MedInTO Medicine and Surgery

Emergency

Emergency

Academic year 2024/2025

Sommario del corso

• Course objectives
• Results of learning outcomes
• Program
• Course delivery
• Learning assessment methods
• Suggested readings and bibliography
• Notes
• Teaching Modules
• Teaching tools
• Course card

Course objectives

The course aims to provide pathophysiological and clinical bases for the early identification, diagnosis and treatment (including pharmacological therapies applied) of the most important diseases and syndromes related to emergency medicine and surgery, including acute dysfunction of the respiratory, cardiovascular and gastrointestinal system, shock, sepsis, trauma, and alterations of acid-base equilibrium.

For this purpose, the course will discuss, for each disorder:

• The clinical context (signs and symptoms)
• The underlying pathophysiological process
• The supportive therapy needed
• The etiologic and pharmacological treatment
• The general course and outcome

Results of learning outcomes

After attending the course, the student will be expected to:

• Know the pathophysiology of the acute dysfunctions of the main systems and organs
• Suspect the most relevant alterations of the respiratory, cardiovascular, gastrointestinal system, as well as the presence of sepsis, shock, trauma, and alterations of acid-base equilibrium
• Activate decision-making processes based on clinical signs and symptoms, altered parameters, laboratory examinations, and imaging assessment
• Lead diagnostic procedures aimed at identifying timely the proper disorder
• Manage the necessary supportive therapies and monitoring assessment to sustain acute respiratory, cardiovascular and gastrointestinal dysfunction, as well as acute patient alterations of metabolism and systemic dysfunction during major trauma
• Identify the appropriate etiologic treatment
• Discuss related clinical cases

Program

Anesthesiology

• Acute Respiratory Distress Syndrome (ARDS) and severe acute respiratory failure
• Acid-base equilibrium
• Physiology and Pathophysiology of fluid therapy
• Sepsis
• Cardiovascular shock
• Airway management
• Basic Life Support Defibrillation (BLSD)
• Advanced Trauma Life Support (ATLS).

Surgery

• Generality about trauma, head trauma, thoracic trauma, abdominal trauma
• Damage Control Surgery
• Generality about acute abdomen (occlusive and peritonitic)
• Acute appendicitis, acute cholecystitis, acute pancreatitis, acute diverticulitis
• Ectopic pregnancy
• Peptic ulcer
• Intestinal ischemia
• Digestive bleeding

Pharmacology

During the course, the following main emergency drugs will be described:

• Acetazolamide,
• Acetylcisteine,
• Acyclovir,
• Adenosine,
• Adrenaline,
• Alteplase,
• Aminophylline,
• Amiodarone,
• Atropine,
• Clopidogrel,
• Dalteparin,
• Dantrolene,
• Dexametasone,
• Diazepam,
• Flumazenil,
• Digoxin,
• Antidigital antibodies,
• Dopamine,
• Dobutamine,
• Fenoldopam,
• Furosemide,
• Haloperidol,
• Ipratropium,
• Labetalolo,
• Latulose,
• Lepidudine,
• Lidocaine,
• Loperamide,
• Mannitolo,
• Metoclopramide,
• Morphine,
• Naloxone,
• Neostigmina,
• Noradrenaline,
• Protamine,
• Salbutamol,
• Sodium valproate,
• Vasopressin,
• Terlipressin,
• Tranexamic acid,
• Vitamine K.

Diseases of the musculoskeletal system

• Traumatology: the basics
how to "read" the x-ray in ER
• Management of the most common fratures (proximal femur, femoral shaft, proximal humerus, clavicle, wrist, scaphoid, tibial plateau, ankle)
• Polytrauma
• Pelvic trauma (fractures of the pelvic ring and of the acetabulum)
• Open fractures
• Joint dislocations (shoulder, elbow, hip, hip prosthesis, knee, patella, ankle)
• Traumatic amputations of the limbs
• Spinal cord trauma
• Compartment syndrome

