Background: With the rise of the novel coronavirus cases and fatalities around the world, researchers were invested in studying not only the therapeutic measures, but also, the preventive ones. As observed in other countries, many governments resorted to the shutdown of all services and closure of all facilities thus isolating people in their homes. Due to the rapidly collapsing local currency and deteriorating Lebanese economy, the local government implemented a two-week lockdown hoping it will reduce the surge in newly diagnosed Corona Virus Disease – 19 (COVID-19) cases without worsening the economic situation. Method: In this study, we aim to understand the effectiveness of such plans in Lebanon and the contribution of the Lebanese people in its accomplishment. We looked at the numbers in all Lebanese territories over 2 weeks before the lockdown, during the 2-week lockdown (from 16 till 28thNovember 2020) and 2 weeks post lockdown. After collecting the data, we analyzed the mean number of cases and death before, during and after lockdown and by followed the growth factor of cases during this period. Result: It was shown that for all studied districts, there was a trend in decline of the total number of cases, but the results were not statistically significant to prove that a 2-week lockdown can impact the epidemic. Conclusion: A short, partial lockdown has no benefit over the growth or reduction in the virus impact or transmission, however, it might have some positive outcomes if implemented for longer periods.

Introduction: Novel Coronavirus Disease 2019 (COVID-19) is seen as the biggest health burden in the world. It is known that there is no type of research on Emergency Department (ED) admissions of the post-COVID-19 patients. Studies indicate that a decrease in emergency admission rates was observed during the COVID-19 pandemic. However, the variables related to admissions to the ED during the long-term follow-up of COVID-19 are not yet known. The role of follow-up centers, which take part in predicting the long-term outcomes of the COVID-19 disease and the early diagnosis of possible long-term complications, is increasing day by day. The study aimed to evaluate the emergency admissions of post-COVID-19 patients according to their follow up in the COVID-19 follow-up center. Methods: The data were obtained by evaluating the admission rate to the ED in the first three months of 2022. The study includes patients discharged from the COVID-19 inpatient of a tertiary hospital in Eskişehir, Turkey, in December 2021. The study groups were divided into two according to whether they applied to the COVID-19 follow-up center after discharge (Group 1, n=185) or not (Group 2, n=383). Patients' ED visits were categorized according to four urgency levels (white code: non-urgent patients; green code: urgent but non-critical patients; yellow code: fairly critical patients; red code: patients in danger of death). Re-hospitalization causes and rates were also compared. Results: 568 inpatients were assessed, 48,2% male and 51,8% female. There was no significant difference between groups in terms of age and gender. The rate of admission to the emergency department in patients in Group 1 (n=25, % 13,5) was statistically significantly lower compared to Group 2 (n=84, % 21,9) (p = 0,017). When the diagnoses at the admission were evaluated, cases of yellow and red code (Group 1: % 39, Group 2: % 16) were statistically significant in Group 2 (p =0,028). In addition, the hospitalization of patients in Group 2 was significantly higher than in Group 1 (p < 0,01). Conclusion: This study determined that post-COVID-19 patients admitted to the ED with a lower rate and milder complaints when they were examined in the COVID-19 follow-up centers. The most obvious finding to emerge from this study is COVID-19 follow-up centers could contribute positively to the burden on ED by preventing avoidable complications and severe emergency situations.

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Background: Attendances at emergency departments in England continue to increase above the capacity of the urgent and emergency care system. There is significant variability in the rates of attendance at emergency departments across different localities. The aim of this study is to model the association of deprivation and non-urgent attendances with locality-based rates of emergency department attendance. The secondary aim is to create an interactive data visualisation tool to engage stakeholders, clinicians, and the public with the research. Methods: We undertook a retrospective, observational study using routinely collected emergency department attendance data from a large region in the North of England (population 5.4 million) with 7,463,272 attendances between January 2013 and March 2017. Attendances where age or address were missing or outside the study region were excluded leaving 6,416,087 attendances across 3,214 localities in the analytical sample. Average annual age and sex standardised attendance rates at emergency departments were calculated for small localities known as lower layer super output areas. Proportions of non-urgent attendances for each locality were calculated using a marker in the data derived from a validated, process-based definition for non-urgent attendance. The association between emergency department attendance rates, deprivation and non-urgent attendances was examined using multivariable linear and logistic regression models. The models were adjusted for travel time to the nearest emergency department, which was calculated using a geospatial information software. Results: The mean annual standardised emergency department attendance rate per 1000 population was 296 (95% confidence interval 292-301, interquartile range 234-381). The mean proportion of non-urgent attendances was 16.5% (95% confidence interval 16.2-16.7, interquartile range 11.7-21.2%). The study found high rates of emergency department attendance were associated with higher deprivation, higher proportions of non-urgent attendances and shorter travelling time to the emergency department. After adjusting for travel time, each increasing decile of deprivation was associated with increased odds of emergency department attendance rates in the top quartile (odds ratio 2.58, P<0.001, 95% confidence interval 2.38–2.82). Localities with non-urgent attendance proportions above the mean had higher odds of attendance rates in the top quartile (odds ratio 2.87, P<0.001, 95% confidence intervals 2.28-3.63) Each minute fewer of travel time to the nearest emergency department was associated with higher odds of high attendance rates (odds ratio 1.11, P<0.001 95% confidence interval 1.09-1.13). The best fitting model explained 54% (P<0.001) of the spatial variability in attendance rates. The data was visualised in an interactive choropleth map. Discussion and conclusion: A large proportion of the variability in emergency department attendance rates in different geographical areas can be explained by deprivation levels and proportion of non-urgent attendances. This provides an opportunity for targeted interventions to reduce emergency department attendances. The visualisation of the data enables stakeholders, clinicians, and the public to explore and understand the variability in emergency department attendance rates across the region and suggest suitable locations and types of interventions. This research provides an example of routine data usage which can be replicated across other regions to inform interventions.

