Background and Objectives: "Inhalant abuse" is a common form of volatile drug abuse throughout the world especially in developing countries. This substance mainly contains toluene.  Acute toluene inhalation produces a biphasic response with an initial central nervous system (CNS) excitation followed by CNS depression as well as various metabolic alterations. Chronic inhalational abuse is associated with muscular weakness, gastrointestinal symptoms, renal and hepatic injury. In this report,  we describe an adolescent presented with jaundice, nausea, vomiting and reduced urine output who developed severe acute renal/hepatic damage due to abuse of gas products.

Case report: A 16-year-old boy admitted to the emergency department with a history of nausea, vomiting,  jaundice and reduced urine output for three days. There was no history of previous illness. He begun to practice "glue sniffing" eight months ago and he increased the amount of inhalant in the last two months. He had sniffed approximately 50 ml/day (one tube) of adhesive (bally) during the previous two days before his admission to hospital.  Upon arrival to the emergency department, he was drowsy with Glasgow coma scale (GCS) 13, mildly dehydrated, his pulse and blood pressure were 90/min and 124/79 mm Hg, respectively. He also had yellowish staining of the sclera and conjunctival hyperemia. Laboratory assessment revealed the serum creatinine was 9,6 mg/dL, urea 178mg/dL, aspartat aminotransferase 778 U/L, alanine aminotransferase 1681 U/L, total bilirubin 4.3 mg/dL, direct bilirubin 2.92 mg/dL. The patient was admitted to the pediatric intensive care unit due to renal, hepatic damage and encephalopathy. Since toluene is the main toxic agent involved in glue sniffing which is metabolized to hippuric acid, the present case was treated with continuous hemodiafiltration, plasma exchange and conservative therapy to eliminate hippuric acid. The jaundice gradually disappeared, he had complete recovery of renal/hepatic functions in ten days.

Conclusion: “Glue sniffing” should be included in the differential diagnosis of any teen patient presenting with unexplained acute hepatorenal failure especially in patients who does not have any environmental and exposure.

Introduction

In major trauma care, computed tomography (CT) has become the golden standard for diagnostic workup. Rapid access to CT facilitates the diagnosis of life-threatening injuries. Door-to-CT time is a crucial determinant of survival in major trauma patients. Getting patients to CT within 30 minutes after arrival at the emergency department (ED) is an important quality indicator in early clinical care. Therefore, a short distance between the CT scanner and the trauma room (<50 m) is recommended. As not every hospital has a CT scanner in close proximity of the trauma room, other solutions to reduce the door-to-CT time should be found.

Materials and Methods

This was an observational, retrospective cohort study in a university emergency department where the CT scanner is not located in the ED. Over a period of 18 months (01/10/2015 - 31/03/2017), 241 major trauma patients received CT. The time from patient arrival in the hospital to first image on the CT table was registered. Stable trauma patients transferred from another hospital were not included. During the study period, we introduced four changes in the initial management to reduce door-to-CT time: increasing awareness of the trauma team (introduced 01/2016), training to increase trauma team efficiency (introduced 09/2016), use of a standardised immobilisation and transfer protocol (introduced 10/2016) and marking of the intravenous contrast access line (introduced 11/2016). No other changes were made during the study period: the distance to CT, the trauma alert procedure and the trauma protocol did not change. We compared door-to CT time between the first and the last trimester of the study period. Continuous variables are reported as mean (standard deviation, range) and analysed with the Unpaired Student T-test (equal variances assumed). Proportions were analysed with the Chi Square test.

Results

The mean door-to-CT time was 31 minutes (11, 17-55) in the first trimester and 21 minutes (10, 8-58) in the last trimester, a reduction of 32% (95% confidence interval 5-16 min). The proportion of patients with a door-to-CT time <30 minutes was 10/21 (48%) and 46/56 (82%), odds ratio 5.06 (95% confidence interval 1.69-15.14).

Discussion and conclusion

A 4-step approach significantly reduced door-to-CT time and increased the chance to get patients from arrival at the emergency department to CT within 30 minutes. This strategy may be helpful, especially when the CT scanner is not closely located to the trauma room.

Introduction: In the emergency department (ED), local anesthetics are often used during various procedures. Local Anesthetic Systemic toxicity (LAST) leads to potentially fatal adverse events. Although the number of reports showing the effectiveness of lipid emulsion therapy for LAST has been increasing, the indication of its use is unclear. We present a case of LAST that was induced by caudal epidural anesthesia and treated successfully with lipid emulsion therapy in the ED. 

Case：A 58-year-old woman presented to the ED with severe low back pain. Since oral analgesic (loxoprofen 60mg) was not effective, caudal epidural anesthesia was performed. Immediately after 20 milliliters of 1% lidocaine was administered, the patient complained of systemic numbness, with rapid progression to an altered mental states. The blood pressure was 134/70 mmHg, the pulse 78 beats per minute, the respiratory rate 24 breaths per minute, and oxygen saturation 95%. We suspected lidocaine toxicity and treated with intralipids. After 90 milliliters of 20% intralipids was rapidly administered, the patient gradually regained consciousness. The continuous infusion of intralipids following initial infusion was not performed. After that, the patient was hospitalized for observation, but there was no recurrence of the symptoms.

Conclusion: The number of reports on LAST has been increasing, but there are few reports from the ED setting. Emergency physicians should be aware of LAST because of its severity. Intravenous lipid emulsion therapy can be the significant treatment in anesthetic overdoses. Although the severity-based criteria of administration is not standardized, lipid emulsion therapy is considered effective for patients with neurological symptoms.

Paradoxical embolism, also known as crossed embolism, happens when an embolus from venous circulation passes through an intracardiac shunting in the arterial system, causing ischemic  events, with different clinical  manifestations, depending on the artery embolized.

A 77 year old woman with a previous history of arrhythmia and depression was transferred to the E.D. complaining about abdominal pain in the epigastrium and LLQ, fatigue and malaise the last 2 days. She also mentioned back pain for the previous 2 months.

Her vital signs were BP:75/30 HR:99 RR:22. The clinical examination revealed an abdomen soft in palpation with pain in the epigastrium and the left lower quadrant  and good bowel sounds.

After she responded to the initial resuscitation with fluids and inotropes, she was transferred to the radiology department for a thorax-abdomen CT scan. The CT showed thrombosis of the superior mesenteric artery, celiac artery, inferior mesenteric  and the renal arteries. A bilateral pulmonary embolism was additionally diagnosed .

The patient was admitted to the I.C.U and underwent thrombolysis with alteplase. She was gradually improved. She remained at nil per os until the 5^th day of hospitalization. Her clinical and laboratory status was returned to normal with no tenderness in the abdomen and oral feeding started.

Further examination with triplex of the venous system, heart ultrasound, CT scan and blood test for cancer markers was performed. There was a deep vein thrombosis  of the right common femoral vein and right deep femoral vein  found. The patient also had a patent foramen ovale. The cancer markers were within physiological ratio and the CT showed amelioration of the P.E., and also fewer and smaller deficits in the lumen of splanchnic arteries, mainly in peripheral branches. The splenic parenchyma was seen with multiple infarcts.

We came to the conclusion that the arterial embolisms with a concomitant DVT and PE in this patient  are an example of paradoxical embolism, taking into consideration  the right to left shunting through an intracardiac communication that the heart ultrasound revealed.

The diagnosis of paradoxical embolism remains very challenging. In order to confirm it a thrombus must be detected in an intracardial defect (in ultrasound or autopsy).

In general, it has a good prognosis. The complications depend on the site of infarction. It can be treated by medication, surgery or a combination of these.

Introduction: Non-typhoidal Salmonellae are an important cause of infectious diarrhoea world-wide, especially in children. In the absence of immunodeficiency, disease is usually self-limiting. However, severe salmonellosis is possible in case of higher infective dose ingestion and virulency especially in host with impaired defensive mechanisms including reduced gastric acidity and immune response. Children are at higher risk of manifesting severe salmonellosis almonelosis especially at younger age due to lack of defensive mechanisms mentioned above. We present a case of severe salmonellosis in a family. 

Case presentation: Two sisters at the age of 8 and 11 years were admitted to Emergency department (ED) because of febrile diarrhoea and somnolence. Their 4-year-old brother was found dead at home the same morning. At the time of admission, older sister had between 6 and 10 watery stools  without pathological impurities and signs of severe dehydration accompanied by encephalopathy. High inflammatory markers and neutrophilia suggested development of systemic inflammatory response syndrome. Hemocultures were negative.  Salmonella enteritidis was positive in stool culture. She was treated in intensive care in other clinic where parenteral rehydration and antimicrobial therapy with ceftriaxone followed by cefotaxime  was administered. During treatment she developed hypertension and bilateral pleural effusions. Additional evaluation revealed acute tubular damage and was treated with antihypertensives. The disease course was complicated by Clostridium difficile colitis. A  8-year-old sister was hypotensive at the time of admission to ED. Hemocultures came negative. However, Salmonella enteritidis was positive in stool culture as well. Antimicrobial therapy with ceftriaxone and parenteral rehidration was administered. Sisters recovered without sequellas.

Conclusion: Severe salmonellosis is potentially life threatening disease especially in children at younger age.

CONCLUSION: Many cases of allergy and anaphylaxis present to the Emergency Department without an obvious definitive cause. With an accurate history, clinical sense and challenge tests the diagnosis can be made and appropriate steps taken to minimise the risk of recurrence.

Aortic dissection is a rare and lethal condition that is difficult to manage. Therefore, combination of early detection, fast response and accurate diagnosis are crucial for better survival rate. This case discusses on atypical presentation of aortic dissection which resulted in haemodynamic instability. A 34-year-old man presented to the Emergency Department (ED), Klang Hospital for lethargy, breathing difficulty and feeling unwell for the past 5 days. A week prior attending the ED, he went to seek treatment at a private medical center for similar complaint. However, there was no significant finding noted from the physical examination and basic blood investigation done. On arrival, he was conscious and appear lethargic. The sclera was pink, extremities were cold and capillary filling time was 2 seconds. His vital signs were as follow; blood pressure 80/64 mmHg; heart rate 110 bpm with poor pulse volume; respiratory rate 28 breath per minute;  oxygen saturation 98% under room air and afebrile. There were no radio-radial delay or radio-femoral detected. ECG was immediately taken which showed sinus tachycardia. His chest radiograph revealed wide mediastinum. Bedside ultrasound was performed to investigate the underlying cause of hypotension. Based on bedside echocardiography, presence of pericardial effusion with tamponade effect was noted. An emergency transcutaneous pericardiocentesis was performed to release the tamponade effect. 100ml of fresh blood was withdrew during the procedure. His blood pressure temporarily improved following the procedure. Subsequently the patient developed one episode of generelized tonic clonic seizure in which aborted spontaneously. He was then intubated for airway protection. CT thorax was requested and result showed dissecting aortic aneurysm with possible leak to the pericardium. The patient was admitted to intensive care unit (ICU) as he was not stable for transfer to cardiothoracic unit center. Unfortunately, the patient was succumbed after 48 hours at the ICU.

The non-specific symptom found in this patient may lead physician to a wrong diagnosis. This patient had no typical presentation of dissecting aorta such as tearing-like back pain or chest pain upon presentation. In this case, the only positive finding identified for his condition was hypotensive. Therefore, it is very important to rule out the cause of hypotensive retrospectively. Bedside ultrasound or echocardiography may differentiate causes of shock such as cardiogenic, hypovolemic or distributive in origin. Emergency transcutaneous pericardiocentesis is a life saving procedure, therefore it is compulsory for emergency medical practitioners especially in emergency department to be able to perform the procedure confidently whenever indicated. The procedure may assist in achieving better cardiac output temporarily whilst waiting for more definitive treatment to take over.   

ABSTRACT: Background:One of the least significant leads on a 12-lead electrocardiogram is the augmented right lead (aVR), as it is not as specific compared to the other leads. In this case series, the value of lead aVRis highlighted. Three cases of aVR ST segment elevation on 12-lead electrocardiogramare described, with the end outcome of demise of all three patients. The importance of immediate revascularization is described to improve prognosis in this group of patients. Objectives: This case series aims to primarily present under-reported cases of isolated aVR ST-segrment elevation myocardial infarction (STEMI), their course and outcome.  More specific aims are to identify the criteria in determination of isolated aVR STEMI, know its clinical significance, and determine appropriate management for patients with this ECG finding. Method: A short review of previous studies, case reports, articles and guidelines from 2011-2016 was done.  The author reviewed available literature, sorted out those that proved to be significant for the presented cases, and described them in conjunction with the aforementioned cases. Findings: Based on the limited information on these rare or under-reported cases, it was found that isolated aVR STEMI had a poorer prognosis that led to significant mortality and morbidity of patients.  The significance of aVR ST-elevation was that of an occlusion of the left coronary artery or a severe three-vessel disease in the presence of an Acute Coronary Syndrome.    Guidelines from American Heart Association/American College of Cardiology Foundation in 2013 already recognized ST-elevation of lead aVRin isolation as a STEMI; hence, recommended that patients with this particular ECG finding should undergo reperfusion strategies to improve prognosis. Conclusion: The indispensability of isolated aVR ST-segment elevation on ECG should alert physicians, especially Emergency physicians, to the high probability of Acute Coronary Syndrome with a very poor prognosis.  If this group of patients is not promptly managed, demise may ensue, with cardiogenic shock as the most probable cause.  With this electrocardiogram finding, physicians must be quick to make clinical decisions to increase chances of survival of this group of patients.

Introduction :

Catastrophic antiphospholipid syndrome (CAPS) is an unusual form of presentation of antiphospholipid syndrome with a poor prognosis. Early diagnosis and treatment are necessary. Acquired thrombotic and thromboembolic disorders may be presented initially with symptoms and signs of acute ischemia or organ dysfunction that will lead many of these patients to seek care in the emergency department. 

Case Report :

We reported a case of a 33-year-old female patient without significant medical history admitted to the emergency department with sudden onset abdominal pain, vomiting and dyspnea. She was managed conservatively, but her symptoms progressed with eventual multi-organ failure. Laboratory tests showed autoimmune anemia at 10 g/dL, and thrombocytopenia at 10,000/mm3. The CRP was measured at 144 mg/L, and the creatinine clearance at  30 ml/ min. The thoracic and abdominal CT scan showed multiple venous and arterial thrombosis: Inferior vena cava, Hepatic veins and pulmonary artery with multiple focal hypo dense liver, pancreas and spleen lesions corresponding to micro infarctions. The patient presented a respiratory distress leading to intubation and mechanical ventilation. The evolution was marked by the death after 12 hours.

Conclusion :

CAPS is a medical emergency which requires early identification and aggressive management to improve outcomes. Clinicians need a heightened awareness of this disease state when managing patients with acute thrombosis of multiple organs with no clear etiology.

54 years old male, with a medical history of benign esophageal stricture since 2007 treated with endoscopic dilation (no more since 2011 by recurrency), presented in the emergency room with retrosternal pain since breakfast. Habitually he eat liquid or crushed food but that morning he eated  bread and omelet of sausage , after hearing a noise, starting pain even swallowing,  foreign body sensation and a vomit only with blood content. Denied taking antiinflamatory agents previous days.

In the hospital blood test, venous blood gases, EKG and chest Rx is requested that presented normal results, but pain persists in spite of endovenous analgesia. Because of this fibroscopy and endoscopy is performed searching foreign body. No foreign body is seen in fibroscopy and in endoscopy is seen an esophageal stricture impassable 20cm from dental arcade. The do not dilate it.

After endoscopy patient have fever and increases pain, requiring intravenous morphine, so that thoracic CT with oral and intravenous iodinated contrast is performed. In CT  is observed extravasation of contrast through continuity solution about 8cm of origin of the esophagus which is associated with pneumomediastinum, compatible with esophageal perforation and secondary mediastinitis at the vertebral body height D3. There isn’t foreign body.

Esophageal strictures are estimated to occur in 7-23% of untreated patients with reflux disease. But 25% are urelated to gastroesophageal reflux. This includes strictures secondary to external beam radiation, esophageal sclerotherapy, caustic ingestions, surgical anastomosis, and rare dermatologic diseases (eg, epidermolysis bullosa dystrophica). Strictures may also result from external compression of the esophagus due to mediastinal fibrosis induced by tuberculosis or idiopathic fibrosing mediastinitis. These conditions result in long and narrow strictures that are difficult to dilate, and in which dilation may be associated with a higher rate of complications.

The best option for the treatment of benign esophageal stricture is dilatation. This procedure is usually performed at the same time when upper endoscopy is done. Perforation is a rare complication, generally associated with dilation

Esophageal perforation is a well-characterized and potentially life-threatening clinical situation. Several factors, including the difficulty of accessing the esophagus, the lack of a strong serosal layer, the unusual blood supply of the organ and the proximity of vital structures, all contribute to this condition's high morbidity and to a mortality rate of at least 20%. In addition, the diversity of clinical symptoms and signs combined with a lack of individual experience regarding this particular condition may impede rapid identification of this potentially hazardous situation. Accordingly, delayed diagnostic work-up may hinder timely and appropriate treatment with a negative effect on patient outcome.

Sepsis is the leading cause of death globally, claiming more lives than lung cancer, breast cancer, bowel cancer and HIV/AIDS combined.  It is a dysregulated inflammatory response whereby normal sterile tissue, fluid, or body cavity is invaded by a pathogenic organism. This leads to Sequential Organ Failure, Septic Shock, Multiple Organ Dysfunction Syndrome and finally Death. Recognition of sepsis in the Emergency department is crucial, and with appropriate education and quick recognition, Emergency Physicians can hugely impact the prognosis of a patient presenting with sepsis.

The aim was to analyze the recognition process, sepsis pathways and protocols, the management and prognosis of septic patients based on the diagnostic criteria for sepsis by the National Clinical Effectiveness Committee (NCEC) guidelines in Ireland. This retrospective study was carried out between the period of July 2015 to November 2015 when the Sepsis screening forms were put into use and highlighted as a risk stratification system for sepsis in Portiuncula University Hospital.   79 patients satisfied the NCEC guideline and their charts were analyzed and data recorded. The main elements studied included: Recognition of sepsis in triage, Completion of sepsis6, class of antibiotics frequently prescribed, adherence to guidelines with regards to antibiotics prescription, document status of Emergency Doctors, time taken to see a septic patient, types of blood tests including blood cultures and imaging, sepsis prevalence in Portiuncula University Hospital, mortality rates and appropriate escalation.

The total number of patients studied were 79(n=79). 43 sepsis cases were recognized during triage recognition of sepsis (54.4% CI,43:79). Patient Appropriately triaged to priority 2 were 71 (89.87% CI, 71:74). The mean time that septic patients are seen records at 39.17minutes. Sepsis6 completion with patients presenting with sepsis (100% CI,78:78). 72 out of 79 Antibiotics prescribed were adhering to guidelines (91.13%, 72:79). The study reported a 100% escalated care in terms of referral to the appropriate departments (100%, 79:79). ICU admissions were 23 in total (29.11%, 23:79). There were no mortalities resulting from sepsis in the ED during the term of the study.

The study showed that quick recognition will lead to prompt resuscitation (sepsis6) ushered by proper escalation. This, in turn, improves the prognosis for our patients significantly, reducing the mortality rate of sepsis. However continuous education, highlighting guidelines and the continuum of sepsis must be done to improve recognition and management.

Background: Epiploic Appendagitis (EA) also known as epiploicae appendices are peritoneal sacs that are protruding from the serosa of the colon. Their size ranges from 0.5 to 5 cm and their numbers range from 50 to 100, with fat or blood vessels in them. They are frequently located at the rectosigmoid junction and shows complications such as torsion or spontaneous venous thrombosis in the primer forms.

Case: A 53 year old female patient presented to emergency department with fever, weakness, loss of appetite, cough and left lower quadrant pain emerging and increasing after coughing during several days. Her vital were noted as fever: 38.1 0C, Pulse rate: 96 pulses/min, Respiration: 18 /min, BP: 113/78 mmHg. The oropharynx was hyperemic and oedematous, and there was no pathological sound in the lungs during her physical examination. But there was rebound in the left lower quadrant and tenderness with palpation with radiating pain on the umbilicus. Laboratory tests showed CRP: 8.21 mg/L, WBC:10160 /UL, Amylase: 60 U/L, urine test: normal. Due to age, fever, and left lower quadrant pain of the patient, Contrast-enhanced abdomen CT was ordered for the exclusion of diverticulitis, but CT revealed a number of images which resemble epiploic appendagitis, 18x11 mm in size in descending colon sigmoid level and contamination in surrounding mesenteric tissue (Figure 1,2). The patient was admitted to the general surgery clinic. The patient followed with conservative treatment was discharged 3 days after the hospitalization.

Discussion:In patients with complicated EA, abdominal pain, abdominal mass, and fever can be seen clinically at various durations and localizations. According to localization, appendicitis, diverticulitis, pelvic inflammatory disease, urinary tract infection, urinary tract stones, ovarian cyst or rupture should be considered. Though ultrasonography may be usefull for diagnosis but contrast-enhanced abdominal CT can detect pathognomonic pericholonic, oval or rounded shaped structures which are more dense and pediculated than adjacent peritoneal structures. Up-to-date management of epiploic appendagitis is conservative treatment and early diagnosis can prevent unnecessary surgery.

Conclusion: EA should be kept in mind besides other reasons in patients admitting to emergency deparments with left lower quadrant pain and abdominal CT use should not be forgotten for early diagnosis of these patients.

Introduction: Epidural abscess is a rare but the infection of the central nervous system(CNS) will potentially cause disastrous complications. The initial manifestations of epidural abscess include many nonspecific signs and symptoms such as fever, chills and malaise. It's hard to come up with the diagnosis at the first visit if patient presents symptom without neurological deficits. However, with more understanding of this disease, prompt recognition and proper management we gave can prevent patients from potentially disastrous complications.

Case Report: This 46-year-old woman presented to our ED because of lower back pain for one week. It occurred progressively with four limbs numbness, chillness, dyspnea and dizziness. The diagnosis of hyperventilation was made by other hospital few days ago. On arrival, her consciousness was clear and vital signs were as following: respiration: more than 30 breaths/min, pulse:103 beats/min, blood pressure:103/66 mmHg, and temperature: 37.1C. Chest auscultation are unremarkable and four limbs showed full muscle power. According to patient's statement, she sprained her back while play bowling a week ago, there was no any symptom of upper respiratory infection. Blood tests reported WBC 19040/ul, Hb 10.1g/dl, PL 492000/ul, N.seg. 87.9%. VBG reported pH 7.456, PCO2 30.0 mmHg, HCO3 20.7 mmol/L, Na 139 mmol/L, K 2.6 mmol/L, GLU 161 mg/dl. Liver and renal function are within normal limits. Urine analysis found no pyuria. After potassium supplement and diphenhydramine was given, her symptom and sign improved dramatically and was then allowed to discharged. However, she came to our ER again 2 days later by the problem of acute urinary distention and then 1000ml urine was drained by foley catheterization. Besides, the neurologic symptom of decreased muscle power of lower limbs (4) was found. The lab data was indicated to infection as CRP: 6.45 mg/dl and ESR >140 mm/hr. MRI was arranged which revealed L5/S1 spondylodiscitis with L5/S1 paraspinal and anterior epidural abscesses. After consultation with neurosurgical physician, she was admitted with antibiotics of Vancomycin and Ceftazidime. Although infection was under control after four-day treatment, urine retention remained a predominant problem while admission.

Discussion: There is no actual epidural space in normal circumstance. If the space was opened by mass or blood, it would cause neurologic deficits. The key to diagnosis is to consider this rare condition then to perform a physical examination followed by appropriate images. Magnetic resonance imaging (MRI) usually provides more information than computed tomography

Background: Chest pain is a common symptom at the emergency department (ED) which often leads to admission for further investigation. HEART score is a structured scoring system which facilitates risk stratification. With the introduction of high-sensitivity cardiac troponin (hs-cTn) assays sensitivity for MI have increased with a lower specificity. The predictive value of HEART-score in patients presenting with an initial elevated (hs-cTnT) is unknown. 

Aim: To study whether HEART-score and its components predict MI and MACE in chest pain patients presenting with an initial elevated hs-cTnT.

Methods: All patients with chief complaint of chest pain presenting to the emergency department (ED) of Karolinska University Hospital, Solna,and Huddinge from January 2014 to December 2015 who had an initial elevated hs-cTnT (>14 ng/L) were followed 30 days regarding MACE defined as myocardial infarction (MI) and/or death in a retrospective observational study. Information on risk factors, history, ECG were extracted from medical files and an ECG-database and HEART-score was calculated. The association between HEART-score components and MACE was studied. In order to improve discrimination for MACE a simpler scoring system was tested (HEA021T) in which R were omitted and age was given 2 points for 45-65 years and 1 point for over 65 years

Results: A total of 648 MACE occurred among 2741 included patients. The proportion of MACE was 16.7% in those with a low (1-3), 23% in those with medium (4-6) and 42.9% in those with a high (7-10) HEART-score (p<0.001). A strong association was observed between MACE and the factors H (history) (p<0.001), E (ECG) (p<0.001) and T (Troponin) (p<0.001) whereas R (risk factors) did not predict MACE (p<0.782). Patients aged 45-65 years had a higher risk (37.1%) than patients over 65 (20.4%) (p<0.001). MACE occurred in 7% with a low (1-2), 29.4% with a medium (3-5) and 66.7% in those with high (6-8) HEA021T-score (p<0.001)

Conclusions: In patients with chest pain and an initial elevated troponin T risk factors did not predict MACE and the risk was highest among patients aged 45 to 65 years. A simpler modified HEAT score improved the predictive value compared to HEART-score. We suggest that HEAT-score should be used in patients with an initial elevated hs-cTnT. 

Background: Erythrocyte aggregation (EA) is a reversible phenomenon which is accelerated in many disease conditions with inflammatory response.  Current EA measurement techniques are too complex to be used in clinical setting.

Purpose: Clinical evaluation of the feasibility and usefulness of a point-of-care (POC) EA measurements in an emergency department (ED).

Method: We use a new POC device invented by one of us (OC) to optically measure EA kinetics (EAK) in 30s through a standard blood collection tube (EDTA). The study was conducted in Lariboisière Hospital’s ED during 11 days between January and June 2016. EAK was measured in consecutive, orally informed, patients who required a blood exam. Basic patient information, time of arrival, arrival modality, vital signs, pain scale, emergency triage level (1-5), patient complain and symptoms, ED diagnosis, ED length of stay, and discharge modality were collected. Each patient was contacted after 7 days to check her/his vital status, final diagnosis and new hospital admission. On-site biological values and hospital reports were reviewed to validate final diagnoses.

Results:  274 patients were included. 793 EAK measurements were performed. A mathematical model can be fitted to each EAK with a square regression coefficient > 0.99. Clinical and biological inflammation was assessed for each patient by two of us (OC, GA). Predicting powers of C-Reactive protein and of 3 halftimes derived from the EAK were compared. All 3 AEAK’s area under the Receiver Operating Characteristic (AUC) curves were larger than CRP’s (0.81). The best halftime (AUC = 0,86) was selected for further analyses. More specifically, patients with renal colitis (n=12), non-angina chest pain (n=16), headache or migraine (n=11) had “normal” EAK halftime (mean (SD))[minimum-maximum]: 2.34s(.44)[1.72-3.47], 2.1s(.49)[1.75-2.39] and 2.19s(.37)[1.53-2.66]. Patients with proven infection (n=23) or solid tissue cancer (n=8) had accelerated EAK: 1.65s(.22)[1.33-1.92] and 1.64s(.21)[1.35-2.15]. Patients with heart failure (without myocardial infarction) (n=14) had “normal” EAK: 2.08s(.49)[1.40-3.47]. In each diagnostic category there are a few outliers. The main reasons for these outliers were comorbidities (e.g. one patient had both renal colic and peripheral arterial disease (1.70s)). A 4-month pregnant woman with pneumopathy had “normal” EAK (2.11s).

Conclusion: Erythrocyte aggregation can be measured at the POC in EDs with results available in 30 seconds. This measure is highly specific of EAK. EAK is a powerful marker of inflammation and the first biological value available for medical decision. EAK can differentiate between patients with purely painful conditions such as renal colic, non-angina chest pain or headache and patients with underlying infection or inflammation. EAK profile in pregnant women should be investigated specifically.

Introduction:

Neck of femur fractures place a tremendous burden on emergency services worldwide. Multiple studies have demonstrated significant morbidity and mortality associated with this type of fracture. An early diagnosis and treatment with surgery has shown improvement in both morbidity and mortality.  An effective analgesic regime is paramount in the treatment of patients with neck of femur fractures. Fascia Iliaca Blocks (FIB) have shown to be effective in reducing pain as well as morbidity and mortality in hip fractures. Significant delays in obtaining X-rays would result in delays in adequate pain relief through FIB and definitive treatment. A novel use of Point of Care Ultrasound (PoCUS) however, could mean a diagnosis of a neck of femur fracture is reached within 2 minutes in Triage, with an immediate Fascia Iliaca Block performed afterwards. We have conducted a pilot study to test the validity of diagnosing neck of femur fracture with PoCUS in the ED. To our knowledge, no such use has been investigated before.

Methods: A prospective diagnostic pilot study was conducted, comparing PoCUS to x-rays of the pelvis/hip as a reference test in diagnosing hip fractures in the local Emergency Department from December 2016 to February 2017. All patients with a suspected hip fracture were included in this study. Objectively agitated and uncooperative patients were excluded. The lead investigator solely performed the hip ultrasound and confirmed ultrasound diagnoses, before x-rays were taken.  X-rays were subsequently reported by the Radiology Department without prior knowledge of the ultrasound diagnosis and compared. A Sonosite X-Porte Ultrasound machine was used. The exam was conducted with a C35XP 8-3 MHz probe, using the MSK setting.  The patient is in a supine position.  The ultrasound probe is placed longitudinally, probe marker cranially, on the lateral aspect of mid thigh.  The femoral cortex is visualised and assessed. The probe is then moved cranially, following the femoral cortex until the level of the greater trochanter is reached.  The probe is moved anteriorly to the groin, in line with the femoral neck, probe marker facing the umbilicus, visualising the acetabulum, femoral head and neck and joint capsule. The femoral neck is then followed down to the intertrochanteric region. Any cortical disruption is carefully assessed.

Results: A total of 46 patients were included in the study. 35 patients were female and 9 were male. The average age was 81. Sensitivity of Hip Fracture Ultrasound in our study was demonstrated to be 100% and specificity was 87.5%. Negative predictive value was 1. Positive predictive value was 0.94. Positive likelihood ratio was 8 and negative likelihood ratio was 0.

Conclusions: This pilot study demonstrated promising potential of PoCUS in diagnosing hip fractures. However, as this study covered a small sample size and one Emergency Physician, further studies are necessary to validate its use.

A prospective study to determine possible confounding factors in the detection of intracranial haemorrhage with the Infrascanner^®.

M. De Leeuw, D. Mesotten, S. Van Boxstael, S. Van Poucke, W. Boer, M. Van Der Laenen, J. Van Zundert, R. Heylen, P. Vanelderen

Ziekenhuis Oost-Limburg, Genk, Belgium

Background: Prehospital detection of intracranial haemorrhage is important in order to triage patients to hospitals with a neurosurgery service. The Infrascanner^® is a portable device designed to detect intracranial haemorrhage in battlefield traumas using near infrared spectroscopy. However, little is known about the accuracy of the Infrascanner^®  in a low prevalence setting such as non-battlefield head trauma and little is known about other intracranial conditions that could influence the measurements of the Infrascanner^®. We aimed to investigate the accuracy of the Infrascanner^® in non-battle field traumas. Furthermore, we hypothezed that ischemic stroke, brain tumours, cerebral aneurysms and recent brain surgery could influence the accuracy of the Infrascanner^®.

Materials and methods: In this prospective study we used the Infrascanner^® in adult patients with non-battle field head trauma, ischemic stroke, recent brain surgery, brain tumours and cerebral aneurysms. A bilateral measurement with near infrared spectroscopy was performed using the Infrascanner^® on the frontal, temporal, parietal and occipital region of the head. Clinical examination and an (angio-)CT scan of the brain was used to diagnose intracranial haemorrhage, ischemic stroke, brain tumour and cerebral aneurysm.

Results: We included 75 patients over a 4 month period (48% women, mean+SD age 61 + 19.3 years). In the majority of patients, the Infrascanner^® was used after non-battle field head trauma (58.7%) followed by patients with a brain tumour (17.3%), ischemic stroke (14.7%), recent brain surgery (5.3%) and a cerebral aneurysm (4.0%). The percentage of false positive results was 65.9%, 76.9%, 100%, 75% and 66.7% in patients with non-battle field head trauma, brain tumour, ischemic stroke, recent brain surgery and cerebral aneurysm, respectively. The percentage of false negative results was 4.55% in patients with non-battle field head trauma and 0% in the other patients groups. In total 9 patients had an intracranial haemorrhage of which 7 were detected by the Infrascanner^®. The overall positive predictive value was 0.11, the negative predictive value was 0.85, sensitivity was 0.78 and specificity was 0.17.

Discussion:  This study showed a high number of false positive results in patients with non-battle field head trauma, ischemic stroke, recent brain surgery, brain tumours and cerebrals aneurysms. However, the number of false negative results was low. Therefore, the Infrascanner^® could be used as a screening tool to exclude intracranial haemorrhage. 

