Continuous positive airway pressure (CPAP) therapy or non-invasive ventilation (NIV) represent th... more Continuous positive airway pressure (CPAP) therapy or non-invasive ventilation (NIV) represent the first line therapy for acute cardiogenic pulmonary edema (CPE) together with medical therapy. CPAP benefits in acute CPE with normo-hypocapnia are known, but it is not clear whether the use of CPAP is safe in the hypercapnic patients. The aim of this study is to evaluate CPAP efficacy in the treatment of hypercapnic CPE. We enrolled 9 patients admitted to the emergency room with diagnosis of acute CPE based on history, clinical examination, arterial blood gas analysis (ABG) and lung-heart ultrasound examination. We selected patients with hypercapnia (pCO2 >50 mmHg) and bicarbonate levels <30 mEq/L. All patients received medical therapy with furosemide and nitrates and helmet CPAP therapy. All patients received a second and a third ABG, respectively at 30 and 60 min. Primary end-points of the study were respiratory distress resolution, pCO2 reduction, pH improvement, lactates norm...
Italy is currently experiencing an epidemic of coronavirus disease 2019 (Covid-19). Aim of our st... more Italy is currently experiencing an epidemic of coronavirus disease 2019 (Covid-19). Aim of our study is to identify the best predictors of Intensive Care Unit (ICU) admission in patients with Covid-19. We examined 28 patients admitted to the Emergency Department (ED) and subsequently confirmed as cases of Covid-19. Patients received, at the admission to the ED, a diagnostic work-up including: patient history, clinical examination, an arterial blood gas analysis (whenever possible performed on room air), laboratory blood tests, including serum concentrations of interleukin-6 (IL-6), lung ultrasound examination and a computed tomography (CT) scan of the thorax. For each patient, as gas exchange index through the alveolocapillary membrane, we determined the alveolar-arterial oxygen gradient (AaDO2) and the alveolar-arterial oxygen gradient augmentation (AaDO2 augmentation). For each patient, as measurement of hypoxemia, we determined oxygen saturation (SpO2), partial pressure of oxyg...
Background Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Departmen... more Background Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Department (ED). In the last years integrated ultrasound examination (IUE) of lung, heart and inferior vena cava be-come an extension of clinical examination for a fast differential diagnosis. The aim of present study is to assess the feasibility and diagnostic accuracy of diastolic function evaluation for diagnosing acute heart failure (aHF) in patients with acute dyspnea. Methods We included 113 patients presenting to the ED of CTO Hospital in Naples (Italy) for AD. All pa-tients underwent IUE of lung-heart-IVC with a portable ultrasound device. Left ventricle diastolic function was assessed using pulse wave doppler at the tips of the mitral valve and E wave velocity and E/A ratio were recorded. The FINAL diagnosis determined by two expert reviewers: acute HF or non-acute HF (non-aHF). We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive and negative predict...
Acute dyspnea is one of the main reasons for admission to the Emergency Department (ED). A rapid ... more Acute dyspnea is one of the main reasons for admission to the Emergency Department (ED). A rapid and accurate diagnosis can be lifesaving for these patients. Particularly, it is important to differentiate between dyspnea due to acute heart failure (AHF) and dyspnea of pulmonary origin. The aim of this study is to evaluate the real accuracy of the evaluation of diameter and collapsibility of IVC for the diagnosis of AHF among dyspneic patients. We analyzed 155 patients admitted for acute dyspnea to the ED of “Maurizio Bufalini” hospital in Cesena (Italy) and “Antonio Cardarelli” hospital in Naples (Italy) from November 2014 to April 2017. All patients underwent ultrasound of inferior vena cava (IVC) examination with a hand-held device in addition to the traditional pathway. Patients were classified into AHF group or non-AHF group according to the current guidelines. The final diagnosis was AHF in 64 patients and dyspnea of non-cardiac origin in 91 patients. Sensibility and specificit...
