clinica e terapia - CG Edizioni Medico Scientifiche

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Trimestrale. Anno VIII • Prezzo di copertina E 9,50 • Poste Italiane. Spedizione in A.P. D.L. 353/2003 (conv. in L. 27/02/2004 n° 46) art. 1, comma 1, DCB Torino n. 1/12. ISSN 18269826
numero 1 - marzo 2012
editoriale
3 Il caso Concordia: alcune riflessioni su un incidente
M. Catino
clinica e terapia
7 Diagnostic significance of haematological testing in patients presenting
at the Emergency Department
Giuseppe Lippi, Giovanni Targher. Giampaolo Neri, Clarissa Cattabiani, Silvia Pipitone, Gianfranco Cervellin
casi clinici
13 Thyrotoxic Hypokalemic Periodic Paralysis (THPP): a challenge for the
Emergency Medicine physician in Western countries. A case report
F. Stella, MD, L. Gottardo, MD, M.T. Busetto, MD, S. Pianetti, MD, and A. Semplicini, MD
Atti del Congresso Nazionale Interdisciplinare
BUONA PRATICA CLINICA E RICERCA SCIENTIFICA
NELL’URGENZA-EMERGENZA
Roma, 2-4 novembre 2011
emergency
care
journal
sommario
emergency care journal - organizzazione, clinica, ricerca • Anno VIII numero 1 • Marzo 2012 • www.ecj.it
Sommario
2
Il caso Concordia: alcune riflessioni su un incidente
M. Catino
3
Diagnostic significance of haematological testing in patients presenting at the Emergency Department
Giuseppe Lippi, Giovanni Targher. Giampaolo Neri, Clarissa Cattabiani, Silvia Pipitone, Gianfranco
Cervellin
7
Thyrotoxic Hypokalemic Periodic Paralysis (THPP): a challenge for the Emergency Medicine
physician in Western countries. A case report
13
Atti del Congresso Nazionale Interdisciplinare
Buona pratica clinica e ricerca scientifica nell’Urgenza-Emergenza - Roma, 2-4 novembre 2011
Direttore responsabile: I. Casagranda
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Mauro Frascisco, Cristina Mazzoleni, Daniele Ebbli,
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Ages Arti Grafiche s.r.l. - Torino - Finito di stampare il 27/03/2012
Emergency Care Journal, periodico ufficiale
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Registrazione al Tribunale di Torino per Emergency Care Journal
n. 5935 del 17/01/2006. Poste Italiane. Spedizione in A.p. DL
353/2003 (conv. in L. 27/02/2004 n. 46) art. 1, comma 1, DCB
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emergency
care
journal
editoriale
Il caso Concordia: alcune riflessioni su un incidente
M. Catino
Gli incidenti nelle organizzazioni complesse non possono essere attribuiti ad una singola causa, anche se sono stati, per
lungo tempo, spiegati come un fallimento della tecnologia, o un errore da parte degli operatori. Ciò che accomuna tali
spiegazioni è l’attribuzione di ogni responsabilità dell’incidente non all’organizzazione e alle sue pratiche di funzionamento, ma al più comodo capro espiatorio: l’errore umano. Tuttavia, quando accade un evento come il disastro della nave Concordia, è tutta l’organizzazione che fallisce: il management della nave, il sistema di gestione del rischio e della sicurezza
della compagnia, il sistema dei controlli. Non soltanto alcuni degli operatori a più stretto contatto col compito anche se,
in questo caso, sembrano aver mostrato particolare negligenza. L’analisi dei maggiori disastri organizzativi ha dimostrato,
infatti, la rilevanza dei fattori organizzativi nell’eziologia di tali eventi (Perrow, 1999; Weick, 1990; Vaughan, 1996; Turner and Pidgeon, 1997; Reason, 1997; Snook, 2000; CAIB 2003; Catino 2010). Le cause prossime di un incidente sono
il prodotto di sottostanti cause e fattori organizzativi. Molte inchieste sugli incidenti commettono lo stesso errore nella
definizione di cause: tendono a concentrarsi prevalentemente sulla persona che ha commesso l’errore o la componente
tecnica che non ha funzionato adeguatamente. Occorre che l’indagine sugli incidenti, come quello della nave Concordia,
non commetta questi errori. Occorre indagare i fattori organizzativi che hanno favorito il disastro, oltre l’errore umano –
certamente presente – e/o il fallimento tecnico.
L’incidente
Nel caso del disastro del Concordia possiamo suddividere i fatti relativi all’evento in due fasi: (1) la fase precedente all’impatto della nave con lo scoglio e (2) la fase di gestione dell’emergenza. In questo editoriale ci concentreremo sulla prima
(precisando che ci basiamo sulle informazioni sinora disponibili), anche se è fin troppo chiaro che la seconda fase, quella
della gestione dell’emergenza, è stata mal gestita, con un’improvvisazione inefficace. Non è solo questione di eroismo o
di codardia, ma di organizzazione. In situazioni di impreparazione e di inadeguata comunicazione, il panico prende il sopravvento a prescindere dalle virtù individuali. L’abilità nel gestire una situazione critica dipende dalle strutture che sono
state sviluppate prima che l’organizzazione si trovi nello stato di piena crisi. Per poter gestire una crisi, quindi, occorre
aver imparato prima che essa si manifesti.
Tornando alla prima fase, l’innesco dell’incidente del Concordia sembra essere stato causato da un mix di: (1) una violazione (intenzionale, anche se non malevola), e da (2) un errore (involontario). Le violazioni di per sé non hanno la volontà
di danneggiare le persone, ma quando si combinano con gli errori, possono diventare fatali. Le violazioni ripetute (di
routine) costituiscono una grave minaccia alla sicurezza, in quanto possono favorire la commissione di errori, difficili da
recuperare. Nel caso del disastro della nave Concordia, si è trattato di (1) una violazione di routine delle regole di prudenza marinaresca. La violazione è costituita dall’inchino, ovvero la deviazione di rotta di una nave da crociera per avvicinarsi
alla costa, la cui ripetizione nel tempo favorisce un senso di overconfidence in chi la pratica che può portare a sottovalutare
i rischi e sopravvalutare le capacità di gestione. Diverse sono le motivazioni che favoriscono le violazioni e nel caso della
pratica dell’inchino le motivazioni possono essere state: finalità promozionali e di marketing e, per il comandante e il
gruppo di comando, maggiore emozione, mostrare skill, apparire “macho”. Derogando dalla rotta prevista, il limite oggettivo da rispettare si trasforma in un limite soggettivo da sfidare per chi comanda la nave.
L’assenza di costi e/o di sanzioni ne favorisce il ripetersi. Nel fare violazioni di questo tipo, si genera negli operatori un’illusione di poter controllare la situazione («io sono in grado di gestirlo…»), un’illusione di invulnerabilità, di superiorità
(«io sono molto competente…»). In un clima aziendale di consenso e di incentivi, come il post sul sito della società Costa
Crociere nel quale si ringraziava il comandante della Costa Concordia coinvolto nel disastro, per un precedente inchino in
altro luogo. Sulle brochure della Compagnia, si pubblicizzavano gli avvicinamenti ravvicinati alla costa, anche se a distanze ben superiori di quella del disastro della nave Concordia. A quel punto, il comportamento deviante diventava la norma,
in un processo di “normalizzazione della devianza” (Vaughan 1996). Su questo punto torneremo più avanti. Si tratta di
una violazione pianificata (alle ore 18.15-18.25), circa tre ore prima dell’incidente. Il comandante (forse dopo aver disattivato i sistemi di allarme di bordo, sonoro e visuale – è questo un dato da verificare) procede con la navigazione manuale,
avendo come strumenti di supporto: il radar, l’ecoscandaglio, le mappe informatiche, il rilevamento a vista, quest’ultimo
reso difficile dalle condizioni (era notte con ridotta luminosità sull’isola). Quel giorno il comandante credeva di navigare
ad una distanza di 0,28 miglia (circa 520 metri) dallo scoglio più prossimo alla riva, ma dall’analisi dei dati AIS è emerso
che in realtà distava solo 150 metri dalla costa. Invece il 14 agosto 2011, in occasione di un altro passaggio davanti all’isola
del Giglio, la Concordia guidata da un altro comandante transitava a 230 metri dalla riva. È interessante notare che nelle
due circostanze la velocità della nave in prossimità degli scogli noti come le Scole è molto simile: il 14 agosto la Concordia
viaggia a 14,5 nodi, mentre il 13 gennaio a circa 15-16 nodi.
Professore di Sociologia dell’organizzazione, Università di Milano Bicocca
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(2) All’interno di una violazione di routine accade un errore, involontario. Il comandante ha commesso un errore di
tipo slip (scivolamento dell’attenzione), in particolare un mancato rilevamento di un oggetto – lo scoglio, un caso di “falso
negativo”. L’aspettativa gioca un ruolo molto forte in questo tipo di errori (il comandante riteneva che lo scoglio fosse in
altro luogo), in una situazione di perdita della situational awareness e di mindless, di scarsa attenzione. Come ha affermato
Ludwig Wittgenstein (1953) «La nostra aspettativa anticipa l’evento. In questo senso, essa prepara un modello dell’evento… Nell’aspettativa, la parte che corrisponde alla ricerca nello spazio, è il dirigere l’attenzione… Se io mi aspetto di vedere
rosso, allora io mi preparo per il rosso».
È da ritenere che la mindlessness del comandante e degli ufficiali abbia giocato un ruolo decisivo nel ridurre la situational
awareness a ognuno dei due livelli. La presenza di altre persone in plancia di comando, le conversazioni non orientate
esclusivamente al compito rischioso da effettuare, l’uso del cellulare ecc. hanno certamente contribuito a ridurre il livello
d’attenzione, individuale e collettivo, richiesto dalla situazione. La situational awareness ha tre fonti: 1) il mondo esterno,
2) gli strumenti di bordo disponibili (principalmente il radar con raggio di scansione sul piano orizzontale, e l’ecoscandaglio che ispeziona sul piano verticale), 3) gli altri colleghi. Data l’ora e le condizioni quella sera, lo scoglio non era facilmente visibile, quindi la situational awareness era resa possibile solo dagli ultimi due elementi. È da capire se gli strumenti
non abbiano funzionato come dovuto o se, piuttosto, non siano stati opportunamente consultati.
Una possibile ipotesi, da verificare, è che vi sia anche stata un’illusione ottica, favorita dalla ridotta situational awareness.
Potrebbe essersi trattato di un’illusione ottica dovuta alla percezione di profondità (ossia alla distanza tra la nave e la
costa). Di notte, con scarsa visuale e con poche luci visibili dalla costa del Giglio (era gennaio) i punti di riferimento per
stimare la distanza tra la nave e l’isola a occhio nudo erano molto scarsi. L’unico segnale era la “��parallasse di movimento”,
cioè lo spostamento laterale dei punti luminosi (es. le case o l’illuminazione comunale) sulla costa dovuti al movimento
della nave. In assenza di altri elementi di riferimento, non era possibile capire se i punti si muovevano lateralmente a una
certa velocità perché la nave procedeva ad andatura elevata o perché era troppo vicina alla riva. A causa della velocità sostenuta e del passaggio molto prossimo all’isola, è possibile che l’equipaggio presente in plancia abbia percepito la velocità
di movimento laterale delle luci sulla costa non come un segno della loro vicinanza eccessiva, ma come il risultato di una
velocità di crociera elevata. È un aspetto che, tuttavia, merita ulteriori approfondimenti.
Tali errori e fallimenti sono sempre possibili, ma una cosa è se tali errori e fallimenti accadono in zone sicure, al largo,
un’altra è se accadono in zone vicine alla costa, dove le possibilità di recupero della situazione sono rese impossibili
dall’inerzia e dalla limitata mobilità della nave (114.500 GRT di stazza lorda; lunghezza: 290,2 metri, altezza: 52 metri;
larghezza: 35,50 m.).
Non era la prima volta che il comandante effettuava un passaggio ravvicinato all’isola del Giglio, ma l’abitudine ed un’eccessiva overconfidence nelle proprie capacità, potrebbero aver condotto il comandante ad una serie di errori che hanno poi
innescato l’incidente. Innanzitutto, come detto in precedenza questa manovra è stata fatta di sera, con il mare calmo ma
davanti ad un’isola poco illuminata, dal momento che a gennaio è quasi deserta. Inoltre quel giorno in plancia insieme
al comandante c’erano anche il restaurant manager e l’hotel directory, che di norma non dovrebbero essere sul ponte di
comando e che probabilmente, chiacchierando, hanno disturbato la manovra del comandante, che sembra stesse parlando al telefono, con un conseguente calo dell’attenzione. È come se un pilota di un aereo, durante una fase delicata come
l’atterraggio in condizioni meteo non ottimali, fosse intento non solo a gestire tale pericolosa fase, ma anche ad intrattenere
passeggeri ed amici presenti nel cockpit, comportamento assolutamente vietato. Questo potrebbe spiegare il motivo per
cui il comandante ha creduto che lo scoglio fosse più lontano, compiendo un errore di tipo slip (si è confuso). Tale evento
è tuttavia indicatore di un clima professionale in plancia di comando certamente singolare e non rispettoso delle regole di
sicurezza. Appare plausibile affermare che l’insieme di persone operanti in plancia di comando non abbia operato come un
team affidabile, secondo le regole e i principi del Crew Resource Management (CRM), un sistema di formazione ben noto in
altri contesti lavorativi, nei quali l’errore umano può avere effetti devastanti. È da capire se il comandante ed il team siano
stati precedentemente addestrati o meno ad operare secondo tali principi.
L’atteggiamento del comandante potrebbe essere dovuto ad una can-do attitude: i successi passati nell’effettuare gli inchini
generano la convinzione che si ripeteranno nel futuro. Ciò rende, da un lato, più difficile individuare i limiti di tali azioni
(fino a quanti metri dalla costa si può arrivare?) e, dall’altro, riluttanti le persone che si dimostrano contrarie a segnalare il
problema (non possiamo farlo; ci stiamo avvicinando troppo). In particolare, in situazioni di pressioni commerciali ed assenza
di controlli significativi, come vedremo più avanti. Anni di successi nella pratica degli inchini, contribuiscono a creare tale
pericolosa credenza.
Sembra esservi stato, quindi, un atteggiamento eccessivamente positivo che può aver portato il comandante a sopravvalutare le proprie abilità, spingendolo ad avvicinarsi eccessivamente alla costa, ad una velocità elevata (15-16 nodi), per dare
un’ulteriore prova della sua bravura, in una condizione di bassa consapevolezza della reale situazione.
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La pratica dell’inchino: drift to danger e la normalizzazione della
devianza
Se l’incidente è stato generato da un mix di errori (involontari) e di violazioni (volontarie anche se non malevole), è ai
fattori organizzativi che occorre guardare per poter comprendere adeguatamente la genesi e la dinamica di questo disastro.
Non si è trattato di un incidente imprevedibile, accaduto come un fulmine a ciel sereno, ma, piuttosto, tale incidente ha
avuto un lungo periodo di incubazione, durante il quale vi sono stati molti segnali di pericolo inascoltati, un fallace sistema di gestione del rischio, un sistema dei controlli poco attivo.
Il termine “inchino” è un’espressione giornalistica utilizzata per indicare il passaggio ravvicinato di una nave in prossimità
di un’isola o di una zona di particolare interesse paesaggistico, compiendo una deviazione rispetto alla rotta normalmente
seguita. Questa pratica è definita da alcuni “navigazione turistica”, dal momento che spesso viene effettuata dalle navi
adibite al trasporto di persone allo scopo di intrattenere i turisti e di “salutare” con tre fischi di sirena gli abitanti delle
isole o della terraferma, che accolgono in maniera festosa il passaggio di queste navi. Sin dagli anni Cinquanta, alcuni comandanti salutavano parenti ed amici, anche se non con passaggi così ravvicinati. L’inchino si è poi diffuso ed è diventato
un’usanza della gente di mare per rendere omaggio ai propri compaesani. È una pratica condivisa dai comandanti con gli
equipaggi, una specie di “rito”. Tuttavia all’inizio le navi erano più piccole, quindi questi passaggi erano più agevoli. Poi
questa tradizione è stata tramandata alle navi da crociera moderne. Il primo ottobre del 1993 ha inizio la pratica dell’inchino, nel senso di passaggio ravvicinato alla costa, anche per la Costa Crociere. Moltissime sono le altre testimonianze
che dimostrano come l’inchino fosse una pratica conosciuta e tollerata (Camogli, a circa 300 metri dalla costa, nel canale
di Venezia davanti a Piazza San Marco ecc.). Appare piuttosto chiaro come l’organizzazione fosse non solo consapevole
degli inchini, ma che ne incentivasse la pratica per finalità commerciali e di marketing, sia verso i clienti (a bordo) che
quelli potenziali (sulla costa).
Come già affermato, il 14 agosto 2011 la nave Concordia effettua un inchino ravvicinato all’isola, solo che alla guida c’era
un altro comandante. Se si confrontano le rotte seguite dalla stessa nave il 14 agosto 2011 e il 13 gennaio 2012, si vede
come quasi coincidano. Tuttavia le circostanze che hanno portato ad effettuare l’inchino sono diverse: il 13 gennaio si
trattava di una “cortesia”; invece il 14 agosto questo “saluto” sembra esser stato programmato dalla Compagnia a scopo
pubblicitario. A seguito di ciò, il Sindaco del Giglio invia una lettera di ringraziamento al comandante Costa Crociere.
Gli enti locali, dunque, sapevano e ringraziavano. È chiaro che in questo clima, aderire alla pratica dell’inchino non era un
comportamento deviante ma normale. Una situazione paradossale di “normalizzazione della devianza”.
La normalizzazione della devianza è un processo che genera una costante erosione delle normali procedure, in cui piccole
violazioni e irregolarità vengono accettate e tollerate. In assenza di incidenti queste deviazioni si “normalizzano”, diventano la prassi. Il risultato finale è una situazione di slittamento verso il pericolo senza esserne pienamente consapevoli. Tale
processo produce i seguenti effetti negativi:
• danneggia la cultura della sicurezza; sposta i confini di sicurezza (verso la costa) senza soffermarsi sul perché i limiti
originari (la rotta prevista) erano stati posti;
• aumenta la tolleranza nei confronti degli errori che non generano danni;
• aumenta il livello di accettazione dei rischi a favore degli interessi legati all’efficienza e alla produttività;
• conduce il sistema della sicurezza in uno slippery slopes, un pendio scivoloso, nel quale gli incidenti sono sempre più
possibili.
Deviando dalla rotta sicura per fare l’inchino, si entra in un’area di rischio, non sempre adeguatamente controllata, nella
quale le modalità di gestione dipendono prevalentemente dal fattore umano e dalla strumentazione tecnica a disposizione.
Possono verificarsi due fattori: il primo è che l’overconfidence del gruppo di comando sposti sempre di più la linea verso
la costa, aumentando i pericoli; il secondo è che in queste situazioni diventa difficile correggere eventuali errori umani –
sempre possibili.
In queste situazioni si entra in un’area di rischio dove, come detto, i limiti oggettivi da rispettare (la rotta di sicurezza)
diventano limiti soggettivi da sfidare. Gli inchini costituiscono dei “segnali” di pericolo che, pur essendo noti, venivano incentivati (anche se non nella forma estrema manifestatasi la notte del 13 gennaio 2012) e tollerati dai sistemi di controllo
(le Capitanerie di porto e la guardia costiera).
Tutto ciò evidenzia una cultura della sicurezza dell’organizzazione lacunosa, che non solo non si accorge dei rischi di una
pratica pericolosa come l’inchino, ma la tollera e la incentiva. Il tutto in un sistema dei controlli fallace. Un aspetto di
rilievo delle criticità a livello interorganizzativo attiene alle Capitanerie di Porto, e alle funzioni di controllo del traffico
marittimo, della disciplina della navigazione marittima e della sicurezza della navigazione. Sulla Concordia era installato
l’AIS, il Sistema di Identificazione Automatica obbligatorio per tutte le navi di stazza lorda superiore ad un certo peso, che
permette di rilevare la rotta, la velocità e la posizione del natante, consentendo così alle autorità marittime di controllare
costantemente il movimento delle navi. Sembra quindi che anche le Capitanerie fossero a conoscenza dei passaggi ravvicinati e che li tollerassero. In una situazione in cui, i controllori non effettuano i controlli, i controllati possono spostarsi
progressivamente verso aree di rischio.
Conclusione
L’incidente della nave Costa Concordia mostra tutte le caratteristiche di un incidente organizzativo. L’incidente non è stato
un evento random, anomalo, imprevedibile, ma piuttosto esso sembra avere origine dalla storia dell’organizzazione e dalla
sua cultura della sicurezza, all’interno di un sistema dei controlli fallace. Il disastro della nave Costa Concordia è stato un
incidente organizzativo con numerose similitudini con altri disastri accaduti in altri settori (Linate, Challenger, Columbia
ecc.). L’innesco dell’evento è stato il mix di violazione di routine (inchino) e errori (di valutazione), in un clima psicologico di overconfidence. La normalizzazione della devianza riguardo i comportamenti poco sicuri come gli inchini, l’assenza di
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regolazione e controllo hanno portato ad una costruzione collaborativa dell’errore. Occorre, dunque, spostare l’attenzione
dall’errore individuale (certamente presente) all’errore collettivo e organizzativo. L’incidente è stato caratterizzato da un
“periodo di incubazione” (la pratica ripetuta dell’inchino) durante il quale i segnali di pericolo non venivano annotati,
anzi, erano incentivati. Il sistema dei vincoli e dei controlli non ha funzionato come avrebbe dovuto, favorendo – involontariamente – la creazione nel tempo di un’ampia zona di pericolo e di un tipo di condotta che violava le regole di prudenza
marinaresca, derogando alla discrezionalità del comandante la distanza dalla costa per l’avvicinamento.
