Gabriele Melegari

Response by Twin Italian Hub Hospitals in a Double Seismic Event: A Retrospective Observational Investigation

Abstract Introduction: The objectives of this study were to compare prevalence rates of different pathologies, ambulance system and emergency department management times, and patient survival and hazard ratios for codes 2 and 3 in two hub hospitals in Modena in the 36-month period across the stages of two major earthquakes in short sequence in Northern Italy in 2012. Methods: Clinical records pertaining to the emergency care of patients were analyzed and only those assigned status codes 2 and 3 by ambulance professionals were included (if the assessment was confirmed by emergency department triage). The statistical analysis of data was divided by three time periods studied: before, during/between, and after the earthquakes. Results: Among the 2,278 retained records, there were no statistically significant differences in the prevalence of the main pathologies presented at the two hubs in the studied period. A Cox regression model was used to analyze the survival of patients in the different stages of the emergency; there were no statistically significant differences in the hazard ratios of death before, during, and after the earthquake. The study found a significant increase in emergency department treatment times. Discussion: Redundancies in the Modena medical system were found to have compensated for damaged hospital facilities. In particular, they helped emergency systems reorganize themselves faster in order to bring medical assistance to people during and around seismic events with as a minimal amount of disruption as possible. Conclusion: The Modena medical system was redundant and ensured that disrupted emergency systems were reorganized and put back online while damaged hospital facilities were compensated for/reproduced elsewhere.

Contemporary Thoracic Aortic and Abdominal Injuries: An Emergency Strategy

Topcu and colleagues [1] interestingly bring attention to the management of contemporary injury of the thoracic aorta and spleen. On the basis of our experience, we would like to consider some basic points. In each case of severe thoracoabdominal trauma, it is essential to perform a hemodynamic monitoring and contrast-enhanced computed tomography (CT) angiography to detect a condition of circulatory instability, and to obtain a complete imaging of the thorax, abdomen, and vessels. The most common injuries of the thoracic aorta involve isthmus. In addition, high-grade lesions (III and IV) are preferentially treated with an endovascular technique [2]. Usually, treatment priority is given to the aortic isthmus injuries, possibly considering an endovascular procedure [3]. Subsequently, the other concomitant injuries, especially abdominal ones, must be treated adequately. This strategy was applied successfully in our last consecutive 5 cases of injuries of the aortic isthmus of grade IV, with an associated spleen rupture (3 cases) and a liver laceration (2 cases), obtaining a complete recovery without important complications. On the contrary, a prompt emergency laparotomy becomes necessary when an endovascular treatment is not possible, and the subsequent cardiovascular surgery requires a cardiopulmonary bypass and a prolonged full heparinization, with the risk of increased or recurrent abdominal hemorrhage [1]. Interestingly, we applied an equivalent strategy in three cases of injuries of the left subclavian artery, with secondary hemothorax and associated blunt abdominal trauma [4]. CT allowed a precise diagnosis of the vascular injury. A prompt endovascular treatment was successful, and the subsequent laparotomy for spleen rupture followed without difficulties. When this strategy is not possible, direct surgery of the injured supraaortic branch is indicated. In cases of polytrauma involving contemporaneously the thoracic aorta or its supraaortic branches and the abdomen, and an associated massive hemoperitoneum and hemodynamic instability, a prompt laparotomy becomes necessary. It must be performed under careful hemodynamic control, avoiding increase or recurrence of the thoracic hemorrhage after resolution of the circulatory hypotension. We believe that these challenging clinical situations merit further study and contributions.