Articole Teza Paul(1) [625533]

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in Resuscitation
Diana Cimpoesu, MD, PhD,1Mihaela Corlade-Andrei, MD, PhD,1
Tudor Ovidiu Popa, MD, PhD,1* Gabriela Grigorasi, MD, PhD Student,1
Catalin Bouros, MD, PhD Student,1Luciana Rotaru, MD, PhD,2
and Paul Lucian Nedelea, MD, PhD Student1
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 resusci-
tation 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 tem-
perature threshold is reached after warming measures. Data sources for this article are scientific
articles describing retrospective studies conducted in CPR performed in special circumstances, ex-
perts ’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.
Keywords: cardiopulmonary resuscitation, special causes, special patients, special environment
BACKGROUND
According to the actual guidelines for cardiopulmo-
nary resuscitation (CPR), early recognition and calling
for help, early defibrillation, high-quality resuscitation
with minimal interruption of chest compressions, and
treatment of reversible causes are the most important1Department of Emergency Medicine, “Grigore T. Popa ”Univer-
sity of Medicine and Pharmacy, Iasi, Romania; and2Emergency
Medicine, University of Medicine and Pharmacy, Craiova, Romania.
The authors have no conflict of interest to declare.
*Address for correspondence: Department of Emergency Medicine, “Gri-
gore T. Popa ”University of Medicine and Pharmacy, Str. Universitatii,
no. 1, 700036, Iasi, Romania. E-mail: ovidiupopa8@gmail.comAmerican Journal of Therapeutics 26, e276–e283 (2019)
1075 –2765 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. www.americantherapeutics.com
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

interventions that can improve the outcomes after car-
diac arrest.1–5
Patients with a medical etiology found in a shock-
able rhythm have the highest chance of survival. There
is a great variability in characteristics among nonmed-
ical cases.6
The 2015 Guidelines for Resuscitation published by
the European Resuscitation Council divide the resus-
citation in special circumstances into 3 parts: special
causes, special environments, and special patients.7
ADVANCE THERAPEUTICS
Special causes
Hypoxia is usually a consequence of asphyxia, which
is defined as pathological changes caused by lack of
oxygen in respired air, resulting in a deficiency of oxy-
gen in the blood (hypoxia) and an increase in carbon
dioxide in the blood and tissues (hypercapnia). Symp-
toms usually include irregular and disturbed respira-
tions, or complete absence of breathing, and pallor or
cyanosis. Asphyxia may occur whenever there is an
interruption of the normal exchange of oxygen and
carbon dioxide between the lungs and the outside air.
The effective ventilation with supplementary oxy-
gen during the early moment of resuscitation is essen-
tial during CPR. In addition, it is recommended to
monitor the efficacy of ventilation via capnometry,
which measures end-tidal CO 2. During CPR, it is indi-
cated to monitor the effectiveness of maneuvers so as
to obtain a value between 10 and 20 mm Hg. An
abrupt increase in end-tidal CO 2values indicates re-
turn of spontaneous circulation (ROSC). If after endo-
tracheal intubation there is no waveform during CPR,
but a flat line, this should alert for misplacement of the
endotracheal tube.1,2,5,6,8
Electrolyte abnormalities can cause cardiac arrhyth-
mias or cardiac arrest. Life-threatening arrhythmias
are most commonly associated with potassium disor-
ders. The treatment strategies for hyperkalemia
address cardiac protection, shifting potassium into
cells, removing potassium from the body, and moni-
toring serum potassium and blood glucose.1,2,5,8
Hypothermia
Accidental hypothermia is defined as the involuntary
decrease of body core temperature ,35°C.5
Hypothermia decreases oxygen consumption at the
cellular level, so the heart and the brain can tolerate
for a longer period cardiac arrest. Sometimes complete
neurological recovery can be found even afterprolonged cardiac arrest, but only if hypothermia was
installed before respiratory arrest.1,2,5,8 –10
The first measure is to remove the patient from cold
environment, remove clothes that are usually wet or
cold, and try to prevent any other heat loss. Quick
mobilization of patient with hypothermia can induce
arrhythmias.1,2,5,8
Hypothermia needs to be treated with gradual re-
warming using normal or electric blankets and warm
IV fluids. The goal is to achieve an increase in temper-
ature with a rate of 1°C –1.5°C per hour. It should be
used IV fluid heated at approximately 40°C, and also
gastric lavage, peritoneal lavage, bladder lavage, using
fluids heated at approximately 40°C.
Electrolyte disorder should also be monitored hourly,
especially hyperkalemia that can appear during re-
warming maneuvers. Oxygen should also be delivered
heated and humidified at 40°C, using a mechanical
ventilator, after endotracheal intubation.1,2,5,8
Thoracic stiffness is present. Thus, chest compres-
sions are harder to perform, and ventilation will require
higher pressures than in normal situation.1,2,5,9,10
Patients with hypothermia without signs of cardiac
instability (systolic blood pressure $90 mm Hg,
absence of ventricular arrhythmias, or core
temperature $28°C) can be rewarmed externally
using minimally invasive techniques [warm air and
warm intravenous (IV) fluid]. Patients with signs of
cardiac instability should be resuscitated in the field
and transferred directly to a center capable of extracor-
poreal life support (ECLS).1,2,5,8 –10
Hypovolemia is a potentially treatable cause of car-
diac arrest that usually results from a hemorrhage, but
relative hypovolemia may also occur in patients with
severe vasodilation (eg, anaphylaxis and sepsis). In
case of anaphylaxis with relative hypovolemia (but
not cardiac arrest), the immediate treatment with intra-
muscular adrenaline is the treatment of choice, fol-
lowed by IV fluids and corticoids. Prolonged CPR
may be necessary if cardiac arrest occurs.1,2,5,8 –11
The treatment is with fluids (crystalloids and col-
loids) and blood products administered rapidly IV. If
colloids are administered, previous blood samples are
necessary, to work compatibility cross-match blood
test, because colloids can interfere with the results.1,2,5,8
Tension Pneumothorax
The mortality from traumatic cardiac arrest (TCA) is
very high.1,2,5,12 –15
The new treatment algorithm for TCA was developed
to prioritize the sequence of life-saving measures.16
Chest compressions should not delay the treatment of
reversible causes. Tension pneumothorax may beCardiac Arrest in Special Circumstances e277
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suspected during cardiac resuscitation if breath sounds
are unequal on chest auscultation after verifying correct
endotracheal tube placement. Treatment is immediate
needle decompression or other technique to decompress
the chest in TCA —to perform unilateral or bilateral tho-
racotomies in the fourth inter costal space. In the presence
of positive pressure ventilation, thoracotomies are likely
to be more effective than needle thoracentesis and quick-
er than inserting a chest tube.1,2,7,12 –15
Cardiac tamponade is the underlying cause of
approximately 10% of cardiac arrest in trauma. Where
there is TCA and penetrating trauma to the chest or
epigastrium, immediate resuscitative thoracotomy can
be lifesaving. If thoracotomy is not possible, consider
ultrasound-guided pericardiocentesis to treat cardiac
arrest with cardiac tamponade. Treatment of tampo-
nade causing cardiac arrest is bedside pericardiocente-
sis.1,2,5,7,13 –15
Thrombosis
For the patients with out-of-hospital cardiac arrest of
suspected cardiac origin, the transfer to the hospital
with continuing CPR could be a solution in case of
acute coronary syndrome –coronary thrombosis.
Ground transport may be beneficial in selected pa-
tients where there is immediate hospital access to the
catheterization laboratory and an infrastructure pro-
viding prehospital and in-hospital teams experienced
in mechanical or hemodynamic support and percuta-
neous coronary intervention (PCI) with ongoing
CPR.1,2,6,17 –19This illustrates the need for the inclusion
of intensive cardiovascular care units within a hospital
network, linking university medical centers, large
community hospitals, and smaller hospitals with more
limited capabilities.20
Acute coronary thrombosis or acute myocardial
infarction is one of the most common causes of cardiac
arrest. Myocardial and neurologic function can
improve after PCI following cardiac arrest. Therefore,
after ROSC, especially facing post-ROSC, electrocar-
diogram evidence of acute myocardial infarction, car-
diac catheterization, and percutaneous coronary
revascularization are recommended, if available and
appropriate.1,2,5,7
Acute pulmonary embolism will be suspected by
clinical symptoms such as dyspnea, chest pain, and
syncope, either just one or in combination.1,2,5 –7,17
The administration of fibrinolytics when pulmonary
embolism is the suspected cause of the cardiac arrest
remains the actual recommendation. Pulmonary em-
bolism causing cardiac arrest requires fibrinolysis or
embolectomy. However, the diagnosis is rarely made
at the time of collapse, and even then, most systemsare not oriented to make such prompt diagnosis and
initiate the necessary procedures for embolec-
tomy.1,2,5 –7,19
Ongoing CPR is not a contraindication to fibrinoly-
sis, and after a fibrinolytic drug is administered, CPR
should continue for at least 60 –90 minutes before ter-
minating resuscitation attempts.1,2,5 –7,17,18,21
Toxics
Airway obstruction and respiratory arrest secondary
to a decreased conscious level is a common cause of
cardiac arrest after accidental or self-poisoning. There
are few specific therapeutic measures for poisoning
that are useful immediately and during CPR and
improve outcomes: decontamination, enhancing elim-
ination, and the use of specific antidotes.
The preferred method of GI decontamination in pa-
tients with protected airways is activated charcoal, but
is most effective only if administrated within the first
hour from ingestion. Drug overdose is rarely identified
as a cause of cardiac arrest during the resuscitation
process. In the event of antidepressant overdose,
sodium bicarbonate should be administrated IV. Lipid
emulsion infusion may be useful in cardiac arrest asso-
ciated with cyclic antidepressants or local anesthetics.
Opioid poisoning causes respiratory depression, fol-
lowed by respiratory insufficiency or respiratory
arrest. The use of naloxone can prevent the need for
intubation. The initial doses of naloxone are 0.4 –2 mg
IV, intraoseous, intra-muscle, or subcutaneous and
may be repeated every 2 –3 minutes. Additional
doses may be needed every 20 –60 minutes. Titrate the
dose until the victim is breathing adequately and has
protective airway reflexes.1,5,7,21
Special environments
The special environments include those specific loca-
tions in which a cardiac arrest may occur: operating
theater, cardiac surgery, catheterization laboratory,
dialysis unit, dental surgery, commercial airplanes or
medical helicopters, playing field, outside environ-
ment (eg, drowning, remote area, high altitude, ava-
lanche, lightning strike, and electrical injuries), or the
scene of a mass casualty incident.
Cardiac arrest after major cardiac surgery is rela-
tively common in the immediate postoperative phase.
The management of perioperative cardiac arrest
starts with the advanced life support (ALS) algorithm,
but with appropriate modifications depending on the
cause identified. Key to successful resuscitation is rec-
ognition of the need to perform emergency resternot-
omy, especially in the context of tamponade or
hemorrhage, where external chest compressions maye278 Cimpoesu et al
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be ineffective. Resternotomy should be performed
within 5 minutes if other interventions have failed.
A defibrillator must be available in the angiography
room, and self-adhesive defibrillation pads may
already be placed at the beginning of the procedure
in high-risk patients.
Cardiac arrest from shockable rhythms (ventricular
fibrillation or pulseless ventricular tachycardia) during
cardiac catheterization should immediately be treated
with up to 3 stacked shocks before starting chest com-
pressions. Use of mechanical chest compression devices
during angiography is recommended to ensure high-
quality chest compressions and reduce the radiation of
the personnel during angiography with ongoing CPR.
Most of the standard reversible causes (4 H ’s and 4
T’s) apply to dialysis patients.
A shockable rhythm [ventricular fibrillation
(VF)/pulseless ventricular tachycardia (VT)] is more
common in patients undergoing hemodialysis than in
the general population,22–27so the delay in delivering
defibrillation must be minimized.
In dental surgery, the causes of cardiac arrest are
related to preexisting comorbidities (acute myocardial
infarction, grand mal seizures, or exacerbation of
asthma), loss of airway patency related to the primary
pathology or complications of the procedure (eg,
bleeding, secretions, and tissue swelling), or anaphy-
laxis to local anesthetics.
The patient will not be moved from the dental chair
to start CPR; the dental chair will be reclined into a
horizontal position or a stool will be placed under the
head to increase its stability during CPR.28–30
CPR on the airplane
In case of cardiac arrest, a universal algorithm for
adult basic life support and automated external defi-
brillation will be followed.24–26
If the CPR equipment is available, attach oxygen to
the facemask or self-inflating bag. Request immediate
flight diversion to the nearest appropriate airport.
Automated external defibrillators and appropriate
CPR equipment should be mandatory on board of all
commercial aircraft in Europe, including regional and
low-cost carriers.30
The incidence of cardiac arrest on board of helicop-
ter emergency medical services and air ambulances is
low.31The preflight preparation is important for the
patients with high risk of cardiac arrest, and the use of
mechanical chest compression devices is
emphasized.1,2,5,7
Sudden and unexpected collapse of a sportsman dur-
ing exercises on the playing field is likely to be cardiac in
origin and requires rapid recognition, initiating basic life
support (BLS) and early defibrillation.1,2,5,7For the drowning patients, the bystanders play an
essential role in early rescue and high-quality resusci-
tation. The victim needs to be removed from the water
promptly. The preferred resuscitation strategies for
those patients in respiratory or cardiac arrest are the
oxygenation and the ventilation. Inflation should take
about 1 second and be sufficient to see the chest
rise.1,2,5,7
Most drowning cases were fatal, but the survivors
of a nonfatal drowning showed a low risk of subse-
quent long-term mortality, similar to the general pop-
ulation, that was independently associated with age
and neurologic status at hospital discharge.32
If the drowning victim is hypothermic or hypovole-
mic, the ALS approach should be modified in accor-
dance with the treatment of hypothermia, and then, IV
warm fluid should be administrated.
Drowning is a leading cause of death among infants
and toddlers. Active adult supervision entails attention,
proximity, and continuity. Educational efforts should
be aimed at reminding parents of this, especially in
the summer months.32,33
Submersion injuries with cardiac arrest can lead to
long-term neurologic morbidity.31
The chances of good outcome from cardiac arrest in
difficult terrain or mountains may be reduced because
of delayed access and prolonged transportation. There
is a recognized role of air rescue and availability of
automated external defibrillators in remote but often-
visited locations.1,2,5,34Resuscitation at high altitude
does not differ from standard CPR. CPR is more ex-
hausting for a single rescuer than at sea level because
of lower PO 2, and the average number of effective
chest compressions may decrease within the
first minute.35
For avalanche victims in cardiac arrest, prolonged
CPR and extracorporeal rewarming are indicated. Car-
diac arrest secondary to avalanche is mainly due to
asphyxia, associated with trauma and hypothermia. In
all cases, extricate the body gently and use spinal pre-
cautions. ECLS is indicated if the duration of burial
is.60 minutes, core temperature at extrication
is,30°C, and serum potassium at hospital admission
is#8 mmol $L21.1,2,5,34,36
Safety measures are essential for providing CPR to
the victim of an electrical injury.10Factors influencing
the severity of electrical injury include the current type
alternating or direct, voltage, magnitude of energy
delivered, resistance to current flow, the area, and
duration of contact. As with industrial and domestic
electric shock, after lightning strikes, death is caused
by cardiac or respiratory arrest.37
Ensure that any power source is switched off and
approach the casualty only if it is safe and startCardiac Arrest in Special Circumstances e279
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standard BLS and ALS without delay. Head and spine
trauma can occur after electrocution, and the spine
immobilization must be performed.
Unlike normal circumstances, CPR is not usually
initiated in mass casualty incidents to avoid delaying
potentially effective treatment for the critically ill but
salvageable victims. This critical decision depends on
the available medical and paramedical resources in
relation to the number of casualties.
A triage system should be used to prioritize treatment
and, if the number of casualties overwhelms the preho-
spital medical resources, withhold CPR for the patients
without signs of life.1,2,7For triage, the simple triage and
rapid treatment triage is used.
Perform life-saving interventions in patients triaged
as red (highest priority) to prevent cardiac arrest: con-
trol major hemorrhage, open airway using basic tech-
niques, perform chest decompression for tension
pneumothorax, use antidotes, and consider initial res-
cue breaths in a nonbreathing child.
Special patients
Special patients with special guidance for CPR are con-
sidered to be the patients with severe comorbidities:
asthma, heart failure with ventricular assist devices
(VADs), neurological disease, obesity, and those with
specific physiological conditions (pregnancy and older
people).
Cardiac arrest in a patient with asthma is often a
terminal event after a hypoxemic period or it may be
sudden. Cardiac arrest is linked to the following:
– Severe bronchospasm and mucous plugging leading
to asphyxia;
– Cardiac arrhythmias caused by hypoxia by stimulant
drugs (beta-adrenergic agonists and aminophylline)
or electrolyte abnormalities;
– Dynamic hyperinflation, that is, auto –positive end-
expiratory pressure: it can occur in mechanically ven
tilated patients with asthma. Gradual build-up of
pressure occurs and reduces venous return and
blood pressure and determines heart failure;
– Tension pneumothorax unilateral/bilateral.
These high-risk patients should be treated to pre-
vent deterioration with oxygen to achieve an SpO 2
94%–98%, inhaled beta-2 agonists (salbutamol 5mg)
or IV beta-2 agonists for those patients in whom
inhaled therapy cannot be used reliably, nebulized
anticholinergics (ipratropium, 0.5 mg 4 –6 hourly),
nebulized magnesium sulfate, IV corticosteroids, IV
bronchodilators, and aminophylline a dose of
5 mg $kg21over 20 –30 minutes. For severe or near-
fatal asthma associated with dehydration and hy-
pervolemia, IV fluids are necessary.Modifications to standard ALS guidelines include
the need for early tracheal intubation.38,39
Respiratory rates of 8 –10 breaths per minute and a
tidal volume required for a normal chest rise during
CPR should minimize dynamic hyperinflation of the
lungs (air trapping). Tidal volume depends on inspi-
ratory time and inspiratory flow. Lung emptying de-
pends on expiratory time and expiratory flow. In
mechanically ventilated patients with severe asthma,
increasing the expiratory time (achieved by reducing
the respiratory rate) provides only moderate gains in
terms of reduced gas trapping when a minute volume
of less than 10 L $min21is used.39
Dynamic hyperinflation increases transthoracic
impedance,40but modern impedance-compensated
biphasic defibrillation waveforms are no less effective
in patients with a higher impedance. Consider increas-
ing defibrillation energy if the first shock is unsuccess-
ful, and a manual defibrillator is available.1,2,5
If a pneumothorax is suspected, the resuscitation
team performs immediate needle decompression
using a large gauge cannula, followed by insertion
of a chest tube.
In patients with VADs, confirmation of cardiac
arrest may be difficult. The management of patients
with VADs is more complex, in which case cardiac
arrest may be due to mechanical failures so that spe-
cific actions on the device may be required. In any
cases, external chest compression in patients with
VADs is not successful without damage to the VAD.
Transthoracic/transesophageal echocardiography,
capnography, or Doppler flow in a major artery may
assist in the cardiac arrest diagnosis. If cardiac arrest is
confirmed, start CPR, check the rhythm and perform
defibrillation for shockable rhythms (VF/VT), start
pacing for asystole, and transfer the patient to the in-
terventional cardiology. If during the first 10 days of
surgery, cardiac arrest does not respond to defibrilla-
tion, perform resternotomy immediately.
Cardiac arrest associated with acute neurological
disease is relatively uncommon and can appear in sub-
arachnoid hemorrhage, intracerebral hemorrhage, epi-
leptic seizures, and ischemic stroke and in brain injury
associated with trauma.
Patients with subarachnoid hemorrhage may pres-
ent electrocardiogram changes that suggest an acute
coronary syndrome. Whether a computed tomography
brain scan is done before or after coronary angiogra-
phy will depend on the clinical judgment regarding
the likelihood of a subarachnoid hemorrhage versus
acute coronary syndrome.
For resuscitation of patients with obesity, to main-
tain sufficient depth of chest compressions (approxi-
mately 5 cm but no more than 6 cm), considere280 Cimpoesu et al
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changing rescuers more frequently than the standard
2-minute interval. Early tracheal intubation by an
experienced physician is recommended. Use of
mechanical resuscitation devices is limited by the slope
of the anterior chest wall and thoracic dimensions but
could be useful for this type of patients.
Optimal defibr illation energy levels in patients
with obesity are unknown,1,2,5so the recommended
energy remain the same, 150 –260 J based on the man-
ufacturer ’s guidance or defibrillator type.
For the pregnant women in cardiac arrest, high-
quality CPR with manual uterine displacement, early
ALS, and emergent delivery of the fetus, if early ROSC
is not achieved, remain the key interventions.
Fetal survival usually depends on maternal survival,
and initial resuscitation efforts should focus on the
pregnant mother. From 20 weeks ’gestation, the uterus
can compress the inferior vena cava (IVC) and aorta,
impeding venous return and cardiac output, therefore
can cause prearrest hypotension or shock and, in the
critically ill patient, may precipitate cardiac arrest.41
Manual displacement of the uterus to the left is recom-
mended to reduce IVC compression. During CPR, the
hand position for chest compressions may need to be
slightly higher on the sternum for patients with
advanced pregnancy (third trimester).42
Early tracheal intubation (using a tracheal tube 0.5 –
1 mm internal diameter smaller than that used for a
nonpregnant woman) with mechanical ventilation
will, however, make ventilation of the lungs easier in
the presence of increased intra-abdominal pressure.
The most important causes are the following:
– Hemorrhage: The key steps for treatment are stop the
bleeding, fluid resuscitation including the use of
rapid transfusion system and cell salvage,43and cor-
rection of coagulopathy including theuse of tranexa-
mic acid and/or recombinant activated factor VII.
– Cardiovascular disease: amniotic fluid embolism
cause most deaths from acquired cardiac disease.
– Pre-eclampsia and eclampsia request magnesium sul
fate infusion for the treatment in peri-arrest situation.
Consider the need for an emergency hysterectomy
or cesarean section as soon as a pregnant woman goes
into cardiac arrest.43
Older people have an increased incidence of cardiac
arrest because the incidence of coronary heart disease
and chronic heart failure increases with age. The inci-
dence of PEA as the first recorded rhythm increases
significantly with age with a decrease in the incidence
of shockable rhythms (VF/pulseless VT).5Whenever
possible, a decision to resuscitate or not should be dis-
cussed in advance with the patient and their family, but
the ethical approach is different in different countriesaccording to legislations and religious and traditional
aspects.
Maybe the really new therapeutics in the resuscita-
tion field for special circumstances is the use of
ECLS/extracorporeal membrane oxygenation. This
is a therapy option for a small range of patients with
cardiopulmonary failure because of drowning or acci-
dental hypothermia, but there are indications for all
cardiac arrests in special circumstances where stan-
dard ALS measures are not successful. In each para-
graph, we described what is new and what it is
constant, according to guidelines.
CONCLUSIONS
In special circumstances, ALS guidelines require modi-
fication and special attention for causes, environment,
and patient particularities. The recommendations
for minimally interrupted high-quality chest compres-
sion, early defibrillation with self-adhesive pads for
shockable rhythm, a variety of approaches to airway
management, and drug therapy must be followed dur-
ing ALS intervention. Special circumstances in cardiac
arrest need special interventions with an appropriate
approach of current guidelines for CPR.
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http://www.revistadechimie.ro REV.CHIM.(Bucharest)♦70♦No.3♦2019 814Determining the Influence of Alcohol on the Pharmacological
Effect of Benzodiazepines by Molecular Docking Tehnique
LUCIANA TEODORA ROTARU1*, PAUL NEDELEA2, RENATA-MARIA VARUT3, ALINA PETRICA4, SILVIA NICA5, CATALIN BOUROS2,
DIANA CIMPOESU6, MIHAELA CORLADE6, MIHAI BANICIOIU COVEI7, MARIUS NOVAC8
1Univesity of Medicine and Pharmacy Craiova, Emergency & First Aid Department, Emergency Department-SMURD, University
County Hospital Craiova, 1 Tabaci Str. 200642, Craiova, Romania
2Grigore T Popa University of Medicine and Pharmacy, 16 Universitatii Str., 700115, Iasi, Romania
3Univesity of Medicine and Pharmacy Craiova, Faculty of Pharmacy, 2-4 Petru Rares Str., 200349, Craiova, Romania
4Emergency Department, Emergency County Hospital Timisoara, 156 Liviu Rebreanu Str, 300723, Timisoara, Romania
5ED Emergency University Hospital Bucharest, 169 Splaiul Independentei, 050098, Bucharest, Romania
6Grigore T. Popa University of Medicine and Pharmacy, Emergency Department and Pre-hospital EMS, University County Hospital
Sf. Spiridon Iasi, 16 Universitatii Str., 700115, Iasi, Romania
7University of Medicine and Pharmacy of Craiova, Emergency & First Aid Department, Emergency Department, Filantropia
Hospital Craiova, 2-4 Petru Rares Str., 200349, Craiova, Romania
8University of Medicine and Pharmacy of Craiova, Anesthesiology and Intensive Care, Emergency County Hospital Craiova, 2-4
Petru Rares Str., 200349, Craiova, Romania
Benzodiazepines represents a large category of medications that were originally developed to treat anxiety
disorders or issues with anxiety, seizures, and issues with sleeping. The most common drugs abused along
with benzodiazepines are other benzodiazepines, prescription pain medications and alcohol. Alcohol and
benzodiazepine have a synergistic depressant effect on the central nervous system. Combining alcohol with
benzodiazepines can be dangerous practice even if it is engaged in only occasionally. In the present study,
using molecular docking technique we followed the binding energy of benzodiazepines with benzodiazepine
receptor and efficacy of the flumazenil antidote against benzodiazepine in the presence and absence of
alcohol. We realized correlation study of molecular descriptors value of benzodiazepines with
benzodiazepine-GABAA complex binding energy.
Keyword: molecular docking, molecular descriptors, benzodiazepines, procedural sedation,
neuroleptanalgesia
*email: lucianarotaru@yahoo.comBenzodiazepines are a class of drugs with psychoactive
effect, being known as minor tranquilizers [1].
Benzodiazepines improve the effect of the neurotransmitter
gamma-aminobutyric acid (GABA) at GABAA receptor
level, having sedative, hypnotic, anxiolytic, anticonvulsant,
and muscle relaxant properties [2]. These characteristics
make benzodiazepines useful in procedural sedation and
analgesia, neuroleptanalgesia, crush induction, treating
anxiety, insomnia, agitation, seizures, muscle spasms,
alcohol withdrawal and as a premedication for medical or
dental procedures [3]. Benzodiazepines can be taken in
overdoses and can cause dangerous deep un-
consciousness but fortunately death rarely results when a
benzodiazepine is the only drug taken. When combined
with other central nervous system depressants such as
alcoholic drinks and opioids, the potential for toxicity and
fatal overdose increases [4]. Alcohol increases activity of
GABA and glycine as well as decreases the activity of
excitatory neurotransmitters such as NMDA (N-methyl-D-
aspirate).
Statistic data collected indicates a steady rise in hospital
emergency department admissions associated with the
misuse of benzodiazepines and alcohol from 2007 through
2011. Mixing two drugs with the same mechanism of
action results in the enhancement of the effects of both
drugs [5]. This means that the effects of both drugs are
increased significantly compared to the use of either drug
alone, a phenomenon known as potency synergism. An
overdose on either drug can have serious and even fatal
ramifications, including significant organ or brain damage
due to a lack of oxygen as both drugs are respiratorydepressants. When an individual drinks alcohol, the
person’s system metabolizes the alcohol before
metabolizing any other substances [6]. This means that
drugs like benzodiazepines remain in the individual’s
system longer if they consume these drugs with alcohol,
the drug reaching higher plasma concentrations than
normal. A person who drinks alcohol and continues to take
benzodiazepines may develop extremely dangerous levels
of benzodiazepines in their system [7]. Fumazenil is known
as a benzodiazepine antagonist and acts like an antidote
for pharmacological and toxic effects of benzodiazepines.
The antagonistic properties of this drug are thought to be
specifically mediated by competitive interaction at the
central-type benzodiazepine receptors [8].
In the present study, using molecular docking technique
we followed the binding energy of benzodiazepines with
benzodiazepine receptor in the presence and absence of
alcohol. We also wanted to see the efficacy of the
flumazenil antidote against benzodiazepine in the presence
and absence of alcohol. We have also highlighted the
correlation of the molecular descriptors values (dipole
moment and molecular energy) with the binding energy.
Experimental part
Materials and methods
We used the Gaussian program suite at DFT/B3LYP/6-
311G for benzodiazepines optimization. The X-ray crystal
structure of GABAA receptor (with 4COF code and X-ray
diffraction at 2.97 Å resolution) was taken from the Protein
Data Bank [9] and and refined with a Modrefiner program
[10].

