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Savioli G, Gri N, Ceresa IF, Piccioni A, Zanza C, Longhitano Y, Ricevuti G, Daccò M, Esposito C, Candura SM. Carbon Monoxide Poisoning: From Occupational Health to Emergency Medicine. J Clin Med 2024; 13:2466. [PMID: 38730995 PMCID: PMC11084260 DOI: 10.3390/jcm13092466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/20/2024] [Accepted: 04/09/2024] [Indexed: 05/13/2024] Open
Abstract
Carbon monoxide poisoning remains a leading cause of accidental poisoning worldwide (both at home and at work), and it is also a cause of suicidal poisoning. Such poisoning can arise following prolonged exposure to low levels of CO or following brief exposure to high concentrations of the gas. In fact, despite exposure limits, high safety standards, and the availability of CO alarms, nearly 50,000 people in the United States visit the emergency department each year due to poisoning. Additionally, CO poisoning in the United States causes up to 500 deaths each year. Despite the widespread nature of this form of poisoning, known about for centuries and whose damage mechanisms have been recognized (or rather hypothesized about) since the 1800s, early recognition, especially of late complications, and treatment remain a medical challenge. A well-designed therapeutic diagnostic process is necessary so that indication for hyperbaric or normobaric therapy is correctly made and so that patients are followed up even after acute exposure to diagnose late complications early. Furthermore, it is necessary to consider that in the setting of emergency medicine, CO poisoning can be part of a differential diagnosis along with other more frequent conditions, making its recognition difficult. The last thirty years have been marked by a significant increase in knowledge regarding the toxicity of CO, as well as its functioning and its importance at physiological concentrations in mammalian systems. This review, taking into account the significant progress made in recent years, aims to reconsider the pathogenicity of CO, which is not trivially just poisonous to tissues. A revision of the paradigm, especially as regards treatment and sequelae, appears necessary, and new studies should focus on this new point of view.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Nicole Gri
- Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milano, Italy;
| | - Iride Francesca Ceresa
- Emergency Department and Internal Medicine, Istituti Clinici di Pavia e Vigevano—Gruppo San Donato, 27029 Vigevano, Italy;
| | - Andrea Piccioni
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy;
| | - Christian Zanza
- Geriatric Medicine Residency Program, University of Rome “Tor Vergata”, 00133 Rome, Italy;
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA 15260, USA;
- Department of Emergency Medicine—Emergency Medicine Residency Program, Humanitas University—Research Hospital, 20089 Rozzano, Italy
| | - Giovanni Ricevuti
- Emergency Medicine, School of Pharmacy, University of Pavia, 27100 Pavia, Italy;
| | - Maurizio Daccò
- ATS Pavia, Continuità Assistenziale, Via Teodoro Lovati, 45, 27100 Pavia, Italy;
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Stefano M. Candura
- Occupational Medicine Unit, Department of Public Health, Experimental and Forensic Sciences, University of Pavia, 27100 Pavia, Italy
- Occupational Medicine Unit, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
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Savioli G, Ceresa IF, Bressan MA, Bavestrello Piccini G, Novelli V, Cutti S, Ricevuti G, Esposito C, Longhitano Y, Piccioni A, Boudi Z, Venturi A, Fuschi D, Voza A, Leo R, Bellou A, Oddone E. Geriatric Population Triage: The Risk of Real-Life Over- and Under-Triage in an Overcrowded ED: 4- and 5-Level Triage Systems Compared: The CREONTE (Crowding and R E Organization National TriagE) Study. J Pers Med 2024; 14:195. [PMID: 38392628 PMCID: PMC10890089 DOI: 10.3390/jpm14020195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 01/18/2024] [Accepted: 02/05/2024] [Indexed: 02/24/2024] Open
Abstract
Elderly patients, when they present to the emergency department (ED) or are admitted to the hospital, are at higher risk of adverse outcomes such as higher mortality and longer hospital stays. This is mainly due to their age and their increased fragility. In order to minimize this already increased risk, adequate triage is of foremost importance for fragile geriatric (>75 years old) patients who present to the ED. The admissions of elderly patients from 1 January 2014 to 31 December 2020 were examined, taking into consideration the presence of two different triage systems, a 4-level (4LT) and a 5-level (5LT) triage system. This study analyzes the difference in wait times and under- (UT) and over-triage (OT) in geriatric and general populations with two different triage models. Another outcome of this study was the analysis of the impact of crowding and its variables on the triage system during the COVID-19 pandemic. A total of 423,257 ED presentations were included. An increase in admissions of geriatric, more fragile, and seriously ill individuals was observed, and a progressive increase in crowding was simultaneously detected. Geriatric patients, when presenting to the emergency department, are subject to the problems of UT and OT in both a 4LT system and a 5LT system. Several indicators and variables of crowding increased, with a net increase in throughput and output factors, notably the length of stay (LOS), exit block, boarding, and processing times. This in turn led to an increase in wait times and an increase in UT in the geriatric population. It has indeed been shown that an increase in crowding results in an increased risk of UT, and this is especially true for 4LT compared to 5LT systems. When observing the pandemic period, an increase in admissions of older and more serious patients was observed. However, in the pandemic period, a general reduction in waiting times was observed, as well as an increase in crowding indices and intrahospital mortality. This study demonstrates how introducing a 5LT system enables better flow and patient care in an ED. Avoiding UT of geriatric patients, however, remains a challenge in EDs.
