Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Utilization of recombinant activated factor VII in a case of spontaneous massive haemothorax in a patient with Von Recklinghausen's disease.

Spontaneous haemothorax is a rare and often lethal complication of neurofibromatosis. Two kinds of vascular involvement are described: 1) stenotic or aneurysmatic modifications of large intrathoracic vessels, mainly treated with endovascular techniques; 2) dysplastic alterations in highly vascularized mesenchymal tumors. We describe a rare case of massive intrathoracic haemorrhage due to an upper mediastinic neurofibroma, successfully controlled with recombinant activated factor VII associated with surgical treatment.

[Air crash simulation at the Torino-Caselle airport]. / Simulazione di incidente aereo all'aeroporto di Torino-Caselle.

PURPOSE: The simulation purpose has consisted in apparising "the aid succour quality indicators". MATERIALS AND METHODS: Study of the succour chain during the air line hypothetical crash with 80 passengers on board, happened at 11:35 "H O". DESCRIPTION: The alarm reaches the control-tower at 11.36. The control-tower sends it out according to an internal protocol. At 12:30 (H + 55) the number 5747 operative station reported the simulation end. ANALYSIS RESULTS: Only the succour sanitary aspects are considered. There was not an adequate arrangement and co-ordination of the rescue-succour components. CONCLUSIONS: The truth is that the succours chain can be improved either in the organisation and in the operative capacity, even if is very difficult to weigh such inadequacy.

[Epidemiology of malignant hyperthermia in Piedmont and Valle d'Acosta. A study conducted with 2 different methods]. / Epidemiologia dell'ipertermia maligna in Piemonte e Valle d'Aosta. Studio condotto con due differenti metodiche.

The Authors report on the results of two researchers about malignant hyperthermia (MH) carried out in Piemont and Valle D'Aosta using two different methods. The former, based on a form sent to 492 anaesthesists got 22.7 per cent answers. They indicated 4 cases of MH during the years between 1982 and 1986, out of 213,444 narcoses with an average rate of 1:71,000. The latter was canned and by questioning directly the head physicians of anaesthesia and reanimation wards about the occurrence of MH in Piemont and Valle D'Aosta in the years between 1984 and 1988. According to this research, there were 5 cases out of 891,729 narcoses (that is 1:178,346).

[5 patients in irreversible coma in which it was not possible to remove the organs for therapeutic transplant]. / Cinque pazienti in coma irreversible nei quali non è stato possibile effettuare il prelievo di organi a scopo di trapianto terapeutico.

The special committee consisting of a neurologist, an anaesthesist and a forensic doctor, refused transplantation permission since spinal reflexes were present. These reflexes persisted until cardiac death occurred. Brain death was diagnosed by instrumental techniques and was confirmed by necropsies.

[Remarks on a clinical case of partial carbamyl phosphate synthetase deficiency]. / Osservazioni su un caso clinico di deficit parziale di carbamil-fosfato-sintetasi.

A preliminary undiagnosed case of partial carbamyl-phosphate-synthetase deficiency in a 14 year old patient is described. This extremely rare metabolic disorder is unlikely to produce clinical symptoms at such an advanced age. Details are given of the clinical picture, the diagnosis (by liver biopsy and post mortem liver examination) and the attempts at treatment.