REV.CHIM.(Bucharest)♦70♦No.3♦2019 http://www.revistadechimie.ro 815The molecular docking analysis was performed using
the Autodock 4.2.6 software together with the
AutoDockTools [11], (a molecular viewer and graphical
support for setup and analysis of docking runs). The
preparation of receptor molecule involves adding polar
hydrogens, computing the Gasteiger charge; the grid box
was created using Autogrid 4 with 100×100×100 Å in x, y
and z directions with 0.9 Å spacing. All the calculations
were performed in vacuum [12].
For the docking process we chose the Lamarckian
genetic algorithm (Genetic Algorithm combined with a
local search), with a population size of 150 and a number
of 20 runs. We exported all Autodock results in Discovery
studio visualizer [13]. For all benzodiazepines we performed
molecular quantum calculations of molecular geometries
using the MOPAC 2016 program. The output data contains
physico-chemical information about selected molecules
[14].
We also realized correlation between molecular
descriptors and estimated binding energy, using Regression
Excel function from Microsoft Office package [15].
Results and discussions
Benzodiazepines are a class of psychoactive drugs
whose core chemical structure is the fusion of a benzene
ring and a diazepine ring. Benzodiazepine drugs are
substituted 1,4-benzodiazepines, many of the
pharmacologically active classical benzodiazepine drugs
contain the 5-phenyl-1H-benzo[e] [1,4]diazepin-2(3H)-one
substructure [16]. Dipole moment reflects the partial
separation of electric charge in the molecule, being a
predictor of the chemical reactivity of the molecules [17].Energy (hartree) of the molecule is an important parameter,
a more negative value representing a more stable molecule
[18]. The highest molecular dipole is encountered for
lorazepam, which contains two chlorine substituents and
a hydroxyl group and the highest energy stability is held by
diazepam and flunitrazepam (table 1).
Alcohol interacts with GABAA, making a conventional
hydrogen bond with alanine E:119, van der waals
asparagine E:120, phenylamine A: 105, histidine A: 107,
glycine A: 108, lysine E: 118, valine A: 109 (fig. 1). The
binding free energy GABAA-alcohol is -2.50 kcal/mol.
The most stable complex benzodiazepine-GABAA , in
the absence of alcohol is found in association with
flunitrazepam. From the molecular docking calculation
there is no clear increase or decrease in binding energy for
the benzodiazepine-GABAA complex when administered
together with alcohol. Even if for alprazolam, clonazepam,
flunitrazepam and diazepam the binding energy GABAA-
benzodiazepine decrease in the presence of alcohol, the
overall pharmacological effect is stronger because it adds
the SNC depressant effect of alcohol [19] (table 2).
We establish that exist a good regression between
estimated free binding energy and the two molecular
descriptors.
Fig. 1 GABAA-alcohol
interaction
Table 1
MOLECULAR DESCRIPTORS FOR BENZODIAZEPINES
Image 1 GABAA receptor

http://www.revistadechimie.ro REV.CHIM.(Bucharest)♦70♦No.3♦2019 816Estimated free binding energy= 10.38817-
0.10336*Dipole moment+0.012353*Total energy
(R2=0.985).
From the 2D diagram we can see the ligand-protein
interaction type and the pocket atoms from the active site.
Table 2
ESTIMATED FREE BINDING ENERGY FOR GABAA +
BENZODIAZEPINES WITH AND WITHOUT ALCOHOL
Diazepam diagram 3D (left), and 2D (right)
Diazepam diagram 3D (left), and 2D (right) in the
presence of alcoholFig.2 Diazepam 3D and 2D
diagram interaction with
GABAA

REV.CHIM.(Bucharest)♦70♦No.3♦2019 http://www.revistadechimie.ro 817Diazepam realize a hydrogen bond with asparagine B:55,
carbon hydrogen bond interaction with serine B:54 and
proline A:276, alkyl interaction with valine B:53, leucine
B:188, lysine A:274, and van der waals interaction with
histidine B:56, glycine B:190, tyrosine B:191, asparagine
B:189, proline B:52, isoleucine A:275, valine A:53.
Flunitrazepam binds with a hydrogen bond with valine
A: 53, tyrosine B: 191, glycine B: 190, valine B: 53,
asparagine halogen link A: 54, alkylation with proline A:
276, lysine A: 274 , methionine A: 55, arginine B: 187, proline
B: 52, van der waals interaction with asparagine B: 189
and leucine B: 188.
We can see how alcohol consumption modifies the
benzodiazepine binding site and the type of interaction with
the GABAA receptor.
Flunitrazepam diagram 3D (left), and 2D (right)
Flunitrazepam diagram 3D (left), and 2D (right) in
the presence of alcoholFig. 2. Flunitrazepam 3D
and 2D diagram interaction
with GABAA
After alcohol consumption, diazepam binds with
hydrogen bonds with histidine D: 102, via carbon bond
hydrogen with serine D: 159, via pi-alkyl linkage with
tyrosine D: 160, tyrosine D: 210, phenylamine D: 100,
tyrosine E : 58, phenylamine E: 77, and van der waals
interaction with valine D: 212, valine D: 203, asparagine E:
60, serine D: 205, serine D: 206, tyrosine D: 207, alanine D:
161.
Also the binding site of flunitrazepam and the interactive
type changed, having hydrogen bonds with serine E: 309,
tyrosine A: 256, carbon hydrogen bond with methionine E:
331, glutamic acid E: 313, alanine A: 249, alanine A: 252,
phenylamine E: 339, alanine E: 342, interactive van der
waals with leucine A: 253, tyrosine E: 334, alanine E: 335,
phenylamine E: 310, valine E: 312 (fig. 2).
Table 3
ESTIMATED FREE BINDING ENERGY FOR
FLUMAZENIL WITH GABAA –
BENZODIAZEPINES COMPLEX WITH AND
WITHOUT ALCOHOL

http://www.revistadechimie.ro REV.CHIM.(Bucharest)♦70♦No.3♦2019 818GABAA-alprazolam complex+flumazenil (red) diagram
3D (left), and 2D (right) in the presence of alcohol
Fig.3 Alprazolam and
clonazepam 3D and 2D
diagram interaction with
GABAA, with and without
alcohol
The highest efficacy of flumazenil as a competitive
antidote is in the case of previous administration of
clonazepam and alprazolam (-6.65 kcal/mol and -6.47 kcal/mol). For both two benzodiazepines the effectiveness of
flumazenil is reduced by alcohol consumption (fig. 3).
GABAA-alprazolam complex+flumazenil (red) diagram
3D (left), and 2D (right)
GABAA-clonazepam complex+flumazenil (red)
diagram 3D (left), and 2D (right)

