The proposal of an integrated ultrasonographic approach into the ALS algorithm for cardiac arrest: the PEA protocol.

BACKGROUND AND OBJECTIVE: Guidelines on cardiac arrest (CA) recommend the prompt beginning of cardio-pulmonary resuscitation (CPR) and the identification and correction of reversible causes. This article deals with the application of clinical ultrasonography (US) in resuscitation, presenting a simple codified US protocol usable during CPR to recognize reversible causes of CA. EVIDENCE ON US IN CA AND STATE OF THE ART: Emergency US is a bedside, point-of-care, focused diagnostic procedure with aim to complete the physical examination. It is performed by emergency physician everywhere to answer briefly important clinical questions. Several trials recently experimented US employment during advanced life support, demonstrating its feasibility without delaying CPR. PERSPECTIVES: The PEA Protocol: We propose a simplified US protocol for non-shockable rhythms, called "PEA protocol" to remember the applications of the study (CA in Pulseless Electrical Activity, PEA) and the US scan sequence: Pulmonary scans to depict pneumothorax and pleural effusion and to differentiate wet or dry lung; Epigastric for pericardial effusion, left and right ventricular sides and motion, IVC filling; Abdominal and other scans for aortic aneurism and dissection, peritoneal effusion, bowel occlusion or perforation, deep venous thrombosis. The PEA protocol could be performed both during CA in PEA and during periarrest conditions. CONCLUSIONS: Clinical US, using a well codified protocol, could effectively help to identify reversible causes in CA, even improving patients outcome.

Natriuretic peptides and atrial fibrillation.

BACKGROUND AND OBJECTIVE: Atrial fibrillation (AF) is the most common arrhythmia in the medical practice, it is associated with an increased total and cardiovascular mortality, as well as cardiovascular morbidity, including stroke and heart failure. AF is encountered in different medical specialties including cardiology, family medicine and emergency medicine as well. Treatment goal is to minimize stroke risk but also taking into account the quality of life. Therefore rate or a rhythm control strategies must be carefully selected. This review focuses on natriuretic polypeptides (NPs) as potential useful markers in AF patients management. EVIDENCE AND INFORMATION SOURCES: Pubmed was searched for natriuretic peptides and atrial fibrillation. Pertinent abstracts were reviewed by the Authors and the articles fully evaluated when considered pertinent. STATE OF THE ART: NP biology and physiology is described and general application in heart failure outlined. With regard to AF, the role of NP as predictor of cardioversion is reviewed and discussed. Patients eligible for rhythm control not always respond to treatment. Classic markers for a suitable cardioversion, such an echocardiography, are not immediately available in most settings. NP might be a resource predicting cardioversion (or not) upon patient's presentation. PROSPECTIVES: Biomarkers, such NPs, might be used to predict treatment response other than in heart failure. CONCLUSIONS: In AF management, NT-ProBNP is a promising tool helping physicians to choose rhythm or rate control strategy.

Heart rate variability and myocardial infarction: systematic literature review and metanalysis.

BACKGROUND: Heart rate, measured as beat-to-beat intervals, is not constant and varies in time. This property is known as heart rate variability (HRV) and it has been investigated in several diseases, including myocardial infarction (MI). The main hypothesis is that HRV embed some physiological processes that are characteristics of regulatory systems acting on cardiovascular system. It is possible to quantify such a complex behaviour starting from RR intervals properties itself with the idea that any event affecting the cardiac regulatory system significantly will disrupt and change HRV. In this article, we first review different methodologies previously published to calculate HRV indexes. We then searched literature for studies published on HRV and MI and we derive a metanalysis where published data allow calculation of composite outcomes. MATERIAL AND METHODS: Articles considered eligible for metanalysis were original retrospective/prospective studies investigating HRV after myocardial infarction, reporting follow up for mortality or significant cardiac complications. Random effect model was used to assessed for homogeneity and calculate composite outcome and its 95% confidence interval (CI). RESULTS: 21 studies were identified as eligible for subsequent analysis. Among these studies 5 large trials were eligible for metanalysis: "they included 3489 total post-MI patient with an overall mortality of 125/577 (21.7%) in patients with standard deviation of RR intervals (SDNN) less than 70 msec compared to 235/2912 (8.1%) in patients with SDNN > 70 msec". Metanalysis demonstrates that, after a MI, patients with SDNN below 70 msec on 24 hours ECG recording have almost 4 times more chance to die in the next 3 years. CONCLUSION: Results from metanalysis and other studies considered (but not included in the analysis) are consistent with the final finding, that a disrupted HRV dynamic (low SDNN) is associated with higher adverse outcome. In this perspective, although data are strongly positive for a direct relationship between SDNN and mortality after MI, SDNN value must be considered carefully on a single patient. The primary purpose of the metanalysis was to address whether studies conducted on HRV and MI were consistent rather than established a cut-off for SDNN. HRV is simple, non invasive and relatively not expensive to obtain.