This research is independent research funded by the National Institute for Health Research, Yorkshire and Humber Applied Research Collaborations. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Objective. Respecting patient wishes and preserving patient autonomy is challenging in emergency medicine. Documentation of patient wishes (DPW), e.g. in form of advance directives, can guide clinicians in end of life decisions, though effectiveness is limited by low availability. Here, we present a systematic review which aims to congregate existing data on the rates of DPW ownership and availability in the emergency department (ED) as well as contributing factors. Methods. We systematically searched the MEDLINE database (Pubmed) in October 2021. All publications that provided primary quantitative data on DPW (excluding power of attorney) in the ED were assessed, culminating in a total of 17 studies included in the analysis. Most (9) were from the US, followed by Australia (4), Germany (2), Canada (1) and Switzerland (1). All but one were conducted in urban tertiary care centers, three were multicentric. In total, a culminated 9.854 ED patients were included, with a mean age variing from 41 to 88 years. Publication dates ranged from 1996 to 2021. Results. In the general adult population presenting to the ED, 12.8% to 27.0% possessed some kind of DPW, fewer than 3.2% had brought it with them to the ED. In older patient samples (heterogeneously defined, from ≥55 to ≥75 years of age), ownership and availability varied widely (7.9% to 51.9% and 1.7% to 48.8% respectively). The following variables were identified as positive predictors for DPW ownership: older age, worse overall health and presence of comorbidities as well as several sociodemographic factors, notably correlating with better social connections (e.g. having children, being female). Results were ambivalent on the influence of having a primary care provider. Conclusion & Discussion. Ownership and availability of DPW among ED patients was low in general and even in the older population mostly well below 50%. While we were able to gather data on prevalence and predictors, further research is needed to explore underlying causes of the high intra- and interfacility variability as well as possible public health measures to increase above mentioned rates.

This study was not registered due to its nature and did not receive any specific funding. Ethical approval was not needed.

Introduction: Prehospital emergency medical services care for patients in any type of setting with the resources that an ambulance can offer. Many of the patients seen for pain, dyspnea or requiring orotracheal intubation require treatment during transport with opioids. The characteristics of the patients requiring opioids, the most frequent reasons for the use of this type of mediation and the percentage of admission and mortality in the short and long term are not well defined. Objectives: To describe the frequency of use of opioids, the characteristics of these patients and the reasons for care requiring it. To analyse the type of analgesic used according to the pathology with which the patient is treated. To know the percentages of admission and mortality in the short and long term in this type of patients. Material and methods: Observational, prospective, multicentre study. Inclusion criteria: over 18 years of age transferred by EMS by ambulance to hospital emergency departments (ED) between October 2019 and March 2021 in 4 Spanish provinces of the same health service. Exclusion criteria: <18 years, patients discharged in situ, follow-up <365 days since care. Variables: epidemiological (age, sex, institutionalization, Charlson comorbidity index (ChI)), opioids yes/no and type, reason for transfer, destination: hospital admission or discharge. Mortality in the first 48 hours, between day 3 and 30, and between day 31 and day 365. Cumulative mortality in 365 days. Statistical analysis: Normality tests. Frequencies, central measures, and dispersion in standard deviation (SD) or interquartile range (IQR). Chi-square (proportions), T Student (means) Mann-Whitney U (medians). Statistical significance: p <0.05, 95% confidence interval (95% CI). Software: SPSS. Results: Of 1508 patients analysed, 297 (19.69%) had required an opioid (Morphine 37.4% and fentanyl 62.6%). Of these 297 patients: 34% were women. Age: median 69 (RIC 53-84). Men: 63 (RIC 50-77) and women 79 (RIC 61-88) (p=0.000). Charlson index: 3 (RIC 0-5). 16.5% were institutionalized. Reasons for transfer: circulatory problems 32.42%, trauma 31.88%, infectious problems 11.77%, central nervous system pathology 8.15%, respiratory diseases 8.69% and others 7.2%. Morphine vs fentanyl according to problem of care: infectious diseases 73.4% vs 26.56%; central nervous system (CNS) diseases 4.44% vs 95.5%; circulatory system diseases 59.2% vs 40.78%; respiratory diseases 80% vs 20%; trauma 1.13% vs 98.84%; others 42.1% vs 58.8% (p=0.000). Hospital admission 91.6% and ICU admission 32%. Cumulative mortality in 365 days: 41.7%. Mortality first 48 hours: 17.8%, between day 3 and 30: 13.8%, and died between day 31 and 365 after care: 10.1%. Conclusions: Around 20% of the patients transferred by the EMS require opioids. These patients are predominantly men, and their age range is between 53 and 84 years. The most used opioid in the EMS are morphine and fentanyl. Morphine is used more for respiratory diseases, circulatory system and infections and fentanyl for polytrauma and CNS pathology. The percentages of hospital admission, ICU and short- and long-term mortality are high in this kind of patients.