Mallet finger is a common tendinous injury of the body (9.3%)¹, which can result in permanent deformity if not treated appropriately.  Literature supports conservative management of closed deformities², however the method and length of splinting varies. We assessed current practice in our emergency department (ED), and investigated management of chronic mallet finger (persistent deformity after 6 weeks).

A survey was sent to 11 ED consultants. The questions assessed diagnosis, treatment options, referrals and rationale for follow-up assessments

Diagnosis was primarily made by clinical findings and X-ray (55%), all treated with a mallet splint, and the majority only referred to orthopaedics if there was an avulsion greater than a third  (90%) of the distal interphalangeal joint. All clinicians arranged follow-up appointments, the primary at two weeks (75%) to assess skin integrity, and a secondary at 4 (9%) or 6 (81%) weeks to assess function and offer advice, with only one clinician having a solo follow up at 6 weeks. If a persistent deformity was present at 6 week follow up, clinicians opted to refer to orthopaedics (27%), persist with a splint (27%) and review in 6 weeks, a combination of both (45%) or remove the splint (9%).

Current practice was on the whole similar for mallet finger deformities, and confirms that mallet finger can broadly be treated in the ED. Given the nature of injury healing times, it was proposed that different regimes should be used for tendinous vs bony injuries. Follow-up is crucial for optimal patient outcomes; we have constructed a protocol for closed mallet finger deformity management based on current evidence.

Introduction: Prolonged mechanical chest compression and extracorporeal life support (ECLS) in the setting of cardiopulmonary resuscitation (CPR) is increasingly employed in patients with refractory out-of-hospital cardiac arrest (OHCA). However, no common consensus on inclusion and exclusion criteria for prolonged resuscitation and extracorporeal CPR (E-CPR) in OHCA patients has been established.

Methods: In 2013, the helicopter emergency medical system (HEMS) in South Tyrol, a mainly mountain province in the north of Italy with an area of 7.400 km² and about 520.000 inhabitants (and high seasonal tourists peaks), was equipped with LUCAS 2. Data were prospectively collected and included information on mission characteristics and clinical information including no-flow and low-flow time as well as the initial cardiac rhythm in OHCA cases were LUCAS 2 was employed. Based on inclusion criteria (i.e., cardiac arrest with primary HEMS transport), the decision to applicate LUCAS 2 and the destination hospital was at the discretion of the emergency physician. In South Tyrol, no hospital has ECLS capacity.

Results: Over a period of three years, LUCAS 2 was applied in 8 out of 271 HEMS-assisted OHCA patients. All 8 patients were transported to the Regional Hospital of Bolzano with no E-CPR capability. Seven of these patients died, one patients had ROSC at hospital arrival. After a review of all the cases, the need for a dedicated protocol emerged. Here we provide a protocol with inclusion and exclusion criteria for prolonged mechanical chest compression and transport to an ECLS-centre out of the province, which is based on a literature review and an agreement of an international group of experts.

Conclusion: The introduction of mechanical chest compression devices in HEMS in a region without ECLS capacity should involve precise indication criteria and the cooperation with an ECLS centre.

S.Z. a 31 years old male came to the ED complaining face edema, weight gain, lower extremity swelling and haemoptysis. No history of neoplastic disease in family.He refered recent access to ED for the same symptoms and hypertension without fever and neutrophilia. The chest  x-ray had showed consolidation with homolateral pleural effusion and pulmonary congestion so he was treated for pneumoniae.At presentation his blood pressure was 150/100 mmHg. Physical examination decreased breath sound in the lower right lung was found. Laboratory studies showed high leukocyte count, high neutrophil, D-Dimer elevation, high LDH, hypokalaemia, metabolic alkalosis, hypercortisolism, hyperandrogenism, suppressed ACTH and normal metanephrines, consistent with adrenal Cushing’s Syndrome diagnosis.Ultrasound revealed right basal lung consolidation with omolateral effusion; an incidental mass was spotted at the upper side of left kidney. The CT scan showed acute pulmonary embolism with pulmonary infarction. Abdomen’s scans described the solid adrenal mass measuring 11x8x6 cm,  with vascular enhancement. It was found to invade diaphragm, vena cava with a big neoplastic thrombus inside. At CT scan paraortic metastatic linfoadenopathy was also reported. The patient underwent surgery with a complete debulking. Biopsy was positive for adrenal carcinoma. In view of the III stage disease he’s in treatment with Mitotane, Cisplatin and Etoposide. Adrenocortical carcinomas are rare malignant tumors (approximately 1-2 per million population per year). Most of them produce enough hormones to present a clinical Cushing's syndrome and/or virilization. In other cases they can be nonfunctional and present as an abdominal mass or as an incidental finding. A careful history and physical examination can help to exclude signs and symptoms of others endocrinology disorder. Fasting blood glucose, serum potassium, cortisol, adrenocorticotropic hormone (ACTH), 24-hour urinary free cortisol, adrenal androgens, and serum estradiol in men and postmenopausal women are useful to formulate a diagnosis; Radiographic studies and Fine-needle aspiration biopsy help to confirm histotype and mass characteristics. It’s important to exclude pheochromocytoma by testing urinary metanephrines and catecholamines. The only potential resolutive therapy is complete resection of the tumor and lymphadenectomy. A surgical pretreatment with glucocorticoid it’s important to avoid postoperative adrenal failure. Other useful therapies are, neoadjuvant  chemotherapy with cisplatinum for mass growth suppression and adrenolytic drug, to  control hormonal excess. The most effective drug is Mitotane. Steroid should be necessary during this treatment. In adults is not proved the utility of chemotherapy with cisplatinum plus etoposide. In conclusion this is a rare and heterogenic disease so it’s difficult to do diagnosis. It’s important not undervalue symptoms in young patients.

Background

Whilst fractures of the neck of femur are commonly occurring diagnoses in the Emergency Department (ED), they rarely occur bilaterally and simultaneously without a high-energy trauma.

A current literature search shows only 23 cases of such diagnoses sustained during a seizure whilst our case being only the second reported in a patient with Down syndrome.

Case

A 56-year-old male was brought to the ED following his first tonic-clonic seizure, which occurred whilst in bed and lasted approximately for 5 minutes. The patient is known with Down syndrome and is non-communicative.

He was found to be immobile since sustaining the seizure and significantly distressed presumably with pain. Radiological imaging revealed bilateral femoral neck fractures and he was referred to the Orthopaedic team for urgent fixation.

Discussion

This case highlights some of the key characteristics found in this subset of patients which pre-dispose them to bilateral, simultaneous femoral neck fractures such as nutritional state, bone health and pharmacology.

Whilst clinical signs and early radiographs led to an early diagnosis, there is often a long delay partly due to the barriers in communication and the general lack of suspicion for bilateral femoral injuries without a significant history of trauma.

Conclusion

This case should serve to remind clinicians to keep an open mind to the possibility of this rare occurrence, both in this group of patients and in those with similar pre-disposing comorbidities.

     Splenic infarction is a rare clinical condition. The most frequent cause is embolic occlusion due to thrombus from atrial fibrillation. However, it is often difficult to diagnose because of its non-specific symptoms. Splenic infarction alone is not an indication for surgery. However, nonoperative management warrants close follow-up, and surgery is indicated for persistent symptoms or in the presence of complications such as hemorrhage, rupture, abscess, or persistent pseudocyst.

     Similarly, acute renal infarction is a rare clinical entity that most commonly occurs as a result of a thromboembolic  event in patients with predisposing risk factors. Its non-specific presentation can lead to delayed or missed diagnosis. However, modern imaging technology has allowed for the diagnosis of renal infarction to be made earlier in its clinical course. Due to its rare nature, treatment guidelines do not exist.

    68-year-old man admitted to emergency medicine department with complaint of abdominal pain and vomitting. He had a medical history of coronary artery disease but he did not use any medication including warfarin.

The pain was intensive On the abdominal examination, there was no rebound or tenderness. Abdominal X-ray revealed normal. On the ECG, he had atrial fibrillation.  The patient had the heart rate of 100 beam/minute, fewer 36.7 °C, arterial blood pressure 110/70 mmHg..The patient’s white blood cell (WBC) count is 10,000/uL, hemoglobin is 11.6 g/dL. The serum creatinine level was 0,8 mg/dL while the D-dimer was elevated to 0.99 μg/mL and LDH to 300 U/L. Abdominal contrast-enhanced CT angiography demonstrated perfusion defects in the left kidney and spleen. Anticoagulation therapy was started.

Splenic and renal  infarction are  a rare cause of abdominal pain. This case highlights the importance of considering alternate etiologies of localized abdominal pain when other common pathologies have been excluded.

Hydatid disease is a parasitic infestation by a tapeworm of the genus Echinococcus. Echinococcosis can involve any organ, but the liver is the most common organ involved, followed by the lungs. We present the case of a of 25 years old woman, who presented in the emergency department complaining of chest pain, cough and fever. Chest radiograph showed homogeneous opacity occupying 2/3 of right lung and an abdominal ultrasound showed the liver cystic image. CT of the chest was done thereafter, which revealed the presence of large cysts both in the lung and liver. The patient was treated surgically by one stage surgery of right thoracotomy with phrenotomy with favourable outcome. This case shows an unusual cause of chest pain in a patient presented in the emergency department, where chest radiography corroborated with a routine ultrasound raised suspicion of hydatidosis.

Introduction

Turkey and Iran have the highest CS rates (47.5% and 47.9% respectively) in Asia based on WHO data. Fetal injuries due to cesarean delivery are less common, compared to the vaginal delivery. In particular, in case of shoulder dystocia, breech presentation, first-feet position, twin pregnancy, and fetal macrosomia, the risk of fetal injury increases. Humeral fractures are the second leading long-bone fractures of the neonatal period.

Herein, we report a case who was delivered via emergency CS and referred to our emergency department (ED) with limited mobility in the right arm.

Case Report

A term female newborn, weighing 3.850g, was born from a 28-year-old mother via emergency CS due to the first-feet position had no history of hypoxia. On the sixth hour of her life, limited mobility in her right arm and lack of Moro reflex on the right side was noticed, and she was referred to our ED. Upon admission, her body temperature was 36.5^oC, cardiac apex beat was 124/min, respiratory rate was 36/min, and blood pressure was 70/36 mmHg. Hypotonia and crepitation were detected in the right arm without Moro reflex. The remaining systems examination was unremarkable and her peripheral pulses were palpable. The right humeral shaft fracture was detected in the plain radiographs of the right arm in the ED. No neurovascular injury was found by doppler ultrasonography. Loss of tone and strength in the right arm was suspected due to pain-related limited mobility. In the ED, the right arm was cast, long arm splint was placed on the right upper extremity by orthopedic surgeon, and the patient was discharged with a scheduled follow-up visit three weeks later. At three weeks, the patient had no motor and sensory deficits. At the final visit at six weeks, the fracture line completely healed without any limited mobility.

Conclusion

Although cesarean delivery reduces the rate of trauma-related morbidity in neonates, it does not fully eliminate it. First full examination of all neonates especially in the operating room is the most critical step to diagnose delivery associated trauma/malformations. It should be kept in mind that mode of delivery, fetal malpresentation, and birth trauma in multiple pregnancies increase the risk. The present case highlights that humeral fractures may occur due to the maneuvers performed during CS. Suspicion, early diagnosis and treatment are critical steps to reduce possible neurovascular complications.

Introduction: Hydatid cyst disease is a parasitic infection caused by Echinococcus granulosus and a common health problem in our country. Hydatid cysts are more common in females and cysts can be identified in any region of the body but they are mostly identified in the liver. Patients are usually asymptomatic for years and cysts are diagnosed incidentally. Rarely, hydatid cysts localized in the liver cause biliary tract obstruction. Then, abdominal pain and jaundice become the leading symptoms of patients admitted to emergency department. Here, we want to present a female patient with huge liver hydatid cyst and biliary tract obstruction.

Case report: A 63-year-old female patient had presented to our emergency department with nausea, vomiting and abdominal pain occurred after each meal and ongoing for three days. She had no known prior disease in her past medical history. Her arterial blood pressure was 150/90 mmHg, pulse rate was 88/min, temperature was 36.6°C and oxygen saturation was 95% on admission. In her abdominal examination, the finding of epigastric tenderness was detected but there was no defense or rebound evidence.  In her laboratory tests, WBC count was 8,890/uL, hemoglobin was 14.1 g/dL, SGOT was 254 U/L, SGPT was 306 U/L, GGT was 284 U/L, ALP was 79 U/L, total bilirubin was 9.34 mg/dL, direct bilirubin was 4.89 mg/dL and C-reactive protein was 26.6 mg/L. We performed abdominal ultrasonography and intravenous contrast-enhanced abdominal computed tomography and the imaging tests revealed that there was a solid lesion compatible with type 5 hydatid cyst with a diameter of 7 cm in the left lobe of liver. Intrahepatic bile ducts are enlarged due to lesion compression in the left side of liver and there were multiple gallstones less than few millimeters in diameter. The patient was consulted with general surgeon and she was transferred to general surgery department for her definite treatment.   

Conclusion: Biliary tract obstruction due to hydatid cyst compression is a rare diagnosis in the management of abdominal pain and jaundice in the emergency department. Also, any anaphylactic reactions can be faced secondary to cyst rupture into the bile ducts. In our case, symptoms were only due to cyst compression and the huge hydatid cyst was diagnosed before rupture.

Study/Objective

To review the publically availabled physical fitness requirements for disaster responders serving on disaster medical assistance teams (DMATs) in the United States.

Background

The United States has trained and credentialed teams of disaster responders which may be rapidly deployed to assist with search and rescue efforts and to provide essential medical care. This field work is physically and mentally demanding, placing team members themselves at risk. On prior deployments, many team members have sustained injury or illness requiring medical attention and, in some cases, extraction for off-site treatment.

Methods

Purpose: Describe the physical fitness requirements for DMAT responders in the United States

Format:Systematic review of public DMAT websites, December 2016. Search engine query for “[State/territory] DMAT” and “[State/territory] disaster medical assistance team,” review of first 3 pages of results

Population: All officially sanctioned DMAT teams in the United States with publically available websites

 Results

Of the 57 DMATs identified, 31 had publically available websites. Of these, 6 publish fitness requirements and 1 team has a self-administered fitness assessment.

Overview of requirements

DMAT 1: affidavit

DMAT 2: provides “Fitness Guide” with overview of basic health and nutrition concepts

DMAT 3: list of required functional capabilities

DMAT 4: list of required functional capabilities by team position

DMAT 5: self-administered fitness test and affidavit

DMAT 6: Health and Safety Assessment Plan, Human and Environmental Risk Assessment (HSAP, HERA)

Limitations 

Data set limited by public availability of DMAT websites

Cross sectional descriptive analysis

Recommendations

Standardization of physical fitness requirements across DMAT units and roles

Development of appropriate fitness testing protocol

Remediation protocols for responders in violation of requirements

It appears that no minimum physical fitness standard currently exists for federal disaster responders in the United States. Individuals may deploy with unknown physical liabilities, placing themselves and team members at risk of illness, injury, or mission failure. Given the hazardous nature of deployment to disaster zones which are, by their very nature, resource limited and may be physically remote from care, efforts should be made to develop and standardize minimum fitness standards for responders. By mitigating the risk of illness or injury to disaster responders, the likelihood of mission success and provider wellness can be increased.

Background

Ectopic pregnancy is the leading cause of first trimester maternal death which often presents as a life-threatening emergency requiring prompt diagnosis and management. Ectopic pregnancy occurs in 2% of all pregnancies. The rate of ectopic pregnancy in Ireland was 14.8 per 1,000 maternities in 2012.

According to CMACE 2011 over 50% of cases of ectopic pregnancy presenting to the Emergency Department are missed on initial presentation.

The purpose of this study was to review all patients who presented with an ectopic pregnancy to a general hospital over an eight-year period and the management pathway of these patients.

Methods

Patients were identified through a hospital database. A retrospective chart review was performed on all cases and data was collected on a standard performa.

Results

Thirty-three women were diagnosed with an ectopic pregnancy during the study period. The average age was 33.1years (range: 27-45yrs). Notably, n=23 (67%) of cases were diagnosed on first presentation with n=10 (30.3%) being referred for further evaluation by a primary care provider. The numeric pain rating score recorded at triage varied from one to nine and positively correlated with the assigned triage category. In almost all cases n=32 (96.9%) vaginal bleeding was present and this was associated with abdominal pain in n=14 (42.2%) cases. The time from triage to review by the Emergency Department Doctor ranged from 0min to 495min with a mean of 124min. Two cases were not included as they were referred directly to Gynaecology-on-call from triage. The time interval to subsequent Gynaecology review ranged from 0min to 465min with a mean of 126min. All cases were managed surgically, with salpingectomy in n=32 (96.9%). There was one case that met acute maternal morbidity criteria, requiring over five units of red cell concentrate and Intensive Care Unit admission. Histology confirmed ectopic pregnancy in n=33 (100%) of cases.

A follow up gynaecology appointment occurred in n=24 (72.7%) cases, with n=8 (24.2%) cases not attending and one death due to multiorgan failure secondary to cardiac arrest.

Discussion

Our review hightlights that there is scope for improvement in the time interval following presentation to the Emergency Department to the time of review by an Emergency Department Doctor and referral to the Gynaecological team in this high risk patient cohort. A prompt diagnosis can help facilitate effective management of these patients and reduce morbidity.

Back ground:A key concept of disaster management and planning is “emergency preparedness”. Development of education and training based on evidence based practice with due importance to regional, cultural and ethical issues is important. Health care workers have different training and exposure in disaster medicine.To prepare health professionals to respond appropriately to challenges and to work with experts in other fields, various organizations have developed competencies in disaster management.

AIM

A survey of health care professionals at Alkhor Hospital in Qatar was conducted to determine their perceived level of proficiency with competencies in disaster management.

Materials and Methods: This study was conducted in Alkhor Hospital during 1 Aug 2016 to 31 st December 2016. Health care professionals working across clinics, Inpatient units and critical araes were included. A survey questionnaire was distributed among the participants .The questions reflected the subject categories covered by the Disaster Medicine Certification Examination.Enrollment was purely on voluntary basis. The questionnaire was validated before the survey.Approval was taken from the ethical committee of the Medical Research Department of the institution. Strict confidentiality was maintained though out the survey .

Results:305 subjects were enrolled in the survey,of which 5 were excluded due to incomplete data. . Majority of them were nurses (n=152).Most of the participants had an experience of more than 8 yrs. 249 ( 83%) of participants had formal training in disaster management among which 51.4% completed online training .details shown in Figure-1.Regarding participation in disaster drills ,203 (67%) participants gave a positive response (Figure 2). On need for mandatory education in disaster management 87.33% (n=262), responded in the affirmative. Regarding competency in disaster management in general majority of the participant gave a score of average and good. While they scored poor regarding psychological issues in disaster

DISCUSSION

We found 78.67 % of the participants did not have any exposure to real disaster during their employment period.Our study validates the past survey done by  slepski et al who reported 85% of the participant to have prior training. Effective prior training ensures the safety and health of the health professional and other responders during a disaster. With the increase in web based training and easy availability of resources, a small study showed a trend in favor of web based interventions. However the trend was not statistically significant

CONCLUSION

Majority of the participant perceived that  they are competent in managing disaster in general. Majority of the participants have undergone formal training in disaster management. Regular drills and practice session are required to maintain the skills of the staff .In managing Psychological issues related to disaster, majority of the participants scored poor or average

Background: Radiofrequency ablation (RFA) of the cavo-tricuspid isthmus (CTI) is one of the most frequently performed procedures in electrophysiology. Cavo-tricuspid isthmus (CTI) ablation is the treatment of choice in preventing recurrences of typical atrial flutter (AFl). Bidirectional isthmus block is a criterion of successful ablation and is associated with the presence of different activation times on each side of the ablation line. Objective: The aim of this study was to determine a novel parameter clarify to improve a success rate in ablation of the CTI. Population and methods: We studied 35 patients with typical atrial flutter (60% male, mean age 48.5 +/- 10 years) who underwent successful ablation during tachycardia. The heart rhythm was sinus in 11% of patients and atrial flutter in 83% before the procedure. Electrophysiology mapping was used to confirm diagnosis of isthmus dependent atrial flutter, electro-anatomic position guide the ablation line creation and assess its efficacy. Before and after CTI ablation, activation times were measured on the low lateral right atrium under pacing from the proximal coronary sinus ostium (with a 600 ms cycle), on the proximal sinus coronary ostium under pacing from the low lateral right atrium. Results: Mean activation time between proximal sinus coronary ostium and atrial bipolar electrogram (SC-RA ) recorded from coronary sinus to low-lateral right atrium in sinus rhythm or in atrial flutter before the creation of the CTI block ablation were 103,7 ± 30,6 ms and. After the creation of the CTI block ablation, Mean activation times were 148,15±24,6 ms at low-lateral right atrium (LLRA) underpacing proximal sinus coronary ostium (PSCO) (PSCO -> LLRA) (P<0,001; r=0,54) and 143, 89±  30,36 ms at proximal sinus coronary ostium under pacing low-lateral right atrium to (LLRA -> PSCO ) (P<0,001; r=0,62). The linear regression equation that best described this result was: LLRA -> PSCO = 0,581 * SC-RA + 83,540; PSCO -> LLRA = 0,437 * SC-RA + 102,863. Conclusion: After atrial flutter ablation, the activation time between proximal sinus coronary ostium and atrial bipolar electrogram recorded at the low-lateral right atrium during atrial flutter or in the sinus rhythm of more than half this time before ablation plus 100 ms was associated with isthmus conduction block. This time criteria is very simplified criteria, make it easy to use in the routine ablation compared to others algorithm. This should however be confirmed before the end of the procedure through demonstration of bidirectional isthmus block.

50-year-old gentleman previously healthy, who presents to Emergency Department (ED) with left hypochondriac colicky non-radiating pain, aggravated by heavy meal for five days and associated with severe diaphoresis and nausea. the patient became afraid to eat because of pain. No history of loss weight, change in bowel habit’s, blood in the stool. The patient denies recent travel, recent surgeries or history of the clot. No family history of clotting disorder or malignancy. The patient does not take any medications, no reported cigarette, alcohol, or drug use.  

He sought for medical advice twice and treated first time as a case of gastritis, and on second visit basic blood work including CBC, U&E, Lactate, LFTs was within normal range and ultrasound showed no abnormalities and discharged on Paracetamol and antacids.

The patient did not improve in spite of compliance with the prescribed medications and presented to our ED with the same complaint. On examination, the patient was stable vitally, with soft non-tender abdomen and normal bowel sounds. He underwent comprehensive study including CT abdomen with contrast which showed thrombosis of Superior Mesenteric Vein and its branches. The thrombus is seen extending, through Portal vein-occluding its lumen, to involve the splenic vein and right portal vein as well. After deemed surgically incorrigible, enoxaparin had been commenced, and the patient admitted to the medical ward.

During his hospital stay, the patient had no complaints, and his physical exam was normal.Gastroenterology consultation was made to arrange for Oesophago – gastro- Duodenoscopy, looking for malignancy which revealed erosive gastritis with significant modularity, Campylobacter-like organism test was negative, tumour markers (CA 125- CA19-9 CEA) were normal, homocysteine 13.9 (high), B12=111(low), work up for thrombophilia was normal.

Outcome and follow-up:

Patient discharged from the hospital with a diagnosis of Portal, superior mesenteric and splenic vein thrombosis secondary to hyperhomocysteinemia, B12 deficiency, and no other thrombophilic state. With a plan to start rivaroxaban 20 mg oral once daily, frequent follow-up at the medicine clinic.  

After six-month repeated CT abdomen revealed recanalization of the portal vein and splenic vein with partial recanalization of the superior mesenteric vein.

To our knowledge, portomesenteric thrombosis is a very rare complication to hyperhomocysteinemia, B12 deficiency as the patient had no other risk factors. For an unusual acute abdomen, not responsive to analgesics; suspicion of a portomesenteric thrombosis should be considered and investigated for.

Aneurysms of the facial vasculature are uncommon, with about 200 cases of superficial temporal artery (STA) aneurysms reported thus far, most of which are pseudoaneurysms presenting within weeks of trauma. We present a case of a gentleman who has a pre-existing vascular malformation of the forehead, who presented with acute onset gross hemifacial swelling due to a massive scalp and facial haematoma with mass effect on the ipsilateral orbital globe, after sustaining a closed blunt injury to his forehead when struck by an opening car door. He was diagnosed with transection and traumatic pseudoaneurysm of the STA via computed tomography scans and angiogram of the STA, for which he underwent extracranial angio-embolisation, with subsequent surgical exploration and evacuation of the haematoma and resection of the underlying vascular malformation. Due to its superficial course, the STA can be injured in blunt head trauma, and a rupture can present with acute hemifacial swelling. Early active intervention with endovascular or surgical means should be considered.

Introduction: Dystonia is a neurological disorder characterized by involuntary, continuous or spasmodic, intense muscular contractions of both agonist and antagonist muscles simultaneously. Acute dystonic reaction manifests with contractions of especially the muscles in the face, neck and back, opisthotonus, torticollis, oculogyric crisis, dysarthria and trismus. Drugs are the most common etiological factors causing dystonia. Various drug groups such as antipsychotics, antiemetics, antihistaminics, decongestants and expectorants can cause dystonia. Even the therapeutic doses of these drugs have been shown to cause dystonia. Haloperidol, an antipsychotic drug, is one of the most commonly encountered cause of this condition. Various conditions including encephalitis, hypocalcemia, seizure, convulsion, insect bite and tetanus may be confused with dystonia. The condition requires prompt diagnosis and treatment.

The Case: Eighteen year-old male patient presented to the emergency department with complaint of involuntary contraction at his neck. He had pain at right side of his neck due the involuntary contractions. He also complained of involuntary gaze toward up and left in both eyes. His medical past history did not include any systemic disease, or chronic drug use or substance abuse. His vital signs were within normal range. In his physical examination, he appeared agitated, he was conscious, oriented, and was cooperating. He had involuntary repetitive contractions at his neck that lasted nearly a minute, tilting the head towards back and left side (Figure). Both eyes showed involuntary movements to up and left side. Other neurological and systemic examination findings were normal. His laboratory findings were normal except elevated creatine kinase levels (CK:653 U/L). In order to rule out central nervous system pathologies, a computed tomography scan was performed, and it was evaluated as normal. Since the patient's clinical findings suggested dystonia, a further detailed history was taken. Drug use was asked insistently, and then the patient told that he was working as a health worker in an intensive care unit of a hospital, and that his symptoms started three hours ago after he took 2mg haloperidol at his own will without consulting anyone, in order to sleep comfortably. As he did not have any previous history, the patient was diagnosed with acute dystonia due to ingestion of haloperidol. Biperiden 5mg (Akineton® ampoule) was administered intramuscularly, and his complaints improved after half an hour. He got well during observation in the emergency department, and was discharged with recommendations.

Conclusion: Dystonia should certainly be considered in every patient presenting to emergency department with involuntary muscle contractions. Since drugs are a common cause of dystonia, a detailed history including drug use should be obtained. It should be kept in mind that patients can sometimes withhold some details that they think are not relevant.

Introduction :

Diarrhea, abdominal pain and distension are frequent findings in emergency department. They can be banal complaints or may lead to the diagnosis of life threatening situations. A clear history taking and examination are the cornerstones of an accurate clinical decision making especially in the emergency department.

Case report :

We report a case of a 42-year-old woman with no medical history, except surgery 4 years prior for intestinal occlusion, wich was admitted to the emergency department with complaint of an important abdominal progressive distension over 2 months, frequent episodes of diarrhea within last 24 hours and few episodes of vomiting. On examination: patient was counscious, afebrile, with stable blood pressure, regular tachycardia 120 bpm, pulse oximetry on air = 92% and respiratory rate = 22 cycles per minute. The abdomen was huge on inspection, asymmetric with bulging flanks, periombilical tympanism and decreased bowel sounds. On rectal exam, loose stools were noticed. Abdominal Computerized tomography showed sigmoid and left colon distension with dolichocolon and voluminous fecal impaction measuring 17 cm. Patient was urgently transferred to the surgical ward but evolution was rapidly fatal on first 24 h after admission.

Discussion and conclusion:

Dolichocolon is an abnormal long large intestine and is often incidental finding on X-rays. This situation is more frequent in elderly and may expose to  mechanical malrotation. while megacolon is an abnormal dilation of the colon and can be congenital or acquired idiopathic, infective, due to toxic or medication use. The association megadolichocolon is rare exposing to fecalomas impaction and mechanical complications.

Introduction: Sudden onset of abdominal pain is one of the most common reasons of admitting to emergency department (ED) but pneumothorax presenting with abdominal pain is rare. In this case; it is aimed to point out that patients with abdominal pain admitted to ED mus t be carefully evaluated and pneumthorax should be considered. 

Case:Twenty-five year-old male ptient with no prior medical history admitted to our ED with severe left upper quadrant pain. There no major physical examination findings except left upper quadrant tenderness. Vital signs were blood pressure: 110/80mmHg Heart rate: 78 bpm sO2: 96%. Lanoratory fşindings were normal. For atypical abdominal pain chest and abdomen graphy performed. The absence of parenchyma in the left lung was determined. Pneumothorax was confirmed with thorax computed tomography. The patient admitted to hospital for chest tube insertion. 3 days after admission no complication observed and patient discharged from hospital.

Discussion: The incidence of primary spontaneous pneumothorax among men is approximately 15 cases per 100000 population per year. Smoking and changes in atmospheric pressure are the risk factors associated with rpimary spontaneous pneumothorax. In this case diaphragma irritation was thought to be the reason of the abdominal pain. most patients with pneumothorax present with acute pleuritic chest pain localized to the side of the pneumothorax. Dyspnea tachycardia, hypotension and hypoxia are also common symptoms of pneumothorax but abdominal pain isnot a common presentation. Clinicians must be careful about abdominal pain and chest x-ray must be perfomed for all patients with abdominal pain.

INTRODUCTION  

Plain abdominal xrays are readily available, however diagnosis and management is not often changed by this investigation. This raises questions about the value of such an investigation. One recent study on the available evidence concluded that in current practice there was no place for routine abdominal radiography. There is evidence that many doctors would benefit from further training in developing skills for reviewing x-rays.

OBJECTIVE   

This is a retrospective study carried out at George Eliot Hospital, Nuneaton to see the efficacy of abdominal x-rays in the diagnosis of acute abdominal pain.

METHODS   

Medical Records of 200 patients who had an abdominal x-ray ordered for acute abdominal pain were reviewed. X-ray reports of the radiologist were recorded. Findings were correlated with the final definitive diagnosis.

RESULTS  

Only 27 out of 200 showed any abnormality. 173 x-rays were reported as normal. Distended loops of bowel were seen in 18, implying acute intestinal obstruction, although further investigations were required to confirm the diagnosis. Renal calculi were seen in 6 cases. Perforation was recognised in two cases and gall-stones were seen in one abdominal x-ray.

DISCUSSION  

It has been customary to do a x-ray of the abdomen routinely for acute abdominal pain. We did not think that x-ray made any contribution in making a diagnosis of acute abdominal pain. This study clearly demonstrates that abdominal x-rays can help in the diagnosis of acute intestinal obstruction but do not provide enough information to confirm the final diagnosis. The diagnosis of perforation requires a chest x-ray. Abdominal x-ray was of no value in the diagnosis of Haematemesis.

CONCLUSIONS

It is clear from our study that abdominal x-ray adds little diagnostic value to the patient who presents with acute abdominal pain. There are other diagnostic modalities that are more efficient and reliable in confirming a diagnosis relating to the acute abdomen. 

Introduction:H1N1(hemagglutinin-H-neuroaminidase-N) influenza infection is associated with high morbidity and mortality because of associated complications and related factors.the aim of our study is to describe the clinical features,complications and different risk factors that affect the outcome in the patients with confirmed H1N1 influenza infection.

Material and methods:a prospective study was conducted in the emergency department of Charles Nicolle hospital in tunis,Tunisia over a period of 4 months going from junuary 2016 through April 2016,including patients aged over 14 years old with acute respiratory distress syndrome.we condidered only patients with confirmed H1N1 infection.

Results:among the 8 patients in the study,62.5% of the patients were male with mean age of 58.38+-18years. Dyspnea and high respiratory rate were observed in all patients,while fever was noted in 62.5% of the cases. On the basis of disease severity,all patients were in hypoxemia,25% in acedemia,62.5% with hyperlactatemia. Non invasive ventilation has been put on in 62.5% of cases,while mechanical ventilation has been required in 37.5%.The average of FINE score was 117.63+-51.75 and CURB65 score at 1.75+-1.035. None antiviral treatment wad administrated,though double antibiotherapy was conducted for all patients. Mean hospitalization period was 56.75+-48.72 hours. During the hospitalization,37.5% of patients required the use of vasoactive drugs. The mortality rate was of 37.5%.

Conclusion:the results of our study suggest that low oxygen saturation during admission,acidemia,hyperlactatemia,high FINE and CURB65 score and the appeal to mechanical ventilation,influence the mortality rate of patients with H1N1 infection.

ABOUT A STRANGE CASE ...NOTHING IS AS IT SEEMS ...