Ultrasound detection of foreign body and gas contamination of a penetrating wound.

We report a case in which ultrasonography (US) examination was used in the Emergency Department to reveal and diagnose gas contamination of a penetrating wound. Air microbubbles are extremely small and their typical distribution and movement are like those of "sparkling-wine microbubbles". US assessment of spontaneous disappearance of the air bubbles can distinguish a harmless traumatic nature of the wound from a life-threatening gas-producing bacterial infection.

Use of oxycodone in polytrauma patients: the "Gemelli" experience.

INTRODUCTION: This is the first study investigating the effect of oxycodone in polytrauma patients. The management of pain in polytrauma patients has become a very relevant issue. Nonsteroidal anti-inflammatory drugs (NSAIDs) represent the most used drugs in polytrauma patients, even though their use is associated with an increased hemorrhagic risk. Previous studies have demonstrated the efficacy of oxycodone for the treatment of acute pain. The aim of this study was to assess the efficacy of oxycodone administration in polytrauma patients, with minor injuries. PATIENTS AND METHODS: 15 polytrauma patients (10 males, mean age 40 +/- 13 years; 5 females, mean age 49 +/- 26 years) were admitted to the Emergency Department of the Catholic University, A. Gemelli Hospital in Rome, Italy. All patients underwent physical examination, FAST ultrasound, total body CT scanning and blood tests. Three patients had multiple costal fractures, three had pelvic fracture, two had tibial fracture, five had vertebral fractures, one patient had clavicle fracture and ulnar fracture, one patient a severe trauma of the left leg, which required amputation. Five patients also reported minor head trauma, with a Glasgow Coma Score (GCS) 15. All patients reported abdominal trauma, while none of them had severe thoracic or kidney damage. Patients with head trauma also underwent a second CT head scanning 12 hours after admission, which excluded the occurrence of cerebral damage. All patients were then treated with oral administration of oxycodone 10 mg two times per day (bid) for 3 days. Pain intensity, before and after the administration of oxycodone, was evaluated using a scale ranging from 0 to 10. RESULTS: The mean pain score at admission was 8 +/- 0.7. All patients reported significant pain improvement after the administration of oxycodone (8 +/- 0.7 vs 1.8 +/- 0.9; p < 0.0001). A dosage increase of oxycodone from 20 to 40 mg bid was required in only one patient with a clavicle fracture. The main side effects were light-headache (5 patients), constipation (4 patients) and nausea (3 patients). CONCLUSIONS: These data indicate that oxycodone is a safe and effective drug for pain relief in polytrauma patients without severe thoracic, kidney or brain damage.

Approach to respiratory failure in emergency department.

OBJECTIVES AND BACKGROUND: The goal of this review is to provide update recommendations that can be used by emergency physicians who provide primary cares to patients with Acute Respiratory Failure (ARF), from the admission to an emergency department through the first 24 to 48 hours of hospitalization. This work wants to address the diagnosis and emergency medical care of ARF and the management of medical complications. STATE OF THE ART: A lot of statement has been developed for the early management and treatment of ARF; moreover, over the last fifteen years, we have assisted to the rise of a new technique of ventilation, in the Emergency Department: Non Invasive Ventilation. This kind of ventilation was firsthy applied in intensive Care and in Respiratory Care Unit. Randomized controlled clinical trials have showed its usefulness in the early treatment of several forms of ARF, together with medical therapy.

Diagnostic and therapeutic approach to acute pulmonary embolism in an emergency department.

