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Repeat head CT in patients on direct oral anticoagulant therapy (DOACs) with minor traumatic brain injury (MTBI) after an initial CT scan without injury on arrival in the Emergency Department (ED) is a common clinical practice but is not based on clear evidence. To assess the incidence of delayed intracranial haemorrhage (ICH) in patients taking DOACs after an initial negative CT and the association of clinical and risk factors presented on patient arrival in the ED. This retrospective multicentre observational study considered patients taking DOACs undergoing repeat CT after a first CT free of injury for the exclusion of delayed ICH after MTBI. Timing between trauma and first CT in the ED and pre- or post-trauma risk factors were analysed to assess a possible association with the risk of delayed ICH. A total of 1426 patients taking DOACs were evaluated in the ED for an MTBI. Of these, 68.3% (916/1426) underwent a repeat CT after an initial negative CT and 24 h of observation, with a rate of delayed ICH of 1.5% (14/916). Risk factors associated with the presence of a delayed ICH were post-traumatic loss of consciousness, post-traumatic amnesia and the presence of a risk factor when the patient presented to the ED within 8 h of the trauma. None of the patients with delayed ICH at 24-h repeat CT required neurosurgery or died within 30 days. Delayed ICH is an uncommon event at the 24-h control CT and does not affect patient outcome. Studying the timing and characteristics of the trauma may indicate patients who may benefit from more in-depth management.

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. 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 24h in the ED. Follow-up was performed up to 1month after the head trauma. 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. 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.

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.

Background The presence of oral anticoagulant therapy (OAT) alone, regardless of patient condition, is an indication for CT imaging in patients with mild traumatic brain injury (MTBI). Currently, no specific clinical decision rules are available for OAT patients. The aim of the study was to identify which clinical risk factors easily identifiable at first ED evaluation may be associated with an increased risk of post-traumatic intracranial haemorrhage (ICH) in OAT patients who suffered an MTBI. Methods Three thousand fifty-four patients in OAT with MTBI from four Italian centers were retrospectively considered. A decision tree analysis using the classification and regression tree (CART) method was conducted to evaluate both the pre- and post-traumatic clinical risk factors most associated with the presence of post-traumatic ICH after MTBI and their possible role in determining the patient’s risk. The decision tree analysis used all clinical risk factors identified at the first ED evaluation as input predictor variables. Results ICH following MTBI was present in 9.5% of patients (290/3054). The CART model created a decision tree using 5 risk factors, post-traumatic amnesia, post-traumatic transitory loss of consciousness, greater trauma dynamic, GCS less than 15, evidence of trauma above the clavicles, capable of stratifying patients into different increasing levels of ICH risk (from 2.5 to 61.4%). The absence of concussion and neurological alteration at admission appears to significantly reduce the possible presence of ICH. Conclusions The machine-learning-based CART model identified distinct prognostic groups of patients with distinct outcomes according to on clinical risk factors. Decision trees can be useful as guidance in patient selection and risk stratification of patients in OAT with MTBI.

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. [...]

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.

The COVID 19 outbreak dramatically highlighted the inadequacy of the Emergency Department (ED) settings in dealing with events that can acutely affect a wide range of population. The immediate urgency to create strictly distinct pathways became also a strategic aspect for reducing possible sources of contagion inside the hospital.1 This need has often clashed with inadequate structural conditions of the hospital: in fact, the rigidity of many EDs is due to the hospital typology and its localization (affected by functional program);2,3 and it prevents them from being quickly adapted to new needs in the case of maxi-emergencies.4 In several recent international projects, the presence of a multifunctional space and/or a buffer area guarantees different scenarios in relation to the healthcare/emergency needs.5[...]

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.

The phenomenon of acute behavioral disturbance is an underrecognized and potentially life-threatening syndrome, and sometimes an emergency in psychiatric settings. Patients presenting to the Italian emergency department (ED) with acute behavioral disturbances account for approximately 3.2% of all ED visits. The spectrum of behaviors and signs overlap with many clinical disease processes. In addition to patients with behavioral problems related to mental disorders or substance abuse, there is also a large group whose behavioral emergencies directly result from medical illness. The complexity of these patients, as well as the interdisciplinary nature of their care, requires a clear and consensual framework for care. A network of Italian scientific societies developed ten reccomendations for good clinical practice. The main purpose is to draw up a document that presents a standardized method for the organization of the care of patients with acute behavioral disorders in ED.

Blunt chest trauma with isolated or multiple rib fractures constitutes a common presentation in Emergency Department (ED), particularly in elderly people. Rib fractures in the elderly create short- and long-term disabilities with a dramatic impact. Pain management in the elderly could be problematic due to non-steroidal anti-inflammatory drugs (NSAIDs) contraindication or interaction with other drugs. We performed this retrospective study collecting and retrieving all patients aged 65 or older, with a diagnosis of rib(s) fracture(s) during an 18-month period. We analyzed the different treatments chosen, and divided them into subgroups: oxycodone- naloxone, and other treatments (also divided in: codeineacetaminophen; NSAID or Acetaminophen; Tramadol or Tapentadol). A total of 475 elderly patients (aged 65 and older) with single or multiple rib fractures were evaluated in our ED in 18 months: of these 410 patients were considered eligible, with a mean age of 79.28 years (standard deviation 7.83). 185 were male and 225 were female. Our study confirms the efficacy and tolerability of fixed association of oxycodone and naloxone. This association determined the highest and fastest reduction on Numeric Pain Scale reported by patients and is significantly better than other drugs in oral administration.