È in questo clima che nasce l’incidente, certamente acuito dallo stile di gestione del comandante e dalla fase 2 (qui non
analizzata) della mancata e ritardata gestione della crisi. Tuttavia, per capire la seconda è alla prima che occorre guardare.
Non ci si può limitare ai soli fattori umani (l’errore scatenante) o al fallimento tecnico ma, come è accaduto per l’investigazione di altri disastri (Shuttle Columbia, vedi rapporto CAIB 2004; disastro aereo di Linate, vedi rapporto ANSV 2004),
è necessario investigare in profondità i fattori organizzativi e sistemici che sono alla base di tale disastro, e la (inadeguata)
cultura organizzativa della sicurezza. La “cultura della produzione” caratterizzata dalla can-do attitude degli inchini, con
incentivi ad affrontare rischi e in un clima di tolleranza da parte dei controllori, prevaleva sulla cultura della sicurezza (tenere il sistema nei margini di sicurezza). Il mix di normalizzazione della devianza e cultura della produzione hanno favorito un processo decisionale fallace, all’interno del quale un errore umano (inevitabile prima o poi) ha condotto al disastro.
Se ci si concentra troppo da vicino sulle azioni rischiose in prima linea, o se si critica solo la fase della gestione dell’emergenza, si corre il rischio di non accorgersi del fatto che si è trattato del risultato di un incidente organizzativo in cui
emergono criticità e mancanze nel sistema del controllo delle operazioni di navigazione.
Si è trattato di un disastro annunciato in quanto conforme alle norme in uso nell’organizzazione. Il sistema non era tenuto
all’interno dei vincoli di sicurezza, come sarebbe stato necessario, ma veniva spinto in un’area di rischio, senza ascolto,
monitoraggio, né apprendimento dai segnali di pericolo.
Si è trattato di un disastro evitabile in quanto caratterizzato da un periodo di incubazione e da una “finestra di recupero”,
un periodo di tempo tra la manifestazione dei potenziali rischi (gli avvicinamenti pericolosi alla costa) e il disastro del
Concordia. Una finestra di recupero non opportunamente utilizzata dal management dell’organizzazione e dal suo sistema
di risk management.
Il disastro della nave Concordia sembra non esser stato il risultato di un problema isolato, di un errore umano, ma il
sintomo di più profondi e ampi problemi organizzativi e di regolazione, come: a. l’incapacità dell’organizzazione di tenere
entro i limiti di sicurezza le navi; b. un errato sistema di incentivi; c. un’inadeguata cultura della sicurezza; d. un sistema
dei controlli critico.
Riferimenti bibliografici
ANSV (Agenzia Nazionale per la Sicurezza del Volo). Relazione d’Inchiesta. Incidente occorso agli aeromobili Boeing MD-87
e Cessna 525, Aeroporto di Milano Linate, 8 ottobre 2001. 2004.
CAIB (Columbia Accident Investigation Board). Report, Volume One. National Aeronautics and Space Administration and
the Government Printing Office, Washington (DC), 2003.
Catino M. Da Chernobyl a Linate. Incidenti tecnologici o errori organizzativi? Bruno Mondadori, Milano, 2006.
Catino M. A multilevel model of accident analysis: The Linate disaster, in Alvintzi P, Eder H (Eds.). Crisis Management. Nova
Science Publishers Inc., Hauppauge NY, 2010.
Perrow C. Normal Accidents: Living with High-Risk Technologies. Basic Books, New York, 1999.
Reason J. Managing the Risks of Organizational Accidents. Ashgate, Aldershot, 1997.
Reason J. The Human Contribution, Ashgate, Aldershot, 2008.
Snook S.A. Friendly Fire. The Accidental Shootdown of U.S. Black Hawks Over Northern of Iraq. Princeton University Press,
Princeton NY, 2000.
Turner BA, Pidgeon N. Man-Made Disasters. Butterworth Heinemann, Oxford, 1997.
Vaughan D. The Challenger Launch Decision. Risk Technology, Culture and Deviance at Nasa. The University of Chicago
Press, Chicago, 1996.
Weick KE. The Vulnerable System: Analysis of the Tenerife Air Disaster. Journal of Management 1990; 16: 571-593.
6
emergency
care
journal
clinica e terapia
Diagnostic significance of haematological testing in
patients presenting at the Emergency Department
Giuseppe Lippi*, Giovanni Targher**. Giampaolo Neri***, Clarissa Cattabiani*, Silvia Pipitone*,
Gianfranco Cervellin***
Key words: emergency department, haematological testing, lavoratory testing, rule-out test, diagnosis.
Abstract
The use of simple and economic tests to rule out diseases of sufficient clinical severity is appealing in emergency department
(ED), since it would be effective for contrasting ED overcrowding and decreasing healthcare costs. The aim of this study
was to assess the diagnostic performance of simple and economic haematological testing in a large sample of adult patients
presenting at the ED of the Academic Hospital of Parma during the year 2010 with the five most frequent acute pathologies
(i.e., acute myocardial infarction, renal colic, pneumonia, trauma and pancreatitis). Both leukocyte count and hemoglobin
showed a good diagnostic performance (Area Under the Curve [AUC] of 0.85 for leukocyte count and 0.76 for hemoglobin;
both p < 0.01). Although the platelet count was significantly increased in all patients groups except pancreatitis, the diagnostic
performance did not achieve statistical significance (AUC 0.53; p = 0.07). We also observed an increased RDW in all groups,
except in those with trauma and the diagnostic performance was acceptable (AUC 0.705; p < 0.01). The mean platelet volume
(MPV) was consistently lower in all patients groups and also characterized by an efficient diagnostic performance (AUC 0.76;
p < 0.01). This evidence led us to design an arbitrary formula, whereby MPV and hemoglobin were multiplied, and further
divided by the leukocyte count, obtaining a remarkable AUC (0.91; p < 0.01). We conclude that simple, rapid and cheap
hematological tests might provide relevant clinical information for decision making to busy emergency physicians, and the
their combination into an arbitrary formula might further increase the specific diagnostic potential of each of them.
Introduction
Hospital-based Emergency Departments (EDs) evolved during the past two decades to provide not only acute emergency
care but also safety net care for indigent patients, public health surveillance, disaster preparedness, observation and
procedural care, occupational care, employee health, and, in many cases, primary health care. Despite these expanding
services, the ED resources, including overall number of ED facilities, beds within those facilities as well as funding, did
not increase proportionally.
The overcrowding in EDs and its potentially adverse consequences, is a well-known phenomenon in Western countries
(1). Multiple factors are likely to be involved in the growing crisis of ED crowding. Among them, in our country, there is the
constantly decreasing number of hospital beds, the steadily increasing number of ED visits and the demographic changes
of the population (i.e. increasing prevalences of elderly people and migrants). ED overcrowding accounts different timing
of various care-paths (e.g. door-to-balloon time in STEMI) and may also influence the degree of care given to patients (1).
ED overcrowding has also a variety of other undesirable consequences, including increased patient waiting times, decreased
ability to protect patient privacy and confidentiality, impaired evaluation and treatment, and difficulties in delivering personcentered care. These consequences can be understood not just as undesirable or unfortunate in terms of obvious operational
and logistic problems for hospitals but also as violations of widely held, fundamental, ethical norms (2). The ED overcrowding
has also been considered as a first-line cause of doctors’ and nurses’ burnout and of verbal or physical assault. Overall, there
is an emerging body of evidence suggesting that ED overcrowding is more effectively influenced by interventions mainly
directed to improve patient’s output from ED to wards; by contrast, interventions mainly directed to reduce the amount of ED
visits failed to be effective. One reliable approach for contrasting ED overcrowding may be represented by the use of simple
and economical laboratory tests to enhance the efficiency of triage. Diagnostics investigations, including laboratory testing,
are typically subjected to a Bayesian approach and thereby are characterized by two leading characteristics, i.e. sensitivity and
specificity, which contribute to define the negative and positive predictive value (i.e. NPV and PPV) as well as the positive and
negative likelihood ratio (i.e. LR+ and LR-) (3). The use of simple and economic tests to rule out rather than diagnose diseases
of sufficient clinical severity –the so-called “negative thinking” – is hence appealing in EDs, since it would be effective for
contrasting ED overcrowding as well as for decreasing healthcare costs. Thus, the main aim of the present study was to assess
the diagnostic significance and performance of simple and economic haematological testing in a large sample of adult patients
presenting at the ED of the Academic Hospital of Parma with acute diseases and requiring a fast triage.
* U.O. Diagnostica Ematochimica, Dipartimento di Patologia e Medicina di Laboratorio, Azienda Ospedaliero-Universitaria di
Parma
** Sezione di Endocrinologia e Metabolismo, Dipartimento di Medicina, Università degli Studi di Verona
*** U.O. Pronto Soccorso e Medicina d’Urgenza, Dipartimento di Emergenza-Urgenza, Azienda Ospedaliero-Universitaria di
Parma
7
clinica e terapia
Material and Methods
8
We selected the five most frequent acute pathologies (i.e. acute myocardial infarction, renal colic, pneumonia, trauma and
pancreatitis) which occurred in adult patients who were acutely admitted to the ED of the Parma University Hospital during
the year 2010. All the hospital records of adult patients who were consecutively visited in our ED from January 1th, 2010
to December 31th, 2010 were extracted from our informatic database. The selection of index cases followed the diagnostic
criteria universally accepted for each specific pathology and the trauma cases included those with Injury Severity Score (ISS)
> 15. Out of the total number of patients identified for each disease, 25% of total cases have been extracted with a program
of randomization to preserve the homogeneity of the sample population and quickening the statistical analysis of data.
The clinical and haematological data were firstly retrieved using both the ICD-9 code and the related diagnostic terms
(i.e. “myocardial infarction”, “renal colic”, “pneumonia”, “trauma” and “pancreatitis”) and were subsequently reviewed
for deleting wrong registrations. The final sample consisted of 462 acutely admitted ED patients (i.e. cases) who had the
following definitive diagnoses: 262 renal colic, 62 pneumonia, 51 acute pancreatitis, 46 acute myocardial infarction (AMI)
and 41 trauma. We also retrieved the demographic and haematological data from a healthy control population, which
consisted of 429 blood donors (i.e. controls), who were matched for age and sex to the cases, and who referred to our
hospital for a regular blood donation.
In both controls and cases, haematological testing were performed on the same laboratory instrumentation (i.e. Sysmex
XE 2100, Sysmex Inc, Mundelein IL, USA). Among the various haematological parameters, we arbitrarily selected those
which were more frequently informative in urgent testing such as hemoglobin, white blood cell (WBC), platelet (PLT)
counts, as well as mean platelet volume (MPV) and red blood cell distribution width (RDW), i.e. two simple parameters
that have been recently shown to be significantly associated with acute diseases. The quality of laboratory results have
been validated throughout the study period by regular internal quality control (IQC) procedures and participation in an
External Quality Assessment Scheme (EQAS).
Data were presented as means ± standard deviation (SD) or proportions. Skewed variables were logarithmically
transformed to improve normality prior to analyses. The significance of differences between the groups was assessed by
the one-way analysis of variance (for continuous variables) and the chi-squared test with Yates’s correction for continuity
(for categorical variables). Univariate linear regression analysis was also performed. Diagnostic performance of the
haematological tests was evaluated by the Receiver Operating Characteristic (ROC) curve analysis. P-values <0.05 were
considered statistically significant.
Results
Values of haematological parameters among the different pathological conditions
The main demographic and haematological characteristics of healthy controls and acutely admitted ED patients (considered as either a whole sample or subdivided according to their acute pathologies) are summarized in Table 1. By study
design, no significant differences were found in age and gender distribution between the control group and the patients’
group, except for those with acute pancreatitis, who were more likely to be older than healthy controls. As regards the
haematological parameters, significant differences were found for hemoglobin concentration (i.e., hemoglobin was lower
in all cases, irrespective of different acute pathologies, than in controls), WBC count (i.e., WBC was higher in all cases,
irrespective of different pathologies) and MPV (i.e., mean MPV was lower in all cases irrespective of different pathologies).
PLT count was also higher in all cases as well as in various disease groups, except in those with pancreatitis. Similarly,
RDW was higher in all cases as well as in AMI, pancreatitis and pneumonia groups, but it was lower in the renal colic
group and non-significantly different in the trauma group.
A significant, inverse, association was observed between MPV and PLT in healthy controls (r = -0.340; p < 0.01) and in
all cases (r = -0.306; p < 0.01) as well as in the renal colic (r = -0.330; p < 0.01), AMI (r = -0.485; p < 0.01), pneumonia (r
= -0.392; p < 0.01) and trauma (r = -0.317; p = 0.01) groups, but not in the pancreatitis group (r p = -0.183; p = 0.199).
ROC curve analysis
The results of ROC curve analyses for hemoglobin, RDW, WBC, MPV and PLT are shown in Table 2. When comparing
healthy controls versus cases, there were significant AUC values for hemoglobin (AUC 0.71; p < 0.01), MPV (AUC 0.76;
p < 0.01) and WBC (AUC 0.85; p < 0.01), but not for PLT count and RDW.
As regards the different acute pathologies, the AUC of hemoglobin was statistically significant in all instances, except
for patients with pancreatitis versus all other pathological groups. The AUC of RDW was significant when comparing
renal colics versus all other pathological groups, AMI versus controls, pancreatitis versus controls, pneumonia versus
controls, and pneumonia versus all other pathological groups. The AUC of MPV was significant in all instances, except
for AMI patients versus all other pathological groups, pancreatitis versus all other pathological groups, pneumonia versus
all other pathological groups, and trauma versus all other pathological groups. The AUC of WBC was significant in all
instances, except for AMI patients versus all other pathological groups, pancreatitis versus all other pathological groups
and pneumonia versus all other pathological groups. Conversely, the AUC of PLT did not achieve a statistical significance
in any case.
clinica e terapia
According to thes above-mentioned results, we then decided to combine the most informative haematological parameters,
i.e. hemoglobin, MPV and WBC count, in an arbitrary formula based on three parameters and derived from a single test
(i.e., complete blood cell count; [hemoglobin x MPV] / WBC). The relative values were substantially different between
healthy controls and cases (as shown in Table 1 and Figure 1).
Table 1. Main demographic and hematological characteristics of the study population.
Healthy All cases
Controls
Renal colic
Myocardial
Infarction
Pancreatitis
Pneumonia
n
429
462
262
46
51
62
41
Age (years)
48±16
49±17
48±18
47±9
56±14‡
46±15
44±18
Gender (M/F)
241/188
245/217
134/128
29/17
24/27
33/29
16/25
Hemoglobin (g/L) 148±12
136±19‡
140±16‡
130±24‡
137±19‡
126±20‡
133±15‡
WBC (109/L)
6.2±1.4
9.7±3.5‡
9.2±2.9‡
10.0±4.3‡
10.4±3.7‡
10.6±4.5‡
12.7±4.6‡
PLT (109/L)
231±48
241±71‡
242±64‡
243±62‡
233±80
243±86†
250±12†
RDW (%)
13.5±0.7
13.8±1.8‡
13.1±1.0†
14.6±2.7‡
14.3±2.1‡
14.8±2.7‡
13.5±0.9
MPV (fL)
11.1±0.9
10.1±1.2‡
10.0±1.2‡
10.3±1.1‡
10.6±1.2†
10.1±1.1‡
10.4±0.9‡
Formula*
277±64
160±68‡
168±62‡
156±67‡
151±62‡
143±89‡
123±46‡
Data are presented as means±SD or proportions.
PLT, Platelet count; WBC, White Blood Cell count; MPV, Mean Platelet Volume; RDW, Red Blood Cell Distribution Width.
* Formula: [hemoglobin x MPV] / WBC count
† p < 0.05; ‡ p < 0.01 for differences versus healthy controls
Figure 1. Distribution values (expressed as mean ± standard
deviation) of the arbitrary formula (calculated as [hemoglobin
x MPV] / WBC) in 429 healthy controls and in 462 patients,
who were admitted to the Emergency Department for various
acute diseases.
Figure 2. Area under the ROC curve analysis of the
arbitrary formula (calculated as [hemoglobin x Mean
Platelet Volume] / leukocyte count) for identifying
patients with acute pathologies and healthy controls (Area
Under the Curve: AUC 0.91; p < 0.01).
Interestingly, we observed a good overall performance of this formula for distinguishing between healthy controls from
patients, i.e., AUC 0.91 (p < 0.01) (Figure 2). The best diagnostic performance of this formula was obtained for an
arbitrary cut-off value of 220.5, which corresponds to an 85% sensitivity, 84% NPV, 0.18 LR-, 80% specificity, 81% PPV and
4.25 LR+. A cut-off value of 274.6 was instead associated with high values of sensitivity (95%), NPV (91%) and LR- (0.1),
combined with an acceptable specificity (i.e. 50%), PPV (66%) and LR+ (1.9). Remarkable diagnostic performances of this
formula were also obtained when comparing the control group with the groups of those with renal colic (AUC 0.89; p <
0.01), AMI (AUC 0.91; p < 0.01), pancreatitis (AUC 0.91; p < 0.01), pneumonia (AUC 0.93; p < 0.01) or trauma (AUC
0.97; p < 0.01). As regards the comparison among the different patient groups, this formula also enabled to significantly
distinguish the renal colic group from all other pathological groups (AUC 0.64; p < 0.01), the pneumonia group from all
other pathological groups (AUC 0.62; p = 0.01) and the trauma group from all other pathological groups (AUC = 0.69; p
Trauma
9
clinica e terapia
< 0.01), respectively, but not the AMI and the pancreatitis groups from all other pathological groups (AUC 0.50; p = 0.49
and AUC 0.55; p = 0.15, respectively). However, the results obtained in these subgroups analyses should be interpreted
with some degree of caution given the relatively low number of patients included.
Discussion
10
Nearly half of the patients presenting at the ED have often non-urgent conditions, which might be safely referred
elsewhere, either to other healthcare settings or discharged (4). This can only be accomplished by using fast, simple
and economical tests, which should also be characterized by efficient sensitivity, NPV and LR-. The conventional
haematological testing provides a variety of parameters, which may also be useful for the diagnostic reasoning of several
non-hematological pathologies. Among the various parameters that are provided by the modern haematological analyzers,
those most informative for acute pathologies as well as those more frequently consulted by emergency physicians are
indeed the hemoglobin concentration, WBC and PLT counts. The hemoglobin value, more than the hematocrit and the
RBC count, provides information about the presence of anaemia, which is defined as a hemoglobin concentration lower
than 120 g/L in women and lower than 135 g/L in men (5). The WBC count helps identify leukopenia or leukocytosis. By
definition, leukocytosis (frequently arising from relatively benign conditions such as infectious diseases or inflammatory
processes as well as from serious causes including primary bone marrow disorders) and leukopenia (mainly due to bone
marrow failure) in the adulthood are diagnosed when WBC count is increased to more than 10x109/L, or decreased to
less than 4.0x109/L, respectively (6). The PLT count, whose reference range is comprised between 150 and 400x109/L, is
instead useful for identifying thrombocytopenia (caused by either decreased production or increased consumption in the
bloodstream) and thrombocytosis (either due to myeloproliferative disorders or reactive causes) (7).
Besides these very common tests, additional well-known hematological parameters, especially RDW and MPV, are now
experimenting an important “resurrection” in the diagnostic approach to several non-hematological disorders. The RDW
expresses the variation in the size of red cells (anisocytosis). Its normal values are typically comprised between 11.5 and
14.5% (8). Beside the undeniable usefulness for the initial classification of anaemia in the ED (9), some recent studies have
evaluated the role of RDW in the diagnostic approach to patients with AMI. In a previous investigation, we found that a
higher RDW value was significantly associated with an increased odds of AMI, showing an overall AUC of 0.705 (p < 0.01)
(10). In a subsequent investigation, using a different instrumentation, we failed to find any significant difference in RDW
values between AMI patients and controls (11). However, a higher RDW value was found to be strongly and independently
associated with an increased risk of incident AMI and death in some large prospective studies (12-15). With regard to other
pathologies, increased RDW values were observed in patients with community acquired pneumonia (16), ischemic stroke
(17), chronic kidney disease (18), thrombotic thrombocytopenic purpura (19) or coeliac disease (20). A significant, graded
relationship was also found between higher RDW and inflammatory biomarkers, namely highly sensitive C-reactive protein
and erythrocyte sedimentation rate, in a large cohort of unselected adult outpatients (18). To our knowledge, no data are
currently available about the association of RDW with other acute pathologies that are commonly observed at the ED, such
as renal colic, trauma and pancreatitis. The MPV expresses the average size of platelets in blood. The typical range of platelet
volumes is 9.7–12.8 fL, which is roughly equivalent to 2.65 to 2.9 µm. Increased MPV has usually been considered as a reliable
index of larger, more reactive, platelets often resulting from an increased PLT turnover. As such, increased MPV has been
observed in patients with AMI (21-23), hypertension (24), sepsis (25), dysglycemia (26), non-alcoholic fatty liver disease
(27), hypothyroidism (28) and chronic spontaneous urticaria (29). Conversely, a decreased MPV has been observed in patients
with persistent bacterial infections (30). Regarding the results of our case-control study, leukocytosis and anaemia were
commonplace throughout the five groups of acutely admitted ED patients (Table 1). Both WBC count and hemoglobin were
characterized by a good diagnostic performance, as attested by the AUC of ROC curve analyses (all cases versus controls: AUC
0.85 and 0.76 for WBC count and hemoglobin, respectively; both p < 0.01) (Table 2). The PLT count was also significantly
increased in all patients groups, except in those with pancreatitis. Nevertheless, a substantial overlap in PLT distribution
values was observed and, accordingly, in no instance the AUC of this parameter achieved a statistical significance (Table 2).
