Alessandro Riccardi

Adenosine in the treatment of supraventricular tachycardia: 5 years of experience (2002-2006).

We report a retrospective analysis of 5 years of adenosine use in our emergency department (2002-2006). We treated 454 patients with an intravenous bolus of adenosine. The cohort was made up of 40.7% men and 59.3% women, with mean age of 47.32 years, mean heart rate of 162.48 beats per minute. Among them, 73% responded immediately to the 6-mg dose, 15% responded after the second 12-mg dose, and 11% responded to a further 12-mg dose, whereas 11% were unresponsive. We observed minor side effects in a high percentage of patients (ie, chest tightness 83%, flushing 39.4%, sense of impending death 7%). Only 1 major adverse effect was recorded, that is, administering 12 mg of adenosine induced a marked acceleration in the ventricular rate of a patient with an undiagnosed atrial flutter, caused by induction of atrioventricular conduction (1:1). Our results confirm that when patients are appropriately selected, adenosine is probably the best available drug to treat paroxysmal supraventricular tachycardias, especially in emergency situations.

Minor head injury in the elderly at very low risk: a retrospective study of 6 years in an Emergency Department (ED)

INTRODUCTION Mild head injury (MHI) is a common clinical problem in emergency departments (EDs). Long-standing debate is still going on about MHI in the elderly: current guidelines recommend to perform a CT scan on this group. MATERIALS AND METHODS We performed a retrospective study by reviewing patients older than 65 years, evaluated in our ED for which a CT scan of the head was performed for MHI, between 2004 and 2010. According to Italian Guidelines, we considered only patients with low-risk MHI. RESULTS We considered 2149 eligible patients: we recorded 47 pathological acute findings on CT scan (2.18%), but only 3 patients (0.14%) underwent neurosurgery. We analysed our patients according to different age groups: in patients in the 65- to 79-year-old group, we documented pathological findings on CT in 0.66% of cases, with a significant increase in the group older than 80 years, with a rate of 3.33% of acute findings on CT (OR 5.22, P < .001); 617 patients were on antiplatelet therapy: 22 of these patients (3.72%) had a pathological finding on CT scan (OR 2.23, P < .005). DISCUSSION Our retrospective analyses demonstrated that the incidence of intracranial complications after MHI is not different from that of the general population, and based on this finding, a CT does not seem to be necessary, at least up to 80 years old. Our data suggest that antiplatelet therapy could be a significant risk factor. Our results suggest that elderly patients between 65 and 79 years old without risk factors could be managed as younger patients.

Intracranial complications after minor head injury (MHI) in patients taking vitamin K antagonists (VKA) or direct oral anticoagulants (DOACs)

Introduction: The correlation between chronic direct oral anticoagulants (DOACs) intake and the incidence of intracranial complications after minor head injury (MHI) is still not well defined. This study examined the incidence of complications in patients receiving vitamin K antagonists (VKA) or DOACs observed in the emergency department (ED) for MHI. Methods: Two hundred twenty‐five patients affected by MHI and receiving oral anticoagulants were recorded between January and December 2016, distinguishing those treated with VKA (118) from those receiving DOACs (107). All patients underwent a CT scan and were observed for 24 h in the ED. Follow‐up was performed up to 1 month after the head trauma. Results: The rate of intracranial hemorrhage was significantly lower in patients treated with DOACs than in patients treated with VKA. We recorded 2 deaths among the 12 patients who experienced intracranial complications in the VKA group. Discussion: DOACs seem to have a more favorable safety profile than VKA in patients affected by MHI. This observation is important in light of the increasing number of elderly patients who are receiving anticoagulant therapy.

Spanish Broom flower ingestion: a very unusual poisoning.

We briefly describe three cases of Spanish Broom flower (Spartium junceum L.) poisoning in adults. To our knowledge, this type of poisoning has never been previously reported. The patients, two women and a man, presented at our emergency department after having eaten rice with Spanish Broom flowers. They had picked the flowers in the meadow near their house. The patients were in good health until 6 h before admission to our emergency department. They had, however, started showing symptoms immediately after the meal. Symptoms consisted of various degrees of vomiting, diarrhoea and diffuse abdominal pain, acute agitation and diffuse tremors. The patients’ symptoms and signs are summarized in Table 1. Laboratory tests were all within the normal range and were inexpressive.

Controversies in the “pill in the pocket” approach to atrial fibrillation

The efficacy of class I antiarrhythmic drugs in terminating atrial fibrillation (AF) has been proven. Both intravenous and oral administration of propafenone and flecainide restore sinus rhythm in a high percentage of cases [1–5]. Furthermore, in selected patients, the possibility of home self-administration of one of these drugs has been studied and is deemed safe for treating the sudden onset of heart palpitations [6]. Indeed, the recurrence of AF is responsible for a number of emergency department (ED) visits and hospital admissions. The ‘‘pill in the pocket’’ approach has proven to be effective in reducing this phenomenon. We report two cases we observed at our ED which could be the launching pad for both discussion and criticism about the ‘‘pill in the pocket’’ approach that is receiving increasing attention and ever-growing application in Italy.

