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Oxidative stress plays an important role in chronic respiratory diseases where the use of non-invasive ventilation seems to reduce the oxidative damage. Data on acute respiratory failure are still lacking. The aim of the study is to investigate the interplay between oxidative stress and acute respiratory failure, and the role of non-invasive ventilation in this setting. We enrolled 60 patients suffering from acute respiratory failure (PaO2/FiO2 ratio <300): 30 consecutive patients treated with non-invasive ventilation and 30 consecutive patients treated with conventional oxygen therapy. Serum levels of soluble Nox2-derived peptide (sNOX2-dp), a marker of NADPH-oxidase activation, and 8-iso-PGF2α and H2O2, markers of oxidative stress, were evaluated at baseline and after 3 h of treatment. At baseline, higher values of sNOX2-dp, 8-iso-PGF2α and H2O2 are associated with lower values of PaO2/FiO2 ratio (p < 0.001). After 3 h, serum levels of sNOX2-dp, H2O2, and 8-iso-PGF2α significantly decrease in patients treated with non-invasive ventilation, but not in patients treated with conventional oxygen therapy. Delta changes of oxidative stress parameters correlate inversely with the delta changes of PaO2/FiO2 (R = -0.623, p < 0.001 for sNOX2-dp; R = -0.428, p < 0.001 for H2O2; R = -0.548, p < 0.001 for 8-iso-PGF2α). In the acute respiratory failure setting, treatment with non-invasive ventilation reduces the levels of oxidative stress in the first hours. This reduction is associated with an improvement of PaO2/FiO2 ratio as well as in a reduction of NADPH-oxidase activity. [ABSTRACT FROM AUTHOR]

Angioedema attacks, characterized by the transient swelling of the skin and mucosae, are a frequent cause of visits to the emergency department. Swellings of the oral cavity, tongue, or larynx can result in life-threatening airway obstruction, while abdominal attacks can cause severe pain and often lead to unnecessary surgery. The underlying pathophysiologic process resulting in increased vascular permeability and plasma extravasation is mediated by vasoactive molecules, most commonly histamine and bradykinin. Based on the mediator involved, distinct angioedema forms can be recognized, calling for distinct therapeutic approaches. Prompt recognition is challenging for the emergency physician. The low awareness among physicians of the existence of rare forms of angioedema with different aetiologies and pathogenesis, considerably adds to the problem. Also poorly appreciated by emergency personnel may be the recently introduced bradykinin-targeted treatments. The main objective of this consensus statement is to provide guidance for the management of acute angioedema in the emergency department, from presentation to discharge or hospital admission, with a focus on identifying patients in whom new treatments may prevent invasive intervention. [ABSTRACT FROM AUTHOR]

'Triage' is a useful tool used in emergency departments (EDs) to prioritize the care of patients. Through a methodical process of different sequential steps, the triage nurse assigns a color code which goes from red-critical patient with immediate access to medical examination-to a white code that represents no urgency. Clinical studies have shown that patients can be victims of errors during the process of care, especially in complex systems such as EDs. To reduce errors it is essential to map the risks in order to identify the causes (both individual and organizational); the introduction of corrective changes cannot be postponed. The incorrect assessment at triage represents one of the major errors in EDs. By monitoring this activity, through the analysis of sentinel events we can reduce adverse consequences. Missed recognition of a red code indicates a sentinel event. We used a 'root cause analysis' to explain an episode of missed recognition of red code at triage. A nurse without specific training in triage and inexperienced in critical care was identified as the 'root cause' of the sentinel event. To make improvements we planned a triage training course (for newly employed nurses and a refresher course for existing staff) and created a team of dedicated triage nurses. [ABSTRACT FROM AUTHOR]