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Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | - Iride Francesca Ceresa
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Viola Novelli
- Medical Direction, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | - Sara Cutti
- Medical Direction, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Yaroslava Longhitano
- Residency Program in Emergency Medicine, Department of Emergency Medicine, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy
| | - Zoubir Boudi
- Department of Emergency Medicine, Dr Sulaiman Alhabib Hospital, Dubai 2542, United Arab Emirates
| | - Alessandro Venturi
- Department of Political and Social Sciences, University of Pavia, 27100 Pavia, Italy
- Bureau of the Presidency, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | - Damiano Fuschi
- Department of Italian and Supranational Public Law, Faculty of Law, University of Milan, 20133 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Roberto Leo
- Department of Systems Medicine, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Abdelouahab Bellou
- Global Network on Emergency Medicine, Brookline, MA 02446, USA
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
- Institute of Sciences in Emergency Medicine, Department of Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
- Occupational Medicine Unit (UOOML), ICS Maugeri IRCCS, 27100 Pavia, Italy
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Gri N, Longhitano Y, Zanza C, Monticone V, Fuschi D, Piccioni A, Bellou A, Esposito C, Ceresa IF, Savioli G. Acute Oncologic Complications: Clinical-Therapeutic Management in Critical Care and Emergency Departments. Curr Oncol 2023; 30:7315-7334. [PMID: 37623012 PMCID: PMC10453099 DOI: 10.3390/curroncol30080531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 07/01/2023] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
Introduction. It is now known that cancer is a major public health problem; on the other hand, it is less known, or rather, often underestimated, that a significant percentage of cancer patients will experience a cancer-related emergency. These conditions, depending on the severity, may require treatment in intensive care or in the emergency departments. In addition, it is not uncommon for a tumor pathology to manifest itself directly, in the first instance, with a related emergency. The emergency unit proves to be a fundamental and central unit in the management of cancer patients. Many cancer cases are diagnosed in the first instance as a result of symptoms that lead the patient's admittance into the emergency room. Materials and Methods. This narrative review aims to analyze the impact of acute oncological cases in the emergency setting and the role of the emergency physician in their management. A search was conducted over the period January 1981-April 2023 using the main scientific platforms, including PubMed, Scopus, Medline, Embase and Google scholar, and 156 papers were analyzed. Results. To probe into the main oncological emergencies and their management in increasingly overcrowded emergency departments, we analyzed the following acute pathologies: neurological emergencies, metabolic and endocrinological emergencies, vascular emergencies, malignant effusions, neutropenic fever and anemia. Discussion/Conclusions. Our analysis found that a redefinition of the emergency department connected with the treatment of oncology patients is necessary, considering not only the treatment of the oncological disease in the strict sense, but also the comorbidities, the oncological emergencies and the palliative care setting. The need to redesign an emergency department that is able to manage acute oncological cases and end of life appears clear, especially when this turns out to be related to severe effects that cannot be managed at home with integrated home care. In conclusion, a redefinition of the paradigm appears mandatory, such as the integration between the various specialists belonging to oncological medicine and the emergency department. Therefore, our work aims to provide what can be a handbook to detect, diagnose and treat oncological emergencies, hoping for patient management in a multidisciplinary perspective, which could also lead to the regular presence of an oncologist in the emergency room.
