Franceschi F (ORCID:0000-0001-6266-445X)

Ojetti V (ORCID:0000-0002-8953-0707)

Petruzziello C

Saviano A

Tilli P

English

Saviano A (ORCID:0000-0002-2820-7180)

PubliCatt

CorrespondenceJennifer A. Sahatjian, PsyDDouglas M. Hansell, MDBaxter HealthcareDeerfield, ILhttps://doi.org/10.1016/j.annemergmed.2021.05.027Funding and support: By Annals policy, all authors arerequired to disclose any and all commercial, financial, andother relationships in any way related to the subject of thisarticle as per ICMJE conflict of interest guidelines (seewww.icmje.org). Dr. Douglas received a research grant forsepsis resuscitation research from Baxter Healthcare toDenver Health Medical Center. Lecture at BaxterHealthcare sponsored symposia, not as a member ofSpeaker’s Bureau. Drs. Sahatjian and Hansell are employeesof Baxter Healthcare.1. Yealy DM, Mohr NM, Shapiro NI, et al. Early care of adults withsuspected sepsis in the emergency department and out-of-hospitalenvironment: a consensus- based task force report. Ann Emerg Med. Inpress.2. Douglas IS, Alapat PM, Corl KA, et al. Fluid response evaluation insepsis hypotension and shock: a randomized clinical trial. Chest.2020;158:1431-1445.3. Rodwin BA, Merchant NB. From bench to every bedside: improving theadoption of evidence- based practices. South Med J.2020;113:538-540.4. Seyfang A, Martínez-Salvador B, Serban R, et al. Maintaining FormalModels of Living Guidelines Efficiently. In: Bellazzi R, Abu-Hanna A,Hunter J, eds. Artificial Intelligence in Medicine. Springer-Verlag BerlinHeidelberg; 2007:441-445.In reply:We thank Douglas et al for their interest in our work. Asnoted in our manuscript, we used a multidisciplinary andmultiorganizational approach to address the opportunitiesand limits of current guidelines on sepsis care.1 Wespecifically did not create a comprehensive and gradedseries of recommendations on early care, seeking instead toidentify key concerns in current recommendations and carequality measures. We sought to address currentcontroversies and help inform future guidelinedevelopment and quality measures that bridge all acute caresettings. Ongoing updates are important along withunifying efforts across disciplines and organizations thatrecognize the many settings in which sepsis care must bedelivered. We all can do better together.We also agree with Douglas et al2 that dynamic fluidresponse assessment in septic shock has promise and thatthe FRESH trial was underpowered to show a clear patient-relevant benefit. Other dynamic fluid assessmenttechniques have also shown promise, and all had a carefulreview by our experts. We affirm our view that dynamicVolume 78, no. 4 : October 2021fluid responsiveness may be useful in emergency sepsis care;however, we do not currently recommend its routine use.Our conclusion aligns closely with that of Douglas et al2 inthe FRESH manuscript, saying the approach “may improveoutcomes for patients with septic shock..”We look forward to new evidence to better informfuture sepsis care.Donald M. Yealy, MDDepartment of Emergency Medicine, University of Pittsburgh,Pittsburgh, PANicholas M. Mohr, MD, MSDepartment of Emergency Medicine, University of IowaCarver College of Medicine, Iowa City, IANathan I. Shapiro, MD, MPHDepartment of Emergency Medicine, Beth Israel DeaconessMedical Center, Boston, MAWesley H. Self, MD, MPHDepartment of Emergency Medicine, Vanderbilt UniversitySchool of Medicine, Nashville, TNhttps://doi.org/10.1016/j.annemergmed.2021.05.028Funding and support:ByAnnals policy, all authors are requiredto disclose any and all commercial, financial, and otherrelationships in any way related to the subject of this article asper ICMJE conflict of interest guidelines (seewww.icmje.org).The authors have stated that no such relationships exist.1. Yealy DM, Mohr NM, Shapiro NI, et al. Early care of adults withsuspected sepsis in the emergency department and out-of-hospitalenvironment: a consensus-based task force report. Ann Emerg Med.Published online April 9, 2021. https://doi.org/10.1016/j.annemergmed.2021.02.0062. Douglas IS, Alapat PM, Corl KA, et al. Fluid response evaluation insepsis hypotension and shock: a randomized clinical trial. Chest.2020;158:1431-1445.The “Crossed Leg Sign” in theEmergency Department (or Tilli’s Sign):A New Semiotic Sign for the EarlyEvaluation of Patients Accessing theEmergency SettingTo the Editor:We noticed that some patients, evaluated in theemergency department (ED), maintained one leg crossedover the other leg during the medical assessment. Nonverbalcommunication and medical semiotics are very important fora patient’s evaluation.1 Patients can communicate indirectlythrough signs, facial expressions, and posture, with theseAnnals of Emergency Medicine 573Correspondencebeing important medical information for emergencyphysicians to find a diagnosis and prescribe the besttreatment. We conducted an observational study at theFondazione Policlinico Universitario Agostino Gemelli toevaluate whether the “crossed leg sign” (we called it “Tilli’ssign”) in the ED could be predictive of an emergency clinicalcondition in patients who access the emergency setting.Patients who present to the ED usually receive a prioritycolor code by nurses at the moment of triage according tothe severity of their condition2: red (very critical), yellow(moderately critical), green (not very critical), and white(not critical).3,4 The emergency physicians can confirm orchange the color code that is initially assigned. In additionto the clinical parameters and the color code assigned,patients’ nonverbal behavior can indicate the severity oftheir disease and the urgency of treatment needed.5 Crossedlegs, for instance, can indicate that the person is relaxed anddoes not have a serious illness. We analyzed data (triagecolor code, length of stay in the ED, color code at discharge,etc) from 100 consecutive patients (47 women and 53 men;mean age, 55.8 þ 12) who presented with the Tilli’s signduring the medical examination. We used Student’s t testand Mann-Whitney U test with 95% confidence intervalsand a significant P value of <.05. We found that 32 of the100 patients (32%) were initially categorized with a greencode, 50% (50 patients) with a yellow code, and 18% (18patients) with a red code. After the medical examination, all32 patients with the green code (100%) received aconfirmation for the treatment urgency. Of the 50 patientswith the yellow code, 38 patients (76%) received a greencode, whereas only 12 (24%) received a confirmation for thetreatment urgency. Of the 18 patients with the red code,only 1 patient (5%) received a confirmation for the redcode, whereas 62% (11 patients) were reassigned with ayellow code and 33% (6 patients) with a green code. Insummary, we found that 87 of the 100 patients (87%)received a lower urgency code. Moreover, 77 of the 100patients (77%) had a length of stay in the ED of less than 12hours, 15% (15 patients) had between 12 and 24 hours, and8% (8 patients) had more than 24 hours. Of the 100patients, 89 (89%) were directly discharged from the EDand 11 (11%) were hospitalized. Crossed leg sign has asensitivity of 89% in ruling out the need for urgenttreatment or hospitalization. Most importantly, none of thepatients with positive Tilli’s sign received an “upper” colorcode during the first medical evaluation, and none of thepatients who were discharged made the second presentationin the ED in the next 30 days of follow-up. In our opinion,the Tilli’s sign, as a form of patients’ nonverbal behavior,may help emergency physicians in the first evaluation ofpatients, letting them be confident of the absence of an574 Annals of Emergency Medicineimminent treatment urgency. However, more studies areneeded to confirm these results.Angela Saviano, MDDepartment of Emergency MedicineUniversità Cattolica del Sacro CuoreRome, ItalyPietro Tilli, MDDepartment of Emergency MedicineFondazione Policlinico Universitario A. Gemelli, IRCCSRome, ItalyCarmine Petruzziello, MDDepartment of Emergency MedicineOspedale Cristo ReRome, ItalyFrancesco Franceschi, MD, PhDDepartment of Emergency MedicineUniversità Cattolica del Sacro CuoreRome, ItalyDepartment of Emergency MedicineFondazione Policlinico Universitario A. Gemelli, IRCCSRome, ItalyVeronica Ojetti, MD, PhDDepartment of Emergency MedicineUniversità Cattolica del Sacro CuoreRome, ItalyDepartment of Emergency MedicineFondazione Policlinico Universitario A. GemelliIRCCSRome, Italyhttps://doi.org/10.1016/j.annemergmed.2021.05.032Funding and support:ByAnnals policy, all authors are requiredto disclose any and all commercial, financial, and otherrelationships in any way related to the subject of this article asper ICMJE conflict of interest guidelines (seewww.icmje.org).The authors have stated that no such relationships exist.1. Kraft-Todd GT, Reinero DA, Kelley JM, et al. Empathic nonverbal behaviorincreases ratings of both warmth and competence in a medical context.PLoS One. 2017;12:e0177758.2. Terenzi C. The triage game. J Emerg Nurs. 2000;26:66-69.3. Jeyaraman MM, Copstein L, Al-Yousif N, et al. Interventions andstrategies involving primary healthcare professionals to manageemergency department overcrowding: a scoping review. BMJ Open.2021;11:e048613.4. Chmielewski NA, Tomkin T, Edelstein G. A systems approach to front-endredesign with rapid triage implementation. Advanced EmergencyNursing Journal. 2021;43:79-85.5. Mast MS. On the importance of nonverbal communication in thephysician–patient interaction. Patient Educ Couns. 2007;67:315-318.Volume 78, no. 4 : October 2021

The "Crossed Leg Sign" in the Emergency Department (or Tilli's Sign): A New Semiotic Sign for the Early Evaluation of Patients Accessing the Emergency Setting.

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The "Crossed Leg Sign" in the Emergency Department (or Tilli's Sign): A New Semiotic Sign for the Early Evaluation of Patients Accessing the Emergency Setting.

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