Internal medicine

• Acute coronary syndromes
• Pulmonary embolism
• Emergencies in diabetic patients
• The endocrinological emergencies (adrenal insufficiency, thyroid storm)
• Hypertensive crisis
• Acute respiratory failure
• Acute circulatory failure
• Sepsis
• Acid-base balance

Cardiovascular Diseases

• Universal definition of myocardial infarction
• Acute coronary syndromes: STEMI
• Acute coronary syndrome: NSTEMI
• Bradyarrhythmias: sino atrial and atrio ventricular blocks
• Atrial Fibrillation
• Supraventricular tachycardias
• Ventricular arrhythmias
• Acute aortic syndromes
• Diagnosis, management and treatment of cardiogenic shock

Course delivery

The integretaed course will be delivered through frontal lessons, which include the possibility of extensive discussions on the topic presented, as well as the discussion on clinical cases. In addition, simulation lab sessions will be proposed, as a complementary tool.

Learning assessment methods

Exams (or assessment procedure) for all students attending the course during past academic years (Italian courses) will be performed according to the previous modality defined, which is described below.

Previous academic years (Italian courses)

The assessment includes both a written test and an oral examination.

Written test

• The written test consists of 6 modules, each of which may include one or more open-ended questions or multiple-choice questions (MCQs), depending on the specific module. All questions will pertain topics included in the syllabus.
• The total duration of the written test is 120 minutes.
• The evaluation of open-ended questions will be performed based on:
  1. the coherence of the answer provided with the contents discussed during the course;
  2. the ability to provide a synthetic and outlined summary of the topic requested;
  3. the degree of in-depth knowledge of the topic requested.
• The written test results in a fail mark if:
1. Two or more modules are failed (i.e., mark lower than 18/30)
2. One module is failed severely (as assessed by the exam committee)

In all the other cases, the written test is considered as passed

Oral examination

• If the written test is passed, but one module is failed non severely, the student will be evaluated in an oral examination on the failed module and another module chosen by the exam committee.
• If the written test is passed and the average mark is lower than 26/30, the student will be evaluated in an oral examination on a module chosen by the exam committee.
• If all modules are passed and the average mark is equal to or higher than 26/30, the student may either accept the average mark as it is, without being evaluated in an oral examination, or may ask for an oral examination in case the student will be willing to improve the final mark.

Please note that the mark obtained with the written test is the starting point for the oral examination but does not guarantee a final passed mark. Depending on the level of preparation shown by the student, the oral examination may result in an improvement, confirmation or worsening of the written examination mark, until a failure of the entire exam.

Current academic years (English courses)

Exams (or assessment procedure) for all students attending the English course (starting from the academic years 2022-2023) will be performed according to the modality described below.

The evaluation includes both a written test and an oral exam.

Written test

• The written test consists of 30 MCQs pertaining topics included in the syllabus for all the modules included in the course.
• The total number of MCQs is divided into each single module according to their relative credit weight (CFU): 9 questions for Internal Medicine, 9 questions for Anesthesiology, 3 questions for Pharmacology, 3 questions for Musculoskeletal System Diseases, 3 questions for General Surgery, 3 questions for Cardiovascular Diseases.
• Each MCQ includes 4 possible true-or-false answers, each of them may be true or false (i.e. total of 120 true-or-false questions).
• The total duration of the written test is 60 minutes.
• Each single correct answer to a true-or-false question will correspond to a mark value of 0.3.
• The written test is passed if the average mark is equal to or greater than 18/30, provided that the number of correct true-or-false questions for each single module equals at least 50% of the total number of them (18 true-or-false questions for Internal Medicine and Anesthesiology; 6 true-or-false questions for Pharmacology, Musculoskeletal System Diseases, General Surgery and Cardiovascular Diseases).

Oral examination

• If the written test is passed and the average mark is lower than 25/30, the student will be evaluated in an oral examination on a module chosen by the exam committee.
• If the written test is passed and the average mark is equal to or greater than 25/30, the student may either accept the average mark as it is, without being evaluated in an oral examination, or may ask for an oral examination, in case the student will be willing to improve the final mark.

