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, Paolo Malerba, Jordan Giordani, Deborah Stassaldi, Carlo Aggiusti, Giuliana Martini, Giulia Arenare, Chantale Premoli, Giulia Bosio, Marco Lancelotti, et al.
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10032

Abstract:
We describe the case of a 64 years-old woman admitted to the Emergency Department of the ASST-Spedali Civili of Brescia with fever and gastrointestinal symptoms 10 days after the first dose of ChAdOx1 nCov-19 vaccine. Laboratory investigations showed severe thrombocytopenia and high D-dimer, while an abdominal CT scan reported a partially occluding thrombosis of the superior mesenteric artery. Following treatment with fondaparinux, immunoglobulins and high dosage steroid therapy, we observed a rapid improvement of patient’s conditions. An ELISA assay showed the presence of antibodies against heparin PF4-complex. Subsequent abdominal CT-scan showed the superior mesenteric artery thrombosis resolution, and the patient was finally discharged after 12 days of hospitalization. Several reports pointed to the venous system as the main district affected by Vaccine-Induced Thrombotic Thrombocytopenia (VITT), while a peculiar feature of this report is the involvement of the mesenteric arterial system. Further investigation of VITT’s pathophysiological mechanisms is mandatory to develop preventive strategies and effective treatments.
, Greta Barbieri, Veronica Salvatore, Francesco Salinaro
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10304

Abstract:
Dear Editors, The COVID-19 pandemic has highlighted several and wellknown limits of the Italian national health system, including the weakness of the territorial medical services and the absence of dedicated structures for patients affected by chronic or end-stage diseases in need of long hospitalization, or with social difficulties.
Emanuela Biscardi, Giuseppe Carpinteri, Pietro Castellino,
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9825

Abstract:
Circulating inflammatory mediators and cytokines play a pivotal role in the progression of sepsis, leading in turn to septic shock, organ failure and resistance to standard therapy. Blood purification therapies may be adjuvant treatment for severe sepsis, but results have been shown to be so far controversial. Recently, CytoSorb has achieved promising outcomes on reduction of cytokine blood levels, improvement of clinical parameters and mortality in sepsis, as well as in other acute conditions. It is mostly used in Intensive Care Unit (ICU), in isolated hemoperfusion, or inserted in other circuits in addition to Continuous Renal Replacement Therapy (CRRT), heart-lung machines and extracorporeal membrane oxygenation. We report a case of septic shock occurred in our Emergency Department-High Dependency Unit (ED-HDU), resistant to standard therapy and improved after CytoSorb, so avoiding ICU hospitalization.
, Valentina Brilli, Cecilia Lanzi, Luca Pratticò, Elisabetta Sarcoli, Maria Grazia Di Milia, Francesco Gambassi, Guido Mannaioni
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10037

Abstract:
Bupropion intranasal misuse potential should be considered in the suspect of sympathomimetic syndrome for illicit drug or medication intoxication. A 31-year-old man was admitted for intranasal misuse of 30 crushed tablets of bupropion with adrenergic mild presentation. Lorazepam infusion was started with complete clinical resolution. Further forensic investigations detected a bupropion serum and urine concentration levels at 18 hours from intake of 1905.26 ng/mL and 2001.57 ng/mL, respectively. This case of intranasal bupropion misuse shared only some features with oral overdose, despite a plasma concentration five times higher than the lowest toxic level. Nasal bupropion snorting in chronic users could have lower toxicity compared to other snorted stimulants but symptomatic treatment remains the gold standard for preventing complications. Bupropion misuse might rapidly become a concerning issue and monitoring by healthcare professionals is needed.
, , Andrea Tenci, Giorgio Ricci, Massimo Zannoni, Christoph Scheurer, Anton Wieser, Antonio Maccagnani, Antonio Bonora, Norbert Pfeifer
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10284

Abstract:
Closed chest traumas are frequent consequences of falls in the elderly. The presence of concomitant oral anticoagulant therapy can increase the risk of post-traumatic bleeding even in cases of trauma with non-severe dynamics. There is limited information about the differences between vitamin K antagonists and direct oral anticoagulants in the risk of post-traumatic bleeding. To assess differences in the risk of developing intra-thoracic hemorrhages after chest trauma with at least one rib fracture caused by an accidental fall in patients over 75 years of age taking oral anticoagulant therapy. This study involved data from four emergency departments over two years. All patients on oral anticoagulant therapy and over 75 years of age who reported a closed thoracic trauma with at least one rib fracture were retrospectively evaluated. Patients were divided into two study groups according their anticoagulant therapy. Of the 342 patients included in the study, 38.9% (133/342) were treated with direct oral anticoagulants and 61.1% (209/342) were treated with vitamin K antagonist. A total of 7% (24/342) of patients presented intrathoracic bleeding, while 5% (17/342) required surgery or died as a result for the trauma. Posttraumatic intrathoracic bleeding occurred in 4.5% (6/133) of patients receiving direct oral anticoagulants and 8.6% (18/209) of patients receiving vitamin K antagonist. Logistic regression analysis, revealed no difference in the risk of intrathoracic haemorrhages between the two studied groups. Direct oral anticoagulants therapy presents a risk of post-traumatic intrathoracic haemorrhage comparable to that of vitamin K antagonist therapy.
Daniele Coen, Ivo Casagranda, Mario Cavazza, Gianfranco Cervellin, Lorenzo Ghiadoni, Roberto Lerza
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10331

Abstract:
Since a few years ago health systems in the western countries have a new problem to face: being a Medical Doctor (MD), especially a hospital or a general practice physician, is less and less appealing for the young generations.
, Alessandro Cipriano, Stella Carrara, Stefano Spinelli, Francesco Cinotti, Francesca Foltran, Matteo Filippi, Ferruccio Aquilini, Michele Tonerini, Massimo Santini, et al.
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9859

