Evaluation of procalcitonin in hemorrhagic shock: a pilot study

Abstract

An increased secretion of procalcitonin (PCT) is primarily due to systemic inflammation of bacterial origin, as PCT is used to diagnose and manage sepsis. However, other conditions can induce high plasma levels of PCT, and hemorrhagic shock may be one of these as we found in clinical practice. The aim of this pilot, observational and prospective study was to investigate the role of PCT in hemorrhagic shock and if it could help in distinguishing between different types of shock. We enrolled 15 patients who entered the shock room of our Emergency Department (ED) with a diagnosis of hemodynamic shock, defined as hypotension (systolic blood pressure < 90 mmHg, or medial arterial pressure < 65 mmHg), and/or elevated lactate level (> 2 mmol/L), with one or more signs of cerebral or systemic hypoperfusion. For all the patients we dosed PCT at the time of admission, and we collected them into three different groups - septic, hemorrhagic and mixed shock - based on clinical presentation and laboratory and instrumental examination. First results did not show a significant increase of PCT in patients with hemorrhagic shock alone (average 0.12 ± 0.07 ng/mL), while PCT levels were similarly high in those with septic and mixed shock (17.63 ± 32.16 and 24.62 ± 33.02 respectively). PCT is not a marker of bleeding shock and does not help in distinguishing if bleeding or sepsis have the major impact on hemodynamics in those with mixed shock. However, patients with sepsis usually access the ED a few days after the initial infectious and inflammatory process has begun, while those with a major bleeding ask for intervention at the very first beginning. Thus, it may be helpful to see is PCT levels rise after some time from the bleeding start, or to investigate a different biomarker that rises earlier in course of systemic disfunction, such as presepsin. Finally, we also aimed at investigating if PCT levels would show any correlation with age of patients, regardless of the type of shock: results provided an higher PCT in individuals ≥ 80 years old, than in those < 80 years old.

Management of maxillary artery pseudoaneurysm in Emergency Department: a narrative review

Tooth extraction is a common procedure that is performed routinely and is associated with very few risks. The formation of a pseudoaneurysm as a direct result of tooth extraction has not been widely reported in published studies; it is more frequent as a complication of orthognathic surgery (1). The purpose of this paper is to describe the literature of maxillary artery pseudoaneurysm and its diagnosis and treatment in the Emer-gency Department. The search engine we used is Pubmed. 39 studies were analyzed; mainly, they were case reports. In this study, we will analyze the cases of pseudoaneurysm formation following dental extraction and orthognotia surgery which are reported in literature.

P270 TELL ME HOW LONG WILL YOU STAY … TELL ME HOW LONG HOW LONG … ANALYSIS OF THE DURATION OF HOSPITAL STAY (HOSPITAL LENGTH OF STAY) OF ELDERLY PATIENTS WITH EMBOLISM: EXPERIENCE OF 4 YEARS IN FIRST AID

Premise

Pulmonary embolism is a disease still characterized by high mortality. It requires emergency department resources to be diagnosed promptly and can require lengthy hospital care.

Purpose

to assess which parameters, in the real life of an Emergency Department, correlate with the duration of a hospitalization for pulmonary embolism (hospital LOS).

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood chemistry and blood gas analyzes performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We also analyzed vital parameters and the various shock indexes from these derivatives. We then analyzed whether patients had massive pulmonary embolism or the presence of organ damage (right ventricular dilation, pulmonary artery dilation and presence of pulmonary infarction).

Results

We enrolled 247 patients, all in need of hospitalization for acute pulmonary embolism. The average age is 83 with female precalence (F = 63%). Regarding the length of hospital stay, the presence of massive embolism shows a good statistical correlation (p &lt; 0.01), while the presence of organ damage seems irrelevant (p &gt; 0.05). The need for resuscitation care and the high sPESI index also show no correlation (p &gt; 0.05). Age and vital signs (blood pressure, respiratory rate, heart rate) as well as derived shock indices are unrelated (rho∼0; p &gt; 0.05). A weak correlation is instead present with high D–Dimer values (rho∼0.20; p &lt; 0.005) while the other blood samples do not show correlation (rho∼0; p &gt; 0.05). No correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests that the presence of massive pulmonary embolism and to a lesser extent high D–Dimer values correlates with a long hospital stay.

P263 ROLE OF VITAL SIGNS AND INDICES OF SHOCK DERIVED FROM THEM IN THE SUSPICION OF MASSIVE PULMONARY EMBOLISM IN ELDERLY: THE ER AS A WINDOW ON REAL LIFE

Purpose

Assess which vital parameters or shock parameters, in the real life of an Emergency Department, correlate with the presence of massive pulmonary embolism to see which ones can be of help to early suspect it.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Anni), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We assess the correlation of vital parameters and shock indexes with the presence of massive pulmonary embolism. We took into consideration: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these, 85 (34.4 %) presented with massive pulmonary embolism. There is no correlation between blood pressure, systolic and diastolic values, respiratory rate with the presence of massive pulmonary embolism (p &gt; 0.05). However, there is a strong statistical correlation between heart rate values and the presence of massive pulmonary embolism (p &lt; 0.0001). The shock index correlates with the presence of massive pulmonary embolism with good statistical strength (p &lt; 0.001); the modified shock index correlates with the with even greater statistical strength (P = 0.0005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p &lt; 0.0001).