Background In Italy, as in many European countries, Pediatric Emergency Medicine is not formally ... more Background In Italy, as in many European countries, Pediatric Emergency Medicine is not formally recognized as a pediatric subspecialty, hindering nation-wide adoption of standards of care, especially in the field of procedural sedation and analgesia (PSA) in the Emergency Department (ED). For this reason PSA in Italy is mostly neglected or performed very heterogeneously and by different providers, with no reference standard. We aimed to describe the procedures and results of the first multidisciplinary and multi-professional Consensus Conference in Italy on safe and effective pediatric PSA in Italian EDs. Methods The preparation, organization and conduct of the Consensus Conference, held in Florence in 2017, followed the recommended National methodological standards. Professionals from different specialties across the country were invited to participate. Results Overall 86 recommendations covering 8 themes (pre-sedation evaluation, pharmacologic agents, monitoring, equipment and di...
Four patients presented to the Emergency Department with dyspnea and they underwent point-of-care... more Four patients presented to the Emergency Department with dyspnea and they underwent point-of-care ultrasound. Lung ultrasound showed a diffuse bilateral B-profile pattern-interstitial syndrome, they underwent contrast-enhanced computed tomography scan of thorax that showed multiple bilateral lung metastases. The detection, in a dyspneic patient, of a diffuse Bprofile pattern not attributable to traditional interstitial syndrome conditions (pulmonary fibrosis, acute respiratory distress syndrome, acute pulmonary edema, interstitial pneumonia) could be indicative of multiple pulmonary metastases.
BACKGROUND thoracic trauma is one of the leading causes of death in all age groups and accounts f... more BACKGROUND thoracic trauma is one of the leading causes of death in all age groups and accounts for 25-50% of all traumatic injuries. With the term lung injury in blunt chest trauma, we identified a spectrum of conditions: lung contusion, pneumothorax and haemothorax. The aim of this study was to evaluate the utility of arterial blood gas analysis parameters in predicting lung injury in blunt chest trauma. METHODS we included 51 patients presenting to the Emergency Department of "C.T.O." Hospital in Naples [Italy] for blunt chest trauma. The patients were assigned to the Lung Injury Group or to the Non-Lung Injury Group basing on CT scan findings. For each patient, we calculated the alveolar-arterial oxygen gradient [AaDO2], the AaDO2 augmentation, the arterial partial pressure of oxygen deficit [PaO2 Deficit] and the ratio between arterial partial pressure of oxygen and fraction of inspired oxygen [P/F]. Areas under the curve [AUC] and receiver operating characteristic [ROC] curve were used to compare the performance of each different test in relation to the detection of lung injury in blunt chest trauma. RESULTS patients with lung injury had lower oxygen saturation, arterial partial pressure of oxygen, P/F and higher PaO2 Deficit, AaDO2, AaDO2 augmentation than patients without lung injury. PaO2 Deficit, AaDO2 and AaDO2 augmentation showed a good accuracy to predict lung injury in blunt chest trauma. CONCLUSION our study demonstrates that the combination of different arterial blood gas analysis variables may be a fast approach for identifying patients with lung injury in the setting of blunt chest trauma in the Emergency Department.
We describe a case of a 83-year-old man who presented to the Emergency Department for bradycardia... more We describe a case of a 83-year-old man who presented to the Emergency Department for bradycardia and reduced level of consciousness. His conditions had progressively worsened in the last few days and bradycardia induced his relatives to call on emergency team. He presented with hypoxia, cough, bradycardia and a reduced Glasgow Coma Scale value. The body temperature was not detected by standard thermometer and the electrocardiogram showed sinus bradycardia with prominent Osborne wave in the lateral precordial leads. His rectal temperature was 30.1 °C and the diagnostic work up showed a right lung pneumonia. He underwent active and passive rewarming treatment and sepsis treatment. Electrocardiographic abnormalities disappeared after rewarming and the patient was admitted to sub-intensive care unit.