Abstract:
SARS-CoV-2 management in Emergency Department: risk stratification and care setting identification proposal based on first pandemic wave in Pisa University Hospital Background: COVID-19 patients require early treatment and admission to an appropriate care setting, considering possible rapid and unpredictable to Severe Acute Respiratory Syndrome. Objective: A flow-chart was developed by a multidisciplinary team of Emergency Department (ED) clinicians, intensivists and radiologists aiming to provide tools for disease severity stratification, appropriate ventilation strategy and hospitalization setting identification. Methods: We conducted a retrospective application of our model on 313 hospitalized patients at Pisa University Hospital including 222 patients admitted to ED for respiratory failure between March and April 2020. Risk stratification score was based on respiratory and chest imaging parameters, while management strategy on comorbidities and age. Results: Age, comorbidities, clinical respiratory and arterial blood gas parameters, semi-quantitative chest computed tomography score were significant predictors of mortality (p<0,05). Mortality rate was higher in patients treated in intensive care units (26,5%) and undergoing endo-tracheal intubation (32,7%), compared to medical area (21,3%). We verified a good concordance (81,7%) between the proposed model and actual evaluation in ED. Outcomes analysis of subgroups of patients homogeneous for baseline features allowed to verify safety of our model: in non-elderly and/or non-comorbid patients (15% mortality) our scheme overestimates the risk in 30% of cases, but it suggests non-intensive management in patients with reduced functional reserve, elderly and with comorbidities (50% mortality). Conclusion: Correct management of respiratory failure COVID-19 patients is crucial in this unexpected pandemic. Our flow-chart, despite retrospectively application in small sample, could represents a valid and safe proposal for evaluation in ED.
, Fabio De Iaco
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9903

Abstract:
Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria ® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.
, Alessio Baldini, Luca Becheroni, Iacopo Cappellini, Barbara Balzarini, Francesco De Antoniis, Alessandra Ieri, Francesco Gambassi, Chiara Pagnini, Lorenzo Pelagatti, et al.
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9941

Abstract:
The Authors report an accidental gas exposure of Chlorine gas in a worker. This accident is very uncommon and can lead to important life-threatening conditions, such as Reactive Airway Disfunction Syndrome (RADS) and Acute Respiratory Distress Syndrome (ARDS) with important pulmonary disfunctions and even death. This syndrome results are reversible when a quick and appropriate intensive treatment is performed.
Sabri Selcuk Atamanalp,
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10294

Abstract:
Sigmoid Volvulus (SV) is principally treated with non-operative decompression, whereas it may require surgical management in some situations. Depending upon the treatment method, SV recurs in about one fourth of the cases, which doubles the mortality and morbidity rates. In this paper, we discuss the management and related recurrence of SV in the light of the largest single-center SV series over the world.
, Abdushakur Ndolo Kioko
Published: 20 December 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10217

Abstract:
Emergency Medical Service (EMS) is the system that organizes all aspects of medical care provided to patients in the pre-hospital environment and emergency department within hospitals. It comprises agencies and organizations (both private and public), communication and transportation networks, hospitals, highly trained professionals and a public aware on how to respond in emergencies. Kenya needs robust EMS due to the high prevalence of acute medical events such as COVID-19, natural and man-made disasters. The objective of this study was to assess utilization of ambulance services in Nairobi County. The study design was descriptive cross-sectional, using quantitative and qualitative research methods. Data was collected using interviewer-administered semi-structured questionnaires and key in-depth interviews from 14 ambulance services, 19 Emergency Care Centers (ECC), and community. Thirty-nine key informants were sampled using purposive sampling technique and 101 community members sampled using simple random sampling technique from 10 sub-counties. Data tools were pretested at Mukuru Kwa Njenga, a populous slum in Nairobi County. Approval to carry out the study was granted by the Ministry of Health, Kenya. Qualitative data was analyzed using NVIVO12 and quantitative data analyzed using descriptive statistics by use of SPSS vs 25 software. Findings are represented as frequencies and percentages. There were 14 ambulance service providers in the Nairobi Metropolitan Services area with a total of 42 ambulances. Forty-one ambulances were facility-based ambulances. All ambulance services had emergency numbers, and only 3 had short-toll free ambulance access numbers. There were 9 different ambulance dispatch centers in the county. Five ambulance services did not have a dispatch Centre. Public members were the first to assist in in 79% emergencies. There was low public awareness on available pre-hospital emergency care services and tollfree lines for emergency services. Ambulances utilization was also low.
Luca Pierantoni, , Carlotta Biagi, Andrea Scozzarella, Federica Camela, Marcello Lanari
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9615

Abstract:
High Flow Nasal Cannula (HFNC) is a noninvasive technique for respiratory support increasingly used in the pediatric wards for the management of respiratory failure. Few data are reported about the safety of HFNC. We describe the case of a 3-months-old infant admitted for acute bronchiolitis Respiratory Syncyctial Virus-related and treated with HFNC for severe respiratory distress. 12 hours after the beginning of HFNC a subcutaneous swelling of the neck, attributable to subcutaneous emphysema, became clinically evident. Radiological imaging showed pneumomediastinum with air leaking up to the neck. Patient was moved to PICU where he further worsened due to a mediastinal shift requiring drainage and mechanical ventilation. He was then progressively weaned from ventilation and was discharged from the hospital. Pneumomediastinum may occur during HFNC, particularly in moderate-severe cases of acute bronchiolitis. Patients undergoing HFNC should be strictly monitored in order to promptly recognize this complication and treat the child appropriately.
, Fabio Tansini, Konstantinos Christodoulakis, Manuela Giovini, Andrea Magnacavallo, Andrea Vercelli
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9847