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Affiliation(s)
- Nicole Gri
- Niguarda Cancer Center, ASST Grande Ospedale Metropolitano Niguarda, Piazza dell’Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Christian Zanza
- Italian Society of Prehospital Emergency Medicine (SIS 118), 74121 Taranto, Italy
| | - Valentina Monticone
- Department of Otorhinolaryngology, University of Turin, San Luigi Gonzaga Hospital, 10043 Orbassano, Italy
| | - Damiano Fuschi
- Department of Italian and Supranational Public Law, School of Law, University of Milan, 20122 Milan, Italy
| | - Andrea Piccioni
- Department of Emergency Medicine, Polyclinic Agostino Gemelli/IRCCS, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Abdelouahab Bellou
- Department of Emergency Medicine, Institute of Sciences in Emergency Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | | | - Gabriele Savioli
- Emergency Department, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
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Savioli G, Ceresa IF, Bressan MA, Piccini GB, Varesi A, Novelli V, Muzzi A, Cutti S, Ricevuti G, Esposito C, Voza A, Desai A, Longhitano Y, Saviano A, Piccioni A, Piccolella F, Bellou A, Zanza C, Oddone E. Five Level Triage vs. Four Level Triage in a Quaternary Emergency Department: National Analysis on Waiting Time, Validity, and Crowding-The CREONTE (Crowding and RE-Organization National TriagE) Study Group. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040781. [PMID: 37109739 PMCID: PMC10143416 DOI: 10.3390/medicina59040781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Triage systems help provide the right care at the right time for patients presenting to emergency departments (EDs). Triage systems are generally used to subdivide patients into three to five categories according to the system used, and their performance must be carefully monitored to ensure the best care for patients. Materials and Methods: We examined ED accesses in the context of 4-level (4LT) and 5-level triage systems (5LT), implemented from 1 January 2014 to 31 December 2020. This study assessed the effects of a 5LT on wait times and under-triage (UT) and over-triage (OT). We also examined how 5LT and 4LT systems reflected actual patient acuity by correlating triage codes with severity codes at discharge. Other outcomes included the impact of crowding indices and 5LT system function during the COVID-19 pandemic in the study populations. Results: We evaluated 423,257 ED presentations. Visits to the ED by more fragile and seriously ill individuals increased, with a progressive increase in crowding. The length of stay (LOS), exit block, boarding, and processing times increased, reflecting a net raise in throughput and output factors, with a consequent lengthening of wait times. The decreased UT trend was observed after implementing the 5LT system. Conversely, a slight rise in OT was reported, although this did not affect the medium-high-intensity care area. Conclusions: Introducing a 5LT improved ED performance and patient care.
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Affiliation(s)
- Gabriele Savioli
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Maria Antonietta Bressan
- Department of Emergency Medicine and Surgery, IRCCS Fondanzione Policlinico San Matteo, 27100 Pavia, Italy
| | | | - Angelica Varesi
- Faculty of Medicine, University of Pavia, 27100 Pavia, Italy
| | - Viola Novelli
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Alba Muzzi
- Health Department, University of Pavia, 27100 Pavia, Italy
| | - Sara Cutti
- Health Department, University of Pavia, 27100 Pavia, Italy
| | | | - Ciro Esposito
- Nephrology and Dialysis Unit, ICS Maugeri, University of Pavia, 27100 Pavia, Italy
| | - Antonio Voza
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Desai
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Angela Saviano
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Andrea Piccioni
- Emergency Department, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Roma, Italy
| | - Fabio Piccolella
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Abdel Bellou
- Institute of Sciences in Emergency Medicine, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou 510080, China
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, MI 48201, USA
| | - Christian Zanza
- Department of Anesthesiology and Intensive Care Medicine-AON Antonio, Biagio e Cesare Arrigo, 15100 Alessandria, Italy
| | - Enrico Oddone
- Department of Public Health, Experimental and Forensic Medicine, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Yamaji F, Okada H, Kamidani R, Kawasaki Y, Yoshimura G, Mizuno Y, Kitagawa Y, Fukuta T, Ishihara T, Suzuki K, Miyake T, Kanda N, Doi T, Yoshida T, Yoshida S, Ogura S. Retrospective cohort study to determine the effect of preinjury antiplatelet or anticoagulant therapy on mortality in patients with major trauma. Front Med (Lausanne) 2023; 9:1089219. [PMID: 36698798 PMCID: PMC9868405 DOI: 10.3389/fmed.2022.1089219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/19/2022] [Indexed: 01/10/2023] Open