Conclusions

The study suggests that the alteration of shock indices, in particular of the AGE–shock index, correlate with the condition of massive pulmonary embolism. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, easily performed in the various Italian situations, can help to raise the suspicion of massive pulmonary embolism early and direct the patient more quickly towards the correct procedure therapeutic diagnostic.

P275 HOLDING AREA IN EMERGENCY DEPARTMENT : A STRATEGY TO IMPROVE ADHERENCE TO INTERNATIONAL GUIDELINES IN CASES OF PULMONARY EMBOLISM IN ELDERLY

Premises

Pulmonary embolism is a disease still characterized by high mortality. Despite a great development of the guidelines it is not clear what adherence to them is in real life, especially in the emergency room.

Purpose of the Study

See if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the area to which the patient is addressed.

Methods

Monocentric retrospective observational study, on a group of geriatric patients (&lt;75 y) that include all the people accessed to our ED, where they received acute PE dignosis. Enrolment started on 2016 and finished on 2019. We collected data from medical history, physical examination, lab tests, imaging; we calculated characteristic scores from the diagostic/therapeutic algorhitm, both regarding PE risk (Wells, Geneva and Years), and the 30–day mortality risk presentazione (sPESI). We then analized guidelines adherence in three decision–making turning–points: 1 Correct applicarion of decisional scores examined, which classify the patient in low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct therapy administration since the ED as suggested by the guidelines; 3 The eventual observation in the medium–intensity care area with close monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzymes impairement (considered at high risk of short–term shock and mortality).

Results

we enrolled 249 patients, with a mean age of 83 years and female prevalence (F = 62%). Of these, 69% were referred by Triage to medium–high intensity of care, the remaining 31% was directed to low intensity of care. 42.5% of the total patients were referred to OBI. The two areas of intensity of care showed similar adherence to guidelines (approximately 50%) without there being a statistically significant difference between the two areas (p &gt; 0.05) Adherence to guidelines was higher in the holding area – OBI (75 %) compared to that of those managed in theaters (50%) in a statistically significant way (p &lt; 0.001).

Conclusions

The study suggests that holding areas located in Emergency Departments can considerably increase adherence to international guidelines.

P271 DOES SENILITY AFFECT THE MANIFESTATION AND MANAGEMENT OF PULMONARY EMBOLISM? EXPERIENCE OF AN ED

Premises

Acute pulmonary embolism is a pathology characterized by high mortality. The elderly population is destined to increase, becoming, according to some authors, 30% of the population in the developed countries.

Purpose of the Study

see if and how, in the real life of an Emergency Department, age can affect the manifestation (more severe or milder forms of pulmonary embolism; typical symptoms and atypical symptoms), patient management and adherence to guidelines. We considered subjects over 75 years of age to be elderly, as per the latest indications of the guidelines.

Methods

Single–center retrospective observational study on all patients who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed the hospitalization rate, in–hospital mortality rate, the hospitalization rate in resuscitation and the length of hospitalization. We then analyzed adherence to the guidelines valid in the period under study.

Results

We enrolled 487 patients, with equal gender distribution (F = 52%). 247 were older than 75 (50.7%). Age has a positive correlation with the presence of massive pulmonary embolism, in a statistically significant way (p &lt; 0.05), and with the presence of organ damage, touching on statistical significance (p = 0.05). On the other hand there is no statistically significant difference in the prevalence of typical or atypical symptoms in the two groups. The vital parameters were instead comparable in the two groups with no statistically significant difference (p &gt; 0.05). Long–term outcomes such as mortality, need for hospitalization, ICU stay and length of stay in hospital are also comparable results without statistically significant difference (p &gt; 0.05). Adherence to international guidelines is also comparable between the two groups (p &gt; 0.05).

Conclusions

The study suggests that age correlates with more severe forms of pulmonary embolism but does not affect either patient management or short–term outcomes.

P278 WHEN HARRY MET SALLY. DESCRIPTION OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM ARRIVING IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Premises

Pulmonary embolism represents one of the major causes of mortality linked to cardiovascular events. The range of symptoms is extremely wide and its recognition difficult. The patients who therefore come to the emergency room are a diverse population.

Purpose

to describe the population that refers to the emergency room and finds there a diagnosis of acute pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes, severity scores.

Results

We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Among those subjected to blood gas analysis 11% showed alteration of pH, 16% showed alteration of pCO2, 8% showed alteration of pO2, 5% of BE, 2% of lactate. 34% showed massive PE, 32% showed organ damage. In particular, 21% showed pulmonary artery dilation, 16% pulmonary infarction and 19% right ventricular dilation. 40% showed elevation of myocardiospecific enzymes. 41% were considered to be at high risk of long–term mortality according to European guidelines, 41% at intermediate risk and 18% at low risk of mortality. 1.4% underwent thrombolysis, 2.4% required intubation. 2.8% needed an operating room for mechanical thrombolysis; 8% of hospitalization in the intensive ward during hospitalization. In–hospital mortality was 7.7%. 5% experienced bleeding during hospitalization following anticoagulation therapy.

