patients scheduled consecutively for elective major open abdominal surgery during a 1-year period starting from January 1st, 2016. BIA parameters-total body water (TBW), extracellular water (ECW), intracellular water (ICW), absolute fluid overload (AFO), and relative fluid overload (RFO) were measured before and after surgery. The results were compared with fluid balance and outcome parameters such as organ dysfunction, ICU-and hospital length of stay (-LOS). The study population included 71 patients aged 60.2 ± 12 of whom 60.6% men and with a BMI of 26.3 ± 5.1 kg/m2. Postoperative acute kidney injury, respiratory dysfunction, and infections occurred in 14.0%, 19.7% and 28.1% of cases, respectively. The median LOS in ICU was 20 h and the hospital-LOS was 10 days. Positive intraoperative fluid balance (2.4 ± 1.0 L) resulted in a significant increase of TBW (1.4 ± 2.4 L) and of ECW (1.4 ± 1.2 L). Intraoperative fluid balance significantly correlated with TBW change (r = 0.23, p = 0.04) and with AFO change (r = 0.31, p < 0.01). A significant correlation was found between pre- and postoperative AFO and RFO on one hand, and ICU-LOS on the other. BIA may be a useful tool for the perioperative assessment of volume status.

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.

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.

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.