Abstract
Objective This study aimed to compare outcomes among patients who sustained major trauma from injury with and without receiving antiplatelet therapy (APT) or anticoagulant therapy (ACT) to test the hypothesis that APT does not increase the risk of mortality. However, ACT increases the mortality risk in the acute phase of trauma. Methods Patients registered in the Japanese Observational body for Coagulation and Thrombolysis in Early Trauma 2 between April 2017 and March 2018 who had sustained a severe injury in any anatomic region of the body, as determined using an injury severity score (ISS) ≥ 16 were included in this retrospective cohort study. We analyzed the mortality within 24 h from the arrival using a multivariable linear regression analysis adjusted for several confounding variables. Results We identified 1,186 eligible participants who met the inclusion criteria for this study: 105 in the APT (cases), 1,081 in the non-antiplatelet therapy (nAPT) group (controls), 65 in the ACT (cases), and 1,121 in the non-anticoagulant therapy (nACT) group (controls). The mortality within 24 h in the ACT group was significantly higher than in the nACT group (odds ratio 4.5; 95%CI: 1.2-16.79; p = 0.025); however, there was no significant difference between the two groups with or without the antiplatelet drug (odds ratio 0.32; 95%CI: 0.04-2.79; p = 0.3) administration. Other outcomes, like the 28-day mortality, mortality at discharge, and surgery for hemostasis, were not significantly different between regular users and non-users of either antiplatelet or anticoagulant drugs. Conclusion Regular antiplatelet medications did not increase mortality within 24 h, 28 days, or at discharge in patients with major trauma, suggesting that standard treatment, including surgery, is sufficient.
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Affiliation(s)
- Fuminori Yamaji
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Hideshi Okada
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Ryo Kamidani
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
- Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuki Kawasaki
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Genki Yoshimura
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Yosuke Mizuno
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Yuichiro Kitagawa
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Tetsuya Fukuta
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Kodai Suzuki
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Takahito Miyake
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Norihide Kanda
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Tomoaki Doi
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Takahiro Yoshida
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
| | - Shozo Yoshida
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
- Abuse Prevention Center, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Advanced Critical Care Center, Gifu University Hospital, Gifu, Japan
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Savioli G, Zanza C, Longhitano Y, Nardone A, Varesi A, Ceresa IF, Manetti AC, Volonnino G, Maiese A, La Russa R. Heat-Related Illness in Emergency and Critical Care: Recommendations for Recognition and Management with Medico-Legal Considerations. Biomedicines 2022; 10:biomedicines10102542. [PMID: 36289804 PMCID: PMC9599879 DOI: 10.3390/biomedicines10102542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/22/2022] [Accepted: 10/06/2022] [Indexed: 11/30/2022] Open
Abstract
Hyperthermia is an internal body temperature increase above 40.5 °C; normally internal body temperature is kept constant through natural homeostatic mechanisms. Heat-related illnesses occur due to exposure to high environmental temperatures in conditions in which an organism is unable to maintain adequate homeostasis. This can happen, for example, when the organism is unable to dissipate heat adequately. Heat dissipation occurs through evaporation, conduction, convection, and radiation. Heat disease exhibits a continuum of signs and symptoms ranging from minor to major clinical pictures. Minor clinical pictures include cramps, syncope, edema, tetany, and exhaustion. Major clinical pictures include heatstroke and life-threatening heat stroke and typically are expressed in the presence of an extremely high body temperature. There are also some categories of people at greater risk of developing these diseases, due to exposure in particular geographic areas (e.g., hot humid environments), to unchangeable predisposing conditions (e.g., advanced age, young age (i.e., children), diabetes, skin disease with reduced sweating), to modifiable risk factors (e.g., alcoholism, excessive exercise, infections), to partially modifiable risk factors (obesity), to certain types of professional activity (e.g., athletes, military personnel, and outdoor laborers) or to the effects of drug treatment (e.g., beta-blockers, anticholinergics, diuretics). Heat-related illness is largely preventable.