Conclusions

The population that arrives in ED for pulmonary embolism presents extremely varied symptomatological pictures, but an overall high degree of clinical risk and assistance and therapeutic complexity.

P276 BLOOD GAS ANALYSIS AND D–DIMER IN CASES OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: POOR CORRELATION IN REAL LIFE IN THE EMERGENCY ROOM

Premise

Pulmonary embolism is a pathology still characterized by high mortality and severe sequelae, greater in cases of organ damage. Raising suspicion and early recognition of this condition is therefore important to avoid delays in undertaking the right diagnostic and therapeutic process.

Purpose

Evaluate which vital parameters and shock parameters derived from them, in the real life of an Emergency Department, correlate with the presence of organ damage from pulmonary embolism to see which ones may be of help in raising the suspicion of this condition early.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt;75) who were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood gas analyzes performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage.

Results

We enrolled 247 patients, with a mean age of 83 years and female prevalence (F = 63%). Of these, 79 (32%) have organ damage from pulmonary embolism. The lactate values do not correlate with the presence of organ damage (p &gt; 0.05). The pCO2 values correlate inversely with the presence of organ damage reaching statistical significance (P &lt; 0.05). Instead, the reduction in pO2 values and the increase in pH values do not have any correlation with the presence of organ damage (p &gt; 0.05). The D–Dimer in turn shows a fair association with the values of organ damage from pulmonary embolism (p &lt; 0.01).

Conclusions

The study suggests a reduced significance of blood gas analysis in the early identification of patients with organ damage in the event of pulmonary embolism. A fair correlation is given only by the reduction in pCO2 values and by the increase in D–Dimer values.

P332 ACUTE HEART FAILURE IN AN ELDERLY, DIABETIC, HYPERTENSIVE PATIENT. A NEVER BANAL CASE UNDERLINES THE ROLE OF EMERGENCY ECHOCARDIOGRAPHY AND AND THE RELIABILITY OF THE ANAMNESIS COLLECTED IN URGENCY

We describe the case of a 78–year old male who acceded to high intensity medicine ward for acute heart failure after some days management in the emergency room, with acuity stabilization. In his history all atherosclerosis‘ risk factors were present (diabetes mellitus type 2, arterial hypertension, dyslipidemia and kidney chronic disease) together with no active IgGk multiple myeloma, diagnosed the month before. A previous echocardiogram demonstrated aortic valve calcifications, preserved ejection fraction and mild mitral valve failure. the emergency echocardiography service was activated and the patient received echocardiography on first day. Echocardiography revealed severe aortic insufficiency secondary to erosive endocarditis of 15 mm in diameter, increased left ventricular filling pressures, and increased estimated right ventricular pressures. empirical antibiotic therapy was immediately undertaken and were carried out blood cultures.from the emergency echocardiography service the cardiology service was activated for a trans–esophageal echocardio execution which confirmed the findings Streptococcus gallolyticus was isolated. only after performing the echocardiogram did the patient remember having had fever for a few days, more than a month before the first symptoms of heart failure. In the next days, colon adenocarcinoma‘s diagnosis was made. Notably Streptococcus gallolyticus‘s infections are frequent in immunocompromised patients and its most common clinical manifestation is infective endocarditis.This kind of infection is usually connected with colon rectum cancer, mostly in patients that have already started chemotherapy. When endocarditis regards people who don‘t make use of intravenous drugs or that haven‘t congenital or acquired valves defects, the most involved one is the aortic valve. This is especially true in elderly patients.That could be explained by aortic valve damage caused by shear stress and atherosclerotic process, that always involves aortic valve‘s endothelium. This damage manifests itselves as calcium endothelium overload and aortic valve stenosis. All of these factors transform the aortic valve into the perfect target for bacteremia.The patient underwent aortic replacement surgery, because of acute massive aortic valve failure, that impaired patient‘s hemodynamic, and proper antibiotics therapy was started, with benefit. Finally, the colon cancer was treated with surgery, no chemotherapy was needed.

P265 RED ZONE: 22 MILES OF FIRE. ANALYSIS OF THE TIMING AND PROCESSES OF ELDERLY PATIENTS WITH ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Purpose

to describe the role of the emergency room in the diagnostic–therapeutic process of acute pulmonary embolism.

Methods

single–center retrospective observational study, on all geriatric patients (&gt; 75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, all requiring hospitalization for acute pulmonary embolism. The average age of 83 with female prevalence (63%). Median wait times for medical examination were 42 minutes. The average waiting times, however, for the large number of low priority codes (40% between 5 and 4 codes), was more than 6 hours. All patients required a chest CT with contrast, 44% first did a chest x–ray and 2% an ultrasound. All patients underwent ECG and blood tests. The time spent in the Emergency Department (LOS) was on average 18 hours. 58% of patients were managed in areas of low or medium intensity, 42% were sent to OBI for therapeutic diagnostic completion or necessary monitoring. OBI patients were on average 504 minutes. 56% face the phenomenon of boarding. 34% showed massive EP, 32% showed organ damage. 41% were considered to be at high risk of short–term mortality according to European guidelines, 8% required intensive care and in–hospital mortality was 7.7%. Under triage is 31%.