PoCUS evaluating blunt thoracic trauma: a retrospective analysis of 18 months of emergency department activity

Blunt thoracic injury (BTI) constitutes a common presentation in emergency department: rib fractures are the most common injuries. Chest X-ray (CXR) has a limited sensitivity to identify rib fractures. We perform this retrospective study in our emergency department collecting all patients with BTI during an 18-month period. PoCUS was performed prior to acquire CXR or CT. We evaluated 1672 patients with BTI, and we reported rib fractures in 689 patients (41.21%). PoCUS was performed in 190 patients. PoCUS in emergency medicine has an increasing role, especially in BTI, but less clear is its role in detecting ribs fracture. PoCUS seems to be an effective method for diagnosing rib fracture in patients with blunt chest trauma if collaborative and with a well-isolated trauma. We used the trick of patients’ self-positioning probe in the most painful site, and this could reduce the time and the pain of the examination.

Embolic Central Retinal Artery Occlusion Detected with Point-of-care Ultrasonography in the Emergency Department

BACKGROUND Ocular emergencies account for 2-3% of all emergency department (ED) visits. Sonographic evaluation of the eye offers a very useful diagnostic tool in the ED. In the ED setting, ocular ultrasound could identify a retinal detachment, or a massive vitreous hemorrhage, and the training for emergency medicine practitioners is quite easy. CASE REPORT An 84-year-old woman presented to our ED with a painless acute vision loss in her right eye. Immediate bedside emergency ocular ultrasound was performed, and it showed a retrobulbar hyperechoic material, suggestive of an embolus within the central retinal artery. Fluorescein angiography showed limited and sluggish filling of the retinal arteries after injection of fluorescein, and optical coherence tomography demonstrated a decrease in the reflectivity and thickness of the inner retinal layers. The final diagnosis was embolic central retinal artery occlusion (CRAO). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Among the causes of acute loss of vision, CRAO is associated with systemic vascular disease. The importance of visible retinal emboli has been well documented due to its association with increase in mortality. A rapid evaluation of the central retinal artery could be a simple tool to identify an embolus, and this could lead to a rapid treatment. The evaluation of central retinal artery is a less defined setting in emergency physician bedside ultrasound, but the identification of CRAO could lead to a rapid acceleration in diagnosis and treatment of a potentially life-threatening disease.

Common Iliac Artery Tortuosity Simulating Aortic Dissection on Focused Abdominal Ultrasound in the Emergency Department

BACKGROUND Bedside ultrasonography performed by the Emergency Physician is a safe procedure for evaluating patients with trauma, hypotension, chest or abdominal pain, and dyspnea of unknown origin. OBJECTIVES To present a case with apparent concordance between the patients history, symptoms, signs, and ultrasound imaging, that lead to diagnostic error. CASE REPORT A 74-year-old man was admitted to the hospital due to epigastric pain, radiating to the back. He reported previous detection of a small dilatation in the ascending aorta. On physical examination, the heart rate was 120 beats/min and the blood pressure was 90/60 mm Hg. These facts suggested the possibility of an aortic dissection; therefore, a bedside emergency ultrasound examination was performed. The first part of the examination focused on the ascending aorta, but the results were not significant. Then, an abdominal evaluation was performed that revealed an ovular and pulsatile anechoic mass in the infrarenal tract, with an echoic wall and an endoluminal flap. A computed tomography scan of the aorta was ordered, and it showed a regular aorta in the entire tract, with an abnormal tortuosity of iliac arteries as the basis of the false-positive ultrasound. CONCLUSIONS The use of ultrasound in emergency settings has improved the clinical evaluation of critical patients by Emergency Physicians, but the possibility of a false-positive diagnostic error always should be considered.

The emergency physician and the prompt management of severe hyperkalemia

We report a case that gives an opportunity to discuss the importance of a faster approach to hyperkalemia, a potentially lethal electrolyte disturbance because of threatening dysrhythmias (asystole, ventricular fibrillation) that can occur at any moment [1]. The availability of an immediate measure of serum potassium is crucial, because the patient’s ECG abnormalities are not often specific and significant enough to give a clear indication to start a timely therapy [2]. Time of laboratory analysis or the lack of specific indications especially in outpatient settings can cause a true therapeutic delay and a risk for the patient’s life.

Hypophosphatemia. From retrospective analysis to the analysis of the potential role of phosphatemia in panic disorders

The detection of a low serum phosphate level is not unusual in an Emergency Department, especially in clinical conditions linked to hyperventilation and subsequent respiratory alkalosis, asthma, sepsis, severe pain, anxiety. Symptoms of hypophosphatemia are typically not specific when the imbalance is not particularly severe, but if hyphophosphatemia does not resolve rhabdomyolisis, hemolysis, decreased tissue oxygenation and respiratory failure can be observed. Only recently some authors have pointed out that the level of serum phosphate in patient with anxiety and panic disorders can give information on the severity of the attacks as well on the clinical course of the disease. In a retrospective analysis on 599 case of hypophosphatemia observed in our ED, the percentage of case of panic disorders was particularly high among patients with lower phosphatemia. Therefore, we decided to examine this aspect closely, assessing if the determination of serum phosphate could be useful in the management of panic attacks at first approach in emergency room. Our observation are consistent with the statement that hypophosphatemia is one of the main clinical aspect of panic attack, and strongly support the hypothesis that hypophosphatemia correlates with the most severe symptoms of panic attack and should be itself considered as one of the most important aspect of this syndrome. Serum phosphate levels appear to mirror its clinical course, and can be used in the clinical setting of an Emergency Department, for the confirmation of a diagnosis of anxiety-panic disorder and as marker of the response to therapy