Please note that the mark obtained with the written test is the starting point for the oral examination but does not guarantee a final passed mark. Depending on the level of preparation shown by the student, the oral examination may result in an improvement, confirmation or worsening of the written examination mark, until a failure of the entire exam.

Anesthesiology

• Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet. 1967 Aug 12;2(7511):319-23. DOI: 10.1016/S0140-6736(67)90168-7
• Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, Neff M, Stern EJ, Hudson LD. Incidence and outcomes of acute lung injury. N Engl J Med. 2005 Oct 20;353(16):1685-93. DOI: 2010.1056/nejmoa050333
• Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2014 Mar 6;370(10):980. DOI: 10.1056/nejmc1400293
• Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, Russo S, Patroniti N, Cornejo R, Bugedo G. Lung recruitment in patients with the acute  respiratory distress syndrome. N Engl J Med. 2006 Apr 27;354(17):1775-86. DOI: 10.1056/nejmoa052052
• ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, Camporota L, Slutsky AS. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun 20;307(23):2526-33. DOI: 10.1001/jama.2012.5669
• Gattinoni L, Caironi P, Pelosi P, Goodman LR. What has computed tomography taught us about the acute respiratory distress syndrome? Am J RespirCrit Care Med. 2001 Nov 1;164(9):1701-11. Review. DOI: 10.1164/ajrccm.164.9.2103121
• Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000 May 4;342(18):1301-8. DOI: 10.1056/nejm200005043421801
• Brower RG, Lanken PN, MacIntyre N, Matthay MA, Morris A, Ancukiewicz M, Schoenfeld D, Thompson BT; National Heart, Lung, and Blood Institute ARDS Clinical Trials Network.. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004 Jul 22;351(4):327-36. DOI: 10.1056/nejmoa032193
• Guérin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, Mercier E, Badet M, Mercat A, Baudin O, Clavel M, Chatellier D, Jaber S, Rosselli S, Mancebo J, Sirodot M, Hilbert G, Bengler C, Richecoeur J, Gainnier M, Bayle F, Bourdin G, Leray V, Girard R, Baboi L, Ayzac L; PROSEVA Study Group.. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013 Jun 6;368(23):2159-68. DOI: 10.1056/nejmoa1214103
• Fencl V, Leith DE. Stewart's quantitative acid-base chemistry: applications in biology and medicine. Respir Physiol. 1993 Jan;91(1):1-16. Review. DOI: 10.1016/0034-5687(93)90085-o
• Langer T, Ferrari M, Zazzeron L, Gattinoni L, Caironi P. Effects of intravenous solutions on acid-base equilibrium: from crystalloids to colloids and blood components. Anaesthesiol Intensive Ther. 2014 Nov-Dec;46(5):350-60. doi:10.5603/AIT.2014.0059. Review. DOI: 10.5603/ait.2014.0059
• Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013 Dec 19;369(25):2462-3. DOI: 10.1056/nejmra1208627
• John A Myburgh, Simon Finfer, Rinaldo Bellomo, Laurent Billot, Alan Cass, David Gattas, Parisa Glass, Jeffrey Lipman, Bette Liu, Colin McArthur, Shay McGuinness, Dorrilyn Rajbhandari, Colman B Taylor, Steven A R Webb, CHEST Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group, Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med. 2012 Nov 15;367(20):1901-11. DOI: 10.1056/nejmoa1209759
• Caironi P, Tognoni G, Masson S, Fumagalli R, Pesenti A, Romero M, Fanizza C, Caspani L, Faenza S, Grasselli G, Iapichino G, Antonelli M, Parrini V, Fiore G, Latini R, Gattinoni L; ALBIOS StudyInvestigators. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med. 2014 Apr 10;370(15):1412-21. DOI: 10.1056/nejmoa1305727
• Linee guida di Basic Life Support Defibrillation (BLSD); American Heart Association; Italian Resuscitation Council.
• Linee guida di Advanced Trauma Life Support (ATLS); Americal College of Surgeons.
• Diapositive utilizzate durante le lezioni.