Conclusions

The population that arrives in ED due to pulmonary embolism presents an overall clinical picture with a high degree and high care and therapeutic complexity. Need for numerous investigations and second level imaging. They often require complex therapies and multi–parameter monitoring during stabilization and observation. Therefore, the time spent in the emergency room is long. The workload to treat these patients is high and requires excellent multi–professional and multidisciplinary integration, especially between the various professional figures in urgency, the laboratory and radiology.

P277 SECRET BEYOND THE DOOR. TRIAGE ANALYSIS AND RECOGNITION AT THE DOOR OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM WHO ARRIVE IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Background

The range of symptoms of pulmonary embolism is wide and its recognition difficult.

Purpose

to analyze the efficiency of triage in the EP.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt;75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Only 4% showed hypotension, 13% tachycardia and 8% desaturation. 39% arrived with their own vehicle. 32% was allocated to the area with low intensity of care, 68% to the area with medium–high intensity of care. As regards the priority code for the visit, 0% received a non–urgency code (white code or code 5), 27.9% a minor urgency code (green code or code 4) and 3.6% a high priority to the visit with assignment to low intensity of care (low intensity yellow or code 3). 63.15% received an emergency code (urgency or code 2) and 5.3% an emergency code (red code or code 1). The severity code at discharge, given on clinical criteria, was a low severity code (white or green) in 18% of cases, while 76% was considered high severity (urgency, yellow code) and in 6% for very high gravity (red code). 34% showed massive PE, 32% showed organ damage. 41% were considered to be at high risk of short–term mortality according to European guidelines, 8% required intensive care and in–hospital mortality was 7.7%. Under triage is 32%.

Conclusions

The population that arrives in ED due to pulmonary embolism presents extremely varied symptomatological pictures, and an overall high degree of clinical risk and care and therapeutic complexity in spite of the symptoms complained of and vital parameters. Under–riage remains a real problem for ED for this category of patients.

P341 DANTE (DIAGNOSTIC ACUTE PATIENT TOOL IN EMERGENCY) & BEATRICE (BEDSIDE ECHOCARDIOGRAPHIC ASSESMENT FOR IMPROVE CLINICAL EVALUATION) FOR GERIATRIC PATIENTS

Objectives

To determine whether comprehensive quantitative bed side echocardiogram could be used as a usual assessment tool in acute geriatric patients and to assess its effect on patient care.

Design

Retrospective. Setting: DEA di II livello IRCSS Policlinico san Matteo.

Patients

Acute ill medical, trauma and surgical patients. A doctor enrolled in the discipline of emergency medicine was assigned to perform bedside echocardiograms of acute inpatients. This work took only geriatric patients into consideration. (&gt; 65aa). Interventions: The Bedside Echocardiographic AssesmenT foR Improve Clinical Evaluetion (BEATRICE), a comprehensive transthoracic echocardiogram was performed.

Measurements and Main Results

6–month period, 369 BEATRICEs were performed. The mean patient age was 76.2 (±14.3) years. 95% were hospitalized in medical departments and 5% in surgical ward. In 97.4% of cases BEATRICE was performed in a timely manner. The ejection fraction, cardiac index and the volumetric indices of the left ventricle is reported in 97% of the reports. Estimated stroke volume, longitudinal systolic function with tissue Doppler and atrium study is reported in 99.7%, 98.6% and 98.9% of BEATRICE studies. The study of diastolic and atrium function is reported in 99.3% and 98.9% of the reports respectively. Estimated left ventricular filling pressures are reported in 98.3% of the measurements. Information on the vena cava reported for 98%. Right heart function was assessed for 91.8%. Mean or systolic right ventricular pressures, or both, were also estimated in 91.9% of the reports. The BEATRICE was judged to be useful by the consulting primary care team in over 96% of cases, BEATRICEs allow the modification of therapy or the diagnostic process in over 40% of cases (in 27% of cases they allow to significantly modify the therapy and in 16% of cases they allow to significantly modify the diagnostic therapeutic procedure) and speeding up the diagnostic process in over 30% of cases.

Conclusions

The BEATRICE is feasible and alters care in the intensive care unit by providing clinical data not otherwise available at the bedside. Further studies are warranted to assess the impact of comprehensive echocardiogram–directed resuscitation on patient outcomes.

P267 EFFECTIVENESS OF SHOCK INDICES AND ALTERATION OF VITAL PARAMETERS IN THE DIAGNOSTIC SUSPICION OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: THE EMERGENCY ROOM AS A WINDOW ON REAL LIFE

Aim

Assess which vital parameters and shock indices correlate with the presence of organ damage from pulmonary embolism to see which ones can help to suspect this condition early.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage. We have considered as shock indices: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results

We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these 79 (32%) have organ damage from pulmonary embolism. There is no correlation between the values of blood pressure, systolic and diastolic, respiratory rate with the presence of organ damage (p &gt; 0.05). However, there is a strong statistical correlation between heart rate values and the presence of organ damage from pulmonary embolism (p &lt; 0.001) The shock index correlates with the presence of organ damage with good statistical strength (p &lt; 0.001 ); also the modified shock index, albeit with a slightly lower statistical strength (P &lt; 0.005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p &lt; 0.001).