 ABSTRACT

What is often mistaken for pneumonia based on objective tests is actually the result of a restorative response of the Lung in a aggredente agent like a virus, toxic fumes or even a medication.

Some people are more susceptible than others to the development of this strange pneumonia-pneumonia, not specifically who is recovering from cancer or recruiters who takes certain medicines such as amiodarone and Statins for cholesterol control.
KEYWORDS

PERSISTENT COUGH-DYSPNEA-BRONCHIOLITIS OBLITERANS ORGANIZING PNEUMONIA

CASE REPORTS

Come to our observation a female subject of 59, a history of episodes of the Navy, home therapy with beta blocker (nebivolol). Denies allergic Diathesis for Aeroallergen or medications.

Log into PS for symptomatology characterized by flu-like framework, dry cough, shortness of breath and fever to worsening trends. The patient had practiced therapy with antibiotics and prescription of his home GP's without benefit of any.

Performing blood tests that show a mild leukocytosis (WBC 12800) not related to the severity of clinical presentation; therefore cash outs for exam emogasanalitico with evidence of mild hypoxemia (pO₂ 72), deficit being compensated.

On physical examination emitoraci symmetric in static, dynamic, ipetrasmesso, auscultano in FVT hypomobile ronchi, boos and hisses.

Practicing therapy with metilprednisoloneemisuccinato 40 mg betamethasone + salbutamol + ev and aerosol therapy ingredient ipatropium, to follow or₂ low flow.

The improvement in symptoms (in spite of the persistence of an improved finding of broncostenosi), you send your patient at the Radiology unit to undergo chest radiography with evidence of "discreet accentuation of interstitial peribroncovasale plot in reticular nature more evident in the lower lung fields. Doesn't documenting pulmonary lesions grates with character of activity norpleural abnormalities ".

You perform detailed diagnostic study with Tc that CHEST documents "at the right lung lobe and localized also distributed to all subpleurica and iuxtascissurale, you document pulmonary parenchymal density gradient areas for multiple looks at" frosted glass ", some with pseudo-Nodular morphology. some Nodular-like area with similar characteristics also left pulmonary lobe densitometric is identifiable in the upper and lower. -Mainly localized in some parenchymal not bilaterally ) Pilomatricoma mantle of undetermined nature seat for small size likely expression of inflammatory involvement of small Airways. Diffuse bronchial wall thickening is detected, nonspecific changes expressions of type bronchitic and peribronchitico. Pleural and pericardial cavity-freepouring " 

So she was  recover at our Department of emergency medicine and takes appropriate oxygen therapy, nutritional support to compensate for the increased caloric requirements due to the work of breathing and proper dose cortisone therapy for symptoms and body weight.

DISCUSSION

The bronchiolitis obliterans (BOOP) is a chronic disorder secondary to a severe impairment of the lower Airways. There are many factors that can cause skin lesions which underlie the development of boop such as inhalation of toxic gases and fumes (especially NO₂), the graft versus host disease following bone marrow or lung Allograft transplantation, Steven-Johnson, bronchiectasis; bronchiolitis is often prodromal expression of systemic disease, generally of the connective tissue (1).

The idiopathic forms generally affect females in adulthood but probably  the incidence is underestimated because it is often a diagnosis of chronic obstructive pulmonary disease (COPD).

From pathogenetic point of view the BOOP is characterized by partial or complete obliteration by the fibro-lumen scar of Terminal Bronchioles and respirators. The noxa determines an initial damage to the epithelium of the small Airways inducing proliferation of myofibroblasts present in the submucosa and the subsequent deposition of endobronchial granulation tissue with concentric fibrosis evolution towards and eventually obliteration of small Airways.

Lymphocytes and neutrophils play a key role in the initiation and maintenance of pathogenetic mechanism, as well as documented by their presents in BL (bronchoalveolar lavage).

In particular increased the activated lymphocytes (CD3 + HLADR +) and Lymphocytic subtype CD8 +

In this regard are interesting observations regarding BO from lung transplant which suggested a central role of T-mediated immune response against the collagen type V.

Diagnosis is formula through a CT scan and a bronchoscopy, thanks to the technique of broncolavaggio, an examination that allows the analysis of cells in the lung. Bronchoscopy, fortunately, is a non-invasive examination which is done in outpatient offices with a light sedation and lasting a few minutes.
Once you have established the existence of the disease, treatment is cortisone-based, which allows an immediate improvement of symptoms and continued for some months. The proportion of patients presenting relapse after stopping the cortisone is very low. In these cases, treatment is resumed, assiduously checking that cortisone will not produce well-known side effects, namely raising the levels of blood glucose, osteoporosis, weight gain. In some cases, it should also be excluded the presence of other diseases, such as rheumatological, whose BOOP might constitute only a signal

As far as diagnosis may include the need to practice a trans-bronchial biopsy (FBS) with a nodule or a lung biopsy needle under CT guidance trans-parietal, unique exams can provide histological confirmation, clinical radiological documentation particularly seriata in time and the lack of response to antibiotic therapy often allow the pulmonologist expert to treat the patient even in the absence of histologic confirmation, with a proper cortisone therapy for amounts and times. The drug predominantly used is prednisone, given generous dose and for sufficient to exclude recidivists (for months). The experience of the specialist can help you resolve often the clinical picture of COP/BOOP without necessarily having to resort to more risky investigations remember above, reducing the risk of recurrence in any case of the disease, however contemplated in a number of cases, although they adopt adequate cortisone therapy and limiting to a minimum the risk of unwanted side effects secondary to prolonged use of cortisone.

 BIBLIOGRAPHY

1. "PATHOPHYSIOLOGY OF OBLITERATIVE BRONCHIOLITIS IN LUNG TRANSPLANTS"-M Reynaud-Gaubert. Rev Mal Respir 20 (2 Pt 1), 224-232. 4 2003.

2. BRONCHIOLITIS OBLITERANS ORGANIZING PNEUMONIA: PATHOGENESIS, CLINCAL FEATURES, IMAGING AND THERAPY REVIEW – Al Ghanem Sara, Al Jahdali Hamdan and Khan Ali Nawaz

3. “BRONCHIOLITIS OBLITERANS ORGANIZING PNEUMONIA AFTER THORACIC RADIOTHERAPY FOR BREAST CARCINOMA” – R. Cornelissen, S. Senan, Joachim GJV Aerts

4. “BRONCHIOLITIS OBLITERANS SYNDROME (BOS), BRONCHIOLITIS OBLITERANS ORGANIZING PNEUMONIA (BOOP) AND OTHER LATE-ONSET NON INFECTIOUS PULMONARY COMPLICATIONS FOLLOWING ALLOGENEIC HEMATOPOIETICSTEM CELL TRANSPLANTATION”- S. Yoshihara, G. Yanik, S. Mineishi

Introduction:  In urban areas, accessibility constraints are frequent and appear responsible for extended emergency mobile services’ response times. Detailed analysis of terminal access until patient contact (ambulance parking, walking path) has been little undertaken. As a result, factors of accessibility constraints remain unknown.

We aimed to describe the components of accessibility constraints encountered by emergency mobile services, and to compare response times upon the presence of accessibility constraints in an urban area.

Method: Multicentre prospective cohort study involving adult patients receiving care of 5 emergency mobile services in a French urban area. Collected data were geographical and architectural criteria, types of accessibility constraints, parking and patient contact times. Comparison of response times upon the presence of accessibility constraints (t-test).

Results: 1021 patients included between July 1st and April 1^st, 2016. Scene locations were mainly at the patient’s home (76%, n=774), which was located in a multi-story building in 54% (n=553). Accessibility constraints were encountered in 41% (n=422). When met during the parking of the ambulance (57%, n=239), 58% were due to physical obstacles (n=144) and 53% to imprecise address (n=128). When met during the walking path (69%, n=291), 67% were exterior (gates, doors, long distance)(n=194) and 52% interior (doors, codes, lift issue)(n=151). When present, time to patient contact was higher (3.3±1.99min vs. 1.8±1.12min, p<0.001).

Discussion: SMUR ADs were frequently seen in our study. They mainly appeared in groups of flats with more than three stories and principally affected journey elements made indoors and on foot. Where ADs occurred, journey times for SMUR teams were higher. SMUR response quality evaluation should take into account journey elements made on foot in order to establish strategies for improvement.

Performing randomized controlled trials in prehospital emergency medicine is challenging: A PubMed search with the expressions “RCT” and “prehospital emergency medicine” revealed 15 publications, of which seven were reviews.  The Cochrane reviews themselves found limited evidence for emergency endotracheal intubation (3 RCTs), prehospital cooling (7 RCTs) or an update on the effectiveness of the Valsalva maneuver (0 new RCTs) due to  lack of sufficient data. Some authors even warn that “… EMS is completely unsupported by scientific fact...”

International registries aim to challenge this lack of evidence by collecting information all over the world. A registry is a database of information about patients with specific types of diagnoses. It collects information that can be used for capturing, organizing, managing, and evaluating information for a population of patients (AHRQ 2014). Especially in rare diseases, where the know-how of the team that takes care of the patient can be vital, registries can help to obtain information about or even recommendations for good clinical practice. In the challenging setting of alpine prehospital emergency medicine, registries that do not only involve medical but also technical and environmental information can be a crucial source to develop important recommendations. The International Hypothermia Registry IHR, the International Alpine Trauma Registry IATR and the International Avalanche Registry IAVAR are three different registries with a focus on special situations in mountains.

The International Hypothermia Registry IHR (www.hypothermia-registry.org) is the first and only world wide database on human accidental hypothermia. This internet based registry was created by the hypothermia working group with the University Hospital of Geneva, Switzerland which hosts the data on its secure server. The IHR’s principle goal is to increase knowledge on accidental hypothermia by gathering sufficient relevant data through international networking, creating the largest data base on deep accidental hypothermia. The registry will enable comparison of treating and rewarming methods, study survival predictor factors and prevention of post rewarming complications. This will help select the most efficient ways to treat these patients and permit the establishment of evidence based diagnosis and treatment guidelines.

EURAC research in Bolzano / Italy established both the International Alpine Trauma Registry IATR and the International Avalanche Registry IAVAR. The IATR aims to collect and report information in a standard form on major alpine trauma. It includes patient pre-hospital, in-hospital and outcome information. The IAVAR aims to determine and compare the key characteristics of prehospital care and patterns of injury in avalanche accidents with persons involved. Its goal is to determine the impact of rescue strategies and treatment recommendations on patient outcomes.

Background: The care of an acute heart disorder (rhythm disorder, conduction disturbance, or acute coronary syndrome) is based on a rapid diagnosis and access to a cardiac unit. For the emergency physician at the dispatch center, the diagnosis of heart disorders may sometimes be difficult, especially in the case of patients with a non-typical clinical presentation. In this situation, the transmission of an electrocardiogram (ECG) by first aid teams to the dispatch center may save the patient some time. The main purpose of this study was to evaluate the time between the first alert and the receiving of the ECG by the dispatch center.

Materials and methods: This prospective observational study was approved by an ethics committee. Inclusion criteria were: 1. absence of an evocative sign of a serious cardiac disorder during the initial call to the dispatch center; 2. decision by the dispatch center's physician to perform an ECG on site by the first aid team. First aid professionals were trained to record and transmit ECG to the dispatch center. We collected patient’s age and gender as well as the time between the first alert and the receiving of the ECG by the dispatch center. We show the median [interquartile range] or the rate (%) according to the quantitative or qualitative nature of the variable.

Results: The median of the time between the first alert and the receiving of the ECG by the dispatch center was 36 min [29–44]. Between the 10^th of October 2016 and the 6^th of November 2016, the dispatch center registered 36,725 calls with involvement of a first aid team. We recruited 950 patients. The median of the age was 53 years-old [39–70]; 486 patients (51%) were men.

Discussion: For patients with cardiac symptoms not evocative of a serious disorder, we believe that the time to obtain an ECG read by a physician would have been much longer if patients must have been brought to the emergency department prior to the aquisition of the ECG.

Conclusion: Electrocardiograms performed by first aid teams are a complementary tool available to the emergency physician at the dispatch center. Their place in the strategy of patient’s care deserves to be studied further.

Background:

Acute aortic dissection (AAD) is a severe condition characterized by the sudden burst of blood inside the aorta wall [1]. The atypical forms mean that the emergency physician must be vigilant before any chest pain presenting to the emergency.

Case report:

We report the case of a 52-year-old man with no past medical history who presented to the emergency department for severe, thoraco-abdominal, syncopal pain, followed by deep asthenia, vomiting and  sweating.

Examination at admission found: BP = 280/120 mm Hg, pulse = 123 beats / min, FR = 20 cycles / min. BP was symmetrical at the two limbs and the peripheral pulse was present and symmetrical. The ECG showed sinus tachycardia with no repolarization or conduction disturbances with presence of atrial extrasystoles. The diagnosis of AAD was discussed in the emergency room in the absence of signs of ischemia on the ECG.

Exploration by aortic angiography showed a type B aortic dissection beginning downstream the left subclavian artery  to the right primitive iliac artery with dissection of the right renal artery emerging through the side channel which is compressive associated to a decreased right nephrogram with the superior mesenteric artery irrigated by the real channel which is in low flow. The cardiovascular surgeons concluded to a type B AAD and declined the surgical emergency. The patient received intravenous antihypertensive therapy (Nifidipine: 15mg / hr + isosorbide dinitrate 7mg / hr) until strict control of the blood pressure BP = 110/60 mm Hg. Evolution was marked by rapid aggravation with an instability of the haemodynamic state, an alteration of the state of consciousness with recourse to mechanical ventilation and the patient died at H24.

Discussion: ACD management differs depending on the type of dissection. However, in severe forms between the two types A and B, the worsening may be sudden and rapid, emphasizing the importance of appropriate cardiovascular surgery.

Background: Coronary heart disease remains among the main causes of mortality, which leads us to strive on improving outcomes in patients with acute coronary syndromes (ACS). Like any other ischemic conditions, time is crucial, so we increasingly try to reduce delays and go as fast as possible to enhance results.

Methods: We studied the path of 50 patients without medical history of coronary heart disease, who came to the emergency department for symptoms which have been related, after investigations, to an acute coronary syndrome. We recorded all stages of care from the moment of registration until his discharge.

Results: The sample consisted of 14 female and 36 male patients. The male/female ratio was 2,57. 78% of patients arrived on their own. Only 6% have been transferred to us by medically-equipped ambulance. 94 % have reported a chest pain. 8% of patients had a cardiogenic shock. Only 14% arrived within the first 2 hours after the beginning of symptoms. 40% arrived within the 6 first hours. The median time to perform an electrocardiogram upon arrival was 17 minutes, with a maximum time limit of 285 minutes. 74% had one ultrasensitive troponin dosage at least. All patients received aspirin after arrival, with a median time of 74 minutes. All patients received heparin, the median time was 57 minutes. 83% received clopidogrel after arrival in the ER with a median time of 116 minutes. Only 8% of patients received clopidogrel before arrival. Fibrinolysis was performed in 19%, with a median time of 49 minutes and a maximum time limit of 86 minutes. 26% received beta-blockers, the median time was 343 minutes. Only 6% received painkillers. 60% were free from symptoms during their stay in the ER. 6% died while in the ER. 66% have been transferred to a cardiac intensive care unit. Only 24% have been transferred directly to the catheterization lab for angioplasty. The median time for discharge was 10 hours.

Conclusion: There is a lot to do to enhance the quality of care in our emergency department for patients who initially present with symptoms that refer to an acute coronary syndrome. Our delays of care are too long and don’t meet the guidelines, this is mainly due to the lack of experience among trainee doctors and the logistical challenges.

BACKGROUND

Chronic digoxin intoxication is more frequent than the acute one, however acute digoxin poisoning is more severe. Sinus bradycardia is the most typical disorder. Serum digoxin concentration is determined in emergency. Its therapeutic limit is set in 2 ng/mL.

 CASE PRESENTATION

A 59-year-old female patient, diabetic, hypertensive and mechanical aortic prosthesis carrier due to severe stenosis and chronic atrial fibrillation, was assisted by the emergency services presenting decreased level of consciousness and hypoglycaemia (33 mg/dL). The patient had voluntary ingested 45 tablets of digoxin (11.25 mg) and injected herself 400 IU of insulin as suicide attempt. Neutralizing treatment with activated charcoal and glucosmon was administrated.

At admission, the patient was haemodynamically instable, conscious with persistent hypoglycaemia. Electrocardiography showed slow atrial fibrillation with ST-segment changes suggestive of digitalis toxicity and frequent ventricular extrasystoles. Serum digoxin concentration was 23 μg/L.  

An empiric dose of digoxin-specific Fab antibody fragments and inotropes were administered intravenously and the woman was then admitted in intensive care unit, where a rapid clinical improvement occurred, thus allowing discharge in a few days.

DISCUSION

A high level of serum digoxin concentration is a factor to be considered for the administration of antibodies but it is not the only one. Its high cost determines a restrictive use, limiting its indications to cases of severe cardiac conduction disorder or severe hyperkalemia, with hemodynamic compromise with poor response to conventional treatment. In our case, the evident symptomatic clinic justifies the use of this drug,

CONCLUSION

1. Acute digitalis intoxication, although infrequent, must be considered within the differential diagnosis due to its potentially serious complications.

2. Digoxin-specific Fab antibodies should be considered when acute digitalis intoxication presents, although its indications are restricted and has only in-hospital use.

Objective

To emphasize the importance of exploration and complementary imaging studies in patients whith diplopia consulting in emergency departments 

Method

A 49-year-old female with a history of fibromyalgia and dyslipidemia, who comes to the emergency place for binocular diplopia and pain in the right orbital region for 2 days. The patient is in treatment with clarithromycin for fever, headache and nausea during a week.  Exploration: slight limitation of lateroduction of the right eye (paresis of the VI pair) with alternating endotropy of 15º. Binocular diplopia in right lateroversion and inferoversion. Anterior pole and normal fundus. Rest of normal and normal neurological examination. COMPLEMENTARY TESTS: Skull CT: seal lesion with small bone erosion. Analytical blood without alterations. Lumbar puncture: no increase in pressure at the outlet of the fluid, Normal Blood Test, AngioTAC skull: Cavernous aneurysm of right internal carotid artery of 15x16mm in diameter. RM-angioresonance: Giant dysplastic aneurysm in the right internal carotid artery at the cavernous sinus level and left internal carotid aneurysm of 5mm diameter. DEFINITIVE DIAGNOSIS: Cavernous aneurysm of the giant right internal carotid artery and smaller size in the left internal carotid artery.

Results

The endovascular treatment of both aneurysms is indicated by flow-through stents, which are established without incident. In successive revisions, permeability of both stents is checked. From the clinical point of view, improvement of the muscular paresis with disappearance of the diplopia.

Conclusions

In the paralyzes of the IV cranial nerve, idiopathic cases or ischemia secondary to small vessel disease in elderly or diabetic patients are frequent. But it may be due to brain tumors or processes that produce increased intracranial pressure, nasopharyngeal tumors, infections, Wernicke's encephalopathy, multiple sclerosis, or aneurysms. Diagnosis of IV paresis is usually simple, but an etiological diagnosis is necessary to identify potentially serious lesions that require urgent specific treatment.

Introduction:

Ischemic stroke is a rare complication of head trauma caused by vascular dissection. We report a medical observation who presented a post-traumatic acute ischemic stroke.

Case report:

A 72-year-old man, with no past history, presented to emergency department (ED) one hour after a head traumatic injury. He had an isolated head trauma without loss of consciousness after a domestic accident. At physical examination, he was conscious with a Glascow coma scale of 15 and no neurological abnormalities. During his stay in the emergency observational unit, he presented dysarthria and right hemiplegia, 6 hours later. Computed tomography scan of the brain with contrast injection, showed no anomalies. Magnetic resonance brain imaging (MRI), performed after 7 hours, revealed a fragmented left superficial sylvan stroke less than 6 hours old, occipital petechial contusion.

The patient was admitted to neurological intensive care unit.

The evolution was marked by the stability of the respiratory, hemodynamic states and regression of hemiplegia.

Conclusion:

It would be important to better manage traumatic brain injury including MRI, to prevent the risk of stroke. Recall that the consequences of a stroke are often dramatic, ranging from rapid death to severe paralysis.

Acute meningoencephalitis in a patient with behavioral disturbance

Clinical case

Patient of 43 years, allergic to Pantomicina and Amoxicillin, with no medical history of interest that comes to the Emergency Department due to cognitive alteration with decreased consciousness level of 12 hours of evolution accompanied by weakness for ambulation after accompanying his daughter to the hospital. The previous day also attends a headache of 5 days of evolution with clinical improvement after medication administered and discharge from the home with a treatment regimen with Metamizol and Dexketoprofen.

Associated vomiting for 5 days.

Exploration

The patient is on a stretcher due to stunning

Conscious, oriented, little collaborator with lethargy, Regular general condition, muco-cutaneous pallor.

Head and neck, cardio-respiratory auscultation and abdomen without alterations

Neurological exploration with good response to orders and after mild painful stimuli, no loss of strength or sensitivity of upper and lower limbs. Impossibility to complete rest of exploration.

Supplementary tests

Blood analysis with leukocytosis with neutrophilia and slight increase of C-reactive protein values

Chest x-ray: normal

CT scan: no significant alterations

Cerebrospinal fluid puncture: 300 leukocytes, 10% polymorphonuclear and 10% mononuclear, 5 red blood cells, 59 mg / dl glucose and 176.1 proteins.

Negative cerebrospinal fluid culture.

JC: acute viral meningoencephalitis with no specific germ.

Evolution:

After requesting evaluation by Neurology we proceed to hospital admission with the performance of serial blood tests of negative LUES control and serology. Cranial Nuclear Magnetic Resonance is performed without alterations.

During her hospital stay, the patient remains hemodynamically stable and afebrile at all times, with favorable neurological evolution and significant improvement of the symptoms present at her arrival. At discharge, the patient is conscious, perfectly oriented, without signs of neurological focal- ity, without headache, nausea, or other associated symptoms.

Background: The management of myocardial infarction with persistent ST segment-elevation (STEMI) is based on coronary recanalization urgently. Fibrinolysis is the reperfusion approach commonly used in emergency department (ED).

The objective of this study was to identify clinical criteria predictive of fibrinolysis success among patients admitted for STEMI to emergencies within 12 hours.

Methods: We conducted a single- center, prospective, observational study. Inclusion of patients with STEMI thrombolysed by Tenectéplase (Métalyse ®). Fibrinolysis success was defined according to clinical and Electrocardiogram criteria. Multivariate study is used to identify the factors associated with thrombolysis success.

Results: Two hundred sixty-three patients were included. Mean age= 57 ± 16 years. Sex ratio= 6.96. Clinical history N (%): Hypertension 62 (23.6), diabetes 59 (22.4). The average time chest pain - emergency admission was 184 ± 126 min (30 min to 12 hours).The distribution of  STEMI N (%): inferior:  127(48.3) ; anterior, 45 (17) ; basal, 85(32) ; extension to the right ventricular, 59(22.4). The average success rate of thrombolysis was 72.2%. In multivariate analysis, the independents predictors factors of a fibrinolysis success were: the delay from onset chest pain to the ED visit less than 180 min [OR=1,5 ; IC à 95%= 0,99-2,26 ; p=0,05] and the delay for first medical contact to qualified ECG less than 10 min [OR= 1,5 ; IC à 95% = 1-2,26 ; p=0,05]. 

Discussion: Regarding the management of myocardial infarction with persistent ST segment-elevation in emergencies; the delays: from onset chest pain to the ED visit less than 180 minutes and for first medical contact to qualified ECG less than 10 min appears as independents factors of a fibrinolysis success.

Introduction:

Myocarditis, often caused by an infectious agent, may have a presentation mimicking that of acute myocardial infraction. The differentiation between acute myocardial infraction and acute myocarditis can be difficult. Electrocardiographic (ECG) changes and enzyme elevation are common in both.

We report a case of patient in whom clinical and ECG findings during the acute phase could have led to an erroneous diagnosis of myocardial infraction.

Case Report:

A 45-year-old male patient with no cardiovascular risk factor presented to the emergency department (ED) with an acute onset of asthenia associated with epigastralgia. He had normal physical examination findings. An ECG performed immediately showed the presence of  a 3rd degree atrio-ventricular block  and an elevation of ST-segment in leads V1 to V6 without a specular reflection in inferior leads. The chest X-ray was normal. The biological results showed high hypersensitive troponins at 24000 ng per liter, with no inflammatory syndrome (normal white blood cells and negative CRP). The diagnosis of ST-segment elevation myocardial infraction (STEMI) was made and the patient received a dual anti-platelet (aspirin and clopidogrel) and anti-coagulant (subcutaneous low molecular-weight heparin) medications.

The evolution was marked by the recurrence of the epigastralgia with electrical modifications in the percritical ECG with apparition of Q wave in anterior leads and persistence of the ST segment elevation. The patient was referred to cardiology department; the coronary angiography revealed no abnormality. A transthoracic echocardiogram done showed segmental abnormalities. The patient was discharged the next day with good outcome.

Conclusion :

The clinician is sometimes confronted with acute myocarditis presenting many of the features of myocardial infraction. This alternative diagnosis should be considered especially with young patient without coronary risk factors.

Acute poisoning in elderly patients: epidemiological, clinical and management

Background: The demographic proportion of the elderly population is increasing continuously worldwide. The number of poisonings is also increasing among elderly people admissions in intensive care units. We carry out a study which aims to study the epidemiological, clinical and prognostic characteristics of elderly poisoned-patients.

Methods: It is a retrospective study spread over 63 months from 1st January 2012 to 31th March 2017 including all poisoned-patients over 65 years old admitted in a 22-bed teaching toxicological intensive care unit.

Results: 115 patients aged of 73 ± 7 among 6240 admissions were eligible with a prevalence of 0,018%. Sex ratio was of 1.16.  29.6 % of patients had psychiatric illness. Poisoning was accidental in 49.5% (n=58) of cases and it was about chemical submission for 3 patients. Pharmaceutics drugs were incriminated in 33,9 % (n=39), chemical substances in 57,4% (n=66), mixed poisoning in 3.5%(n=4) and Viper bite envenomation was observed in 6 patients. Among pharmaceutics drugs, the most often ones implicated in poisonings included cardiovascular drugs 14.8% (n=17), benzodiazepines in 11.3% (n=13), other psychotherapeutic drugs in 20% (n=23), theophylline in 3.5% (n=4), analgesics and anti-inflammatory drugs in 2.6% (n=3), and oral hypoglycemic in 3 patients. The most observed substances among chemical poisoning were pesticide in 22.5% (n=28), Carbon monoxide in 21.7% (n=25), herb poisoning 3.5% (n=4) and caustic products in 3.5% (n=4). One hundred and seven patients (93%) were symptomatic. Neurological signs were in 70,4 % (n=81) including consciousness loss in 54,8 % of cases (n=63), seizures in 4.3 % (n=5) and motor deficit in one patient. Digestive signs were present in 24.3% (n=28). As to the treatment, antidotes were administered for 18 patients, mechanical ventilation was required in 24.3% of cases (n=28) with a mean duration of 33 ± 20 hours. One hundred twelve of patients (95.7%) of patients were discharged alive from ICU with a mean delay of 3 ± 2 days.

Discussion: Poisoning is a significant problem in the elderly patients. Most cases were unintentional and may result from improper use of the product, improper storage of mistaken identities. Depression is also common in the elderly and suicide attempts are more likely to be rare in this age group.

Background:

Methomyl is a carbamate pesticide worldwide used in agriculture, particularly in our country. Acute poisoning in humans is rare but could be severe leading to death in few cases [1].

The aim of this study was to describe clinical features, management and prognosis in patients presenting with acute methomyl poisoning.

Methods:

It was a retrospective study extended over 8 years from January, ^1st 2009 to April 2017, about all cases of acute methomyl poisoning admitted in our Intensive Care Unit. Methomyl poisoning was retained on a history of methomyl ingestion, clinical presentation and decrease of serum anticholinesterase activity.

Results:

One hundred patients aged of 28.2 ±14.6 years were eligible. They were 74 female and 26 male. Poisoning was by oral way in 98% cases in a suicidal attempt in 85%. The onset of clinical signs was rapid with an average delay of 13±24 mn.The most frequent symptoms were Miosis (n= 92), abdominal pain (n=63), Vomiting (n= 60), hypersialorrhea (n=36), Bronchorrhea (n=34), Coma (n=31), Diarrhea (n=27), fasciculation (n=27), acute pulmonary edema (n=17) and cardiac arrest in seven patients (7%). The most frequent biological abnormalities were hypokalemia (n=42), hyperlipasemia (n=9), hyperglycemia (n=24). Serum cholinesterase activity was decreased in 75% of cases with a median serum level on admission at 3374,50[140-14450] UI/L. Gastric lavage was required in 50 patients , atropine infusion in 96 patients, and assisted ventilation in 35 cases, among whom 13 patients suffered from acute respiratory syndrome. Vasoplegic shock was noted in 13 patients and acute pancreatitis in 9 cases among which 1 grade D and another grade E. Eight patients (8%) died during ICU hospitalization due to refractory hypoxemia in 62.5% cases and after resuscitation from cardiac arrest in 37.5% cases.

Discussion:

Methomyl poisoning is observed mainly in young female subjects. Muscarinic syndrome is the most frequent one. Serum cholinesterase activity could be normal due to its rapid and transitory action. Early intensive care management based on the administration of atropine is recommended to reduce mortality rate which remains high. 

Personal history:

No allergy to medications. Smoker 15 cigarettes / day. Casual beer drinker.

No previous surgical interventions

Current illness

A 32-year-old patient who comes to the emergency department for pain in the right renal fossa irradiated with a hypogastrium of 3 days of evolution accompanied by urine coluric dysuria, hyporexia and food vomiting in a number of 15 episodes per day.

The patient was studied for a similar picture two weeks prior with imaging tests (abdominal ultrasound and abdominal CT scan) that were normal.

On physical examination, hemodynamically stable patient with bilateral iliac fossa pain and positive bilateral percussion. Rest of physical exploration without pathological findings.

Complementary tests in emergencies:

Blood test:

Hemoglobin 14.4, Platelets 140, Leukocytes 16,000 (89% neutrophils) Prothrombin time 105% Glucose 101 Creatinine 6.38 mg / dL, Glomerular filtrate 11, sodium 131, potassium 4.80, chlorine 91, lipase 161, Creatin kinase 60469, Creatin kinase MB 170, GOT 1744, GPT 645, GGT 31 FA 69, total bilirubin 1.10 (direct bilirubin 0.40) Venous gasometry: pH 7.31 pCO 2 37, pO 2 49.9 Standard bicarbonate 18.7.

Urine Systematic: Positive Hematies, Positive Proteins

Biochemistry of urine: Proteins 2,4, Creatinine 350, Sodium 21, Potassium 46, Osmolarity urine 294.

Fraction Excretion of Sodium> 1: Prerenal Renal Insufficiency.

Abdominal ultrasound: Both kidneys of normal size and globulous aspect, with preserved cortico-medullary difference. Diffuse increase of cortical echogenicity suggesting nephropathy of prerenal origin, taking into account lso vomiting persistent).

During admission to the observation area, the patient denies having performed any over-exertion in previous days, as well as consumption of toxic substances, except alcohol. Nonetheless, urine toxicity analysis is carried out to evaluate positive values for cocaine.

Subsequently the patient is reinterrogated confessing cocaine use the previous day.

The patient was transferred to acute nephrology unit and after stabilization was discharged 4 days after admission with normalization of renal function

Introduction: theophylline toxicity continues to be a major clinical problem in our country because its wide use for the management of asthma and various other respiratory diseases.it could be associated to a high risk of death related to cardiac toxicity.Our study aims to describe theophylline poisoning characteristics and correlation between the theophylline serum level and biological abnormalities.

Methods:during January 2011 to April 2017 we followed up all patients who had been referred to our Toxicological Center for theophylline poisoning.Were collected age,sex,supposed ingested dose and clinical manifestations of toxicity. All ingested form of theophylline were of prolonged liberation.A plasma theophylline concentration≥30 mg/l had been considered as reference for the diagnostic of poisoning.

RESULTS:89 cases of theophylline poisoning were reviewed. All cases represented intentional self poisoning.Patients were young (mean age:23 years[12-75]) and predominantly female (91%).Only 12% were known asthmatics and 4.5% had chronic obstructive airway disease.Sustained release theophylline preparations accounted for the majority of cases,the amount of ingested dose varied widely from 1000 mg to 18000 mg(mean 4512mg).In 87% of cases,theophylline was considered the sole drug involved,other drugs were reported in 13% cases.The delay between theophylline ingestion and emergency presentation ranged from 1 to 24 hours (mean delay:7.4 ± 5,3 hours).The initial mean serum level of theophylline was of 45.8 mg/l.Only one patient had a theophylline serum level of 156 mg/l.All patients had tachycardia and digestive symptoms (vomiting, epigastralgia).One patient had seizures and had been intubated.Hypotension was seen in one patient and was resolved under fluidloading.Electrolyte and metabolic abnormalities were frequent as hypokalemia in 66 patients (74%) with a mean of 3.07±0,3 Meq/l and lactic acidosis in 18.4% with a mean of 4±1,8,hyperglycemia in 69% cases with a mean of 8.6±2,8 mmol/L and Hyperleukocytosis in 69% cases (mean:13456± 4788).Hypokalemia appeared early in the course of overdose with a delay of 5 hours after ingestion).Gastric lavage was done in 5 cases,activated charcoal was required in 72% cases as a single dose, oral beta blokers in 35% of cases.In one patient who presented with shock, Norepinephrine was associated to fluid expansion.The mean ICU length stay was of 19.6± 13,5 h,less than 24 h in 80%.The analysis of correlations between biological abnormalities and blood theophylline concentrations showed a significant correlation between the blood theophylline concentration and the serum glucose level(p<0.001), hypokaliemia(r²=0,005),lactic acidosis level (r² = 0,06) and the ICU length stay(p< 0.001).