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Affiliation(s)
- Gabriele Savioli
- Emergency Department, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
- Doctoral Program Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Christian Zanza
- Foundation “Ospedale Alba-Bra”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy
- Correspondence:
| | - Yaroslava Longhitano
- Foundation “Ospedale Alba-Bra”, Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy
| | - Alba Nardone
- Department of Internal Medicine, Università degli Studi of Pavia, 27100 Pavia, Italy
| | - Angelica Varesi
- Department of Internal Medicine, Università degli Studi of Pavia, 27100 Pavia, Italy
| | | | - Alice Chiara Manetti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy
| | - Gianpietro Volonnino
- Department of Anatomy, Histology, Forensic Medicine and Orthopedics, Sapienza University, 00185 Rome, Italy
| | - Aniello Maiese
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy
| | - Raffaele La Russa
- Department of Clinical and Experimental Medicine, University of Foggia, 71122 Foggia, Italy
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Sartini S, Spadaro M, Cutuli O, Castellani L, Sartini M, Cristina ML, Canepa P, Tognoni C, Lo A, Canata L, Rosso M, Arboscello E. Does Antithrombotic Therapy Affect Outcomes in Major Trauma Patients? A Retrospective Cohort Study from a Tertiary Trauma Centre. J Clin Med 2022; 11:jcm11195764. [PMID: 36233632 PMCID: PMC9573302 DOI: 10.3390/jcm11195764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
Antithrombotic therapy may affect outcomes in major trauma but its role is not fully understood. We aimed to investigate adverse outcomes among those with and without antithrombotic treatment in major trauma. Material and methods: This is a retrospective study conducted at the Emergency Department (ED) of the University Hospital of Genoa, a tertiary trauma center, including all major trauma between January 2019 and December 2020. Adverse outcomes were reviewed among those without antithrombotic treatment (Group 0), on antiplatelet treatment (Group 1), and on anticoagulant treatment (Group 2). Results: We reviewed 349 electronic charts for full analysis. Group 0 were n = 310 (88.8%), Group 1 were n = 26 (7.4%), and Group 2 were n = 13 (3.7%). In-hospital death and ICU admission, respectively, were: n = 16 (5.6%) and n = 81 (26%) in Group 0, none and n = 6 (25%) in Group 1, and n = 2 (15.8%) and n = 4 (30.8%) in Group 2 (p = 0.123-p = 0.874). Altered INR (OR 5.2) and increasing D-dimer levels (AUC: 0.81) correlated to increased mortality. Discussion: Group 2 showed higher mortality than Group 0 and Group 1, however Group 2 had fewer active treatments. Of clotting factors, only altered INR and elevated D-dimer levels were significantly correlated to adverse outcomes. Conclusions: Anticoagulant but not antiplatelet treatment seems to produce the worst outcomes in major trauma.
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Affiliation(s)
- Stefano Sartini
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Marzia Spadaro
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Ombretta Cutuli
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Luca Castellani
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Maria Luisa Cristina
- Department of Health Sciences, University of Genova, 16128 Genoa, Italy
- Hospital Hygiene Unit, Galliera Hospital, Via Alessandro Volta 8, 16128 Genoa, Italy
- Correspondence: (S.S.); (M.S.); (M.L.C.)
| | - Paolo Canepa
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Chiara Tognoni
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Agnese Lo
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Lorenzo Canata
- Emergency Medicine Post-Graduate School, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Martina Rosso
- School of Medicine, University of Genoa, Via Balbi 5, 16126 Genoa, Italy
| | - Eleonora Arboscello
- Emergency Medicine Department, UOC MECAU, San Martino Policlinic University Hospital, Largo Rosanna Benzi 10, 16132 Genoa, Italy
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Pathophysiology and Therapy of High-Altitude Sickness: Practical Approach in Emergency and Critical Care. J Clin Med 2022; 11:jcm11143937. [PMID: 35887706 PMCID: PMC9325098 DOI: 10.3390/jcm11143937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 12/26/2022] Open
Abstract
High altitude can be a hostile environment and a paradigm of how environmental factors can determine illness when human biological adaptability is exceeded. This paper aims to provide a comprehensive review of high-altitude sickness, including its epidemiology, pathophysiology, and treatments. The first section of our work defines high altitude and considers the mechanisms of adaptation to it and the associated risk factors for low adaptability. The second section discusses the main high-altitude diseases, highlighting how environmental factors can lead to the loss of homeostasis, compromising important vital functions. Early recognition of clinical symptoms is important for the establishment of the correct therapy. The third section focuses on high-altitude pulmonary edema, which is one of the main high-altitude diseases. With a deeper understanding of the pathogenesis of high-altitude diseases, as well as a reasoned approach to environmental or physical factors, we examine the main high-altitude diseases. Such an approach is critical for the effective treatment of patients in a hostile environment, or treatment in the emergency room after exposure to extreme physical or environmental factors.