REV.CHIM.(Bucharest)♦70♦No.3♦2019 http://www.revistadechimie.ro 819GABAA-clonazepam complex+flumazenil (red)
diagram 3D (left), and 2D (right) in the presence of
alcohol
Fig. 3.
Conclusions
There are important reasons that the warnings on the
instruction labels of benzodiazepines strongly advise
against drinking alcohol with these drugs.
Combining alcohol with benzodiazepines can be
dangerous practice even if it is engaged in only
occasionally. Chronic abuse of these two drugs together
can result in a number of serious short-term and long-term
effects.
The highest molecular dipole is encountered for
lorazepam, which contains two chlorine substituents and
a hydroxyl group and the highest energy stability is held by
diazepam and flunitrazepam.
From the molecular docking calculation there is no clear
increase or decrease in binding energy for the
benzodiazepine-GABAA complex when administered
together with alcohol, but the overall pharmacological
effect is stronger because it adds the SNC depressant effect
of alcohol (-2.5 kcal/mol).
We establish that exist a good regression between
estimated free binding energy and the two molecular
descriptors: dipole moment and molecule energy.
The highest efficacy of flumazenil as a competitive
antidote is in the case of previous administration of
clonazepam and alprazolam, being reduced by alcohol
consumption.
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© Filodiritto Editore – Proceedings
209 CPR – Could be Inappropriate? The Emergency Medicine
Professionals’ Perception

NEDELEA P.1,2, POPA T.O.1,2*, CORLADE-ANDREI Mihaela1,2, BOUROS C.1,2,
CIMPOESU Carmen Diana1,2

1 University of Medicine and Pharmacy Grigore T. Popa Iasi (ROMANIA)
2 Emergency County Hospital Sf. Spiriodon Iasi (ROMANIA)
* Corresponding author: Popa Tudor Ovidiu, email: ovidiupopa8@gmail.com
Emails: dcimpoiesu@yahoo.com, paul.nedelea@yahoo.com, ovidiupopa8@gmail.com

Abstract

Introduction
Cardiopulmonary resuscitation (CPR) is started irr espective ly of comorbidity or the cause
of the cardiac arrest. We aimed to determine the prevalence of the perceptio n of inappropriate
CPR of the Emergency D epartmen t (ED) personnel , the factors asso ciated with this
perception and the relation to the patie nt characteristics .

Methods
A survey based on questionnaire was conducte d in a n ED of a University Hospital, as a
part of a multicentric E uropean study . Factors associated with perception of CPR and
outcome s were analysed on statistic base .

Results
Out o f the 54 pa rticipating clinicians, 57,4% perceived their la test CPR attempt as
appropriate, 38,9 % were uncertain abo ut its appropriateness and 3,7% perceived it as
inappropriate . The prevalence of perception of inappropriate CPR was higher when one of
these factor s was present : non-shockable initia l rhythm, inappropriate quality of CPR
performed by witnesses before arri val, the advanced age of the patient, terminal neoplasia,
low qu ality of life before cardiac arrest. The E D staff needs an early recognition of CPR
futility, feedback, training and team work and performance evaluation after each CPR attempt.

Conclusions
The perception of inappropriate CPR is present in a small percent inside ED staff.
Factoring clinical judgment into the decision to (not) atte mpt CPR may reduce harm
inflicted by excessive resuscitation attempts.

Keywords: CPR, ED personnel, inappropriate, survey

Introduction

Cardiopulmonary resuscitation (CPR) was introduced in 60’s to reverse the cardiac arrest
of patients with reversible c onditions such as acute myocardial infarction within the first
minutes after collapse [1]. Currently, most cardiac a rrest patients receive CPR irrespective of
their functional status and comorbidity, cause of the arrest and delay after the collapse [2, 3].
Some studies have shown that over time neurologically favourable outcome after CPR has
improved, but this improveme nt is lower for cardiac arrests with an initial non -shockable
rhythm compared to an initial shockable rhythm. Data from the Cardiac Arrest R egistry to

© Filodiritto Editore – Proceedings
210 Enhance Survival (CARES) from 2005 until 2012 show an increased adjusted rate of survival
to hospital dis charge from 2.1 to 3.9% for non -shockable rhythms and from 16.1 to 21.1% for
shockable rhythms [4]. A nation -wide Japanese registry from 200 5 until 2014 reports an
increase of 1 -month survival with favourable neurological outcome from 0.8 to 1.2% for
bysta nder-witnessed non -shockable arrests and from 10.1 to 24.9% for bystander -witnessed
shockable arrests [5].
Inappropriate CPR attempts are un desirable from both the medical personnel and the
scientific perspective. The patients suffering a cardiac arrest ar e particularly suscep tible to
loss of dignity and to suffer dehumanization, because they lack many typical attributes of
modern human beings such as consciousness and self -determination. Furthermore, patients
who are successfully resuscitated have residual cognitive and physic al deficits and never
recover, thus prolonging their vulnerability to disrespect, often with profound negative
conseque nces for their relatives [10]. From the logistic and financial health perspective,
undifferentiated application of c ardiopulmonary resusc itation may unbalance the appropriate
allocation of resources.
Previous studies by Marco et al., found in 1995, and aga in in 2007, that 55% and 57% of
surveyed emergency physicians, respectively, reported having attempted more than ten
resuscitations that w ere perceived as futile in the prior three years [8]. A survey found that
emergency medical technicians estimated 50% of resuscitation attempts to be futile, defined
as a very low likelihood of success [9]. Studying clinician percepti ons of inappropriate c are is
important since they have been associated with moral distress [11, 12] and burnout [13],
which are related to s elf-reported suboptimal patient care practices [14,15]. The quality of
future resuscitation attempts may be negative ly affected if medical professionals perceive
CPR attempts as inappropriate and resulting in a poor outcome.
No studies in Central and East European countries related the ED team perception of
inappropriateness of CPR to actual patient outcomes. The object ive of this study was to
determine the prevalence of the uncertainty about CPR appropriateness and of the perception
of inappropriate CPR in pre-hospital and emergency departments and the association with
survival to hospital discharge. The secondary objec tives ware to assess t he association
between patient and situation related factors, personnel characteristics, organizational and
work -related factors, the perception of inappropriate CPR and return of spontaneous
circulation (ROSC).

Methods and materials

This Romanian study is a part of an international multi -centre cross -sectional survey
conducted in 288 centres in 24 countries, the REAPPR OPRIATE study, coordinate by
Belgium [1]. The study popula tion consisted of ED personnel from University Emergency
County Hospital St. Spiridon Iasi who are directly involved in the management of cardiac
arrest in the emergency department or the pre -hospit al setting. The data collection period was
from March until November 2015 and a modified Delphi method was used to a djust a
questionnaire. First version of the questionnaire was prepared by a multidisciplinary expert
panel: two emergency physicians, two in tensivists, two emergency nurses, one geriatrician
and two clinical psychologists from Netherlands. This Dutch versi on had an adaptation and
translation into English and after the questionnaire was translated into Romanian followed by
re-translation, neces sary to achieve cultural and functional equivalence [16]. We designed the
survey based on the questionnaire, using a 4-point rating scale, similar with Likert scale from
“Fully agree” to “Fully disagree”. ED personnel, physicians and nurses, were asked abo ut
their demographic and professional background and ED working environment. Also , they
were asked to recall the lat est cardiac arrest they encountered and to answer if they “fully
agreed with starting the resuscitation” (own perception of appropriate CPR) , “were unsure

© Filodiritto Editore – Proceedings
211 resuscitation should have been started” (uncertain about CPR appropriateness) or “were sure
resuscita tion should not have been started” (inappropriate CPR). Subsequently questions were
about details of the resuscitation circumstances such as : site of arrest, patient age, gender,
initial arrest rhythm , presence of a witness, ROSC, personal impression of th e patient’s
physical condition, probable cause of arrest. All the data was included in a statistical analysis
using SPSS 25.0 . This study wa s conducted in accordance with the Declaration of Helsinki.
Because informed consent was not required, the study was approved by the Ethical
Committee of University of Medicine and Pharmacy Grigore. T. Popa Iasi.

Results

We sent 58 questionnaire and we r eceived 54 completed. The latest CPR attempt
encountered was reported by 54 physicians and nurses. The average age o f the participants
was 31 +/-7,192 years , with a maximum of 53 and a minimum of 22 years . The distr ibution by
gender was : 68.5% women and 31. 5% males , similar with the gender structure insi de the
health system in Romania. Of the entire group, 51.8% were training doctors, 18.4% were
Emergency consultant s and 29,8% nurses. According to the activity field: 87% were direct ly
involved in emergency m edicine inside ED and 13% were indirect ly involved in emergency
medicine , such as the radiologist s. The number of working hours/weeks : average 40 with the
limits between 30 (1.7%) and 78 (1.7%)
Years of the experience in the ED inside the population group were: less than 1 year –
14,8%, 1 -5 years (29,7%), between 5 -20 years – 53,6% and up to 25 years (1.9%).
74.1% ad mitted to have religious beliefs, 18.5% showed no religious beliefs while 7.4%
wouldn’t answer. There is no correlation between religion and th e initiation of resuscitation
manoeuvres or their uselessness.
Only 6.9% of respondents are involved in teaching ALS and BLS courses. The hours of
BLS training attended in the last 12 months varies between 0 (for 50% of the respondents)
and 48 hours (for t he 5.2% of respondents).
The number of ALS course hours varies from 0 (55.2% of the respondents) to 120 hours
(1.7% of the respondents).
The answers about the personal perception of work effort recognition showed that 48.1%
feel appreciated, 33.3% do not f eel appreciated, 9.3% do not feel apprec iated at all and 9.3%
feel very appreciated.
They c onsider thems elves to be hard-working: 51.9% +33.3%, only 5.6% and 9.3% admit
not to be hard -working.
The perception about s ufficient time to finish the work indicate d that : 51.9% agree to have
enough time, 9.3% totally agree, 27.8 do not agree with having enough time , 11.1% totall y
disagree .
Emergency medicine is a field with continuous learning environment. For the item “ Learn
new things ”: 59.3% total agree, 31.5% ag ree, 7.4% disagree and 1.9% total ly disagree. Also ,
the working environment is important for the item , for “Working with helpful colleagues ”, the
answer demonstrated: 48.1% agreement, 42.6% total agreement, 1.9% total disagreement and
7.4% disagreement . Learning from the mistakes of others: 35.2% tot al agreement, 57.4%
agreement, 7, 4% disagreement . The vast majority dis agree with the difficulty of
communicating with people of other culture (11.1 totally disagree and 57.4%
disagree =68.5%), 1.9% admit to have communication difficulties with people bel onging to
other culture.
The ED staff feel appreciated within the CPR tea m: 64.8% agree, 14.8 totally agree, 20.4%
do not feel appreciated. Only 5, 6% planned to quit the profession and 59.3% total ly disagree
and 3 5.2% disagree.

© Filodiritto Editore – Proceedings
212 When we analysed the perce ption about the appropriate or inappropriate CPR, we also
studied the perce ption of CPR futility. They could confidently express their doubts about the
futility of the CPR: 11.1% total ly agree , 74.1% agree and 14, 8% disagree .
The presenc e of the family during the CPR is still a subject of debate in ED and about this
subject t he population of the study demonstrated: agreement 11.1%, total agreement 3.7%,
disagreement 53.7%, total disagreement 31.5%.
Necessity of debr iefing time after CPR is consider important : total agreement 5.6%,
agreement 57.4%, disagreement 31.5%, total disagr eement 5.6%
About the l atest case with CPR during the recent professional life the answers
demonstrated : ED personnel e valuation of the CPR opportunity: total agreement 14.8%,
agreement 42.6%, disagreement 38.9%, total disagreement 3.7% .
Early recognition of CPR futility received the follow answers : 3,7% totally disagree ,7,4%
disagree , 57 ,4% agree , 31, 5% totally agree . These answers demonstrat e the need to
understand the CPR futility inside the ED staff.
The team leader appreciates the team effort during th e latest experience in resuscitation :
35.2% totally agree, 53.7% agree, 11.1% disagree .
Regarding the perception of the ED personnel for ina ppropriate CPR, n o correlation was
found between the opportunity to start CPR and the patient particularities: the p resence of the
family, the presence of the DNR order, the age of the patient, the presence of dementia, the
low quality of life, the initial shockable rhythm , the possibility of an organ donor, the patient
age: child or adult.
There is a direct correlation of the initiation of the CP R with the site of the cardiac arrest :
pre-hospital CPR is consider ed the right site to start CPR (p=0.354), the pregnancy status of
the female patient is a clear indication to st art CPR ( p=0.285 ) but also the neoplasia in the
terminal phase ( p=0.410 ).
We tried to explore the f actors that made them feel the CPR is unnecessary and we
obtained the next results :
• Inappr opriate quality of CPR performed by witnesses until arrival: 38.9% very
important, 37% important, 11.1% rather impor tant, 13% unimportant
• Initial non -shockable rhythm: 22.2% very important, 42.6% important, 16.7% rather
important, 18.5% unimportant
• The adv anced age of the patient: 14.8% very important, 24.1% important, 22.2%
rather important and 38.9% unimportant
• Patie nt with dementia: 5,5% very important, 20,4% important, 16,7% rather important
and 57,4% unimportant
• Termina l neoplasia : 27.8 % very importan t, 37% important, 14.8% rather important
and 20.4% unimportant
• Low quality of life before CPR: 11.1% very importa nt, 20.4% important, 20.4% rather
important and 48.1% unimportant

Discussion

From our knowledge, this is the fir st study conducted in ED in R omania , regarding the
perception of futility of CPR, including emergency staff involved in cardiac arrest care,
exploring potentially relevant organizational, clinical and work -related factors, as well as
patient and situation -related factors, and relating these factors with patient outcome (ROSC) .
ED personnel were specifically asked about the latest cardiac arrest they encountered. As
such the reported prevalence of perception of inappropriate CPR was based on a specific
clinical event attended by the cli nicians and not just on a vague general impression. Basing on
our survey , we found that 57,4 % of clinicians work ing in emergency departments and
ambulance services perceived their latest C PR attempt as appropriate, and 42,6 % perceived

© Filodiritto Editore – Proceedings
213 their last CPR attemp t as inappropriate. Moreover, we found that the presence of objective
indicators of poor prognosis only moderate ly increased the prevalence of perception of
inappropriate CPR . In patients with non -witnessed non -shockable arrests, a group known for
its high ly unfavourable prognosis [4, 20] and a low rate of survival to hospital discharge,
22,2% of ED considered it ve ry important and 46,2% considered impo rtant the early
recognition of futility o f CPR. Une xpectedly , the neo plasia in terminal phase is consider an
important situation of inappropriate CPR only by 64,8 % of ED personnel . These findings
indicate that the maj ority of physicians and nurses are either unaware of the inappropriateness
of their CPR a ttempt or only become aware of the potential consequence s of their actions in
extreme patient situations. The most important determinants of perception of inappropriat e
CPR were objective criteria such as non -shockable initial rhythm, non -witnessed arrest, older
age and a poor first physical impression of the p atient . This may indicate that perception of
inappropriateness of appraisal and warranting team leaders to invi te an d take into account the
opinion of all experienced resuscitation team members, regar dless of their role. Our results
highlight the need of c losed -loop syst ems assuring that all staff involved in resuscitation
receives feedback on the results of their attem pts. Debriefing and interdisciplinary ethical
reflection on difficult patient cases are needed, more specifically when one team members has
doubts about the appropriateness of resuscitation. More advance care planning conversations
with patients and f amily are needed [26], based on realistic information about outcome of
resuscitation thus avoiding inaccurate expectations of CPR [27]. Complianc e of clinicians
once advance directives are established s hould be further improved [8, 25 ]. This study has
several limitations. First, the possibility that the perceptions about the appropriateness of CPR
may have been affected by the resuscitation outcome s. However, the questionnaire was
structured in such a way that questions concerning outcome were listed at the very end.
Second, data on ROSC and survival to hospital discharge were provided only for the study
team and not for population included in the s tudy.