Introduction : The impact of biology in the medical understanding in pre-hospital is little studied. The main objective of the study was to measure the decisional impact of the various paraclinical parameters in the formulation of diagnostic hypothesis at the end of treatment. The secondary objective was to show the existence of a hierarchy in the measured gasometry parameters for the formulation of diagnostic hypothesis. Method : The data analyzed came from the preliminary study for the BIOSMUR study carried out between 2019 and 2020 with the use of an on-board gas monitoring device in pre-hospital interventions. The clinical cases used were part of a nosological framework defined a priori: cardio-circulatory or respiratory failure. These data were transcribed in the form of clinical cases with a script concordance test type questionnary. Each thirty-three emergency physicians responded to three clinical cases assigned randomly and anonymously. Results : After collecting the various clinical cases, it turns out that gasometry has the highest impact compared to heart rate (OR=3.58, 95% CI [1.589; 4.880], p<0.001) compared to capillary saturation (OR= 1.811, 95% CI [1.048; 3.128], p=0.03). Blood pressure, ECG and temperature have no significant impact compared to the other parameters in these specific cases. Blood sugar is the parameter with the least impact (OR= 0.503, 95% CI [0.282; 0.895], p=0.03). Conclusion : Overall, the use of gasometry in the development of diagnostic hypothesis seems to have a significant impact compared to other parameters used routinely. It even seems to be the parameter with the most impact. We also observe that the paraclinical values have a significant place with a reduction of the number of hypothesis in more than 60% of the cases.

INTRODUCTION: Diabetes Mellitus (DM) describes diseases of abnormal carbohydrate metabolism characterized by hyperglycemia. It is associated with a relative or absolute impairment of insulin secretion, along with varying degrees of peripheral resistance to insulin action. It is a frequent comorbidity among patients seen by Prehospital Emergency Medical Services (EMS), however, there is little literature on the characteristics of diabetic patients seen by EMS. OBJECTIVES: To study demographic variables and causes of transfer of patients with DM at the time of EMS care. To determine percentages of hospital admission, mortality in the first 48 hours, 30-day mortality, mortality between 30 and 365 days, and cumulative mortality in one year. To compare the mortality of patients with DM with target organ damage (TOD) with patients with DM without TOD. MATERIAL AND METHODS: Prospective, multicentre, observational study. Inclusion criteria: over 18 years of age with a diagnosis of DM in their medical history transferred by SEMP by ambulance to hospital emergency departments (ED) between October 2019 and January 2021 in 4 Spanish provinces of the same health service. Exclusion criteria: <18 years, patients without a diagnosis of DM or patients discharged in situ, follow-up <365 days since care. Variables: epidemiological (age, sex, institutionalization, Charlson comorbidity index (ChI), reason for ambulance transfer, DM with or without LOD), hospital admission, mortality in the first 48 hours, between day 3 and 30 and between day 31 and 365, and cumulative one-year mortality. Statistical analysis: normality tests. Frequencies, central measures and dispersion in standard deviation (SD) or interquartile range (IQR 25-75%). Chi-square (proportions), T Student (means), Mann-Whitney U (medians), ANOVA (means) and Kruskal-Wallis H (medians). Kaplan-Meier log rank. Statistical significance: p<0.05, 95% confidence interval (95% CI). Software: SPSS. RESULTS: N: 378. Women 39.9%. Median age in years: overall 76 (RIC 64.75-83), women 78 (RIC 68-85) and men 74 (RIC 64-81) (p=0.003). ICh: 1-2 (23%), 3-4 (27%) and ≥5 (49.2%). Diabetics with LOD: 44.2%. Institutionalized: 23%. Reason for transfer: circulatory system disease (36.2%), nervous system disease (17.5%), infectious diseases (12.7%), respiratory diseases (8.7%), endocrine system diseases (8.5%) and others (16.4%). Hospital admission: 74.1%. Mortality in the first 48h (7.9%), between day 3 and 30 (13%), between day 31 and 365 (14.6%). One-year cumulative mortality: 37.6%. DM without LOD vs DM with LOD: survive 1 year (72%-55.1%), mortality first 48h (7.1%-9%), mortality between 3 and 30 days (10%-16.8%) and mortality between day 31 and 365 (10.9%-19.2%) (p=0.007). CONCLUSIONS: Patients transferred by EMS suffering from DM have an age range around 76 years old. Many of them have a high comorbid burden, with almost half of them having an organ affected by DM itself. The most frequent reason for transfer is circulatory system problems. The admission and mortality rates are high. Having DM with organ involvement seems to be associated with increased mortality in the short and long term.