Conclusion:With the widespread availability of theophylline preparationsand their extensive use for pulmonary conditions clinicians should be aware of the possible complications and risk of metabolic complications.

ACUTE TRAMADOL INTOXICATION

Introduction: The cleansing of acute wounds does not currently have a standardised protocol in both our paediatric Emergency and Surgical consultation services. A preliminary survey found that a 9% saline solution was used in 70% of cases, wound debridement by soaking or swabbing the wound with an antisepsis in 90% of cases relating to wounds which are thoroughly dried. The data from scientific literature is not in line with our current acute wound care management.

Methods: Presenting our survey results to Nursing, Medical and Paramedical teams with reference to the data from literature reviews such as: the absence of benefit from using saline solution in comparison to tap (drinking) water, no advantage but rather same detrimental effect of using mild soaps, antiseptics, and wound drying techniques. Evidence-based guidelines were established and validated by Coordinating Centre for Health-care-associated Infections Control (CCLin). This study brought together other stakeholders including hospital hygiene unit, technical services and the pharmacy department.

Results: The validated protocol prioritize the use of tap water and the limitation of antiseptic use. The wash techniques must be made under a pulsated pressure of at least 8 psi (example 35 mL syringe and cathlon® gauge 19) and a sufficient volume of water (250 mL to 500 mL). The use of the drinkable water requires regular bacteriological monitoring, graphic identification of sinks used for hand and wound cleaning, the strict adherence of a purging technique of the water supply in the morning, a stringent cleaning of tap fixtures and shower heads and the bleaching of siphons. This protocol is accessible on the hospital website and to private medical practitioners.

Discussion and perspectives: A pre/post survey indicated a favourable response to the protocol without it being systematically implemented. Debriefing meetings were organised within the institutional framework. The mentoring of students/trainees served to advance these practices. Excluding the medical costs (study scheduled) our work highlighted the importance of an interdisciplinary and cross-sectional update of the acute wound care management taking into account the data published on a National level including the National Health Authority (HAS), and International level (professional societies and scientific literature).  With the institutional support, we value the quality of care and in-house training, for an informative update with an analytical and critical approach.

Background. Implementation of new organizational strategies and tactics of diagnostics and treatment in the Strokes (Cerebrovascular Accident-CVA) from the last years are influenced by the aging of the population, increase number of repeated CVA, and high share of the contraindications of thrombolytic treatment

Materials and Methods: During one year there were analyzed 2805 calls of patients with CVA (1.01.15 – 31.12.15), the average age 68,0±12,9 years, including women 53% (1367) and men 47% (1213). It was assessed the structure of CVA, diurnal and seasonal addressability and diagnostics which mimics Stroke.

Results Ischemic CVA’s constituted 1983 (70,7%); 402 (14,3%) transient CVA’s; 228 (8,1%) other diagnosis and sequels of CVA; 181 (6,4%) hemorrhagic CVA and 11 (0,4%) subarachnoid hemorrhage. The most affected categories of age are 60-69 years (33,1%), 70-79 years (23,3%) and patients over 80 years were 17,6%.The study of diurnal and seasonal addressability attests us a high risk for days of Monday, Tuesday, Wednesday and Friday in which were registered 63%, in winter season were registered 27,4%, in spring season 28,4%, in summer season 24,5% and in autumn season 23,3% from the total number of CVA. A higher share of CVA are registered in the months of January (10,6%), March (9,2%) and December (8,6%). The diurnal study attests us that 56,6% from CVA appear between 08:00 – 16:00, 32,4% from 16:00 to 24:00 and 10,7% from the cases from 24:00 till 08:00 in the morning. The average length of call reception was 2 min, 46 sec ± 0,92 sec (interval 68 sec – 5 min 16 sec). During an hour from the appearance of symptoms 42,7% patients called. In 28,9% cases it was reported only one symptom, in 31,5% cases 2 symptoms and in 39,6% cases 3 and more symptoms. Only in 18,9% from the calls were present words which indicated CVA, fact which speaks about that only about 1 from 5 persons understands the CVA problem. The most frequent symptoms which were reported while calling to emergency were the speech disorder (27,3%)  paresis in limbs (19,8%), disturbances of consciousness (16,4%) and in 7,4% cases disturbances of sensibility. The diagnoses which mimics include: syncope 54 cases (2.1%), coma 46 cases (1,8%), sequels of CVA 75 cases (2,9%), epilepsy 28 cases (1,1%) and hypertensive encephalopathy 5 cases (0,2%)

Conclusions: CVA affects preponderantly the age over 60 years constituting 74%, including 17,6% for the age over 80 years. Days of week Monday, Tuesday, Wednesday and Friday and the months of the year January, March and December present a high risk of CVA .The most frequent symptoms were the speech disorder (27,3%),weakness or numbness of arm or leg (19,8%) and disturbances of consciousness (16,4%).The most common non-stroke conditions were syncope, coma and sequels of CVA.

Introduction

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, about 25% of the world's population over 40 years age will suffer it across their life. AF is associated with a high risk of thromboembolic complications, fundamentally stroke, and oral anticoagulants have shown their ability to reduce this risk.

Objective:

To rate track clinical practice guidelines (CPGs) through the analysis of the indication of antithrombotic prophylaxis, and their relationship with oral anticoagulants therapies.

 Patients & Methods:

Descriptive, observational and retrospective study in a General Hospital in Murcia (Spain), which manage  a population of  200.000 people and 275 emergencies / day.  In the study 762 patients with AF from 1^st October 2012 to 30^th December 2013 were included. The analyzed variables are: average age, sex, CHA2DS2-VASc and HAS-BLED scores and previous anticoagulant therapies and at discharge. IBM® SPSS, version 21.0 was used as statistical program.

Results:

The sample under study was constituted by 64.59% and 35.61% of women and men respectively, with an average age of 72 years. The distribution of oral anticoagulant therapies received by the patients at home was: acenocumarol 28.25%, dabigatran 3.68%, rivaroxaban 2.37% , warfarin 0.66%, apixaban 0.13% , and without therapy received 63.34%. After an evaluation in the emergency room, The distribution of oral anticoagulant therapies prescribed at discharge change to: acenocumarol 27.4% , rivaroxaban 18.9%, dabigatran 12.6% and no therapy prescribed 29.96%.  The average of the CHA2DS2-VASc risk stratification score was 3.39, obtaining a score ≥ 2, 1 and 0 for the 82.76%, 9.20% and 8.02% respectively. And being the average of the HAS-BLED bleeding risk score 2.25, with a score of ≥ 3, 2, 1 and 0 for the 39.95%, 32.13%, 16.69% and 11.30% respectively.

Conclusions

In some situations, the decision to initiate anticoagulation is complicated because of the potential risks. According to the CPGs on anticoagulant therapy for the prevention of cardioembolic events in patients with AF, in our study, most patients received anticoagulant therapy at discharge according to CHA2DS2-VASc risk stratification score and HAS-BLED bleeding risk score correctly.

BACKGROUND: The prevalence of clinically important abnormalities on head CT scans in patients presenting with a variety of neurologic complications in absence of head trauma varies from 8%-35%. In the last two decades, we have observed a sustained increase of CT scans use at the emergency department (ED). Accordingly, two main concerns have been growing: medical radiation exposure and cancer. The aim of this study is to ascertain the predictors of a positive head CT scan in patients with headache and demonstrate the feasibility of implementing a clinical decision rule (CDR) to improve the adequacy without compromising safety.

METHODS: After a bibliographic systematic review, a CDR was designed to improve the adequacy of the indication of head CT scans in patients attending an emergency department for headache. In the CDR, we have included the following alarm signs: age >60, neck pain/stiffness, loss of consciousness/neurological focus, onset during exercise, sudden pain, fever (not explained in clinical setting), meningism, HIV/immunosuppressed, progressive worsening/persistent headache and first episode in oncologic patient. If one of these was present, a head CT scan should be performed. In case of being negative, the indication of the performance was based on the clinical opinion of the emergency physician in agreement with the radiologist. The study and intervention was indicated to all patients who were referred for headache, as the main symptom, to the general emergency department of the Cruces University Hospital, a third level hospital in the Basque Autonomous Region (Spain). The data of the 6 months previous and after the implementation of the CDR were analyzed.

RESULTS: In all patients in the post-intervention phase in which the CDR was performed, there were no alarm factors at 37% and no head CT scan was performed in 99.5%, of whom 3.8% were reconsidered and in none of them was acute pathology. Of those who had alarm factors, no brain CT scan was performed in 6% and in none of them were acute pathology one month after the consultation in the emergency ward. The remaining 63% of the patients attending for headache with alarm signs head CT scan was performed to 94% and acute pathology was observed in 35%. Those patients who did not refer alarm factors (37%), a brain CT scan was performed to 0.5% of them and no acute pathology was observed. The pre-intervention inadequacy rate was 74% and 12% after the implementation of the CDR. Among those patients who consulted for headache in the pre-intervention phase, brain CT was performed to 40% versus to 30% post-intervention, with an estimated annual cost savings of 16,632 €.

DISSCUSSION: We observed that the CDR was 100% safe, and reduced costs and radiation exposure. Nevertheless we found a significant percentage of patients with alarm signs and non-pathological CT scan, which means that further adjustments should be made to the CDR, without compromising safety.

INTRODUCTION

The Belgian guideline for treatment of acute otitis media (AOM) in children does not recommend systemic antibiotics (ABs), except in clearly defined cases (Grade 1A). The guideline additionally allows using delayed AB prescriptions. If treatment is started, amoxicillin should be the first choice (Grade 1B). Poor guideline adherence has been reported before.

Our aim is to analyse adherence to the guideline in a paediatric emergency department (PED) in a tertiary teaching hospital.

MATERIALS AND METHODS

In a retrospective sample study, electronic health records of paediatric patients who presented in 2015 and were diagnosed with AOM were analysed regarding age, gender, diagnoses and AB use.

RESULTS

Of 17698 patients that presented to the PED, 875 (5%) were diagnosed with AOM as primary or secondary diagnosis, and after exclusion of patients already AB treated, 773 children were included.

Median age was 2 years (range 0–15), 436 (56%) were girls, 27 were <6 months old, 347 were 6-24 months old, and 399 were >2 years old.

Primary diagnosis was AOM (73%), cold (16%), pneumonia (4%), tonsillitis (3%), and other (5%).

We identified 297 patients (38%) for whom ABs were recommended: 27 (9%) because they were < 6 months old; 140 (47%) because they were 6 to- 24 months old and had severe symptoms, complications (mastoiditis, meningitis), or were not improving within 48 hours of the diagnosis; and 130 (44%) because they were >2 years old and had severe symptoms, complications, no improvement within 72 hours, or relapsing within 12 months.  Regardless of their age, high risk patients and children with persistent otorrhoea are also recommended to be treated with ABs.

Considering adherence to the guideline: of the 297 children for whom AB were recommended, 216 (73%) were indeed treated (3 received a delayed prescription), but 81 (27%) were not. For 476 children ABs were not recommended, yet 107 (26%) were started on AB (18 of whom received a delayed prescription. Overall, the guideline was not followed in 206 of the 773 patients (27%).

The guideline was most often violated in the group of 6-24 months old (104/347; 31%) than in both other groups of <6 months old and > 2 years old (respectively 7/27; 26% and 77/399; 19%).

When AB were administered (n=341) the guideline (proposing amoxicillin) was followed in 281 cases (82%); 29 (8%) received amoxiclav, 1 (0.3%) received trimethoprim-sulphamethoxazol, and 1 (0.3%) received macrolides.

As supporting treatment, 404 children (52%) received local drops containing antibiotics, 311 (40%) received local nasal decongestives, 252 (32%) analgetic eardrops, 252 (32%) local corticosteroids. The majority (n=632; 82%) received additional oral analgesia.

DISCUSSION AND CONCLUSION

Adherence to the Belgian guideline for AB treatment in paediatric acute otitis media patients is fair in the majority of cases, and most physicians at the PED treat AOM with the recommend antibiotic drug, but there is still room for improvement. 

Case report:

23 years old woman with personal history of autoimmune primary hypothyroidism.

The patient comes to the emergency department for two days of fever, vomiting and diarrhea accompained by deterioration in the cognitive level in the last few hours. She had hypoglycemia (42 mg/dl) that improved (134 mg/dl) after administration of glucagon and glucose serum.

Physical examination:

Blood pressure: 60/30 mmHg, temperature: 37.6º C, heart rate: 137 beats per minute, oxygen saturation 95% (fraction of inspired oxygen 31%).

Generally poor condition. Glasgow coma scale 13. Poorly perfused. Dry skin and mucous membranes. Cutaneous hyperpigmentation. Rhythmic heart tones, no murmurs. Breathing sounds conserved without pathologic sounds. Abdomen not tender to palpation without peritoneal irritation. Increased peristalsis. Without edemas or data of deep venous thrombosis in extremities.

Investigations:

In blood test highlight hyponatremia (124 mmol/L), hypokaliemia (3.4 mmol/L), metabolic acidosis (pH 7.3, HC03- 12.3 mmol/L), coagulopathy (prothrombin time 19.3 seconds), 11.700 leukocytes/mm³ with 8.700 neutrophils/mm³,  procalcitonin 50.16 ng/mL, C-reactive protein 5.46 mg/L.

The brain scanner suggests the possibility of diffuse cerebral edema. Rx thorax and abdominal CT without alterations of interest.

Evolution:

With the diagnosis of abdominal septic shock, treatment is initiated with intensive volume replacement, empirical antibiotic therapy with piperazillin/tazobactam and noradrenaline infusion . Despite this, hypotension persist and she presented deterioration of the level of consciousness (GCS 9) and respiratory worsening.

Patient is admitted to the ICU. She required orotracheal intubation and mechanical ventilation for acute pulmonary edema. With suspected adrenal insufficiency, treatment with hydrocortisone was started. A hormonal study was performed which showed low levels of cortisol (0.7 μg/dL) and ACTH highs (>2000 pg/mL). With a good posterior evolution, the patient was discharged five days later to the internal medicine plant to continue the study.

Conclusions:

It is important to keep in mind the adrenal insufficiency in a septic shock of poor evolution. Some data that may support the presence of this entity are refractory hypotension, hypoglycemia, hyponatremia and cutaneous hyperpigmentation.

Background: Admission to an emergency department at weekends has been associated with a higher risk of adverse events. However, limited information is available concerning this “weekend effect”. This study investigated numbers and types of adverse events occurred in an emergency department weekdays and weekends, and explore how the employees in the emergency department relate to these adverse events, including their perception of barriers to and incentives for reporting the adverse events.

Methods: This study followed a mixed-methods design consisting of 1) a prospective descriptive observational study, 2) focus groups interviews and 3) a questionnaire. The prospective descriptive observational study consists of two hundred twenty-nine adverse events, occurred in an emergency department at a Danish regional hospital, reported to the mandatory national reporting system during a two-year period (2014-2015). Based on results of four focus groups interviews with four nurses in each group, an anonymized self-completion questionnaire was developed and handed out to nurses and consultants in the department. The response rate was 64%. The material was generated in 2016.

Results: The analysis showed that most adverse events happen on weekdays (0.13 per shift) when compared to weekends (0.07 per shift). In all 27 % (61/229) of reported adverse events occurred in weekends. Different types of adverse events happen weekdays and weekends. Most of the adverse events happen on weekdays are related to 1) samples, patient examination and test results and 2) medication. Adverse events related to 3) treatment and nurse care and 4) information handover, patient responsibility and documentation happen more often in weekends. Furthermore, most adverse events happen between 2pm and 4pm. The focus group interviews and the questionnaire suggest that employees perceive reported adverse events as a tool to optimize the work processes and quality of patient care provided in the emergency department. However, because of workload, uncertainty and a lack of focus, they did not report all adverse events, which creates bias in the register data.

Conclusion: This study presented different tendencies in when and what kinds of adverse events are happening in an emergency department weekdays and weekends. Additionally, when only some adverse events are reported to the mandatory national reporting system this study also indicated problems in registration practices. Reporting adverse events has become an opportunity instead of a requirement. This highlights that high rates of reporting depend on the continual reinforcement and education of the aims on adverse events reporting to employees - a dimension that would benefit from leadership attention.

Background: The excessive use of alcohol is a worldwide problem. Alcohol abuse is a cause of many health risks and contributes to an important part of the global mortality. In addition, alcohol-related problems cause significant financial costs for the society.

Objective: All patients of the emergency department of the Nikolaas General Hospital in Sint-Niklaas (Belgium) were examined whether the use of alcohol was a major cause of the current medical problem. This study focused on the importance of age and gender as risk factors.

Methods: From 14/09/2015 until 13/09/2016 a prospective observational study was completed: 97 pre-determined shifts of 12 hours each were randomly distributed. This could have been a day shift (from 7.00 am to 6.59 pm) or a night shift (from 7.00 pm to 6.59 am the next day).The weekend shifts were defined as starting at Friday 7.00 pm and ending at 6.59 pm the next Monday. Based on the routine approach of anamnesis, clinical evaluation and technical examinations the patients were divided into two groups: the intoxication group (the study population) and the control population. Blood or urine tests were requested because of the study.

Results: After exclusion of nine patients, 4693 patients were selected for further analysis. In total, 241 cases were alcohol-related (5.1%). The average age of the study population was 43.0 years. Males were overrepresented in both the general population (52.7%) and in the study population (61.4%). On weekend nights, alcohol-related emergency admissions raised to 12.5%. Between the different age groups there was not much difference, but in the study population 42.5% of the patients were between 41 and 65 years old. In the study population, no patient was younger than 15 years, but 25.4% of the study population was between 15 and 25 years of age and 11.7% was older than 65 years. Traumatic injuries were the most common alcohol-related complaint (46.1%). In the study population most patients stayed only for a short period of time in the emergency department, but a significant part was referred to a psychiatric ward (4.6%). Finally the study population made more frequently use ofthe ambulance servicesin comparison with the general population46.9% versus 19.9%.

Discussion: Gender is a significant risk factor for excessive alcohol consumption. The age of a patient plays a less prominent role. Alcohol however is not only a problem among young people. Middle-aged men report themselves often with alcohol-related problems at the emergency department. Because 5.1% of all patients had alcohol-related symptoms, the providing of early detection and treatment of these problems is important. It is also important to focus on older patients. However, our study design is bias-prone, because it was not a continuous registration. Therefore, a prospective study that includes a whole year of registration is needed to complement the present data.

Popular demand for high quality care has increased in recent years. This is also the case for medical services and support at all times of the day and night. During the last ten years, there has been a marked increase in the demands on hospital emergency hospitals, particularly in western industrial countries.

Aims of the study: The present retrospective study investigates how the demands on a large Swiss university centre have changed over a period of 10 years; patient numbers are differentiated by age, gender, nationality, weekday and mode of referral.

Methods: A retrospective analysis was performed of the data of the patients admitted to the Emergency Centre of Bern University Medical Hospital – the Inselspital – in the ten year period from 2004 up to and including 2013 and who were treated as emergency patients.

Results: A total of 264,272 patients were included in the study. It was shown that there was an uninterrupted annual increase from 23,555 patients in 2004 to 34,918 patients in 2013 (+48%). For the whole period, a mean of 42% female and 58% male patients were treated. The gender distribution was constant over 10 years. As regards the age distribution, the values were markedly higher for younger patients, with a peak at 26 years of age. The age group with the most patients was for the 20-29 year olds, with 19% of the total (50,636 patients). From the peak for the 26 year olds, the mean age decreased continuously up to the 80 year olds and then dropped sharply for the over 80s, who made up 8% of the total patient population. The greatest increase was from 2012 to 2013 and was observed in each age group. The relative increase over the 10 years was greatest for patients aged over 90 from 8 to 14%. Most self-referrals were during the weekend or on Mondays. GPs most frequently referred on Mondays and Fridays and internal departments on Fridays. Referrals by the ambulance service, external hospitals or the police were evenly distributed throughout the week.

Conclusions: In the coming years emergency centres will have to adapt to the continued increase in patient numbers. For the organisation and optimisation of patient care in emergency centres, it is important to know that the weekdays with the highest patient numbers are Monday – with mostly younger patients – and Friday – with mostly older patients. Most patients refer themselves. The number of self-referrers is also continuing to climb.

It was also found that emergency centres must prepare for a marked increase in the number of geriatric patients. In particular, the group of very old patients of over 90 will increase. For this reason; emergency centres must prepare themselves to provide adequate care to this group of patients.

These trends will continue, so that it is essential to consider the sociodemographic structure of a region when planning the availability of emergency medical care.

INTRODUCTION: 
Corpus callosum agenesis (CCA) is the most common form of cerebral malformations with an incidence of 0.05 to 0.7% in the general population. It is characterized by the absence of the main inter-hemispherical commeasure: the corpus callosum. In 50% of the cases, the CCA is isolated; it can be symptomatic or asymptomatic.
CASE Report: 
H.B.S 26 years old, a factory worker, smoker, with no significant medical history, was sent to the emergency by the civil protection following a road accident. He was hit by a car while walking. The trauma was a dual component, traumatic brain injury with initial loss of consciousness and altered consciousness, and closed thoracic trauma. At admission, the patient was confused, with a GS of 8, and a vertical occipital wound of 4 cm and a right per orbital ecchymosis. His hemodynamic state was stable, the blood pressure was 113/69 mmHg and π at 74 cy/min. At pulmonary auscultation there was a diminution of the vesicular murmur on the left. The abdomen was supple and painless within the limits of the examination. The patient was intubated from the start because of neurological distress, and he benefited from an urgent resuscitation with monitoring of blood pressure and ACSOS targets. The thoracic Xray in bed and ECG was without anomaly. An emergency Bodyscan has demonstrated colpo-cephaly with thinning of the frontal horns in relation to an agenesis of the corpus callosum and intraventricular haemorrhage at the intersection and occipital horns.

DISCUSSION: 
Agenesis of the corpus callosum is a rare cerebral malformation usually detected in children. In a study by Lemesle et al, epilepsy was the most frequent mode of revelation. In the absence of epilepsy, the discovery may be fortuitous; It is revealed then by the neuroradiological explorations. These patients generally have no mental retardation or inter-hemispheric disconnection syndrome. Facial malformations are minimal.
CONCLUSION: 
Agenesis of the corpus callosum may be latent and can only be revealed by epilepsy. Regardless of age, the prognosis appears to be related to the associated malformations, which are incriminated in the genesis of epileptic seizures and neuropsychic disorders observed.

Background. Acute exacerbation of chronic obstructive pulmonary disease (COPD) is one of the most common reasons for hospital admissions worldwide. In the last few decades, atmospheric pollution has been identified as a cause of COPD exacerbations, but recent results suggest that adverse health effects of air pollution exist at levels of pollutants around and below the current national and international air quality guidelines and standards. Visits to the emergency respiratory department can be a direct result of short-term exposure to air pollution. The aim of this study was to investigate the short term relationship between air pollution, meteorological variables and the daily number of ED admissions for COPD.

Methods. We conducted an ecological time-series study. Daily records of COPD ED visits for patients older than 30 years were obtained from Clinical hospital Sveti Duh, Croatian teaching hospital, from 1 January 2010 to 31 December 2016. Demographic characteristic, incidence rate of ED, reasons for visit, length of ED stay, factors such as day of week, and season were analyzed retrospectively. Daily measures of ozone (O3), nitrogen dioxide (NO2), carbon monoxide (CO), sulfur dioxide (SO2) and particulate Matter (PM10) were extracted from the Croatian Air Resources Board database.

Results. We enrolled 2553 COPD-related ED visits for the study period (2010-2016), predominantly male 61,1%, mean age 73,94 years. Those aged 65 years or over accounted for 77,84% of all treatment periods with monthly higher deviation in comparison with younger age group. COPD-related ED visits showed a distinct seasonal pattern, in March exceeding the mean monthly average by 18,61%. The monthly figure continued to be above average in the early spring but started to decline markedly during summer. The winter peak in admissions and summer through were seen in both sexes, but the monthly variation was more notable among the man. Analyze the effect of season on recurrent exacerbations, showed 54% of first exacerbations during October to March were followed by a second exacerbation within 8 weeks, whereas during April to September this fraction was 46%. We observed a positive linear association between PM10, SO2, NO2 and CO, and a negative correlation was noted with O3 and temperature. COPD-related ED visits showed significant correlations with primary pollutants, but not with CO. There were also significant correlation with temperature, but not with absolute daily temperature variation or humidity.

Conclusion. The results confirm that air pollution is associated with daily admissions for COPD. We identified a sharp increase in admissions starting in November and peaking in March of the following year. These results indicate that air pollution affects health in a gender- and age-specific manner and should be considered a relevant risk factor that exacerbates COPD in urban environments.

Introduction: It is widely reported that pressure on the NHS has reached an all-time high, with Emergency Departments (ED) particularly stressed. Performance against the government 4 hour breach target is at a 10 year low. Reasons for this include increased service use; patient attendances, and decreased discharges secondary to lack of social care provision. On a practical level, Emergency Departments are increasingly overcrowded due to exit block.

To combat this, AEC (Ambulatory Emergency Care) was developed as a National initiative. St Helens and Knowsley Hospital (STHK) enrolled in cohort 3 in 2013. AEC aims to streamline patient treatment and deliver care on an outpatient basis, avoiding unnecessary admissions overnight.

Together with inpatient specialities STHK ED has developed several pathways to manage conditions traditionally requiring admission. Pathways include dedicated next day radiology slots and speciality review clinic appointments. It is hoped that reduced admissions and optimised patient care will lead to improved flow in the ED.

In July 2016 a clinical area was repurposed to house AEC. A 4 bedded Observation ward bay was transformed into a seated area for 8 patients. This was a dedicated area for AEC, logistically unifying it’s components.  It was envisioned that a space for pathways and staff would further increase efficiency and turnover. To investigate this we audited patient number and space occupancy pre and post AEC.

Method : Retrospective audit of bed space occupancy, total attendances and average length of stay. Results correlated and mapped against departmental attendances and breaches.

Results : Prior to relocation of AEC, average bed occupancy was one patient per 24 hour period, with average though put of 4 patients in 24 hours. Post repurposing and relocation attendances varied from 28 -40 patients in 24 hours, 4.8 patients per space.

Breach impact was calculated as a 5% reduction in numbers of breaches; and was the single most effective intervention at reducing breaches.

Discussion : Often compared to introduction of day case surgery; AEC involves a paradigm shift – “can we deliver the same care at home?” “No patient should spend an unnecessary night in hospital” Our audit shows increased patient throughput, increased flow and improved ED performance. Of note, is that the audit was performed when AEC ran between 0900- 1700, a fully running 24 hour service is likely to yield greater results. Our aim is to further develop this service and repeat our audit.

Background: Amyand hernia is defined as the presence of normal or inflamed appendix vermiformis within hernia sac and constitutes 1% of all inguinal hernias. Most of the cases have right side clinic. Left sided Amyand’s hernia is even less common.

Case:A sixtysix year old male patient was admitted to our clinic with a 2-year history of swelling in the left groin and acute pain, nausea and vomiting during the last 3 hours. There was nonreducible inguinal hernia in the left inguinal region on his physical examination. There was no systemic finding other than rhonchi in lungs with a medical history of COPD. He didn’t also have any operation history. Serum laboratory values were unremarkable with normal range leukocyte count WBC: 9300/mm3. He was taken to urgent surgical exploration. In the operating room, the indirect herni sac descending to scrotum was explored. Vermiform appendix, cecum, and some small intestine segments, which form part of the sac wall were observed in the hernial sac (Figure 1 and 2). Appendectomy was performed and then hernia defect was repaired with prolen mesh by Lichtenstein method. After postoperative care, the patient was discharged for outpatient follow-up.

Discussion: Amyand’s hernia is diagnosed during surgery in patients admitted to emergency departments and general surgery clinics with a pre-diagnosis of incarcerated inguinal hernia. By reporting a case that was hospitalized and underwent to urgent surgery due to left-sided incarcerated inguinal hernia from our emergency department and surgically detecting acute appendicitis in the hernial sac, we aimed to remind the diagnosis of Amyand’s hernia which is a very rare clinical entity in the literature.

Conclusion:Amyand’s hernia is a very rare presentation of appendicitis and correct preoperative diagnosed is almost impossible for it.  

Introduction: - Tracheobronchial injury (TBI) can result from non-penetrating or penetrating trauma. Tracheal disruption is a rare occurrence and is seen in 14% of the penetrating neck and chest trauma cases and 0.34-1.5% of all blunt trauma cases including adults and children. In 8% of the injuries, the lesions are complex occurring in more than one location, with more than one type of lesion or on both of the main bronchi and trachea. Of the patients who die of TBI, most of them do so before receiving emergency care either due to airway obstruction, exsanguination, or from injuries to other vital organs. Mortality among survivors who reach the hospital may be as high as 30%. We report a case of 24 years old male surviving such an injury.

Case report: - An, otherwise, healthy 24 years old male presented after sustaining an accidental injury while operating heavy machinery at work place. He was primarily treated outside and had an endotracheal tube in situ. There was an open chest wound near right axilla on chest and avulsion injury over frontal scalp. Patient was hemodynamically unstable. His heart rate was 145 beats per minute, respiratory rate of 40 cycles per minute, SpO₂ of 57% with O₂ at 15 liters per minute and blood pressure of 102/62 mmHg. Patient had impaired mental status. There was extensive subcutaneous emphysema extending from neck up to lower abdomen. After initial primary treatment patient had undergone computed tomography of head to abdomen which was suggestive of discontinuity involving right main bronchus from its origin for a length of approximately 3cm with rent of 6.7mm in trachea, left sided moderate pneumothorax and right sided marked hemopneumothorax with complete collapse of right lung and left lung contusions, pneumomediastinum, pneumopericardium, pneumoperitoneum, multiple rib fractures of right and left side, multiple facial bone fractures, bilateral clavicle fractures. Management included bilateral intercostal drainage in emergency department. Bronchoscopy guided one lung ventilation to left lung followed by surgical repair in form of right thoracotomy with re-implantation of right main bronchus to carina was performed. No obvious air leak noted after switching on to normal double lung ventilation. Patient’s stay in hospital was uneventful and discharged after 28 days

Discussion: -  Tracheobronchial injury appears to occur approximately in 2-9% of individuals sustaining penetrating injuries. In terms of clinical manifestations, hemorrhagic shock with systolic blood pressure less than 80 mmHg and heart rate more than 120 beats/min are best predictors for poor outcome. Hypoxemia is shown not to be a poor prognostic factor. Paramount in managing suspected partial tracheal transections is to avoid converting the injury to a complete transection. Positive pressure ventilation or an unguided placement of a large-bore tracheal tube can complete a partial tracheal transection. 

Background: Upper gastro-intestinal bleeding (UGIB) is a majorly urgent medical condition involving the upper digestive tract up to Treiz’s angle, usually expressed through melena and/or haematemesis. The main causes for UGIB are gastric ulcer and duodenal ulcer, these two disorders being responsible for around 70% of the total UGIB cases. Gastritis, on the other side, presents a relatively low risk of bleeding, around 15%, rarely life-threatening. Esophageal pathologies (like esophageal cancers, diverticular diseases, esophageal erosions) and hiatal hernia represent just around 2% of all UGIB, whereas liver cirrhosis complicated by esophageal varices raises the percentage to 15-17%. Mallory-Weiss syndrome consists of just 3% of the cases, while gastric tumors around 5% of the total upper gastrointestinal bleedings. There are also atypical cases of UGIB like our patient, R.I., aged 66, accusing an acute episode of abundant UGIB, complicated by septic shock, in association to post-chemotherapy medullary aplasia related to malignant small B-cell non-Hodgkin’s lymphoma.

Methods: This is a retrospective clinical case study from 2015, involving a patient presenting, amid immunosuppressive background pathologies, namely small B-cell non-Hodgkin’s lymphoma CD20+ follicular I/IInd degree, diagnosed on the 3^rd of June 2014 through left laterocervical lymph node biopsy, septic shock from Klebsiella pneumoniae, complicated by an abundant episode of UGIB – most probably stress-related, the contributory factor being severe thrombocytopenia, of 2000 thr/mm3. The patient was admitted to the Clinical Emergency County Hospital of Sibiu, considered in critical state and received emergency treatment aimed towards stabilizing his general condition. The therapy, which included sodium bicarbonate administration on the nasogastric tube in parallel to famotidine, intravenously, for the first few hours, was essential, because the pH of the gastric lumen tends to decrease below 4. If this happens, the hemorrhage reappears, due to dissolution of the thrombi.