Conclusions

Our findings suggest that emergency medicine professionals who are working on daily
basis i n an emergency system consider that performing the CPR manoeuvres was a ppropriate
in most of the cases but the ones who perceive CPR as inappropr iate are entitled to express
themselves regardless the role played inside the resuscitation team. Factoring thi s clinical
judgment into the decision to attempt resusci tation may redu ce harm by excessive
resuscit ation attempts to a number of patients, facil itating DNR order in Romanian legislation
for very strict defined situations and maybe a more dignified death f or so me people.

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Med. Surg. J. – Rev. Med. Chir. Soc. Med. Nat., Iași – 2020 – vol. 124, no. 3
INTERNAL MEDICINE – PEDIATRICS ORIGINAL PAPERS
374 CPR – COULD BE INAPPROPRIATE? THE EMERGENCY MEDICINE
PROFESSIONALS PERCEPTION IN NORTH-EAST ROMANIA
P. Nedelea 1,2, O. T. Popa1,2, Corlade-Andrei Mihaela1,2, C. Bouros1,2,
Cimpoesu Carmen Diana1,2
“Grigore T. Popa” University of Medicine and Pharmacy Iasi
1. Faculty of Medicine
2.“Sf. Spiridon” County Clinical Emergency Hospital Iasi
*Corresponding author. E-mail: ovidiupopa8@gmail.com
CPR – COULD BE INAPPROPRIATE ? THE EMERGENCY MEDICINE PROFESSION-
ALS PERCEPTION IN NORTH-EAST ROMANIA (Abstract): Cardiopulmonary resuscita-
tion (CPR) is started irrespective of comorbidity or cause of cardiac arrest. We aimed to de-
termine the prevalence of perception of inappropriate CPR of the personnel from Emergency
Department (ED), the factors associated with perception and the relation to patient charac-
teristics. Material and methods: A survey based on questionnaire was conducted in an ED
of University Hospital, as a part of multicentric European study. Factors associated with
perception of CPR and outcome were analyzed on statistic base. Results: Of the 54 partici-
pating clinicians, 57.4% perceived their last CPR attempt as appropriate, 38.9 % were uncer-
tain about its appropriateness and 3.7% perceived inappropriateness. The prevalence of per-
ception of inappropriate CPR was higher when one of this factor was present :non-shockable
initial rhythm, inappropriate quality of CPR performed by witnesses before arrival, the ad-
vanced age of the patient, terminal neoplasia, low quality of life before cardiac arrest. The
ED staff needs an early recognition of CPR futility, feedback, training and teamwork and
performance evaluation after each CPR attempt. Conclusions: The perception of inappropri-
ate CPR is present in a small percent inside ED staff. Factoring clinical judgment into the
decision to (not) attempt CPR may reduce harm inflicted by excessive resuscitation attempts.
Keywords: CPR, ED PERSONNEL, INAPPROPRIATE, SURVEY.
Cardiopulmonary resuscitation (CPR)
was introduced in 60’s to reverse the cardiac
arrest of patients with reversible conditions
such as acute myocardial infarction within
the first minutes after collapse (1). Current-
ly, most cardiac arrest patients receive CPR
irrespective of their functional status and
comorbidity, cause of the arrest and delay
after the collapse (2, 3). Some studies have
shown that over time neurologically favora-
ble outcome after CPR has improved, but this improvement is lower for cardiac arrests
with an initial non-shockable rhythm com-
pared to an initial shockable rhythm. Data
from the Cardiac Arrest Registry to Enhance
Survival (CARES) from 2005 until 2012
show an increased adjusted rate of survival
to hospital discharge from 2.1 to 3.9% for
non-shockable rhythms and from 16.1 to
21.1% for shockable rhythms (4). A nation-
wide Japanese registry from 2005 until 2014
reports an increase of 1-month survival with

CPR – could be inappropriate?
The emergency medicine professionals perception in North-East Romania
375 favorable neurological outcome from 0.8 to
1.2% for bystander-witnessed non-shockable
arrests and from 10.1 to 24.9% for bystand-
er-witnessed shockable arrests (5).
Inappropriate CPR attempts are unde-
sirable from both the medical personnel
and the scientific perspective. The patients
suffering a cardiac arrest are particularly
susceptible to loss of dignity and to suffer
dehumanization, because they lack many
typical attributes of modern human beings
such as consciousness and self-
determination. Furthermore, patients who
are successfully resuscitated have residual
cognitive and physical deficits and never
recover, thus prolonging their vulnerability
to disrespect, often with profound negative
consequences for their relatives (10). From
the logistic and financial health perspec-
tive, undifferentiated application of cardio-
pulmonary resuscitation may unbalance the
appropriate allocation of resources.
Previous studies by Marco et al. found
in 1995, and again in 2007, that 55% and
57% of surveyed emergency physicians,
respectively, reported having attempted
more than ten resuscitations that were per-
ceived as futile in the prior three years (8).
A survey found that emergency medical
technicians estimated 50% of resuscitation
attempts to be futile, defined as an excep-
tionally low likelihood of success (9).
Studying clinician perceptions of inappro-
priate care is important since they have
been associated with moral distress (11, 12)
and burnout (13), which are related to self-
reported suboptimal patient care practices
(14, 15). The quality of future resuscitation
attempts may be negatively affected if
medical professionals perceive CPR at-
tempts as inappropriate and resulting in a
poor outcome.
No studies in Central and East European countries related the ED team perception of
inappropriateness of CPR to actual patient
outcomes. The objective of this study was
to determine the prevalence of the uncer-
tainty about CPR appropriateness and of
the perception of inappropriate CPR in pre-
hospital and emergency departments and
the association with survival to hospital
discharge. The secondary objectives ware
to assess the association between patient
and situation related factors, personnel
characteristics, organizational and work-
related factors, the perception of inappro-
priate CPR and return of spontaneous cir-
culation (ROSC).

MATERIAL AND METHODS
This Romanian study is a part of an in-
ternational multi-center cross-sectional
survey conducted in 288 centers in 24
countries, the REAPPROPRIATE study,
coordinate by Belgium (1). The study
population consisted of ED personnel from
“Sf. Spiridon” County Clinical Emergency
Hospital from Iasi who are directly in-
volved in the management of cardiac arrest
in the emergency department or the pre-
hospital setting. The data collection period
was from March until November 2015 and
a modified Delphi method was used to
adjust a questionnaire. First version of the
questionnaire was prepared by a multidis-
ciplinary expert panel: two emergency
physicians, two intensivists, two emergen-
cy nurses, one geriatrician and two clinical
psychologists from Netherlands. This
Dutch version had an adaptation and trans-
lation into English and after the question-
naire was translated into Romanian fol-
lowed by re-translation, necessary to
achieve cultural and functional equivalence
(16). We designed the survey based on the
questionnaire, using a 4-point rating scale,

P. Nedelea et al.
376 similar with Likert scale from “Fully
agree” to “Fully disagree”. ED personnel,
physicians and nurses, were asked about
their demographic and professional back-
ground and ED working environment. Also
they were asked to recall the latest cardiac
arrest they encountered and to answer if
they “fully agreed with starting the resusci-
tation” (own perception of appropriate
CPR), “ were unsure resuscitation should
have been started” (uncertain about CPR
appropriateness) or “were sure resuscita-
tion should not have been started” (inap-
propriate CPR). Subsequently questions
were about details of the resuscitation cir-
cumstances such as: site of arrest, patient
age, gender, initial arrest rhythm, presence
of a witness, ROSC, personal impression of
the patient’s physical condition, probable
cause of arrest. All the data was included in
a statistical analysis using SPSS 25.0. This
study was conducted in accordance with
the Declaration of Helsinki. Because in-
formed consent was not required, the study
was approved by the Ethical Committee of
“Grigore T. Popa” University of Medicine
and Pharmacy from Iasi.

RESULTS
We sent 58 questionnaire and we re-
ceived 54 completed. The latest CPR at-
tempt encountered was reported by 54 phy-
sicians and nurses. The average age of the
participants was 31+/-7.192 years, with a
maximum of 53 and a minimum of 22
years. The distribution by gender was:
68.5% women and 31.5% males, similar
with the gender structure inside the health
system in Romania. Of the entire group,
51.8% were training doctors, 18.4% were
Emergency consultants and 29.8% nurses.
According to the activity field: 87% were
directly involved in emergency medicine inside ED and 13% were indirect involved
in emergency medicine, being radiologist.
The number of working hours / week: aver-
age 40 with the limits between 30 (1.7%) to
78 (1.7%)
Years of the experience in the ED inside
the population group were less than 1 year-
14,8%, 1-5 years (29,7%), between 5-20
years- 53.6% and up to 25 years (1.9%).
74.1% admitted to have religious be-
liefs, 18.5% showed no religious beliefs
while 7.4% would not answer. There is no
correlation between religion and the initia-
tion of resuscitation maneuvers or their
uselessness.
Only 6.9% of respondents are involved
in teaching ALS and BLS courses. The
hours of BLS training attended in the last
12 months varies between 0 (for 50% of the
respondents) and 48 hours (for the 5.2% of
respondents).
The number of ALS course hours varies
from 0 (55.2% of the respondents) to 120
hours (1.7% of the respondents).
The answers about the personal percep-
tion of work effort recognition showed that
48.1% feel appreciated, 33.3% do not feel
appreciated, 9.3% do not feel appreciated
at all and 9.3% feel very appreciated.
They consider themselves to be hard-
working: 51.9% + 33.3%, only 5.6% and
9.3% admit not to be hard-working.
The perception about sufficient time to
finish the work indicated that: 51.9% agree
to have enough time, 9.3% totally agree,
27.8 do not agree with having enough time,
11.1% totally disagree.
Emergency medicine is a field with con-
tinuous learning environment. For the item
“Learn new things”: 59.3% total agree,
31.5% agree, 7.4% disagree and 1.9% total
disagree. Also, the working environment is
important for the item “Working with help-

CPR – could be inappropriate?
The emergency medicine professionals perception in North-East Romania
377 ful colleagues” and the answer demonstrat-
ed: 48.1% agreement, 42.6% total agree-
ment, 1.9% total disagreement and 7.4%
disagreement. Learning from the mistakes
of others: 35.2% total agreement, 57.4%
agreement, 7.4% disagreement. The vast
majority disagree with the difficulty of
communicating with people of other culture
(11.1 totally disagree and 57.4% disagree =
68.5%), 1.9% admit to have communica-
tion difficulties with people belonging to
other culture.
The ED staff feel appreciated within the
CPR team: 64.8% agree, 14.8% totally
agree, 20.4% do not feel appreciated. Only
5.6% planned to quit the profession and
59.3% total disagree and 35.2% disagree.
When we analyzed the perception about
the appropriate or inappropriate CPR, we
also studied the perception of CPR futility.
They could confidently express their
doubts about the futility of the CPR: 11.1%
total agree, 74.1% agree and 14.8% disa-
gree.
The presence of the family during the
CPR is still a subject of debate in ED and
about this subject the population of the
study demonstrated: agreement 11.1%,
total agreement 3.7%, disagreement 53.7%,
total disagreement 31.5%.
Necessity of debriefing time after CPR
is consider important: total agreement
5.6%, agreement 57.4%, disagreement
31.5%, total disagreement 5.6%.
About the latest case with CPR during
the recent professional life the answers
demonstrated: ED personnel evaluation of
the CPR opportunity: total agreement
14.8%, agreement 42.6%, disagreement
38.9%, total disagreement 3.7%.
Early recognition of CPR futility re-
ceived the follow answers: 3.7% totally
disagree, 7.4% disagree, 57.4% agree, 31.5% totally agree. These answers demon-
strate the need to understand the CPR fu-
tility inside the ED staff.
The team leader appreciates the team
effort during the latest experience in resus-
citation: 35.2% totally agree, 53.7% agree,
11.1% disagree.
Regarding the perception of the ED per-
sonnel for inappropriate CPR, no correla-
tion was found between the opportunity to
start CPR and the patient particularities: the
presence of the family, the presence of the
DNR order, the age of the patient, the pres-
ence of dementia, the low quality of life,
the initial shockable rhythm, the possibility
of an organ donor, the patient age: child or
adult.
There is a direct correlation of the initi-
ation of the CPR with the site of the cardiac
arrest: pre-hospital CPR is consider the
right site to start CPR (p = 0.354), the
pregnancy status of the female patient is a
clear indication to start CPR (p = 0.285)
but also the neoplasia in the terminal phase
(p = 0.410).
We tried to explore the factors that
made them feel the CPR is unnecessary and
we obtained the next results:
• Inappropriate quality of CPR per-
formed by witnesses until arrival:
38.9% very important, 37% important,
11.1% rather important, 13% unim-
portant
• Initial non-shockable rhythm: 22.2%
very important, 42.6% important,
16.7% rather important, 18.5% unim-
portant
• The advanced age of the patient: 14.8%
very important, 24.1% important,
22.2% rather important and 38.9% un-
important
• Patient with dementia: 5.5% very im-
portant, 20.4% important, 16.7% rather

P. Nedelea et al.
378 important and 57.4% unimportant
• Terminal neoplasia: 27.8% very im-
portant, 37% important, 14.8% rather
important and 20.4% unimportant
• Low quality of life before CPR: 11.1%
very important, 20.4% important,
20.4% rather important and 48.1% un-
important

DISCUSSION
From our knowledge, this is the first
study conducted in ED in Romania, regard-
ing the perception of futility of CPR, includ-
ing emergency staff involved in cardiac
arrest care, exploring potentially relevant
organizational, clinical and work-related
factors, as well as patient and situation-
related factors, and relating these factors
with patient outcome (ROSC). ED personnel
was specifically asked about the latest cardi-
ac arrest they encountered. As such the re-
ported prevalence of perception of inappro-
priate CPR was based on a specific clinical
event attended by the clinicians and not just
on a vague general impression. Basing on
our survey, we found that 57.4% of clini-
cians working in emergency departments
and ambulance services perceived their
latest CPR attempt as appropriate, and
42.6% perceived their last CPR attempt as
inappropriate. Moreover, we found that the
presence of objective indicators of poor
prognosis only moderately increased the
prevalence of perception of inappropriate
CPR. In patients with non-witnessed non-
shockable arrests, a group known for its
highly unfavorable prognosis (4, 20) and a
low rate of survival to hospital discharge,
22.2 % of ED considered it very important
and 46.2% considered important the early
recognition of futility of CPR. Unexpected-
ly, the neoplasia in terminal phase is consid-
er an important situation of inappropriate CPR only by 64.8 % of ED personnel. These
findings indicate that the majority of physi-
cians and nurses are either unaware of the
inappropriateness of their CPR attempt or
only become aware of the potential conse-
quences of their actions in extreme patient
situations. The most important determinants
of perception of inappropriate CPR were
objective criteria such as non-shockable
initial rhythm, non-witnessed arrest, older
age and a poor first physical impression of
the patient. This may indicate that percep-
tion of inappropriateness of appraisal and
warranting team leaders to invite and con-
sider the opinion of all experienced resusci-
tation team members, regardless of their
role. Our results highlight the need of
closed-loop systems assuring that all staff
involved in resuscitation receive feedback
on the results of their attempts. Debriefing
and interdisciplinary ethical reflection on
difficult patient cases are needed, more
specifically when one team members has
doubts about the appropriateness of resusci-
tation. More advance care planning conver-
sations with patients and family are needed
(26), based on realistic information about
outcome of resuscitation thus avoiding inac-
curate expectations of CPR (27). Compli-
ance of clinicians once advance directives
are established should be further improved
(8, 25). This study has several limitations.
First, the possibility that perceptions about
appropriateness of CPR may have been
affected by the resuscitation outcome. How-
ever, the questionnaire was structured in
such a way that questions concerning out-
come were listed at the very end. Second,
data on ROSC and survival to hospital dis-
charge were provided only for the study
team and not for population included in the
study.

CPR – could be inappropriate?
The emergency medicine professionals perception in North-East Romania
379 CONCLUSIONS
Our findings suggest that emergency
medicine professionals who are working on
daily basis in an emergency system consid-
er that performing the CPR maneuvers was
appropriate in most of the cases but the
ones who perceive CPR as inappropriate
are entitled to express themselves regard-less the role played inside the resuscitation
team. Factoring this clinical judgment into
the decision to attempt resuscitation may
reduce harm by excessive resuscitation
attempts to a number of patients, facilitat-
ing DNR order in Romanian legislation for
very strict defined situations and maybe a
more dignified death for some people.
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629.