Pulmonary embolism (PE) is the obstruction of the pulmonary arteries by the dislodging and embolization of thrombotic material coming in most cases from the deep veins of the leg. PE is a relatively common disease with an estimated annual incidence up to 37 cases diagnosed per 100,000 persons it is the third cause of death in the United States. Clinical signs and symptoms are non specific and in the 70% of cases there isn't a correct diagnosis. The aim of this review is to summarize the state of the art of the diagnostic and treatment algorithms of PE in the evidence based medicine in order to minimize the "clinician gestalt" by the only guide for the early diagnosis and treatment of the disease. A correct diagnosis based on pre test probability, the use of computed tomographic pulmonary angiography, early anticoagulation/fibrinolysis started in the Emergency Department can change the natural history of the disease. In perspective, a combined approach of localyzed fibrinolysis and mechanical fragmentation could improve the overall outcome of these patients.

Long-term taurine supplementation reduces mortality rate in streptozotocin-induced diabetic rats.

Oxidative stress is implicated in the pathogenesis of diabetes mellitus. Taurine and vitamin E+selenium supplementation has some benefits in experimental models of diabetes mellitus. This study evaluates whether taurine and vitamin E+selenium supplementations reduce a hard end-point such as mortality due to diabetes. Streptozotocin-induced diabetic rats were fed with standard diet or taurine (5%, w/w) or vitamin E (500 UI/Kg)+selenium (8 mg/Kg) enriched diets. Taurine significantly decreased mortality rate (p < 0.04), while vitamin E failed to increase survival. In the late phase of the disease, taurine significantly decreased glycaemia, being vitamin E ineffective. No correlation between glycaemia and survival was found. None of supplementations modified body weight. Thus, only taurine decreases the mortality rate and glycaemia. These results encourage new research in the field, since classical hypoglycaemic agents are unable to decrease mortality in diabetic patients.

Hypertensive crises: diagnosis and management in the emergency room.

Hypertensive crises are commonly observed in an emergency room. Regardless blood pressure values, hypertensive crises are classified in emergencies, characterized by life-threatening acute organ damage, and urgencies, with no evidence of acute or progressive organ injury. In an hypertensive emergency an appropriate and immediate management with parenteral drugs is mandatory, while in an hypertensive urgency blood pressure should be decreased within 24-48 h with orally active agents. This article reviews the spectrum of clinical syndromes that comprise hypertensive emergencies, focusing on specific drugs and therapeutic strategies available in the emergency department, based on current literature. Since no randomized prospective trials are available, an evidence-based approach recommending an optimal therapeutical management is not possible. Much of the therapy is therefore entirely empirical and based on the underlying pathophysiologic and clinical findings. Further studies are needed to clarify pathophysiologic mechanisms in order to optimize therapeutic approach.

Liver, pancreas and biliary tract enhanced lipoperoxidation products in pure pancreatic juice: evidence for organ-specific oxidative stress in chronic pancreatitis.

BACKGROUND: Oxygen-free radicalscan play a role in the development of chronic pancreatitis, altering the redox state with damage of cell constituents and decrease in antioxidant defences. AIMS: To measure levels of lipoperoxidation products, conjugated dienes and lipid hydroperoxides, in pure pancreatic juice and serum of chronic pancreatitis patients and compare them to that in controls. To investigate a possible correlation with serum indexes of pancreatic inflammation (amylase and lipase). PATIENTS: Pancreatic juice was collected during ERCP, after secretin stimulation, in 20 patients with chronic pancreatitis and 11 controls with biliary diseases. METHODS: Lipid hydroperoxide levels were determined with FOX2 method and measured as absorbance at 560 nm. Conjugated diene levels were measured using second-derivative spectroscopy. RESULTS: No substantial difference was present in serum levels of lipid hydroperoxides, conjugated dienes (in both isomeric forms) and isomer-ratio values between those of patients with chronic pancreatitis and controls. In pancreatic juice, there was a significant increase in lipid hydroperoxides and conjugated dienes levels (especially trans-trans isomers) in chronic pancreatitis patients compared with controls, with a decrease in cis-trans isomers and a significant difference in isomer-ratio values. CONCLUSIONS: Increased levels of lipid hydroperoxides and conjugated dienes in the pancreatic juice of chronic pancreatitis patients is indicative of an enhanced lipoperoxidation and antioxidants consumption in pancreatic tissue, confirmed by the decreased isomer-ratio values as an indirect index of decreased antioxidant capacity. The lack of significant difference in conjugated diene and lipid hydroperoxide levels in the serum of chronic pancreatitis patients versus that of controls suggests an oxidative stress limited to pancreatic tissue and indicative of an organ-specific pathology, confirmed by the parallel behaviour of oxidative parameters (lipid hydroperoxides and conjugated dienes) and indexes of pancreatic inflammation (amylase and lipase).