Results: The blood samples collected during the UGIB episode revealed 2000 thr/mm3 (n.r. 150,000-400,000/mm3), hemoglobin of 9.3 g/dl (n.r. 13-16 g/dl), hematocrit of 28.1% (n.r. 37-47%), SBP - 70 mmHg. Following thrombocyte and erythrocyte mass transfusion, sodium bicarbonate and famotidine administration through the nasogastric tube, the blood parameters of the patient have known positive modifications as follows: thrombocytes – 22,000/mm3, Hb – 10.7 g/dl, SBP 120 mmHg, whilst the bleeding was stopped.

Discussions: Although patients with primary or recurrent UGIB are usually known with chronic gastrointestinal pathologies (of the esophagus, stomach or duodena), and/or decompensated liver cirrhosis, other atypical life-threatening situations may occur, worthy of being taken into account, just like the one presented afore.

Background:

Epidural Abscess (EA) is an uncommon disease with a wide variety of clinical presentations. The disease's triad of back pain, fever and neurological deficits is seldom present. EA incidence has has risen from 0.2/10,000 to 3/10,000 in the United States, but it is still missed diagnosed in 75% of cases during the first medical encounter. The delay in diagnosis and treatment leads to permanent neurological damage and increases mortality from 2-20%. 

Case Description:

We present the case of a 35 -year-old diabetic male who walks into Emergency Department (ED) with 1 week of worsening chest pain with associated palpitations. He also reported sporadical  back discomfort that irradiated from chest onto trapezius. Patient denied fever, chills, weakness, urinary difficulty or any other classic symptoms that would suggest EA.

Clinical Findings:

Physical examination was remarkable for tachycardia of 115 beat per minute without fever. All labs, chest X-Ray, bedside cardiac sonogram and chest CT Angiogram were normal. Tachycardia nor chest pain improved after analgesia or IV hydration. Patient was consulted due to intractable symptoms, eventually being discharged after unremarkable observation period. He was admitted 2 days later for, when he returned with initial complains in addition to jaundice. On day 4 of admission patient developed lower extremity weakness and urinary retention.Thoracic  Magnetic Resonance Imaging (MRI) showed T3-T8 EA. Patient was managed medically due to extent of irreversible damage.

Conclusion:

This patient had a rare presentation of EA since chest pain and tachycardia were the predominant signs and symptoms. These are not widely described in the literature as initial complains. Increased awareness is essential for rapid diagnosis, especially when other more common diagnosis are excluded. Erythrocyte sedimentation rate (ESR) is the only laboratory consistently found elevated. It is increased in 95% of cases, therefore while unspecific, it is clinically useful. Emergency physician can use ESR and CT myelogram in settings where MRI is not available. This, plus awareness of such challenging diagnosis can decrease its catastrophic consequences.

Background: Acute urinary retention is the inability to voluntary pass urine. It is a common urological emergency seen in the emergency department. Affected patients often present in distress and discomfort. Patients with suspected acute urinary retention have a bladder scan performed to confirm the diagnosis. A volume of 300ml or greater with inability to void suggests urinary retention. The STHK trust KPI for management of acute urinary retention aims for 90% of patients to be catheterised within 1 hour of triage. The emergency ambulatory care unit (AEC) is an area of the emergency department in which patients identified matching a certain criteria can be sent straight from triage to be seen by a nurse and doctor team. Acute urinary retention is one of the selected cases seen in AEC.

Method: Retrospective audit of patients attending AEC with acute urinary retention over a 3 month period. Searched electronic case notes to determine time to catheterisation against the time of arrival to AEC. Obtained data from electronic database for patients attending the emergency department with the inability to pass urine over a one month period prior to the opening of the AEC. Searched electronic case notes to find the times of triage and catheterisation.  

Results: 15 patients attended the emergency department with inability to pass urine in January 2016 prior to the opening of AEC. 40% of these patients were catheterised within 1 hour of triage. 20 patients attended AEC over a three month period in acute urinary retention. 55% of these patients were catheterised within 1 hour of their arrival on AEC, only 1 patient required admission, discharge rate of 95%.

Discussion: Acute urinary retention is a common presentation to the emergency department. The hospital KPI is to catheterise these patients within 1 hour of triage. Unfortunately this target has not been met on review of this audit, however there was some improvement toward this target seen with the introduction of the AEC. Delays to this target are often a result of a busy department in which problems arise from space to see patients, longer waiting times and engaged use of the bladder ultrasound to confirm diagnosis of patients. The AEC department aims to reduce this problems with a more stream line approach to patient with acute urinary retention, once more established in the trust the target of 90% of patients catheterised within an hour of triage should be met. Changes that can be implied to help achieve this target is for greater awareness and education of the usage of AEC, ideally the addition of a new bladder ultrasound machine designated to the either the triage or ambulatory care area therefore allowing quicker identification of urinary retention, the addition of a second triage nurse in triage will allow for these patients to be identified and assessed more quickly, the presence of a doctor on AEC for 24hr period (currently 12rs covered). We aim to re-audit once all these measure are in place.

Background:

Since venous thromboembolism (VTE) disease is a life-threatening medical condition requiring urgent evaluation and treatment, this is the first clinical audit to evaluate adherence of clinicians to international guidelines for antithrombotic therapy for VTE disease.

Methods:

This was a retrospective clinical audit conducted from January to December 2016. Files of patients admitted to European Gaza Hospital and Al-Shifaa Hospital were reviewed and compared to the standard of the American College of Chest Physicians (ACCP) Guidelines 2016.

Results:

In total, 95 cases were identified.  The mean age was 44 ±17 years and that of duration of hospitalization was 6 ± 3 days.  Interestingly, 43% of patients were males and almost half of the patients (n=46) had no co-morbidities. We were able to identify 10 different categories of VTE.
Proximal deep vein thrombosis (DVT) was the most frequent category (46.3%). Over 80% of patients with proximal DVT were treated with extended therapy (no scheduled stop date) using vitamin K antagonists (VKA). Half of these patients were not switched to aspirin after 3 months of anticoagulation therapy as indicated in the ACCP guidelines and none of them was tested for D-dimer level after 1 month of stopping the anticoagulant. Recurrent VTE on VKA or novel oral anticoagulants (NOAC) was the second most frequent category with 20% (n=19). Surprisingly, 18 of these 19 cases were continued on extended therapy using a higher dose of VKA rather than being switched, even temporarily, to low molecular weight heparin (LMWH) as suggested by ACCP guidelines while only 1 case was switched.  Cancer-associated thrombosis was the third most common category (6.3%). All patients in this category were treated with extended therapy using VKA rather than LMWH as suggested. Other categories identified were similar in terms of deviating from the guidelines and choosing the anticoagulant.
Among all cases who received extended therapy, only 48.4% were reassessed for continuing use of treatment at periodic intervals. However, 3.2% used compression stockings, which are not suggested.

Discussion:

The results of this audit reflect the fact that the antithrombotic therapy for VTE does not comply with the standards of the ACCP guidelines. This could be attributed to the shortage of NOAC and unaffordability of LMWH at governmental hospitals. Another reason is the lack of local guidelines and awareness of the international guidelines. Furthermore, the poor documentation system causes loss of data and physician orders which in turn causes less compliance from the patients and deviation from the standards and guidelines. Therefore, there is an urgent need for the development of local guidelines as well as promotion of knowledge of evidence-based practice among clinicians. In addition, an improvement of the current documentation system should be implemented as soon as possible to facilitate the process of evaluating the clinical practice in future.

Background:

Acute heart failure (AHF) is a life-threatening medical condition requiring urgent evaluation and treatment.  This is the first clinical audit to evaluate the adherence of clinicians to international guidelines for management of AHF.

Methods:

This was a retrospective clinical audit conducted from January to December 2016. Two-hundred files of patients admitted to Nasser Hospital (n=74) and Al-Shifaa Hospital (n=126) were reviewed and compared to the European Society of Cardiology (ESC) Guidelines 2016.

Results:

The mean age of our sample was 66 ± 13 years. Fifty percent of patients were females and 96% had co-morbidities including hypertension, DM and heart disease. Shockingly vital signs were poorly documented (51% temperature, 59% pulse rate, 71.5% respiratory rate and 13% blood pressure) and SpO₂ in only 69.5%. From the available data, at time of presentation, 40% had a high blood pressure, 37.7% had an SpO₂ < 90%, 50.5% were anemic and 33% had leukocytosis. ECG, chest x-ray and echocardiography were done in 94.5%, 48.5% and 45%, respectively. Creatinine and urea levels were obtained in 93.5% and 89% with elevated values observed in 45.5% and 96.6%, respectively. Electrolytes (Na⁺ and K⁺) were measured in 63% of cases, glucose level in 88% but only 10% had arterial blood gases measured and 2.5% TSH level. It was found that 21.4% had hyperkalemia and 77.3% had hyperglycemia. Cardiac troponins were only done in 5.5% while 66.5% of patients had CKMB measured and BNP level wasn’t utilized at all. Although 37.7% of patients had an SpO₂ < 90%, it was surprising that only 12.5% received oxygen therapy. Intravenous furosemide was used in 69% and opiates were only administered to 30%. Vasodilators were given to 46.5% where systolic blood pressure was > 90 mmHg in 89.1% of them. Beta blockers (BB) were used in 57% (70.2% bisoprolol, 29.8% carvedilol). It was noted that BB were given to 2 hypotensive patients, which is not consistent with ESC guidelines. Digoxin 0.25 mg was given in 28.5% of which 53.4% had atrial fibrillation. Venous thromboembolism prophylaxis was administered to 70%.

Discussion:

The results of this audit reflect the fact that the management of AHF does not comply with the ESC guidelines. This could be attributed to the lack of local guidelines and unawareness of international guidelines. Furthermore, the poor medical record and registry systems cause loss of data and physician orders which in turn causes more deviation from the recommended guidelines. Therefore, there is an urgent need for the development of local guidelines as well as promotion of knowledge of evidence-based practice among clinicians. In addition, the current documentation system should be improved as soon as possible to facilitate the process of evaluating the clinical practice in future.

Background:

Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year. Since early identification and appropriate management in the initial hours after sepsis develops improves outcomes, adherence to clinical guidelines is very important.  This audit assesses the guideline adherence by physicians in the Gaza-Strip (GS) for management of sepsis and septic shock.

Methods:

This was a prospective clinical audit conducted in the medical departments of three of the GS hospitals from January to March 2017 according to surviving sepsis campaign (SSC) guidelines for management of sepsis and septic shock (2017).

Results:

In total, 70 cases were identified. The mean age was 75 ± 12 years and the mean duration of hospitalization was 7 ± 6 days.  Seventy percent were females and 88.6% of patients had co-morbidities with 19.4% having all of hypertension, diabetes and past stroke. It was noted that 25.7% had a breach of skin integrity as a risk factor for sepsis.
Starting intravenous (IV) antimicrobial therapy within the first hour was achieved in 89% of cases; however, requesting blood cultures was not done at all. In contrast, 4.3% had their blood cultures withdrawn within the first 3 hours and 28.6% received 30ml/kg crystalloid fluids. A specific anatomical diagnosis to control infection in the first 12 hours was made in 71.4%. Both of administering initial empiric therapy and daily reassessment of antimicrobial regimen were done in all cases. Combination empirical therapy was given to 72.9%. About 54% received therapy for longer than 10 days. Only 8.6% had selective oral decontamination using nystatin. Surprisingly, 18.6% did not receive crystalloids for resuscitation which were indicated. Only 2 cases (2.8%) had vasopressors, of which one was administered dopamine which should be avoided. Corticosteroids were administered in the absence of shock in 5.7%. A target of ≤ 180 mg/dL for blood glucose level was achieved in 72.9%, but before obtaining this target, its value was monitored every 4 hours only in 8.6%. Stress ulcer and deep vein thrombosis prophylaxis were given in 92.9% and 78.5%, respectively.

Discussion:

The results of this audit reflect the fact that the current practice for management of sepsis and septic shock doesn’t comply with the SSC guidelines. This could be explained by the lack of local guidelines and poor knowledge of international standards. Furthermore, the shortage of some laboratory tests (blood cultures and lactate level) may affect the clinical practice and the overall adherence to guidelines. Despite the fact that management of sepsis should be guided by lactate level, it was not done due to its unavailability in the GS hospitals. Therefore, there is an urgent need for developing local guidelines as well as promoting awareness and knowledge of evidence-based practice among clinicians and making key tests available to clinicians in the GS.

Introduction

Regardless of the recent advances in cardiopulmonary resuscitation and post-resuscitation care, most out-of-hospital cardiac arrest (OHCA) patients admitted to the Intensive Care Unit (ICU) decease due to post-anoxic neurological injury. Changes in carbon dioxide (CO₂) increase the cerebral blood flow due to its vasodilating effect.

The aim of the study was to determine at what time interval the partial pressure of carbon dioxide in arterial blood (PaCO₂) should be measured ideally in the post-resuscitation care setting in order to capture significant changes.

Methods

A prospective observational study was performed in 108 patients, successfully resuscitated from OHCA, and treated with Targeted Temperature Management (24 hours at 33°C, followed by 12 hours rewarming at 0.3°C/h). Following admission at the ICU, an hourly blood gas analysis was performed during the first 48 hours. Ventilation was adjusted to maintain mild hypocapnia (PaCO₂ between 32 and 38 mmHg; pH stat approach). A delta PaCO₂ was calculated with an interval of four hours (D₄PaCO₂) in order to capture significant differences in PaCO₂ values over time. A Two-Way Anova with Bonferroni post-hoc analysis was performed to investigate whether the calculated delta PaCO₂ values were different over time and between outcome groups. Outcome was assessed at 180 days post-CA using the Cerebral Performance Category (CPC) scale (CPC1-2: good neurological outcome and CPC3-5: poor neurological outcome).

Results

While 50 patients (46%) survived with a good neurological outcome at 180 days post-CA, 58 patients (54%) had a CPC score of 5. In total, twelve delta PaCO₂ values were calculated over the first 48 hours after ICU admission. The calculated D₄PaCO₂ values were not different between patients with a good and poor neurological outcome (p=0.719). A significant time effect was present with respect to the calculated delta PaCO₂ values (p<0.001). The first D₄PaCO₂ value (H5-H1) was significantly different from all subsequently calculated delta PaCO₂ values (p<0.05), while the second D₄PaCO₂ value (H9-H5) was only significantly different from the first (H5-H1) and third D₄PaCO₂ value (H13-H9) (p=0.019 and p=0.047, respectively). No significant changes in delta PaCO₂ values were measured twelve hours after ICU admission (p>0.05).

Conclusion

Our study suggests the need for an hourly assessment of PaCO₂ during the first twelve hours after ICU admission for all OHCA patients treated with TTM at 33°C. Hereafter, a measurement of PaCO₂ every four hours is sufficient to capture relevant changes in PaCO₂ in hemodynamic stable patients.

A 31-year-old man was referred to the emergency room for acute abdominal pain and vomiting associated with psychomotor agitation.

He deny ingestion of alcohol or other toxins. Afebril at all times. No diarrhea, rectal bleeding or melena. No respiratory or urinary symptoms.

His relatives explain similar previous episodes in the last 6 months, all assessed and studied in the emergency room without an etiological diagnosis, and they añso denied any family epidemic environment.

On examination: afebrile and hemodynamically stable, agitated by pain, with soft abdomen, depressive, diffuse pain, abdominal noises present, no masses or megaly palpation, no pain in back renal zones.

Pain control with morphine is required.

Initial results =

1) ECG: sinus rhythm at 75lpm, heart axis at + 60º, PR <200ms constant, QRS <120ms correct morphology, no acute alterations of repolarization.

2) GSA (aa): pH 7.54 mmHg, pCO2 26mmHg, pO2 87mmHg, HCO3- 25.8mEq / l, lactic 1.87mmol / l, Na 135, K 3.1, Cl 104, Ca 4.75, glucose 151

3) Analytical: no leukocytosis. Hemoglobin, coagulation, renal function, ions, hepatic profile and amylase without notable alterations

4) Ethanol: negative

5) Urinary sample: no alterations

6) Toxics in urine: negative

7) Rx thorax: no condensations, no pleural effusion, no pneumothorax.

The results of initial tests were anodyne, likewise  the acute abdominal pain persist ... and the pacient explain previously similar episodes, it was decided to study urinary porphyria = 

porphobilinogen urgent for the diagnosis of porphyria crisis and abdominal CT scan. 

Abdominal-pelvic CT with contrast & complete abdominal ultrasonography (including renal): findings suggestive of enteritis secondary to intestinal infestation by parasites (to rule out Ascaris lumbricoides).

After assessing results of images with radiology equipment, the case is oriented as an enteritis secondary to intestinal infestation by parasites (to rule out Ascaris lumbricoides in stool samples, wich are taken for microbiology. Empirical treatment with Mebendazole.

 A. lumbricoides infects over 1 billion people; despite not being frequent in Europe, it has to be take into account when the most common causes have been discarded.

Self-poisoning with plant seeds or fruits is a common method of self-harm in South Asia and India, but uncommon in Europe. Cerbera odollam is a dicotyledonous angiosperm, a plant species in the Family Apocynaceae and known by a number of vernacular names depending on the region. The kernels of Cerbera odollam contain cerberin, a potent cardenolide glycoside belonging to the cardiac glycoside family of toxins that includes digoxin. We present the case of a 25-year-old man with a history of depression presented to the ED with abdominal pain accompanied by nausea and vomiting, blurred vision and diplopia. Upon further questioning in the ED, the patient admitted the intentional ingestion of two seeds of Cerbera odollam that he purchased from an online website. An electrocardiogram demonstrated first degree AV block, diffuse ST-segment depressions. He quickly became bradycardic and developed second degree AV block and afterwards third degree AV block. Repeated administration of digoxin immune Fab determined normalization of ECG abnormalities. The patient recovered was uneventfully and was later discharged in stable condition after 5 days in hospital. In conclusion, we report the first described case of cardiac glycoside toxicity in Romania due to self-poisoning with Cerbera odollam seeds. The ECGs for this case depicted the evolution of classic dysrhythmias, morphologic features, and electrolyte abnormalities associated with severe cardiac glycoside toxicity.

Pneumocephalus is defined as an intracranial gas collection. Trauma is the most common cause of pneumocephalus (75-90%), but it may also be caused by infection, barotrauma following scuba diving and surgery involving the sinuses, orbit, nasal passages or intracranial space. We present the case of a 57-years-old man with severe head trauma, secondary to a road traffic accident, brought by ambulance in ED with altered mental status. On physical examination, the patient was agitated, confused, GCS of 7/15. An immediate brain computed tomography scan showed a basal skull fracture with massive pneumocephalus and pneumorrhachis, subdural hematoma without compressive effects. The patient was treated conservatively with a favorable outcome, complete neurologic recovery, without complications and was discharged after 11 days.

Background

Primary survey plays an essential role in the initial assessment of major trauma patients by identifying life-threatening injuries and initiating simultaneous resuscitation. Once completed, secondary survey can start along with radiological imaging as dictated by the primary examination findings.

Case

A 34-year-old female was brought in as a major trauma to our emergency department (ED) after being involved in a road traffic collision. She lost control of her car at 70 mph (113kmph), hitting the central reservation before squashing her car against a tree. She was wearing a seatbelt and the airbags were deployed.

On arrival to the ED, she was haemodynamically stable and her Glasgow coma score (GCS) was 12. The primary survey revealed facial and neck wounds, obvious deformity of the right wrist and swelling to the left knee.  A whole-body CT scan followed the primary survey and showed undisplaced fractures of the lateral aspect of the right 11^th and 12^th ribs, and a separation of the 9^th and 10^th ribs likely to be secondary to trauma. Through the separation there was a narrow necked hernia sac, containing the hepatic flexure, with the possibility of strangulation. This finding was in keeping with a Grynfeltt-Lesshaft hernia.

The patient underwent urgent surgical repair of the hernia and fixation of the ribs fractures.

Discussion

Abdominal hernias can be classified by location, content or aetiology. Our case would be regarded as a lumbar hernia which accounts for 2% of all reported abdominal hernias.

Anatomically the lumbar region is defined by the base of the 12^th rib, the crest of the ilium, the external oblique muscle and erector spinae muscles. This area is then divided into the superior (Grynfeltt-Lesshaft) and inferior (Petit) triangles. The boundaries of the superior triangle are: lower border of the 12^th rib, internal oblique and quadratus lumborum muscles. An inherent weakness is present in the superior triangle, compared to the inferior, due to the thin aponeurosis, and transiting nerves and vessels, within the floor. This makes hernias in the Grynfeltt-Lesshaft region more common than Petit’s hernias, although both are relatively rare.

In our case, it is a possibility the protective effect of the seatbelt might have contributed to the formation of this lumbar hernia by increasing the intra- abdominal pressure.

Complications of abdominal hernias include bowel obstruction, incarceration and strangulation. The risk of strangulation, and the tendency for these hernias to increase in size, makes surgical repair preferable to conservative management. The benefit of open versus laparoscopic repair remains contentious and the use use of mesh is a popular choice.

Conclusion

CT imaging is useful in the secondary survey and management planning of major trauma patients. It highlights pathologies with little physical signs, which are therefore hard to pick up on during the primary survey.

INTRODUCTION:

DRESS (drug rash with eosinophilia and systemic symptoms) syndrome is characterized by rash, fevers, eosinophilia, lymphadenopathy, and systemic organ involvement. We report a case of DRESS syndrome caused by colchicine.

CASE REPORT:

A 67-year-old woman presented in April 2017 with an acute gout attack (first episode).  Colchicine was started .Two weeks after, the patient noticed diffuse itching, worsening from day to day. A generalized rash , face oedema and  fever appeared a few days later. Blood examination revealed moderate eosinophilia (7%) and hepatic failure (including cholestatic jaundice and cytolysis) , renal failure and metabolic acidosis. Additional investigations: Viral serologies were negative for cytomegalovirus, rubella, hepatitis B and C and  HIV . Thyroid function was normal. Abdominal echography and chest radiographs were normal.  All medications were stopped and  oral corticosteroid treatment was started. The  symptoms resolved and laboratory data normalized after 7 weeks. The diagnosis of drug rash with eosinophilia and systemic symptoms (DRESS) induced by colchicine was made.

CONCLUSION :

In conclusion, colchicine can be added to the list of drugs inducing DRESS syndrome. Pathogenesis is unknown, but may involve drug detoxifying pathways and accumulation of reactive metabolites.

Ethylene glycol is an alcohol found in many household products, odorless, colorless, and sweet in taste it is  frequently ingested by children, animals and in suicide purposes.

We present the case of an 57 old femele.  With a medical history significant for hypertension, diabetes  presented in the ED with slurred speech, dizziness, the lacking of coordination and nausea   On presentation, the patient was afebrile,GCS =15P,  BP=160/95, tachycardic, and tachypneic. Pulse oximetry showed a hemoglobin saturation of 98% on room air. Physical exam findings were normal except for nistagmus, dysarthria, Romberg+. The diagnosis seemed obvious - vertebrobasilar stroke.

 Her blood profile was normal, head CT was negative,  however, a point-of-care arterial blood gas revealed a Ph=7,25, Pco2=28, serum bicarbonate of 14mmoli/l, lactic acid=171mg/dl.

 The patient strongly deny any toxic ingestion, and we made a thorough investigation into the cause of this perceived severe lactic acidosis was undertaken and no clear etiology was identified. There was no evidence of sepsis (PCR=2,8 mg/L),. Furthermore, there were no signs of gangrenous tissue and surgical and radiological evaluations were negative for ischemic bowel or incarcerated hernia.

This was the moment when we returned to the patient and his family The patient and her family deny once again any ingestion of toxic substance. Then I sent her family home to bring us all the medications and syrups the patient had ingested in the last week. When they returned, they realized that ,accidentally, the patient consumed instead of pumpkin syrup – antifreeze.

During this time treatment was initiated, and after several fluid boluses and sodium bicarbonate administration, the acidosis and lactate levels  improve. The patient was admitted , with a favorable outcome, with renal function preserved. The patient was lucky to have ingested a small amount of antifreeze, and he quickly came to the hospital at the onset of the first symptoms.

The symptoms for which the patient came to the ER are very common, and we often have a tendency to jump quickly with a diagnosis, this case taught me that not everything is what it looks like and we must always go over all differential diagnostics, you never know when pumpkin syrup is actually antifreeze!

Tapeworm Echinococcus granulosus is a common cause of hydatid disease, but the association between hydatid disease and jaundice is unusual. Obstructive jaundice associated with hydatid disease may occur in 3 ways: obstruction of bile ducts by intrahepatic cysts, rupture of cysts into the bile ducts, and extrinsic compression of bile ducts by a hydatid cyst. We present the case of a 49-years old female who presented to the emergency department with a five day history of jaundice and dark urine. Laboratory tests demonstrated bilirubinemia, and ultrasound showed a cystic image in the right hepatic lobe. Contrast-enhanced computed tomography (CECT), magnetic resonance imaging (MRI) and MR cholangiopancreatography (MRCP) showed a hydatid cyst in the right hepatic lobe without communication with the ducts. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) after MRCP confirmed the absence of hydatid material in the main bile duct and lack of communication with hydatid cyst. The patient was treated with albendazole, followed by surgical intervention. Postoperative evolution was favourable with no complications and the patient was discharged after 10 days.

An Unusual Case of Post- Traumatic Facial Nerve Palsy

Rana J H Hussein, MBBS, MRCEM, CABEM; Muhammed Ershad, MBBS, MRCEM

INTRODUCTION

Trauma accounts for 19% of facial nerve palsy in children. It is more common in girls than boys. Children from 2 to 8 years are most effected.

We report an unusual case of unilateral facial nerve palsy in a child after minor head trauma.

CASE REPORT

2 year old female child presented by her mother for mouth deviation after a fall, one day ago. The child slipped and hit her forehead on the floor. There was no loss of conscious, no vomiting, and no seizures. But the mother noticed the child’s mouth deviated to the right, after one hour of the fall.She had no flu or ear pain . No past history of diseases. Examination: patient was conscious, playful. CNS exam showed inability to close the right eye ,mouth deviated to the right, no wrinkles on the right forehead, localized small swelling, bruise on the forehead. No signs of basal skull fracture,systemic  examination was normal.

CT head reported no skull bone fractures, but a small subgleal hematoma was noted in the frontal region.

The pediatric and ENT surgeons, advised discharge with lubricant eye drops, only. After six weeks, the child was followed up in the clinic.The facial nerve palsy totally resolved.

DISCUSSION

Post-traumatic facial nerve palsy is evident with direct trauma to the ear, or head injury. Usually there is basal or temporal bone fracture. The pathophysiology of facial nerve palsy is either direct laceration to the nerve or edema of the facial nerve due to compression.Within 3 months, 90% of cases resolve with steroids

CONCLUSION

Post traumatic facial nerve palsy can happen in children with no skull bone fractures and can be managed conservatively, without the use of steroids.Spontaneous resolution  can be within six weeks. In pediatrics, consider non accidental injuries , in post traumatic facial nerve injury.

REFERENCES:

1-www.uptodate.com

2-Head injury with sudden onset bilateral facial palsy-can happen without temporal bone fracture and brain injury. Egyptian journal of ENT and allied sciences. Vol 17, issue march 2016

Santosh Kumar sawan, Ishwar Chandra behera, Mahesh Chandra Sahu

3- Post traumatic bilateral facial nerve paralysis associated with temporal bone fracture. J Coll Physicians Surg Pak 2015 Suppl 2: S132-3. Doi: 10 2015/JCPSP. S132133

Habib SS,Al Rouq F,Meo I

4- Clinical features of outcomes of delayed facial palsy after head trauma. Auris Nasus Larynx. 2016 Oct, 43(5). 514-7. Doi: 10. 2016/j.anl 2015.12.017.Epub 2016 Feb 1.

Li Q,Jia Y, Feng Q, Tang B,Wei N, Zhang Y, Li Y , Zhang X

5-Facial nerve palsy after head injury: case incidence, causes, clinical profile and outcome.

Department of neurosurgery, college of Medicine, university of Ilorin, PMB1515, Nigeria

Jtrauma 2006, August 61(2):388-91

Introduction:

Salmonella species are facultative intracellular pathogens that most frequently cause self-limiting gastrointestinal disease, often acquired through the ingestion of contaminated food. Gastro-enteritis is the main clinical aspect of salmonellosis which is becoming more frequent. Extra-digestive manifestations, less frequent, affecting usually patients at risk, must be recognized. Different localizations of infection are possible. Some can be severe and fatal. The possibility of salmonella sepsis must be considered when immunodepressed patients have fever and no obvious source of infection.

Case Report :

We reported the case of a patient aged 45 years old. She had a charged medical history, in fact, she is diabetic and she is treated for Takayaschu pathology by Methotrexate and corticoid. She was hospitalized for gastroenteritis salmonella four months ago, also another time one month ago for urine infection from salmonella treated with intravenous antibiotic. She returns for fever.

On physical examination revealed patient with fever: 38, 5. She was conscious, glycemia was correct, her blood pressure was normal. The abdominal examination revealed lower right quadrant tenderness.

Biological test show: normal glycemia, renal failure with clearance of creatinine at 20 ml/min. CRP level was 235 mg/dl. Urine culture and blood culture was positive in salmonella enteritidis .She was immediately given Ceftazidime.

12 hours later, the patient developed a septic shock .She become confused, with an hypotension, anuria and respiratory distress. She required an endotracheal intubation and mechanical ventilation and she was charged to the intensive care unit. Multiorgan failure occurred rapidly leading to death in 24 hours.

 Conclusion :

Salmonella can produce bacteremia and disseminated disease. The sever form can be fatal especially in immunodepressed patients.

Case Report

A 38-year-old male presented to our emergency department (ED) with sudden onset of intermittent abdominal pain in the right upper quadrant. Besides obesity (BMI of 34), he had no previous medical history. His vital signs were a heart rate of 120 per minute, blood pressure of 154/77 mmHg and temperature of 36.7°C. Physical examination revealed right upper quadrant pain on palpation with rebound tenderness and positive Murphy’s sign. Laboratory findings showed mildly elevated inflammatory parameters with C-reactive protein of 70 mg/L (normal range <3 mg/L) and white blood cell count of 11.6 x10⁹/L (normal range 4.3-10.0 x 10⁹/L). Ultrasound of the abdomen revealed a normal gallbladder without signs of cholecystitis. The tentative diagnosis of cholecystitis remained and the patient was admitted for observation. He was discharged the next day because of spontaneous resolution of the symptoms. One day later he represented to our ED with similar symptoms. A computed tomography (CT) of the abdomen was performed and revealed an omental infarction. The patient was treated conservatively and made a full recovery. He was discharged three days later.

Discussion

Omental infarction is a rare cause of acute abdominal pain, mimicking acute appendicitis, cholecystitis and other intra-abdominal emergencies. The clinical presentation is atypical, with a subacute onset of severe abdominal pain and signs of peritonitis. Approximately 400 cases have been reported, of which 85% in adults, most frequently in the age group of 40-50 years and twice more common in males. Leitner et al. classified omental infarction into primary and secondary types. Secondary infarction can be induced by omental torsion, thrombosis due to hypercoagulopathy or vascular malformations. When no clear etiology is found, omental infarction is called primary or idiopathic and these cases may be related to obesity and local trauma.

Diagnosis can be established by CT scan. Usually, a large triangular or oval-shaped encapsulated fatty mass interspersed with areas of hyperattenuating streaky infiltration is found. These findings are virtually pathognomonic for omental infarction. Yet a significant number of patients are still diagnosed intra-operatively. Ultrasound is less useful as it may not distinguish infarcted fatty lesions from normal intra-abdominal fat.

Because of the self-limiting course of this disease, conservative treatment with analgesics and anti-inflammatory drugs is recommended. However, persistent pain and complications such as intestinal obstruction and abscess formation have been reported. In these cases, surgical treatment may be required.

Conclusion

Omental infarction is easily mistaken and should be considered in the differential diagnosis of acute abdomen. CT scan of the abdomen confirms the diagnosis. The typical course is self-limiting and therefore a conservative approach is recommended. In cases of persistent pain or progressive peritonitis, surgery may be required.

Miliary tuberculosis (TB) is a potentially lethal disease if misdiagnosed or left untreated. We present a case of a 58-year-old man complaining of left arm pain and swelling, coughing, dyspnoea and malaise. His past medical history included left arm trauma two years prior. The patient was abusing alcohol. On admission the patient was pale and cachexic with a blood pressure of 110/60 mmHg. Auscultation of the lungs was not conclusive; some fine crackles were audible bilateraly. Physical examination revealed left upper arm deformity and swelling of the soft tissue, tenderness on palpitation, lack of movement in left shoulder and elbow, bilateral leg weakness. Laboratory tests revealed a slightly elevated white blood count,  decreased hemoglobin of 81 g/l, CRP of 212,6 mg/l, slightly elevated ionized Calcium level of 1,64 mmol/l. Plain radiograph of the left shoulder showed bone destruction of proximal humerus. The chest radiograph showed a bilateral micronodular interstitial pattern indicative of miliary tuberculosis and left pleural effusion. Left upper arm ultrasound showed subcutaneous edema and small fluid collections about 15 mm. On the basis of clinical presentation, laboratory test results and radiographic findings the diagnosis of military tuberculosis with dissemination to the bones was made. TB should be kept in mind when differentiating the cause of bone lessions. 