Abstract:
We describe the case of a 68-year-old man with a known history of hypertension and diabetes mellitus presented to our Emergency Department, complaining of hematuria and vomiting in the last 12 hours, stypsis and urinary incontinence in the last week, and worsening hyporexia in the last 6 months. Bedside ultrasound documented a slight right pleural effusion with B lines in the middle and basal right field, gastrectasis, dilated fluid-filled bowel loops, potential signs of gas in the upper right quadrant, grade 3 bilateral hydronephrosis, and bladder globe. Abdominal CT scan confirmed the bilateral hydroureteronephrosis and showed the right kidney with Emphysematous Pyelonephritis (EPN) with extension into the perinephric and muscular planes for 24 cm, and initial EPN in the left kidney. A RT-PCR nasopharyngeal swab for SARS CoV-2 was negative. A diagnosis of ileum paretic, acute renal failure and urosepsis due to EPN was made.
, Naime Meriç Konar, Hacı Mehmet Çalışkan, Bedriye Müge Sönmez, Burak Çelik
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9812

Abstract:
People who emigrated from Turkey to European countries for work are called expatriate. It was aimed to analyze demographic characteristics of expatriate patients who presented to the emergency department, to compare satisfaction levels of emergency departments between their country of residence and Turkey, and to identify the factors that affect patient satisfaction. This descriptive study was conducted with questionnaires filled by face-to-face interviews in 150 expatriate patients who were living abroad, came to Turkey for vacation/annual permit and applied to the emergency department with any complaint. We found a statistically significant difference when we evaluated expatriate patients’ monthly average number of emergency department applies and their views on priority to apply to emergency departments for health problems, the cleanliness of emergency departments, attitude of doctors, security and receptionist/nursing staff towards patients in Turkey and in their country of residence. It has been found that expatriates prefer the emergency department more in our country and they are more satisfied in their country of residence in terms of the cleanliness of emergency department, attitude of doctors, security and receptionist/ nursing staff.
, Riccardo Brandolini, Laura Biondi, Claudia Corsini, Carlo Fraticelli, Rosa Sant'Angelo, Giovanni De Paoli
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9827

Abstract:
The aim was to study the number of accesses to the Emergency Room (ER) requiring psychiatric evaluation in the four months following the lockdown period for the COVID-19 outbreak (May 4th, 2020-August 31th, 2020). The study is a retrospective longitudinal observational study of the ER admissions of the Hospitals of Cesena and Forlì (Emilia Romagna region) leading to psychiatric assessment. Sociodemographic variables, history for medical comorbidities or psychiatric disorders, reason for ER admission, psychiatric diagnosis at discharge and measures taken by the psychiatrist were collected. An increase of 9.4% of psychiatric assessments was observed. The difference was more pronounced in the first two months after lockdown, with a 21.7% increase of number of ER accesses, while after two months numbers were the same as those of the year before. Admission with anxiety symptoms and history of psychiatric disorder decreased significantly. Moreover, there is an age trend with an increasing age of admission.
, Rachel O'Brien, Polly L. Black, Steff Lewis, Hannah Ensor, Matt Wilkes, Christopher McCann, Stewart Whiting
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9711

Abstract:
Continuous novel ambulatory monitoring may detect deterioration in Emergency Department (ED) patients more rapidly, prompting treatment and preventing adverse events. Single-centre, open-label, prospective, observational cohort study recruiting high/medium acuity (Manchester triage category 2 and 3) participants, aged over 16 years, presenting to ED. Participants were fitted with a novel wearable monitoring device alongside standard clinical care (wired monitoring and/or manual clinical staff vital sign recording) and observed for up to 4 hours in the ED. Primary outcome was time to detection of deterioration. Two-hundred and fifty (250) patients were enrolled. In 82 patients (32.8%) with standard monitoring (wired monitoring and/or manual clinical staff vital sign recording), deterioration in at least one vital sign was noted during their four-hour ED stay. Overall, the novel device detected deterioration a median of 34 minutes earlier than wired monitoring (Q1, Q3 67,194; n=73, mean difference 39.48, p<0.0001). The novel device detected deterioration a median of 24 minutes (Q1, Q3 2,43; n=42) earlier than wired monitoring and 65 minutes (Q1, Q3 28,114; n=31) earlier than manual vital signs. Deterioration in physiology was common in ED patients. ED staff spent a significant amount of time performing observations and responding to alarms, with many not escalated. The novel device detected deterioration significantly earlier than standard care.
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10135

Abstract:
What should be an Emergency Physician? A doctor and a man accustomed to extreme and courageous choices, able to decide quickly, capable of brilliant intuitions and strong standpoints, guided by great determination, self-awareness, enlightened by deep convictions and clear ideas, and an empathy that allows him to never lose his humanity and always know which side to stand on… I worked and had the privilege of being a friend of a great doctor with these characteristics.
, Erika Poggiali, Veronica Salvatore, Francesco Salinaro
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.10139

Abstract:
One of the greatest and most famous Greek philosophers, Socrates, believed that “here is only one good, knowledge, and one evil: ignorance”, but nowadays we can tentatively add that knowledge without sharing is like sterile ground. Today, social media play a central role not only in connecting people worldwide, but overall to access news and information, and for decision making.
Daniela Aschieri, , Cristina Maestri, Luca Rosato, Michela Giovanna Coccia, Paola Novara, Gianluca Lanati, Maria Teresa Di Dio, Cosimo Franco, Giuseppina Bisceglie, et al.
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9795