The concept of a medical emergency, i.e., a time when immediate action is required to stabilize and restore the vital functions, is absent in the tradition of ancient medicine, which seeks to cure the sick. The theoretical and conceptual development of a prompt medical assistance definitely owes much to the refinement of instruments and surgical techniques that were develop in the early modern age, allowing the extension of therapeutic action to 'healthy' individuals who are suddenly life-threatened due to an accident or to some external events that affect their vital functions. But it is especially in the eighteenth century that the epistemic basis of medical emergency is structured, when the Enlightenment gave rise to the ethical and political imperative of public assistance that required the planning of first aid at multiple levels, and medicine developed the concept of life-saving treatment. In particular, eighteenth century medicine, studying systems to assure immediate relief to the victims of accidents-especially to the drowned-allowed the development of specific and methodological systems of resuscitation and emergency treatment. [ABSTRACT FROM AUTHOR]

ial Fibrillation management is still a matter for debate. Past research has largely been based on the outpatient setting in which patients are followed during ambulatory visits. Very little data exist on the optimal management of AF in the Emergency Department (ED). This study investigated which factors drive different AF treatments in the ED, describing their use in different hospitals. Finally, the efficacy of different strategies in terms of cardioversion in the ED was analyzed. Charts of patients treated for atrial fibrillation (AF) were collected in 6 EDs in a large metropolitan area over a 24-consecutive month period and were reviewed and analysed. Demographics, comorbidities, treatment strategy and ED outcome were collected. Inclusion criteria were symptom onset <3 weeks and stable hemodynamic conditions at presentation. A propensity score was used to adjust for baseline clinical characteristics and to compare the efficacy of different treatments. 3,085 patients were included in the analysis. Variables associated with a rhythm control strategy were onset of symptoms <48 h, age, dyspnea, palpitations, renal failure and the presence of a mechanical valve. Different EDs applied different strategies in terms of drugs used and the electrocardioversion rate, showing heterogeneity in AF management. Adjusting for the propensity score, electrocardioversion and antidysrhythmic drugs of class Ic were more effective than a wait-and-watch strategy in the ED. Despite international guidelines being respected, AF management is heterogeneous in different ED settings. A rhythm control strategy with electrocardioversion and Class Ic drugs is more effective than a wait-and watch approach during the ED visit. Further research, toward an evidence-based approach to the emergent management of AF in the ED, is still needed. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study were: (i) to assess the role of B-type natriuretic peptide (BNP) in the course of hypertensive crisis; (ii) to evaluate the possible role of BNP in the differential diagnosis between hypertensive emergencies (HE) or urgencies (HU); and (iii) to investigate the relationship between BNP concentration and blood pressure (BP) acute burden with consequent myocardial ischaemia or brain damage. Methods: 57 consecutive patients were admitted to the emergency department for acute elevated BP levels (systolic BP [SBP]/diastolic BP [DBP]: 200.7 ± 24.7/121.2 ± 12.4 mmHg) were enrolled. On the basis of clinical data, patients were subdivided into two groups: (i) 25 patients with HE: SBP/DBP 204.16 ± 29.1/123.3 ± 13.0 mmHg with heart (acute coronary syndrome) or brain involvement; (ii) 32 patients with HU: SBP/DBP 198.1 ± 20.7/120 ± 11.7 mmHg, without any acute or ongoing deterioration of target organs. For each patient, a serum dosage of BNP was performed. Results: In the whole population, no significant relationship was found between BP total burden and BNP level. In HE, BNP concentration (113.22 ± 87 pg/mL) was significantly (p < 0.001) higher than in HU (23.5 ± 21.3 pg/ mL) patients. There was a significant increase (p < 0.01) of BNP blood level in HE patients with acute coronary syndrome (162.02 ± 95.7 pg/mL) compared with those with neurological complications (80.7 ± 65.2 pg/mL). Moreover, in HU patients, there was a significant relationship (r = 0.37; p < 0.05) between BNP levels and pulse pressure. Conclusions: During hypertensive crisis, BNP blood level increase seems to have a role as a diagnostic tool for the screening of hypertensive emergencies due to an acute coronary or brain injury, and the BNP elevation is greater in the presence of myocardial ischaemia than brain damage. [ABSTRACT FROM AUTHOR]