Background: Cardiovascular diseases are the leading cause of death in Portugal therefore strategies to minimize the impact in mortality and mobility are imperative. As both Stroke and STEMI (ST elevation myocardial infarction) are time-dependent situations, strategies for the appropriate approach include implementation of clinical pathways from symptoms identification on the 112 call to hospital referral and treatment. The National Institute of Medical Emergency (INEM) is the agency responsible for coordinating the Integrated Medical Emergency System (SIEM) in mainland Portugal. INEM manages 112 medical calls, organizing Portuguese prehospital emergency services throughout CODU (Urgent Patient Guidance Centres) dispatch unit. INEM has since 2018 a paper-free technological system that allows clinical record and management of information produced by INEM’s units on the field -ITEAMS (INEM Tool for Emergency Alert Medical System). It contributes to real-time decision-making support and regulation based on clinical data in CODU. ITEAMS identifies clinical pathways aiming to bring value to the chain of help/surviving, optimizing early identification and allowing adequate patient referral during a time window of reference to the most adequate hospital. Methods: Retrospective descriptive analysis of out-of-hospital clinical records registered during 2021 in iTEAMS, referring to STEMI and Stroke. Results: During 2021, INEM attended 219,977 patients. From those 0.96% were reported as STEMI (n=852) and Stroke (n=1264). The population analyses revealed a prevalence of male in both subgroups, whereas age incidence, as expected, differed between the subgroups: Most STEMI patients had ages between 40-64 years while Stroke patients were mostly over 80 years old. We verified that both STEMI and Stroke patients had associated cardiovascular risk, with arterial hypertension accounting for 46% of all cases, while dyslipidemia was identified in 28%. Particularly in STEMI, smoking accounted for 20% of the records. In 39% of STEMI and in 44.8% of Stroke records the onset of symptoms had less than one hour when patients called 112. The Out of hospital time between the call and the arrival of the EMS team on scene was of 17min in STEMI and 15min in Stroke. The transportation time from the scene to hospital was higher in STEMI (27min) than in Stroke (18min). The total out-of-hospital actuation time (from 112 call to hospital) differed from STEMI (1h37min) to Stroke (1h26min) in a medium time of 11min. Conclusions: Well-structured Clinical Pathways are essential for improving prognosis in specific time dependent situations like STEMI and Stroke. Out-of-hospital performance dictates the initial compliance with the times stipulated in the STEMI and Stroke guidelines. Moreover, the referral to the correct hospital, capacitated with PCI (Percutaneous Coronary Intervention) and Trombectomy accordingly, elevates the responsibility not only of the out-of-hospital teams but also of the coordinating centers. The implementation of a monitoring and follow-up structure of STEMI and Stroke events in INEM pretends to alert, inform and educate our professionals in order to optimize out-of-hospital performance. In Portugal, INEM acts as the first link of the entire chain that represent the national pathways and can therefore promote a better outcome for patients with sudden onset of cardiovascular emergencies.

Cardiovascular diseases are the main cause of death and mobility in Portugal. With the creation of clinical pathways in out-of-hospital service, we pretend to improve the response and outcome of patients with STEMI and Stroke.

Background: Pulmonary embolism is a pathology still characterized by high mortality, 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. 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 (> 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> 0.05). However, there is a strong statistical correlation between heart rate values and the presence of organ damage from pulmonary embolism (p < 0.001) The shock index correlates with the presence of organ damage with good statistical strength (p < 0.001 ); also the modified shock index, albeit with a slightly lower statistical strength (P <0.005). The age-shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p < 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.

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%. Some authors have highlighted how adherence to the guidelines is more critical in patients with atypical symptoms, because diagnostic delay can be more likely in these. 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 (>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> 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> 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 <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.

Premise: Pulmonary embolism is a pathology still characterized by high mortality, greater in cases of massive embolism. Raising suspicion and recognizing this condition early is therefore important to avoid delays in undertaking the right diagnostic and therapeutic process. 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 (> 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> 0.05). However, there is a strong statistical correlation between heart rate values and the presence of massive pulmonary embolism (p <0.0001). The shock index correlates with the presence of massive pulmonary embolism with good statistical strength (p <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 <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.

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 (> 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.