Abstract:
Hypercoagulability is a common complication of the systemic inflammation related to coronavirus disease 2019 creating debate within the critical care community on the therapeutic utility of Low Molecular Weight Heparin (LMWH). We collected data on consecutive patients with COVID-19 admitted to the Emergency Department of Castel San Giovanni Hospital, between February 29th and April 7th, 2020. Exclusion criteria were age <18 years, hospital stay <7 days, patients on dialysis and patients who had been transferred to other centers for which we could not collect data. Of the 257 patients included in the study, 49 (19.1%) died during hospitalization. We considered a wide set of variables as independent variables (age, sex, comorbidities and in-hospital treatments). We used a multivariate logistic regression model and, being heparin the only one therapy affecting survival rate, we compared prophylactic LMWH (p-LMWH) and Therapeutic LMWH (T-LMWH) groups. Kaplan Meier curve showed a higher survival probability in the T-LMWH and the difference between the two groups was statistically significant according to the log-rank or Mantel- Haenszel test (p< 0.0001). In a stratified analysis by ventilation type, the subgroup of patients who benefited from therapeutic LMWH was that in non-invasive mechanical ventilation. Using a multivariate analysis and adjusting for the drugs intake, TLMWH was the only therapy impacting on survival (HR 0.293, p <0.001). No fatal bleeding was observed. Therapeutic dose of LMWH in patients admitted to hospital with COVID-19 pneumonia was 70 associated with a decrease risk of intra-hospital mortality.
Giorgio Fiore, Carlo Gaspardone, Silvana Di Maio, Michele Oppizzi, Alberto Margonato
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9806

Abstract:
Acute coronary syndromes can develop with an unusual and challenging presentation. Kounis syndrome is a mostly overlooked Acute Coronary Syndrome (ACS) in the setting of anaphylactic or anaphylactoid reactions in response to an allergic insult that can lead to severe complications including cardiac arrest. A 52-yearold- man presented to the emergency department of our hospital because of acute transient loss of consciousness that developed some minutes after almonds ingestion. The complex diagnostic workup led to the diagnosis of vasospastic Kounis syndrome, an infrequent type of acute coronary syndrome, mostly overlooked, with challenging diagnostic and therapeutic features. Peculiarities on clinical presentation, the approach adopted by the emergency physician and the consultant cardiologist to achieve the correct diagnosis and our proposed management with a brief revision of the literature will be reported. Unusual clinical presentations of acute coronary syndromes represent part of the pitfalls that an emergency physician can face during the everyday practice. Prompt identification of these conditions is always struggling but of crucial importance to improve patient prognosis with a correct diagnostic work-up and therapeutic management.
Beatrice Vergnano, Serena Calcinati, , Annalisa Benini, Maria Rosa Pozzi, Luisa Verga, Jonata Pizzagalli, Paolo Bonfanti, , Giuseppe Foti
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9888

Abstract:
The pathogenesis of COVID-19 appears to be characterized by a dysregulated immune response. During the first pandemic wave in Lombardy, we started to administer glucocorticoids to some patients with severe respiratory failure requiring support with Continuous Positive Airway Pressure (CPAP) therapy. We retrospectively collected data to identify the effect of glucocorticoids in this COVID-19 particular population. With a multidisciplinary consensus, we administered to selected patients with severe COVID-19 disease (PaO2/FiO2 159±71 mmHg) 0,91 mg/kg/die of methylprednisolone equivalent dose after a median of 8 days of hospitalization. In our study we compared 57 patients from the steroid group with 123 from the control group: the event of invasive mechanical ventilation or death was reduced by 43% between steroid group and control group (19.3 % vs. 34.1 % respectively, p=0.001) and mortality was reduced by about 31% between steroid and usual care alone (15.8 % vs. 22.8 % respectively, p=0.011). Corticosteroids in selected COVID-19 patients may have a relevant impact on outcome, better profiling of the heterogeneity of this disease may be essential to guarantee the best treatment choices.
, Saltuk Buğra Kaya, Özge Can Bostan, Ebru Damadoğlu, Gül Karakaya, Ali Fuat Kalyoncu
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9848

Abstract:
The present study aimed to evaluate patients who were referred to adult allergy clinic due to allergic reactions after concomitant multiple intravenous-drug administrations in Emergency Department (ED). Between January 2017 and January 2019, patients admitted to our allergy clinic with hypersensitivity reactions to intravenous drugs administered in ED were included retrospectively. Fifty-seven patients who developed allergic reactions after intravenous drug administration in EDs were evaluated. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) were the most common cause of allergic reactions (n = 40, 70.2%). Skin Prick Tests (SPT) were positive in 6 (10.5%) patients. Drug Provocation Tests (DPT) were positive in 10 (17.5%) patients. No significant correlation was found between the total number of drugs in the intravenous fluid and the degree of allergic reaction (r = -0.145, p = 0.282). There was no statistically significant difference between the degree of allergic reaction and history of atopic disease (p = 0.579). In conclusion, concomitant administration of multiple drugs in intravenous fluids may increase the risk of allergic reactions.
, Roberto Ghezzi, Anna Chiara Cadonici, Paolo Dalino Ciaramella, Chiara Martes, Adriano Basile, Andrea Bellone
Published: 21 September 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9548

Abstract:
One of the most frequent cause of hypercalcemia is primary hyperparathyroidism, which can lead to systemic involvement and life-threatening conditions. We described a rare case of a parathyroid adenoma rupture with consequent bleeding and respiratory airway compression. An 84-year-old man presented to the emergency department complaining neck swelling and related dysphagia. A computer tomography of the neck revealed an extensive left lateral hematoma, and a neck ultrasonography evidenced a hemorrhagic parathyroid adenoma, later confirmed by a 99 mTc-MIBI scintigraphy. To date only 40 cases of ruptured parathyroid adenomas have been described in literature, however due to the possibility of massive bleeding and compression of the airways this diagnosis should always be ruled out. The rupture of a parathyroid adenoma is a rare, but possibly life-threatening event due to airways compression and hemodynamic instability. Testing for hypercalcemia and hyperparathyroidism is mandatory to obtain a correct diagnosis.
, Paola Bartolucci, Maria Luisa Matteucci, Luigi Gori, Alessandra Ieri, Francesco Gambassi, Roberto Baronti, Simone Vanni, Guido Mannaioni, Attilio Del Rosso
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9736