Conclusions

The alteration of the shock indices, in particular the AGE–shock index, correlate with the condition of organ damage. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, which can be easily performed in the various Italian situations, can help to raise the suspicion of organ damage from pulmonary embolism early and address more quickly the patient towards the therapeutic diagnostic process.

P266 D–DIMERO: AN OLD NEGLECTED TEST THAT GOES BEYOND EXPECTATIONS D–DIMER ANALYSIS IN THE STRATIFICATION OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM: EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Purpose

To see if D–Dimer correlates, in the real life of an Emergency Department, with more severe forms of pulmonary embolism (massive pulmonary embolism, presence of organ damage), with the need and duration of hospitalization in resuscitation or the length of hospital stay. We then analyzed correlations with sPESI index, shock indices and blood gas parameters.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Anni), and for the presentation of the risk of mortality at 30 days (sPESI). We analyzed all the blood chemistry and blood gas tests performed upon access to the emergency room. We then had all chest CTs retested by an experienced radiologist. We also analyzed vital parameters and the various shock indexes from these derivatives. We then analyzed whether patients had massive pulmonary embolism or the presence of organ damage (right ventricular dilation, pulmonary artery dilation and presence of pulmonary infarction).

Results

We enrolled 247 patients, all in need of hospitalization for acute pulmonary embolism. The average age of 83 with female prevalence (62%). High values of D–Dimer show a strong correlation with the presence of massive pulmonary embolism (p &lt; 0.001) and a correlation, albeit to a lesser degree, with the presence of organ damage (p &lt; 0.01). D–Dimer values show a strong correlation (p &lt; 0.005) even with patients at high risk of short–term mortality (presenting right cardiac ventricular dilation and myocardiospecific enzyme elevation). However, the AUC of the ROC curve is not optimal (0.63; with specificity 63% and sensitivity 62%). They also showed a correlation with the need for hospitalization in the ICU (p &lt; 0.01) and a slight correlation with the length of stay in resuscitation (rho = 0.25; p = 0.05) and hospital stay (rho = 0.20; p &lt; 0.01).

Conclusions

D–Dimer values appear to be useful in the severity stratification of patients with pulmonary embolism.

P264 ROLE OF BLOOD GAS ANALYSIS AND D–DIMER IN RAISING THE SUSPICION OF MASSIVE PULMONARY EMBOLISM IN GERIATRIC PEOPLE: THE EMERGENCY ROOM AS A WINDOW INTO REAL LIFE

Premise

Massive pulmonary embolism is burdened with high mortality. Raising suspicion and recognizing this condition early allows to avoid delays in the diagnostic and therapeutic process.

Purpose

Assess which parameters of blood gas analysis, in the real life of an Emergency Department, correlate with the presence of massive pulmonary embolism to see which ones can help to suspect it early.

Methods

single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We looked at all the blood gas analyzes performed at the emergency room access. We then had all chest CTs retested by an experienced radiologist.

Results

We enrolled 247 patients, with a mean age of 83 years with prevalence of female prevalence (F = 63%). Of these, 85 (34.4%) have massive pulmonary embolism. Lactates do not correlate with the presence of massive pulmonary embolism (p &gt; 0.05). The pCO2 values correlate inversely with the presence of massive pulmonary embolism with excellent statistical strength (p &lt; 0.0001). The reduction in pO2 values also correlates with the presence of massive pulmonary embolism, with good statistical strength (p &lt; 0.005). The increase in pH values also correlates with the presence of massive pulmonary embolism, albeit with a lower statistical strength (p &lt; 0.05). The D–Dimer shows a strong association with massive pulmonary embolism values (p &lt; 0.0001).

Conclusions

The study suggests that the reduction of pCO2 values, with an increase in pH and D–Dimer show a strong correlation with the condition of massive pulmonary embolism. Similarly, the pO2 can play a role in the identification of this condition, while no role would seem to have the alteration of lactates. Taking into consideration these parameters, which are quickly available and easily performed in the various Italian situations, can help to raise the suspicion of massive pulmonary embolism early and direct the patient more quickly towards the therapeutic diagnostic process.

P273 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN GERIATRIC PATIENTS IN THE EMERGENCY ROOM: DOES ADHERENCE TO INTERNATIONAL GUIDELINES REDUCE IN ATYPICAL SYMPTOMS?