Acute dyspnea due to acute heart failure (AHF) is one of the most common reasons for admission to... more Acute dyspnea due to acute heart failure (AHF) is one of the most common reasons for admission to the Emergency Department (ED). The importance of lung ultrasound (LUS) examination in the diagnostic workup of AHF has been widely established. Limited anterior LUS examination for the diagnosis of AHF is controversial. This study compares the accuracy of LUS examination limited to the anterior or lateral lung zones for the diagnosis of AHF and their accuracy among patients with different levels of hypoxemia according to PO2/FiO2 ratio evaluation. We analyzed 170 patients admitted to the ED for acute dyspnea, who underwent multi-organ ultrasound examination of lung, heart and inferior vena cava for differential diagnosis. The thorax was examined following a simplified protocol that provides two scans at each side (anterior and lateral) to sample upper and lower lobes and the presence or the absence of interstitial syndrome (IS) was evaluated. The presence of anterior symmetric IS exhibited lower accuracy than lateral symmetric IS in the diagnosis of AHF in the whole population, but its diagnostic accuracy improves in sub-groups of patients with severe and critical hypoxemia.
We describe a case of a 70-year-old man who presented to the emergency department with dyspnea an... more We describe a case of a 70-year-old man who presented to the emergency department with dyspnea and chest pain. He had history of atrial fibrillation, chronic obstructive pulmonary disease, prosthetic mitral valve and pacemaker implantation. He had a sepsis related to multiple bilateral septic emboli pointed out by chest computed tomography scan. Point of care echocardiography showed a pacemaker-related endocarditis with large vegetation on the right ventricular lead. The patient started empiric antibiotic therapy and he was addressed to complete hardware removal.
Cardiogenic pulmonary edema is a common presentation of acute heart failure normally treated with... more Cardiogenic pulmonary edema is a common presentation of acute heart failure normally treated with continuous positive airway pressure (CPAP), diuretics and nitrates. This therapy is contraindicated in case of cardiac tamponade. We describe a case of pulmonary edema due to cardiac tamponade in which integrated lung-heart ultrasound examination allowed prompt diagnosis and pericardiocentesis before administration of CPAP thus avoiding circulatory collapse.
Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive ... more Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delir...
Continuous positive airway pressure (CPAP) therapy or non-invasive ventilation (NIV) represent th... more Continuous positive airway pressure (CPAP) therapy or non-invasive ventilation (NIV) represent the first line therapy for acute cardiogenic pulmonary edema (CPE) together with medical therapy. CPAP benefits in acute CPE with normo-hypocapnia are known, but it is not clear whether the use of CPAP is safe in the hypercapnic patients. The aim of this study is to evaluate CPAP efficacy in the treatment of hypercapnic CPE. We enrolled 9 patients admitted to the emergency room with diagnosis of acute CPE based on history, clinical examination, arterial blood gas analysis (ABG) and lung-heart ultrasound examination. We selected patients with hypercapnia (pCO2 >50 mmHg) and bicarbonate levels <30 mEq/L. All patients received medical therapy with furosemide and nitrates and helmet CPAP therapy. All patients received a second and a third ABG, respectively at 30 and 60 min. Primary end-points of the study were respiratory distress resolution, pCO2 reduction, pH improvement, lactates norm...
Italy is currently experiencing an epidemic of coronavirus disease 2019 (Covid-19). Aim of our st... more Italy is currently experiencing an epidemic of coronavirus disease 2019 (Covid-19). Aim of our study is to identify the best predictors of Intensive Care Unit (ICU) admission in patients with Covid-19. We examined 28 patients admitted to the Emergency Department (ED) and subsequently confirmed as cases of Covid-19. Patients received, at the admission to the ED, a diagnostic work-up including: patient history, clinical examination, an arterial blood gas analysis (whenever possible performed on room air), laboratory blood tests, including serum concentrations of interleukin-6 (IL-6), lung ultrasound examination and a computed tomography (CT) scan of the thorax. For each patient, as gas exchange index through the alveolocapillary membrane, we determined the alveolar-arterial oxygen gradient (AaDO2) and the alveolar-arterial oxygen gradient augmentation (AaDO2 augmentation). For each patient, as measurement of hypoxemia, we determined oxygen saturation (SpO2), partial pressure of oxyg...