Abstract:
A 51-years-old male presented with drooling, hematemesis and diarrhea in emergency department after accidental ingestion of homemade aconitine tincture. Examination revealed shock and initial ECG showed atrial fibrillation. The patient suddenly developed a pulseless wide QRS complex tachycardia requiring resuscitation maneuvers. The rhythm varied from monomorphic ventricular tachycardia to torsade de point to ventricular fibrillation. Repeated direct-current cardioversions were unsuccessful. After intravenous electrolyte correction and anti-arrhythmic drugs administration, a last direct-current shock was finally successful. Bradycardia and ventricular excitability persisted over 12 hours with gradual normalization. Patient was discharged in normal sinus rhythm without any medication and on follow-up he was totally asymptomatic. With the increasing popularity of traditional medicine, clinicians should be alerted to the risk of herbal substances with low margins of safety like Aconitum in order to allow correct diagnosis and treatment. The general public should be educated that herbal medicine is not always safe.
, Paolo Bientinesi, Marta Monteverdi, Roberto Lerza
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9677

Abstract:
If acute carbon monoxide poisoning is a well-known emergency situation, this is not the case for chronic poisoning. The missed diagnosis of acute CO poisoning is a well-known problem but the identification of a chronic poisoning is very challenging. Knowledge and awareness of chronic poisoning is less defined and probably there is a great number of patients with undiagnosed chronic CO poisoning. It is possible that in case of missed diagnosis because of non-specific symptoms, chronic CO poisoning could be responsible for significant morbidity. We describe the case of a married couple who were rescued almost simultaneously, to show this clinical condition.
, Sergio Leonardi, Giovanni Cappa, Stefano Perlini
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9782

Abstract:
We describe a rare complication of COVID-19 long after infection in a 76-years-old man presented to the Emergency Department with dyspnea and palpitations. A 12-lead Electrocardiogram (ECG) showed sinus tachycardia PR depression in the inferior leads associated with an apparent pseudo ST elevation. In the absence of elevation of inflammatory indices, considering the lack of symptoms neither NSAIDs nor colchicine were prescribed, and the patient was referred for clinical follow-up. After ten days ECG documented initial reduction of the widespread concave STE and PR depression, and the 1-month follow- up visit, the patient was asymptomatic with unremarkable physical examination, and a 12-lead ECG showed almost complete normalization of the ST and PR segments. Although pericardial involvement after COVID-19 infection has been already described, the incidence of subclinical pericarditis has not and may have implications for the monitoring of patients with uncomplicated COVID-19 infection managed as outpatients.
, Eve Gaughan
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9562

Abstract:
Many medical disciplines reported a decline in patient attendance during the coronavirus pandemic. Our paper examines the effects that the coronavirus pandemic had on obstetric Emergency Department (ED) attendances in a tertiary maternity centre in the Republic of Ireland. A retrospective cross-sectional analysis was performed on administrative data regarding the number of obstetric patients attending the ED from January to July in 2019 and 2020. These numbers were compared to the number of reported coronavirus cases in Ireland as released in official government publications. A paired sample t-test was carried out to see if there was a significant difference in attendance in the obstetric ED in 2020 compared to in 2019. When COVID-19 cases peaked at 17,377 in April 2020, ED attendance showed their largest decline of 27%. The cumulative decline in ED attendances from January to July in 2019 to 2020 was 13%. However, this decline was not found to be statistically significant. In contrast to other disciplines, the COVID-19 pandemic did not cause a decrease in obstetric ED attendance.
, Caroline Howard, Mohamed Barakat, Ali Navi
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9718

Abstract:
Infections with COVID-19 can induce thrombophilia and increase the risk of thrombotic events. We describe a case of a 64- years-old male who presents with intermediate-risk pulmonary embolism and brachial artery thrombosis secondary to an undiagnosed patent foramen ovale and COVID-19 infection. The patient was successfully treated with thrombolysis and heparin infusions and was discharged home with long-term anticoagulation. Managing patients with multiple pathologies occurring concurrently requires effective inter-speciality working in order to take a holistic approach to managing the patient opposed to managing the conditions in isolation. This case report highlights how clinical guidelines can support decision making of the individual pathologies but working as a team will enable the best care.
Sanne Vonk, Jaap Leermakers, Susan J.J. Logtenberg, Sanjay U.C. Sankatsing
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9570

Abstract:
Emergency Department (ED) Length Of Stay (ED-LOS) is associated with quality of care, patient safety and treatment outcome. The aim of this study is to identify factors associated with ED-LOS of internal medicine patients and provide recommendations to shorten ED-LOS. A retrospective cohort study was conducted in a single center in the Netherlands. Anonymised data of 7,380 ED attendances from January 2016 to January 2018 were analyzed. Data included time of ED arrival and departure, sex, age, source of referral, triage category, first or consecutive visit and number of radiological examinations. Univariate analyses were used. Mean ED-LOS was 220 minutes. Factors which significantly prolonged ED-LOS were older age, source of referral, triage category, need for admission, first visit, number of radiological examinations, presentation in winter or spring and time of arrival (day and evening). Several patient and circumstantial factors are associated with ED-LOS. To shorten ED-LOS, we recommend to anticipate need for admission for older patients who arrive by ambulance and to create time slots in the radiology program and to restructure the morning report.
Fabrizio Giostra, Maria Grazia Mirarchi, Gabriele Farina, Ciro Paolillo, Catello Sepe, Francesca Benedusi, Andrea Bellone, Lorenzo Ghiadoni, Greta Barbieri, Massimo Santini, et al.
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9705