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Multiplate Platelet Function Testing upon Emergency Room Admission Fails to Provide Useful Information in Major Trauma Patients Not on Platelet Inhibitors. J Clin Med 2022; 11:jcm11092578. [PMID: 35566704 PMCID: PMC9100631 DOI: 10.3390/jcm11092578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 02/05/2023] Open
Abstract
Platelet dysfunction is a suggested driver of trauma-induced coagulopathy. However, there is still a paucity of data regarding the impact of injury pattern on platelet function and the association of platelet dysfunction on transfusion requirements and mortality. In this retrospective cohort study, patients were grouped into those with isolated severe traumatic brain injury (TBI group), those with major trauma without TBI (MT group), and a combination of both major trauma and traumatic brain injury (MT + TBI group). Platelet function was assessed by whole blood impedance aggregometry (Multiplate®, MP). Three different platelet activators were used: adenosine-diphosphate (ADP test), arachidonic acid (ASPI test), and thrombin activated peptide-6 (TRAP test). Blood transfusion requirements within 6 h and 24 h and the association of platelet dysfunction on mortality was investigated. A total of 328 predominantly male patients (75.3%) with a median age of 53 (37–68) years and a median ISS of 29 (22–38) were included. No significant difference between the TBI group, the MT group, and the MT + TBI group was detected for any of the investigated platelet function tests. Unadjusted and adjusted for platelet count, the investigated MP assays revealed no significant group differences upon ER admission and were not able to sufficiently predict massive transfusion, neither within the first 6 h nor for the first 24 h after hospital admission. No association between platelet dysfunction measured by MP upon ER admission and mortality was observed. Conclusion: Injury pattern did not specifically impact platelet function measurable by MP. Platelet dysfunction upon ER admission measurable by MP was not associated with transfusion requirements and mortality. The clinical relevance of platelet function testing by MP in trauma patients not on platelet inhibitors is questionable.
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Marchese P, Lardone C, Canepele A, Biondi S, Roggi C, Massart F, Bonuccelli A, Peroni D, Giotta Lucifero A, Luzzi S, Foiadelli T, Orsini A. Pediatric traumatic brain injury: a new relation between outcome and neutrophil-to-lymphocite ratio. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 92:e2021417. [PMID: 35441607 PMCID: PMC9179059 DOI: 10.23750/abm.v92is4.12666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 01/27/2022] [Indexed: 11/23/2022]
Abstract
Leading causes of death in industrialized countries are traumatic injuries and acquired disability, and entry to the emergency department in childhood. TBI (traumatic brain injury) may involve the onset of both primary lesions and a complex immune response (sterile immune reaction to brain injury), which, in addition to neuro-protective effects, can mediate secondary neurological injury. The neutrophil-to-lymphocyte ratio (NLR), as a circulating inflammatory marker, has been related to outcomes in adult patients with non-neurologic diseases (such as gut tumours) or neurologic diseases (such as stroke or brain tumours), and to the prognosis of traumatic brain injury in adolescents and adults. However, the potential role of NLR in predicting outcomes in paediatric head trauma is not clearly defined. The aim of this retrospective observational study is to evaluate the association between clinical features predictive of intracranial and extracranial lesions in TBI and NLR and to establish whether an elevation of NLR is indirectly associated with adverse outcomes in pediatric patients with TBI. We analysed a sample of 219 pediatric patients, between 2-18 years old, after a TBI, and evaluated if differences in NLR were associated with neurological signs or positive CT in pediatric patients. We then compared the NLR values between healthy subjects and patients with TBI. (www.actabiomedica.it)
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Affiliation(s)
| | | | | | | | | | | | | | - Diego Peroni
- Department of Pediatrics, University of Pisa, Italy.
| | - Alice Giotta Lucifero
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy.
| | - Thomas Foiadelli
- Pediatric Clinic, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy.