• Objectives : For the past 5 years in a ward of the University Hospital in Pleven passed 40 135 patients with various injuries .From these fractures of the hip are 6.9% and of them specifically the femoral neck - 13.5% .These patients are mainly adults over 70 age with multiple comorbidities and higher risk of complications with standard analgesia with intravenous opioids. This study aims to compare the standard pain management with opiates or NSAIDs with regional nerve block made in a compartment under ultrasound guidance.
• Study selection: Randomized trial including adult patients with a hip or femoral neck fracture  who had a 3-in-1 femoral nerve block, traditional femoral nerve block and traditional pain menagment with opioids or NASIDs.
• Conclusions: Regional nerve blocks for hip and femoral neck fractures reducing pain and the need for IV opiates. We recommend using these units for management of pain in emergency rooms as a safe and relatively easy for  these patients. 

Introduction: the aim of this study was to analyze calls for unconsciousness in the call reception and control center (CRCC) and in particular to identify the proportion of patients really unconscious

Methods: this was a prospective, observational study using the MECU-database for calls about unconsciousness, during one month. Were considered unconscious at the arrival of SMUR teams, patients with GCS<9 or those descibed as such. We studied the demographic characteristics of patients and the evaluation of conscious by the regulator physician and by the SMUR physician. The results were expressed an mean±SD and percentage.

Results: Ninety six patients were included. The sex ratio was 0.8. The mean age was 50±22 years. The phone evaluation by the ragulator physician, was identified 36% unconsciousness, 30% were aware and there was a doubt for the state of conscious in 34% of cases. The intervention team was engaged in 81% of cases. At the arrival of the SMUR team, 27% of patients were unconsciuous, 49% were aware and 22% had a brief knowledge loss.

Conclusion: Among the calls for unconscious subject, one patient in two was conscious at the time of the call, and that two patients out ot three are conscious at the arrival of the SMUR teams. These results hihlight the difficulty of medical regulation for the calls.

Background: Aging of the population and changing global demography is resulting in older people presenting to emergency departments (EDs) more frequently. Such patients admitted to hospital as medical emergencies are a more heterogeneous population than younger population, often present with atypical sign and symptoms that complicate diagnosis and treatment. The aim of this study is to describe the trend in ED visits by patients aged 85 years and over between 2010 and 2016 encompassing reasons for attendance.

Methods: Data considered were all ED visits to the Clinical hospital Sveti Duh, Croatian teaching hospital, between 2010 and 2016 by patients aged 85 years and over. Demographic characteristic, incidence rate of ED, reasons for visit, length of ED stay and factors such as day of week, and season were analyzed retrospectively.  For the purpose of analyses, patients were classified into three groups related to the clinical symptomatology: internal medicine, surgical and neurological patients.

Results: We analyzed 18,892 visits by patients aged over 85, accounting for 5,3% of the total ED visits for the study period (2010 -2016). Most of them were female (69,6%). Overall ED visit for patients over 85 years increased from 1948 visits in 2010 (4,2%) to 3362 (6,9%) in 2016.  The season in which emergency visits are the most frequent was winter and Mondays saw the highest number of ED visits over the study period (2935 visits). The number of visits decreased as the week continued and weekend days, Sundays and Saturday had the lowest number of ED visits (2169, 2262 visits, respectively). The most common chief complaints and ED diagnoses were cardiovascular (31,6%), trauma (20,4%), neurological (15,3%), pulmonary (8,7%), gastrointestinal (8,5%) and  disease of the skin and subcutaneous tissue (3,5% ).

Conclusion: The proportion of emergency department (ED) attendance of elderly people over the age of 85 increased during the study period. The most common diagnosis was disorder of the cardiovascular system.

INTRODUCTION:

A simulation of an aircraft accident was performed in 2017 to analyze the Multi-Victim Care Plan (MVCP) in the Virgen del Rocio University Hospital, a .3rd level Hospital of Seville (Spain). This Plan was analyzed to measure our assistance response and detect deficits to be corrected.

OBJECTIVES:

Check the operation of the emergency plans, the effectiveness and coordination of the personnel involved in a real accident. Evaluate the Hospital's MVCP protocols to improve the services and resources involved in a real accident and  to verify the coordination between the different participants.

MATERIAL AND METHODS:

The simulation consisted in an aircraft accident which occurred during the landing maneuvers of a 19-passenger plane. The plane burned because of fuel spills, four of passengers died, three were unharmed and another 12 were injured. They were transferred to the emergency service of our Hospital by the out-of-hospital emergency team.

- It was activated the Emergency Services of different Units like Traumatology , Intensive Care, Rehabilitation, Plastic Surgery, Maxillofacial Surgery, Traumatology, General Surgery, among others.

-The family waiting room was included as a care area and the emergency capacity of the emergency area was doubled in both health personnel and care material for the care of Critical patients.

-Every person external to our emergency department was evacuated to the other areas.

-Multidisciplinary emergency care teams were created to care different types of patients.

RESULTS

Alert phase: lasting 19 minutes. Incidence: the alert call of out-of-hospital emergency team did not enter by communication channel  planned.

Alarm activation phase: the call center did not have an updated staff list for the cascade of incoming calls.

Evacuation of victims: lasting 45 minutes

Number of victims 12 (7 with red label 7 patients with a Revised Trauma Score (RTS) less or equal to 10 and 5 with green labels (2 of them converted to yellow and 1 to red) Patients destination: ICU: 4, Operating room and ICU: 3; General admission: 3; External consultations 2.

Number of real patients attended during the simulation: 25,

Training time for the multidisciplinary teams: 5-8 minutes

We found out that the care coordinator cannot be the leader of the emergency room which performs the prioritization of complementary tests and surgery planning of the critical patients due to the excess of assigned tasks

Ambulances for the transportation of mild patients waiting for getting the medical equipment needed blocked the access to the Hospital

CONCLUSIONS:

1- The activation and implementation of MVCP was correct and adequate.

2 - The capacity for simultaneous clinical care of 6 critical patients has been confirmed (patients with Revised Trauma Score (RTS) less or equal to 10)

3 - Improvements and modifications of the MVCP were detected in the phase of alert, alarm, evacuation and reception.

Introduction:

Atrial fibrillation (AF) is the most frequent arrhythmia in clinical practice and implies an increase in mortality. The ischemic stroke is the most serious complication. It is important to know the factors that favor its appearance and development. An appropriate treatment can reduce the likelihood of new recurrences of AF or prevent it becoming permanent.

Objective:

To know the clinical profile of patients diagnosed with AF in the Emergency Department.

Material or patients and method:

Observational, retrospective study developed at the General University Hospital Reina Sofía. We included 761 patients diagnosed with AF attended between October 2012 and December 2013. The clinical profile of these patients is analyzed.

Results:

We evaluated 761 patients with AF. The mean age of these patients was 72.3 ± 13.3 years. Of these patients, 490 (64.4%) were women and 271 (35.6%) were men. Regarding clinical characteristics, 566 patients (74.4%) had hypertension (HTA), 204 (26.8%) diabetes mellitus (DM), 311 (40.9%) dyslipidemia (DLP), 16 (2.1%) hyperthyroidism, 100 (13.1%) bronchopathy, 75 (9.9%) chronic kidney disease, 85 (11.2%) previous stroke, 17 (2.2%) peripheral embolism, 106 13.9%), heart failure, 79 (10.4%)  anemia. In addition, 58 (7.6%) of the patients were smokers, 20 (2.6%) chronic alcohol users, and 7 (0.9%) consumed drugs. The mean score of the HAS-BLED scale of our patients was 3.4 ± 1.9 and of CHA2DS2-VASc 2.2 ± 1.4.

Conclusion:

After the study of the clinical characteristics of patients with AF attended at the Emergency Department, we found that this arrhythmia is more frequent in patients older than 70 years and in women. In addition, all patients have a high rate of cardiovascular risk factors.  The most frequent risk factor was hypertension.

Aim and methods :

A monocentric, prospective, qualitative and quantitative study was carried out in an emergency department. The main criterias were the analysis of prescribing, patient's compliance, and the efficiency of physiotherapy rehabilitation in ankle's collateral ligament sprains.

Results :

142 patients were included, 43% of whom were women. 53.6% with a sprain recurrence, of which 67% occurred on the same ankle. The RICE protocol was applied in 100% of cases, but only 60.5% of patients had a physiotherapy prescription, and 54% believed that they had an explanation about the aim of rehabilitation. Patients who received an explanation were 12% more likely to visit the physiotherapist than those who did not.

In total, 71% of patients with a prescription had physiotherapy. However, 28.5% of patients who did not receive a prescription benefited from physiotherapy through the secondary intervention of their general practitionner. 76.3% of patients began rehabilitation within 2 weeks of the trauma, 32.7% within 5 days. Rehabilitation is judged efficient in this study if exercises of mobility gain and stability as well as muscular reprogramming techniques are performed, with at least 3 of the following 5 criterias performed: proprioceptive massage / unipodal and bipodal exercises / discharge and weight-bearing exercices. 78.7% of the medical treatment brought by physiotherapists met these criterias. Ultrasound and external electrical stimulation, which are discouraged, but were carried out in 36.5% and 27.3% of cases, respectively. The average number of sessions is 10, with 2 to 3 sessions per week.

Discussion :

Lack of information on the need for rehabilitation as early as possible, influencing the number of patients with follow-up and rehabilitation. However, encouraging results with a high rate of compliance and effective rehabilitation.

Conclusion :

Need for standardization of practices, updating of knowledge on the latest recommendations, generalization of physiotherapy prescriptions with a clear explanation for the patient's compliance to the care project, and didactic information tools.

There could be an advantage to interdisciplinarity with physiotherapists in order to know their rehabilitation techniques and methods to reduce recurrences and complications in the medium and long term.

Brazil has a Unified Health System to serve the population. Its scope ranges from simple ambulatory care to organ transplantation, thus ensure universal, free and universal access for all country population.

The services in the Unified Health System are divided according to their severity in: basic care, intermediate level and medium and high complexity.

Basic care services are provided in the Primary Care Service Unit and by Family Health. Those at the intermediate level are performed by the Mobile Emergency Service (Mobile Pre-hospital Care) and the Municipal Emergency Care Units (pre-hospital fixed care). The medium and high complexity services are performed in tertiary referral hospitals accredited to the public network.

The Municipal Emergency Care Unit is qualified to care for any type of medical emergency, traumatic or non-traumatic. It has offices of medical clinic, pediatrics, dentistry, radiology service, laboratory and observation beds are available. Patients are seen attendance according to the Manchester protocol.

In Ribeirão Preto, the Municipal Emergency Care Unit was inaugurated in June of 2013 and became a reference for the care of all city population (674,405 inhabitants), due to the quality of care offered.

The University of Ribeirão Preto has an agreement with the city hall, so that this Unit can be used as a clerkship for medical students.

In 2016, 228,294 attendance were made to this Unit. The majority of these services are of low complexity, but the care for medium and high complexity levels has been increasingly over the last years.

Methodology: We performed a retrospective study of patients who were treated at this unit and who needed hospitalization to complement their treatment. We analyzed the following variables:  pathologies, sex, age. With these data, it was possible to trace an epidemiological profile of the main pathologies that affect the population and to draw action plans so that the medical attention has been improved. Statistical analysis: multivariate analysis.  

Results: Most of the cases requiring hospitalization were basically due to three general causes: pneumonia, ischemic heart disease and stroke.

Conclusion: The Ribeirão Preto's Emergency Care Unit was useful for the initial approach of clinical and surgical emergency cases. The integration of Units with other health services is crucial for the proper medical care of emergencies.

Introduction: the aim of our study was to determine the epidemiological profile of accidents with multiple victims during the year 2016 and pick up the dysfunctions of organization of intervention and the victim's management

Methods: it was a prospective study that deals with mass casualty accidents managed by the SMUR teams during the year 2016. Data have been provided by the regulation notes. We define a multiple victim's accident as an accident leading to five victims or more. We have established an adapted a simplified procedure of alert and response that is carried out in case of multiple casualities accident. Procedure dysfunctions are systematically analyzed after each accident.

Results: we have managed 26 accdents with multiple victims between January the first and December the 31 st 2016. The total number of victims was 284 (average: 10,92 per accident) and 11 deaths recorded on the scene of accidents. After the analysis of the data related to these interventions, the quality committee identified the following dysfunctions: delayed alert from fire-man operating center. Absence of a referent physician or specific phone number in the emergency services in order to receive the first call from the regulation center. That results in delayed information of an imminent massive affluence of many victims to the emergency services. Delayed access to the accident scene by the SMUR teams because of the road traffic

Conclusion: to correct all these dysfunctions, we elaborated an immediate alert system involving paramedics and radio communication means with emergency services.

We present a case of a 79 years- old patient, with a medical history of high blood pressure and atrial flutter and surgical history of dupuytren illness. In treatment with Proton pump inhibitors, angiotensin enzyme converting inhibitors, acenocumarin and flecainide.. No allergies. He was attended at the Emergency Department reporting pain after having twisted the left ankle and he was not able to put weight on the foot. At first, it seemed to be a severe ankle sprain. Physical examination revealed a haemodynamics stability of patient, but he referred intensive pain, which precluded ambulation.  In the left foot, both malleolus had swelled up and were painful, specially tibial intern malleolus area where we felt a gap. He also presented pain in deltoid ligament, in the collateral ligament and mild pain in the head of fibula. Achilles tendon was not damaged . Rest of tarsus relief were not painful. Flexion and extension were preserved actively. There were neither distal neurovascular disorders nor distal trophism disorders.

The radiological study revealed an internal malleolus fracture , and a fracture of the fibula´s head. It was treated with orthopedic surgery successfully.

Discussion:  

Maisonneuve fractures are rare ankle injuries, they represent up to 7% of all ankle fractures. They consist on a proximal third fibula fracture, syndesmotic disruption, and medial ankle injury (either a deltoid ligament disruption or a medial malleolus fracture. Most patients refer significant ankle pain but very little pain over the fracture. The clinical examination and radiological studies are usually directed to the ankle region; and the proximal fibula is often ignored so, the clinical assessment should consist on a comprehensive history including mechanism of injury followed by a specific physical examination.

INTRODUCTION

A 25-year-old male presented to the emergency department with a right shoulder dislocation post fall while playing rugby. 

On examination, contour of the right shoulder was lost, arm abducted and externally rotated with normal neuro-vascular examination. Clinically looks anterior shoulder dislocation, confirmed by Ultrasound and X-ray (no fracture).  Previously 6 months ago, Same Shoulder was tried to reduce using entonox, and other techniques, upon failure, then reduced under full sedation, extending his stay more than 4 hours in ED.

TREATMENT

Patient was given different options for shoulder relocation, and after full informed consent from patient, ultrasound guided right shoulder intra-articular injection of 2% 10ml, Lidocaine was given, using full aseptic conditions. Patient shoulder was successfully reduced after 10 minutes of Lidocaine injection using Modified Kocher's technique. Post reduction neurovascular examination was normal with no complications of the procedure. Reduction was confirmed by Ultra-sound as well as by the X-ray. Patient was very comfortable and pain free until he left the emergency department in broad arm sling in 45minutes after the procedure

Patient discharged to fracture clinic with closed follow up of patient was done at 3^rd day, 2 weeks and then at 3 months , no complications were reported by patient, post IAL injection.

DICUSSION

Shoulder joints accounts for 50 % of all major joint dislocations ^(1). Emergency physician role is to diagnose type of dislocation ^2-, manage by reducing with suitable technique.

Shoulder dislocation is common presentation to the emergency department. Intra-articular lidocaine injection in adult patients is not common method to reduce dislocated shoulder. It can be an alternative to reduce shoulder dislocation as compared to sedation with or without analgesia, in the busy emergency department and, with fewer complications and side effects^{3, 4,5} . Whereas sedation has more complications or limitations.                                                   

With its benefits, more work needs to be done to adopt this as possible alternative to conventional sedation.

BACKROUND

Cardiac arrhythmias are among the most common cardiac complications during pregnancy. This is likely due to a combination of hemodynamic, hormonal and autonomic changes. These changes include a 30-50% increase in cardiac output until 34 weeks, with heart rate rising at 20 weeks, and increases until 32 weeks; and stradiol and progesterone have been shown to be proarrythmics. Acute supraventricular arrhythmia in pregnancy is a problem because it impairs maternal and fetal blood circulation. However, severe arrhythmias that need aggressive treatment are unusual. We present a clinical case on the management of a pregnant woman with supraventricular tachycardia.

CLINICAL CASE

A 38-year-old pregnant woman was admitted to the emergency department with uterine dynamics. She was 29 weeks twin pregnant and obstetricians started fetal lung maturity and tocolysis.  During admission, she referred sudden onset of chest palpitations, commenting that she usually had these. Maternal and fetal monitoring was initiated. Physical examination revealed a heart rate of 195 bpm, a blood pressure 97/62 mmHg and an oxygen saturation of 99%. Twelve-lead ECG showed narrow-QRS complex tachycardia. We contacted with the cardiology team, agreeing to perform vagal stimuli as first-line treatment, with adenosine as second-line if this were not enough. Carotid sinus massage and Valsalva maneuvers failed, thus pharmacological cardioversion was succesfully performed with 3mg of intravenous adenosine, converting the tachycardia in normal sinus rhythm. Cardiotocographic monitoring did not show any effect of adenosine on any fetal heart rate during the drug administration and the following 30 minutes. Tocolysis was reinitiated and uterine dynamics stopped. The patient was discharged after four days hospitalization. Catheter ablation was suggested but the patient refused.

DISCUSSION

Symptomatic exacerbation of paroxysmal supraventricular tachycardia occurs during pregnancy in 20-44% of cases. Even though most palpitations are benign, patients should be investigated for the presence of structural heart disease.

Therapeutic approach to arrythmias in pregnancy is similar to that in non-pregnant patients. Most of antiarrhythmics are considered by the Food and Drugs Administration (FDA) as category C, meaning that risk to the fetus cannot be ruled out.  They have the maximal teratogenic risk on the first trimester and they should be used at theirlowest effective dose.

Adenosine has been used safely in pregnant women without significant adverse effects. Electric cardioversion is a reasonable option at all stages of pregnancy when arrhythmias are associated with hemodynamic instability. Cardioversion does not compromise blood flow to the fetus.

Background/ Aim

Closed tube thoracostomy (TT) insertion for trauma patients is associated with an infectious complication rate for empyema, pneumonia and wound infection of 5.8-13%. The British Thoracic Guidelines (BTS) recommend prophylactic antibiotic use. However, implementation of this recommendation is variable.

Standard

BTS advises that antibiotic prophylaxis should be considered at TT insertion in the context of trauma.

Methods

A retrospective case review of all patients who received a TT in UHNM Emergency Department, over the 18 month period from April 2013 and September 2014 was conducted. In total, 84 patients (23 female, 61 male) with an average age of 47.9 years and ISS score of 20.1 were identified from data submitted by UHNM for TARN audit purposes. Their medical notes were requested and used for data collection.

Results

A ratio of 1:7.4 for penetrating vs bunt injury was found. In total, 22/84 patients (28.6%) developed an infectious complication attributable to TT. Of these, 12 had not received prophylactic antibiotics. Overall, the likelihood of acquisition of an infectious complication when given prophylactic antibiotics was associated with an odds ratio of 0.225 (CI 0.079-0.631) and a NNT of 3. Thus, support for the use of antibiotic prophylaxis for TT in the context of trauma was found, in concordance with BTS guidance.

Conclusion

As supporting evidence was found, guidance was produced, advocating prophylactic use of Co-Amoxiclav for patients requiring TT insertion due to trauma. This is currently, being proposed for inclusion in UHNM’s Emergency Medicine guidelines.

Background:

Anticholinergic syndrome is widely described after ingestion of some drugs or plants. Inadequate debittering of Lupine beans can also cause this syndrome. However, there are few case reports in the literature; we describe a case of rare lupine toxicity with  significant clinical findings.

History:

A 65 years old male, with DM on metformin, HTN on Amlodipine , cholecystectomy and prostatic hypertrophy on Tamsulosin, presented to Emergency Room.

He gave a history of 2 hours of dizziness, dry mouth, urinary retention, constipation, abdominal pain with distention  and blurred vision, after ingestion of about 200 ml of water used to debitter lupine or Turmus seeds. He drank it to try to improve control of his blood sugar.He had no history of fever.

Examination:

He looked with no flushing and was apyrexial (36.4º C). He had dry skin and oral mucosa. His pulse rate was 102 bpm, blood pressure 148/89 mmHG, respiratory rate 19/min, and 100% oxygen saturation in room air.

He was noted to have abdominal distension.

He was fully conscious and orientated; he had bilateral mydriasis but no other cranial signs and normal power, sensation, reflexes and co-ordination.

Abdominal XR showed bowel distention and air-fluid multiple levels.
CT Abdomen showed diffuse dilatation of the mid and distal small bowel loops, extending up to the ileocecal junction, indicating small bowel obstruction.                  

His WBC, blood sugar, electrolyte, kidney and liver function, and cardiac enzymes were within normal range.

The clinical diagnosis was anticholinergic syndrome complicated by intestinal obstruction due to ingestion of the water used to debittered the Lupine seeds. The patient was seen by the on-call surgical team and apart from administration of a rectal enema, he was treated conservatively.

The day after, he was completely asymptomatic. No further tests or interventions were done, and the patient was discharged home.

Conclusion:

Acute anticholinergic syndrome can arise after the consumption of a wide range of plant extracts,  of which lupines (Turmus in Arabic) are an uncommon example.

Lupine seeds need to be well prepared (cooking then soaking with several changes of water over days) to debitter before consumption. The spontaneous bitter taste is mainly due to the presence of a toxic substance with anticholinergic properties.

The Lupine toxicity is clinical diagnosis, it needs high index of suspicion based on history and clinical manifestations.

Treatment is mainly supportive. In severe cases with peripheral and central anticholinergic findings, or persistent features, physostigmine may be considered.

Acknowledgment: We would like to express our great appreciation to Dr. Simon Clarke ED consultant at Hamad Medical Corporation for his help and support.

Figure 1:Turmus beans

Case report: A 43-year old male was admitted to the ED a few hours after an

intentional auto-intoxication with 74mg biperiden (=1mg/kg). Clinical examination

revealed an open airway, normothermia, tachypnea, and a tachycardia (120 bpm) with

normotension (129/113 mmHg). He was severely agitated with hallucinations, mydriasis

and urinary retention. Laboratory results showed a mildly elevated CK of 835U/L and

normoglycemia. Toxicology screen on blood was positive for benzodiazepines, which he

used on daily basis. ECG demonstrated a sinustachycardia. Therapy included balanced

fluids (1L Hartmann/8hrs), high-dose benzodiazepines (110 mg diazepam titrated over

6hrs) and bladder catheterization. Physical restraint was required due to severe

agitation and aggression. Physostigmine 0.5mg was administered over 10 min and had a

modest and short-acting effect on the agitation.  Administration was repeated after

30 min with the same effect. The patient was admitted to the ICU for further

observation and received a midazolam infusion (starting at 25mg/h) for several hours

with down-titration overnight.  The symptoms resolved 24hrs after ingestion. Prior

to discharge the patient was assessed the psychiatry team and a close follow-up by

his generalist and psychiatrist was planned. Conclusion: Biperiden is an

anticholinergic drug used for the treatment of Parkinson’s disease and

drug-induced extra-pyramidal effects. Intoxication with biperiden is rare and causes

an anticholinergic toxidrome. The peak effect is reached within 1-2h and its

half-life is approximately 18h. Differential diagnosis of an anticholinergic

toxidrome includes a sympathomimetic toxidrome, acute psychiatric disorder,

delirium, viral encephalitis or malignant neuroleptic syndrome. Treatment of

biperiden overdose consists of supportive measures and symptomatic treatment, with

timely administration of activated charcoal and administration of high doses of

benzodiazepines. Indications for physostigmine use include the presence of

peripheral or central antimuscarinic manifestations without significant QRS or QT

prolongation, i.e. those with convulsions, agitation and hallucinations, delirium,

narrow QRS, supraventricular tachydysrhythmias, hemodynamic deterioration, or

ischemic pain, but its use remains controversial. Physostigmine should be administered in monitored conditions with availability of resuscitation equipment and atropine. The recommended dose is 0.5-2mg, given slowly IV over 5 min. If the agitated delirium reoccurs without

muscarinic effects, physostigmine may be repeated in smaller doses after 20-30min.

Take home message

Biperiden intoxication is very rare and presents with an anticholinergic toxidrome.

Treatment consists of supportive measures and symptomatic treatment including

benzodiazepines, and may be supplemented with physostigmine.

Introduction:

Atrial fibrillation (AF) increases the risk of ischemic stroke. Anticoagulation is the main preventive tool. The limitations of anti-vitamin K (AVK) have driven the search for other agents with new features; direct-acting anticoagulants (DOACs). The safety of new anticoagulants in elderly patients is unknown but it is advisable to evaluate the associated comorbidities.

Objective:

To analyze the type of anticoagulant treatment used in patients with AF diagnosed in the Emergency Department according to their age.

Material or patients and method:

Observational, retrospective study developed at the General University Hospital Reina Sofía. We included 761 patients diagnosed with AF attended between October 2012 and December 2013. The type of anticoagulant used (AVK or DOACs) was analyzed and the patients were classified into two groups (≤75 years or> 75 years).

Results:

We evaluated 761 patients with AF. There were 405 patients (53.2%) ≤ 75 years and 356 (46.8%)> 75 years. The percentage of males is higher in this second group (57.0 vs 72.8%, p <0.001). Patients > 75 years were more hypertensive (87.9 vs 62.5%, p <0.001), more diabetic (33.4 vs 21.0%, p <0.001), they had more renal disease (13.2 vs 6.9 %, P <0.001), anemic syndrome (14.0 vs 7.2%, p <0.001) and a history of stroke (16.3 vs 6.7%, p <0.001). In addition, they presented a higher result in the CHA2DS2-VASc score (2.9 ± 1.1 vs 1.7 ± 1.4, p <0.001) and in the HAS-BLED score (4.5 ± 1.5 Vs 2.4 ± 1.6, p <0.001). With regard to anticoagulant treatment at discharge, 94 (26.4%) of the patients> 75 years received treatment with DOACs. This percentage is similar in ≤75 years (23,2%, p = 0,31). The AVKs present a similar distribution (37.9 vs 40.0%, p = 0.56).

Conclusion:

Although the group of >75 years has more associated comorbidities, they don't present significant differences in the anticoagulant treatment used at discharge compared to the group of ≤75 years. Therefore in these patients, age was not a limiting factor to choose the best anticoagulant treatment.

1) Introduction and Objectives:

In the last 5 years, the appearance of direct action anticoagulant therapy prescription and the use of CHA2DS2-VASC risk scale, has improved the percentage of anticoagulated NVAF patients. Even so, antiplatelet drugs are being used in some cases. We review what NVAF patients are treated with antiplatelet therapy considering Guide ESC 2016 recommendations: "Disaggregants can not be recommended for cardioembolic events prevention in atrial fibrillation (AF) patients".

2) Material and Methods:

Observational, descriptive and retrospective study enrolled all older than 14 years patients, diagnosed in computerized clinical history of AF or flutter, that were taken after at the emergency departments of hospitals of SALUD Aragon. The period of the study includes from 1^st of July to 31^st of December 2013, 2014 and 2015. Data were collected with ACCESS and studied afterwards with SPSSv15.

3) Results:

Total number of studied patients: 6738. Average age, 75.2 years. Gender distribution: 49.4% male, 50.6% female. Average CHA2DSVASC: 3,1; Average HAS BLED: 1,8. NEW treatment to prevent cardioembolic events: antiplatelet initiated therapy in a total of 507 patients (9,6%). Per years: 2013: in 192 patients (11,6%); 2014: in 162 patients (9,2%); 2015: 153 (8,2%).  Per scale risk CHA2DS2 VASC punctuation: 0 points in 85 patients (17%); 1 point in 43 patients (11%); ≥2 points: in 379 patients (8,6%). Per Hospitals: Hospital B: 4,4% of the patients; Hospital G: 27,3% of the patients were treated, for the first time, with antiplatelet therapy.

4) Conclusions:

4.1.- It is seen a result improvement over the years, using less antiplatelet therapy for the prevention of cardioembolic events in NVAF patients, (an 8,2% in 2015), but it is still not at the correct percentage suited by Guidelines (below 5%).

4.2.- High percentage of antiplatelet initiated therapy in patients with ≥2 points at the CHA2DS2 VASC scale (8,6%).

4.3.- Great disparity in the criteria used by Hospitals to initiate antiplatelet therapy, with a significant difference of a 23%

Abstract:

Background: Aortic dissection is an emergent disease that needs to be diagnosed as soon as possible. Early diagnosis can reduce the mortality and morbidity of patients. The common signs and symptoms of aortic dissection are related to the site of the dissection. Such symptoms include chest pain, neck and jaw pain, interscapular pain, and abdominal pain. Iliac artery thrombosis is a rare and emergent condition that appears acute, with sudden onset of decreased arterial flow. The symptoms of this include severe leg pain and weakness. It can end in leg amputation.

Case presentation: We present a 54-year-old man, with the sudden onset of weakness of the lower extremities. He was very agitated. Upon examination, we detected the weakness of the dorsalis pedis pulse in both legs, but especially so on the right side. We also detected abdominal tenderness, especially on the periumbilical area. He had vague chest pain too. With a bedside ultrasonography in the emergency department, we could diagnose that he had abdominal aortic flap. After CT scan of the chest and abdominal areas, we found aortic dissection of thoracic and abdominal, with right iliac artery occlusion.

Conclusion: Aortic dissection can occur in conjunction with iliac artery occlusion. So, the sudden onset of lower extremity weakness with lack of pulse or weakness of lower extremity pulse should alert us. The association of these symptoms with abdominal pain or chest pain can guide us to detect aortic dissection with the occlusion of iliac artery.

Keywords: aortic dissection, iliac artery occlusion.

An 83-year-old female, who presents to the emergency department with abdominal pain localized in the left renal fossa of 7 days of onset, stinging, irradiated to ipsilateral iliac fossa, associated to nausea and oral intolerance. No fever. In the ED with TA 165/83 mmHg, HR 86 bpm, Temperature 36 ° C, Respiratory rate 18 rpm, globular abdomen at the expense of abdominal distension, hypoperistaltic, painful palpation in the left iliac fossa, positive left renal percussion. Pyelonephritis is suspected. Tomography of the abdomen and pelvis with intravenous contrast is performed, which documents an infrarenal abdominal aortic aneurysm that extends to the iliac bifurcation, with a loculated paraaortic lesion that resembles collection and left pyelonephritis. It is considered by the ED as an inflammatory or mycotic aneurysm. We call the Vascular Surgery service, and they perform an exploratory laparotomy with resection of infected aortic aneurysm and placement of dacron graft and duodenal repair. A saccular aneurysm of the aortic arch is observed, so an endoprosthesis of thoracic aorta is placed. Positive culture of specimen for Candida albicans.

Mycotic aneurysm of the aorta is infrequent and has high morbidity and mortality due to the recurrence of infection, fulminant sepsis or aortic rupture. Approximately 1% of all aneurysms are associated with an arterial infection. The prevalence is between 0.7% and 2.6%. Infectious aneurysms can occur in any arterial segment and are the most difficult to treat. At present, it occurs mainly as a result of vascular trauma or intravenous drug abuse and usually occurs in patients with some degree of immunosuppression. With preference of the bacteria for the vasa vasorum and the bifurcations of the vessels and arteries of small and medium caliber, affecting in order of frequency: the femoral arteries, abdominal aorta, superior mesenteric. As in this example, it occurs more in the elderly with atherosclerotic disease. The common microorganisms in this entity are: Staphilococcus aureus, Salmonella and Escherichia coli. Unlike in this case, in immunodepressed and IV drug users, any opportunistic germ can be found, however our patient doesn’t t have this criteria. The clinical picture is usually nonspecific and insidious and often the patients have sepsis of difficult control with early and rapid rupture of the aneurysm. Diagnosis is based on clinical suspicion, so primary infection data should be sought and supported by imaging techniques.

This is a unique case because of the patient’s clinical presentation, characteristics and the microorganism isolated.

Purpose: Apical hypertrophic cardiomyopathy (AHM) is a variant of hypertrophic cardiomyopathy, involving nearly exclusively apex. It is very common among Asian patients, predominantly in Japanese, which is considered relatively benign condition. However, severe clinical manifestations, including sudden cardiac death, severe arrhythmias and apical infarction have been described in case reports. The electrocardiographic changes (giant negative T waves ) and associated symptoms (chest pain, palpitations, dyspnea…) often present as acute coronary síndromes. AHM diagnosis is based on the demonstration of myocardial hypertrophy in the apical region of the left ventricle, usually by echocardiography with classical image "ace of spades", although in many cases the use of contrast necessary. We present a case of young patient admited at ER with palpitations.

Material & Methods: The most frequent morbid events in Eriksson et al study of AHM were atrial fibrillation (AF), probably related to left atrial enlargement and impaired LV relaxation. It is prudent to also closely examine the heart on bedside emergency echocardiography looking for the  presence of left atrial enlargement.

Results:  37 year old male, with no significant medical history, was admitted to the ER by palpitations. The electrocardiogram showed AF with deep, negative T-waves in leads V3-V6. Bedside emergency echocardiography  (BEE) initially performed to look for left atrial enlargement, revealed apical hypertrophy, with apical cavity obliteration during systole. These findings were confirmed by contrast ecocardiography. The patient was diagnosed with AHM (Yamaguchi's syndrome) and started on beta-blocker therapy.