Abstract:
In Northern Italy the coronavirus infection has spread since February 2020: the increase in admissions of COVID-19 patients corresponded to a drastic decrease in admissions of regular patients to the Emergency Room (ER). This retrospective study was conducted by Academy of Emergency Medicine and Care (AcEMC). During the lockdown period the accesses were reduced by more than 50%, and in the following months of May and June 2020, there was a recovery clearly below (70%) previous year’s numbers. We have observed a drastic reduction in white and green codes, a fair reduction in yellow codes, while red codes remained stable. The decrease in access to the ER mainly concerned patients with low priority color codes, but also the reduction in the number of accesses of yellow and red codes, insignificant at a superficial glance, is notable. If we consider that yellow and red codes during the months of the lockdown included many patients with COVIDrelated respiratory insufficiency, it is evident that there was a clear reduction in the number of serious illnesses not COVID-related. This is certainly another serious consequence of the COVID-19 pandemic.
, Davide Bastoni, Mariachiara Ferrari, Dario Moretto, Federico Buttafava, Pau Mateo Ramos, Valentina Burzio, Jolanda Petri, Andrea Magnacavallo, Andrea Vercelli
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9708

Abstract:
In the COVID-19 era the real challenge for the Emergency Departments (ED) is to avoid the spread of the viral infection within the so called “clean area” of the emergency room and the hospital. Different protocols have been proposed and adopted in the EDs to quickly identify suspected COVID-19 patients and to correctly manage these patients, all based on clinical and epidemiological criteria. To the best of our knowledge, our pre-triage decisional making-process first integrates the pre-triage interview with pointof- care Lung Ultrasound (LUS) performed in the triage area. The aim of our study is to assess the sensitivity and specificity of our screening clinical and/or epidemiological criteria, and to investigate the role of LUS in the triage decision-making process during the “phase 2” of the COVID-19 Italian epidemic. Our study confirms the pivotal role of the triage in the decision-making process and the management of the entire ED, and it demonstrates that further studies are necessary to validate the role of LUS as tool to promptly identify COVID-19 patients, if combined with a correct pre-triage interview.
, , Andreas Synetos, Antonis Karanasos, Eleni Melidi, Kostas Toutouzas, Kostas Tsioufis
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9525

Abstract:
Research regarding the use of mechanical compressions in the setting of a cardiac arrest, either outside of or inside the hospital environment has produced mixed results. The debate whether they can replace manual compressions still remains. The aim of this review is to present current literature contemplating the application of mechanical compressions in both settings, data comparing them to manual compressions as well as current guidelines regarding their implementation in everyday clinical use. Currently, their implementation in the resuscitation protocol seems to benefit the victims of an in-hospital cardiac arrest rather than the victims that sustain a cardiac arrest outside of the hospital.
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9923

Abstract:
I have accepted the role of Editor of Emergency Care Journal with great enthusiasm. I wish to thank Ivo Casagranda, who will continue into the future in the role of Senior Editor (and my guide) and all previous Editors for the contribution made to this journal up to now. (...)
Massimo Salvetti, Sara Capellini, Paola Delbon, , Maria Lorenza Muiesan, Adelaide Conti
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9738

Abstract:
The management of an acute hemolytic event in a patient suffering from favism is based on transfusion support to ensure adequate tissue oxygenation. If this measure could not be pursued, in case of severe anemia the risk of death from multiorgan failure would be relevant. Most of Jehovah’s Witness decline transfusion of whole blood and its main components, even in life-threatening situations. In this context, the treatment of severe anemia in these patients still represents a challenge from both medical and legal stand points. Authors report a case of a Jehovah’s Witness suffering from favism who refused blood transfusion, surviving a severe event of critical anemia associated with acute renal failure, thanks to the application of alternative therapies. It is essential that clinicians know the medico-legal aspects in such situations and are able to act promptly to support the patient’s vital functions, by complying with his/her wishes.
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9436

Abstract:
Dear Editor, In 2020, global society was disrupted by the COVID-19 pandemic, which has confronted everyone with an unusual, unknown situation, an unprecedented humanitarian emergency. The sudden outbreak has put health systems under enormous pressure and has caused major organisational problems, operational uncertainties and ethical conflicts. In particular, health workers had to deal with the emergency in both their personal and their working lives. While we wanted and had to treat our patients, we risked and feared getting infected too. (...)
, Massimiliano Carrozzini, Giuseppe Tata, Claudio Francesco Russo
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9123

Abstract:
We describe an unexpected complication in a 46-years-old man affected by ischemic cardiomyopathy who received a prolonged mechanical cardiac support by means of right transaxillary Impella 5.0. The postoperative course was complicated by recurrent septicemia from multi-durg resistant Acinetobacter baumanii. He underwent implantation of venoarterial extracorporeal membrane oxygenation because of refractory cardiac arrest, followed by Impella removal that has been complicated by embolic stroke. The likely source of the embolus was a large thrombus inside the innominate artery. After a long-standing right transaxillary device implantation, particularly in patients with intercurrent septic episodes, a CT angiographic scan should be planned to exclude arterial thrombosis before removal of the transarterial device.
Annum A. Bhullar, , Amir Rouhani, Steven Lai
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9204

Abstract:
Spontaneous, atraumatic rupture of the spleen is an uncommon but potentially fatal cause of acute abdominal pain. Splenic abscesses are equally rare and can be a risk factor for spontaneous splenic rupture. We present a 45-year-old man with no past medical or surgical history who presented with acute worsening of left upper abdominal pain that had been present for months, who was discovered to have a ruptured spleen. Splenic abscess was discovered intra-operatively and was thought to have developed after dental work. Recognizing presenting features of spontaneous splenic rupture and understanding its potential causes, such as splenic abscesses, may prevent delayed or missed diagnosis and guide treatment, which typically includes emergent splenectomy.
Mobina Tahmasebivand, Hassan Barzegari, Mandana Izadpanah
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9082