Introduction Despite numerous studies on airway management in out-of-hospital cardiac arrest (OHCA) patients, the choice of prehospital airway management technique remains controversial. Our study aimed to investigate the association between prehospital advanced airway management and survival outcomes according to a transport time interval (TTI) using nationwide OHCA registry database in Korea Methods The inclusion criteria were patients with OHCA aged over 18 years old with a presumed cardiac etiology between January 2015 and December 2018. The primary outcome was survival to hospital discharge. The main exposure was the prehospital airway management technique performed by the emergency medical technicians (EMTs), classified as bag-valve mask (BVM), supraglottic airway (SGA), or endotracheal intubation (ETI).We performed multivariable logistic regression analysis and interaction analysis between the type of airway management and TTI for adjusted odds ratios (aORs) and 95% confidence intervals (CIs) Results Of a total of 70,530 eligible OHCA patients, 26,547 (37.6%), 38,391 (54.4%), and 5,592 (7.9%) were managed with BVM, SGA, ETI, respectively. Patients in the SGA and ETI groups had a higher odds of survival to discharge than BVM groups (aOR, 1.11 (1.05-1.16) and 1.13 (1.05-1.23)). And the rates of survival to discharge with SGA and ETI were significantly higher in groups with TTI more than 8 minutes (1.17 (1.08-1.27) and 1.38 (1.20-1.59)). Discussion The survival to discharge was significantly higher among patients who received ETI and SGA than in those who received BVM. The transport time interval influenced the effect of prehospital airway management on the clinical outcomes after OHCA.

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Background: During the COVID-19 pandemics, patients were submitted to endotracheal intubation (ETI) in the Emergency Department (ED) at higher rates than usual. It is unclear how different such intubations are in relation to those performed in patients without Covid-19, especially with the gradual return to pre-pandemic patient populations and ED volumes. Therefore, our objective was to compare baseline characteristics and periprocedural outcomes of ETIs performed during and after the COVID-19 pandemics. Methods: This analysis used two prospective cohort studies that enrolled patients at a large academic ED in Sao Paulo (Brazil). The first cohort was composed of Covid-19 patients aged ≥ 18 years who were intubated between March and May 2020 (Covid-19 cohort). In contrast, the second cohort was composed of adult patients without Covid-19 who were intubated between February and May 2022 (non-Covid cohort). Both cohorts excluded patients under cardiac arrest. The primary outcome was first-pass success (FPS) rate. Secondary outcomes included rates of periprocedural hypotension, hypoxemia, esophageal intubation, and cardiac arrest. Results: A total of 164 patients (112 in the Covid-19 cohort and 52 in the non-Covid cohort) were analyzed. Patients intubated with Covid-19 were older (61 vs. 53 years old, respectively), and hypoxemia was the main indication for ETI (98.2%). In the non-Covid cohort, most patients were intubated either due to decreased level of consciousness (61.5%) or anticipation of clinical course (21.2%). Rapid sequence intubation was more frequently performed for the Covid-19 cohort (96% vs. 86%, p<0.01). Patients in the Covid-19 cohort were more frequently pre-oxygenated with non-invasive ventilation (64% vs 11%, p<0.01), sedated with ketamine (72% vs 30%, p<0.01), blocked with succinylcholine (61% vs 50%, p=0.03), intubated by a senior resident (65% vs 11%, p<0.01), and the procedure was performed with a video device (55% vs 42%, p<0.01). The rate of FPS was higher in the Covid-19 cohort (82% vs. 69%, p<0.01). Although success in the first attempt was more common in Covid-19 patients, they also presented a higher incidence of one or more periprocedural complications (78% vs. 48%, p<0.01), including hypotension (42% vs. 23%) and hypoxemia (52% vs. 27%). The incidence of esophageal intubations (2% vs. 5%) and post-intubation cardiac arrest (1% vs. 1%) were relatively similar. Discussion & Conclusions: Emergency intubations performed in patients with Covid-19 were significantly different than those performed in patients without Covid-19 in an academic ED in Brazil. Nevertheless, despite higher rates of FPS in those with Covid-19, these patients had higher incidences of post-intubation complications. As an academic center in the post-pandemic period, it is part of the training for the junior resident to learn practical skills but we need to be careful not to increase risks to the patient. Further research is required to understand the reasons behind such large differences in emergency airway management and the need of a more systematic and homogeneous approach to intubating patients in the ED.

Funding: FAPESP and HCFMUSP Ethical approval and informed consent: The study protocol was approved by the local Ethics Committee (opinion number 3.990.817; CAAE: 30417520.0.0000.0068), which also waived the need for written informed consent. We adhere to STROBE guidelines.