In agreement with previously published studies, we observed an increased RDW value in all groups of sdmitted ED patients,
except in those with trauma, confirming that this parameter would mirror the presence of anisocytosis that might aspecifically
occur throughout a variety of acute disorders. Nevertheless, the rather broad distribution and the substantial overlap of RDW
values between cases and controls consistently decreased the diagnostic performance of RDW (all cases versus controls:
AUC 0.23; p = 0.34) (Table 2). Our finding of lower MPV values in all patients groups than in controls apparently disagrees
with previous observations, inasmuch as a higher MPV value was described in a variety of disorders. A reliable explanation
however may exist. The platelets undergo at least two patterns of reactive size changes, i.e. an early rise, which is associated
with thrombocytopenia, and a later fall, which is often associated with thrombocytosis (30). In our investigation, the mean
PLT value was significantly higher in all acute disease groups than in the control group, except in those with pancreatitis.
Even more importantly, an inverse association between PLT count and MPV could be observed in all patient groups, except
in those with pancreatitis. It is thereby conceivable that the lower MPV value observed in our acutely admitted ED patients
would reflect the latter phase of reactive size change (i.e. reduction), which has been described to occur in association
with thrombocytosis. Accordingly, patients with pancreatitis had the highest value of MPV as well as the lowest PLT count.
Interestingly, MPV was characterized by an efficient diagnostic performance (all cases versus controls: AUC 0.76; p < 0.01).
The two evidences of significant AUC values for WBC count, MPV and hemoglobin, along with the value distributions in
Table 2. Diagnostic performances of different haematological parameters in 429 healthy controls and in 462 patients who
were admitted to the Emergency Department for various acute pathologies.
PLT
All cases versus
controls
Renal colics
versus controls
Renal colics
versus all cases
AMI versus
controls
AMI versus all
cases
Pancreatitis
versus controls
Pancreatitis
versus all cases
Pneumonia
versus controls
Pneumonia
versus all cases
Trauma versus
controls
Trauma versus
all cases
Hemoglobin
RDW
MPV
WBC
AUC
P
AUC
P
AUC
P
AUC
P
AUC
P
0.53
0.07
0.76
<0.01
0.71
<0.01
0.76
<0.01
0.85
<0.01
0.54
0.06
0.67
<0.01
0.51
0.89
0.78
<0.01
0.83
<0.01
0.52
0.41
0.61
<0.01
0.65
<0.01
0.55
0.03
0.61
<0.01
0.55
0.86
0.75
<0.01
0.66
<0.01
0.72
<0.01
0.84
<0.01
0.52
0.71
0.55
<0.01
0.63
0.04
0.51
0.41
0.53
0.29
0.53
0.15
0.69
<0.01
0.60
0.02
0.73
<0.01
0.86
<0.01
0.56
0.06
0.53
0.08
0.59
0.01
0.53
0.24
0.45
0.87
0.51
0.49
0.83
<0.01
0.64
<0.01
0.77
<0.01
0.78
<0.01
0.52
0.38
0.58
0.01
0.59
0.01
0.49
0.56
0.56
0.07
0.57
0.10
0.80
<0.01
0.45
0.84
0.72
<0.01
0.94
<0.01
0.51
0.76
0.54
0.03
0.53
0.25
0.57
0.06
0.71
<0.01
Data are presented as area under the ROC curve (AUC)
PLT, Platelet count; WBC, White Blood Cell count; MPV, Mean Platelet Volume; AMI, Acute Myocardial Infarction; RDW, Red
Blood Cell Distribution Width.
Important limitations of this study are that the significance of haematological testing was only assessed in five acute
pathologies, and that we have enrolled healthy blood donors as the control population, whereby patients afflicted by
similar symptoms but different final diagnosis might have been more informative in this setting. It is however noteworthy
that, taken together, renal colic, AMI, pancreatitis, pneumonia and trauma cover the vast majority of acute causes for
ED access in our facility (i.e., more than 50% of high priority – yellow and red codes). Moreover, the use of healthy
blood donors is currently considered the gold standard for establishing whether a biochemical test is helpful or not for
the acute disease groups (increased values of WBC count, decreased values of hemoglobin and MPV), prompted us to design
an arbitrary formula, whereby MPV and hemoglobin values were multiplied, and further divided by the WBC count. The
highest the value of this formula, the lowest the probability of diagnosing one of the five acute diseases investigated in this
study, as shown in Figure 1. The AUC of this formula was remarkable; the choice of a 274.6 cut-off value would have yielded
an optimal performance for rapid rule out of all of the five acute pathologies investigated in our study.
The are two leading take-home messages from this case-control study. First, we demonstrated that three parameters
(i.e., MPV, Hb and WBC) deriving from simple, rapid and cheap laboratory tests, such as those attainable from routine
hematological testing, show optimal diagnostic performance and might provide relevant clinical information for decisionmaking to busy emergency physicians. Second, we demonstrated that the combination of three of these simple laboratory
tests within an arbitrary formula might consistently increase the diagnostic potential of each of them when considered
separately. It is however noteworthy that the arbitrary formula which we developed was derived from a local database
of acutely admitted ED patients, and that the results were obtained using a single specific laboratory instrumentation.
As such, the clinical usefulness of this formula needs to be further validated in other clinical settings and using different
hematological analyzers. Nevertheless, we believe that this finding represents a paradigmatic example, which can be
assessed in further larger investigation, to establish whether either different threshold values of this proposed formula
or different combination of simple and inexpensive haematological parameters could help the clinical decision-making
of physicians in acutely admitted ED patients. In synthesis, these findings represent a reliable example on how easy and
inexpensive parameters or indices such as those proposed in this study can be incorporated within a more comprehensive
approach to risk stratification of patients acutely admitted to the ED. A very simple parameter such as the WBC, for
example, does not confirm or rule out any pathology alone, but it can be included in some steps of the diagnostic reasoning
along with other clinical and laboratory parameters, where it can instead provide meaningful clinical information.
Relazioni
clinica e terapia
11
clinica e terapia
distinguishing between health and disease. Another potential limitation of this study is the high prevalence of patients
with renal colic, which represented nearly half the sample population and might have thereby somehow affected the
outcome of the study.
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knowledge translation in the Emergency Department. Acad Emerg Med 2007; 14: 1036-1041.
5. World Health Organization. Worldwide prevalence of anaemia 1993-2005. WHO Press, Geneva, 2008.
6. Munker R. Leukocytosis, Leukopenia, and Other Reactive Changes of Myelopoiesis, in Munker R, Hiller E, Glass J,
Paquette R eds. Modern Hematology: Biology and Clinical Management. Humana Press-Springer, New York, 2007.
7. Schmaier AH. Laboratory evaluation of hemostatic and thrombotic disorders, in Hoffman R, Benz EJ Jr, Shattil SJ et al,
eds. Hoffman Hematology: Basic Principles and Practice. Churchill Livingstone Elsevier, Philadelphia, Pa, 2008.
8. Sarma PR. Red Cell Indices, in Walker HK, Hall WD, Hurst JW eds. Clinical Methods: The History, Physical, and
Laboratory Examinations. Butterworths, Boston, 1990.
9. Evans TC, Jehle D. The red blood cell distribution width. J Emerg Med 1991; 9 (suppl. 1): 71-4.
10. Lippi G, Filippozzi L, Montagnana M, Luca Salvagno G, Franchini M, Cesare Guidi G et al. Short Communication:
Clinical usefulness of measuring red blood cell distribution width on admission in patients with acute coronary syndromes.
Clin Chem Lab Med 2009; 47: 353-7.
11. Cemin R, Donazzan L, Lippi G, Clari F, Daves M. Blood cells characteristics as determinants of acute myocardial
infarction. Clin Chem Lab Med 2011; 49: 1231-6.
12. Zalawadiya SK, Veeranna V, Niraj A, Pradhan J, Afonso L. Red cell distribution width and risk of coronary heart disease
events. Am J Cardiol 2010; 106: 988-93.
13. Dabbah S, Hammerman H, Markiewicz W, Aronson D. Relation between red cell distribution width and clinical outcomes
after acute myocardial infarction. Am J Cardiol 2010; 105: 312-7.
14. Patel KV, Semba RD, Ferrucci L, Newman AB, Fried LP, Wallace RB et al. Red cell distribution width and mortality in
older adults: a meta-analysis. J Gerontol A Biol Sci Med Sci 2010; 65: 258-65.
15. Perlstein TS, Weuve J, Pfeffer MA, Beckman JA. Red blood cell distribution width and mortality risk in a community-based
prospective cohort. Arch Intern Med 2009; 169: 588-94.
16. Braun E, Domany E, Kenig Y, Mazor Y, Makhoul BF, Azzam ZS. Elevated red cell distribution width predicts poor outcome
in young patients with community-acquired pneumonia. Crit Care 2011; 15: R194.
17. Ani C, Ovbiagele B. Elevated red blood cell distribution width predicts mortality in persons with known stroke. J Neurol
Sci 2009; 277: 103-8.
18. Lippi G, Targher G, Montagnana M, Salvagno GL, Zoppini G, Guidi GC. Relationship between red blood cell distribution
width and kidney function tests in a large cohort of unselected outpatients. Scand J Clin Lab Invest 2008; 68: 745-8.
19. Nagajothi N, Braverman A. Elevated red cell distribution width in the diagnosis of thrombotic thrombocytopenic purpura
in patients presenting with anemia and thrombocytopenia. South Med J 2007; 100: 257-9.
20. Sategna Guidetti C, Scaglione N, Martini S. Red cell distribution width as a marker of coeliac disease: a prospective study.
Eur J Gastroenterol Hepatol 2002; 14: 177-81.
21. Endler G, Klimesch A, Sunder-Plassmann H, Schillinger M, Exner M, Mannhalter C et al. Mean platelet volume is an
independent risk factor for myocardial infarction but not for coronary artery disease. Br J Haematol 2002; 117: 399-404.
22. Lippi G, Filippozzi L, Salvagno GL, Montagnana M, Franchini M, Guidi GC et al. Increased mean platelet volume in
patients with acute coronary syndromes. Arch Pathol Lab Med 2009; 133: 1441-3.
23. Klovaite J, Benn M, Yazdanyar S, Nordestgaard BG. High platelet volume and increased risk of myocardial infarction:
39,531 participants from the general population. J Thromb Haemost 2011; 9: 49-56.
24. Ntaios G, Gurer O, Faouzi M, Aubert C, Michel P. Hypertension is an indepedent predictor of mean platelet volume in
patients with acute ischemic stroke. Intern Med J 2010 Jan 4. [Epub ahead of print].
25. Van der Lelie J, Von dem Borne AK. Increased mean platelet volume in septicaemia. J Clin Pathol 1983; 36: 693-6.
26. Zuberi BF, Akhtar N, Afsar S. Comparison of mean platelet volume in patients with diabetes mellitus, impaired fasting
glucose and non-diabetic subjects. Singapore Med J 2008; 49: 114-6.
27. Shin WY, Jung DH, Shim JY, Lee HR. The association between non-alcoholic hepatic steatosis and mean platelet volume in
an obese Korean population. Platelets 2011; 22: 442-6.
28. Yilmaz H, Erturul O, Erturul B, Erturul D. Mean platelet volume in patients with subclinical hypothyroidism. Platelets
2011; 22: 143-7.
29. Magen E, Mishal J, Zeldin Y, Feldman V, Kidon M, Schlesinger M, Sthoeger Z. Increased mean platelet volume and
C-reactive protein levels in patients with chronic urticaria with a positive autologous serum skin test. Am J Med Sci 2010;
339: 504-8.
30. Robbins G, Barnard DL. Mean platelet volume changes in infection. J Clin Pathol 1983; 36: 1320.
emergency
care
journal
casi clinici
Thyrotoxic Hypokalemic Periodic Paralysis (THPP):
a challenge for the Emergency Medicine physician in
Western countries. A case report
Internal Medicine 1, Department of Internal Medicine, SS. Giovanni e Paolo Hospital, ULSS 12 Veneziana, Venice, Italy
Thyrotoxic hypokalemic periodic paralysis (THPP) is an endocrine emergency with sudden onset of acute muscle hypoasthenia associated with severe hypokalemia and normal acid-base balance, due to thyrotoxicosis. It may develop in patients
of Asian and Native American descent, but it is very rare and undiagnosed in Western countries. Standard treatment
includes β-blockers and thyrostatic drugs, but hypokalemia should not be treated with high potassium doses due to the
risk of hyperkalemic rebound. Since early diagnosis and correct treatment can prevent life-threatening cardio-pulmonary
complications, the emergency physician should keep in mind this rare possibility. We report a case of a 43 year old Caucasian
man presenting at ED with tetraparesis as the first symptom of thyrotoxicosis with no other remarkable symptoms or signs.
Case Report
A 43 year old Caucasian man was admitted to ED for sudden onset of severe muscular weakness, affecting mainly the
lower limbs. He was unable to sit up on the bed while waking up in the early morning. The day before he had walked for
a long time. Neither drugs nor illicit substances, nor heavy carbohydrate intake were reported.
The vital signs were the following: HR = 96 bpm rhythmic, BP = 160/105 mmHg, RR = 14/min, body temperature = 36.2°C,
random glucose test = 94 mg/dl. EKG, acid-base and gas balance were normal at first laboratory tests. Serum chemistry
was unremarkable except for serum potassium level of 1.9 mEq/L.
Cardiopulmonary physical exam was normal. The neurological examination revealed tetraparesis with greater involvement
of the lower limbs. Proximal muscles were mainly involved in the legs, and, on the contrary, distal muscles were involved
in the arms; the left side more involved than the right side; mild pain was reported at rest and excruciating evocable pain
while passive and active movements were performed; mild osteo-tendon hyporeflexia. The thyroid gland was normal.
Particular attention was paid in searching signs of thyrotoxicosis, but neither tachycardia, nor ophthalmopathy nor weight
loss nor tremors were found.
After stabilization of serum potassium level with low doses of intravenous KCl administration in the cardiologic ICU, the
patient was reassigned to the Internal Medicine Department.
A complete laboratory work-up showed TSH = 0.07 mUI/L, fT3 = 8.4 ng/L, fT4 = 37.6 ng/L, Ab anti-TPO = 165 U/mL, Ab
anti-TSHrec = 10.7 U/L.
Imaging showed enlarged thyroid lobes with homogenously increased iodine captation. We, therefore, started β-blockers
and thyrostatic therapy as soon as possible, with fast recovery of all the neurological symptoms. Upon discharge, the
patient had completely recovered his neuromuscular functions and he had stable normalization of laboratory data.
Discussion
THPP is a rare complication of thyrotoxicosis in Western countries, presenting with acute muscle hypo-asthenia (paresis
rather than paralysis) associated with muscular pain and stiffness, hypokalemia and normal arterial acid-base balance due
to potassium intracellular shift.
THPP is a well-known complication of hyperthyroidism in Asian countries: it is reported in approximately 2% of Asian
patients with thyrotoxicosis. In non-Asian people hypokalemic paralysis due to hyperthyroidism is unusual (0,1-0,2%),
and it is mainly reported among Native American, Black and Hispanic peoples. THPP is very rare in Caucasian, as reported
in Pompeo and Kung works. Despite a higher incidence of thyrotoxicosis in women, THPP occurs predominantly in
men (male/female ratio = 20:1). The different distribution of HLA antigen subtypes may make certain populations more
susceptible to THPP than others (such as HLA-DRw8 in Japanese, HLA-A2, Bw22, Aw19, and B17 in Singapore Chinese,
and B5 and Bw46 in Hong Kong Chinese). Mutations in genes controlling Na+/K+ATPase pump activity and the exchange
of intracellular potassium with extracellular sodium within the same HLA antigen subtype, may explain ethnic differences.
The male predominance may reflect the action of androgen on Na+/K+ATPase activity. Furthermore, polymorphism of the
CACNA1S gene (coding for a calcium channel) has been demonstrated in Asiatic THPP patients. The genetic pattern in
non-Asiatic patients has not been studied.
Introduction
13
casi clinici
emergency
care
journal
When facing a sudden hypokaliemic paralysis, emergency physicians in Western countries look for more frequent clinical
conditions, such as myasthenia gravis, Guillain-Barré syndrome, polyneuritis, FHPP or hysteria. However, the prompt
recognition of the disease is crucial for the best acute management and to prevent recurrent episodes that may lead to
life-threatening cardiopulmonary complications such as respiratory insufficiency and cardiac arrhythmias. THPP will
recur if hyperthyroidism is not treated, but thyrotoxicosis is often subclinical at paralysis onset, in particular, in Western
countries: only a few patients (approximately 10%) showed symptomatic hyperthyroidism at presentation of THPP.
Muscular hypotonia may be the only symptom at first appearance of hyperthyroidism, and the correct diagnosis is only
made possible by measuring the thyroid hormone levels.
The relevant characteristics of the onset of THPP are (Lin, 2005): presentation in an adult male with no family history of
periodic paralysis; presence of systolic hypertension; tachycardia; high QRS voltage; first-degree atrioventricular block on
ECG; normal blood acid-base state; hypokalemia; hypophosphatemia and hypercalciuria.
The present clinical report, describing THPP in a patient of non Asian or native American descent, suggests that emergency
physician should raise his index of suspicion also in Western countries. THPP is an endocrine emergency, and its early
recognition is critical to guide the correct therapeutic decision, that should not include large potassium supplementation,
in view of the risk of rebound hyperkalemia.
References
Pompeo A, Nepa A, Maddestra M, Feliziani V, Genovesi N. Thyrotoxic hypokalemic periodic paralysis: An overlooked
pathology in western countries. Eur J Emerg Medicine 2007; 18: 380-90.
Lin S.H. Thyrotoxic periodic paralysis. Mayo Clin Proc 2005; 80: 99-105.
Kung A.W. Clinical review: Thyrotoxic periodic paralysis: a diagnostic challenge. J Clin Endocronol Metab. 2006; 91, 7:
2490-5.
14
Laboratory medicine and critical care: need for a
closer collaboration
Relazioni
Buona pratica clinica e ricerca scientifica nell’EU - Roma, 2-4 novembre 2011
M. Plebani
The clinical needs of the Emergency Departments (ED) in terms of laboratory testing correspond to the availability of
three main items: 1) 24-hours access to laboratory testing for a panel of tests which are really necessary for the clinical
decision-making process and patient care; 2) response time (TAT) that allows an effective and safe management of critical
patients; 3) analytical and process quality assurance appropriate to the specific diagnostic use.
Laboratory tests that are useful for the management of critical patients should be grouped into three main categories: a)
tests whose results are needed as soon as possible (e.g arterial blood gases analysis, electrolytes ecc); b) tests whose results
are needed rapidly that means within 60 minutes (e.g cardiac biomarkers including cardiac troponin, D-dimer ecc); c)
tests whose results are still useful if available within an acceptable timeframe (2 hours), including ALT, GGT, bilirubin
and toxicological tests.
All these tests, namely tests included in the group a, should be measured by a centralised laboratory or by POCT according
to some logistic and organizational issues that should be specifically discussed and solved in each institution.
Data available in the current literature underline that major criticisms in ED and critical care units (CCU) derive both
from analytical problems and by defects in the pre- and post-analytical phases. In particular, the lack of an appropriate
test request and an appropriate interpretation of results translate into missed or delayed diagnoses in the ED setting. In
papers dealing with missed or delayed diagnosis in EDs, the extent of failure to follow-up diagnostic tests in ED ranged
from 1.0% to 75% (radiology from 0% to 5.6%, microbiology from 3% to 75%, and urgent biochemistry 44.7%), stressing
the need for corrective actions.
The source of these errors relates to a complex mix of human factors, team work, and system breakdowns that lead to
communication mistakes and mishandling of critical patient information. This is particularly true for the notification of critical
values that remain a fundamental issue for the quality of care and patient safety.
References
Kachalia A, Gandhi TK, Pupolo AL et al. Missed and delayed diagnoses in the Emergency department: a study of closed
malpractice claims from 4 liability insurers. Ann Emerg Med 2007; 49: 196-205.
Plebani M. The detection and prevention of errors in laboratory medicine. Ann Clin Biochem. 2010; 47: 101-10.
Innovazione tecnologica nell’ambito della medicina
d’emergenza-urgenza: workshop. Ecofast e utilizzo
del mezzo di contrasto
L. Barozzi
U.O.C. di Radiologia, Dipartimento di Emergenza/Urgenza, Chirurgia Generale e dei Trapianti
Policlinico S.Orsola-Malpighi, Bologna
L’ecografia è l’indagine più utilizzata nel trauma chiuso dell’addome per rapidità di esecuzione e sensibilità nella ricerca
dell’emoperitoneo (84-98%). Può essere impiegata senza interferire con le manovre di rianimazione.
La tecnica FAST (Focused Abdominal Sonography for Trauma) consiste nell’esecuzione di 4 scansioni: ipocondrio e fianco
destro, epigastrio, ipocondrio e fianco sinistro, scavo pelvico. Nel paziente instabile il riscontro di versamento endoperitoneale pone indicazione all’intervento chirurgico di laparotomia senza ulteriori accertamenti. Nel paziente stabile con
versamento peritoneale acquista notevole importanza l’esatta valutazione delle lesioni presenti, rendendosi quindi necessari ulteriori accertamenti. In questo contesto la TC costituisce l’esame gold standard per la sua panoramicità, sensibilità
e specificità (98% con VPN 100%).
L’ecografia ha elevata sensibilità nella rilevazione dell’emoperitoneo ma scarsa sensibilità nella valutazione delle lesioni
degli organi addominali. Inoltre, l’assenza di emoperitoneo non esclude lesioni parenchimali anche di grave entità.
Department of Laboratory Medicine, University-Hospital, Padova
15
Relazioni
16
L’implementazione tecnologica delle apparecchiature, con l’introduzione dell’imaging armonico e degli algoritmi a basso
indice meccanico, ha migliorato notevolmente le possibilità dell’ecografia. Inoltre l’introduzione del SonoVue, mezzo di
contrasto (MdC) di seconda generazione altamente stabile e con scarsi effetti collaterali, ha drasticamente incrementato le
possibilità della metodica. Si tratta di una soluzione di microbolle capace di entrare in risonanza con il fascio di ultrasuoni,
che consente di ottenere un imaging real time in scala di grigi con una efficace rappresentazione dell’architettura microvascolare dei parenchimi.