Abstract:
This study aimed to evaluate the polypharmacy extent and the frequency and severity of drug interactions by evaluating inpatients in the emergency department. In this epidemiologicaldescriptive study, data were collected retrospectively by reviewing medical records of 92 hospitalized patients in the emergency department with a stay over 48 hours. Out of the study population, 54.3% and 45.7% were respectively male and female, with a mean age of 59.09. In terms of hospitalization, 27.2% and 16.3% were hospitalized due to heart problems and trauma, respectively and the mean length of hospitalization was 3.91 with a standard deviation of 2.57 days. The mean drug received was 8.48, with a standard deviation of 4.48. Of the patients, 81.5% received more than 5 drugs; in addition, the observed amounts of drug interactions of A, B, C, D, and X were 2.5%, 17%, 59.3%, 19.5%, and 1.9%, respectively. The drug interaction prevalence in inpatients in the emergency department was high. The presence of a pharmacist is necessary to identify drug interactions and reduce drug-therapy problems to provide quality services.
, Stefano Geniere Nigra
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9226

Abstract:
We describe a case of 83-years-old women admitted to the Emergency Department after massive ingestion of slow release Oxycodone pills for suicidal purpose. After gastric lavage only few tablets has been retrieved and Naloxone infusion was necessary. After 2 hours from drug ingestion Esophagogastroduodenoscopy (EGDS) was performed and a number of tablets have been removed. Intoxication symptoms completely resolved and Naloxone infusion has been stopped. The clinical courses of this intoxication suggest that the utility of EGDS to remove tablets should be considered in selected cases of drug poisoning.
Massimo Salvetti, Anna Paini, Efrem Colonetti, Claudio Mutti, Silvia Bonetti, Alberto Broggi, Fabio Bertacchini,
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9150

Abstract:
The aim of this study is to assess practice and effectiveness of Peripheral Venous Catheter (PVC) insertion and intravenous fluid administration in the Emergency Department (ED). A prospective study was conducted at a single primary ED in Brescia, Italy. 455 participants were included in the analysis. PVC were placed in 88 % of patients, 18 gauge catheters were the most frequently used (63%). In 360 patients PVC placement required one attempt. In 99 % of patients PVCs were used at least once. Fluid administration was considered appropriate in 23 patients. Out of 402 PVC placements, 244 were not necessary (in 225 patients PVCs were used only for blood samples withdrawal, and in 16 patients they were used for blood samples withdrawal, and inappropriate fluid administration). We concluded that a large number of PVC placements in the ED was potentially avoidable, and, when PVCs were used for IV fluid administration, the indication was often inappropriate. Physicians should carefully assess the real need of PVC placement in patients admitted to the ED and critically assess some issues of everyday practice, like PVC placement or IV fluids prescription, with evaluation of cost savings.
Paolo Groff, Giuseppina Petrelli, Paolo Giorgini, Roberto Pilotti, Vito Maurizio Parato, Andrea Fabbri
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9502

Abstract:
FEV1-based Chronic Obstructive Pulmonary Disease (COPD) severity does not account for the complexity of the disease. Recent studies point to the high frequency of comorbidities responsible for unfavorable outcomes. There is a lack of data on this concerning the patient evaluated in the emergency setting. Aim of the study was to prospectively evaluate patients admitted to the ED for “exacerbated COPD” to describe their clinical heterogeneity and the influence that it may have on outcomes: death, length of hospitalization, exacerbation recurrence. The following data were recorded: history, symptoms, blood gas analysis, laboratory and radiological findings and comorbidities. Each patient underwent electrocardiography, echocardiography and spirometry. In order to identify a correlation between these variables and the selected outcomes, a multivariate linear logistic regression analysis was carried out. This study was conducted on 41 eligible patients consecutively admitted to the emergency room for exacerbated COPD. A consistent proportion showed ECG, Echocardiographic and laboratory abnormalities. At spirometry a FEV1 7 days. Our study shows that the term “exacerbated COPD” underscores a heterogeneous population, with a high prevalence of cardiovascular comorbidities, which significantly influence outcomes. Multicenter studies are needed to better investigate the clinical relevance of these findings.
, Iolanda Parente, Thailjlia Gagliardo, Anna Bonadies, Raffaele Mancusi, Vincenzo Tipo, Eduardo Ponticiello
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9089

Abstract:
Methemoglobinemia is an alteration of the oxidative state of hemoglobin. When methemoglobin values rise above 10%, the symptoms and signs related to this condition appear, such as cyanosis, respiratory problems, fatigue and headache. Acquired methemoglobinemia is characterized by the sudden onset of cyanosis in a previous healthy child, which can be due to exposure to medications or chemical substances including nitrates, copper, sulfates, chlorites, chloramines and chlorates which can be present in food and water. We illustrate two cases of acquired methemoglobinemia related to nitrate ingestion from a vegetable source.
, Giovanni Cappa, Bruno Barcella, Stefano Perlini
Published: 18 March 2021
Emergency Care Journal, Volume 17; https://doi.org/10.4081/ecj.2021.9747

Abstract:
In late January 2020, the first cases of Covid-19 were diagnosed in Italy. A month later the epidemic broke out in Lombardy bringing along dire consequences. Up to January 23rd 2021, the region counted 522,000 cases, and 26.518 deaths on a population of nearly 10 million. For many weeks thereafter tens of emergency COVID-19 patients were admitted every day through the ED requiring further adjustments in the organization of the Hospital, always in close cooperation with the out-of-hospital Emergency network. Among these, important and time-sensitive changes took place in the role of Residents in Emergency Medicine. As residents who worked through the first and second wave of the Sars-CoV-2 pandemic in the Emergency Department, we would like to discuss the consequences of our massive involvement on the front line of the healthcare effort to fight it.
, Antonietta Giannattasio, Geremia Zito Marinosci, Eduardo Ponticiello, Margherita Raffaella Iodice, Maria Erennia Vitullo, Vincenzo Tipo
Published: 28 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.9105