Surgery

• F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, Lillian S. Kao, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock, Schwartz’s Principles of Surgery, 11th edition, McGraw-Hill 2019
• Moshe Schein, Paul N. Rogers, Ari Leppäniemi, Danny Rosin, Jonathan E. Efron, Schein's Common Sense Emergency Abdominal Surgery, 4th Edition, TFM 2016.

Pharmacology

• Slides and learning material will be provided by the lecturer.
• Laurence Brunton; Bjorn Knollmann, Goodman and Gilman's The Pharmacological Basis of Therapeutics.

Orthopaedics and traumatology

• Ashley Blom, David Warwick, Michael Whitehouse, Apley & Solomon's System of Orthopaedics and Trauma, 10th Edition, CRC Press 2017.

Internal Medicine

• Dennis L. Kasper ... [et al.], Harrison Principi di Medicina Interna, Ambrosiana, 2017.
• Shivani Misra et al., Diabetic ketoacidosis in adults BMJ 2015;351:h5660. DOI: 10.1136/bmj.h5660
• Ebenezer A. Nyenwe *, Abbas E. Kitabchi, Evidence-based management of hyperglycemic emergencies in diabetes mellitus, Diabetes Research And Clinical Practice 94 (2011) 340-;351. DOI: 10.1016/j.diabres.2011.09.012
• M. W. Savage et al., Joint British Diabetes Societies guideline for the management of diabetic ketoacidosis, Diabet. Med. 28, 508-;515 (2011). DOI: 10.1111/j.1464-5491.2011.03246.x
• Ronald Van Ness-Otunnu, Jason B. Hack, Hyperglycemic Crisis, The Journal of Emergency Medicine, Vol. 45, No. 5, pp. 797-;805, 2013 C. DOI: 10.1016/j.jemermed.2013.03.040
• Ali S. Raja et al., Evaluation of Patients With Suspected Acute Pulmonary Embolism: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians  Annals of Internal Medicine, Vol. 163 No. 9, 3 November 2015. DOI: 10.7326/m14-1772
• Marco Roffi, Carlo Patrono, Jean-Philippe Collet, Christian Mueller, Marco Valgimigli, Felicita Andreotti, Jeroen J Bax, Michael A Borger, Carlos Brotons, Derek P Chew, Baris Gencer, Gerd Hasenfuss, Keld Kjeldsen, Patrizio Lancellotti, Ulf Landmesser, Julinda Mehilli, Debabrata Mukherjee, Robert F Storey, Stephan Windecker, ESC Scientific Document Group, 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC), European Heart Journal, doi:10.1093/eurheartj/ehv320.
• Patrick T O'Gara, Frederick G Kushner, Deborah D Ascheim, Donald E Casey Jr, Mina K Chung, James A de Lemos, Steven M Ettinger, James C Fang, Francis M Fesmire, Barry A Franklin, Christopher B Granger, Harlan M Krumholz, Jane A Linderbaum, David A Morrow, L Kristin Newby, Joseph P Ornato, Narith Ou, Martha J Radford, Jacqueline E Tamis-Holland, Carl L Tommaso, Cynthia M Tracy, Y Joseph Woo, David X Zhao, 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, Journal of the American College of CardiologyVol. 61, No. 4, 2013. DOI: 10.1016/j.jacc.2012.11.018