LACTATING ADENOMA – DIAGNOSIS AND MANEGEMENT
Lactating adenomas are benign breast tumors that typically occur in the peri-partum period
and commonly present as painless breast masses late in pregnancy or in the postpartum peri-
od. They are often palpable, mobile lesions that undergo rapid growth and may be large in
size. Lactating adenomas resolve or decrease in size in the postpartum period or with cessa-
tion of lactation but may recur during subsequent pregnancies. Ultrasound is the initial imag-
ing modality of choice most lactating adenomas; the lesions have sharp margins are homo-
geneous and hypoechoic or isoechoic, may contain large cystic areas (infarction and necro-
sis), have posterior acoustic enhancement. Mammography is seldom performed and shows a
well-defined lobulated breast mass which may have radiolucent central areas or asymmetri-
cally increased density. Treatment is not necessary because the lactating adenoma frequently
undergo spontaneous regression after pregnancy and lactation. Core biopsy is recommended
for the differential diagnosis with other pathological entities (fibroadenoma, breast lympho-
ma). Some complications can occur, for example development of a milk fistula following
core biopsy. (Henry Knipeand, Radswiki et al. Lactating adenoma. Radiology Reference Ar-
ticle, Radiopaedia.org, https:// radiopaedia. org/articles/lactating-adenoma). NOUTĂȚI NEWS

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 371 https://doi.org/10.37358/RC.20.2.7939
Air Medical Interventions at Comatose Pediatric Patients
in Eastern Romania – Particularities of Airway Management
and Cardio-Pulmonary Resuscitation

ANGEL LIVIU TRIFAN1,2, LILIANA DRAGOMIR1,3, EVA-MARIA ELKAN3,4*, VIOLETA SAPIRA1,3,
MIHAELA LUNGU1,3, MONICA ZLATI5, ANA-MARIA PAPUC6, LAURA FLORESCU7,
MAGDA MIULESCU3,4, DIANA CARMEN CIMPOESU8,9, PAUL LUCIAN NEDELEA2,8
1Emergency County Hospital "Sfantul Apostol Andrei", Emergency Department, 177 Brailei Str., 800578, Galati,
Romania
2Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Str., 700115, Iasi, Romania
3Dunarea de Jos University of Medicine and Pharmacy, 47 Domneasca Str., 800008, Galati, Romania
4Sfantul Ioan Emergency Hospital, 2 Gheorghe Asachi Str., 800487, Galati, Romania
5Stefan cel Mare University, 13 Universitatii Str., 720229, Suceava, Romania
6Dunarea de Jos University of Medicine and Pharmacy, AMG, 47 Domneasca Str., 800008, Galati, Romania
7Grigore T.Popa University of Medicine and Pharmacy, Department Mother and Child, 16 Universitatii Str., 700115,
Iasi, Romania
8Sfantul Spiridon Emergency Clinical Hospital, 1 Independentei Blvd.,700111, Iasi, Romania
9Grigore T.Popa University of Medicine and Pharmacy, II-nd Surgical Department, 16 Universitatii Str., 700115, Iasi,
Romania

Pediatric comas are particular situations of terrestrial or aerial medical intervention, requiring knowledge
of specific protocols and prioritization and hierarchy of emergency interventions. The reactivity of the
comatose child is modified according to multiple biological, physiological parameters and generating
pathologies. The study aims to analyze the specific elements of aerial medical interventions with helicopter,
HEMS (Helicopter Emergency Medical Service) at comatose child that influences the emergency path, but
especially the medium and long term prognosis of these cases. The transfer of comatose children at Galati
aeromedical base, both primary and secondary interventions, were studied. The study was a prospective
randomized study involving pediatric comas transferred over a 4-year course (2014-2017) according to the
criteria in force. A total of 24 children between the ages of 0-18 years were transferred, with primary and
secondary interventions. In the study lot, the correlations between Glasgow scores and associated
pathology, epidemiological characteristics, therapeutic elements, complications and case evolution were
analyzed. A profile of the patient requiring emergency intervention for the comatose state was created,
making it possible to predict the services they will need and to design the specialized interventions that will
follow the transfer of these patients. Although still intensely disputed due to cost considerations, the air
transfer of the comatose child facilitates a more prompt response of medical systems to manage this type of
emergency and presents management particularities in pre-hospital. Based on this type of results, a strategy
takes shape by which the Romanian emergency system aligns with the continuous improvement of life-saving
interventions for children.

Keywords:Aerial Medical Transfer (HEMS), children, comas, associated pathologies

For any patient who has suffered an injury and has his/her general state influenced, it is important to manage the
time required both for intervention at the destabilizing event site and for bringing it to a near hospital as soon as
possible. In the 1970s a golden hour concept emerged in which fundamental maneuvers could be made for the
subsequent good evolution of decompensated cases. As the state of coma is known to have multiple causes that may
be vascular, traumatic, metabolic, intoxication, hereditary decompensated metabolic diseases, immunological. Rapid
management of a coma case minimizes its impact on the child's body by influencing it in the long run. The condition
of coma is often not defined very clearly, nor does it suffer from a very fixed frame, especially as for staff coming into
contact with a comatose child the technical and emotional challenge is immense. The transport of a comatose child
requires special preparations both before and after, but also after receiving the patient by the unit. The device that
maintains the vital support must be checked, like the aircraft, the delicate maneuvers in the air requiring strong team
cohesion. Not to be neglected is the psychic state of the staff during the mission, rest periods being essential, therefore
the entire team's knowledge of the incidents and accidents that occur is strictly necessary.

Study of the specialized literature
Coma [1] involves a state of inhibition of varying degrees of nervous activity. The patient's consciousness is totally
or partially lost, and motility is also suppressed. Reactions to external stimulation are nonspecific and vegetative
functions are maintained [2].

*email: cojocarumariaeva@yahoo.com

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 372 https://doi.org/10.37358/RC.20.2.7939
Epidemiology
In Germany, interventions for pediatric emergencies are 2-9% of all missions. The groups most affected by
children requiring emergency intervention are, according to the German authors, 0-5 year olds as well as the 14-16
year olds, and the pediatric intubation is still high, 20% of the patients requiring emergency specialized intervention.
Presentation with GCS <9 points was 16.3% at pediatric patients [3].
Not to be neglected is the number of people killed by fatal accidents in the world, 1.3 million / year [4].

Intervention time
Traumatology is known to have golden hour – patients can die in the first hour after the accident. It is precisely the
decrease in these times possible due to assisted air transport in severely traumatized patients. Helicopter-assisted aerial
medical services have been applied to civilian patients since the 1947s, benefiting from much faster and more trained
crews than those on ambulances. There are also disadvantages of this type of transport: these services are much more
expensive, the medical space for manoeuvre is very small, but also the risks given by the weather that makes
helicopters collapse, endangering and crew`s and the patient`slives. That is why before the air transport there are still
discussions between the specialists who make the decision for this type of transfer, and in the literature there is still
controversy in some cases [5]. Air transport helps provide equal medical services irrespective of the patient's health
status or social or economic background before the impact of the destabilizing event on its physical condition. These
services will be continually improved by every country in the world [6].
In the case of accidents in general, the average time from the accident site to the hospital is 69.4 minutes with a
standard deviation of 28.3 min. These times are very variable in the case of motor vehicle accidents with the patient
inside the vehicle and / or if he/she has claimed intubation. [1] In order to evaluate the power of intervention of a
system, the term first intervention is used which applies to the one who appears first at the intervention site, such as
authorities, family members, crew who intervene, etc. and how effective they can be, and times of intervention
depends on this effectiveness that significantly influence the total time of intervention [7]. It is also essential to
educate the population for timely intervention in a major emergency until the specialized crews come.
In the 1990s, only paramedical crews were chosen, but a doctor being in the helicopter lead to a better airway
emergency management, more prompt patient analgesia, and even invasive helicopter procedures [8].
Helicopter alert can be split and refined in several times as proposed by Kruger so it is analyzed 1) the moment
when the first emergency call comes 2) a type called the helicopter pre-dealer 3) the takeover of the helicopter by the
crew 4) bringing the helicopter to take-off place 5) the effective take-off 5) reaching the hospital. In some areas
missions have a seasonal summer pattern of 41%, unlike winter where air transport is required in 67% of cases. The
most frequent weekday flights were Wednesday and Sunday[9].

Cardiopulmonary resuscitation and management of coma problems
Cardiopulmonary resuscitation aims to re-establish vital functions. Goldberg has shown that advanced
cardiopulmonary resuscitation may be considered to be complete if, for an hour, cerebral or cardiac functions did not
respond after a cardiopulmonary arrest. However, at patients in whom spontaneous circulation has returned, the
cerebral flow suffers a significant reduction for 18 hours from the time of its onset demonstrated by White et al [10].
Intubation is a very delicate moment for the emergency specialist, neurologist anesthetist, neurosurgeon. This
decision is sometimes very difficult especially when preparing patients for brain operations knowing that the brain has
a different behavior after applying protocols and the therapeutic induction of some. Protocols on advanced vital
function support as well as traumatology protocols show that there are four post-trauma situations when intubation is
required.
There is the notion of Schutzintubation used in German space, as it is sometimes intubation to a Glasgow even
greater than 9 in some circumstances. Pre-hospital intubation adherents say that the patient is out of the agitation that
can be installed after trauma, agitation that may occur in more complex mental disorders just after trauma at some
patients. At the same time, these patients may develop more complications than non-intubated such as stasis
pneumonia. Another disadvantage of intubation is hypotension, but also hypertonia that may occur at the time of
induction to prepare for intubation. Intubation has the role of providing a better oxygenation of the organs. At the
same time, intubated patients will receive more catechol amines as treatment than those who do not benefit from this
maneuver. Sepsis is also higher at these patients [11].
The management of the volumes of liquids administered to the patient in the pre-hospital requires caution these
volumes influencing the coagulation systems when they exceed 1500 mL administered. The amount of liquid
increases as the blood pressure at the moment of take-up is lower such a threshold is at the blood pressure of 60 mm
Hg when the volume of infusions administered is greater. Mortality increases proportionate to the hight of the volley
correction intake [12]. Oligoalgezia is the term that defines the inappropriate and / or insufficient treatment for the
acute-type pain, which is often found at the critical patient. A study of traumatic destabilized patients showed that
43% of patients had oligoalgezia [13].

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 373 https://doi.org/10.37358/RC.20.2.7939
Hipo / and / or Hyperthermia management
Patients who suffer from hypothermia require a careful evaluation because the temperature at which they are found
prevails as well as the associated medical conditions. Before the patient is warmed up, the cardiopulmonary
resuscitation is the one that needs to be taken into account first [14].

Managing the hypoxic phenomena
It is important to manage breathing, which can be assisted by special devices such as AirQLA, and the physician
can visualize the airways through fiber optic as shown by Jagannathan et al. Thus, assisting ventilation on the mask
that sometimes leads to hypoxia installation is replaced by this type of assisted ventilation, improving airway
management thus becoming controlled and assisted [15].

Management of Severe Poisoning
Carbamazepine can cause coma by blocking sodium channels and acetylcholine synapses with the involvement of
adenosine A1 receptors. In addition to this, cardiac arrhythmia, epileptic crying and respiratory failure may occur.
Thus, in these situations, barbiturates for a therapeutic coma are also used to protect the brain from the destruction of
carbamate-coma [16].

Managing rare diseases causing coma
Often pediatricians do not know or omit to look for rare coma-inducing diseases. On the surface are often the
complications which are treated, the associated respiratory or cardiac failure, hypoxia, sepsis, bleeding. An example is
the mixedematous coma that can surprise any pediatrician, although it appears rare and rare but can also occur in an
infectious context. However, it must be considered because there are still many families who neglect the treatment for
thyroid disease at children. The presentation may be misleading, consisting of signs such as low body temperature, but
also alteration of cardiac and renal functions [17].

Evaluation
Different scores at patients experiencing consciousness help determine subsequent conduct. There is trauma score
and the score of the vital signs. Of the two scores the trauma score gives a better insight into the risk of death. If this
score is either equal to 12 or less than 12 the significance for a possible death is very high [18].
There is also a score called Therapeutic Intervention Scoring System (TISS). It can be applied more than one
verification score on a patient. However, the Glasgow Score (GCS) remains the base, with Revised Trauma Score,
NACA and Intervention Score (TISS) being the most commonly used trauma score [19]. A scale was designed for
children and consists of four items of four points each. It encodes 4 items of ocular reactivity, motor reactivity,
presence of cerebral torso reflexes, respiratory status. It is very difficult to say whether this pediatric scale is more
accurate to assess the evolution of patients after the destabiliatory event than the Glasgow scale.
After the cardiopulmonary arrest, the EEG is one of the most accurate prognostic tests on the subsequent
progression of cases that have benefited from support measures of vital functions. The stimulations to achieve an
interpretive EEG response are the pressure at the navel bed (62%) as well as the stern pressure (46%) and for the
chlidren are used the hearing impaired potentials (86%), the nerve bed pressure (57%) and 29 % have used tracheal
stimulation [20]. Assessing the impact of hepatic steatosis at obese patients can be done quickly ultrasonographically
so hepatic function can also be appreciated from this prism[21].
There is a new method of investigating head trauma, facile, non-traumatic, called proximal infrared spectroscopy.
It's a small device that can be manually operated and detects intracreberal bleeding. The wavelengths with which it
operates are 600-1,000 nm, and this device is folding on air transport as it has already happened in Netherlands in a
study [22].
There are a number of proteins secreted by neurons and glial claws in response to inflammation that can be
measured in the blood, and whose values can be predictive for assessing the patient who suffered a severe cerebral
trauma with coma. Osteopontin is secreted by macrophages and microglia when the brain suffers a severe lesion [23].
The assessment also includes an assessment of the context in which the injuries occurred, thus also defining a new
type of rescue action for patients dedicated to extreme sports such as the passing of narrow canyons, sports practiced
in very dangerous and turbulent waters [24]. Related to winter sports, the percentage of severely affected traumatized
patients is higher among children than adults [25].

Evolution and recovery
In the case of trauma, any extra bleeding leads to a worse prognosis [12]. The term of vegetative state was
introduced as a term by Jennett and Plum. It refers to apalic syndrome found in 0.5-2 / 100.000 cases at European
patients in postresuscitation status. The efforts of rehabilitation of apalic patients and the adequacy of home services
for them after they were discharged puts the medical systems in difficulty [26]. Despite the very good management of
apalic patients, the mortality of patients with residual apalic syndrome still widely varies between 1.2% and 15.2%
every year. There are still very large polemics about the active and /or passive euthanasia of these patients. Passive

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 374 https://doi.org/10.37358/RC.20.2.7939
euthanasia would consist in withdrawing nutrition and hydration from these types of patients, a decision that is
virtually impossible to take because forensic euthanasia is actually creating willingly the conditions for a person to die
sooner [27].
Electroencephalogram is integrated into the comatose patient's monitoring tools that are hospitalized by
anticipating the impact of cerebral disturbance events. The EEG monitors both patient recovery and the new
pharmaco-EEG method. Somatosensory potentials evoked also measures the impact of the comatose patient's brain
disruption, in this analysis the P300 wave being essential also with prognostic value. The gold standard of surveillance
for these patients still remains the cerebral CT and the NMR that will be individualized chosen from case to case, but
also according to the existing protocols for each particular condition in conformity with the guides in force. A follow-
up protocol is a first evaluation after 3 weeks after leaving the coma with a 6-month repetition over a 3-year interval
from the event [26].
The risk of brain death is directly influenced by intracerebral pressure, which in turn alters the infusion pressure. At
children, intracranial pressure measurement is made less often than at the adult. Increased intracrebral pressure
produces ischemia and irreversible brain damage, installing through this mechanism the brain death. It is possible to
calculate risk classes that will influence this intracrebral pressure and therefore brain death so if there is a unilateral
fixed mydriasis, the risk of cerebral death will increase 4 times [28].
The evolution of neonates is also influenced by how the mother takes care of them intrauterine so they can present
coma because of the use of toxins by the mother, even if the urinary toxicological test is negative, it can be taken into
consideration the coma given by the neonatal intrauterine exposure and then the management of these coma becomes
extremely delicate [29].
Recovery of patients with neurological sequelae and major dysfunctions in everyday life respects several
principles. In 1964 the Helsinki Declaration was made, which shows that the doctor has the duty to put in human
service all the means to save the patient. The goal is to maximize the comfort, prevent and treat existing and potential
complications, and at the same time to ensure a recovery as good as possible and to optimize the capacities of the
organism to function at the highest level. German Coma Remission Scale GCG allows the evaluation of recovery after
a coma in the most effective way. The environment in which these patients are recovered must be structured to adapt
to the new postcomatose status [27]. Another problem not to be neglected at comatose patients is obesity, if present,
these patients are much more difficult to manage. This can occur in metabolic X syndrome that includes central
obesity and insulin resistance. Both type 1 diabetes and type 2 diabetes are more and more common at the child
complicating both clinical pictures of different diseases and pediatric coma [30].
Diabetes having a ketoacidosis complication can lead to a life threatening vasogenic cerebral edema at the child.
This type of impairment occurs at younger patients, newly diagnosed and correlated with a low socio-economic level
[31]. A reason for these metabolic skews is also food that is richer in calories and salt, but cheaper for consumers, who
think they are economizing, especially when a single fast-food meal can contain 2000 kcal [32] and exposure to
phthalates at obese children increases the metabolic drift of these obese children [33].

Renal retention
This can also be due to acute renal failure and, on the other hand, the kidney is affected at ½ of the patients who
have experienced a coma. There is a link between kidney malfunction and inflammatory mechanisms of the brain, a
mechanism that explains these phenomena by affecting renal clearance in serious pathological processes [34].