Abstract:
The outbreak of coronavirus disease 2019 caused by severe acute respiratory syndrome coronavirus 2 is a reason of concern worldwide. While a high proportion of adult patients have been severely ill, requiring intensive care assistance and mechanical ventilation, pediatric patients seem to have a less invasive clinical expression of the disease. Reasons for a milder disease in children compared to that seen in adults are yet to be elucidated. Nonetheless, severe and fatal cases have been reported in children and are expected to continue to increase with the growing community transmission and overall current disease prevalence. We report the first case of an infant with a very mild not-respiratory COVID- 19 infection and a concomitant invasive bacterial sepsis.
Marco Montanari, Pierpaolo De Ciantis, , Marta Venturi, Giuseppe D'antuono, Gianfilippo Gangitano, Giulio Cocco, Damiano D'ardes, Cosima Schiavone, Fabrizio Giostra, et al.
Published: 23 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.9333

Abstract:
SARS-CoV-2 infection is characterized by extremely heterogeneous features, going from cases with few symptoms to severe respiratory failures. Chest Computed Tomography (CT) is currently the gold-standard imaging method, although burdened by the risk of exposure to ionizing radiation and management / organizational concerns. In particular, the critical patient undergoing ventilation (invasive or not) seems to be difficult to monitor by repeated CT scan over time. We report the case of a 55-year-old male patient subjected to Continuous Positive Airway Pressure (CPAP) and prone positioning, in which the use of ultrasound monitoring allowed to verify the effectiveness of the pressure support used in recruiting previously atelectasis lung areas. Lung ultrasound can guide pulmonary recruitment and pronation maneuvers in patients undergoing non-invasive ventilation. Ultrasound can identify atelectatic lung areas, which demonstrate an alveolar re-expansion following the setting of high PEEP values, as underlined by the reappearance of pleural/air interface.
, Annarita Tullio, Francesca Valent
Published: 23 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.9201

Abstract:
The Audit and Feedback process (AandF) is commonly accepted as a good way to improve quality in health care, also in Emergency Departments (ED), where health aspects and pathologies are very different, usually acute and highly complex. Within an Italian Ministry of Health research project called EASY-NET, we conducted a systematic review of literature on AandF in EDs from 2014 to December 2019 to evaluate the impact of this approach in a particular setting where time-dependent indicators are fundamental. We selected 24 articles: 9 about infective pathologies (i.e. antibiotic stewardship), 6 about cardiovascular acute emergencies (i.e. cardiac arrest), 2 about stroke, 3 about laboratory tests, and 4 about other fields (i.e. diabetic ketoacidosis or use of prothrombin complex). Most of articles proposed a multimodal approach: only 7 concerned AandF alone. Despite the wide range on interventions modality and the poor comparability of the considered studies, the results are encouraging and confirm the importance to implement AandF both in emergency and in other clinical settings.
, Ashton Barnett-Vanes,
Published: 23 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.9205

Abstract:
Over a billion Peripheral Intra-Venous Cannulas (PIVC) are used globally every year with at least 25 million sold annually in the UK.1,2 The NHS spends an estimated £29m of its annual acute sector budget on PIVC procurement3 and around 70% of all hospitalised patients require at least one PIVC during their stay.4 Despite their extensive and routine use, PIVC failure rates are reported as high as 50-69%.5-7 In addition, many PIVCs remain unused following insertion, particularly in the Emergency Department (ED).8,9 The risk factors for PIVC failure are not well understood and the literature has found extensive regional variation in practice when it comes to PIVC insertion and management.1,7,10 While various technologies have been developed to address these issues, there remains a need for standardised, evidence-based guidelines.
Published: 23 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.9242

Abstract:
Hospitals managing the pandemic more successfully were the ones which started working on it ahead of times: so, let’s look back at it. Those who acted early, differentiating routes within the Emergency Department (EDpt), creating different areas with varying intensity of care (...)
Published: 23 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.8985

Abstract:
Cyanide poisoning via the oral route is a remarkably rare entity in the United States. Though acute toxicity from this poison may present with classic signs and symptoms (smell of bitter almonds on breath and cherry-red skin), these signs are frequently not clinically observed in the intoxicated patient, making it low on the routine differential diagnosis leading to both diagnostic and therapeutic challenges for the bedside clinician. This is a case of a 17-yearold male with a history of depression who presented to the Emergency Room (ER) with altered mental status, abdominal pain, and emesis. A severely elevated and worrisome lactic acidosis triggered the ER’s septic shock bundle and algorithm, but further investigation ultimately led to the unifying diagnosis of intentional cyanide poisoning.
Riccardo Gerloni, , Ugo Giulio Sisto, Saverio Tollot, Roberto Copetti
Published: 23 December 2020
Emergency Care Journal, Volume 16; https://doi.org/10.4081/ecj.2020.8911

Abstract:
We present a case of a 66-year-old man with history of myasthenia gravis, severe obesity and osteopenia self-presented to our Emergency Department (ED) with severe pain in his left hemithorax, occurred after an episode of cough three days before. No history of trauma was reported. The patient underwent a chest-XR showing uncomplicated spontaneous fractures of the 5th and 6th left ribs. He was therefore discharged with appropriate analgesic treatment. Five days later, the patient came back to our ED for a wide left abdominal hematoma, though hemodynamically stable and eupneic. A CT-scan with contrast showed a rare and unexpected spontaneous left intercostal lung herniation complicated with a diffuse subcutaneous emphysema, pneumothorax, loculated bilateral pleural effusion and abdominal hematoma. The patient was admitted, treated conservatively and safely discharged after two weeks. We also provide a pathophysiological discussion of the case and a literature review.
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