Inizialmente testata nelle lesioni focali epatiche, ha dimostrato grandi possibilità anche nella valutazione delle lesioni
traumatiche parenchimali.
L’esame ecografico con MdC (CEUS) richiede apparecchiature performanti, dotate di softwares dedicati. Il MdC viene
iniettato per via endovenosa, a bolo, usualmente alla dose di 2,4 ml. Nella valutazione dell’effetto “contrastografico” è
necessario tenere conto della vascolarizzazione dell’organo indagato e delle caratteristiche della lesione da evidenziare. I
tempi di rilevazione sono ormai noti e codificati dalla TC, con una tempistica che distingue diverse fasi: arteriosa, venosa
e tardiva.
Per lo studio del paziente traumatizzato bisogna considerare come i vari organi richiedano tempi diversi. Nel rene le lesioni traumatiche sono meglio identificate in fase arteriosa; il fegato è meglio valutabile in fase portale (a 70”); per la milza è
necessaria una buona e completa opacizzazione (circa 3’). L’intero studio prevede circa 6 minuti.
Le lesioni traumatiche appaiono come aree fortemente ipoecogene nel contesto di un parenchima che incrementa fortemente la sua ecogenicità dopo infusione di MdC. L’ecografia consente una perfetta visualizzazione delle lesioni, con
precisa valutazione delle dimensioni e della sede.
La CEUS si propone in maniera importante anche nella sorveglianza delle lesioni trattate conservativamente. Rimangono, però, irrisolti i limiti propri della metodica ecografica, quali l’habitus difficile del paziente, le difficoltà nell’apparato
gastro-intestinale, la presenza di ferite aperte e di enfisema.
In conclusione è possibile affermare che i MdC di seconda generazione migliorano l’accuratezza diagnostica dell’ecografia
nella valutazione delle lesioni degli organi addominali, con risultati sovrapponibili a quelli della TC.
La semplicità di esecuzione, anche al letto del malato, la rendono metodica eligibile nella valutazione del trauma chiuso
dell’addome, prima della TC che rimane metodica indiscussa nel politrauma e nel trauma maggiore stabilizzato.
PCT come strumento di stewardship antimicrobica
P. Viale
Clinica di Malattie Infettive, Policlinico S. Orsola-Malpighi, Alma Mater Studiorum Università di Bologna
In un momento di significativa contrazione delle risorse farmacologiche nei confronti delle malattie da infezione, correlato alla costante e preoccupante espansione delle resistenze microbiche, l’approccio alla terapia antibiotica non può più
prescindere da una visione di sistema, dove il prescrittore associ alla gestione del singolo caso anche la valutazione del
potenziale impatto ecologico delle sue scelte.
Questo “matrimonio” tra l’aspetto clinico e la valenza epidemiologica del management della terapia antimicrobica è il
principio su cui su basa la stewardship antimicrobica, che si propone come un insieme di interventi finalizzati a contenere
i rischi correlati all’uso degli antimicrobici senza che ciò vada a scapito della qualità assistenziale.
Nel corso dell’ultimo decennio la stewardship antimicrobica da un insieme di misure, spesso messe in atto in modo non coordinato, è diventata una materia di studio, grazie a numerosi contributi culturali che progressivamente ne hanno spostato
le finalità, da strumento di controllo a metodologia di governo clinico, ad approccio scientifico idoneo a definire e monitorizzare non tanto i costi delle prescrizioni quanto l’appropriatezza della gestione globale della terapia antimicrobica.
In tale contesto, l’identificazione di ulteriori strumenti capaci di guidare le scelte, quali ad esempio parametri oggettivi
espressione di malattia da infezione, ha sicuramente un’importante valore teorico.
La determinazione dei livelli plasmatici di procalcitonina può in effetti rappresentare uno strumento utile per aiutare il
clinico ad affrontare le numerose “zone grigie” relative alla prescrizione di antibiotici, in particolare in quelle situazioni
in cui non vi siano chiare evidenze né di infezione né di localizzazione d’organo, quali ad esempio i pazienti con febbre
senza fattori di rischio specifici e/o segni e sintomi evocativi per una peculiare condizione di malattia correlata ad infezione oppure i pazienti affetti da broncopatia cronica ostruttiva che presentino riacutizzazione della tosse, variazioni delle
caratteristiche dell’escreato senza altre manifestazioni di super-infezione batterica.
Non è casuale che le esperienze più favorevoli relative all’utilizzo di procalcitonina come strumento decisionale verso la
prescrizione o la non prescrizione di antibiotici, siano state condotte soprattutto nel setting delle infezioni delle vie aeree
inferiori e non necessariamente in pazienti critici, dove i segni e sintomi della condizione di sepsi grave fossero eclatanti.
Molto significativi in tal senso sono i dati dello studio Pro-HOSP dove in una coorte prospettica di pazienti con infezioni
delle vie aeree inferiori, randomizzati a terapia secondo linee guida vs terapia basata su valori di procalcitonina, si evidenziava un chiaro vantaggio in termini di esposizione ad antibiotici sia globalmente su tutti i 1359 soggetti arruolati, sia dopo
stratificazione per soggetti con polmonite di comunità o broncopatia cronica ostruttiva riacutizzata.
Più conflittuali sono invece i dati acquisiti nel setting della terapia intensiva. Esaustivi sono i dati di un recente studio
condotto prospetticamente su oltre 1200 pazienti ricoverati in terapia intensiva, randomizzati a ricevere o implementare
la terapia antimicrobica secondo lo standard of care o in base al valore di PCT, dove una concentrazione superiore a 1 ng/
ml era considerato il parametro di alert. Con riferimento all’end point primario, sopravvivenza a 28 giorni, non si sono
registrate differenze significative; tuttavia il braccio PCT-driven risultava significativamente peggiore in termini di giorni
spesi in terapia intensiva (6 vs 5 p = .005), giorni di ventilazione meccanica (3.59 vs 2.81 p = .001), numero di giorni di
ricovero occupati da terapia con almeno tre farmaci (65 vs 75% p = .002), tempo medio di terapia antimicrobica corretta
(0.1 vs 0.8 giorni p =.02).
All’opposto, altri autori, valutando una popolazione di 119 soggetti con cause variabili di immunodepressione ricoverati
in terapia intensiva con condizione di sospetta sepsi, hanno verificato livelli di PCT all’ingresso più elevati nei soggetti con
successiva dimostrazione di infezione batterica rispetto a coloro in cui la stessa era stata esclusa (4.42 [1.60-22.14] vs 0.26
[0.09-1.26] ng/ml P < 0.0001). Valori di PCT inferiori al classico cut off di 0.5 ng/ml si rivelavano massimalmente sensibili
(100%) sebbene poco specifici (63%) per la diagnosi di infezione batterica. In ogni caso all’analisi multivariata valori > 0.5
ng/ml erano indipendentemente predittivi per sepsi ad eziologia batterica (Odds Ratio, 8.6; intervallo di confidenza 95%
2.53-29.3; P = 0.0006), mentre non vi era alcuna predittività riguardo la mortalità.
Questi risultati devono ovviamente essere letti con attenzione prima di giungere ad una conclusione definitiva circa l’utilità di PCT nel guidare le scelte terapeutiche in terapia intensiva, perché gli stessi disegni degli studi possono contribuire
alla variabilità dei risultati, ma certamente concorrono a mantenere ancora un certo livello di incertezza riguardo il suo
ruolo in questo ambito clinico, dove l’unico dato verosimilmente assodato è che la concentrazione di PCT non è di per sé
predittiva di mortalità.
Al di fuori dell’ambito intensivistico, dove il clinico ha normalmente a disposizione molti altri elementi per porre diagnosi di malattia da infezione grave, il ricorso alla determinazione routinaria di PCT sembra avere invece un ruolo più
importante nel definire linee comportamentali di prescrizione, specie in quelle nelle condizioni borderline dove gli elementi per porre diagnosi di infezione non sono decisivi. Due recenti esperienze sono il linea con questa affermazione: la
prima concerne il management della febbre del paziente neutropenico, contesto clinico dove tradizionalmente vengono
prescritte grandi quantità di antibiotici spesso in modo acritico, semplicemente a fronte dell’insorgenza di febbre. In 194
episodi febbrili occorsi in 90 pazienti neutropenici è stata studiata prospetticamente la cinetica di PCT, che è risultata
aspecificamente e mediamente elevata (valore medio 1.9 ng/ml) indipendentemente dalla presenza o meno di dimostrazione microbiologica di malattia; tuttavia valutando il valore di PCT a 48 ore dall’insorgenza della sintomatologia febbrile,
vi erano significative differenze in termini di concentrazione plasmatica in rapporto alla presenza o meno di infezione
microbiologicamente dimostrata ed altresì in rapporto al tipo di isolato: nelle infezioni documentate, causate da patogeni
diversi da Stafilococchi coagulasi negativi (spesso espressione di contaminazione durante la fase pre-analitica) il valore
a 48 ore era significativamente superiore rispetto ai pazienti con FUO senza diagnosi microbiologica (6.56 vs 2.05 ng/
ml p < .001); in più un livello superiore a 5 ng/ml in terza giornata occorreva in 17 su 21 infezioni fungine invasive, con
sensibilità e specificità diagnostica rispetto ai criteri EORTC-MSG pari rispettivamente ad 81 e 57%. Ancora, nei pazienti
con infezione fungina invasiva e risposta clinica si apprezzava una riduzione del valore plasmatico significativamente più
consistente e rapida. Pertanto pare ragionevole affermare che la determinazione di PCT in questo contesto, sebbene non
utile per l’impostazione terapeutica iniziale potrebbe invece essere uno strumento idoneo a guidare regimi di semplificazione terapeutica.
La seconda esperienza, riferita da un gruppo cinese, concerne ancora pazienti con polmonite di comunità, gestiti in regime
ambulatoriale: un piccolo gruppo di 172 soggetti è stato randomizzato per terapia in base al valore basale e/o al trend di
PCT secondo l’algoritmo proposto da Shueltz e collaboratori (che prevede un’indicazione a trattamento per valori > 0.25
ng/ml) ovvero secondo giudizio medico. In assenza di casi mortali in entrambi i gruppi, la percentuale di prescrizione di
antibiotici, il rischio relativo di esposizione e la durata totale del trattamento sono sempre risultati nettamente minori dove
la decisione è stata guidata dal valore di PCT.
Entrambi gli studi, oltre a ribadire il possibile ruolo di procalcitonina come strumento idoneo a guidare la decisone se
porre o meno in terapia un paziente, ne identificano ulteriori settori di utilizzo, sia nella semplificazione dei regimi terapeutici sia nell’accorciamento del tempo di trattamento. Questi aspetti sono di notevole importanza, in quanto all’interno
delle misure di stewardship antimicrobica trovano posto non solo criteri inerenti la decisionalità circa l’inizio della terapia
antibiotica, ma altresì quelli concernenti le modalità di sospensione. Quello dei criteri idonei a guidare la sospensione
della terapia antimicrobica è certamente uno dei campi di ricerca clinica meno esplorati. Molte linee guida di prestigiose
società scientifiche indicano ancora tempi di trattamento predefiniti per molteplici patologie, senza che vi siano evidenze
che sostengano tali affermazioni, e ciò dà adito a tempi di terapia spesso estremamente prolungati, dove il confine tra una
medicina basata sull’evidenza ed una medicina difensiva diventa estremamente sottile.
In un contesto ancora nebuloso, PCT potrebbe avere un ruolo estremamente importante, e già alcune evidenze portano a
sostenerne il valore. Nel corso dell’ultimo quinquennio sono stati infatti pubblicati i dati di almeno 6 trials randomizzati
finalizzati a verificarne l’utilità come strumento per guidare la interruzione terapeutica. Tutti sono stati condotti in terapia
Relazioni
17
Congresso Nazionale Interdisciplinare
Relazioni
intensiva e si sono proposti di confrontare protocolli di sospensione terapeutica basati sull’andamento di procalcitonina
verso lo standard of care, impiegando variamente come end points l’intensità dell’esposizione antibiotica, il tempo di ricovero in terapia intensiva, i tasso di recidiva di malattia da infezione, la mortalità.
La durata della terapia antimicrobica risultava significativamente ridotta nei soggetti dove la stessa era interrotta la terapia
in base al valore di PCT in 5 studi su 6. I pazienti nel braccio PCT-driven presentavano un incremento globale di giornate
di degenza prive di antibiotici che variava da 23 a 37%, una riduzione dal 21 al 38% della durata del primo ciclo di terapia
antibiotica ed una contrazione dal 20 a 23% dei giorni di terapia antimicrobica per 1000 giornate di degenza in terapia
intensiva. In due studi si registrava anche una riduzione dei giorni di degenza, mentre mai si documentavano differenze
significative in termini di mortalità.
Mediamente, infine, il costo della terapia antimicrobica per paziente risultava pari a 2597.94 dollari per i soggetti gestiti in
base all’andamento di PCT versus 3068.56 in quelli riferiti ad un management basato sullo standard of care.
Questi dati, unitamente a quelli prima riportati sono globalmente convincenti riguardo questa possibilità di impiego della
determinazione di procalcitonina, sebbene siano stati tutti prodotti in ospedali universitari nord europei, si riferiscano
solo alla terapia intensiva e manchino analisi farmaco economiche puntuali. Non è detto dunque che questi riscontri
siano del tutto esportabili fuori dalla terapia intensiva e/o in ospedali diversi da quelli universitari, e/o in contesti diversi
da quelli nord europei. In più al di fuori dell’ambito intensivistico è ancora da verificare se il concetto della stabilizzazione clinica, da tempo strumento condiviso per la semplificazione e la riduzione dei tempi di trattamento, sia più o meno
efficace rispetto a procalcitonina. È verosimile che l’uso combinato di entrambi, un parametro clinico ed uno bioumorale,
possa rappresentare la strada del futuro per razionalizzare un aspetto della terapia antimicrobica ancora dominato dall’empirismo. Ed è pertanto auspicabile che su di essi vengano costruiti i prossimi trials.
References
Dellit TH, Owens RC, McGowan JE Jr et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis
2007; 44: 159-77.
Schuetz P, Christ-Crain M, Thomann R et al. Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use
in lower respiratory tract infections: the ProHOSP randomized controlled trial. JAMA 2009; 302: 1059-66.
Jensen JU, Hein L, Lundgren B et al. Procalcitonin-guided interventions against infections to increase early appropriate antibiotics and improve survival in the intensive care unit: a randomized trial. Crit Care Med 2011; 39: 2048-58.
Bele N, Darmon M, Coquet I et al. Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients. BMC
Infect Dis 2011; 24, 11: 224.
Robinson JO, Lamoth F, Bally F et al. Monitoring procalcitonin in febrile neutropenia: what is its utility for initial diagnosis of
infection and reassessment in persistent fever? PLoS One 2011; 6: e18886.
Long W, Deng X, Zhang Y, Lu G, Xie J, Tang J. Procalcitonin guidance for reduction of antibiotic use in low-risk outpatients
with community-acquired pneumonia. Respirology 2011; 16: 819-24.
Nobre V, Harbarth S, Graf JD, Rohner P, Pugin J. Use of procalcitonin to shorten antibiotic treatment duration in septic patients:
a randomized trial. Am J Respir Crit Care Med 2008; 177: 498-505.
Stolz D, Smyrnios N, Eggimann P et al. Procalcitonin for reduced antibiotic exposure in ventilator-associated pneumonia: a
randomised study. Eur Respir J 2009; 34: 1364-75.
Hochreiter M, Kohler T, Schweiger AM et al. Procalcitonin to guide duration of antibiotic therapy in intensive care patients: a
randomized prospective controlled trial. Crit Care 2009; 13: R83.
Layios N, Lambermont B, Ledoux D et al. Usefulness of procalcitonin for the decision of antibiotic treatment in ICU patients.
Intensive Care Med 2009; 35: S82.
Schroeder S, Hochreiter M, Koehler T et al. Procalcitonin (PCT)- guided algorithm reduces length of antibiotic treatment in
surgical intensive care patients with severe sepsis: results of a prospective randomized study. Langenbecks Arch Surg 2009;
394: 221-6.
Bouadma L, Luyt CE, Tubach F et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units
(PRORATA trial): a multicentre randomised controlled trial. Lancet 2010; 375: 463-74.
Agarwal R, Schwartz DN. Procalcitonin to Guide Duration of Antimicrobial Therapy in Intensive Care Units: A Systematic
Review. Clin Infect Dis 2011; 53: 379-387.
Heyland DK, Johnson AP, Reynolds SC, Muscedere J. Procalcitonin for reduced antibiotic exposure in the critical care setting: a systematic review and an economic evaluation. Crit Care Med 2011; 39: 1792-1799.
Hayashi Y, Paterson David L. Strategies for Reduction in Duration of Antibiotic Use in Hospitalized Patients. Clin Infect Dis
2011; 52: 1232-1240.
18
The role of a general medical ward
Relazioni
F. Lari
In the last years Non-Invasive Ventilation (NIV) reached an important role in the treatment of Acute Respiratory Failure
(ARF). Prospective randomised controlled trials show improvement in clinical features (Respiratory Rate, Neurological
Score), pH and arterial blood gases and in particular clinical conditions (Acute Cardiogenic Pulmonary Edema, ACPE, and
acute exacerbation of Chronic Obstructive Pulmonary Disease, COPD), systematic reviews and metha-analysis confirm
reductions in the need for intubation and in-hospital mortality compared to standard medical treatment. Early application
and staff’s training seems to be determinant on NIV’s success. Even if the first important data on NIV come to studies
performed in Intensive Care Units (ICU), subsequently these methodologies of ventilation have been used with increasing
frequency in Emergency Departments (ED), respiratory wards and general medical wards. This for several reasons:
• increase of Elderly patients with various chronic diseases;
• increase of complicated clinical conditions in which endo tracheal intubation (ETI) and invasive ventilation lead to
poor outcomes (immunodeficiency, neoplasm ecc.);
• lack of bed places in ICU.
However, the use of NIV in general medical wards is largely incomplete, and is more significant in small and middle
size Hospitals where the absence of ICU forces the management of ARF with NIV in general wards for the first hours of
treatment. Aetiology remains one of the most important factors determining prognosis: different pathological mechanisms
sustain different clinical conditions and not in all cases the application of positive pressures to the airways is useful. ARF
due to acute exacerbation of COPD and ACPE is associated with a better outcome and stronger evidences in literature: the
addition of NIV significantly lead to lower “need for intubation” and lower mortality rate compared to standard medical
therapy alone. In ACPE Pts CPAP and bi-level ventilation seems to be similar in effectiveness: high positive pressure
inside the chest produces ventilatory and hemodynamic useful effects such as alveolar recruitment, increase of functional
residual capacity (FRC), decrease of pre- and after-load. The choice to use CPAP rather than bi-level ventilation depends
on the local experience and organisation. In COPD Pts bi-level ventilation is effective because: 1. external expiratory
positive pressure (EPAP or PEEP) contrasts the intrinsic end expiratory positive pressure (iPEEP) of these patients; 2.
an higher inspiratory positive pressure (IPAP or Pressure Support) decreases the work of breathing (WOB), reducing
Airway Resistance, improving Tidal Volume and alveolar ventilation. Hypoxemic ARF related to ALI/ARDS and severe
pneumonia show a worst outcome and controversial data in literature: for this reason it is not advisable to manage
these conditions with NIV outside the ICU and further studies are needed to support real advantages of NIV. NIV in
addition to standard medical therapy for the treatment of ARF due to COPD exacerbation and ACPE is feasible, safe and
effective also in a general medical ward if, after a correct selection of patients, staff’s training and a simple monitoring, it
results appropriate: its early application improve clinical parameters, arterial blood gases values and can prevent ETI, ICU
transfer and invasive ventilation, events related to high mortality rate, complications, longer hospitalisation. This should
encourage the diffusion of this type of ventilation in this specific setting. According to strong evidences in literature, NIV
should be considered a first line and standard treatment in these clinical conditions irrespective of the setting.
References
Plant PK, Owen JL, Eilliott MW. Early use of Non-invasive ventilation (NIV) in acute exacerbations of COPD on general
respiratory ward: a multicentre randomised controlled trial. Lancet 2000; 355: 1931-1935.
Bardi G, Pierotello R, Desideri M, Valdisserri L, Bottai M, Palla A. Nasal ventilation in COPD exacerbations: early and late
results of a prospective, controlled study. Europ Resp J 2000; 15: 98-104.
Bott J, Carroll MP, Conway JH, Keilty SE, Ward EM, Brown AM, Paul EA, Elliott MW, Godfrey RC, Wedzicha JA.
Randomized controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease.
Lancet 1993; 341: 1555-1557.
Barbe F, Togores B, Rubi M, Pons S, Maimo A, Augusti AG. Noninvasive ventilatory support does not facilitate recovery from
acute respiratory failure in chronic obstructive pulmonary disease. Eur Respir J 1996; 9: 1240-1245.
Lari F, Scandellari N, DeMaria F, Zecchi V, Bragagni G, Giostra F, DiBattista N. La ventilazione meccanica non invasiva nel
trattamento dell’insufficienza respiratoria acuta: efficacia ed applicabilità in reparto medico. Emergency Care Journal
2009; V, 5: 8-20.