Background: The incidence of traumatic brain injury (TBI) in our environment is 200/100,000 inhabitants/year, with rates of admission to intensive care units (ICU), related-mortality and morbidity, non-negligible. TBI is a complex condition involving Emergency Medical Systems (EMS), Emergency Departments (ED), ICU, surgery units, and so on. In short, TBI is a serious medical condition requiring a systematic evaluation and management at all levels to make a meaningful difference. The purpose of this report is to examine the predictive ability of a basic prehospital biochemical panel (potassium, sodium, calcium, chloride, glucose, lactate, and creatinine) to detect the risk of non-unplanned ICU-admission in TBI. Methods: Prospective, multicentric, EMS-delivery, ambulance-based, pragmatic cohort study of adults with prehospital TBI, referred to five hospitals (Spain), between January 2020, and December 2021. Any traumatic patient treated consecutively by EMS with prehospital diagnosis of TBI and transferred with high priority by ambulance to the ED was included in the study. Patients under 18 years of age, pregnant women, non-traumatic patients, risk in the scene and patients discharged on site were excluded. Demographic data (age and sex) and venous sampling were collected during the first contact with the patient in prehospital care. The basic prehospital biochemical panel was measured with the epoc® Blood Analysis System (Siemens Healthcare GmbH, Erlangen Germany). Data were obtained by reviewing the patient's electronic history. The primary dependent variable was all-cause ICU-admission. The area under the curve (AUC) of the receiver operating characteristic (ROC) of the biomarkers were calculated in terms of ICU-admissions. Results: A total of 475 patients with a prehospital diagnosis of TBI were included in our study. The median age was 56 years (IQR: 33-74), with a range from 18 to 99 years, predominantly males with 302 cases (63.5%). The rate of non-unplanned ICU-admission was 23.3 % (111 cases), and in-hospital mortality was 14.1 % (67 cases). The AUROC for potassium, sodium, calcium, chloride, glucose, lactate, and creatinine were 0.591 (95%CI: 0.53-0.65; p=0.003); 0.518 (95%CI: 0.45-0.57; p=0.575); 0.369 (95%CI: 0.31-0.42; p=0.273); 0.588 (95%CI: 0.52-0.65; p=0.005); 0.634 (95%CI: 0.57-0.69; p=0.001); 0.803 (95%CI: 0.75-0.85; p<0.001); and 0.604 (95%CI: 0.54-0.66; p=0.001). Conclusions: the role of lactate is well-known in prehospital care, especially in trauma cases. Upper lactate levels are significantly correlated with a strong relationship with a marked increase in morbi-mortality. And according to our data, prehospital lactate above 3.19 mmol/L is associated with a rate of non-unplanned ICU-admission. Know this bedside data may help to determine from the scene the most appropriate hospital for TBI.

This work was supported by the Gerencia Regional de Salud, Public Health System of Castilla y León (Spain) [grant number GRS 1903/A/19 and GRS 2131/A/20]

Background Pre-hospital emergency anesthesia (PHEA), despite being potentially lifesaving when delivered on a regular basis by specialist teams with high caseloads, currently remains a complex, high-risk procedure, at times leading to significant adverse events. The routine utilization of standard operating procedures (SOPs) and periprocedural checklists has been advocated to reduce the cognitive overload of clinicians, reduce procedural variance and improve patient safety. The ultimate goal is to improve long-term patient outcomes, but in spite of a significant build-up in literature on this topic, results so far have been controversial. Therefore, pre-hospital systems are sometimes reluctant to implement periprocedural checklists as part of their daily practice. Objectives This study aims to identify the main barriers to implementation of preprocedural checklists during PHEA and to gather a broader understanding of the rationale behind the hesitance in routine use. Our emphasis is both on optimizing human factors such as clinician reluctance when facing safety innovations, and technical aspects such as the compatibility with current practice and structural complexity of the checklists. Methods This study is a non-systematic review of the current literature regarding checklist implementation and utilization during PHEA. A literature search on Cochrane CENTRAL library, PubMed and Embase database was carried out to identify articles related to the topic of checklists during pre-hospital emergency anesthesia. Articles published in English during 2014-2021 were included after being thoroughly sorted according to their relevance. The data extracted in our study represent a preliminary investigation facilitating the future development of a local periprocedural PHEA checklist along with a pre and post implementation simulation-based study on checklist augmented PHEA in our physician-led pre-hospital critical care system. Results Qualitative data from the selected articles was analyzed. Most studies indicated that checklist implementation in real life without prior, supervised simulation-based training leads to increased reluctancy and failure to comply from clinicians. Continuous, standardized team-training is mandatory in order to improve familiarity with complex procedures like PHEA and to familiarize the clinician with novel tools. Mandatory checklist implementation through local guidelines drastically increases compliance but fails to take into consideration their suitability in special circumstances (in extremis patients). Advances in PHEA technology (video laryngoscopy, digital tools) might make checklists less feasible if their content is not regularly reviewed and modified accordingly. Real-time feedback from clinicians facilitates the adaptation to local specific needs in the pre-hospital environment (urban vs rural; ground-based vs air ambulance). Checklists must be written using non-ambiguous, concise language, focusing solely on the vital information for the procedure. Key elements on the list must be highlighted in case of sudden patient deterioration. Group-based discussions enhance familiarization with standardized PHEA protocols, leading to a more open-minded approach towards checklists. Conclusion The human mind is prone to errors when encountering challenges in high-risk, time-limiting environments. Periprocedural checklists must be viewed as practical and relevant by the clinician performing challenging procedures like PHEA. Regular training with pre-hospital critical care team members, preferably during simulation scenarios, increases compliance towards SOPs and standardized checklists.