Background Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Departmen... more Background Acute dyspnea (AD) is one of the main reasons for admission to the Emergency Department (ED). In the last years integrated ultrasound examination (IUE) of lung, heart and inferior vena cava be-come an extension of clinical examination for a fast differential diagnosis. The aim of present study is to assess the feasibility and diagnostic accuracy of diastolic function evaluation for diagnosing acute heart failure (aHF) in patients with acute dyspnea. Methods We included 113 patients presenting to the ED of CTO Hospital in Naples (Italy) for AD. All pa-tients underwent IUE of lung-heart-IVC with a portable ultrasound device. Left ventricle diastolic function was assessed using pulse wave doppler at the tips of the mitral valve and E wave velocity and E/A ratio were recorded. The FINAL diagnosis determined by two expert reviewers: acute HF or non-acute HF (non-aHF). We used 2 × 2 contingency tables to analyze sensitivity, specificity, positive predictive and negative predict...
Acute dyspnea is one of the main reasons for admission to the Emergency Department (ED). A rapid ... more Acute dyspnea is one of the main reasons for admission to the Emergency Department (ED). A rapid and accurate diagnosis can be lifesaving for these patients. Particularly, it is important to differentiate between dyspnea due to acute heart failure (AHF) and dyspnea of pulmonary origin. The aim of this study is to evaluate the real accuracy of the evaluation of diameter and collapsibility of IVC for the diagnosis of AHF among dyspneic patients. We analyzed 155 patients admitted for acute dyspnea to the ED of “Maurizio Bufalini” hospital in Cesena (Italy) and “Antonio Cardarelli” hospital in Naples (Italy) from November 2014 to April 2017. All patients underwent ultrasound of inferior vena cava (IVC) examination with a hand-held device in addition to the traditional pathway. Patients were classified into AHF group or non-AHF group according to the current guidelines. The final diagnosis was AHF in 64 patients and dyspnea of non-cardiac origin in 91 patients. Sensibility and specificit...
Background In Italy, as in many European countries, Pediatric Emergency Medicine is not formally ... more Background In Italy, as in many European countries, Pediatric Emergency Medicine is not formally recognized as a pediatric subspecialty, hindering nation-wide adoption of standards of care, especially in the field of procedural sedation and analgesia (PSA) in the Emergency Department (ED). For this reason PSA in Italy is mostly neglected or performed very heterogeneously and by different providers, with no reference standard. We aimed to describe the procedures and results of the first multidisciplinary and multi-professional Consensus Conference in Italy on safe and effective pediatric PSA in Italian EDs. Methods The preparation, organization and conduct of the Consensus Conference, held in Florence in 2017, followed the recommended National methodological standards. Professionals from different specialties across the country were invited to participate. Results Overall 86 recommendations covering 8 themes (pre-sedation evaluation, pharmacologic agents, monitoring, equipment and di...
Four patients presented to the Emergency Department with dyspnea and they underwent point-of-care... more Four patients presented to the Emergency Department with dyspnea and they underwent point-of-care ultrasound. Lung ultrasound showed a diffuse bilateral B-profile pattern-interstitial syndrome, they underwent contrast-enhanced computed tomography scan of thorax that showed multiple bilateral lung metastases. The detection, in a dyspneic patient, of a diffuse Bprofile pattern not attributable to traditional interstitial syndrome conditions (pulmonary fibrosis, acute respiratory distress syndrome, acute pulmonary edema, interstitial pneumonia) could be indicative of multiple pulmonary metastases.