Experimental part
Material and methods
24 children with coma carried by helicopter were surveyed between 2014-2017, at the Galați Aeromedical Base.
Coma is a medical emergency that needs to be treated with the utmost care. Medical protocols have been applied
according to the medical guides present on the territory of Romania and according to the legal operation provisions in
the authorized medical air transports. The study is observational mixed prospective randomized. We have evaluated
the patients transported from Galati and the neighbouring settlements either to Galati or from Galati to Bucharest to a
higher echelon. We want to highlight the intervals of intervention but also the correlation between pathologies most
commonly encountered at our work point. At the same time, it was also wanted to highlight the optimal reaction times,
the flight schedule and the flight routes were chosen under the Bucharest air traffic control and it was taken into
account the weather conditions to offer the possibility of timely intervention and no accidents and incidents according
to the legislation in force on the Romanian territory.
The inclusion criteria in the analyzed group were:
Child under 18 years old
A patient in coma when picked up by the helicopter crew
Patient transferred by medical helicopter
Base of operation Galati
Exclusion criteria:
Patient aged over 18

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 375 https://doi.org/10.37358/RC.20.2.7939
Fig. 1. Sex of pediatric air
transported patients in coma A patient who is not comatose
Patient transferred by terrestrial means
A comatose patient ready for transfer but deceased before the transfer
We have evaluated the vital functions.
It were applied partition classes according to the age, gender, origin according to the aeromedical point, major
pathologies, comorbidities, reaction times. Patients were evaluated using the Glasgow Scale at the time of take-over,
parameters of vital functions were also taken, respiratory rate, tension, SaO2. Oxygen saturation has been an extremely
important parameter.

Results and discussions
At the level of Aeromedical Base Galati, between 2014 and 2017 a number of 14 children in coma were
transported. The rapidity of the intervention was relatively high, four speed reaction rates were identified from the
time of the helicopter alert until the take-off.
Thus, 21.43% of the cases were between 4-5 minutes, 21.49% of the cases, 6-7 minutes 35.71% of patients, and the
7-9 minute response in 21.43% of patients. Primary interventions were 42.85% and secondary interventions were
57.14%.
The sex of the patients illustrates that 64.29% of the cases were males and 35.71% of the cases were females as
seen in Figure 1.

Glasgow Coma Score we have divided into 4 classes, so GCS=3-6 points were 78.57% of cases, Glasgow score 7-9
were 7.14% of cases, 10-12 were 0.00%, and 13-15 were 14.29% of the cases as shown in Figure 2. As is known the
decrease of the Glasgow score by 2 points is a severity index, and the Glasgow scores indicated were those at
takeover. A child may come with a Glasgow of 10 points and may follow the medical interventions to increase in
points, but he will under certain conditions still benefit from air transfer as the generating factor of gravity is still
persisting. This explains some higher scores in our series.

Fig. 2. Glasgow Scale for air transported pediatric patients

Another factor of case severity analysis is the others parameters of vital functions, so the respiratory rate was 12-16
breaths per minute at 64.29% , 16-18 breaths per minute 14.29%, 18-20 breaths per minute were 7.14% of patients and
20-25 breaths per minute or more had 14.29% of patients as shown in Figure 3.

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 376 https://doi.org/10.37358/RC.20.2.7939

Fig. 3. Respiratory rate at air transported pediatric patients in coma

The heart rate and pulse were analyzed in the following groups:75-90 beats per minute were 14.29% of patients,
90-110 beats per minute were 21.43%, 110-120 beats per minute in case of 28.57% of patients and heart rates between
120-160 beats per minute in case of 28.57% of pediatric patients. Figure 4 show the distribution of heart rates.

0.00%10.00%20.00%30.00%
75-90 90-110 110-120 120-160Heart rate (beats per minute)

Fig. 4. The distribution of heart rate and pulse at air transported comatose children

Blood pressure distribution was as follows: hypotensive are 28.57%, normal 57.14% and hypertensive 14.57%,
how can we see in Figure 5.

Fig.5. Blood pressure distribution at air transported pediatric patients

The oxygen saturation was analyzed and were obtained the following values: SpO2 75-80% was found at 14.29%,
80-85% was 00.00%, 90-95% was at 78.57% of patients, as illustrated in figure 6.

14.29%0.00% 7.14%78.57%
y = 0.3442ln(x) -0.0235
-50.00%0.00%50.00%100.00%
75-85 85-90 90-95 95-100spo2

Fig. 6. The distribution of pediatric patients in coma transferred by helicopter

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 377 https://doi.org/10.37358/RC.20.2.7939
In the case of blood glucose, 85.71% of patients were normal at the time of transport, so they had no diabetes, but
14.29% had glucose metabolism difficulties, since the percentage of young diabetic patients continuing to rise. This
fact is illustrated in figure 7.

Fig. 7. Distribution of blood glucose value at air transported pediatric patients in coma

Patients who used the Guedel pipe were 14.29% because a percentage already required intubation, or there were
mixed intubated situations after all, that started with the Guedel pipe and then the patient was intubated after all. The
use of the Guedel pipe is shown in figure 8.

Fig. 8. The use of the Guedel pipe at air transferred pediatric comatose patients

Endotracheal intubation is an important and necessary moment in sustaining the critical patient. Successful
intubation involves safety, solid knowledge and technical skills. Non-intubated patients were 35.71%, intubated
without induction were 21.43% of patients, and patients with rapid sequence intubation were 42.86% of patients.
Induction is often very necessary when conditions impose intubation, and for intubation in comfort and not to produce
patient injuries is preferable the endotracheal intubation with induction as shown in figure 9.

Fig.9. Endotracheal intubation with and without induction at air transferred pediatric comatose patients

The haemostasis maneuvers were necessary at a few patients, in 7.14%, and 92.86% do not necessitate
haemostasis. The need for a haemostasis , especially on a large blood vessel greatly complicates the clinical picture
and the entire emergency response.
Advanced cardiopulmonary resuscitation was required in 14.29% of cases, the children being found in
cardiorespiratory stop or cardiac arrest during the intervention. The reasons for requesting the helicopter either at the

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 378 https://doi.org/10.37358/RC.20.2.7939
domicile or other location, or at the hospitals for air transfer were analyzed. Three major medical conditions were the
criteria for initiating aeromedical intervention: resuscitated cardiorespiratory stop (21.43%), coma of unspecified
aetiology (28.57%) and diagnosis of intoxication (14.29%).
A statistical pattern has been developed to evaluate witch case is more frequent, a pattern of cases witch will
generate a more focused and specialized response from the HEMS-helicopter emergency medical services. In Table 1
the cases were represented according to the need for intubation, the necessity of mechanical ventilation, if the
intubation was with or without induction, if the aspiration was necessary, the Glasgow coma score type.
The resulting model is a male patient – decided after having a 64% prevalence, more likely the age of 1-2 years
(42%), transported with secondary mission type – 51% of cases, and after a first presentation in an Emergency
Department of a first hospital from where it refers to a superior echelon. The patient profile is that of a very seriously
ill patient with a GCS of 3-6 points, with a pulse of 110-120 beats per minute, but with medical efforts, the oxygen
saturation was maintained at good parameters, at 90-92%, without pathological history known of hyperglycemia with
a probability of 85.71%, who can usually be intoxicated in 35.71% of cases, is taken by helicopter, intubated and
mechanical ventilated in 42.86%, and from those ventilated the need for aspiration is 71.43%.

Tabel 1
THE PATTERN OF CASES WITH THE HIGHEST PROBABILITY OF OCCURRING FOR HEMS MEDICAL
INTERVENTIONS AT THE AEROMEDICAL POINT GALATI.

Helicopter response times can always be improved by constant and good communication with the pediatric service
that sends, but also with the ambulance that brings the child to the helicopter, thus, by knowing the case in advance,
the speed reaction increases and the response is faster and more appropriate to the pathology in question. On the other
hand, they cannot be artificially decreased because the flight preparing involves checks and stages beyond which it
cannot be overtaken. The Glasgow Coma Score analysis shows that a helicopter is predominantly required for the
deep coma of Glasgow score of 3-6 points when each won minute is vital. But the gravity of a case is not only
reflected by the Glasgow Scale.
The air transport differs greatly according to the region due to the differences regarding the endowment and the
appreciation of emergency where we cannot speak yet about a complete unitary vision. There is European Aviation
Safety Agency (EASA) which sets the flight policy in the European Union. Under such conditions, night flight
missions can also be provided. However, the regulations for night flight in primary missions are not yet clear even in
some German Länders. There is the possibility of a night-time navigation using special night glasses that are approved
under some circumstances as well as using advanced systems such as night vision googles (NVG). It must be licensed
both the night flight crew and the helicopter to have certain facilities, but an essential role is played by the weather
conditions.
For example, for a two-pilots flight, the horizontal visibility must be at least 2500 meters and the clouds span at
1200 feet height.( EU Directive 965 // 2012 SPA HEMS 120) [35]. With a very high probability of cardiopulmonary
arrest at seriously ill patients, it is good for certain groups of people to have basic concepts of cardiopulmonary
resuscitation (Basic Life Support) through authorized courses by authorized trainers in order to be trained for these
situations [36,37]. Thus, we see the relatively high rate of mobilization in Goteborg community, where
cardiopulmonary resuscitation by people who are not active in sanitary field has increased in recent years from 31% to
47% in 2004, this being the result of population’s education programs and in institutions [38]. When intubation fails, it
generates many frustrations and many accidents and incidents of intubation are due to the fact that physicians are
sometimes too proud to call a colleague to support them, but generally the teams are pre-established in advance and
such incidents happen less and less often. The statistical model developed is very sensitive to international protocols
and statistics. The predominantly exposure of boys and also young boys is also linked to a gender-related
vulnerability. Even though the patient has signs of gravity with a much lower Glasgow often up to 3-6 points,
however, there is a very good reaction speed of UPU-SMURD services in Romania reflected by getting a good oxygen
saturation through medical interventions because the goal is saving patient's life and his/her functions of the highest
possible level, depending on the patient's previous problems. In Romania, there are many disputes between clinicians
(neurologists, neurosurgeons and air and ground prehospital crew members) whether or not the patient is intubated, as
neurosurgeons' argument is that after sedation / intubation is much more difficult to operate for the brain behaves
differently at a lasting coma induction because the local infusion of the brain is changing [39-41]. However, we
usually intubate at 7 Glasgow points, but in Germany they intubate even greater than 9 points in some circumstances.
The statistical model elaborated shows that in Romania, however, the probability of the patient being accidentally sex age departure arrival type of
intervention time to takeoff Glasgow Coma
Score respiratory
rate
male
=64.29% 1-2years
=42.86% Galați
=35.71% București
=50% Secondary
=57.14% 6-7 minutes
=35.71% 3-6 points
=78.57% 12-16/ minute
=64.29%
pulse/heart
rate blood
pressure Sa O2 blood
glucose mechanical
ventilation intubation with
induction Intoxication
110-120 bpm
=28.577% Normal
57.14% 90-95%
=78.57% Normal
=85.71% No
=42.86% No
=42.86% Yes=35.71%

Rev. ♦ Chim. ♦ 71 ♦ no. 2 ♦ 2020 ♦ https://revistadechimie.ro 379 https://doi.org/10.37358/RC.20.2.7939
intoxicated with various substances found at home still persists. In the rural environment, children can find different
solutions for household such as entomoxane which is intended for the disinfestation of sheep and with high toxicity
for the nervous system after ingestion by children and high risk of death, organophosphorus products. Intoxication
with nitrite remains another public health problem.
Another way through which patients are poisoned is with antiepileptics, antidepressants or with trihexiphenydil,
which is associated with these treatments. Because of the new lifestyle with occupations that keep parents very busy
and grandparents often absent from the extended family life, children can often escape unsupervised and take the
parents` and / or grandparents` medicines, who develop depression just because they cannot manage a balanced life on
multiple plans [42, 43].
Another way of presenting, which is not yet found in our statistical model but is already noted in some situations
and is more and more common in the world, is that of extreme sports, in which groups of amateurs arrogate their
performances (skateboards, bikes on dangerous surfaces and trampolines, parcour practiced by children in gangs).
That is why some insurance houses have considered how to ensure those who want to practice such sports, and to
compel them to be more responsible towards their own lives. We can talk about mountain sports like climbing or
skiing of a certain type [44].
There have been intense discussions in recent years at us as well as in other countries if in some cases at children
due to the existing pressure and the emotional impact of a coma child we made an excessive triage of the children to
be transported by helicopter or where ground emergency services would be just as effective, the idea being that
sometimes valuable resources are consumed which in other cases cannot beused when a life is in danger, and this
subject is still alive and they are many polemics [45, 46]. In this sense, it is beneficial for us to train pediatricians who
are already in pediatric emergency departments in emergency medicine.

Conclusions
Child intoxication is a major reason for aerial medical interventions in the eastern region of Romania, the
prevention being essential (parents need to be educated regarding the use of toxic substances in households).
The use of induction medication it is not always necessary, orotracheal intubation not being the only modality of
airway management during transport.
Understanding the roles of the team members, the succession of the times of maneuver, the preparation for transfer
of the comatose patient streamlines the services, increasing the efficiency, the promptness of the missions and the
shortening of the time for the stabilization of the patient in the hospital after arrival as well as a better and more
comfortable life for the patient and his / her family.

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Manuscript received: 06. 02. 2020

ISSN: 2320-5407 Int. J. Adv. Res. 5(5), 1229-1232
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Article DOI:10.21474/IJAR01/4236
DOI URL: http://dx.doi.org/10.21474/IJAR01/4236

RESEARCH ARTICLE

HEMS BENEFITS IN TRANSFERING SEPSIS PATIENTS – NORTH-EAST ROMANIAN EXPERIENCE

Tudor Ovidiu Popa1,2 , Diana Cimpoesu1,2 , Mihaela Corlade1,2 and Paul Nedelea1,2.
1. University of Medicine and Pharmacy “Gr. T.Popa” Iasi, Emergency Medicine Department.
2. County Emergency Hospital “Sf.Spiridon” Iasi – Emergency Department.
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Manuscript Info Abstract
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Manuscript History

Received: 21 March 2017
Final Accepted: 24 April 2017
Published: May 2017

Key words:-
HEMS, SEPSIS, TRANSFER,
PRESEPSIN, EMS

Sepsis syndrome is a common and have devastating implications on
health care systems worldwide. HEMS provide the most benefit when
there is a clear, time-sensitive therapeutic intervention available at the
receiving hospitals. With the appearance of early goal- directed
therapy, sepsis has become a "time critical” pathology, so the patients
and EMS systems can benefit from Helicopter EMS (HEMS)
utilization. This article describes the Nord-East Romanian HEMS
experience with sepsis patients, from 2014 up to 2016. The endpoint
of interest is to find a specific indications for air transfer which can
help taking decisions into the medical dispatch in case of sepsis. The
most important outcomes are potential benefits for the patients,
accessing earlier the highest level of intensive care. The benefits of
HEMS missions for the remote area are: the ability to provide timely
access to higher level hospital, to facilitate the transport of trauma,
cardiac, stroke, and also sepsis patients. HEMS crews have ALS
capabilities that bring a different level of care to this category of
patients, especially in the remote, less capable of according necessary
level of care hospitals. Regional healthcare and EMS system’s benefit
from HEMS by their capability to extend the advanced level of care
throughout a region, minimizing transport times and beginning of
advanced medical care, make available direct transport to specialized
centers. Presepsin as biomarker, together with clinical findings, could
have a high value in helping physicians to take the decision to transfer
the patient with sepsis to a higher level hospitals.

Copy Right, IJAR, 2017,. All rights reserved.
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Introduction:-
Helicopter Emergency Medical Services (HEMS) significantly extends patient access to tertiary care facilities,
leading to rapid transport of critical cases to hospitals of this type. A recent review of the literature on HEMS has
shown a general benefit of 2.7 extra lives saved on 100 HEMS missions. For a specific pathology, the benefit of
using HEMS is clear. STEMI (STEMI) -Acute myocardial infarction and trauma cases are representing the clear
majority of pathology described in the literature that studies HEMS missions. HEMS have been shown to provide
substantial benefits to patients suffering from trauma and acute myocardial infarction, without any doubt.

HEMS seem to provide the greatest benefits when there is a clear, time-sensitive treatment available at the receiving
unit. With the emergence of therapy targeted at early goal therapy, sepsis also became a critical pathological entity
Corresponding Author:-Diana Cimpoesu.
Address:-University of Medicine and Pharmacy “Gr. T.Popa” Iasi, Emergency Medicine Department.

ISSN: 2320-5407 Int. J. Adv. Res. 5(5), 1229-1232
1230
at the time elapsed from diagnosis to initiation of therapy. Unfortunately, little is known about the recommendation
of using aerial transfer and efficacy of HEMS in sepsis. There are currently no data on the efficacy of HEMS
transport in patients with severe sepsis or septic shock. Physicians in tertiary care institutions are forced to make
difficult and expensive decisions on how and when to transport a septic case, without a possible orientation from
literature.