Background: The diagnosis of pulmonary embolism (PE) in Covid infection is a challenge due to its associated morbidity and mortality. In published studies, a prevalence of 13-21% of PE has been found in Covid patients. The Wells scale and the D-dimer could be useful to request an angioCT, but the limit for its efficiency has not been established. The objective is to determine the level of Dimer D related to the suspicion of PE and the association of the Wells scale with the presence of PE in COVID patients. Methods: Retrospective descriptive study of a cohort of patients with Covid infection diagnosed by PCR from January 2021 to June 2021 in the Emergency Department of a regional hospital in Barcelona who had undergone CT angiography. Sociodemographic data, comorbidities, presence of pneumonia, PaFi, vaccination, D-dimer level, and Wells scale value were collected when CTangiography was requested. The level of statistical significance considered for the analysis was 5%. The study was approved by the ethics and drug research committee of the Terrassa Hospital. Results: Of the 512 AngioCT performed in the Emergency Department, 148 met the inclusion criteria. The mean age was 64 ± 16 years, 55% were men. 56% of the patients had arterial hypertension, 27% diabetes, 40% dyslipidemia. 82% were not vaccinated, 89% had Covid pneumonia, mean PaFi was 330 ± 132. Mean D-Dimer was 5335 ± 11618, with a modified Wells Scale of 3.5 ± 1.2. In 20 (13.5%) of the 148 AngioCT, PE was diagnosed. Statistically significant differences (p<0.001) were obtained between the different levels of D-dimer higher than 1500, 2000, 3000 and 5000 and the diagnosis of PE by AngioCT. Requesting an AngioCT with D-dimer higher than 1500 collected 100% of those diagnosed with PE, with a limit of 2000, 10% of patients who had not undergone the test were found. Being 45% if the limit was 5000. No statistically significant relationship was found between the elevated Wells score and the presence of PD in COVID patients, but it was considered a clinically relevant finding that all patients with PD had a moderate or high risk. on the Wells scale with more than 3 points. Conclusion: A D-dimer limit higher than 1500 allows the diagnosis of all PE by AngioCT in COVID patients. The Wells scale has been clinically useful in the diagnosis of PE if they presented a moderate-high value of it.

Reliability of the HEART score using Point of care Troponin in the prehospital setting. Introduction Chest pain remains a common complaint for consultation of Emergency Medical Services (EMS) worldwide. In order to combat overcrowding at the emergency department (ED), decreased referral of low risk patients with chest pain would be favourable. Our study aims to validate the reliability of the HEART-score with a point of care troponin (POCT) in the prehospital setting. Methods This Dutch prospective observational study was performed in Rotterdam. A selected group of dedicated EMS nurses calculated a HEART-score using a POCT device (Roche Cobas, cut off value 40 ng/L). Two blood samples were collected in the prehospital setting (T0) and at the hospital (T1), in order to calculate a HEART-score with POCT (HEART-poct) and with central laboratory troponin (HEART-laboratory). Endpoints were overall agreement between HEART-poct and HEART-laboratory at T0 and at T1 and secondary the percentage of MACE after 30 days. Results In total 257 patients with acute chest pain were enrolled, average age was 62.6 ± 14.9 years (mean ± SD). In total 44 patients (17,1%) developed a MACE within 30 days, while 95 (37,0%) patients were deemed as low risk (HEART 0-3). Comparing HEART-poct and HEART-laboratory in the prehospital setting resulted in a Kappa value of 0,958, 95% CI [0,925 - 0,991] with a p < 0.001, meaning almost perfect agreement. While at the hospital, a Kappa value of 0,966, 95% CI [0,937 – 0,995] with a p < 0.001 was found, also showing almost perfect agreement. Conclusion The prehospital HEART-score using POCT shows almost perfect agreement with a HEART-score based on central laboratory troponin, demonstrating the reliability of the prehospital HEART-score. This study supports the implementation of the HEART-score in the ambulance by which patients with a low HEART-score could potentially be left at home without immediate referral to the hospital.