UO Medicina Interna, Dipartimento Medico AUSL Bologna, Ospedale di San Giovanni in Persiceto
19
Relazioni
Acute medical unit or rapid intensive observation of
patients with intermediate risk of acute critical illness
G. Realdi, S. Giannini, P. Fioretto, F. Fabris, F. Simoni, G. Vettore, F. Tosato
Department of Medical and Surgical Sciences and Department of Emergency Care and Pronto Soccorso, Policlinico Universitario
and Azienda Ospedaliera of Padova
20
In acute care hospitals of these last decades it has been observed a great increase of emergency presentations, with
overcrowding of Emergency Departments and access to the wards, increased waiting times and length of stay, difficult
discharge, increased readmission rate and finally increased mortality. Breaking the steps of the patients pathways allows
to simplify the problems and to face the individual aspects of the complexity related to the management of patients in the
hospital. A variable percentage of patients indeed has to be considered at intermediate risk of acute conditions and needs
more care than that provided on a general ward. One solution proposed in the Anglo-Saxon world is the institution of
Acute Medical Units, otherwise defined with different terminology, being in Unites States called Adult Intermediate Care
Unit. The concept is a rapid intensive observation of the patients in acute hospital setting within Internal Medicine wards.
Acute Medical Unit has been designated as hospital wards specifically staffed and equipped to receive medical inpatients
presented with acute medical illness, from Emergency Department or from the Community services, for expedited general
internal medicine assessment, care and treatment, to discharge or transfer patients within 24-72 hours.
We describe the model of AMU experience in Internal medicine departments as proposed and adopted in Anglo-Saxon
countries, the methods of clinical approach and the practical organisation of the units in close collaboration with the
ED ward of our Hospital. Finally we report our experience at an Internal Medicine Department in Padova and the initial
results obtained during the first four months of the project. Our approach of intensive rapid observation of intermediate
risk patients admitted from the ED led to a significant reduction in the duration of hospitalization, without increasing
readmission rate after discharge and fatality rate. Factors significantly associated to a short hospital stay were a preserved
function and a lower number of previous admissions to the hospital. Several gray zones in the realisation and management
of the project were identified and the possible solutions are still matter of discussion and debate.
Clinical Policy: indicazioni e risultati del monitoraggio
ECG prolungato
F. Ammirati
Direttore UOC Cardiologia, Ospedale G.B. Grassi, ASL RMD
ILR is implanted subcutaneously under local anaesthesia and have a battery life of up to 36 months. This device has a
solid-state loop memory that stores retrospective ECG recordings, when activated either by the patient or a bystander,
usually after a syncopal episodeor automatically activated in the case of occurrence of predefined arrhythmias. Some of
these devices have the capability of transmitting the signals transtelephonically. ILR is used for:
• Patients at high risk after a conventional inconclusive diagnostic work-up;
• Patients at low risk at the beginning of the work-up or at the end of a complete clinical evaluation;
• Patients who have suspected recurrent neurally mediated syncope when the understanding of the mechanism of
spontaneous syncope may alter the therapeutic approach;
• Patients with bundle branch block (BBB) in whom paroxysmal AV block is likely despite negative complete
electrophysiological evaluation;
• Patients with definite structural heart disease and/or nonsustained ventricular tachyarrhythmia in whom a ventricular
tachyarrhythmia is likely despite a negative complete electrophysiological study (EPS);
• Patients with unexplained falls.
In a small series of highly selected patients, symptom-ECG correlation was achieved in 88% of patients within a mean of
5 months of implantation. Pooled data from nine studies, including 506 patients with unexplained syncope at the end
of a complete conventional investigation, show that a correlation between syncope and ECG was found in 176 patients
(35%); of these, 56% had asystole (or bradycardia in a few cases) at the time of the recorded event, 11% had tachycardia
and 33% had no arrhythmia.
Most recently, external and implantable device systems that are able to provide continuous ECG recording or 24 h loop
memory, with wireless transmission (real time) to a service centre, have been developed. Daily and warning reports for
predefined events are sent from the centre to the physician. Initial data showed that a mobile cardiac outpatient telemetry
system had a higher diagnostic yield than a patient-activated external looping event monitor in patients with syncope or
pre-syncope. The potential role of these systems in the diagnostic work-up of patients with syncope needs to be further
evaluated.
Relazioni
F. Brunato
Hand Surgery Department, AzULSS 15 Alta Padovana, Camposampiero, Padova
Traumatic lesions of the hand represent a disease frequently encountered in emergency departments. Statistics show that
about 10% of all emergency accesses are trauma of the hand and almost half of these injuries are hand wounds. The most
affected are males in the workplace, while female subjects suffer of superficial wounds made at home. The latest INAIL
data show that injuries to the hand, alone, account for about 30-40% of all accidents and this data rises as high as 50% if
we consider the accidents in the woodworking industry.
Given their frequency and impact on the population, it is essential that they are properly addressed. Faced with a wound
of the hand, it is necessary to understand the mode and mechanics of the trauma, to know the hand position at the time
of injury, perform a physical examination, assess an accurate active and passive motility, assess the sensitivity of the
affected area and compare it with the contralateral hand, for not being misled by false responses of the patient or their
hawksbill innervations. An initial diagnostic hypothesis on whether deep lesions is now possible. Only when a nerve
injury is excluded is possible to perform anesthesia to clean and/or irrigate the wound, to do deep tissue debridement
and to inspect in order to assess the true extent of the lesion. The emergency room doctor at each step has to decide
whether to deal definitively with the possible immobilization and tight follow-up, or temporarily by sending the patient
to a specialist. The experience of the physician, logistical and overcrowding situations, will be the basis of the decision,
knowing that the definitive treatment can be deferred even 24-72 hours, with the exception of vascular emergency. The
complexity of the hand lesions, the diagnostic difficulties due to the complexity of the anatomy depending on the affected
area, the appearance of a sometimes banal wound, often associated with inadequate knowledge of its structure, can lead to
frequent non-recognition or underestimation even of important diseases. Not suitable treatment can result with disabling,
severe and prolonged sequelae, which may have medico-legal implications, given the high functional value of this organ.
Only a precise timing of conduct in the performance of this urgency, allows an accurate diagnostic evaluation and a
correct therapeutic approach. The “early” recognition or the doubt of a possible lesion with referral to a specialist, are
the essential and decisive moments, in order to avoid or minimize damage due to post-traumatic stress and improve the
prognosis quoad valetudinem.
Algorithm for treatment of hand wounds in the
emergency department
21
Comunicazioni
A high sensivity troponin above cut off early after ER
admission as predictor of high short-term mortality
G. Alberto*, C. Runzo*, D. Vallino*, D. Cosseddu**, I. Talarico**, D. Somale**, M. Migliardi**, A. Soragna*
*Emergency Unit, AO Ordine Mauriziano, Turin, Italy
**Analysis Laboratory, AO Ordine Mauriziano, Turin, Italy
Objective
22
Troponin is the biological marker of choice for diagnosis of acute coronary syndrome, since it is produced and released
only by myocardial cells and elevated circulating levels are found in any pathological situation in which there is a heart
damage. Moreover troponin is known to be a marker of higher mortality, but the effect of the recent introduction of a new
ultrasensitive troponin assays has yet to be clarified. Aim of the study: to assess the role of our ultrasensitive troponin assay in predicting short-term mortality in a ED setting.
Methods
From October 2009 to January 2010 we retrospectively analyzed patients admitted to ER and requiring troponin assays
(troponin I AIA 360, TOSOH) according to hospital protocols and physician sight and we assessed the mortality at 90 days.
Results
1658 patients met the inclusion requirements, 227 (13,7%) of whom had a troponin above the cut off set by our internal
procedure (0.06 ng/ml) at the sample collected just after the ER admission visit and were immediately handled according
to initial diagnosis whereas 40 (2,4%) showed an above cut off troponin in a subsequent sample. The mortality at 90 days
in the first group was 13,7% vs 7,5% in the last group (p<0,01). The 90-day mortality was higher in female (16,9%) and
in patients suffering from disease other than acute coronary syndrome (23,5%), irrespectively of age and troponin levels
above the cut off.
Conclusions
High sensitivity troponin assay above the cut off seems to be a good predictor of short-term mortality independently from
levels and especially in female and for diagnosis other than acute coronary syndromes.
Treatment of pulmonary embolism with low
molecular height heparin: our experience
M. Barchetti, A. Ciuffreda, F. Leonardi, A. Parise, E. Gottardi
Unità Operativa di Medicina d’Urgenza e Pronto Soccorso (Resp. Dr. E. Gottardi), Nuovo Ospedale Civile, Sassuolo
Background: Low molecular weight heparin (LMWH) is a relatively new treatment for pulmonary embolism (PE).
Objective: In this study we aimed to investigate our experience with such a therapy. Methods: We retrospectively evaluated the
records of 57 patients with acute PE. Analysis involved demographic characteristics, severity of symptoms, diagnostic methods, echocardiography data, ECG signs, presence of deep vein thrombosis (DVT), outcome, 30 days follow-up. Results: From
1/1/2008 to 31/12/2010 57 patients were admitted to our department for PE: 43 women (75%) and 14 men (25%). The average
age was 75 years (from 19 to 87); the most frequent presentation symptom was dyspnea (82%), whereas syncope was present
in 12%. On admission 7% had hypotension (systolic pressure < 90 mmHg); 19% had severe tachycardia (cardiac frequency >
120 b/min); 23% had hypoxia (O2 saturation < 90%); 21% had dilatation of the right ventricle, 23 pts. had DVT (40,3%). In 11
pts. (19,3%) the PE was idiopathic, in 46 was secondary (80,7%). In 45 cases (79%) the diagnosis was made with spiral chest
computed tomography pulmonary angiography (CTPA), in 12 (21%) ventilation perfusion lung scan was performed. All pts.
received LMWH, in 3 cases inotropes (dopamine) were used to reach hemodynamic stability. Two (4%) patients died, and we
had 3 (5%) major hemorragic complications. 79% of the pts. were discarged with oral anticoagulation. The mean length of hospital stay was 6,4 days (1 to 14). At 30-days follow-up we observed 2 (4%) re-admission for respiratory problems. Conclusions:
In our experience treatment of PE with LMWH was safe and effective and according to the most recent international literature.
The role of bedside ultrasound in the diagnosis and
outcome of patients with acute respiratory failure
Comunicazioni
A. Bellone, MD, M. Etteri, MD, C. Bonetti, MD
UOC di Pronto Soccorso, Azienda Ospedaliera Sant’Anna, Como, Italy
Background
The impact of bedside ultrasound in the diagnosis and outcome of patients with acute respiratory failure is not well known.
This was a retrospective observational study conducted in the Emergency Departments (EDs) of two Hospitals of Como
(Sant’Anna Hospital and Valduce Hospital) over two years, investigating 256 consecutive adult patients with acute
respiratory failure. 108 patients (group A) had immediately a bedside ultrasound diagnostic test by expert investigastors at
the time of ED admission, whereas 120 patients (group B) were evaluated and managed without a preliminary ultrasound
diagnostic approach. The aim of our study was to evaluate the relationship between a bedside ultrasound evaluation in the
acute setting and the patient’s outcome and diagnosis.
Results
In-hospital mortality was significantly lower in group A compared with group B, respectively: 2 (1.8%) versus 6 (5%),
p < 0.01. In group A only nine patients (8.3%) compared with seventeen patients of group B (14.1%), p < 0.01, were
transferred to the ICU for monitoring and treatment; finally, the concordance between the initial and final diagnosis was
statistically significant in group A.
Conclusions
Our results show that the use of a bedside ultrasound in the ED at the time of the admission of patients with acute
respiratory failure is strongly recommended, because it provided an accurate diagnosis and it might be directly related to
the patients’ improved outcome.
The role of continuos positive airway pressure in
acute cardiogenic pulmonary edema with preserved
left ventricular systolic function: a preliminary study
A. Bellone, MD, M. Etteri, MD, C. Bonetti, MD
UOC di Pronto Soccorso, Azienda Ospedaliera Sant’Anna, Como, Italy
Objective
To compare the effect of continuous positive airway pressure (CPAP) in patients with acute cardiogenic pulmonary edema
(ACPE) with preserved or impaired left ventricular systolic function with regard to resolution time.
Methods
In a prospective, preliminary observational cohort study, eighteen patients with preserved left ventricular systolic function
(group A) and eighteen patients with systolic heart dysfunction (group B) with acute cardiogenic pulmonary edema,
underwent CPAP (10 cm H20) through a face mask with standard medical therapy after a morphological echocardiographic
investigation shortly before CPAP.
Results
Resolution time did not differ significantly between the two group of patients (64±25 min in diastolic group versus 80±33 min in
systolic group). One patient in preserved left ventricular systolic function group required endotracheal intubation (not statistically
significant). No patients died during hospital stay. Arterial blood gases improved after a trial of CPAP in both group of patients.
Conclusions
The results of this preliminary study show that resolution time is not significantly different in patients with ACPE with
preserved or impaired systolic function submitted to CPAP.
Methods
23
Comunicazioni
Boussignac CPAP for acute hypoxaemic respiratory
failure in community acquired pneumonia: use in a
general medical ward
F. Lari*, R. Bortolotti*, F. Giostra**, G. Bragagni*, N. Di Battista***
* UO Medicina Intera AUSL Bologna, Ospedale di San Giovanni in Persiceto
** UO di Medicina d’Urgenza e PS, AOU di Bologna, Policlinico S.Orsola - Malpighi
*** UO PS e Medicina d’Urgenza AUSL Ravenna, Ospedale di Faenza
24
Background
Hypoxaemic acute respiratory failure due to severe community acquired pneumonia may lead to acute respiratory distress
syndrome. Non invasive ventilation may improve blood gases and clinical parameters if compared with conventional
oxygen therapy but do not affect survival and need of intubation.
Aim
To verify the effect of a simple CPAP (continuous positive airway pressure) device (Boussignac) in patients with
hypoxaemic acute respiratory failure due to severe community acquired pneumonia in a general medical ward.
Methods
20 patients with PaO2/FiO2 <160 in conventional oxygen treatment (Venturi mask FiO2 60%) were enrolled and treated
with Boussignac CPAP: mean pressure was 9 cm H2O, mean FiO2 74%. All patients received conventional medical
treatment at the same time.
Results
14 patient improved in clinical (respiratory rate, Kelly score, heart rate, Figure 1) and gasanalytic parameters (Figure 2)
since the first hour of treatment (p < 0.05). 6 patients need intubation and conventional invasive ventilation in intensive
care unit: 2 of these died.
Conclusions
Boussignac CPAP, a simple device, may be useful in general medical ward to treat hypoxaemic acute respiratory failure due
to severe community acquired pneumonia unresponsive to conventional oxygen therapy.
Figure 1. Clinical parameters during CPAP treatment.
Figure 2. Gasanalytic parameters during CPAP treatment.
The management of acute respiratory failure in
general medical wards: the development of a bedside
trolley
Comunicazioni
F. Lari*, R. Bortolotti*, N. Scandellari*, V. Zecchi*, F. Giostra**, G. Bragagni*, N. Di Battista***
Background
In the last years Non-Invasive Ventilation (NIV) has reached an important role in the treatment of Acute Respiratory
Failure (ARF), improving clinical features and arterial blood gases and in particular clinical conditions, such as Acute
Cardiogenic Pulmonary Edema and acute exacerbation of Chronic Obstructive Pulmonary Disease, decreasing the need
for intubation and in-hospital mortality compared to standard medical treatment. NIV’s success seems to be determined by
early application, staff training and a good organization of the setting. Although the first important data on NIV are from
studies performed in Intensive Care Units (ICUs), subsequently these methodologies of ventilation have been successfully
used in Emergency Departments and general medical wards as a result of an increasing number of elderly patients with
various chronic diseases, complicated clinical conditions in which endo-tracheal intubation (ETI) lead to poor outcomes
(immunodeficiency, neoplasm ecc.), a lack of bed places in ICUs.
Aim
In order to improve the organization of the ward, to optimize the treatment of patients with ARF we developed a trolley
for NIV in which all the devices for ventilation, oxygenation, aerosol therapy are easily and quickly available at the bedside
of the patient (Figure 1).
Methods
In the rear panel we attached two IV drip poles used for IV therapy but also used to sustain two Venturi – like flow
generator for CPAP (Continuous Positive Airway Pressure) with oxymeters. On the top two ventilators are present,
a smaller one (domiciliary) and a bigger one (ICU ventilator): they are able to perform different kinds of ventilation
such as controlled (pressure and volume, generally used for intubated patients), assisted/
controlled, SIMV (synchronized intermittent mandatory ventilation), PSV+PEEP (Pressure
Support). In the front panel there are 4 drawer. In the first one there are sets to draw venous
or arterial blood sample, a pulse oxymeter and essential drugs (IV diuretics, IV steroids,
short acting beta 2 agonists). In the second drawer we put simple oxygen therapy devices:
nasal prongs, Venturi masks, reservoir masks, aerosol kits, 2-15 L/m flow meters. In the
third drawer we find CPAP complements such as facial masks, PEEP valves, circuits. In
addition a complete Boussignac CPAP system is present: 2-30 L/m flow meter, Boussignac
devices, a manometer. In the last drawer are present complements for ventilators: circuit,
nasal masks, facial masks, total face masks, helmets, aerosol kits. A check list is verified
every day.
Results
The management of every kind of ARF results simpler, easier and safer with this trolley:
every device needed is promptly disposable at the bedside of the patient and useless lacks
of time are avoided.
* UO Medicina Interna AUSL Bologna, Ospedale di San Giovanni in Persiceto
** UO di Medicina d’Urgenza e PS, AOU di Bologna, Policlinico S.Orsola - Malpighi
*** UO PS e Medicina d’Urgenza AUSL Ravenna, Ospedale di Faenza
Conclusions
This bedside NIV trolley, as far as the emergency trolley, could be useful in general medical
ward lacking in critical care areas in order to improve interventions in patients with ARF.
Figure 1. Bedside trolley for acute respiratory failure
25
Comunicazioni
Arterial Blood Gas Analysis to predict Outcome in
Acute Cardiogenic Pulmonary Oedema treated with
Non-invasive Positive Pressure Ventilation
R. Ferrari, F. Giostra, D. Agostinelli, F. Nastasi, M. Cavazza
UO di Medicina d’Urgenza e PS, AOU di Bologna, Policlinico S.Orsola - Malpighi, Dipartimento Emergenza/Urgenza, Chirurgia
Generale e dei Trapianti. Azienda Ospedaliero-Universitaria di Bologna; Università degli Studi di Bologna, Alma Mater Studiorum
26
Background
Noninvasive positive pressure ventilation (NIPPV) is a first line intervention in Acute Cardiogenic Pulmonary Oedema
(ACPO): robust evidence supports the efficacy and safety in reducing the need for endotracheal intubation (ETI) and
mortality.
Emergency Physicans (EP) need objective parameters as an adjunct to clinical judgement when deciding on managing
Acute Respiratory Failure (ARF). Arterial Blood Gas Analysys (ABG) is largely available in clinical practice in the
Emergency Department (ED) and showed promise to predict outcome in ARF treated with NIPPV.
Aims
To assess the role of ABG, since the early phases in the ED, in recognizing the response to treatment of carefully selected
and controlled patients with ACPO treated by NIPPV, and to predict the outcome.
Materials and Methods
Outcome as treatment failure was defined as hospital mortality and/or need for ETI and invasive mechanical ventilation
at any time.
Observational, prospective clinical study in the ED in a University teaching Hospital, during 5 months, including every
patient emergently admitted for ACPO according to EP early clinical indication to first-line NIPPV (referring to an
institutional protocol). Blood gas samples were evaluated at baseline just after admission, and in the early (1 to 6 hours)
phase of follow up.
Results
214 patients (media 1.42 / day) were included. Failure rate was 14.5% and success 85.5%. Results are showed in Table 1
and Table 2
Table 1. ABG parameters at time 0'.
ABG - 0
Failure
Success
Media (median, min, max)
PaO2
57.6 (53.7, 33.6, 126)
61.8 (56, 21, 154.7)
pH
7.330 (7.317, 7.146, 7.520)
7.323 (7.329, 7.017, 7.549)
PaCO2
50.6 (39.4, 27.5, 120)
51.8 (47.8, 20.5, 123.3)
HCO
25 (23, 13.1, 40.5)
25.6 (25.1, 12.3, 41.9)
SaO2
83.6 (88.8, 57.9, 100)
85.6 (87.8, 29.4, 99.8)
FiO2
0.29 (0.21, 0.21, 0.6)
0.31 (0.27, 0.21, 0.9)
P/F
211 (196, 104, 382)
211 (208, 42, 357)
3
Table 2. ABG parameters variation (delta) at time + 120'.
ABG ∆t 120’
(∆ 120’-0)
Failure
Success
∆ PaO2
12.6 (22.1, -37.8, 30,1)
15.3 (13.7, -81.6, 89)
∆ pH
-0.030 (-0.021, -0.225, 0.097)
0.074 (0.061, -0.029, 0.213)
∆ PaCO2
1.1 (1, -11.2, 16.5)
-8.2 (-6.9, -48.7, 2.1)
∆ HCO
-3 (-0.1, -25.2, 4.1)
1.2 (0.2, -5, 16.9)
∆ SaO2
6 (8.9, -17.6, 18.3)
4.8 (6.8, -80.2, 28.2)
∆ P/F
-5 (-14, -63, 91)
12 (31, -126, 181)
3
Conclusions
Our data show that, in patients with ARF due to ACPO and treated with NIPPV, ABG at presentation is not able to carefully
predict the outcome. After 60’ of NIPPV both groups (success versus failure) improved in ABG parameters without any
significant difference and with a similar delta. After 120’ patients in the failure group stop sustaining the correction in gas
exchange and the improvement in ABG parameters; we showed a significant delta increment in the success group. This
trend is confirmed after 3 to 6 hours.
In well selected ACPO patients, NIPPV improves gas exchange and avoids ETI. The improvement of ABG after 120’
initiating NIPPV is associated with success; these patients will likely benefit from continuation of NIPPV. The inability
to improve gas exchange after 120’ of NIPPV in ACPO is predictor of failure; these patients should be closely monitored
with a low threshold for ETI.