Conclusion: In this case, BEE helped to identify an AHM. It was the findings on emergency ultrasound, performed and interpreted by EPs, that helped to identify the correct diagnosis and prompted the appropriate consultations to cardiologist, with a final diagnostic of AHM.

APIXABAN-ASSOCIATED SPONTANEOUS SPLENIC RUPTURE: A CASE REPORT

INTRODUCTION

Splenic rupture is a rare life threatening condition. Most cases of are secondary to truama. However sponatenous rupture of the spleen (SRS) has been reported which in most cases are assocaited with infection or neoplasm. Previous cases of SRS has been reported with warfarin but none assocaited with Novel Oral Anticoagulation (NOACs). We present a case of SRS in a 62 year old female on apixaban for Atrial Fibrillation 2 days prior.

METHODS

A 62 year old lady Emergency Department (ED) with 1 day history of dizziness, vomiting and feeling weak. She was pale and hypotensive. On examination GCS was 15, BP: 70/50 PR: 80bts/min. Systemic examination was unremarkable. The abdomen was soft and non-tender. Her hemoglobin came back at 8.7g/dl which had dropped from 12g/dl in 2 days. CT-Abdomen showed a large splenic hematoma and thickening of the of the inferior wall of the stomach. The Surgical team was informed and she was then taken for an emergency laparotomy with Splenectomy and Partial gastrectomy. She became septic post-op, responded well to antibiotics and was discharged day 18. The Apixaban was stopped and was discharged on lifelong prophylactic oral antibiotics.

RESULTS

CONCLUSION 

This case demonstrates the importance of prompt recognition of a spontaneous splenic rupture in a patient on anticoagulation with NOACs. This diagnosis should be considered in any patient on apixaban whom have a  sudden drop in their hemoglobin with no obvious abdominal pain or no history of trauma. Close observation may be done for those patients who are hemodynamically stable, but more invasive treatment should be available and considered if the patient’s condition deteriorates.

Introduction: The knowledge of disaster medicine included many subjects such as Management Science, Medicine, and  Overall-Planning. The classic teaching method（lecture） is incredibly boring and is difficult for students to learn and memory. Therefore, searching for the methods of disaster medicine education for medical students has become an important topic. Objective: To explore the application value of "Game-based learning" in medical student emergency medical rescue knowledge education. Methods: Based on the knowledge point of the medical student emergency medical rescue knowledge education, we design the Table Game for disaster medicine. After the Table Game course for disaster medicine, a questionnaire survey was done to all the medical students. Results: For disaster medicine education, Game-based learning was priority to traditional lecture in many ways such as interest in learning, class atmosphere, mastery of knowledge, team work and problem solving(p<0.05). Conclusion: Game-based learning method for medical students to study disaster medicine is superior to the traditional lecture and can be used in the education of disaster medicine.

Background: Intravenous injection of clinically routine invasive techniques, with chronic diseases, obesity, or increased due to repeated and long-term injections of intravenous injections, thus increasing the difficulty of intravenous injection and children are also intranasal injection of ethnic groups due to emergency Room business characteristics, often need to implement this technology, it is facing critical cases of critical illness, peripheral intravenous injection or family anxiety of emotional reactions, will also increase the pressure on nursing staff and consumption of nursing hours and security expenses. To motivate the discussion of this issue.

Objective: evidence-based, explore ultrasound guided Zhou Bian intravenous injection technology for difficult patients of results.

Methodology: Based on the empirical grade used by Oxford (2010) as the classification, the Cochrane Library, CINAHL PLUS and PubMed 3 databases were selected for data collection. The age was limited to 2007-2017, and then ultrasonographically-guided, sonography- Guided, peripheral venous, peripheral catheterization, Single operation.

Results: Ultrasound guided technique could significantly improve the success rate of first injection (74 ~ 90%) and reduce the number of injections (MD = 1.4 ~ 2.0 ± 0.09 ~ 1.31) in patients with intravenous injection, which were superior to traditional intravenous injection Time still need to spend (MD = 1.06 ~ 27.6 ± 2.5 ~ 19.8).
Clinical advice: Ultrasonic guidance technology using the probe image frequency of 5 ~ 10 MHz, and the need for ultrasound positioning training at least 1 to 2 hours, with the practice of practice> 5 times, help to perform peripheral venous ultrasound guidance technology The success rate.
Restrictions: clinical implementation of peripheral venous ultrasound guidance technology is not much, and the clinical peripheral intravenous injection by the implementation of nursing staff, and nursing staff generally did not accept the training of ultrasound positioning for this limited, hoping to more empirical research Confirmed the success rate of peripheral venous ultrasound guidance technology, to promote the acceptance of this technology to enhance the clinical care division to participate in the study of this technical will and ability to enhance the overall peripheral intravenous care skills evolution. The patient side can reduce the number of pain and enhance the comfort and dignity of the feelings.

Introduction

Intracranial hemorrhage (ICH) is a life threatening condition which can precipitate electrocardiogram (ECG) changes and arrhythmias. We present a case of a patient which had subarachnoid hemorrhage (SAH) causing arrhythmia and cardiovascular collapse.

Case

A 59 year old Chinese lady was conveyed by ambulance to the emergency department for confusion. She was found confused in the bathroom after she went swimming with her husband. The patient was previously well and had no intercurrent illness. She was known to have nasopharyngeal cancer status post radiotherapy more than 10 years ago.

Upon arrival, she was tachycardic (134 bpm) and hypertensive. Her Glasgow Coma Scale (GCS) was 13 (E3V4M6). Physical findings included a small hematoma over her right forehead, a dilated right pupil, and left hemiparesis.

While awaiting the urgent CT scan, a 12-lead ECG was performed showing ventricular bigeminy. Cardiac monitoring was instituted and the patient developed bizarre idioventricular rhythms and premature ventricular complexes in salvos. An urgent blood gas revealed a potassium of 2.2 mmol/L, which in retrospect given that the formal lab potassium level turned out to be 3.2 mmol/L, was likely an technical error.

A few minutes later, the patient developed pulseless electrical activity arrest. Cardiopulmonary resuscitation and intubation was performed and potassium and magnesium replacement was given. After return of spontaneous circulation, CT brain and Circle of Willis angiogram showed diffuse SAH with intraventricular extension and multiple aneurysms. An urgent extra-ventricular drain insertion was done and she was admitted to the surgical intensive care unit, where she demised 4 days later.

Discussion

There is evidence that SAH can lead to ECG changes and arrhythmias. Some of the underlying mechanisms include autonomic neural stimulation from the hypothalamus or elevated levels of circulating catecholamines[i]. In a study by Di Pasquale et al[ii], it was found that cardiac arrhythmias were seen in up to 90% of patients with SAH. Sinus bradycardia, supraventricular arrhythmias, sinus tachycardia, and sinus arrhythmia were most common.

That patients with arrhythmias are sometimes misdiagnosed and worked up for cardiac or electrolyte causes is worrying as it leads to unnecessary investigations and delay in diagnosis of the underlying ICH. On the flip side, patients presenting with ICH who do not receive cardiac monitoring may develop serious life threatening arrhythmias which may be undetected and further deteriorate into cardiac arrest. This case serves to highlight both that patients with ICH should have at least an ECG and correlating the workup of arrhythmias with history and physical examination is paramount.

Clinic history:
• Personal history: No allergies. Smoker 40 packs/year. Alcoholism. No other background. No treatments.
• Anamnesis: A 37-year-old woman going to emergency with pain and paresthesias in the left foot that is increasing with intense coldness and distal cyanosis in the last hours.
• Exploration: TA: 145/90, HR: 85 bpm, Oxygen saturation: 98% basal, resting euphonic. Septic mouth. No neurological focal. No jugular engorgement, palpable and symmetrical carotid pulses. ACR: rhythmic without blows or extratons. MVC without pathological noises. Abdomen without interest. MMII: Cold lower left limb with distal cyanosis without showing inferior pulses to popliteus.
• Supplementary tests:
   - Blood Analyze at admission: Hb 11.5 gr / dl, VCM 120, platelets 417000, leukocytes 9200. Coagulation without alterations. Glucose 86, liver profile with GGT 631 and FA 155, rest without alterations. PCR 121.
   - ECG: sinus rhythm at 90 bpm without other findings.
   - Rx chest: Normal.
   - AngioTC: Normal caliber abdominal aorta with mural thrombus in the first cut, another mural thrombus at the infrarenal level. Complete obstruction is observed at the level of the tibio-peroneal trunk of 6.4 cm, which is subsequently recanalized with distal flow observed in the three distal trunks. Popliteal left with complete occlusion in the third sector of 7.8 cm that is recanalized distal to the tibio-peroneal trunk with presence of collateral circulation.
• Evolution:
   - Arterial fibrinolysis is performed with bolus rTPA 20 mg and with continuous infusion 1 mg/hr together with heparin 1000 U/hr in catheter with end in refusal defect and maintained for 24 hrs due to persistent obstruction of the tibialis anterior and peronea In a middle third that is finally solved.
   - Subsequently, a complete study with transesophageal echocardiography has been performed. Descending aortic atheromatosis is seen with small aortic ulcer, plaque fracture, small linear thrombus of 8x30 mm over rupture zone and thrombus that protrudes in vascular lumen and that will improve in respective controls.
   - Extended study during admission showed 55 mmol/L hyperhomocysteinemia along with low levels of folic acid and vitamin B12 that appear to be related to lifestyle and alcohol consumption of the patient. No other findings are found during the study. At discharge, anticoagulation is indicated with acenocoumarol, folic acid, vitamin B12 and pitavastatin.

Conclusions:
Hyperhomocysteinemia may predispose to arterial thrombosis and venous thromboembolism, perhaps by damage to endothelial cells. The most frequent causes of hyperhomocysteinemia are considered to be acquired deficiencies of folic acid, Vitamin B12 and Vitamin B6.
Levels of less than 13 mmol/L are usually considered normal. Between 13 and 60 mmol/L is considered moderately elevated, and from 60 mmol/L is severely elevated.

ARTIFICIAL NUTRITION EVALUATION IN THE ICU

Background: Lymphangioleiomyomatosis (LAM) is a disease that affects especially young women and usually results with respiratory failure. The frequency of occurrence in the whole population is 1 in a million. It has been reported that the disease is typically seen in women between menarche and menopausal periods but also occurs in women receiving estrogen therapy and in patients with tuberosclerosis. Pneumothorax is frequently encountered clinical presentation during emergency department (ED) admission of these patients.

Case: A 78-year old woman who had previously been treated for gastric bleeding admitted to ED due to syncope and the presence of blood coming from her mouth. Her medical history revealed pulmonary thromboembolism and heart failure diagnoses and she had a history of gastric bleeding treated several times. At the time of admission, her general appearance was moderate, her conscious was clear with normal orientation and co-operation and her vitals were Fever: 36.3 ºC, Pulse rate: 78 /min, Respiration: 20 /min, BP: 147/96 mmHg. Physical examination revealed a minimal incision on the anterolateral aspect of the tongue. Both lungs were normal and no pathological sound was heard, there was no defense, rebound or tenderness on the abdominal with normoactive bowel sounds. Melena was not detected on the rectal examination. In laboratory tests Glucose:135 mg /dl, Kr:1.1 mg/dl, Troponin I:46.6 pg/ml, CRP:13.39 mg/L, WBC:14700/uL, Hb:8.9 gr/dL, D-dimer:4.16 µg/ml, INR:0.99, PTT:21.1sn, pH:7.48, pO2:48.2 pCO2:31.3. Atrial fibrillation and pathologic Q waves in D2, D3, aVF were noted on ECG but no ST-T change was observed. There was no acute pathological change in brain CT. Angio CT due to PTE suspicion (Reinfarct) was reported as diffuse, thin-walled air cysts in both lungs but no thrombus in the main pulmonary arteries or branches was detected (Figure 1). 

Discussion: Respiratory symptoms such as cough, progressive dyspnea, hemoptysis and chyloptysis are predominant symptoms during the clinical course of LAM patients. Pneumothorax which is often recurrent and causes significant morbidity is seen in approximately two-thirds of patients. Such LAMs are often asymptomatic. Physical examination is often normal in the early stages of the disease. If there is no pneumothorax at the time of diagnosis, chest X-ray may be inadequate. Thorax CT, HRCT or MRI can be used for diagnosis.  The gold standard for the diagnosis of LAM is tissue biopsy, showing nodular infiltrates generated by abnormal smooth muscle cells, called LAM cells, in lung or retained lymphatics. The initial approach in ED treatment is the same as other lung diseases and if pneumothorax is detected, it should be intervened by appropriate treatment.

Conclusion: LAM patients are not often admit to EDs but it should be remembered that these patients may have pulmonary complications such as recurrent pneumothorax.

Purpose: Case study of gallbladder ascariasis complicated with acute hepatitis, diagnosed at Emergency Department, through the use of ultrasonography (US) scanning by emergency physician (EP).

Material & Method: A patient with jaundice, with a final diagnosis of Ascariasis infestation assessing US, performed by EP.

Results: 16-year-old male suffering malaise and jaundice for two days, without fever. He was hemodynamically stable, with extended jaundice. Abdomen was soft, depressible, painless and non-palpable masses or organ enlargement, no signs of peritoneal irritation. The analytical tests showed AST 1488, LDH 552 and bilirubin of 9.1, along with coagulopathy with INR of 1.88. The emergency physician made an abdominal ultrasound scan, which showed an echogenic tubular image without posterior acoustic shadowing, mobile, several centimeters long and about 6 mm in diameter, compatible with helminth infestation. The patient was admitted to the Infectious Diseases Unit. Within 24 hours of admission there was a rapid and progressive deterioration of the liver and renal function, and progressed to severe acute liver failure, requiring an urgent liver transplant.

Conclusions: Ascaris lumbricoides is the largest and most predominant of the human helminths. Infection occurs by ingestion of the embryonated eggs. The released larvae from the eggs in the intestine pass through a pulmonary migration phase for maturation. The larvae attain sexual maturity within three months after reaching the small intestine. It is proven that ultrasound can diagnose this worm infestation hepatobiliary in up to 84% of cases, it may however, fail in cases where the parasite has died or the visualisation is hindered by the presence of stones.

Ascariasis of the gallbladder is a very rare occurence and its relationship with acute hepatitis has not been well studied. Therein lies the importance of this case, along with the news of the diagnosis of a case of this type, for the use of ultrasound by the emergency physician.

Background: Injury is a global public health problem and the dominant cause of morbidity and mortality among the young, particularly in industrialized countries. Numerous scoring systems have been developed for trauma. Trauma scoring tools include anatomically-based systems, physiologically-based systems and combined anatomically- and physiologically- based scoring systems. The most frequent scores used in trauma are: Glasgow Coma Score (GCS), Revised Trauma Score (RTS) and Injury-Severity Score (ISS).

Methods: This is a retrospective study, based on data drawn from SMURD (Mobile Emergency, Resuscitation and Extrication Service) and the Clinical Emergency County Hospital of Sibiu, involving patients injured and then admitted between January 2014 and December 2016. The analysis includes 108 patients. For these patients, we have calculated the RTS score considering GCS, the respiratory rate (RR) and the systolic blood pressure (SBP), using the following equation: RTS=0.9368*GCSc+0.7326*SBPc+0.2908RRc,where ”c” represents a coded value between 1 and 4, known from a table based on the parameter value. The RTS values range from 0 to 7.8408, with a higher value indicating increased probability of survival (Ps). After calculating the RTS in the prehospital sheet, we have looked for the final diagnosis after the emergency assessment to observe the evolution of the patient, correlated to those two data. Another score used in trauma is ISS.  For each body region - head and neck, face, chest, abdomen, extremities (including pelvis) and external - we assigned an AIS code (Abbreviated Injury Scale), from 1 to 6.

Results: We’ve evaluated 108 patients aged between 8 and 89, averaging 40 years. Out of the lot, 73.1% were men, whilst de remaining 26.9% were women. By calculating the RTS score, we notice that 83% of the patients have near-maximum chance of survival, over 90%, 4% have 80% chance of survival, 30% chance of survival was attributed to 1% of the patients, 2% of the lot were calculated with 17% chance, while  2% have been scored with extremely low chance of survival, between 4-7%. On the other hand, the ISS score shows 38% are unlikely to cause death, 22% noted with critical values, 33% - linear increase in mortality, 6%-50% probability of mortality, 1% nonsurvivable injury. Tracking patients’ evolution in the emergency department, we notice that 6% of the patients have died in the ER, 81% of the lot were admitted to one of the adjacent departments: surgery, orthopaedics and traumatology, neurosurgery. An additional 2% were transferred to other medical centers and 11% were discharged with instructions/recommendations.  

Discussions:  By comparison between a score based on physiological parameters on spot (GCS, RR and SBP) and an anatomical score (ISS), we notice that the patients’ chances of survival are way higher in RTS compared to ISS. By taking age into consideration, we may have found a reason for a higher RTS score.

Background:Undiagnised and untreated Pulmonary Thromboembolism (PTE) results in high mortality. Echocardiographic assessment is a current vastly used technique in diagnosis of PTE. However, patient’s instablity of situation may provoke a need for faster diagnosis and treatment and lack of access to a cardiologist in emergency department might slowen the procedure.

According to the latest case reports, an emergency medicine specialist is abe to reach favorable results using ultrasonography machine.The purpose of this study is to assess diagnostic accuracy of ultrasound machine in prescription of thrombolytic for patients with massive pulmonary embolism in emergency department.

Methods:This is a cross-sectional study of patients suffering PTE, attending emergency department of Emam Reza hospital (Edalatian) within six monthes. All patients were assessed simultaneously by a cardiologist and an emergency medicine specialist. Both diagnostic methods were assessed according to the presense of four signs including right ventricular dilatation, Mc connell’s sign, hypokinesia of right ventricle and septal paradoxal movements. Results were evaluated using SPSS software (V-19) . Sensitivity, specificity, true positive and negative rates were calculated based on echocardiographic results.

Results:28 patients (17 male and 11 female) were included in the study. The most common abnormal finding was right ventricular dilatation ( 71% in sonograghy and 89% in evhovardiography), followed by septal paradoxal movements and Mc connell’s sign. Sensitivity, specificity, true positive and negative rates of right ventricular dilatation using sonography were assessed to be  80%, 100%, 100% and 37.5 % respectively. And for McConnell's sign the numbers are 67%, 85%, 83%, 69% respectively. In the same manner, the results for hypokinesia of right ventricle are 45%, 75%, 82% and 35%. And for the septal paradoxal movements the results are 57%, 71%, 86% and 36% respectively.

Conclusion:According to the present study, using ultrasonography machine in emergencies is considered to be an appropriate adjunctive utility accompanying echocardiography in diagnosis of cardiac problems resulting from thromboemboly.

Keywords:

Pulmonary thromboembolism, echocardiography, ultrasonography, right ventricular dilatation, Mc connell’s sign, right ventricular hypokinesia, septal paradoxal movements.

Focal assessment sonography is replacing DPL in examinating patient with blunt abdominal trauma gradually .in addition non-radiology physician can perform FAST to improve pation care .assesment pationts with blunt abdominal trauma in emergency department is a problem .specially the assesments and the resusitation of trauma pationts shold be fast .therfor FAST ecan is a suitable diagnostic tool on experienced hands. Emergency physition have used FAST for years .this research was run to evaloate the ability of emergency medicin resident bat pations in comparison to radiology assistants.

Methods:

Across sectional study was doun during three months in tow teaching hospital in tehran iran .Firstly pationt was assessed by an emergency resiedent then a radiologhy resident did FAST .Oral and intravenus contrast-enhance abdominal compioted topograghy CT scanwere applide as refrfenc standard.sencitivity and espicifity FAST of ultrasound determindby any of the groups tothe CT scan.

results:

200 pationt(107 men and 93 women) with the mean age age of30.99+_8 yearswith complaint of abdominal trauma were inclouded .In emergency medicin reports only 16 out of 200 cases(8)were abnormal ,indicating freeabdominal flouid .radiology reported 19 case of abdominal flouid ct scan shoud 18cases of free abdominal flouid. in emergency resident reportthe sencitivity and spicifity 77.77 and 98..90 respectivly .on the other handin radiologhy group had sencitivity of 88.88 and spicifity of 98.35

coclusion:

finally,according to the finding of the study it can be cocluded the fast ultrasoun performed the emergency residentin patient with blant abdominal trauma is accebteble method to detect fiouid in abdominal cavity

Background and objectives

Exposure to ionising radiation represents an increased cancer risk for children. Also the mechanism, severity and management of injuries are different in children compared to adults. Therefore, an alternative approach to imaging in paediatric trauma is necessary. The recent (2014) guidelines of the Royal College of Radiologists (RCR) and the National Institute of Clinical Excellence (NICE) regarding imaging in paediatric trauma reflect the same, advocating judicial use of chest and cervical spine imaging. The objective of this study was to examine whether emergency departments across the East of England Trauma Network use the updated guidance in C-spine and chest imaging for paediatric trauma.

Methods

A questionnaire-based survey was sent to all the hospitals in the East of England Trauma Network to be completed by emergency doctors of any grade. We collected data about the grade of doctors responding and local guidelines used for paediatric trauma imaging. In addition we included a set of six hypothetical scenarios reflecting changes in imaging guidance. For the scenarios the participants were asked to choose what imaging modality they would use (none, plain radiograph, CT, MRI). Examples of these scenarios include: a) a child in a road traffic collision with GCS 12 at the scene, breathing in air, with blocks immobilising the spine, b) a child whose plain films are normal but there is continued clinical suspicion of injury, c) In your practice what is the first-line imaging modality used to assess blunt chest trauma in an unconscious child?

Results

49 ED doctors completed the survey. Analysis of the results showed that a range of different guidelines are used across the region, and 21 respondents (n=49) did not use any specific guidelines. The answers to the scenarios showed that the choice of imaging modalities was largely consistent with the recommendations of NICE and RCR in four of the six scenarios. In two of the six scenarios [b) and c)], the choice reflected the lack of explicit guidance about these clinical situations. However, there was no increased risk of exposure to imaging modalities with higher radiation doses in these particular cases. In fact, comments from several respondents showed that they would like to make more use of MRI, however, organising an MRI is often not possible without delay.

Conclusions

The results of the survey show that there is inconsistent use of national guidelines for C-spine and chest imaging in paediatric trauma. Furthermore, the results demonstrate a need for more clarity in national and regional guidelines. Additional data collection to examine the impact of adherence to guidelines on clinical outcomes represents an exciting future direction for this work.

Abstract

Background:  Hazards of chemical disasters are continuing to increase especially in industrial oil fields. The number of chemical manufacturing facilities and the presence of large quantities of toxic chemicals and hazardous substances among population pose a significant threat to global health and environment.

Objectives:  This study was done to assess preparedness towards chemical disaster among medical staff in remote oil clinics in 2015.

Methodology:   This is a descriptive cross-sectional hospital study.  The population targeted in this research are doctors, nurses and paramedics who work in remote oil clinics in eastern provenance of Saudi Arabia in 2015.

Results:  The total number of 150 participants included in our study .It is noted that nurses are more common to this study 98 (65.3%), the bachelor degree is the most prevalent 75 (50.0%). The age group of 30-39 years is the most common 62 (41.3%).   The number of years which is working in remote area clinic:  the range in less than 5 years was 87 (58.0%), and improved in 5-10 years were 45 (30.0%) attending the lecture in chemical disaster noted that more than a year ago was 70 (46.7%) and less in 6 month and who   reading articles or book in chemical disaster is more common in more than a year ago were 47 (31.3%); according to   utilizing the internet resources to read in chemical disaster is more common in within last 6 months were 56 (37.3%) and also who participated in inside of clinic disaster were 39 (26.0%).  Also within the last 6 month who receiving training/in service on how to use PPE (Personal Protective equipment) was 88 (58.7%), also who receiving training on how to use SCBA full face-piece ( self-contained breathing apparatus) within last 6 months was 49 (32.7%).

It is noted that the difference statistically is not significant in correlation between rate the clinic ability and the number of years working in remote area clinics (P value 0.297)

Conclusion:  The medical staff is not well prepared to take an effective action in case of a chemical disaster.  The essential knowledge of the medical staff in all investigated aspects of chemical safety has been found out to be not satisfactory. The majority of the study population of age group between 30-39 years and had less than 5years work in remote area clinics.

Introduction: Community acquired pneumonia (CAP) is a frequent leading cause of hospital admission worldwide. Through this study we investigate the accurancy of Murray radiological  score (RS) associated to Fine score (FS) as a triage tool for CAP in the emergency department.  

Methods: a prospective observational study including patients admitted in an emergency department of a general teaching hospital for a CAP. FS and RS were calculated on admission and we analysed the rate of hospitalization and outcome at 30 days and analysed  the correlation between the two scores. Statistical analysis were based on Chi 2 test with significant statistical difference (SSD) if p < 0,05.

Results: 174 CAP, 104 men and 70 women, mean age = 57,5 ± 17,7 years. RS was 3 ± 0 in FS class I (n = 6), 3.6 ± 1.4 in class II (n = 46), 3.54 ± 1.5 in class III (n = 40), 4.1 ± 2 in class IV (n = 67) and 4.33 ± 2 in class V (n = 15).  Among patients who were hospitalized in medical ward, 60% of them belongs to class I, 83.3% to class II, 53.4% to class III, 15.1% to class IV and 16.6% to class V. 17.5% of patient hospitalized in ICU had a fine score class III , 52.8% had a class IV and 41.1% had a class V. Checking out  was possible for 40% of patients in class I, 13.9% in class II, 22.6% in class III and 11.3% in class IV. Mortality ranged from 2.8% in class II to 41.7% in class V.

We found an association  between FS and RS (r=0.16, p=0.034). The RS in survivors versus  not survivors in the FS categories was respectively 3.46± 1.3 vs 5±1 in class II, 3.25 ± 1 vs 5 ± 2.4 in class III, 3.7 ± 1.7 vs 4.8 ±2.3 in class IV and 4 ±1.3 vs 5 ±2.5 in class V. There was a SSD only in category II (p = 0.01).

Conclusion: Radiological score may improve Fine score. Further studies with larger cohort are necessary to show better results.

Background:

In the emergency department, admission or discharge decisions are based on clinical symptoms and physical examination. The aim of this study is the Comparison of Assessment of emergency  physician clinical  judgment  accuracy with actual amount of peak expiratory flow rate (PEFR).

Method:

Our research was a cross-sectional study. In this study, 138 patients with asthma by the age of 18 to 55 years were enrolled. From admission to discharge, Clinical signs and symptoms investigated and recorded by emergency  physician then determinate the severity of asthma (mild, moderate, severe). In both stages (admission and discharge) the PEFR was measured by the researcher and compared with severity of asthma (determinate based on clinical symptoms and physical examination).

Results:

37.7% patients were male and the rest were women and the mean age of participants was 49.84 years. The number of cases of mild, moderate and severe asthma were 14, 36 and 88  , respectively in peak flow meter. The number of cases of mild, moderate and severe asthma were 37, 32 and 69  , respectively in clinical judgment. In Assessment of emergency  physician clinical  judgment  accuracy in severity of asthma  in comparison  with  peak  flow  metery the result was the kappa value 0.231 (P <0.001).

Conclusion:

The study showed that clinical judgment of physicians in the emergency department is not a good predictor for prediction of severity of asthma.

Keywords:asthma  attack, peak expiratory flow rate, clinical judgment

Introduction:

  The extra-hospital unexpected delivery is an obstetric-pediatric emergency. Medical tools to determine the imminence of unplanned out-of-hospital birth have not been validated.

The main goal of this study was to analyze assessments of the imminence of these deliveries, by methods such as the Manilas score and the need to push

Patients and method: This was a prospective descriptive study. We searched the MECU-database for all women who gave birth outside the maternity ward with or without the assistance of EMAS teams related encounters registered during 3 months. The results of our study were gathered in an Excel table.

 Results:

 we included Fifteen unexpedcted deliveries. Eight (53%) deliveries occurred in the presence of the SMUR and seven (47%) had already given birth or before the arrival of the mobile emergency care unit (MECU). Risks of unplanned out-of-hospital deliveries represented 1.9% of the calls during the study period.

The mean age was 31 years with extremes ranging from 21 to 47 years.The Malinas score was used for dispatching in only 13% and was not used for intervention in any case. It was estimated that the need-to-push feeling was used for 48% (dispatching) and 44.8% (intervention) of patients. Its sensitivity, specificity and predic-tive values were higher than those of the Malinas score in dispatching and substantially higher in intervention.

14 newborns had an Apgar score of 10; only one stillbirth was recorded with an Apgar score at 0. The average glycemia was 0.82 g / L ± 0.2.

Fifteen women were transferred to a maternity center and 14 newborns were admitted in neonatology service.

Conclusion:

These results argue for the development of tools for estimating the imminence of unplanned delivery. Such tools should be applicable in extra-hospital emergency situations to ensure their use in practice.

Background:

Cervical spine trauma is frequent among trauma patients and is a major public health problem. Spine immobilization is the first procedure of the initial management of patients with a potential injury to the cervical spine in emergency department (ED)

The objective of our work is to assess the knowledge and the technical skills of  paramedics in cervical spinal immobilization.

Methods:

This was a descriptive observational study conducted in the ED that included 44 paramedics. Firstly, self-reported questionnaire survey was distributed, then a practice test using a standardized sheet allowed assessment of technical competencies. The results were analyzed with Microsoft Excel.

Results:

Cognitive abilities:

70% of the students consider that senior supervision in ED is satisfactory. However, they made some suggestions to improve the management of spinal trauma: 75% asked for continuing practical training, 18.8% asked for theoretical lessons and 7% asked for a longer training period in prehospital emergency department.

The management of patients with a spinal injury starts at the scene and continues through to rehabilitation in order to minimize the risk of secondary injury and maximize the potential for recovery.  The management of vertebral column and spinal cord injuries requires an interdisciplinary team approach. Paramedics have a crucial role in initial assessing and managing of spinal injuries and in spinal immobilization which might avoid complications. Continuous training program for all emergency staff seems essential to maintain cognitive and technical abilities of these primary survey actors in the ED.

RESEARCH IS ATHESIS APPROVED BY  EMDM TO ACIEVE THE DGREE

Background Traumatic head injuries are the most common cause of mortality and disability among patients suffering trauma. Applying proper trauma scoring systems plays an important role in the management of these patients thus by means of special treatment guidelines, we can improve traumatic patients’ prognosis.

Objective To determine prognosis in head trauma patients by Madras Head Injury Prognostic Scale (MHIPS) and to compare this scale with Glasgow Outcome Scale (GCS) at discharge.

Methods In this cross-sectional study we evaluated 117 patients with head trauma who were admitted in Shahid Mohammadi Emergency Department (ED) in Bandar Abbas. MHIPS (containing 6 prognostic factors) was used to determine patients’ prognosis at the initial visit in the ED. We used GCS in order to measure patients’ outcome at discharge. All patients’ data were recorded through questionnaire with two separate section: Demographic and Clinical data. We compared the correlation of these two prognostic scales.

Results Of 117 patients, 98 (83.8%) were male and 19 (16.2%) were female. The mean age range of patients was 31.15±17.7. 61 patients (52.1%) had intracranial injuries with subdural hematoma (SDH) being the most common. The highest rate of full recovery (67 patients (87%)) was observed in the group with MHIPS score above 15 and the highest rate of mortality (26 patients (86.7%)) was observed in the group with MHIPS less than 12. There was a significant difference between the two scale when comparing patients’ prognosis (p-value<0.001). MHIPS had correctly estimated patients’ prognosis in 92.3% of cases.

Conclusions: MHIPS has the ability to determine patients’ prognosis in head trauma with high sensitivity and specificity. Thus, it is suggested that an appropriate scale like MHIPS should be provided for the emergency physicians to determine patients’ prognosis in head trauma

Introduction. Meningitis and meningoencephalitis, especially bacterial or herpetic ones, are severe infections who can lead to disabilities or even death in case of non optimal treatment. The first role of the emergency physician is to quickly identified viral from bacterial meningitis. However, some uncertainty in the sequence of initial diagnostic procedures may delay the administration of the appropriate treatment and moreover, delay antibiotics first dose. The objective of our study was to assess the management of these patients in our emergency department.

Methods. We conduced a retrospective, monocentric, observational and descriptive study from January 2009 to December 2015. All patients admitted to the ermergency department for meningitis or meningoencephalitis were included. The primary endpoint was the median time between management and administration of antibiotics.

Results. Of the 276 patients included, 46% had the fever-headache-stiffness triad. The median age was 47.3 years (Inter-Quartile Range (IQR): 28.2-64.2). Twenty patients (7.2%) had sepsis (qSOFA≥2) and 2 (0.7%) experienced septic shock. The diagnostic procedure distinguished 64 (23%) patients suspected of bacterial etiology, 158 (57%) of viral etiology and 54 (20%) unspecified. A cerebral scan was performed for 150 patients (54%) before lumbar puncture. The median time to perform lumbar puncture was 4.78 hours (IQR= 2.57-7.3) and the appearance was cloudy for 31 patients (11%). Patients with an abnormal cerebrospinal fluid received C3G in combination with amoxicillin in 75% of cases, and with aciclovir in 29%. When a viral origin was suspected by the clinician, 40% of the patients were not treated. However, in the case of viral encephalitis or meningoencephalitis, only one patient haven’t be treated with aciclovir. In case of suspected bacterial meningitis, the median time to first antibiotics was 5.15 hours (IQR = 2.03-7.52) after admission and 1 hour (IQR= 0.22-1.97) after the lumbar puncture. Interestingly, only 53% (N=145) of the emergency diagnosis was consistent with the final diagnosis.