Purpose of the Study

Evaluate if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the presence of atypical symptoms. We understood dyspnoea, chest pain, signs and symptoms of deep vein thrombosis and syncope as typical symptoms. As atypical symptoms all the others (low–grade fever, vertigo …)

Methods

Single–center retrospective observational study on all geriatric patients (&gt;75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and YEARS), and for the presentation of the risk of mortality at 30 days (sPESI). We then analyzed adherence to the guidelines in three decision turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with evidence of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 63%). Of these, only 17 with atypical symptoms and 231 with typical symptoms. The vital signs were comparable in the two groups with no statistically significant difference (p &gt; 0.05). Long–term outcomes such as mortality, need for hospitalization, hospitalization in intensive care and length of stay in hospital are also comparable results with no statistically significant difference (p &gt; 0.05). However, adherence to international guidelines was statistically significantly lower in patients with atypical symptoms (33%) than in patients with typical symptoms (59%) (p &lt; 0.05).

Conclusions

The study suggests that patients with atypical symptoms are more likely to have reduced adherence to international guidelines, most likely due to diagnostic delay.

P274 GUESS WHO‘S COMING TO REANIMATION? ANALYSIS OF THE ELDERLY PATIENT WITH EMBOLISM IN NEED OF HOSPITALIZATION IN INTENSIVE CARE: REAL LIFE IN THE EMERGENCY ROOM

Premise

Pulmonary embolism is a disease still characterized by high mortality and which may require hospitalization in intensive care.

Purpose

Evaluate which parameters, in the real life of an Emergency Department, correlate with the need and the duration of hospitalization in intensive care.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt; 75) who refer to our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results

We enrolled 247 patients, with a mean age of 83 years and female prevalence (F = 63%). Of these 12 (14 %) required hospitalization in intensive care from the emergency room. Regarding the need for hospitalization in resuscitation, age and vital parameters (arterial pressure, respiratory rate, heart rate), as well as derived shock indices are not correlated (p &gt; 0.05). Only the systolic blood pressure values and it show a trend which however does not reach statistical significance (p = 0.06). Among the blood gas analysis parameters, only low pCO2 has a slight correlation (p &lt; 0.05). The D–Dimer (p &lt; 0.01) and creatinine values (p &lt; 0.05) show correlation between the blood chemistry tests. Regarding the length of stay in resuscitation, age and vital parameters (blood pressure, respiratory rate, heart rate), as well as derived shock indices, do not show any correlation (rho∼0; p &gt; 0.05). A weak correlation is instead present with high values of D–Dimer (rho∼0.25; p &lt; 0.005) and creatinine (rho∼0.33; p &lt; 0.0005). The presence of massive pulmonary embolism shows no correlation (p &gt; 0.5). The presence of organ damage, on the other hand, correlates in a statistically significant manner (p &lt; 0.0005). Excellent correlation is shown by the sPESI index (p &lt; 0.0001). Discrete correlation showed the alteration in pH (rho∼0.61; p &lt; 0.0001). Correlation for the blood gas analysis parameters taken into consideration (pH; pO2; pCO2; lactates).

Conclusions

The study suggests a reduced significance of vital parameters and indices derived from them for the need and duration of hospitalization in resuscitation. Presence of organ damage, low pCO2 values and high D–Dimer and creatinine values are associated with both the need for hospitalization in resuscitation and duration.

P268 MANAGEMENT OF ACUTE PULMONARY EMBOLISM IN THE EMERGENCY ROOM IN ELDERLY: DOES ADHERENCE TO INTERNATIONAL GUIDELINES INCREASE IN THE MOST SERIOUS CASES?

Premises

Pulmonary embolism is a pathology still characterized by high mortality. Some international studies have actually shown that adherence to guidelines is generally quite low in both primary and secondary care and ranges, depending on the studies, between 40 and 60%.

Purpose of the Study

see if and how, in the real life of an Emergency Department, adherence to the Guidelines varies according to the severity of the acute pulmonary embolism. We understood this severity as the presence of organ damage or massive pulmonary embolism.

Methods

Single–center retrospective observational study, on all geriatric patients (&gt;75 y) who entered our ED, where they received a diagnosis of acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic / therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We therefore analyzed adherence to the guidelines in three decisional turning points: 1 Correct application of the decision scores examined, which classify the patient at low, intermediate or high risk of PE, calculated with Wells and simplified Geneva score; 2 Correct administration of therapy starting from ED as suggested by the guidelines; 3 Any observation in the care area of medium intensity with careful monitoring for the subpopulation of patients with finding of right ventricular dilation or myocardial enzyme elevation (considered to be at high risk of shock and short–term mortality).

Results

We enrolled 248 patients, with a mean age of 83 years with female prevalence (F = 62%). Of these, 81 (32.7%) have organ damage and 86 (34.7%) have massive pulmonary embolism. Patients with organ damage received treatment with a higher adherence to the guidelines (68%) than those who did not have organ damage (51%) in a statistically significant way (p &lt; 0.01). Patients with massive pulmonary embolism received treatment with a higher adherence to the guidelines (69 %) than those with peripheral pulmonary embolism (50%) in a statistically significant way (p &lt; 0.005).

Conclusions

The study suggests that patients with organ damage or massive pulmonary embolism are more likely to receive treatment in the emergency room with greater compliance with international guidelines.