Observation units for syncope: an useful approach to
a challenging symptom
E. Pennacchio, S. Limauro, M. Martorano, M. Ricapito, G. Staffa, G. Viggiano, M. Autilio
U.O.C. Pronto Soccorso, Accettazione e Medicina d’Urgenza, Azienda Ospedaliera Regionale “San Carlo”, Potenza
Introduction
Syncope is a frequent cause of emergency department (ED) visit. Sometimes, a great effort is needed to make an accurate
diagnosis. The presence of an observation unit (OU) allows to perform a further evaluation of the patients with diagnosis
of indeterminate syncope after ED visit.
Aim of the study: evaluate the differences in the admission rate and diagnosis of syncope by comparing the data from 2003
(from 1th January to 30th June; OU unavailable) and 2010 (from 1th January to 30th June; OU available since 2006).
Design: before-after study.
Setting: Emergency Department of a community-based, 700-bed hospital.
Patients and methods
The data of 2003 were extracted from the ED manual report. The data of 2010 were extracted from the AIRO (Area
Informativa Ricoveri Ospedalieri) hospital software. In 2003: 25149 visits; syncope 681 (2.7%; M/F 316/365). In 2010:
20229 visits; syncope 398 (1.97%; M/F 211/187). Were admitted to the OU the patients with indeterminate syncope and
one of more of the following: cardiac disease, age > 45 years, secondary trauma, abnormal ECG findings, orthostatic
hypotension. All the patients had continuous ECG monitoring and routine blood tests. In patients with age > 65 years, the
carotid sinus compression was performed. Further tests (head CT scan, myocardial necrosis markers, echocardiography,
EEG) were performed in selected patients.
Comunicazioni
27
Comunicazioni
Results
In 2003 389/681 patients were admitted to the hospital wards (57.1%). In 2010 135/398 patients were admitted to the
hospital wards (33.9%). The difference was statistically significant (X2 = 53.21; p < 0,00001). In 2003 the following diagnosis
were made: neurally mediated syncope 275 (40.3%); cardiogenic syncope 115 (16.8%); neurological syncope 30 (4.4%);
orthostatic syncope 65 (9.5%); indeterminate syncope 196 (29%). In 2010 the following diagnosis were made: neurally
mediated syncope 200 (50.2%); cardiogenic syncope 48 (12%); neurological syncope 23 (5.7%); orthostatic syncope 80
(20.1%); indeterminate syncope 29 (7.2%); non-syncopal transient loss of consciousness 18 (4.5%). The difference between
2003 and 2010 of the patients with diagnosis of indeterminate syncope was statistically significant (X2 = 66.53; p < 0,00001).
Conclusions
Admitting selected patients with syncope to an OU with ECG monitoring allows to reduce the number of admitted
patients to hospital wards (by diminishing the number of patients with the diagnosis of indeterminate syncope). Risk
stratification is also more accurate after observation than after ED visit alone.
28
Short term prognosis of syncope and performance of
some of existing CDRs to identify adverse outcomes
versus physician judgment
A. Poggi*, E. Migliore*, V. Olocco**, P. Crida**, B. Tartaglino*
* Dipartimento di Emergenza-Urgenza, Azienda Ospedaliera Santa Croce e Carle, Cuneo
** Facoltà di Medicina e Chirurgia, Università degli Studi di Torino
Objective
To evaluate short-term (10 days) adverse outcomes in syncope and to assess if existing clinical decision rules performe
better than physician judgment in stratify the patient’s risk in the Emergency Department.
Methods
We screened 255 consecutive subjects aged ≥ 16 years who presented for possible syncope at our Emergency Department
between October and December 2010. We assessed short-term adverse outcomes (death, myocardial infarction, lifethreatening arrhythmia, acute pulmonary embolism, hemorrhage requiring blood transfusion, pacemaker insertion,
cerebrovascular accident, serious trauma, acute surgical procedures or endoscopic intervention) in all enrolled patients.
Results
After thorough work-up, 106 patients had neurally-mediated syncope (41.6%), 38 had orthostatic syncope (14.9%), 23
had cardiac syncope (9%), 1 had “neurologic” syncope (0.4%: a case of subclavian steal), 33 had unknown cause (12.9%)
(Figure 1). A total of 201 patients were included in the study (54 patients, 21.2%, had non-syncopal TLOC and were
excluded).
Causes of syncope
21,2%
orthostatic
41,6%
cardiac
neurologic
12,9%
0,4%
neurally med.
unknown
9%
14,9%
non-syncopal
Figure 1. Causes of syncope in
study population.
Hospital admission was decided for 65 patients (25.5%), whereas 187 patients (73.3%) were discharged.
Twenty-three patients of 201 (11.4%) experienced adverse outcomes in the 10 days after presentation: eight of them had
not been identifyied in the ED (Table 1).
Comunicazioni
Adverse outcome
Number of cases
Predictable in the ED?
Death
Hemorrhage
Pulmonary embolism
Myocardial infarction
1
2
2
2
Yes
No for either
No for one
Yes
Pacemaker
6
No only for one
Cerebrovasc. accident
2
No for either (1 discharged)
Trauma
4
Yes
Surgical procedures
4
No for 2 (1 discharged)
We retrospectively applied four Clinical Decision Rules (San Francisco Syncope Rule; ACEP Guidelines 2007; ESC
Guidelines 2009; Risk Factors from the STePS study) to the eight patients whose adverse outcomes were not expected in the
ED. We couldn’t apply ROSE Study Risk Factors because we hadn’t BNP concentration available for all the patients enrolled.
We found that none of CDRs can identify 100% of adverse outcomes: ACEP GL and STePS study Risk Factors identify 7
patients out of 8, SFSR and ESC GL 6 patients out of 8.
So the ED physician couldn’t identify 8 adverse outcomes, whereas CDRs seem to performe better missing only 1-2
adverse outcomes; but actually only 2 patients were discharged directly from the ED, the others being admitted.
The two patients discharged had respectively a stroke after 6 days and a transient ischemic attack after 7 days.
Conclusions
In our experience (with the possible exception of ROSE study CDR) an absolute CDR to direct syncope admissions is not
feasible, and no rule overrides physician judgment, supported by knowledge of existing Guide Lines (expecially ESC GL).
Cardiac adverse outcomes are more easily predictable than the others.
References
Quinn JV, McDermott DA, Stiell IG et al. Prospective validation of the San Francisco Syncope Rule to predict patients with
serious outcomes. Ann Emerg Med 2006; 47: 448-53.
Costantino G, Perego F, Dipaola F et al. Short- and long-term prognosis of syncope, risk factors, and role of hospital admission.
Results from the STePS (Short-Term Prognosis of Syncope) study. J AM Coll Cardiol 2008; 51: 276-83.
Huff JS, Decker WW, Quinn J et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting
to the emergency department with syncope. Ann Emerg Med 2007; 49: 431-44.
Moya A et al. ESC guidelines on syncope. Eur Heart J 2009.
Can chest ultrasonography becomes the only imaging
modality for minor thoracic trauma?
A pilot study
C. Paolillo*, E. Belotti*, C. Padalino**, I. Spallino***, R. Sbrojavacca***, C. Arici*
* Centro EAS Ospedali Riuniti di Bergamo
** Medicina Generale Sant’Antonio, San Daniele del Friuli
*** SOC di Medicina D’Urgenza e Pronto Soccorso AOU SMM Udine
Table 1. Adverse events - 10 days observation.
29
Objective
The aim of the study was to examine the concordance between chest ultrasonography (US) and chest radiography (RX) in
the diagnosis of pneumothorax (PNX), and emothorax (ETX) in patients with mild thoracic trauma.
Comunicazioni
Methods
A pilot study was conducted in ED of two different hospitals. We enrolled 96 (41 females and 55 males) consecutive patients presenting to the ED for mild thoracic trauma from november 2008 to august 2011.
Inclusion criteria were: not penetrating minor energy trauma according to ATLS criteria, age above 16 years old, GCS 15,
sPO2 > 95%, FR < 20, hemodynamically stable, not anticoagulated.
Chest US has been performed by trained emergency physicians at bedside in supine and in seated position, with linear
probe (7,5-10 MHz) for PNX and with convex probe (3,5-5 MHz) for ETX. We consider the absence of gliding and presence of lung point as diagnostic of PNX and we defined the ETX as the detection of pleural fluid. X ray has been performed
after US and in posteroanterior and anterolateral position.
Results
30
Because of the low incidence of PNX and ETX in this setting, the number of patient enrolled is unsufficient to estimate
sensitivity and specificity of US, we limited our analysis to a description of results.
In 5 of the 96 enrolled patients (5,2%) PNX has been diagnosed. In 2 cases both US and RX detected complicated PNX
with ETX; in other 2 cases both US an RX resulted positive for PNX; in 1 case US detected a small ETX missed by RX.
Conclusion
Our study suggests high concordance between US and RX in this group of patients. US could become the only routine
imaging modality for patients with mild thoracic trauma, howewer further, multicentric studies are needed to confirm
our suggestion.
NTproBNP role in chest pain early evaluation in an
Emergency Department compared to TnThs
P. Mulè*, G. Farina*, M. Kolletzek*, E. Beltrandi**, R. Motta**. M. Cavazza*
* UO di Medicina d’Urgenza e PS, AOU di Bologna, Policlinico S.Orsola - Malpighi
** UO Laboratorio Centralizzato Azienda Ospedaliero-Universitaria di Bologna; Policlinico Sant’Orsola-Malpighi
We studied 79 patients who reached our Emergency Department (ED) for chest pain of suspected ischaemic origin (CP).
On these patients it has been assayed TnT-hs (Roche-Elecsys 2010; normal value < 14 ng/l) and NTproBNP (Roche-Elecsys
n.v. < 300 pg/ml). Assays has been taken at admission, after 3 and 6 hrs. “Old” TnT assay (Roche Elecsys) was also done.
Clinical evaluation of CP has been made by Chest Pain Score (CPS) and showed a mean value of 5.7. Among these 79
patients, 70 had a CPS ≥ 4. Concerning to risk factors, TIMIs mean value was 1.5 as 36 patients had a TIMIs ≥ 2.
Among all the inspected patients, 8 have been increased TnT-hs values > 50% at the second assay after three hours and 3
others patients have increased their levels > 50% compared to the first assay at the 3rd sample. In 10 of these 11 patients
new “hs” assay – in association with clinical criteria - allowed the diagnosis of Acute Coronary Syndrome (ACS) while the
previously utilized TnT assay missed the diagnosis.
In these 11 patients NTpro BNP mean value on 1st sample was 608 pg/ml, but with a high variation rate (SD 690). After
three hours (2nd sample) NTproBNP concentration raised on a mean of 18%, with only 1 case of increase over 50%, which
is considered a significant threshold. Even considering 3rd sample just 3 patients have shown a significant increase of
NTproBNP serum levels.
In another group of 13 patients it has been found (at 1st assay) a TnThs serum concentration beyond the cut-off value of
14 ng/l. During observation TnThs did not change significantly its levels at 2nd and 3rd sample. In this group TnT values
have been considered related to other pathologies rather than ACS, and their levels were considered as signal of higher
cardiovascular risk.
In this group basal serum NTproBNP levels have shown very high variability (mean: 3006 pg/ml; SD: 2989). The increase
rate at 2nd and 3rd assay was too small to achieve clinical relevance.
This study, even if based on a narrow population, seems do not reveal any role – in terms of diagnosis accuracy and
earliness – of measuring NTproBNP levels in case of suspected ACS.
Spontaneous retroperitoneal haematoma in acquired
haemophilia syndrome
Comunicazioni
A. Bruzzone, R. Boverio, A. De Francisci, A. Chiappano, M. Marenco, C. Lauritano, M. Santoro, I. Casagranda
Emergency Department, Ospedale Civile S.S. Antonio Biagio e Cesare Arrigo, Alessandria, Italy
Abstract
Case report
We evaluated a caucasian 73 years old woman presenting in Emergency Department because of appearance of a painful
mass in right abdomen.
In anamnesis idiopathic arterial hypertension (in treatment with losartan) and diabetes mellitus (in treatment with
metformine and glicazide); recent deep venous thrombosis in treatment with subcutaneous low molecular weght haeparin
(LMWH), 100 UI per kg.
At admission BAP 100/60 mmHg, HR 130 bpm, SO2 98% at FiO2 21%, GCS 15, RR 25/min, TA 36C; clinical examination
was normal except for mucous pallor and tense right abdomen mass. Electrocardiogram revealed sinusal rhythm and
physiologic morphology, while arterial blood gas analysis was normal except for haemoglobin value of 81 gr/L.
Ultrasonographic bedside examination revealed presence of free-abdominal fluid, with inferior cava vein collassable at
inspiration of about 25%. Fluid resuscitation and analgesic therapy (morphine 0,1 mg/kg) was started.
Contrast enhanced computed tomography of abdomen revealed a paravertebral and retroperitoneal haematoma (diameter
20 cm) with signs of venous bleeding.
Transfusion of three units of packed red cells was suddenly performed, while LMWH was interrupted. Surgical referral
gave indication to medical therapy and clinical/radiologic follow up.
Biochemistry examination did not pointed out any pathological finding except for haemoglobin 92 gr/dl (after transfusion
of 2 packed red cells units), and aPTT ratio 1,71 (0.8-1.2).
Completed coagulation study (Table 1), pointed out diagnosis of “acquired coagulation factor VIII deficiency”; therapy
with concentrate of factor VIII, cyclophosphamide (900 mg weekly for four weeks), glucocorticoids (prednisone 1 mg/
kg), protonic pump inhibitors was performed, with complete resolution of coagulation disorder within ten days.
Table 1. Patient’s coagulation values at diagnosis
Test
Value
Unit
Range
PLT
Fibrinogen
aPTT
PT/INR
384.000
911
1,71
1.18
/ml
mg/dl
ratio
ratio
140-390
200-400
0.8-1.2
0.85-1.25
Factor IX
137
%
70-130
Factor VIII
22
%
70-130
Factor VIII inhibitor
1
UI/ml
vW:Ag
188
%
60-40
Discussion
Acquired inhibitors against coagulation factor VIII is a rare condition (about 1-4 per million/year) and it results in severe
life-threatening spontaneous or post-traumatic bleeding (about 90% of cases). The antibodies neutralize procoagulant
function and arise in individuals with no prior history of clinical bleeding. About half of the cases are associated with
postpartum period, autoimmune diseases, malignancy, infections or medications. Clinical manifestation includes
spontaneous bleeding into the skin, muscles or soft tissues or excessive bleeding during surgery. Hemarthrosis which
is the hallmark of congenital severe haemophilia A seldom occurs. The diagnosis of acquired haemophilia A is based
on the prolongation of aPTT (which does not normalize after the addition of normal plasma), reduced FVIII levels and
We present a case report of acquired haemophilia in a 73 years old woman presenting in Emergency Department with large
retroperitoneal haematoma and acute anemia due to venous bleeding; the identification of this coagulation disorder and
the availability of a specific treatment could effectively resolve this very uncommon pathological condition.
31
Comunicazioni
evidence of FVIII inhibitor (expressed in Bethesda Unit = BU). The treatment of acute bleeding episodes and the longterm eradication of the autoantibodies consist, despite of immediate transfusion therapy, in using rFVIIa (90 mcg/kg
every 2-6 hours) or activated prothrombin complex concentrate (FEIBA 50-100 IU/ kg every 8-12 hours) in patients
with higher inhibitor titer (> 5 BU); or raising the level of FVIII by administration of desmopressin (DDAVP 0.3 mcg/
kg) or concentrates of FVIII (40 IU/kg plus 20 IU/kg for each BU of inhibitor) in patients with low level of inhibitors (<
5 BU). Long-term management is necessary for eradication of inhibitors by immunosuppression (prednisone 1 mg/kg 3
weeks alone or in combination with cyclophosphamide 2 mg/kg). Other treatments such as intravenous immunoglobulin
(HD IgG 2 g/kg for 2 or 5 days), physical removal of antibodies (plasmapheresis or immunoadsorption), or anti-CD20
monoclonal antibody Rituximab has shown to be effective in acquired haemophilia.
Conclusions
32
Despite its low incidence rate, acquired haemophilia can be suspected in cases of spontaneous or excessive unexplained
bleeding in presence of alterated coagulation laboratory tests (PT, aPTT, INR). Combination of clinical presentation and
knowledge of coagulation cascade can bring to a correct differential diagnosis before referring to Haematology Unit for
definitive diagnosis (table 2).
Table 2. Simplifyed differential diagnosis of haemostasis disorder
PLT
Fibr
aPTT
PT/INR
D-dim
ATIII
Possible diagnosis
↓
=
=
=
=
=
Platelet deficiency
=
=
↑
=
=
=
Haemophilia A-B
Von Willebrand’s disease
Factor XI deficiency
=
=
=
↑
=
=
Vit K deficiency, dicumarolic therapy
=
=
↑
↑
=
=
Protrombin deficiency, Heparin therapy
Factor V, VII, X deficiency, LAC
=
=
=
=
=
=
Factor XIII deficiency
↓
↓
↑
↑
↑
↓
Disseminated intravascular coagulation
References
Elezović I. Acquired haemophilia syndrome: pathophysiology and therapy. Srp Arh Celok Lek. 2010; 138, supp. 1: 64-8.
Shetty S, Bhave M, Ghosh K. Acquired hemophilia A: diagnosis, aetiology, clinical spectrum and treatment options. Autoimmun
Rev. 2011; 10 (6): 311-6.
Franchini M, Lippi G. Acquired factor VIII inhibitors. Blood 2008; 112: 250-255.
Ambulatorio di follow-up del Pronto Soccorso. Analisi
di una esperienza e degli effetti sull’attività.
G Lauria*, O Cerrina**, B Tartaglino***
* Responsabile S.S. Pronto Soccorso (S.C. Medicina d’Urgenza e DEU) Azienda Ospedaliera S.Croce e Carle, Cuneo
** Coordinatore Infermieristico Dipartimento di Emergenza e Urgenza (DEU) Azienda Ospedaliera S.Croce e Carle, Cuneo
*** Direttore S.C. Medicina d’Urgenza e DEU Azienda Ospedaliera S.Croce e Carle, Cuneo
Il progressivo incremento del volume di attività dei servizi di Pronto Soccorso (PS), l’aumento della complessità dei
pazienti (pz) e la diminuzione dei posti letto costituiscono le principali criticità dell’attività nei Dipartimenti di Emergenza.
Ne consegue il sovraffollamento delle strutture, che rischiano di non poter assolvere adeguatamente i compiti istituzionali,
con riduzione della qualità delle cure, aumento del rischio clinico e notevole ripercussione negativa sul personale sanitario.
Per fronteggiare la situazione di crescente difficoltà, nel Dipartimento di Emergenza dell’A.O. S.Croce e Carle di Cuneo, in
accordo con la Direzione Sanitaria, si sono adottate molteplici soluzioni organizzative, di seguito indicate:
• aumento del numero dei Medici e degli Infermieri in servizio in PS nelle ore di maggior afflusso dei pazienti;
• potenziamento dell’attività di osservazione breve (OBI);
• realizzazione di un sistema preordinato che prevede l’attribuzione giornaliera di posti letto dedicati al PS da parte dei
Reparti di area medica;
• attivazione dell’ambulatorio di follow-up.
L’ambulatorio di follow-up ha assunto particolare rilevanza nell’ottica di favorire dimissioni protette e continuità delle cure
per le persone dimesse dal PS, dall’OBI e dalla Medicina d’Urgenza.
Comunicazioni
• Effettuare una rivalutazione clinico-diagnostica a breve termine di pazienti con patologia a media complessità e bassa
evolutività (es. febbre in pz immunocompetenti, polmonite classe PORT I-III; scompenso cardiaco moderato,
• FA non databile, TVP), evitando “ritorni programmati” in PS.
• Valutare l’esito di interventi/terapie praticati in PS (es. ferite complesse, drenaggio di ascessi).
• Migliorare la sicurezza della dimissione.
• Migliorare l’appropriatezza dei ricoveri.
Organizzazione
L’attività ambulatoriale è iniziata nel mese di aprile 2010, si svolge in locali dedicati attigui all’area di PS ed è prevista dal
lunedì al venerdì, per due ore al giorno.
L’accesso alla visita avviene tramite un sistema di prenotazione semplificato, attivo 24 ore, sette giorni su sette, su
indicazione esclusiva del Medico d’Urgenza che dimette il paziente.
Le visite vengono effettuate da un Medico d’Urgenza a rotazione, coadiuvato da un Infermiere dedicato alle attività
connesse al PS (ambulatorio dei codici a bassa priorità).
Sono previste anche prestazioni assistenziali e diagnostiche, quali medicazioni, ECG, prelievo per indagini di laboratorio
(con referto entro un’ora dall’esecuzione).
Tutta l’attività viene gestita in regime ambulatoriale con percorsi facilitati e rapidi, ma soggetta alle normative vigenti per
quanto concerne il pagamento del ticket.
Attività anno 2010/2011
Nel 2010 sono stati prenotati 373 pz, di cui 336 hanno regolarmente effettuato la visita, mentre nel 2011 sono stati
prenotati (dati aggiornati a settembre 2011) 486 pz di cui 434 effettivamente valutati (90%).
I pazienti ricoverati prima di effettuare la visita programmata sono stati 14/373 (3,7%) nel 2010 e 14/486 (2,8%) nel 2011;
di questi 28 ricoveri nei due anni, 17 (60%) si sono verificati entro 3 giorni dalla dimissione del PS.
Un solo paziente (< 0,5%), affetto da cardiopatia ipocinetica avanzata, giunto in PS per scompenso cardiaco, è deceduto
improvvisamente prima della visita programmata. Nell’anno 2011, altri 18 pazienti sono stati ricoverati dopo la visita di
controllo (4% del totale), di cui 4 entro 3 gg dalla visita.
Dopo circa sei mesi dall’attivazione dell’ambulatorio di follow-up, è stata eseguita un’indagine somministrando un
questionario anonimo ai medici coinvolti, relativo all’attività di PS e Med. Urg. Tutti i medici hanno compilato il questionario.