Cardiovascular Diseases

• Ibanez B, et al; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119-177. doi: 10.1093/eurheartj/ehx393. PMID: 28886621.
• Thygesen K, et al.; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). Circulation. 2018 Nov 13;138(20):e618-e651. doi: 10.1161/CIR.0000000000000617. Erratum in: Circulation. 2018 Nov 13;138(20):e652. doi: 10.1161/CIR.0000000000000632. PMID: 30571511.
• Byrne RA, et al.; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-3826. doi: 10.1093/eurheartj/ehad191. Erratum in: Eur Heart J. 2024 Apr 1;45(13):1145. doi: 10.1093/eurheartj/ehad870. PMID: 37622654.
• Gulati M, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454. doi: 10.1161/CIR.0000000000001029. Epub 2021 Oct 28. Erratum in: Circulation. 2021 Nov 30;144(22):e455. doi: 10.1161/CIR.0000000000001047. Erratum in: Circulation. 2023 Dec 12;148(24):e281. doi: 10.1161/CIR.0000000000001198. PMID: 34709879.
• Agewall S, et al.; WG on Cardiovascular Pharmacotherapy. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2017 Jan 14;38(3):143-153. doi: 10.1093/eurheartj/ehw149. PMID: 28158518.
• Van Gelder IC, et al.; ESC Scientific Document Group. 2024 ESC Guidelines for the management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2024 Sep 29;45(36):3314-3414. doi: 10.1093/eurheartj/ehae176. PMID: 39210723.
• Brugada J, et al.; ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J. 2020 Feb 1;41(5):655-720. doi: 10.1093/eurheartj/ehz467. Erratum in: Eur Heart J. 2020 Nov 21;41(44):4258. doi: 10.1093/eurheartj/ehz827. PMID: 31504425.
• Wyckoff MH, et al. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces. Circulation. 2022 Dec 20;146(25):e483-e557. doi: 10.1161/CIR.0000000000001095. Epub 2022 Nov 3. Erratum in: Circulation. 2024 May 21;149(21):e1218. doi: 10.1161/CIR.0000000000001253. PMID: 36325905.
• Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019 Aug 20;74(7):e51-e156. doi: 10.1016/j.jacc.2018.10.044. Epub 2018 Nov 6. Erratum in: J Am Coll Cardiol. 2019 Aug 20;74(7):1016-1018. doi: 10.1016/j.jacc.2019.06.048. PMID: 30412709.
• Baran DA, et al. SCAI clinical expert consensus statement on the classification of cardiogenic shock: This document was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), the Society of Critical Care Medicine (SCCM), and the Society of Thoracic Surgeons (STS) in April 2019. Catheter Cardiovasc Interv. 2019 Jul 1;94(1):29-37. doi: 10.1002/ccd.28329. Epub 2019 May 19. PMID: 31104355.
• van Diepen S, et al.; American Heart Association Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; Council on Quality of Care and Outcomes Research; and Mission: Lifeline. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association. Circulation. 2017 Oct 17;136(16):e232-e268. doi: 10.1161/CIR.0000000000000525. Epub 2017 Sep 18. PMID: 28923988.
• Lüsebrink E, et al. Cardiogenic shock. Lancet. 2024 Nov 16;404(10466):2006-2020. doi: 10.1016/S0140-6736(24)01818-X. PMID: 39550175.
• Vincent JL, Cecconi M, De Backer D. The fluid challenge. Crit Care. 2020 Dec 28;24(1):703. doi: 10.1186/s13054-020-03443-y. PMID: 33371895; PMCID: PMC7771055.
• Writing Committee Members; Isselbacher EM, et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 Dec 13;80(24):e223-e393. doi: 10.1016/j.jacc.2022.08.004. Epub 2022 Nov 2. PMID: 36334952; PMCID: PMC9860464.
• Mazzolai L, et al.; ESC Scientific Document Group. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J. 2024 Sep 29;45(36):3538-3700. doi: 10.1093/eurheartj/ehae179. PMID: 39210722.

Notes

The assessment procedure detailed above holds for all students (even those who took the course in past academic years).

Students with DSA or disabilities are kindly requested to take note of the reception services and support services offered by the University of Turin, and in particular of the procedures required for exam support.

Teaching Modules

• Emergency - module of Anesthesiology (SCB0230F)
• Emergency - module of Cardiovascular Diseases (SCB0230E)
• Emergency - module of General Surgery (SCB0230D)
• Emergency - module of Internal Medicine (SCB0230B)
• Emergency - module of Musculoskeletal System Diseases (SCB0230C)
• Emergency - module of Pharmacology (SCB0230A)

• Teaching material
• Exams and finals
• Class schedule
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