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11
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Emergency Department Overcrowding: Understanding the Factors to Find Corresponding Solutions. J Pers Med 2022; 12:jpm12020279. [PMID: 35207769 PMCID: PMC8877301 DOI: 10.3390/jpm12020279] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/14/2022] Open
Abstract
It is certain and established that overcrowding represents one of the main problems that has been affecting global health and the functioning of the healthcare system in the last decades, and this is especially true for the emergency department (ED). Since 1980, overcrowding has been identified as one of the main factors limiting correct, timely, and efficient hospital care. The more recent COVID-19 pandemic contributed to the accentuation of this phenomenon, which was already well known and of international interest. Considering what would appear to be a trivial definition of overcrowding, it may seem simple for the reader to hypothesize solutions for what seems to be one of the most avoidable problems affecting the hospital system. However, proposing solutions to overcrowding, as well as their implementation, cannot be separated from a correct and precise definition of the issue, which must consider the main causes and aggravating factors. In light of the need of finding solutions that can put an end to hospital overcrowding, this review aims, through a review of the literature, to summarize the triggering factors, as well as the possible solutions that can be proposed.
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Cheng L, Cui G, Yang R. The Impact of Preinjury Use of Antiplatelet Drugs on Outcomes of Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:724641. [PMID: 35197919 PMCID: PMC8858945 DOI: 10.3389/fneur.2022.724641] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 01/12/2022] [Indexed: 11/15/2022] Open
Abstract
Objective The study aimed to compare outcomes of traumatic brain injury (TBI) in patients on pre-injury antiplatelet drugs vs. those, not on any antiplatelet or anticoagulant drugs. Methods PubMed, Embase, and Google Scholar databases were searched up to 15th May 2021. All cohort studies comparing outcomes of TBI between antiplatelet users vs. non-users were included. Results Twenty studies were included. On comparison of data of 2,447 patients on pre-injury antiplatelet drugs with 4,814 controls, our analysis revealed no statistically significant difference in early mortality between the two groups (OR: 1.30 95% CI: 0.85, 1.98 I2 = 80% p = 0.23). Meta-analysis of adjusted data also revealed no statistically significant difference in early mortality between antiplatelet users vs. controls (OR: 1.24 95% CI: 0.93, 1.65 I2 = 41% p = 0.14). Results were similar for subgroup analysis of aspirin users and clopidogrel users. Data on functional outcomes was scarce and only descriptive analysis could be carried out. For the need for surgical intervention, pooled analysis did not demonstrate any statistically significant difference between the two groups (OR: 1.11 95% CI: 0.83, 1.48 I2 = 55% p = 0.50). Length of hospital stay (LOS) was also not found to be significantly different between antiplatelet users vs. non-users (MD: −1.00 95% CI: −2.17, 0.17 I2 = 97% p = 0.09). Conclusion Our results demonstrate that patients on pre-injury antiplatelet drugs do not have worse early mortality rates as compared to patients, not on any antiplatelet or anticoagulant drugs. The use of antiplatelets is not associated with an increased need for neurosurgical intervention and prolonged LOS.
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Savioli G, Alfano C, Zanza C, Bavestrello Piccini G, Varesi A, Esposito C, Ricevuti G, Ceresa IF. Dysbarism: An Overview of an Unusual Medical Emergency. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:104. [PMID: 35056412 PMCID: PMC8778177 DOI: 10.3390/medicina58010104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/27/2021] [Accepted: 12/29/2021] [Indexed: 02/03/2023]
Abstract
Dysbarism is a general term which includes the signs and symptoms that can manifest when the body is subject to an increase or a decrease in the atmospheric pressure which occurs either at a rate or duration exceeding the capacity of the body to adapt safely. In the following review, we take dysbarisms into account for our analysis. Starting from the underlying physical laws, we will deal with the pathologies that can develop in the most frequently affected areas of the body, as the atmospheric pressure varies when acclimatization fails. Manifestations of dysbarism range from itching and minor pain to neurological symptoms, cardiac collapse, and death. Overall, four clinical pictures can occur: decompression illness, barotrauma, inert gas narcosis, and oxygen toxicity. We will then review the clinical manifestations and illustrate some hints of therapy. We will first introduce the two forms of decompression sickness. In the next part, we will review the barotrauma, compression, and decompression. The last three parts will be dedicated to gas embolism, inert gas narcosis, and oxygen toxicity. Such an approach is critical for the effective treatment of patients in a hostile environment, or treatment in the emergency room after exposure to extreme physical or environmental factors.