We aim to understand the effect on transfer and in-hospital mortality and other important side effects of helicopter
transport in patients who develop severe sepsis or septic shock.

The idea of using HEMS to urgently treat patients with serious injuries and illnesses is not a new one. There is a
significant number of articles in literature that demonstrate the usefulness of HEMS for the time-saving (and to the
benefit of decreasing mortality) in the transport of trauma and acute myocardial infarction. Recent analysis of the
national database shows that the use of HEMS in the US is associated with significant time savings. Loss of HEMS
availability has been recognized as a potentially important factor that causes increased traumatic mortality in
patients presenting with non-Level I centers. In addition to using HEMS for trauma cases, the focus is increasingly
on engaging HEMS to speed the care for patients with non-trauma diseases, but time critical disease. The usefulness
of HEMS's logistics / speed capabilities to extend the level I coverage of heart and stroke centers over time has been
the subject of increased attention, with emphasis on the ability of HEMS to speed up the specific treatment of these
diagnoses. The use of air medical resources for the rapid movement of patients in specialized centers is gaining
some attention, partly because of the increasing "time is myocardium", "time is brain tissue" and so on. In terms of
cardiac transplantation and time saving, the focus is increasingly on the access of patients with acute myocardial
infarction to primary PCI as the treatment of choice if it can be reached for 90 minutes from the "first door to
balloon ".

Sepsis, a long-recognized pathological process, was generally not considered "time critical". This view has changed
with the emergence of studies demonstrating an improved outcome associated with outcome-oriented therapy, with
the goal of setting the appropriate sepsis therapy within the first six hours. Although many patients with sepsis do
not undergo transport, HEMS may, in some cases, provide a useful mechanism for rapidly achieving the goals –
appropriate therapy set up in due time.

Material and Methods:-
This study is a retrospective study conducted on a group of 20 patients diagnosed with sepsis, out of a total of 1102
patients that were transferred with Iasi HEMS crew between 01.06.2014-01.06.2016. Iasi city is located in North-
East of Romania, and HEMS missions cower 6 counties with a surface of approximately 40.000 Km2 and all forms
of relief, with a population of approximately 3.600.000 people. HEMS crew is formed by 4 people: 2 pilots, one
nurse and one physician specialized in Emergency Medicine-Intensive Care.

The study aims to establish the following: frequency of sepsis patients and transfer decision; mortality during and in
first 2 days from transfer; the need to initiate mechanical ventilation, the need for vasoactive agents.

The procedure for HEMS transfer is: physician from primary or secondary level of care center ask for transfer
approval in tertiary level of care hospital, and after that will call medical dispatch using National Emergency Phone
number (112 in Romania). At this moment, together with physician from medical dispatch they chose how, (aerial or
ground), will be the patient transferred.

The study protocol included the following data taken from group of patients: HEMS mission type, clinical and
laboratory variables, treatment procedure initiate by HEMS crew, patient evolution after transfer.

Inclusion criteria was: patients with age over 18 years and clinical signs of infection accompanied by the presence of
at least two of the following criteria: temperature> 380C or <360C, heart rate> 90 / min, respiratory rate > 20 /min
and leukocytosis (> 12,000 mm3) or leukopenia (<4000 mm3).

Exclusion Criteria:-
Patients under 18 years of age
The diagnosis of sepsis was made based on the clinical specific and usually signs in conjunction with other
investigations, respecting the diagnostic criteria establish in Surviving Sepsis Campaign.

ISSN: 2320-5407 Int. J. Adv. Res. 5(5), 1229-1232
1231
Data collected from patients meeting inclusion criteria were statistically processed using statistical analysis software
IBM-SPSS V.23.

Results:-
The 20 patients with sepsis included in the study represent 1,81% from total number of Iasi HEMS crew intervention
performed between 01.01.2014-01.06.2016.
Mean age of patient was 54,05 years old, with a standard deviation of 16,567.

Gender distribution was equal, 50% each.
All these 20 missions (100%), were secondary type mission-transfer from a hospital to other hospital.

Mean time for intervention was 75 minutes, with a minimum of 60 minutes and a maximum of 130 minutes. This
value imply take-of from base to the case and time back to base, to the tertiary level care center.

The biggest distance covered was 210 km, and the shortest was 70 km.
A percentage of 30 % from these patients were intubated before transfer moment. The HEMS crew initiate oro-
tracheal intubation in other 10 %, and in the end 40% from the cases arrive to the high-level hospital intubated,
being mechanically ventilated during transport time with helicopter.

A percentage of 40% required vasopressor therapy. This was decided and administered by HEMS crew during and
transfer.

The mortality was 5%, 1 patient died in first 24 hours after transfer, developed Cardio-respiratory arrest just before
helicopter take-off, this patient respond to cardio-pulmonary resuscitation maneoeuvres but died after transfer was
finished and another one in interval of time between 24-48 hours from transfer. The survival rate was 90%. None of
the patient died during transfer.

Limitations:-
There are some limitations in our study. The sample size was small, and our data are only from a single tertiary care
center. Larger multicenter studies will overcome this limitation.

Discussion:-
This paper is trying to overview the low degree of using HEMS in sepsis cases in Romania and to emphases the
important questions of HEMS possible benefits for sepsis patients and for healthcare systems.

Because of this small number of sepsis transferred patient cases, we did not try to find any statistically correlations,
considering from the beginning that this was not enough to obtain some significant statistical data.

What we try to describe and discuss in this paper is the fact that only so few patients diagnosed with sepsis were
transfer using HEMS crew advanced medical care capability during 30 months, representing only 1,81 percent from
total number of Iasi HEMS crew missions and also the fact that from this 20 critically ill patients, 90 percent’s
survive to 48 hours from transfer moment.

Sepsis is now considered "time critical " pathology. For sure HEMS may, in some cases, provide a useful
mechanism for rapidly achieving the golden goals – appropriate therapy set up in due time, but now we miss some
guideline to decide when and in what condition to recommend transfer of sepsis cases to a higher-level hospital.
Probably including the patient simple in septic shock category is not enough, we could miss the window of time for
transfer, because one of the main restriction of HEMS transfer is that the patient need to be hemodynamical stable
during aerial transfer.

Time necessary for air transfer was in all cases shortest compare to time necessary for transfer by land.
We could find help in taking an early decision to transfer the patient using Presepsine, described in literature as
having also not only diagnostic value but also prognostic value. Presepsine is described as the only independent
variable that can be associated with survival at 28 days or hospitalization in the intensive care ward and prognostic

ISSN: 2320-5407 Int. J. Adv. Res. 5(5), 1229-1232
1232
accuracy is increased compared with procalcitonin and other biomarkers. The correlation between the occurrence of
septic shock, presepsine value and need for vasopressor therapy was recently described in the literature.

The combination of traumatic injuries and further development of sepsis and severe sepsis is described in the
literature, with a predominance of this pathology in males, with a mortality still high, ranging from 19.5% -23% of
cases. Due to the increased severity of this association is explained correlation with the need for advanced airway
management and low Glasgow coma score on this category of patients.

Conclusions:-
HEMS crew advance care skill is not used to its full potential in cases of sepsis transfer in Romania.

There are no clear criteria to help physician to take the decision when and by what type of transport to transfer a
sepsis cases.

The potential benefits of HEMS must be considered by national health policymakers and others institution which
provide HEMS use guidance.

Presepsin early diagnostic value may also have prognostic value over the subsequent evolution of the patient and for
decision to transfer sepsis patient to a higher-level center.

References:-
1. Air-Medical-Physician-Association. Medical condition list and appropriate use of air medical transport. Position
statement of the Air Medical Physician Association. PrehospEmerg Care. 2002;6(4):464-70.
2. Endo S, Suzuki Y, Takahashi G,et all: Usefulness of presepsin in the diagnosis of sepsis in a multicenter
prospective study. Journal of infection and chemotherapy. 2012 Dec;18 (6):891-893
3. Kashyap R, Anderson PW, Vakil A, Russi CS, Cartin-Ceba R. A retrospective comparison of helicopter
transport versus ground transport in patients with severe sepsis and septic shock. International Journal of
Emergency Medicine. 2016;9:15. doi:10.1186/s12245-016-0115-6.
4. Leopardi, M., &Sommacampagna, M. (2013). Emergency Nursing Staff Dispatch: Sensitivity and Specificity in
Detecting Prehospital Need for Physician Interventions During Ambulance Transport in Rovigo Emergency
Ambulance Service, Italy. Prehospital and Disaster Medicine, 28(5), 523-528.
doi:10.1017/S1049023X13008790
5. Pedersen PB, Henriksen DP, Mikkelsen S, Lassen AT. Dispatch and prehospital transport for acute septic
patients: an observational study. Scand J Trauma ResuscEmerg Med. 2017 May;25(1) 51. doi:10.1186/s13049-
017-0393-x.
6. Ringburg AN, et al. Lives saved by helicopter emergency medical services: an overview of literature. Air Med
J. 2009;28(6):298–302. doi: 10.1016/j.amj.2009.03.007.
7. Schramm GE, et al. Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve
the process of care and mortality. Crit Care Med. 2011;39(2):252–258. doi: 10.1097/CCM.0b013e3181ffde08.
8. Stephen H. Thomas and Annette O. Arthur, “Helicopter EMS: Research Endpoints and Potential Benefits,”
Emergency Medicine International, vol. 2012, Article ID 698562, 14 pages, 2012. doi:10.1155/2012/698562
9. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016, Int.
Care Med, March 2017, Volume 43, Issue 3, pp 304–377
10. T.O.Popa, Diana Cimpoeșu, Carmen Dorobăț, Diagnostic And Prognostic Value Of Presepsin In Emergency
Department, Rev. Med. Chir. Soc. Med. Nat., Iași –2015–vol. 119, no. 1, pp 223-231
11. Takahashi G, Shibata S, Ishikura H et al. Presepsin in the prognosis of infectious diseases and diagnosis of
infectious disseminated intravascular coagulation: A prospective, multicentre, observational study. Eur J
Anaesthesiol. 2014; 9;11.

Rev. Med. Chir. Soc. Med. Nat., Iași – 2016 – vol. 120, no. 4
INTERNAL MEDICINE – PEDIATRICS ORIGINAL PAPERS
790 ETHNOBOTANICAL AND CANNABIS DRUG USE:
A STEP BETWEEN DANGER AND PLEASURE
Gabriela Grigorași1, Diana Carmen Cimpoeșu1*, Viorica Popa1, P. Nedelea1,
O. T. Popa1, A. I. Ciumanghel2, Simona Drochioi3, Mihaela Corlade-Andrei1
“Grigore T. Popa” University of Medicine and Pharmacy Iași
Faculty of Medicine
1. Department of Surgery (II)
2. Department of Surgery (I)
3. Department of Mother and Child Medicine
*Corresponding author. E-mail: dcimpoiesu@yahoo.com
ETHNOBOTANICAL AND CANNABIS DRUG USE: A STEP BETWEEN DANGER AND
PLEASURE (Abstract): Aim: The study aimed to identify the risk factors and the particular-
ities of ethnobotanicals and cannabis users who needed medical care in the Emergency De-
partment 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) consump-
tion. The variables studied for creating the consumer profile were sex, age, social back-
ground, 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, curi-
osity 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 fol-
lowed by ethnobotanical products. For a while, ethnobotanical products were falsely con-
sidered as risk-free, but they contain dangerous substances with devastating effects, which,
unless treatment is initiated immediately, can lead to death. Keywords: CANNABIS USE,
ETHNOBOTHANICALS, POISONING.
Drugs have been known ever since an-
tiquity, but their use has changed through-
out history. In the beginning, they were
used in medical and religious practice,
being nowadays a source of expensive
pleasure for teenagers and young adults (1).
In 2008 cannabis was the most widely used illicit drug in Romania. In 2008 Ro-
mania ranks fourth among the cannabis-
consuming countries after England, Ger-
many and Holland (2, 3, 4). Starting with
2009, new psychoactive substances have
been increasingly used reaching a peak in
2010. The new legislation and the media

Ethnobotanical and cannabis drug use: a step between danger and pleasure
791 involvement led in 2013 to a slightly re-
duced usage of ethnobotanicals, which
came second (18 per cent) immediately
after heroine (42.7 percent) and before
cannabis (15.6 percent). According to the
2014 National Antidrug Agency annual
report the use of the new psychoactive
substances has slight increased.
In 2014, the most commonly used drug
in Romania was cannabis -10 percent in
Bucharest and Ilfov, 5.9 percent in South-
east Romania, 2.9percent in the Western
part of the country,2.5 percent in the
Northwest, 1.6 percent in the South and
Centre, 1.5 percent in the Northeast and 0.4
percent in Southwest (5, 6, 7, 8, 9, 10, 11).
Per “European Monitoring Centre for
Drugs and Drug Addiction”, Romania
ranks eighth among the cannabis-
consuming European countries, after
France, Czech Republic, Italy, Denmark,
Poland, Austria and Portugal (12, 13).

MATERIAL AND METHODS
This retrospective study covers 18
months and includes the patients cared at
the Emergency Department of the Iasi “St.
Spiridon” Hospital due to the use of the
new psychoactive substances or canna-
binoid substance.153 patients were includ-
ed in this study, represented by 141
(92.15%) male and 12 (7.85%) female. The
minimum age was 18.
Variables included were: age, sex, so-
cial environment, the main cause of addic-
tion, drug type, method and age at onset of
drug use, drug-related clinical and labora-
tory changes.
Vulnerable patients and patients having
refused toxicological analysis were not
included. Information was taken from pa-
tient medical records.
Data were analyzed and statistically processed using Microsoft Excel and SPSS
18.0 statistics software. Patients character-
istics were expressed as the mean standard
deviation or as a number and percentage.

RESULTS
The study was conducted between Janu-
ary 1, 2015 and June 30, 2016 and included
153 patients who presented at the Emer-
gency Department of the Iasi “Sf. Spir i-
don” Hosp ital for having used ethnobotani-
cal and/or cannabinoid substances. Sex
distribution of patients did not differ from
that in the statistics of the Annual Reports
of the National Antidrug Agency. Thus, in
our study the clear majority of cases were
male, 141 (92.15%) only 12 cases (7.85%)
being female. Of the patients needing med-
ical care following the use of ethnobotani-
cal and/or cannabinoid substances 78.57%
were brought to hospital by ambulance,
71.89% of them being hemodynamically
stable. A significantly smaller percentage
came by their own means (20.26%).
Educational, economic, and sociocultural
factors contributed to an uneven distribution
by place of residence –75.97% being urban
patient. Age ranged from 18 to 54 years,
with most cases aged 18-24 years (52.28%).
74.50% of the patients received medical care
1-3 hours after substance use. Per statistics,
most patients had consumed ethnobotanical
substances (96.07%) compared to 3.92%
who used cannabis and marijuana. The most
commonly used delivery method was via
inhalation, declared by 98.69% of the users,
the remaining 1.31% preferring the admin-
istration via ingestion or injection (fig. 1).
Of the ethnobotanical substance con-
sumers (134 males and 13 females) 63.94%
claimed to be occasional users, 30.61%
chronic users (5 months-13 years) and
5.44% accidental user, smoking ethnobo-

Gabriela Grigorași et al.
792 tanical cigarettes offered by acquaintances
or found on the street. Of the occasional
users, 61.70% declared curiosity as main reason for substance use, the remaining
38.30% mentioning pleasure as main moti-
vation (fig. 2).

