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The decision to initiate or continue advanced life support (ALS) in out-of-hospital cardiac arrest (OHCA) could be difficult due to the lack of information and contextual elements, especially in non-shockable rhythms. This study aims to explore factors associated with clinicians' decision to initiate or continue ALS and the conditions associated with higher variability in asystolic patients.This retrospective observational study enrolled 2653 asystolic patients on whom either ALS was attempted or not by the emergency medical services (EMS) physician. A multivariable logistic regression analysis was performed to find the factors associated with the decision to access ALS. A subgroup analysis was performed on patients with a predicted probability of ALS between 35% and 65%. The single physician's behaviour was compared to that predicted by the model taking into account the entire agency.Age, location of event, bystander cardiopulmonary resuscitation and EMS-witnessed event were independent factors influencing physicians' choices about ALS. Non-medical OHCA, younger patients, less experienced physicians, presence of breath activity at the emergency call and a longer time for ALS arrival were more frequent among cases with an expected higher variability in behaviours with ALS. Significant variability was detected between physicians.Significant inter-physician variability in access to ALS could be present within the same EMS, especially among less experienced physicians, non-medical OHCA and in presence of signs of life during emergency call. This arbitrariness has been observed and should be properly addressed by EMS team members as it raises ethical issues regarding the disparity in treatment.

The role of prehospital focused assessment sonography for trauma (FAST) is still under debate and no definitive recommendations are available in actual guidelines, moreover, the availability of ultrasound machines in emergency medical services (EMS) is still inhomogeneous. On the other hand, time to definitive care is strictly related to survival in bleeding trauma patients. This study aimed at investigating if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time.This retrospective observational study included all the patients affected by an abdominal trauma with an abdominal abbreviated injury score ≥ 2 and a spleen or liver injury admitted to Maggiore Hospital Carlo Alberto Pizzardi, a level 1 trauma centre between 2014 and 2019. Prehospital and emergency department (ED) clinical and laboratory variables were collected, as well as in-hospital times during the diagnostic and therapeutic pathways of these patients.199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%-80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model.Prehospital FAST information of intraperitoneal free fluid could significantly hasten door-to-CT scan or door-to-operating theatre time in abdominal trauma patients if established hospital response protocols are available.III, (Therapeutic / Care Management).

Background:Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected.Methods:A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated.Results:Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags.Conclusions:Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.

The COVID-19 pandemic required a global increase in intensive care unit (ICU) resources and the recruitment of a great number of nurses without any tprior critical care experience. The opportunities for traditional education and supervised clinical training were limited to prevent infections. The massive increase of nursing staff resources required a rethinking of the usual educational strategies for newly acquired nurses. This short communication describes our experience of an "in-situ" simulation training course in an Italian tertiary level hospital. A series of two-part classes were structured with short lectures on fundamental principles of intensive care nursing and brief hands-on sessions, and a set of simulated scenarios, based upon the most common situations to be faced in the ICU. In-situ simulation offers greater realism and transferability and represents a cost-effective strategy, avoiding the costs and the maintenance of a dedicated simulation center. The simulated multidisciplinary teamwork in the real ICU setting contributes to an effective experiential learning, improving staff familiarity with devices, equipment, and environment, and allows trainees to improve both technical and nontechnical skills.