Ed accesses severity for intossication and substance abuse during the first pandemic wave of 2019 coronavirus pandemic (COVID-19). experience of a lombardy ed

Introduction

The 2019 coronavirus epidemic (CoViD-19) in Italy originated in Lombardy, on February 21, 2020. The Fondazione IRCCS Policlinico San Matteo di Pavia has been involved in the management of the outbreak since its beginning

Objectives

We evaluated all the population who went to the ED for intossication and substance abuse to assess the severity of cases evaluated as exit code and rate of hospitalization.

Methods

We enrolled all patients accessing our ED for intossication and substance abuse form February 22 to May 1, 2020 and during the same period of the previous year.

Results

We enrolled 142 patients. 41 in the CoViD period and 101 in 2019. The vital parameters, and sex were overlapping. patients during the pandemic were younger (38 vs 46) The priority codes for the medical examination were not different. CoViD pandemic patients have higher codes (yellow and red) for the medical examination (66% vs 59%); discharge severity codes (red) more frequently than in the reference period (2.4% vs 0.9%) and more frequently need hospitalization (26.8% vs 16.8%).

Conclusions

The epidemic has led to a reduction of accesses for intossication and substance abuse. Patients had more frequent hospitalization needs and more severe exit codes. the data may be due to the fact that during the pandemic only the most serious patients access the E.D., but also to the fact that a pandemic has contributed to destabilizing this class of fragile patients.

Access to E.D. for mental disorders during the first pandemic wave of 2019 coronavirus epidemic (CoViD-19): Presentation and severity at a lombardy ED

Introduction

The 2019 coronavirus epidemic (CoViD-19) in Italy originated in Lombardy, on February 21, 2020. The Fondazione IRCCS Policlinico San Matteo di Pavia has been involved in the management of the outbreak since its beginning. ED’ psychiatric population is considered fragile, at risk of under triage.

Objectives

We evaluated all the population who went to the ED for mental disorder to assess the severity of cases evaluated as exit code and rate of hospitalization.

Methods

We evaluated all patients accessing our ED for mental disorder from February 22 to May 1, 2020 and during the same period of the previous year.

Results

We enrolled 345 patients. There was a severe reduction in the total number of accesses for mental disorder: 142 in the CoViD period and 203 in 2019. The vital parameters, age (mean about 40 years) and sex were overlapping without statistically significant differences. The priority codes for the medical examination were not different. CoViD pandemic patients have higher discharge severity codes (yellow and red) more frequently than in the reference period (9.9% vs 5.9%) and more frequently need hospitalization (25.3% vs 18.6%).

Conclusions

The epidemic has led to a reduction of accesses for mental disorder. Patients had more frequent hospitalization needs and more severe exit codes. the data may be due to the fact that during the pandemic only the most serious patients access the E.D., but also to the fact that a pandemic has contributed to destabilizing this class of fragile patients.

Crowding analysis for patients with intossication and substance abuse during the first pandemic wave of 2019 coronavirus epidemic (COVID-19) at a lombardy ED

Introduction

The 2019 coronavirus epidemic (CoViD-19) in Italy originated in Lombardy, on February 21, 2020. Crowding has been defined as a worldwide problem as cause of reduced quality of care and patient satisfaction. It is due and identified by three orders of factors: those at the access (input); those related to the patient’s process (throughput); and those at the exit from the ED (output).

Objectives

We evaluated all the population who went to ED for intossication and substance abuse. Due to the high level of care needed by these, an excessive duration of LOS (length of Stay) can be counterproductive.

Methods

We evaluated all patients accessing our ED for intossication and substance abuse from February 22 to May 1, 2020 and during the same period of the previous year.

Results

We enrolled 142 patients. The Crowding input factors are lower in the pandemic period: reduced attenders (41 vs 101) and reduced average waiting times (59 min vs 86 min). The Crowding throughput factors have instead worsened: LOS for both the visit rooms (810 vs 544 min) and the holding area (1205 min vs 947 min). The Crowding output factors also worsened: the percentage of access block is higher during the pandemic (10% vs 5%). The Total Access Block Time is significantly higher in the CoViD period for the holding area (1053 vs 930 min).

Conclusions

The pandemic period presented a worsened crowding for these patients due to the Access Block.

Crowding analysis for patients with mental disorders during the first pandemic wave of 2019 coronavirus epidemic (CoViD-19) at a lombardy ED

Introduction

The 2019 coronavirus epidemic (CoViD-19) in Italy originated in Lombardy, on February 21, 2020. Crowding has been defined as a worldwide problem and causes reduced quality of care. It is due and identified by three orders of factors: those at the access (input); those related to the patient’s process (throughput); and those at the exit from the ED (output).

Objectives

We evaluated all the population who went to ED for mental disorder. Due to the high level of care needed and the simultaneous exposure to risk factors, an excessive duration of ED process can be counterproductive.

Methods

We evaluated all patients accessing our ED for mental disorder from February 22 to May 1, 2020 and during the same period of the previous year.

Results

We enrolled 345 patients. The Crowding input factors are lower in the pandemic period: reduced attenders (142 vs 203) and reduced average waiting times (40 min vs 54 min). The Crowding throughput factors have instead worsened: LOS (length of stay) for both visit rooms (383 vs 271 min) and holding area (1735 min vs 797 min). The Crowding output factors also worsened: the percentage of access block is higher during the pandemic (100% vs 20%). The Total Access Block Time is significantly higher in the CoViD period for both the visit rooms (3.239 vs 649 min) and the holding area (590 vs 185 min).