Fig. 1. Percentage distribution of used drugs

Fig.2. Patient distribution per substance use manner

Upon presentation to the Emergency
Department, 11.56% of the chronic users
had been admitted to substance abuse
treatment and 2.72% had been treated for
various psychiatric disorders at the Iasi
Hospital of Psychiatry. Of the users of
ethnobotanicals requiring medical care
70.06% were urban male patients
(113/76.87%), aged 18-30 years (85.71%),
brought by ambulance. 131 inhalation cases
self-procured the ethnobotanical substance (89.11%) and 43 of them (29.25%) used
ethanol as well.
Clinical symptoms included dizziness
(19.04%), nausea and psychomotor agita-
tion (18.36%), vomiting (14.28%) and
palpitations (13.60%). ECG demonstrated
sinus bradycardia, early repolarization, and
minor right bundle branch block in 26.53%
of ethnobotanical drug users. Urine toxi-
cology testing done with the Triage Meter
Pro using fluorescence for the immuno-
96.07% 3.92%
ETHNOBOTANICAL
CONSUMERS
CANNABIS CONSUMERS
94
45
8
ETHNOBOTANICAL
OCCASIONAL USE CHRONIC
ETHNOBOTANICAL USE ACCIDENTAL
ETHNOBOTANICAL USE
63,94% 30,61% 5,44%

Ethnobotanical and cannabis drug use: a step between danger and pleasure
793 chemical tests performed at patient’s be d-
side showed 26.53% patients positive for:
BZO (10.88%), THC (10.20%), BAR
(4.08%), APAP (2.72%), OPI (2.04%),
TCA (1.36%). 7.47% of the toxicology
tests could not identify the substance, alt-
hough the patients declared and clinical
evidence indicated ethnobotanical drug use.
The emergency physician has an ex-
tremely important role in case of over-
dose/intoxication where the substance,
consumed amount, subsequent course and
possible complications are unknown, in
most such cases the doctor acting as inter-
face between the patients in various stages
of intoxication, and the hospital environ-
ment. Immediate emergency procedures are
vital in such cases.
Early diagnosis and specific therapy re-
duce the risk of possible complications in
ethnobotanical drug intoxication. History
and clinical examination were thoroughly
considered as they are key in diagnosing
the patient with ethnobotanical drug intoxi-
cation.
Medical and scientific publications
make little reference to the best treatment
in cases of synthetic drug addiction. Early
diagnosis and therapy are the best ways of
reducing possible complications in ethno-
botanical drug intoxication. There is no
specific antidote or standard treatment
because we have little information on the
substance composition (substances being
extremely varied), therefore vital signs
(circulation and breathing) were stabilized
first, and then the symptoms were treated.
Of the 147 patients consuming new
psychoactive substances only 4.76% need-
ed continuous follow-up at the Toxicology
Clinic of the Iasi “Sf. Spiridon Hospital”,
the remaining 95.24% being referred to the
Psychiatry Hospital (32.65%), to other hospitals (4.76%), back home (44.22%)
and 13.61% left the hospital by themselves,
being hemodynamically stable.
In the patients requiring medical care
for cannabis and marijuana use (3.92%),
aged 19-42 years, the sex ratio was like that
recorded for the ethnobotanical drug users –
83.33% males. 66.67% arrived by ambu-
lance, most patients residing in urban areas
(66.67%). One patient reported cannabis
cake ingestion (16.67%), 33.33% reported
inhalation of cannabis and 50% inhalation
of marijuana. 83.33% of the cases were
occasional users. 50% of the cannabis and
marijuana users reported pleasure as main
reason whereas 33.33% reported curiosity
as main motivation. The average time in-
terval between inhalation and arrival at the
Emergency Department was 1 to 2 hours,
83.33% of the patients being hemodynami-
cally stable with palpitations (50%) and
dizziness (33.33%).
Of the cannabis and marijuana users,
66.67% had positive urine toxicology tests
in equal ratios for THC and BZO (33.33%).
The emergency department length of
stay was approximately 5 hours, the vital
signs being stabilized during this interval.
16.67% required hospital admission, the
remaining patients being either discharged
home or leaving the hospital after being
stabilized.

DISCUSSION
The analysis and comparison of data
provided by the National Antidrug Agency
and the statistical data obtained from the
present study show major differences be-
tween drug types consumed at a national
level and drugs consumed in the North-East
region, mainly in Iasi (5, 6).
Although during the past 8 years at na-
tional level cannabis has been the most

Gabriela Grigorași et al.
794 commonly used drug among teenagers and
young adults, followed, starting with 2009,
by the new psychoactive substances, most
drug users in the Iasi area have been using
ethnobotanical substances (96.07%), can-
nabis being consumed only by 3.92% (2, 3,
4, 5, 6).
The distribution by sex and area of resi-
dence is like that at the national level –the
majority being male urban consumers.
Age group distribution of the study cas-
es showed that most ethnobotanical drug
users were young: 15-24 years (4.3%) with
52.38% in the 18-24 age group. Most can-
nabis consumers were aged 25 to 34 years
(7.4%) at the general population level (4).
University students cover 29.41% of the
studied population, percentage close to the
one at the national level.
At the national level, 2 thirds of the
ethnobotanical drug users (60% in 2014
compared to 61.2% in 2013) live in Bucha-
rest, Iasi, Cluj, Galati.
Both cannabis and ethnobotanicals pre-
vail in Bucharest-Ilfov (10% and 3.9%,
respectively), whereas in the North-Eastern
region the recorded percentages are only
1.5% and 0.8%, respectively (5, 6, 15).
Insufficient data concerning chemical
composition, ingredients and possible dan-
gerous substances used in the new psycho-active drug fabrication make more difficult
the evaluation of health risks and toxicity
levels. (1, 14, 15) Some drugs are com-
bined with alcohol and other illegal drugs
with dangerous side effects. Teenagers are
tempted to diversify their drug consump-
tion even if they know the risks involved
by the association of illicit drugs with al-
cohol, tobacco, barbiturates and ampheta-
mines (16).
Easy access and accessible prices make
ethnobotanical drug intoxication an im-
portant issue. Alongside long term effects,
ethnobotanical drugs are a social danger
leading in time to the use of more danger-
ous drugs.

CONCLUSIONS
In Romania, the most commonly used
drugs are cannabis followed by ethnobotan-
ical 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.
Data concerning chemical composition
and ingredients are insufficient and these
substances used among alcohol and other
type of drugs can be dangerous and can
lead to death of patient.
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and Developments. Lisbon: EMCDDA, 2016.
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PHOTODYNAMIC THERAPY AS A PROMISING METHOD USED
IN THE TREATMENT OF ORAL DISEASES
Photodynamic therapy is a innovative therapeutic method that has already been successfully
adapted in many fields of medicine (e.g. gynecology, urology, dermatology) and can-
cer therapy. Dental medicine is also beginning to incorporate photodisinfection for treatment
of the oral cavity. Photodynamic therapy consists of three elements: photosensitizer, light
and oxygen. The photosensitizer has the property of selective accumulation in abnormal or
infected tissues without causing any damage to the healthy cells. The antibacterial and fun-
gicidal properties of the photosensitizer have been used to achieve better results in root canal
treatment, periodontal therapy and the eradication of candidiasis in prosthodontics. Photody-
namic therapy could be considered as an alternative treatment protocol in oncology, endo-
dontics, periodontology and other fields of dentistry. (Prażmo EJ, Kwaśny M, Łapiński
M, Mielczarek A. Photodynamic Therapy As a Promising Method Used in the Treatment of
Oral Diseases. Adv Clin Exp Med. 2016 Jul-Aug; 25(4):799-807).
Irina Grădinaru NOUTĂȚI NEWS

Rev. Med. Chir. Soc. Med. Nat., Iași – 2016 – vol. 120, no. 4
INTERNAL MEDICINE – PEDIATRICS ORIGINAL PAPERS
841 ATTEMPTED SUICIDE: A CROSS-SECTIONAL SURVEY 2015
Mihaela Corlade-Andrei1, Diana Carmen Cimpoeșu1*, Viorica Popa1,
P. Nedelea1, O. T. Popa1, Simona Drochioi2, Gabriela Grigorași1
“Grigore T. Popa” University of Medicine and Pharmacy Iași
Faculty of Medicine
1. Department of Surgery (II)
2. Department of Mother and Child Medicine
*Corresponding author. E-mail: dcimpoiesu@yahoo.com
ATTEMPTED SUICIDE: A CROSS-SECTIONAL SURVEY 2015 (Abstract): 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 con-
tributing 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 discus-
sion: The study included 368 patients (53.81% female and 46.19% male). 63.58% were ad-
mitted 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 inges-
tion (20.10%) followed by self-inflicted cut injuries (13.85%) and corrosive substance inges-
tion (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 at-
tempt. The admission rate was 57% and mortality rate 0.27%. Conclusions: Suicidal behav-
ior 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. Keywords: SUICIDE, SUICIDE
METHOD, SUICIDE ATEMPT, RISK FACTORS, SELF-INFLICTED CUT WOUNDS.
Suicide is a major health problem
worldwide, particularly among teenagers
and young adults (1, 2, 3, 4).
Suicide attempt is the main cause of
death in young people, accounting for over
50% of violent deaths (5, 6, 7, 8, 9). Ac-
cording to the statistics published by spe-
cialized institutions (EUROSTAT, OECD
and WHO) for the years 2013 and 2014,
Romania ranked ninth among the countries with the highest suicide rates (12.2 per
100,000 population), Lithuania ranked first
(27.1 per 100,000 population) followed by
Hungary (18 per 100,000) and Estonia
(17.3 per 100,000 population) (10, 11, 13).
Per the 2008-2015 annual reports of the
"Mina Minovici" Institute of Forensic Med-
icine, between 2,477 and 3,050 suicides
were recorded annually in Romania, ac-
counting for 25% of all violent deaths.

Mihaela Corlade-Andrei et al.
842 Analyzing the deaths registered in the last 8
years by the mechanisms of death, the most
common were: mechanical asphyxia by
hanging (78.62%), voluntary intoxication
(7.12%) and falling (5.56%) (4, 13, 14).

MATERIAL AND METHODS
A retrospective descriptive study was
conducted that included all patients who
presented in 2015 (January 1 – December 31,
2015) to the Emergency Department of the
Iasi “Sf. Spiridon” Hospital and were diag-
nosed at presentation with suicide attempt.
Our study included 368 patients, 198
(53.81%)women and 170 (46.19%) men.
The selection of cases was based on the
diagnosis at the time of admission, positive
findings on physical examination, results of
laboratory tests that confirmed the ingestion
of drugs or other toxic substances, patient or
witness statements. Toxicological determi-
nations were made by using a Triage Meter
Pro that allows fluorescence immunochemi-
cal tests. The device is available in the ED
and provides quality results fast (~15
minutes), next to the patient.
The study cases were selected per the
inclusion criteria from a total of 69,232
patients admitted to the ED of the Iasi “Sf.
Spiridon” hospital during the year 2015.
Thus, included in the study were 368 pa-
tients aged 18 to 87. Excluded from the
study were the patients under 18 years of
age, patients who died before reaching the
hospital, patients with accidental ingestion
of toxic substance, and patients with incon-
clusive history.
The data collected and inserted in data-
bases were statistically analyzed using
Microsoft Excel and SPSS 18.00 statistics
software. Patients characteristics were
expressed as the mean standard deviation
or as a number and percentage. RESULTS
Only 0.53% (368 from 69.232) of all
patients presenting to the Emergency De-
partment of the Iasi "Sf. Spiridon", Hospi-
tal during 2015 were eligible for the study
(368, aged 18 to 86).
Data processing was primarily intended
to identify the personal characteristics of the
selected patients. It is a first starting point in
strategic planning best practices. Most study
patients were in the 18-30 age group
(38.31%) and gender distribution showed a
relatively equal distribution of subjects
(53.81% women and 46.19% men, respec-
tively), unlike the national statistics showing
that the percentage of men attempting sui-
cide was constantly higher than that of
women ((82% vs.18%, respectively).
The sociocultural, educational and eco-
nomic implications lead to an uneven distri-
bution of cases by area of residence, 638%
of the study cases being rural patients.
Regarding the suicide mechanism,
63.58% were admitted to the ED for volun-
tary drug ingestion, 14.13% reported intake
of toxic substances (organophosphates,
rodenticides, corrosives, herbicides and
alcohols) and 22.28% traumatic suicide
attempts (cut wounds, stab wounds, self-
immolation, mechanical asphyxia by hang-
ing and falls from heights).

Fig. 1. Method of suicide attempt

Attempted suicide: a cross-sectional survey 2015
843 The most common suicide method
among female patients was voluntary drug
ingestion (78.28%), while men preferred
traumatic mechanisms (35.29%) and inges-
tion of toxic substances (18.23%). Accord-ing to the statistical study conducted, pa-
tients in rural areas resorted much easier to
ingestion of toxic substances and traumatic
mechanisms, while patients in urban areas
preferred drug ingestion.

Fig. 2. Suicide method by gender

Of the patients who attempted suicide
by drug ingestion, 73.07% were brought to
hospital by ambulance from home, being
found by the family, the average time in-
terval elapsed between ingestion and hospi-
tal arrival being 2 to 6 hours (61.96%).
32.90% of patients used their prescribed
medication for suicidal purposes.
Qualitative toxicological determinations
in the ED revealed the presence of benzo-
diazepines in 29.67% of cases, followed by
antiepileptics (17.41%) and tricyclic anti-
depressants (4.27%). 31.19% of patients
took drugs in combination with alcohol.
In patients who ingested toxic substanc-
es, the most common were: corrosive sub-
stances (48.07%), organophosphates
(21.15%), rodenticides (11.53%), toxic
alcohols (7.69%) and herbicides (1.92%).
Traumatic suicide attempt was mostly
preferred by male rural patients and the
most common mechanisms were self-
inflicted wounds (70.83%), followed by
foreign body ingestion (12.5%), mechani-cal asphyxia by hanging (9.72%), self-
immolation (2.77%) and falls from heights
(2.77%). Six patients (7.31%)were impris-
oned with a history of multiple suicide at-
tempts, and sought medical care for foreign
body ingestion (66.66%) and self-inflicted
wounds. Per the Suicide Prevention Alli-
ance, every year in Romania there are
around 13 deaths by suicide per 100,000
inhabitants, thus ranking third in the hierar-
chy of violent death circumstances.
Of all the study patients 83.69% said
that it was the first attempted suicide, trig-
gered by a family conflict or pre-existing
psychiatric diseases.
The average length of stay in ED was
about 6 hours, during which the patients
received therapy to stabilize the vital signs.
Early diagnosis and initiation of specific
therapy is the best way to reduce the com-
plications that may occur.
Importance was given to medical histo-
ry and physical examination. Blood and
urine toxicology tests had an important

Mihaela Corlade-Andrei et al.
844 place among the biological parameters
analyzed in all study patients. Throughout
the ED stay, all the patients were moni-
tored in terms of Glasgow Coma score,
blood pressure, heart rate, respiratory rate,
peripheral blood oxygen saturation
(SatO2), temperature and diuresis. 92.94%
of patients were hemodynamically stable,
however 7.06% of patients required sup-
portive care (orotracheal intubation, me-
chanical ventilation and positive inotropic
and chronotropic agents). Also, depending
on the associated pathology, patients re-
ceived specialist advice (toxicology, cardi-
ology, surgery, gastroenterology, gynecol-
ogy, etc.). Simultaneously with the symp-
tomatic treatment and detoxification the
supportive therapy was initiated, by which
the patients were helped to understand how
and why they resorted to these methods and
what they can do in the future to prevent
relapse.
All patients presenting to the emergency
department were stabilized. Subsequent-
ly,57% of the patients required hospital
admission because of significant medical
complications that required further treat-
ment and follow-up. The remaining 43% of
patients were hemodynamically stable and
were referred to other hospitals, returned
home or left the ED against medical advice.
Two cases (3.84%) of voluntary methyl
alcohol ingestion referred to the Nephrol-
ogy Clinic required hemodialysis. One
death was recorded (0.27%) because of
mechanical asphyxiation by hanging in a
patient with pre-existing psychiatric dis-
order.

DISCUSSION
Comparing the rate of suicide attempts
in our study with the national statistics for
Bucharest, the capital municipality of Ro-
mania, reported by the "Mina Minovici" Institute of Forensic Medicine we found an
equal incidence, in both cases with an av-
erage of 10% (13, 14).
Nationally, mechanical asphyxia by
hanging is the most frequently used suicide
method followed by voluntary drug inges-
tion (14) and fall from heights while in the
Iasi County 63.58% reported voluntary
drug ingestion and 14.13% ingestion of
toxic and non-pharmacological substances
for suicidal purposes and only 22.28% had
attempted suicide by traumatic mechanism.
As suicide mechanism women prefer drug
ingestion, while men resort to more painful
methods: traumatic mechanisms or inges-
tion of toxic substances, which can lead to
a much higher death rate among men.
The time elapsed between ingestion of
toxic substance and arrival at the hospital is
extremely important in determining patient
prognosis.
Even if worldwide suicide attempt is the
main cause of death in young people, ac-
counting for over 50% of violent deaths, in
our case study one death was recorded
(0.27%) because of mechanical asphyxiation
by hanging in a patient with pre-existing
psychiatric disorder (4, 5, 6, 7, 8, 9).
Mental disorders and physical illness
may lead persons to commit suicide. In a
retrospective study of suicide notes, medi-
cal and police charts of persons who com-
mitted suicide, the patients were examined
at the Department of Forensic Medicine of
Ludwig-Maximilians-University Munich
between 2009 and 2011. The study includ-
ed 1069 cases,18.9 % gave a physical dis-
order as reason for committing suicide and
32.7 % a medical disorder. Regarding to
method of suicide, patients with mental
disorders had more often previous suicidal
attempts and jumping in front of a car was
the most frequent method of suicide while
persons with physical diseases most often

Attempted suicide: a cross-sectional survey 2015
845 shoot themselves. Comparing to literature,
in our case, 83. 69% said that it was the
first attempted suicide, triggered by a fami-
ly conflict or pre-existing psychiatric dis-
eases (15).

CONCLUSION
Patients included in the study were in
most of cases women, with ages less than
30 years old, from urban area, who chose
as a suicide method the voluntary drug
ingestion.
Suicidal acts are rarely an act of free
will. In most cases, suicidal attempts are the
result of untreated psychiatric disorders. Suicidal behavior can be prevented by
psychotherapeutic, pharmacological or
neuromodulatory treatments for mental
disorders. Also, regular follow-up of peo-
ple who attempted suicide by mental health
services is key to preventing future suicide
attempts.
Reduced access to toxic substances (or-
ganophosphates, methyl alcohol) fighting
alcoholism, early detection, treatment and
medical care given to people with mental
disorders and monitoring people who have
experienced a suicide attempt are some
steps that should be taken to prevent and
reduce the size of this phenomenon.
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