BACKGROUND thoracic trauma is one of the leading causes of death in all age groups and accounts f... more BACKGROUND thoracic trauma is one of the leading causes of death in all age groups and accounts for 25-50% of all traumatic injuries. With the term lung injury in blunt chest trauma, we identified a spectrum of conditions: lung contusion, pneumothorax and haemothorax. The aim of this study was to evaluate the utility of arterial blood gas analysis parameters in predicting lung injury in blunt chest trauma. METHODS we included 51 patients presenting to the Emergency Department of "C.T.O." Hospital in Naples [Italy] for blunt chest trauma. The patients were assigned to the Lung Injury Group or to the Non-Lung Injury Group basing on CT scan findings. For each patient, we calculated the alveolar-arterial oxygen gradient [AaDO2], the AaDO2 augmentation, the arterial partial pressure of oxygen deficit [PaO2 Deficit] and the ratio between arterial partial pressure of oxygen and fraction of inspired oxygen [P/F]. Areas under the curve [AUC] and receiver operating characteristic [ROC] curve were used to compare the performance of each different test in relation to the detection of lung injury in blunt chest trauma. RESULTS patients with lung injury had lower oxygen saturation, arterial partial pressure of oxygen, P/F and higher PaO2 Deficit, AaDO2, AaDO2 augmentation than patients without lung injury. PaO2 Deficit, AaDO2 and AaDO2 augmentation showed a good accuracy to predict lung injury in blunt chest trauma. CONCLUSION our study demonstrates that the combination of different arterial blood gas analysis variables may be a fast approach for identifying patients with lung injury in the setting of blunt chest trauma in the Emergency Department.
We describe a case of a 83-year-old man who presented to the Emergency Department for bradycardia... more We describe a case of a 83-year-old man who presented to the Emergency Department for bradycardia and reduced level of consciousness. His conditions had progressively worsened in the last few days and bradycardia induced his relatives to call on emergency team. He presented with hypoxia, cough, bradycardia and a reduced Glasgow Coma Scale value. The body temperature was not detected by standard thermometer and the electrocardiogram showed sinus bradycardia with prominent Osborne wave in the lateral precordial leads. His rectal temperature was 30.1 °C and the diagnostic work up showed a right lung pneumonia. He underwent active and passive rewarming treatment and sepsis treatment. Electrocardiographic abnormalities disappeared after rewarming and the patient was admitted to sub-intensive care unit.
Acute dyspnea due to acute heart failure (AHF) is one of the most common reasons for admission to... more Acute dyspnea due to acute heart failure (AHF) is one of the most common reasons for admission to the Emergency Department (ED). The importance of lung ultrasound (LUS) examination in the diagnostic workup of AHF has been widely established. Limited anterior LUS examination for the diagnosis of AHF is controversial. This study compares the accuracy of LUS examination limited to the anterior or lateral lung zones for the diagnosis of AHF and their accuracy among patients with different levels of hypoxemia according to PO2/FiO2 ratio evaluation. We analyzed 170 patients admitted to the ED for acute dyspnea, who underwent multi-organ ultrasound examination of lung, heart and inferior vena cava for differential diagnosis. The thorax was examined following a simplified protocol that provides two scans at each side (anterior and lateral) to sample upper and lower lobes and the presence or the absence of interstitial syndrome (IS) was evaluated. The presence of anterior symmetric IS exhibited lower accuracy than lateral symmetric IS in the diagnosis of AHF in the whole population, but its diagnostic accuracy improves in sub-groups of patients with severe and critical hypoxemia.
We describe a case of a 70-year-old man who presented to the emergency department with dyspnea an... more We describe a case of a 70-year-old man who presented to the emergency department with dyspnea and chest pain. He had history of atrial fibrillation, chronic obstructive pulmonary disease, prosthetic mitral valve and pacemaker implantation. He had a sepsis related to multiple bilateral septic emboli pointed out by chest computed tomography scan. Point of care echocardiography showed a pacemaker-related endocarditis with large vegetation on the right ventricular lead. The patient started empiric antibiotic therapy and he was addressed to complete hardware removal.
Cardiogenic pulmonary edema is a common presentation of acute heart failure normally treated with... more Cardiogenic pulmonary edema is a common presentation of acute heart failure normally treated with continuous positive airway pressure (CPAP), diuretics and nitrates. This therapy is contraindicated in case of cardiac tamponade. We describe a case of pulmonary edema due to cardiac tamponade in which integrated lung-heart ultrasound examination allowed prompt diagnosis and pericardiocentesis before administration of CPAP thus avoiding circulatory collapse.
Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive ... more Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delir...
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