Aims Out of hospital cardiac arrest (OHCA) is still a leading cause of mortality worldwide. In recent years, resuscitative endovascular balloon occlusion of the aorta (REBOA) has been progressively studied as an adjunct to standard advanced life support (ALS) in both traumatic and non-traumatic refractory OHCA. Since January 2019, the REBOA procedure has been applied to all the patients experiencing both traumatic and non-traumatic refractory OHCA (≥15 min of cardiopulmonary resuscitation) not eligible for ECPR for clinical or logistic reasons. We aimed at describing the feasibility and effects of REBOA performed both in the Emergency Department and in the pre-hospital environment served by the local HEMS for refractory OHCA. Methods Twenty consecutive patients experiencing refractory OHCA and in whom REBOA was attempted in 2019 and 2020 were included in the study, Utstein data and REBOA specific variables were recorded. Results Successful catheter placement was achieved in 18 out of 20 patients, 11 of these were non-traumatic OHCAs while 7 were traumatic OHCAs, the 2 failures were related to repeated arterial puncture failure. Median time between the EMS dispatch and REBOA catheter placing attempt was 46 min. An increase in etCO2 over 10 mmHg was observed after balloon inflation in 12 out of 18 patients (8/11 non-traumatic and 4/7 traumatic OHCAs), a sustained ROSC was observed in 5 patients (1 traumatic and 4 non-traumatic OHCA) that were subsequently admitted to the ICU. Four out of the 5 patients reached the criteria for brain death in the subsequent 24 h while one patient experienced another episode of refractory cardiac arrest in ICU and subsequently died. Conclusion Our data confirm the feasibility of REBOA technique as an adjunct to ALS in both the ED and prehospital phase and most of the treated patients experienced a transient ROSC after balloon inflation while 5 out of 18 experienced a sustained ROSC. However, while in the trauma setting increasing evidence suggests an improved survival when REBOA is applied to refractory OHCA, in non-traumatic OHCA this has yet to be demonstrated and large studies are needed.

The return of spontaneous circulation (ROSC) after cardiac arrest (RACA) score was developed as a tool to predict ROSC probability (pROSC) based on easily available information and it could be useful to compare the performances of different EMS agencies or the effects of eventual interventions.We performed an external validation of the RACA score in a cohort of out of hospital cardiac arrest (OHCA) patients managed by the EMS of the metropolitan city of Bologna, Italy.We analyzed data from 2,310 OHCA events prospectively collected between January 2009 and June 2021. Discrimination was assessed with the area under the ROC curve (AUROC), while the calibration belts were used for the comparison of observed versus expected ROSC rates. The AUROCs from our cohort and other validation cohorts were compared using a studentized range test.The AUROC for the study population was 0.691, comparable to that described by previous validation studies. Despite an acceptable overall calibration, we found a poor calibration for asystole and low pROSC ranges in PEA and shockable rhythms. The model showed a good calibration for patients aged over 80, while no differences in performance were found when evaluating events before and after the implementation of 2015 ERC guidelines.Despite AUROC values being similar in different validation studies for RACA score, we suggest separating the different rhythms when assessing ROSC probability with the RACA score, especially for asystole.

An amendment to this paper has been published and can be accessed via the original article.

Background The catastrophic fail of a container holding a pressure-liquified gas can generate a boiling liquid expanding vapor explosion (BLEVE) with a subsequent blast wave, flying fragments, and fire or toxic gas release. Case Report This report describes the management of a mass casualty disaster related to a BLEVE in an urban area due to a highway accident involving a tanker carrying liquified petroleum gas and a truck transporting chemical solvents. The event resulted in 158 casualties that were triaged, stabilized, and transported into the “hub” and “spoke” hospitals of the regional trauma network within 3 h and 22 min from the event by the Emergency Medical Services. The logistic complications related to the partial collapse of the highway bridge on an underlying urban road and the relative solutions adopted, as well as the application and advantages of the use of the Simple Triage and Rapid Treatment (START) algorithm in the field and the criteria adopted for the distribution of patients within the trauma network, are discussed, along with the potential pitfalls observed. Why Should an Emergency Physician Be Aware of This? BLEVE events are rare but can be complex in both logistical management and clinical presentation of the lesions related to the event. The START algorithm is a valuable tool for rapid triage in mass casualty incidents.

Extracorporeal CO2-removal devices have been introduced in clinical practice to provide protective and ultraprotective ventilation strategies in different settings to avoid retention of carbon dioxide. The need to facilitate lung-protective ventilation is required not only for the treatment of acute respiratory distress syndrome but also in thoracic surgery during complex operations, especially in respiratory compromised patients. This report describes a case of giant bullectomy for vanishing lung syndrome in which intraoperative hypercapnia secondary to protective ventilation was managed with a CO2-removal device (Decap-Hemodec s.r.l., Salerno, Italy). To the best of our knowledge, this is the first report in the literature of the intraoperative use of the Decap system for giant bullectomy.