Introduction: The National Institute of Medical Emergency (INEM) is the agency responsible for coordinating the Integrated Medical Emergency System in Portugal. INEM manages 112 medical calls, organizing prehospital emergency services throughout its CODU (Urgent Patient Guidance Centres) dispatch unit. Since 2018, INEM started a technological system that allows clinical record and management of information produced by INEM’s units on the field (ITEAMS – INEM Tool for Emergency Alert Medical System). It contributes to the real-time decision-making support and regulation based on clinical data in CODU, and enables the stratification of patient clinical deterioration risk in the first contact with an emergency medical services (EMS) team, with the support of clinical scores; specifically in major trauma we use RTS (Revised Trauma Score) and MGAP (Mechanism of Injury, Glasgow Coma Scale, Age, and Systolic Blood Pressure). The aim is to bring value to the chain of help/surviving, optimizing the early identification and allowing the adequate patient referral during a time window of reference to trauma centers. It should be noted that the portuguese emergency teams are stratified accordingly to skills, teams can have of technicians, nurse or doctor. Methods: Retrospective descriptive analysis out-of-hospital clinical records during 2021 in iTEAMS, referring to major trauma. Results: During 2021, INEM attended 107 606 trauma patients; from those 1.6% were referred as possible major trauma (n=2643). The population analyses revealed a prevalence of male (70.9%) , with 71.3% of the victims aged between 18-64 years old. 66.1% of this suspected major trauma patients were attended by teams including a physician or/and a nurse (n=1746). The average time between the emergency call and the arrival of the EMS on scene was 21 minutes, with an average time spent on scene of 29 minutes. Out-of-hospital average actuation time in major trauma was of 78 minutes. When in the presence of a nurse or a doctor intra-venous analgesic treatment was administered in 69% of the cases. Endotracheal intubation was performed in 43.4% and tranexamic acid administered in 43.5% of the population identified as major trauma when a phisician was deployed on scene. Conclusion: Well-structured clinical pathways are essential for improving prognosis in specific time dependent situations like major trauma. Out-of-hospital performance dictates the initial compliance with trauma guidelines. Moreover, the referral to the correct trauma center elevates the responsibility not only of the out-of-hospital teams but also of the coordinating centers. The implementation of a monitoring and follow-up structure of trauma events in INEM pretends to alert, inform and educate our professionals in order to optimize out-of-hospital performance. In Portugal, INEM acts as the first link of the entire chain that represent the national pathways and can therefore promote a better outcome for patients with sudden onset of emergencies like trauma.

Introduction High Flow Nasal Oxygen (HFNO) therapy has become the first line in-hospital treatment of acute hypoxemic respiratory distress. In 2020, the COVID pandemic was responsible for an acute hypoxemic respiratory distress pandemic. Consequently, the use of HNFO therapy increased significantly. Despite the logistical and technical challenge, our Emergency Medical Service (EMS) made it possible to provide transport by Advance Life Support (ALS) ambulance under HFNO. The objective of this study was to present the feasibility of using HFNO in pre-hospital care through a series of 107 patients COVID + transported by an Advanced Life Support (ALS) ambulance. Methods All patients treated by HFNO in an ALS ambulance in a catchment area of 1,600,000 inhabitants bordering Paris from 01/17/21 until 05/04/21 (3rd COVID wave in France) were included. All inter-hospital or on-scene-hospital transportations were considered. HFNO was provided through the Fisher & Paykel MR 850® humidifier-heater, compatible with available respirators (Air Liquide Medical System Monnal T60®). Patients’ status was collected: gender, age, Body mass index (BMI), blood pressure and heart rate, prior ventilation support, prior HFNO use, ROX index (respiratory rate-oxygenation, calculated by the ratio of SpO2/FiO2 to respiratory rate). Transportation time stamps and HFNO transport conditions were collected such as its stability, any change or incident occurring during transport, oxygen consumption. Finally, the patients’ outcome including ROX index at hospital arrival, change of ventilation system, death or hospital discharge were collected. Results 107 patients were included. 98 (91.59%) benefitted from inter-hospital transport. 74 were male (69.16%), mean age was 64 years old (SD: 13) – 45% were obese and 36% had overweight; They were all hemodynamically stable. 46 patients (42.99%) had HFNO prior to transport. Mean SpO2 was 92%, mean Respiratory rate was 29,5/min. ROX index before transport: low ROX index (< 2,85) 21 patients (30.39%), intermediate ROX index (2,85-4,87) index: 65 patients (63.11%) and high ROX index (≥ 4,88) 17 patients (16.50%) Mean transport time was 15 min 24 sec (SD: 7 min 44 sec). For 1 out of 107, HNFO was switched, no one was intubated during transport. No technical incident has been reported (lack of energy or oxygen supply, fall of material). Upon ALS arrival, ROX index category was low for 7 patients (6.93%), intermediate for 62 patients (61.39%) and high for 32 patients (31.68%). 47 patients (47.47%) switched to oro-tracheal intubation (OTI), the mean time to be intubated was 2,19 days. In hospital outcome was death for 28 patients (26.17%), hospital discharge for 19 patients (17.76%) and transfer to other hospital facilities for the rest. Conclusion Despite the logistical and technical challenge, our Emergency Medical Service (EMS) made it possible to provide transport by Advance Life Support (ALS) ambulance under HFNO. HNFO is feasible in pre-hospital care. No technical incident has been reported and clinical condition of patients has improved. Nevertheless, further studies are needed to evaluate the use of HNFO in pre-hospital setting.

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