Per quanto riguarda gli items relativi all’ambulatorio di follow-up, il 90% dei medici interpellati ha ritenuto che tale
attività abbia incrementato la sicurezza della dimissione dei pz e l’85% ha dichiarato che l’invio in ambulatorio aveva
consentito anche la riduzione di alcuni ricoveri; in questi casi il 50% degli intervistati ha affermato che tale diminuzione
si poteva indicare con una percentuale percepita come significativa (> 25%).
Conclusioni
Dai dati in nostro possesso risulta che solo il 6% dei pazienti inviati in ambulatorio è stato ricoverato, prima o dopo la
visita, e si è registrato un solo decesso, mentre la compliance dei pazienti è stata estremamente elevata, con valori > 90%,
dimostrando il favorevole impatto dell’iniziativa su di essi. Inoltre, l’attivazione dell’ambulatorio di follow-up è stata
positivamente accolta dai Medici d’Urgenza, che lo ritengono uno strumento utile per la dimissione in sicurezza dei pz, in
quanto garantisce un’adeguata gestione clinica a breve termine, che potrebbe anche ridurre il numero dei ricoveri.
Bibliografia
Asplin BR, Magid DJ, Rodhes KV, Solberg LI, Lurie N, Camargo CA. A conceptual model of emergency department crowding.
Ann Em Med. 2003; 42: 173-80.
Barlas D, Homan CS et al. How well do patients obtain short term follow up visit after discharge from the emergency department?
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Obiettivi perseguiti
33
Comunicazioni
Incidence, clinical features and management of acute
allergic reactions: the experience of a single, Italian
Emergency Department
E.C. Lauritano, R. Boverio, G.L. Guido, M.C. Santoro, M. Marenco, I. Casagranda
Emergency Department, SS. Antonio e Biagio e Cesare Arrigo Hospital, Alessandria
Objective
Few data on the incidence, aetiology, clinical features and management of patients with acute allergic reactions presenting
to the Emergency Department are currently available. The aim of the study was to report the annual experience of a single
Italian adult Emergency Department about anaphylaxis.
Methods
This is a retrospective, case-based study of adult patients attending the Emergency Department in Alessandria, Italy, during
the years 2009-2010. We evaluated the medical records of patients satisfying diagnostic codes involving acute allergic
reactions. Incidence, demographic data, causative agents, clinical features, management and outcome were reported.
Results
In all, 390 patients with acute allergic reactions were evaluated during the year, corresponding to 0.7% of all Emergency
Department visits. Causative agents were recognized in 55.1% of patients and more commonly included drugs (26.9%),
insects (14.8%) and foods (8.9%). Cutaneous features were the single most common clinical presentation although two
or more clinical features were frequently reported (17.7%). Anaphylaxis was diagnosed in 4.6% of patients. After therapy
and a period of monitoring, 92.8% of patients were discharged directly from the Emergency Room, 7.0% were admitted
and one patient died, corresponding to a fatality rate of 0.2%.
Conclusions
Acute allergic reactions are common diseases referring to our Emergency Department. In the half of cases, a precipitant
agent was identified and cutaneous and/or mucosal changes were often the first feature. Most patients were definitely
treated and discharged but about 7.0% of patients required hospitalisation. Observation Unit and Intermediate Care Unit
were essential for clinical management of these patients.
References
Brown SG. Clinical features and severity grading of anaphylaxis. J Allergy Clin Immunol 2004; 114: 371-6.
Bochner BS, Lichtenstein LM. Anaphylaxis. NEJM 1991; 324: 1785-90.
Soar J, Pumphrey R, Cant A, Clarke S, Corbett A, Dawson P, et al. Working Group of the Resuscitation Council (UK).
Emergency treatment of anaphylactic reactions-guidelines for healthcare providers. Resuscitation 2008; 77: 157-69.
Sheikh A, Alves B. Hospital admissions for acute anaphylaxis: time trend study. BMJ 2000; 320: 1441.
34
Mild head injury in old patients: is the age an
independent risk factor in low risk patients?
Comunicazioni
A. Riccardi, F. Frumento, G. Guiddo, B. Spinola, M. Castelli, F. Robba, R. Lerza
S.C. Medicina e Chirurgia d’Accettazione e d’Urgenza-OBI, Ospedale San Paolo, Savona
Mild head injury (MHI) in adults is a common clinical problem in emergency department (ED) worldwide, but its
management is not homogeneous. Several guidelines had been produced in order to focus on the need of CT scans
for higher risk patients (see Figure 1). A long-standing debate is still going on about MHI in the elderly. Some authors
consider patient age (> 60 or 65 years) an independent risk factor, however the agreement on this issue is not complete.
According to Italian guidelines (IG, 2006), in patients older than 65 years with low risk MHI a CT scan of the head and
a short time of observation are recommended, but the high number of scans negative for intracranial complications
suggested to perform a retrospective study.
Figure 1. Clinical characteristics of minor head injury.
Matherials and methods
We performed a retrospective study retrieving patients over 65 years old evaluated in our ED in which a CT scan of the
head was performed for low risk MHI, between April 2004 and April 2010. We analyzed their CT scans of the head, and
in case of pathological finding related to trauma, we documented further follow up.
Results
Between April 2004 and April 2010, 2149 patients over 65 years were evaluated in our ED for low risk MHI: the mean
age was 81 years, 985 patients were male and 1164 were female. We documented 47 intracranial acute complications
on CT scan (2.18%) (Figure 2), but only 3 patients (0.14%) underwent surgical procedures. We analyzed our patients
according to different age groups (Figure 3): in 916 patients aged between 65 and 79 we documented 6 cases of positive
findings on CT scan (< 1%) and in 1233 patients older than 80 years we documented an increased rate of acute intracranial
complications (> 3%). 617 patients were in antiplatelet therapy: 22 of these patients (3.72%) had pathological acute
findings on CT scan (Odds Ratio 2.23).
Discussion
According to some authors, the age over 60-65 years is considered an indipendent risk factor for predicting a positive
TC scan in patients with MHI. Their assertion is obviously true, but the issue is the different criteria to define a MHI. In
Introduction
35
Comunicazioni
some studies, researchers include in MHI patients with a history of loss of consciousness, amnesia and other risk factors,
which are actually considered a striking recommendations for a TC scan. In our study, old patients with those risk factors
were excluded and the following retrospective analyses on eligible patients showed that the percentage of intracranial
complications was similar to that observed in younger patients.
2500
2149
2000
emergency care journal - organizzazione, clinica, ricerca • Anno VIII numero 1 • marzo 2012 • www.ecj.it
1500
1000
500
0
47
Patients
Intracranial complications
3
Surgical
procedure
Figure 2. MHI in elderdy (>65 years) from april 2004 and april 2010.
5%
4%
4%
3%
3%
2%
2%
1%
1%
0%
65-69 70-7475-7980-84 85-89 90-94 >95 overall
years year yearsyears years yearsyears
Figure 3. Intracranial acute complications - age distribution.
Therefore we can claim that selecting accurately the lack of risk factors, physicians could avoid to submit to TC scan a
large number of old patients, at least until 80. Our results are intriguing because of the possibility of markedly reduce costs
and the length of stay of many old patients in the ED. In very old patients and in the group receiving antiplatelet therapy,
neuroimaging is recommended because of the increased incidence of intracranial complications.
36
Ultrasound caval index as bedside predictor of
dehydration
Comunicazioni
A. Riccardi, B. Chiarbonello, M. Ghinatti, A. Dacol, P. Minuto, G. Guiddo, L. Corti, R. Lerza
S.C. Medicina e Chirurgia d’Accettazione e d’Urgenza-OBI, Ospedale San Paolo, Savona
Dehydration is a clinical problem frequently observed in emergency departments (ED), but it’s a difficult clinical diagnosis
because of the lack of specific signs. No single laboratory value has been found to be completely accurate in predicting the
degree of dehydration, however the concentration of blood urea nitrogen (BUN) and the ratio of BUN to serum creatinine (B/
Cr) appear to be among the most sensitive parameters. An invasive approach as the measurement of the central venous pressure
is a useful method to evaluate the intravascular volume status and expecially to monitor intravenous fluid therapy; recently, the
ultrasonographic measurement of the inspiratory collapsibility of the inferior vena cava (Caval Index, CI, see Figure 1) has been
reported as a useful non-invasive data which correlates to the central venous pressure. CI could also be a non-invasive marker of
low volume status for the emergency physician, thereby aiding the clinician in fluid management. The present study is performed
with the aim to explore the relationship between CI and B/Cr ratio in patients observed for the first time in an emergency room.
Materials and methods
This prospective, observational study was conducted at our ED, between November 2010 and January 2011. CI was
measured by two experienced emergency physicians in all patients evaluated during that period for medical or traumatic
causes, when the clinical picture indicated need of blood analysis. During the data collection phase, physicians performing
the measurements were blinded to blood sample results. Patients were ineligible if an ultrasonographic measurement of
the inferior vena cava could not be performed because of technical limitations, if the patients were intubated, or in case of
enlargement of the right cardiac cavity (as in case of right cardiac failure, either acute or chronic).
Results
During the observational period, 112 patients were considered eligible (59 female, 53 male, with a mean age of 63 years),
with a mean CI of 55.38% and mean B/Cr of 18.16. Our preliminary data suggest a good correlation between CI and B/Cr
(Pearson Index 0,76, p < 0.001, Figure 2), however we are waiting for a further statistical analysis.
Discussion
The close relationship between CI and the central venous pressure has been proven by recent studies. This observation
allows to use ultrasonography for aggressive fluid replacement in dehydrated patients, sometimes avoiding invasive
hemodynamic monitoring. Our study appears to support this statement because the measurement of CI seems to directly
correlate to B/Cr, which is considered an important marker of dehydration. Then bedside sonography can give the
emergency physician immediate information on patients’ volume status long before obtaining laboratory findings. This
can be a useful support in diagnosis and therapy especially in our time-dependent patients’ evaluations.
Utilizzo di una scala comportamentale ALGOPLUS
in soggetti inabili acomunicare verbalmente in un
dipartimento di emergenza
A. Allione, M. Orusa, L. Dutto, V. Olocco, P. Crida, B. Tartaglino
Department of Emergency, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy
Introduzione ed obiettivi del lavoro
Il dolore è il disturbo più comune nelle persone che si presentano in un Dipartimento d’Emergenza con una prevalenza
del 61% e l’oligoanalgesia è un fenomeno universalmente riconosciuto. Tuttavia, pazienti anziani con età maggiore di 65
anni che giungono in DEA inabili a comunicare rappresentano fino al 25 % del totale degli accessi (Hustey FM, Meldon
SW. The prevalence and documentation of impaired mental status in elderly emergency department patients. Ann Emerg Med
2002; 39: 248-253). Trattare il dolore in questa categoria di pazienti può rappresentare una sfida per il personale sanitario
medico ed infermieristico.
Introduction
37
Comunicazioni
38
Lo scopo del nostro lavoro è stato quello di valutare se l’utilizzo della scala comportamentale ALGOPLUS in soggetti
inabili a comunicare verbalmente l’intensità del dolore incida su una migliore gestione dell’analgesia in DEA.
Materiali e metodi
Pazienti con dolore acuto inabili a comunicare verbalmente sono stati sono stati randomizzati a ricevere la valutazione
del dolore con la scala ALGOPLUS. La scala comprende la valutazione: dell’espressione facciale (arriccia le sopracciglia,
smorfie, mascella serrata, sguardo fisso);
dello sguardo (sguardo fisso, distante; supplicante; pianto; occhi fissi);
del pianto (espressioni di dolore; gemiti; urla; ho male);
del corpo (protezione di una parte del corpo; rifiuto di mobilizzazione; immobilità);
del comportamento (cambiamento comportamentale, agitazione, aggressività).
Un punteggio maggiore o uguale a due è stato ritenuto il valore soglia per discriminare la presenza di dolore in soggetti
inabili a comunicare con una sensibilità del 87% e una specificità dell’80% (Rat P et al. Validation of an acute pain-behavior
scale for older persons with inability to communicate verbally: Algoplus. Eur J Pain 2010, doi:10.1016/j.ejpain.2010.06.012).
I pazienti sono stati arruolati secondo il metodo convenience sample, subordinatamente alla presenza dello sperimentatore
nel luogo della raccolta dati e in giorni random per ridurre al minimo i bias di selezione. L’end point primario è stato definito
come riduzione statisticamente significativa del punteggio ALGOPLUS in sede di dimissione confrontato con la valutazione
iniziale. L’end point secondario è stato definito come somministrazione di farmaci analgesici, in particolare di oppiacei ed il
tempo di somministrazione dei farmaci. È stata inoltre valutata la prescrizione di farmaci in sede di dimissione.
Risultati
Tra i 103 pazienti considerati eleggibili da novembre 2010 a giugno 2011, 17 non hanno partecipato e sono stati esclusi.
I rimanenti 86 pazienti sono stati randomizzati a ricevere valutazione del dolore con la scala ALGOPLUS (N = 43) o
trattamento convenzionale (N = 43). Le caratteristiche di base dei due gruppi erano sovrapponibili per età, sesso, scolarità,
stato coniugale e sede di provenienza. Degli 86 pazienti inabili a comunicare 19 (22 %) erano affetti da delirium e 67 (78
%) avevano un alterato stato cognitivo.
La differenza tra il livello di dolore medio tra ingresso in DEA e dimissione era significativa sia nel gruppo ALGOPLUS
(T0 2,97 ± 0,8 vs Tend 1,72 ± 0,9) (p = 0,0000) che nel gruppo di controllo (T0 2,79 ± 0,5 vs Tend 2,30 ± 0,8) (p = 0,001).
Quando i pazienti venivano seguiti con la scala osservazionale ALGOPLUS, il 48,8% (21/43 pazienti) riceveva analgesia,
ma solo l’11,6% (5/43 pazienti) riceva oppiacei.
Nei soggetti seguiti con il metodo tradizionale solo il 23,2% (10/43 soggetti riceveva analgesia e a solo il 9,3% (4/43) veniva
somministrata una terapia con oppiacei. I soggetti seguiti con la scala ALGOPLUS, pertanto, avevano una probabilità
maggiore di ricevere un analgesico rispetto al gruppo di controllo [3,15 (95% CI 1,2-7,9)].
Discussione e conclusioni
L’utilizzo della scala comportamentale ALGOPLUS ha un impatto significativo in termini quantitativi e di tempistica nel
trattamento analgesico delle persone afferenti in DEA inabili a comunicare. Si ritiene che la sua introduzione nella pratica
quotidiana possa significativamente contribuire ad una migliore gestione del dolore.
Tuttavia, è possibile che la conoscenza diretta ed esplicita del punteggio ALGOPLUS da parte del personale sanitario
abbia influenzato un loro più adeguato trattamento del dolore indipendentemente dalla scala ALGOPLUS in sé, in
considerazione della significativa riduzione finale del punteggio ALGOPLUS in entrambi i gruppi di trattamento.
Parole chiave individuate: Pain, Emergency Department, oligoanalgesia, Pain Assessment, ALGOPLUS Scale.
Oligoanalgesia in the Emergency Department:
recognizing the need of new clinical strategies for
acute pain management
E. Pennacchio, M. Carbone, M.G. D’Adamo, L. De Nicola, P. Delmonaco, G. Gaudino, L. Genzano, M.
Autilio
U.O.C. Pronto Soccorso, Accettazione e Medicina d’Urgenza, Azienda Ospedaliera Regionale “San Carlo”, Potenza
Introduction
Acute pain is the most common presenting symptom in the Emergency Department (ED); nevertheless, in this setting,
oligoanalgesia is known to be a very frequent problem.
Objective: to recognize the presence of oligoanalgesia in our ED. This is the background to develop new strategies for
acute pain management.
Design: retrospective study. Setting: ED of a community-based, 700-bed hospital.
Comunicazioni
Retrospective analysis of the first 3000 ED visits in 2011 (software AIRO, Area Informativa Ricoveri Ospedalieri), with
regard to the following indicators: A) assessment of pain intensity at triage using pain scales; B) number of patients
with moderate/severe pain who received analgesics; C) analgesic drugs used in the ED; D) average door-to-drug time in
patients with moderate/severe pain; E) number of patients with severe pain with door-to-drug time > 20 min.; F) number
of patients with moderate pain with door-to-drug time > 60 min.; G) number of patients who received a reassessment of
pain; H) number of patients who received a home prescription of analgesic drugs at discharge.
Patients with age < 12 years, chest or abdominal pain, severe headache (yellow code) and major trauma were excluded.
We identified 606/3000 patients (20.2%) with potentially treatable pain (68/606 yellow code 11.3%, 538/606 green code
88.7%). In patients with severe pain, diagnoses were the following: minor trauma 56 (82.5%); renal colic 9 (13.3%);
biliary colic 1 (1.4%); low back pain 1 (1.4%); other kind of pain 1 (1.4%). In patients with moderate pain, diagnoses
were the following: minor trauma 410 (76.3%); renal colic 16 (2.9%); biliary colic 11 (2.1%); low back pain 23 (4.2%);
headache 26 (4.9%); other kind of pain 52 (9.6%).
Results
A) All the patients received an assessment of pain intensity with verbal rating scale (mild, moderate, severe pain); B)
23/68 (33.8%) patients with yellow code and 97/538 (18.9%) patients with green code received analgesics; C) the drugs
used were the following (single doses): acetaminophen IV (45), ketoprofen IV (35), tramadol IV (3), diclofenac IM
(35), miorelaxants IM (20), antispastics IV (20), lorazepam OS (6), betamethasone IV (3), acetylsalicylic acid IV (1),
methylprednisolon IV (2), Oxygen (2); D) average door-to-drug time was 90.2 min. for yellow code (range: 7-679 min.)
and 93.7 min. for green code (range: 9-908 min.); E) 39% of the patients with yellow code who received analgesics (9/23)
had a door-to-drug time > 20 min.; F) 50.5% of the patients with green code who received analgesics (49/97) had a doorto-drug time > 60 min.; G) none of the patients received a reassessment of pain intensity; H) 22/37 (59.4%) patients
with yellow code discharged home received a clear prescription of analgesics. 314/490 (64%) patients with green code
discharged home received a clear prescription of analgesics.
Conclusions
As reported in previous studies, acute pain is undertreated also in our ED. Recognizing this problem could be the first step
to develop clinical pathways for pain management in this setting.
Pediatric triage applied to “children with special need
of care”: a pilot study
B. Cantoni*, S. Maiandi*, A. Selicorni**
* RN, Fond. IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, SITRA Area delle Pediatrie
** MD, Fondazione MBBM Ospedale San Gerardo Monza, Pediatric Genetics
Background
Children with special care needs have or are at increased risk for a chronic physical, developmental, behavioral or emotional condition and they also require health and related services of a type or amount beyond the one generally required by
children. Thanks to the important clinical and therapeutic innovations, today these children have an increasingly higher
perspective of living, therefore, more frequently, they turn to pediatric emergency services, as all other children, in order to
treat or to solve acute phenomena. Considering that these children have a pathological chronic clinical picture, this behavior causes issues of evaluation (either undervaluation or overvaluation) of the health problem that lead to an inadeguate
emergency color-code assignement during the triage phase.
The purpose of this study is to determine if triage cards, specifically designed for children with special care needs (containing information about the syndrome, the comorbidities most frequently found, the main complications and major causes
of death) may increase the accuracy of the color code assignment, ensuring specificity and sensitivity of the procedure as
well as giving a higher confidence to the triage nurse in charge of children with special care needs.
Patients and methods
39
Comunicazioni
Methods
In order to prove our theory, we conducted a prospective research project involving a triage nurse population that, through a pre-post tests methodology, had to apply the pediatric triage procedure on different simulated clinical cases related to
rare syndroms (Fanconi, Cornelia de Lange, Williams, Noonan, 22q11.2 Microdeletion, Down, Mowat-Wilson, Tuberous
Sclerosis, Noonan, Wolf-Hirshhorn). The collected data were processed using nonparametric tests (Fisher’s exact test
MxN) and the subjectivity of triage nurse regarding the application of the procedure have been developed through selfevaluation Likert 5-item forms.
Results
40
The analysis of the data shows that in 5 cases syndromes and triage cards are highly correlated (p < 0.0001) and in 2 cases
they are quite related (p = 0.0281). The cases without statistical significance, however, show greater sensitivity to award
the code linked to the correct identification of health problems and linked to a determination of overestimation of the
color code.
Discussion
Despite the correlation between the specific triage cards is not present for all syndromes considered, it is desirable that all
hospitals that accept children boards should adopt to improve the performance of triage nurses especially for the syndromes commonly treated into hospital organizations.
Ottimizzazione della profilassi antitetanica nei
pazienti con ferita in Pronto Soccorso mediante
l’utilizzo del Tetanos Quick Stick® (TQS)
M. Ricca, R. Melchio*, V. Peloponneso, L. Dutto, A. Allione, G. Martini, O. Cerrina, B. Tartaglino
S.C. Medicina d’Urgenza, Dipartimento di Emergenza e Urgenza, AO S.Croce e Carle, Cuneo
* S.C. Medicina Interna, AO S. Croce e Carle, Cuneo
Il tetano è una grave malattia prevenibile con presidi profilattici (vaccino ed immunoglobuline, IG), non sempre
somministrati in maniera corretta (spesso per l’anamnesi non puntuale o difficoltosa). È disponibile una metodica, il
Tetanos Quick Stick® (TQS), che permette di conoscere in 10 minuti (sensibilità 80% e specificità 100% circa) lo stato
di immunizzazione di un soggetto nei confronti del tetano. L’integrazione del TQS con le linee guida vigenti potrebbe
migliorare l’appropriatezza nella profilassi antitetanica non programmata, con ricadute anche in termini di costeffectiveness.