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Affiliation(s)
- Gabriele Savioli
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
- PhD School in Experimental Medicine, Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy
| | - Claudia Alfano
- Emergency Medicine and Surgery, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Christian Zanza
- “Ospedale Alba-Bra Onlus”—Department of Emergency Medicine, Anesthesia and Critical Care Medicine, Michele and Pietro Ferrero Hospital, 12060 Verduno, Italy;
- Research Training Innovation Infrastructure, Research and Innovation Department, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
| | | | - Angelica Varesi
- Department of Biology and Biotechnology, University of Pavia, 27100 Pavia, Italy;
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, ICS Maugeri, University of Pavia, 27100 Pavia, Italy;
| | - Giovanni Ricevuti
- School of Pharmacy, Department of Drug Sciences, University of Pavia, 27100 Pavia, Italy;
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14
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Mild Head Trauma (MHT) and Antiplatelet Therapy. Reply to Lorenzati et al. Comment on "Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357". MEDICINA-LITHUANIA 2021; 57:medicina57090889. [PMID: 34577811 PMCID: PMC8469365 DOI: 10.3390/medicina57090889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 11/17/2022]
Abstract
We read your data with interest, and we truly appreciate the similar experience [...].
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15
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Lorenzati B, Bruno A, Racca G, Giamello J, Allione A, Barutta L, Bernardi E, Blangetti I, Bono A, Dutto L, Fulcheri C, Galaverna R, Grosso A, Maggio E, Martini G, Peloponneso V, Perotto M, Prinzis T, Ramonda P, Raviolo A, Rega M, Tortore A, Tosello F, Sciolla A, Lauria G. Comment on Savioli et al. Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications? Medicina 2021, 57, 357. MEDICINA-LITHUANIA 2021; 57:medicina57090887. [PMID: 34577810 PMCID: PMC8470498 DOI: 10.3390/medicina57090887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/13/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Bartolomeo Lorenzati
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
- Correspondence:
| | - Alice Bruno
- School of Emergency Medicine, University of Pavia, 27100 Pavia, Italy;
| | - Giulia Racca
- Internal Medicine, Department of Medicine, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy;
| | - Jacopo Giamello
- School of Emergency Medicine, University of Turin, 10100 Turin, Italy;
| | - Attilio Allione
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Letizia Barutta
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Emanuele Bernardi
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Ilaria Blangetti
- Intensive Care Unit, Regina Montis Regalis Hospital, 12084 Mondovi, Italy;
| | - Alessia Bono
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Luca Dutto
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Chiara Fulcheri
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Remo Galaverna
- Intensive Care Unit, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (R.G.); (P.R.)
| | - Alberto Grosso
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Elena Maggio
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Gianpiero Martini
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Vincenzo Peloponneso
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Massimo Perotto
- Internal Medicine, Department of Medicine, P.O. Michele Ferrero Hospital, 12060 Verduno, Italy;
| | - Tania Prinzis
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Paola Ramonda
- Intensive Care Unit, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (R.G.); (P.R.)
| | - Alessandro Raviolo
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Massimo Rega
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Andrea Tortore
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Francesco Tosello
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Andrea Sciolla
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
| | - Giuseppe Lauria
- Emergency Medicine, Department of Emergency and Critical Care, A.O. S. Croce e Carle Hospital, 12100 Cuneo, Italy; (A.A.); (L.B.); (E.B.); (A.B.); (L.D.); (C.F.); (A.G.); (E.M.); (G.M.); (V.P.); (T.P.); (A.R.); (M.R.); (A.T.); (F.T.); (A.S.); (G.L.)
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