Conclusions

The pandemic period presented a worsened crowding for these patients due to the Access Block.

Between the first and second wave of the 2019 coronavirus pandemic (COVID-19): Presentation and crowding of attenders for mentale disorder and intossication/substance abuse

Introduction

During the 1st wave of CoViD-19 pandemic there was a drastic reduction in total number of accesses, with more serious cases and a exorbitant increase in crowding, due to access block.

Objectives

evaluate population who went to ED for (1) mental disorders requesting a psychiatric visit and for (2) intossication and substance abuse, between the first and second wave of the coronavirus pandemic

Methods

We enrolled all patients who went at our ED from May 1 to October 20, 2020 and during the same period of 2019. We analized: vital parameters, age, sex, exit severity codes, hospitalization rate, Crowding input factors (number of access, waiting time, priority time to doc), Crowding throughput factors (LOS: Length Of ED Stay), Crowding output factors (percentage of access block; Total Access Block Time).

Results

The results are shown in table 1Table 1Mental-disorderintossication/substance-abuseMay1-October 20,2020May1- October 20,2019May1-October 20,2020May1- October 20, 2019number of ED access543564182254higher (yellow and red) priority time to doc (%)28%29%50%39%worse exit severity codes (%)10%6%16%11%rate of hospitalization (%)26%20%16%9%average waiting times (min)60647679LOS lenght of stay (min)369326629506access block (%)3%2%5%4%Total Access Block Time: examination rooms (min)11.5388.3848.0598.889Total Access Block Time: holding area (min)8.3823.963182254

Conclusions

We would like to thank all employees of the IRCCS Policlinico San Matteo Foundation for their extraordinary efforts during the pandemic.

149 Acute effects on left ventricular systolic and diastolic function of a post-implant echocardiographic biventricular pacemaker optimization protocol following cardiac resynchronization therapy

Background

Cardiac resynchronization therapy (CRT) has demonstrated efficacy in at least 60% of patients with left ventricular (LV) failure and guideline-based indication to CRT. Whereas lack of response to CRT in up to a third of patients is multifactorial, a relevant factor is thought to be inadequate biventricular pacemaker (BIV) optimization (OPT) of either the intraventricular (VVd) or atrioventricular (AVd) delay

Purpose

In this echocardiographic observational study, we compared the acute effects on LV contractility, output, and diastolic function of BIV intra-implant QRS duration-based (OPTq) and post-implant Doppler echocardiography-based (OPTe) OPT of VVd and AVd.

Methods

In 160 patients with ischemic (n = 86) or idiopathic (n = 74) dilated cardiomyopathy, guideline-based different de novo CRT systems were implanted followed by immediate OPTq. Post-implant (10 days) OPTe was performed measuring: transmitral velocity-time integral (MVFi), % diastolic filling time (MVFt%), and E/A ratio, LV outflow integral (LVOTi), ejection time (LVOTt), and stroke volume (SV), isovolumic contraction (IVCT) and relaxation (IVRT) times, and LV myocardial performance index (MPI). The protocol included, sequentially: 1) Doppler measurements with OPTq settings; 2) measurements (separated by 3’ intervals) during a range (80/200 ms) of AVd with synchronous VVd; 3) algorithm-based AVd selection (at least 2 of following: increase in MVFi or SV, decrease in MPI); 4) measurements, with set AVd, during range of VVd: LV-first (-20, -40ms); RV-first (20, 40ms); synchronous; 5) VVd selection based on same algorithm used for AVd selection. Results. At OPTq, 58.6% of patients were set synchronous, 38.6% LV-first and 3% RV-first, with a 126 ± 29 mean AVd. This increased to 137 ± 36 after OPTe, when 49.1% were set synchronous, 38% LV-first and 12.4% RV-first, resulting in modifications of AVd and VVd in 59% and 36% of patients. Further, gain in SV with OPTe, compared to OPTq, was 8.3% (p&lt;.001), paralleled by an increase in MVFi (21.2 ± 8 cm vs 20.5 ± 8, p&lt;.001) and decrease in E/A (1.25 vs 1.45, p&lt;.001). The greatest increase in SV with OPTe was found in patients in whom both AVd and VVd were modified (n = 48; 81 ± 26 ml vs 71 ± 23, p&lt;.001) vs. patients without modifications (n = 42), or with change of either AVd or VVd (n = 70; 77 ± 20 vs 72 ± 20, p&lt;.01). Only in the first patient group both MVFi (22 ± 9 vs 20 ± 9, p&lt;.001) and MVFt% (52 ± 7 vs 49 ± 8, p=.004) increased, along with a decrease in MPI (.82±.31 vs .92 ± 36, p=.007) and IVRT (144 ± 51 vs 156 ± 62, p=.02.

Conclusions

These preliminary results point to a significant incremental role of post-implant OPTe to enhance LV output, contractility, and diastolic function in patients with CRT. The prognostic role of OPTe-determined AVd and VVD changes remains to be determined.