Disegno studio
È stato sviluppato ed applicato c/o il DEA dell’A.S.O. S.Croce e Carle di Cuneo un protocollo per la gestione delle ferite
traumatiche che contempla l’uso del TQS nei casi di ferite a rischio tetanico (almeno uno tra: occorsa oltre le 6 ore;
contaminazione terra, ecc.; morso/graffio di animale; ustione; ferita cronica, “da giardinaggio” o da punta; margini
laceri, necrotici o contusi; presenza di corpi estranei/pulizia difficile; denervata/ischemica; segni di infezione). In caso
di negatività del TQS si attua la profilassi a seconda dello stato vaccinale del paziente, mentre in caso di positività viene
omessa la somministrazione di IG.
Scopo: valutare affidabilità e ricadute in termini di cost-effectiveness derivanti dall’applicazione dell’algoritmo. Endpoint secondario è la valutazione epidemiologica della popolazione afferente al DEA in termini di prevalenza della
immunizzazione verso il tetano.
Risultati
Nello studio dal gennaio al giugno 2011 sono stati coinvolti 290 pazienti di età > 18 anni (62.7% ♂), 31.3% risultava di
età > 65 anni. Solamente 13 pazienti (4.4%) erano in possesso del certificato di vaccinazione; per 184 pazienti (63.4%) lo
stato vaccinale risultava “non noto” o “incompleto”, 76 (26.2%) riferivano l’ultimo richiamo ad oltre 10 anni, 21 (7.2%)
lo riferivano tra i 5 e 10 anni e 6 (2%) da meno di 5 anni. Il TQS è risultato positivo in 179 casi (61.7% del campione,
IC 95% 56-67%); di questi 114 rientravano nello stato vaccinale “non noto/incompleto”. Il TQS è risultato negativo nel
54.9% (IC 95% 49-60%) dei pazienti di età > 65 anni e nel 30,6% (IC 95% 25-35%) di quelli di età < 65 anni. Le ferite
a rischio sono state in totale 240 (82.7%), di cui 168 meritevoli, secondo il dato anamnestico, di vaccino + IG; il TQS è
risultato positivo in 94 pazienti (55.9% IC 95% 48-63%), in cui si è evitata la somministrazione di IG. Dei 27 pazienti con
anamnesi positiva per una corretta immunizzazione vaccinale il TQS è risultato negativo in 2 casi. Il costo stimato in base
al protocollo Ministeriale sarebbe stato circa 2540 €, quello effettivo (TQS + vaccino + IG) è stato circa 3155 € mentre
ricorrendo all’utilizzo del TQS in pazienti selezionati (età inferiore a 65 anni, senza certificato di vaccinazione) tale costo
scenderebbe a circa 2945 €, garantendo comunque una elevata appropriatezza della somministrazione di IG.
Comunicazioni
Conclusioni
Sviluppo di un protocollo sulla profilassi antitetanica
delle ferite traumatiche in Pronto Soccorso
M. Ricca, R. Melchio*, V. Peloponneso, L. Dutto, A. Allione, A. Sciolla, O. Cerrina, B. Tartaglino
S.C. Medicina d’Urgenza, Dipartimento di Emergenza e Urgenza, AO S.Croce e Carle, Cuneo
* S.C. Medicina Interna, AO S. Croce e Carle, Cuneo
Il tetano è una malattia causata da una tossina prodotta dal Clostridium tetani, gravata da elevata mortalità (39%),
per la quale esistono validi presidi profilattici (vaccino ed immunoglobuline, IG) che tuttavia non sempre vengono
somministrati in maniera corretta. Al fine di valutare lo stato di immunizzazione di un paziente nei confronti del tetano
(e quindi l’eventuale necessità di somministrazione di presidi specifici) si ricorre alla raccolta anamnestica, che pur
rappresentando il fulcro dell’albero decisionale sulla profilassi antitetanica non sempre è puntuale o di facile esecuzione
(basti pensare agli anziani o agli stranieri immigrati nel nostro Paese). È disponibile il Tetanos Quick Stick® (TQS), un
test immunocromatografico per la determinazione rapida degli anticorpi anti-tetano in campioni di siero, plasma o sangue
intero umano, che permette di conoscere in 10 minuti con un prelievo di sangue capillare lo stato di immunizzazione di
un soggetto nei confronti del tetano. Dalla letteratura è emerso che l’applicazione del TQS è sia affidabile (sensibilità 80%
e specificità 100% circa) che valida dal punto del rapporto costo-efficacia.
Obiettivo: il TQS potrebbe venire utilizzato dei pazienti con ferita traumatica in Pronto Soccorso come integrazione della
raccolta anamnestica al fine di ottenere un’ottimizzazione della profilassi antitetanica in tali pazienti (presidio “giusto” al
paziente “giusto”). È stato quindi sviluppato un algoritmo per la gestione di questi pazienti che contempla l’utilizzo del TQS®.
Tale algoritmo prevede:
• Determinazione dello stato vaccinale (non noto; ultimo richiamo da meno di 5 anni, tra 5 e 10 anni o oltre 10 anni,
ciclo vaccinale primario incompleto).
• Identificazione tra i pazienti di coloro i quali presentano una ferita con caratteristiche a rischio di tetano (presenza
di almeno una delle seguenti condizioni): non recente, occorsa oltre le 6 ore; contaminazione terra, feci ecc.; morso/
graffio di animale; ustione; ferita cronica; ferita “da giardinaggio”; ferita da punta; margini laceri, necrotici o contusi;
presenza di corpi estranei/pulizia difficile; denervata/ischemica; segni di infezione.
• Nei casi di ferita a rischio, oltre alle normali manovre dettate dal tipo di ferita, eventuale determinazione dell’immunità
nei confronti del tetano mediante esecuzione di TQS.
• In caso di ferita a rischio e negatività del TQS si attuano le normali manovre profilattiche (vaccino ed IG), mentre in
caso di positività viene omessa la somministrazione delle IG, procedendo ad eventuale somministrazione di vaccino
antitetanico a seconda dello stato vaccinale del paziente.
Il risultato atteso dall’applicazione di tale protocollo è quello di una razionalizzazione delle risorse con una maggior
appropriatezza dell’utilizzo delle IG (diminuzione del numero totale di IG praticate e conseguente riduzione dei costi e
del rischio di esposizione a potenziali malattie infettive o reazioni allergiche in pazienti non a rischio).
Bibliografia
Circolare n. 16 Prot. I.400.2/19/6367 del 11.11.96: Tetano: misure di profilassi.
Elkharrat D et al. Evaluation of a bedside immunotest to predict individual anti-tetanus seroprotection: a prospective concordance
study of 1018 adults in an Emergency Department. Emerg Med J 2010; 27(1): 36.
A fronte di un modesto aumento dei costi l’utilizzo del TQS consente un netto incremento dell’appropriatezza nella
gestione della profilassi antitetanica rispetto alle attuali indicazioni ministeriali basate unicamente sul dato anamnestico.
41
Comunicazioni
Heterogeneous management of tetanus risk in
traumatic wounds among different hospitals
C. Prevaldi*, E. Salvatico**, A. Guiotto**, G. Buffolo*, F. Laterza*
*U.O.C. di Pronto Soccorso e **U.O.C Farmacia Ospedaliera ULSS n. 10 Veneto Orientale, San Donà di Piave
Abstract
42
Unscheduled tetanus prophylaxis (UTP) used in the emergency room (ER) in patients with wounds is erroneous in 40% of
cases.
Recent studies have shown that the management of tetanus infection risk is heterogeneous. Only 54% of the physicians
recorded for each patient informations about the characteristics of the wound and the tetanus immunization history and only
1.5% of the physicians correctly adhere to guidelines on tetanus prophylaxis and immunization practices in traumatic wound
management.
This study evaluated the heterogenity in use of tetanus vaccines and antitetanus serum in Emergency Departments (EDs) of
three non-academic acute care public hospitals of an Italian North-East public health agency named ULSS 10 Veneto Orientale.
1 Methods: in order to measure the heterogeneity of tetanus risk in traumatic wounds we compared the consumption
of serum and vaccine in each ED, related to the total number of accesses to every ED in 2010. Also the different ratios
between serum and vaccines consumption have been evaluated.
2Results: the consumption and also the serum to vaccines doses ratios were highly heterogeneous.
3Conclusions: Our results show that management of tetanus risk in traumatic wounds is highly heterogeneous from one
hospital to another, although being part of the same health agency.
Our data so confirm similar data found in literature and the need of widely accepted protocols for management of UTP in ED.
Health and safety in emergency workers
N. Magnavita*, G. De Cassan**, L. Livigni***
* Istituto di Medicina del Lavoro e ** Servizio di Prevenzione e Protezione, Università Cattolica del Sacro Cuore, Roma
*** Cattedra di Medicina del Lavoro, Università di Roma Tor Vergata, Roma
The health and safety principles that inspire the European directives are born about 70 years ago in the Scandinavian
countries. Full employment and high levels of civilization of these countries have allowed the development of democratic
relationships between employers and employees. In Mediterranean countries, on the contrary, the high level of
unemployment has led to unbalanced relationships and have inspired an authoritarian model.
The authoritarian approach produces poor implementation of rules and the lack of verification of the effectiveness of the
process. Employees’ participation is often deemed unnecessary and the attitude of workers becomes “negotiation”. The
occupational hazard is not prevented, but monetized. Examples of this approach are: the recognition of the “cause of
service”, according to a law in force in Italy since 1895, and the “job burnout” that assumes “occupational factors that can
not be prevented”. These institutions are the opposite of prevention.
Another example of an authoritarian, not European setting of Italian laws, is the way in which the work-related stress is
addressed. While the incorrect compilation of Risk Assessment Document is criminalized, no national or regional action
to reduce stress in the workplace has been planned.
The most widely used method to assess stress, proposed by ISPESL/INAIL, is an algorithm that allows to evaluate the
emergency department of a hospital as a “stress free” workplace.
In fact, the literature indicates that work in emergency and first aid is objectively stressful, because it adds to all the
traditional stressors (such as workloads) and those typical of healthcare (the confrontation with death) also the need to
instantly switch from a resting to an alert state, when the patient needs it.
Job stress may also create a vicious circle. Indeed, stress increases the frequency of medical errors. Errors may cause
litigation, and the lawsuit against the doctor is a powerful stress factor (“Malpractice stress”).
The emergency workers are particularly exposed to biological risk, and musculoskeletal disorders. Even exposure to
chemical hazards and radiation can sometimes be done in emergency conditions that restrict safety.
The emergency workers are exposed to physical violence by patients and their friends or relatives. In an Italian health unit,
between 2005 and 2011, emergency personnel has a relative risk of physical aggression equal to 8.8 (95% CI = 3.8-20.5)
compared to those who operate in the services.
The consequences of violence are significant and persistent and may adversely affect the professional skills and care
provided.
In conclusion, we may state that emergency and first aid workers are exposed to many specific and relevant occupational
risks. Each hospital has a moral and legal duty to provide sustainable and verifiable health plans aimed at the prevention
of such risks.
Comunicazioni
Apparently pain-free aortic dissection in patients with
neurological symptoms
Accident and Emergency Medicine Department, San Giovanni and Paolo Hospital, Venice
Abstract
Aortic dissection (Ad) has to be considered in patients with acute thoracic or abdominal pain and accompanying
cardiovascular symptoms. However neurological symptoms at onset of aortic dissection are frequent (17-40% of the
patients) and may mask the underlying condition, especially in pain-free dissection (5-15%) with predominant neurological
symptoms. Therefore diagnosis of Ad can be difficult and delayed diagnosis can be fatal. Emergency physicians should be
aware of apparently pain free dissection.
We report two cases of patients who presented to our Emergency Department with shock and altered consciousness. In
both cases the patients did not complain of abdominal or back pain and there was no difference between peripheral pulses,
but after a thorough and fast examination in both cases we found some clues that helped us to find the correct diagnosis.
Introduction
Neurological symptoms at onset of aortic dissection (Table 1, 2 and 3) are not only frequent, but often dramatic and may
mask the underlying condition. Especially in pain-free dissections with predominant neurological symptoms diagnosis of
aortic dissection can be difficult and delayed. Chest pain is not an obligatory symptom of aortic dissection, the frequency
of pain-free dissections ranges between 5 and 15%. While Hagan et al. reported that most of their patients who presented
with stroke also gave a history of pain, Gaul et al. found that only 2/3 of patients with neurological symptoms at onset of
dissection complained of pain, whereas most patients without neurological symptoms (94.4%) experienced initial pain.
Extension of dissection to aortic
arch vessels
Reduced cerebral perfusion due to
general hypotension
e
Nerve compression by enlarging
false lumen
Stroke
TIA
TGA-like syndrome
Hypoxic encephalopathy
Horner syndrome
Cardiovascular syndrome
Seizure, altered consciousness
Table 1. Causes of central nervous system symptoms associated with aortic dissection.
Spinal cord ischemia due to
obstruction of spinal cord
supplying arteries
e
Paraparesis
anterior spinal cord syndrome,
Brown-Sequard syndrome,
progressive myelopathy or
transient spinal cord ischemia
Table 2. Causes of spinal cord symptoms associated with aortic dissection.
Obstruction of vasa nervorum
Compression of a nerve by the
enlarging false lumen
e
Ischemic neuropathy (paraparesis,
polyneuropathy,
mononeuropathy)
Ischemic plexopathy
Nerve compression syndrome
Table 3. Causes of peripheral nervous symptoms associated with aortic dissection.
A. Musumeci, M. Alzetta
43
Comunicazioni
We report two cases of patients
who presented to our Emergency
Department.
Patient 1: 82 y.o., female. Vital signs: BP
bilaterally 90/60, HR 74, SO2% 98%, RR
24, T 36C°. History of syncope a few
hours before being conducted to the
ED. Presenting symptoms: GCS 14/15
(E4,V5,M5), altered consciousness,
tense abdomen, pulsatile mass, not
painful. Patient unable to explain her
symptoms. No other previous history
available. Home medications: aspirin,
diuretic, Calcium antagonist, alpha
blocker. FAST: no free fluid, huge
abdominal aneurysm. Blood Sugar:
93 mg/dl, D Dimer 7,25 mcg/mL FEU
(normal range 0.00-0.50).
The patient was immediately sent to the
reference centre for vascular surgery
where she underwent an abdominal CT
scan that showed a 8,5 x 9,3 cm dissected
infrarenal abdominal aneurysm and
retroperitoneal hematoma (see Figure 1).
Immediately sent to the OR where she
underwent abdominal aortic repair.
Postoperative complications: kidney
failure. The patient is now on dialysis,
but has otherwise recovered well.
Patient 2: 83 y.o. female. Vital signs: BP
bilaterally 90/50, HR 70, SO2% 95%, RR 12, T 36C°. Presenting symptoms: sudden altered consciousness, slowed speech.
Signs: GCS 13/15 (E3, V5, M5), anisocoria (right > left) , deviation of the mouth (right > left). Patient unable to explain
her symptoms but when she was insistently questioned she complained of back pain. FAST: no free abdominal fluid.
TTE: no pericardial effusion. ABG: Lactate 2,3 . Blood Sugar: 107 mg/dl, D Dimer > 10 mcg/mL FEU. Immediate Brain
CT Scan and thoracoabdominal CT scan with iv contrast that showed a dissected type I (Class I) thoracoabdominal aortic
aneurysm and associated right carotid dissection (see Figure 2). Patient rapidly sent to cardiac surgery reference centre
where she underwent aortic replacement surgery. Recovery uneventful.
Conclusions
Diagnosis of aortic dissection can be very difficult because it may mimic stroke. The presence of shock associated to
neurological symptoms can suggest the presence of this disease.
References
Hagan PG et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;
283: 897-903.
Erbel R et al. Diagnosis and management of aortic dissection. Recommendations of the Task Force on Aortic Dissection, European
Society of Cardiology. European Heart Journal 2001; 22: 1642-1681.
Gaul C et al. Neurological Symptoms in Aortic Dissection: A Challenge for Neurologists; Cerebrovasc Dis 2008; 26: 1-8.
44
Circulating levels of matrix metalloproteinases
8 and 9 in patients presenting to the emergency
department with suspected aortic dissection
Comunicazioni
F. Giachino*, M. Loiacono**, M. Manzo**, S. Battista*, E. Saglio*, C. Moiraghi*, E. Lupia*, G. Mengozzi**,
F. Morello*
Background
In the Emergency Department, the diagnosis of aortic dissection (AD) is challenging, as the clinical presentation of AD is
heterogeneous and the available tools for rapid differential diagnosis of AD are presently limited. Circulating biomarkers
of AD are thus urgently needed to improve the diagnostic approach to suspected AD. Matrix metalloproteinases (MMP)
are expressed in the aortic extracellular matrix and have been implied in the pathophysiology of aortic dilation and
dissection. Preliminary studies have reported that circulating levels of MMP-8 and MMP-9 are increased in patients with
AD compared to normal controls (Figures A, B). However, the utility of circulating MMP-8 and MMP-9 in the diagnostic
approach to suspected AD in a clinical setting is presently unknown.
Methods
Circulating levels of MMP-8 and MMP-9 were measured by enzyme-linked immunosorbent assay (Amersham) on plasma
samples obtained from 58 consecutive patients presenting to the Emergency Department of the San Giovanni Battista
Hospital from January to June 2011 with clinically suspected AD. D-dimer levels were also routinely assessed. All patients
underwent angio-computed tomography to identify or to rule out AD. An aortic prosthesis was present in 6/27 patients
with AD and in 6/31 patients without AD. AD was diagnosed in 27/58 patients (15 type A, 12 type B) and ruled out
in 31/58 patients. In patients without AD,
the clinical diagnosis was acute coronary
syndrome (1/31), pneumonia (2/31), aortic
aneurysm without signs of AD (12/31) or
unspecific (16/31).
Results
Circulating levels of MMP-8 and MMP9 presented a significant correlation (r =
0.72, p < 0.0001), while neither MMP-8 nor
MMP-9 levels correlated with D-dimer levels.
Plasma MMP-8 levels were 42,2 ± 6,1 ng/ml
in patients with AD and 21,7 ± 4,2 ng/ml in
patients without AD (p < 0.01). Plasma MMP9 levels were 200,9 ± 30,4 ng/ml in patients
with AD and 119,2 ± 18,2 ng/ml in patients
without AD (p < 0.05) (Figure C). D-dimer
levels were 12,3 ± 2,6 ng/ml in patients with
AD and 1,9 ± 0,4 in patients without AD (p
< 0.05). Receiver Operating Characteristic
(ROC) curves were obtained for MMP-8
and MMP-9 as diagnostic markers of AD in
a clinical setting representing the emergency
department (Figure D).
Figures A, B. Circulating levels of MMP-8
and MMP-9 in patients without AD (CTRL)
and with AD (*p < 0.05). Figures C, D. ROC
curves of MMP-8 and MMP-9.
emergency care journal - organizzazione, clinica, ricerca • Anno VIII numero 1 • marzo 2012 • www.ecj.it
* S.C. Medicina d’Urgenza, A.S.O. San Giovanni Battista, Torino
** S.C. Chimica Clinica, A.S.O. San Giovanni Battista, Torino
45
Comunicazioni
Conclusions
Circulating levels of MMP-8 and MMP-9 are significantly higher in patients presenting to the Emergency Department with
AD and may help in the differential diagnosis of AD.
References
Li Y, Shao AZ, Jiang HT, Dong GH, Xu B et al. The prominent expression of plasma matrix metalloproteinase-8 in acute
thoracic aortic dissection. J Surg Res 2010; 163: e99-104.
Sangiorgi G, Trimarchi S, Mauriello A, Righini P, Bossone E et al. Plasma levels of metalloproteinases-9 and -2 in the acute
and subacute phases of type A and type B aortic dissection. J Cardiovasc Med 2006; 7: 307-315.
STEMI e rete interospedaliera: centri Hub e centri
Spoke, i tempi di trasferimento
C. Prevaldi, G. Buffolo, F. Laterza
U.O.C. Pronto Soccorso ULSS 10 Veneto Orientale, San Donà di Piave
I pazienti con STEMI secondo gli standard attuali devono essere sottoposti a riperfusione mediante angioplastica coronarica
primaria (PCI), se questa è attuabile entro 12 ore dall’insorgenza di sintomi, entro 90 minuti dalla presentazione (timeto-balloon inflation), da personale esperto (> 75 PCI/anno/operatore), in un laboratorio di emodinamica idoneo (> 200
PCI/anno di cui 36 primarie per STEMI).
Poiché buona parte delle terapie intensive coronariche (UTIC) in Italia (circa il 40% da un censimento ANMCO del 2000),
non dispone di emodinamica interventistica funzionante h/24 e quindi disponibile per le urgenze, le aziende sanitarie
devono trasferire i propri pazienti con STEMI nei centri che ne sono provvisti.
L’intervento focalizzerà l’attenzione sui dati dell’ospedale di San Donà di Piave, relativi ai tempi dalla chiamata al 118, o
dall’arrivo del paziente in PS, alla diagnosi, fino al trasferimento interospedaliero ed alla procedura di riperfusione, relativi
all’anno 2010. Dai tempi rilevati si denota un allungamento significativo dei tempi necessari alla riperfusione, sia intrache interospedalieri, nei pazienti giunti con i propri mezzi e sottoposti al triage di bancone, rispetto a qu elli giunti con il
canale del SUEM /118, e quindi in ambulanza. I tempi peggiori (2 pazienti), sono risultati correlati al numero di accessi,
al numero di uscite dell’ambulanza, e al numero totale di pazienti in carico al PS nel giorno in oggetto. Da questo studio
osservazionale retrospettivo effettuato nel nostro Pronto Soccorso, l’indicatore di riferimento (tempo di trasferimento per
la PCI primaria in caso di STEMI), risulta a volte correlato allo stato di crowding del Pronto Soccorso.
46

clinica e terapia - CG Edizioni Medico Scientifiche

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