Conclusions. Our study showed that the delay in the management of meningitis and meningoencephalitis in the emergency department did not respect the guidelines deadline for treatment. Particularly, it seem that the time required to perform the lumbar puncture could be the the reason for increasing treatment delay.

Aim: The aim of this systematic analysis of the International Alpine Trauma Registry was to identify associated factors of hypothermia in patients sustaining multiple trauma in alpine or wilderness environment.

Methods: Patients included into the International Alpine Trauma Registry between 2011 and 2013 were analysed. This registry is a prospective, comprehensive multicentre study implemented to collect data based on the Utstein Style Protocol from multiple trauma patients rescued from alpine or wilderness environment. An exploratory data analysis was performed using a classification tree with CHAID, CRT, multinomial logistic regression and One-way ANOVA.

Results: A total of 104 patients (15.4% female and 84.6% male) were included into the study; overall mortality was 13.5%. According to their body core temperature (mean 31.0°C±5.3°C) patients were divided into three groups: group 1 ≤31,0°C (9,1%), group 2 31,1°C – 35°C (49,1%) and group 3 ≥35,1°C (41,8%). The exploratory data analysis using CHAID identified primarily external factors like avalanche burial (p=0.004), winter season (p=0.023) to be associated with hypothermia. Secondary classification associated internal factors like severely impaired coagulation (INR > 1.3) (p=0.025) with the presence of hypothermia. Considering the severity of a critical multiple trauma, hypothermia was related with a lower injury severity score (ISS) 16-49 (p=0.011). Logistic regression identified further shock related factors like lower systolic blood pressure (p=0.001), severely impaired coagulation (INR > 1.3) (p=0.025) and higher arterial base excess (p=0.005) to be associated with hypothermia.

Conclusion: This systematic review of accidents in an alpine or extra-urban terrain identified environmental factors (avalanche burial and winter season) and accident associated factors like severe anaemia and shock as associated factors for hypothermia in the multiple trauma patient. In the present study, patients with an ISS

Outlook: A subsequent analysis including a larger number of cases is planned to further explicate the critical role of accidental hypothermia for multiple trauma patients. Furthermore, an in-vitro study, elucidating the effects of hypothermia on coagulation in an experimental setting is currently in progress.

Introduction: It is known that overcrowding, length of stay (LOS) and boarding in the Emergency Department (ED)  increase the risk of patient safety events and increase patient dissatisfaction. The effect of EDLOS on patient in-hospital mortality (IHM) remains unclear.

Objectives: Our main objective was to systematically review the literature for evidence on the association between EDLOS and 30-days IHM.

Methods: Articles selected were focus on the association between EDLOS and 30-days IHM. Literature search strategies used MeSH and text words related to EDLOS. Search was performed on Medline, Embase, Cochrane Library, Web of Science, CINAHL and PsycNET. The selection of articles was done with F1000 software. Two reviewers independently screened the titles and abstracts yielded by the search to identify relevant abstracts. Full articles with the title or abstract meeting the inclusion criteria were retrieved and the reviewers selected those that meet inclusion criteria. Data extraction included study characteristics, prognostic factors, outcomes, and 30-days IHM. After the systematic review, we performed a meta-analysis using the Mantel–Haemszel method and the DerSimonian Laird estimator for the estimation of heterogeneity with tau² and I²_. The cut off of the EDLOS was 8 hours (<8 hours or >8 hours). Odds ratio were combined by using the inverse variance method.

Results: From 3,577 references screened by the two independent reviewers 135 references were selected. After the first step of exclusion of references that didn’t match with the search, 68 papers were selected. Finally, after the last round of screening, the reviewers selected 5 papers. The total number of patients included was 119,174. The random effects model found an OR of 0.98 with CI [0.79; 1.21] and a p-value of 0.8505. The heterogeneity was high with Tau² of 0.0342 and I² of 83%.

Conclusion: Our systematic review and meta-analysis didn’t find an association between EDLOS and 30-days IHM. There is no increase in mortality in patients staying more than 8 hours in the ED. Because of a high heterogeneity, further large and multicenter studies are needed.

Aim:

To clarify the relationship between number of ambulance visits to 0 to 18 years old patients with asthma and weather conditions - air temperature and relative humidity.

Topicality:

5–10% of the population suffer from asthma – it affects approximately 300 million individuals worldwide. Asthma is the most common chronic disease in children – about 7 million children have asthma. Asthma cannot be cured, but it can be controlled and patients can live a wholesome life.

Material and methods: State Emergency Medical Service records of 0–18 years old asthma patients (n = 1 031) were analysed during the period from 2010 to 2012. Meteorological monitoring data (average temperature and relative humidity) from 23 monitoring stations of Latvian Environment, Geology and Meteorology Centre were used.

Conclusions:

1. The largest number of ambulance visits were performed to 0 to 5 years old patients – 481 ambulance visits or 46.7%;
2. Number of ambulance visits statistically significantly differs by gender and age (χ2=37.88, p=0.003, df=17). 66.8% or 689 visits were to boys and 33.2% or 342 visits to girls;
3. The largest number of ambulance visits were performed in September – 16.6%  (n = 171);
4. 94 % or 970 ambulance visits were made when 3 days average relative air humidity was above 60%;
5. Statistically significant difference was observed in number of ambulance visits in different groups of 3 days average temperature and relative humidity. The largest number of ambulance visits were observed when 3 days average temperature was from  +10,1ºC to +20ºC and relative humidity was above 60% – 41.1% (n = 399), (χ2= 23.1; P<0.001; df=5);
6. The largest number of ambulance visits - 77,3% (n – 797) were performed out of GPs working time between 5:00pm – 8:00pm and in holidays:
7. Asthma patient health care in primary health care level has to be sustained and promoted to improve asthma control for children.

Objective: Evaluation of the mortality rate (MR) and its association with the blood pressure levels (BP) in the first 24 hours of an hemorraghic cerebral vascular accident (H CVA) of patients in the ICU of the Clínicas Hospital Complex of UFPR (CHC – UFPR) and, among the survivors, evaluation of the consequences by using scales of Rankin and Barthel

Methods: Analytical, retrospective and observational study of 47 medical records of patients hospitalized in the Adult ICU of the CHC-UFPR with diagnosis of H CVA in the years 2012, 2013 and 2014.The patients were divided in 3 groups according to the arrival systolic blood pressure (SBP). The group 1: SBP between 110-140 mmHg, group 2: between 140-180 mmHg, group 3: above of 180 mmHg. Three functional scales were used to analyses the results: Glasgow coma scale, Barthel index and modificated scale of Rankin. 

Results: Among the 47 patients, 25 developed to death (53,19%). The group 1 with 7 patients in total showed the highest MR (71,42%), followed by the group 3 with 19 patients (52,63%) and, the last one, the group 2 with 21 patients (47,61%). In the evaluation of the modificated scale of Rankin the values were from 1 (10%) to 5 (20%) and for the Barthel index were from 5 (5%) to 100 (11%).   

Conclusion: The BP levels in the first 24 hours of an H CVA could not work alone, however in assotiation with age, days of hospitalization and arrival Glasgow values for example to determinate the mortality rate.

INTRODUCTION

Bronchial asthma is currently one of the most common diseases worldwide, with over 30 million affected people in Europe alone.

This study aims to highlight the evolution of the number of patients with asthma in the last three years, and the existence of many associated pathologies that may be an impediment to appropriate treatment.

MATERIAL AND METHOD

We conducted a retrospective observational study on a total of 190,864 patients presented at the Emergency Room of Sibiu County Emergency Clinical Hospital with the following annual distribution: 62,804 (32.9%) - 2014, 64,023 (33.54% ) - 2015, 64.037 (33.5%) - 2016.

RESULTS

In the study period, of the total of 190,864 patients presenting with UPU-SMURD Sibiu, 418 (0.22%) were diagnosed with asthma, with the following yearly distribution: 182 (43.54%) in 2014, 145 , 69%) in 2015 and 91 (21.77%) in 2016.

The monthly distribution of patients diagnosed with asthma is the following: January - 49 (11.72%), February - 54 (12.92%), March - 29 (6.94%), April - 35 (8.37% ), June - 37 (8.85%), July - 17 (4.07%), August - 29 (6.94%), September - 33 (7.90%), October - December - 32 (7.66%).

204 (48.80%) of patients diagnosed with asthma during the study had associated pathology as follows: 92 (22.19%) - 2014, 74 (17.66%) - 2015, 38 (9.06% 2016.

127 (30.38%) of patients required hospitalization, thus in 2014 - 59 (32.2%), 2015 - 48 (33.1%), and 2016 - 20 (21.97%).

CONCLUSIONS

Patients diagnosed with asthma represent 0.22% of all patients who presented themselves during the study at UPU-SMURD Sibiu.

During the study, there is a tendency to decrease the number of patients with asthma present at Sibiu Emergency Room.

The manifestations of the bronchial asthma are more frequent in January, February and lower in July.

Almost half (48.80%) of patients with asthma have associated pathology.

Almost one-third (30.38%) of them needed hospitalization.

Back pain is one of the commonest presentation to the Emergency Department and is a leading cause of days of work in the world.A large majority of this is related to traumatic injuries.

We will try and describe a case about a 67 year old female who presented to the Emergency Department with a 3 month history of atraumatic lower back pain and gradual loss of the ability to walk.We will try and describe the various possible differential diagnosis and then go onto to describe the vaious investigative modalites used for this patient.

This was an unusual case whereby the patient had a spinal abscess with no obvious causative reasons and we will describe how this was treated at our facility

INTRODUCTION:

The most frequent arrhythmia in an Emergency Department (ED) is atrial fibrillation (AF). It is important to observe how these patients are managed at their exit from the ED.

OBJECTIVE:

To know the variables that influence the decision of discharge or admission of the patients with diagnosis of AF in the ED.

MATERIAL AND METHODS:

A retrospective, descriptive, observational study to rewiev the medical histories, collecting 762 patients diagnosed with AF in the period from 1^st October  2012 to 30^th December 2013 in the ED of Hospital General Universitario Reina Sofía in Murcia (Spain). Studied variables: patient disposition (discharge, home, consultation), length of hospital stay [less than 48 hours (<48h), more than 48 hours (> 48h), undetermined], history of AF, referral to cardiology, anticoagulation at discharge and if they had AF or sinus rhythm (SR) before leaving the SU. For statistical analysis: ISBN® SPSS.

RESULTS:

Of the 762 patients diagnosed with AF, 70.99% were discharged and 23.62% were admitted.

Of patients discharges, 54.52% were in RS, of these, more than 92% had a clinic of <48h of evolution. In FA, 45.28% of the patients went home, 13 of them, 46% had no previous history of AF, anticoagulated to 85.42% and referred 50% to cardiology consultations.

Of the patients admitted to hospital, 22.22% were hospitalized in sinus rhythm, of these, in 65.0% the length of hospital stay was <48h. In the AF, 74.44% were admitted, with a symptomatology duration of one third for each group of this variable .

CONCLUSION:

Most patients with AF are discharged directly home, half of them in SR, with 90% having a duration of symptoms <48h, so it is deduced that intervention in ED is effective in a high percentage.

A 13.46% without history of AF are discharged in AF, with anticoagulants being more than 85%.

More than 22% were admitted in RS, where 65% had a duration of <48 hours, deducing that there are other factors that are influencing the decision of admission and requires further study.

INTRODUCTION:

Atrial fibrillation is a common reason for consultation in the Emergency Services, requiring rapid and effective treatment, especially in cases involving hemodynamic instability, taking into account specific situations such as structural heart disease.

OBJECTIVE:

To evaluate in patients with structural heart disease who needed control to sinus rhythm those who underwent pharmacological cardioversion, efficacy and type of antiarrhythmic drugs used.

MATERIAL OR PATIENTS AND METHOD:

A descriptive, observational, retrospective study in the Emergency Department of the Reina Sofía University General Hospital of Murcia, which serves a population of 200,000 inhabitants and 275 urgencies / day in which all patients with a diagnosis of Atrial Fibrillation (AF) Between October 1, 2012 and December 30, 2013, who had previous structural cardiopathy measured by previous echocardiography up to 2 years previously meeting the inclusion criteria 762 patients.

Variables to study: presence of structural heart disease, pharmacological cardioversion (FCV) performed, efficacy of FVC, antiarrhythmic drug used.

RESULTS:

During the years 2012 and 2013, 762 patients were diagnosed with AF, of whom 31.76% had structural heart disease, 38.4% had hypertrophic heart disease, 35.95% had valvular heart disease, and in one 16.94% ischemic. Of the total percentage of structural heart defects, 16.94% of the patients had a rhythm control, 39.02% of which was effective in 75% of the cases. Of the same, 58.33% were treated with Amiodarone, 16.67% with Flecainide and 16.67% with Vernakalant.

CONCLUSION:

- In approximately 50% of patients with structural heart disease treated with FVC the antiarrhythmics of choice was Amiodarone in line with clinical practice guidelines.

- Most previous echocardiographies showed Hypertrophic and Valvular Cardiopathies as shown in the literature.

- Some patients were treated with Vernakalant as an alternative to Amiodarone for FCV in patients with AF as they support clinical practice guidelines in patients with mild HF (NYHA I-II), including patients with ischemic heart disease, provided they do not Hypotension or severe aortic stenosis.

Eighty nurses working in Emergency Room, ICU, Intensive Neurological Department, Cardiac and Vascular surgery were anonymously polled.

The survey was conducted between 01.10and 31.12.2016 at the work place.

1. Aim

To examine attitudes and opportunities for continuous education and professional development for nurses at the National Cardiological Hospital - Sofia.

1. Methods

Database research- Documents and statistical data of the National Cardiological Hospital – Sofia were examined.

Monitoring - Observation of nurses working in the Emergency Room in the course of three months.

Survey methodology - Questionnaire consisting of 18 questions.

1. Results

20% of nurses who took part in the survey are aged 30 to 40 years, 22% - 40 to 50 years, 32% - 50 to 60 years, and 6% are over 60 years old.

10% of respondents have secondary education, 28% have a college education, 30% have undergraduate education and 12 % have master's education.

68% of the medical professionals consider it necessary to continue their education.

34% of nurses wish to continue their education in higher educational degree, 45% seek to participate in training and other vocational courses, 8% wantto participate in research projects and 13% wish to further their education on their own.

82% of surveyed nurses statethat they have participated in training courses before.

78% of nurses explicitly state that they are willing to re-engage in various post-graduate courses.

25% of respondents were met with understanding and support from their superior in their desire to improve their skills, 55% weren’t met with support and understanding, and 20 percent only had partial support from their superiors.

15% of nurses responded that they would like to develop skills in the field of research and to pursue a doctoral degree, 64% have no desire for scientific work, while 31% are undecided.

1. Conclusion

A large percent of nurses at the National Cardiological Hospital - more than 50% -have the desire and opportunity tocontinue their education and increase their qualifications. Most of them have attended post-graduate courses.

Surprisingly a lot of the questioned medical professionals want to participate in courses focusing on improvement of communication skills for working with rude and aggressive patients.Frequent attacks on medical teams are well known and are becoming part of everyday life for nurses and doctors.Therefore emergency care professionals should have to pass through such courses periodically.

Another conclusion of the study is that nurses associate receiving additional training and skills with higher pay.

Continuous training of medical professionals helps them to perform their tasks more accurately and to fully realize their capabilities. Improving staff qualification is the main factor that ensures continuous advancement of health care efforts.

Introduction:

In Romania there is a shortage of healthcare professionals who provide care to patients in need. Migration of health personnel has led to situations that require a workforce management adapted to new requirements.

 Objectives:  Romania's accession to the EU has had a positive result on the quality of nursing provided by nurses. The new socio-professional offered to conduct the profession led to the development of nursing Romanian to new areas: scientific research, psycho-pedagogical training, continuing medical education.Through this work I intend to stress the importance of nursing research results in developing the nursing profession in extreme situations experienced in medical practice.

Material and method: Descriptive transversal study conducted in the North East region Romanian of investigation used as a method of quantitative research in the period 1 March to 30 April 2017. The instrument is the questionnaire applied research nurses. It comprises 10 factual questions, closed questions with pre-coded answer open questions with answers and free. The sample includes a total of 357 participants. Study data were statistically analyzed whit program Microsoft Office Excel 2007 .

Results:  In the NE of Romania there are 164 health units representing 12.07% of all health units in Romania in public ownership. Some hospitals  in poor condition with outdated technical equipment and human resources (56.88%) presents favorable conditions for the emergence low situations. Supervision and care of large numbers of patients causes conflict situations (64.51%), complaints of patients that have an impact physically, mentally and emotionally on the nurse (76.75%). Limit situations in medical practice management was performed by the entire medical team (69.19%). The nurse has an important role in managing critical situations involving the elaboration of the practice. Health education of patients represents a gain in nurse-patient relationship with a positive influence on the quality of nursing( 66.95%). 

Conclusion:

Awareness campaign about the effect on the quality of nursing limit is achieved by developing good practice guides and courses of prevention and management situations. 

Enhancing medical education of the population through health promotion actions and the introduction of health education as a subject in schools.

Involving government policymakers towards equipping the health units and medical personnel deficit reduction can reduce the occurrence of situations.

Bibliografy:

1. http://www.mdrl.ro;

2. Arch Pediatr. 2010 December; 17 (12): 1696- 708. The alliance of the parent, child and the nurse to challenge medical error;

3. Int J Nurse Stud. 2016 Jan; 53: 95-104. Distress working on dementia wards - A threat to compassionate that: A Grounded Theory study. 

Background: Acute coronary syndrome (ACS) includes all clinical syndromes occurring with acute myocardial ischemia. The pain in ACS is difficult to assess and can be misleading because its subjectivity. Depending on the ECG changes ACS can be divided to ST - elevation (STEMI) and non–ST- elevation (NSTEMI) myocardial infarction. About 30% of all heart attacks are NSTEMI. Changes in biomarkers of myocardial ischemia depend on how much time has passed, as well as the patient’s comorbidity and it can give false-positive or negative results.

Methods: Analysis of 2 cases of atypical ACS

Results: I.B.K. man at the age of 57 is admitted to the ER 12 hours after he was awakened by severe pain in the left shoulder and neck, which lasted 2 hours and decreased after intake of Metamizole 500mg. Accompanying diseases: hypertension, dyslipidemia, IHD triple-vessel disease 2012 (PCI D2, PCI+ x2LAD, PTCA D2). Six months ago – CPET interrupted due to hypertensive crisis without ECG changes. Intake of medicines stopped 6 months ago. Status: hemodynamically stable, ECG - discrete depression of the ST segment in V4-V5; Vesicular breath sounds bilaterally; Abdomen – soft, non-painful with preserved peristalsis; Limbs - no swelling. Laboratory - TrI 28,86; SCAG - calcification of coronary arteries, trunk of LCA - eccentric calcified plaque in the distal segment without stenosis; LAD artery - open stents. D1 – restored blood flow after PTCA, OM2 80-85% stenosis. RCA - dominant artery with long significant stenosis 85-90% in the medial segment. PCI of D2 and RCA.

S.S.D. man at the age of 55 is admitted to the ER 14 hours after in the night he had pulsing chest pain after exercise and consumption of alcohol. In the morning the pain was stronger. The patient was examined by cardiologist and referred for consultation in the emergency room. In ER he complains from tightness in the chest. Comorbidities - not reported. Status- hemodynamically stable. ECG - discrete ST- depression in lateral leads; Vesicular breath sounds bilaterally; Abdomen – soft, non-painful with preserved peristalsis; Limbs without swelling; Chest X-ray - suspected infiltrative shadow in the right apical area. Laboratory - TrI 6,69. SCAG - chronic occlusion of RCA with collateral filling of LAD and subtotal occlusion of OM1. PCI + 2xDES OM1.

Discussion: It is difficult to diagnose ACS in ER because of lack of medical records and history, misinformation from patient and relatives, exaggerated or neglected complaints, lack of time for thorough examination. Diagnosing ACS must be a dynamic assessment of the presenting symptoms and ECG changes; assessment of the co-morbidity and risk factors; evaluation of lab results. Assessing these factors separately could be misleading.

Introduction :

Recreational scuba diving has become a popular activity in the past 30 years. Although divers are concentrated along coastal regions, many others dive in inland lakes, quarries and reservoirs, or pit dive. Emergency Physicians may see patients with non-specific complaints and need to think to dive-related accidents. A new dive center with a scuba diving pit dive is in place since 6 years training more than 500 divers every weekend. We present 6 cases of patient’s visits in our ED (43,000 visits/year) with non-specific disorders and unusual clinic presentations.

Case Report

Case N°1: Male, 50 y-o, visits the ED with a non-traumatic tendinopathy on his left ankle. A second visit 48h later diagnose a Decompression illness (DCI)

Case N°2 : Female 40 y-o, no medical history, activation the ED Team Stroke for a sudden weakness in her right leg. MRI was normal. Diagnosis of DCI  

Case N°3: Male 53 yo, suspicious of Transient ischemic attacks (TIA) accompanied by nonfocal symptoms like paresthesia on his lips since 24h. DCI (bend) accident was confirmed.

Case N° 4: Male 51 yo, suspicious of ischemic stroke after a 25 minutes dive at 20 meters depth with a “yo-yo diving”. MRI was normal

Case N° 5: Male 37 yo, no medical history, weakness and paresthesia on his left elbow 24h after a 20m dive.

Case N°6 : Female 49 yo, sudden hypoesthesia of left leg 4 hours after her 18m dive. MRI normal.

The majority of disorders are presenting during the first 24 hours after the dive. We searched for nonfocal symptoms like decreased consciousness, amnesia, non-rotatory dizziness, and paresthesia and search for DCI linked to patient’s dives. Three patients with neurologic disorders (case N° 2 ,4,6) went to the hyperbaric recompression chamber in the first hours after their dives, with a complete recovery of the symptoms.

Discussion:

The Divers Alert Network reports 1,000 divers are treated with recompression therapy for severe dive-related complications with an average rate of 90 fatalities per year. In France, 350 related-dive accidents happen every year. Patients are male (2/3) mean age 45 y-o, 12 % are beginners and 45% good experience in scuba diving. The majority (98%) of dive accidents are along coastal regions (sea, lake), 2% in pools. Risks factors of DCI are related to the maximum depth of the dive: 5-25m (30,5%); 25-40m (47,5%); 40-60m (17%); >60m(1,7%). According to literature the risk of DCI or arterial gas embolism is 2 for 10,000 dives: 66 % spine accidents, 23 % strokes 8 % vestibular 3 % articular events. International scuba diving guidelines provide instructions to all divers and first aid recommendations to first responders, paramedics and emergency physicians for the diagnostics and treatment of diving accidents with therapeutic hyperbaric chambers recommendations.

Conclusions: Diagnostic of DCI are not easy when symptoms are unusual 24 h after a scuba diving exercises particularly when the ED is not familiar with specific procedures. Procedures may include early detection of DCI and rapid transport to recompression hyperbaric center.

Objectives

The objective of this study was to explore the outcome of patients admitted to ACB (Acute Care Bay, Medical HDU) from ED (Emergency Department) who required further ICU(Intensive Care Unit) admission.

Methods

We conducted a retrospective study for 1 year period 01/01/2016-31/12/2016 for 54 patients admitted from ED initially to ACB who required ITU admission afterwards.

Results

The patient’s age were:14.81% of 16-34 years old;18.51% of 35-54 years old;42.59% of 55-74 years old;24.07% of 75-95 years old.

The patient’s functional status was:83.33% independent;3.69% using a stick;7.41% using a frame;3.69% using a wheelchair and 1.85 % requiring full daily care and being morbid obese respectively.

In ED 16.66%cases were reviewed by solely a junior doctor,whilst 27.77% cases were reviewed by solely a senior doctor and 40.74% cases were  reviewed by a junior doctor&senior . 

Following referral to ICU from ED 20.37%cases were reviewed by ICU team within ED from which 5.55% were  declined;1.85%cases were discussed with ICU  over the phone and declined. For 77.77% cases ICU contact wasn't recorded in ED notes.

In ED-14.81%cases were reviewed by ACB team12.96%cases were discussed with ACB registrar over the phone and for 72.22% cases the ACB contact wasn't documented in ED notes.

The length of stay on ACB was:less than 14 hours for 31.48% patients:15 hours-1 day for 42.59% patients;1-2 days for 9.25% patients;2-3 days for 3.70% patients;3-6 days for 7.40% patients;6-10 days for 3.70% patients. The interventions performed on ACB were NIV for 7.40% patients and CPAP for 18.51% patients.

The ICU length of stay was:less than 1 day for 12.96% patients;1-5 days for 51.85% patients;5-10 days for 14.81% patients;10-20 days for 12.96%  patients;20 days-1 month for 3.70% patients and 1-3 months for 3.70% patients.The ICU admitted patients received  interventions as:invasive ventilation-50% patients from which 11.11% patients required tracheostomy;CPAP-12.96% patients;haemofiltration-24.07% patients; Noradrenaline infusion-37.037% patients;Noradrenaline and Vasopressin infusion-1.85% patients;Adrenaline infusion-3.70% patients;Potassium infusion-11.11% patients.The ITU outcome was:68.51% patients were discharged alive and 31.49% patients died.

Conclusions

68.52% cases were reviewed by ED senior.Whilst only 14.81% patients were reviewed by ACB registrar in ED and only 20.37% were reviewed by ITU registrar in ED.Documentation couldn't be found in more than 70% of cases. All this aspects will require further improvement.

74.07%cases had a length of stay on ACB for less than 1 day before being transferred to ICU.

The average admission on ICU was 1-5 days for 51.85% patients and ICU outcome death was 31.49% patients.

The aspects highlighted above including early senior input & documentation within medical notes will require improvement;a meeting between ICU, ACB and ED senior team members to agree a more seamless transfer process and earlier patient reviews will be organized.

Objectives

The objective of this study was to explore the outcome of patients admitted to ACB (Acute Care Bay, Medical HDU) from ED (Emergency Department) who required further ICU(Intensive Care Unit) admission.

Methods

We conducted a retrospective study for 1 year period 01/01/2016-31/12/2016 for 54 patients admitted from ED initially to ACB who required ITU admission afterwards.

Results

The patient’s age were:14.81% of 16-34 years old;18.51% of 35-54 years old;42.59% of 55-74 years old;24.07% of 75-95 years old.

The patient’s functional status was:83.33% independent;3.69% using a stick;7.41% using a frame;3.69% using a wheelchair and 1.85 % requiring full daily care and being morbid obese respectively.

In ED 16.66%cases were reviewed by solely a junior doctor,whilst 27.77% cases were reviewed by solely a senior doctor and 40.74% cases were  reviewed by a junior doctor&senior . 

Following referral to ICU from ED 20.37%cases were reviewed by ICU team within ED from which 5.55% were  declined;1.85%cases were discussed with ICU  over the phone and declined. For 77.77% cases ICU contact wasn't recorded in ED notes.

In ED-14.81%cases were reviewed by ACB team12.96%cases were discussed with ACB registrar over the phone and for 72.22% cases the ACB contact wasn't documented in ED notes.

The length of stay on ACB was:less than 14 hours for 31.48% patients:15 hours-1 day for 42.59% patients;1-2 days for 9.25% patients;2-3 days for 3.70% patients;3-6 days for 7.40% patients;6-10 days for 3.70% patients. The interventions performed on ACB were NIV for 7.40% patients and CPAP for 18.51% patients.

The ICU length of stay was:less than 1 day for 12.96% patients;1-5 days for 51.85% patients;5-10 days for 14.81% patients;10-20 days for 12.96%  patients;20 days-1 month for 3.70% patients and 1-3 months for 3.70% patients.The ICU admitted patients received  interventions as:invasive ventilation-50% patients from which 11.11% patients required tracheostomy;CPAP-12.96% patients;haemofiltration-24.07% patients; Noradrenaline infusion-37.037% patients;Noradrenaline and Vasopressin infusion-1.85% patients;Adrenaline infusion-3.70% patients;Potassium infusion-11.11% patients.The ITU outcome was:68.51% patients were discharged alive and 31.49% patients died.

Conclusions

68.52% cases were reviewed by ED senior.Whilst only 14.81% patients were reviewed by ACB registrar in ED and only 20.37% were reviewed by ITU registrar in ED.Documentation couldn't be found in more than 70% of cases. All this aspects will require further improvement.

74.07%cases had a length of stay on ACB for less than 1 day before being transferred to ICU.

The average admission on ICU was 1-5 days for 51.85% patients and ICU outcome death was 31.49% patients.

The aspects highlighted above including early senior input & documentation within medical notes will require improvement;a meeting between ICU, ACB and ED senior team members to agree a more seamless transfer process and earlier patient reviews will be organized.

The Emergency Department (ED) at Portiuncula University Hospital currently has 2 Advanced Nurse Practitioners providing a 5 day a week 8am-6pm minor injury service integrated with a full 24 hour Emergency Service. 2,685 patients were seen by ANP’s in 2016. The ANP service has made a significant impact on patient waiting times, patient satisfaction and confidence. ANP’s clinical remit is to focus on minor injuries in adults and children over the age of 4 years and under the age of 16 years.

The study analysed attendances to the ANP service by children between the ages of 0 to 16 years over a period of 12 months in 2016. The aim was to identify the prevalence of minor injury types in smaller children and strategies to improve service delivery to this cohort. The age of the patients, type of injury, waiting times and patient disposals/referrals were recorded to a data sheet.

During the 12 month audit period 506 new cases received treatment. This was reflective of 19% of total patients seen by ANP’s (N=2,685) and 7% of total paediatric ED attendance (N=7,094). There was no major disparity in the timeliness of the service in comparison to the adults with the average check in to be seen by ANP (10 minutes) and check in to discharge 1hr 19 mins. The most common age groups were 13 to 16 years: 50% (N=255) and 5 to 12 years: 39% (N=197).The 0 to 4 years age group (currently shared care with ED Doctors) accounted for 11% (N=54).  Below elbow injuries (N=113) were more common in the 13 to 16 years age group whilst wounds (N=16), burns/scalds (N=6) and elbow injuries (N=9) were more common in the 0 to 4 year age groups. 71% of patients were treated completely by the ANP ED service while orthopaedic and plastics referrals were required by 27% (N= 137) and 2% (N=8) respectively.

Paediatric attendances account for a significant portion of minor injury attendances. Paediatric attendances often pose greater challenges in terms of examination, communication and treatment. There appears to be a number of patterns in terms of age related injuries but these may not be generalisable as the figures for the 0 to 4 years (currently outside the ANP scope of practice) would not be representative of overall injury attendance for this age group. An increase in upper limb injuries in older children most likely reflects sports related in particular hurling, however more investigation is required. Minor wounds, burns/scalds, and elbow injuries specifically pulled elbow in age groups younger than four years are of interest in terms of development of local policies to allow for expansion of scope of practice to provide autonomous service in these areas.

Automated External Defibrillator (AED) - use on public places in Slovakia. 

Abstract

About 23% sudden cardiac arrest (SCA) have shockable rhythm. Defibrillation within 3-5 min of collapse can produce survival rates as high as 50-70%. Early defibrillation can not be achieved through Emergency Medical Service, because average arrival time on scene in Slovakia is 11 min for crew with physician and 12.38 min for crew with paramedic. Early defibrillation can be achieved by public access or onsite AEDs.

Situation about AEDs in Slovakia is described. Poster presents expected AEDs, their location and use. Authors point to fact, that there are no binding obligation for registration of purchased AED and its localization. Central register of AEDs does not exist. Surrounding European countries have registers of AEDs and projects of early defibrillation with good outcomes. Analyse shows that defibrillation through AED did not run regularly in Slovakia, few case reports are illustrated. Therefore urgent priority is established the national register of AEDs. Emergency Dispatch Center should coordinate and evaluate use of AEDs, they have an advantage because of authority on whole Slovak area.

Unknow is number (estimate approximately about 600 AEDs per 5,4 mil. inhabitants), exact localization and owner of AED, so authors suggest:

1. Obligatory register of purchased AEDs by law
2. Establish a central register of AEDs (place, type, brand, phone contact, public access AEDs or mobile AEDs and each use) connected to Emergency Dispatch Center of Slovak Republic.
3. Gain approvals for public use also in surroundings of  owning institution.
4. 4.      Optimize an existed placed AEDs. Placing AEDs in area of most effective use.
5. Ensure periodic control and revision of AEDs
6. Create a network of first responders and ensure their training
7. Train laypersons in basic life support and use an AED
8. Support and disseminate AEDs use by laypersons.
9. Establish serious research and support

Key words: sudden cardiac arrest, early defibrillation, automated external defibrillator, register of AED.                                                    

Purpose: The central veins that are usually cannulated are the jugular, subclavian and femoral. As we know ultrasound guidance can reduce complication rates and increase the success of cannulation. We present a case of ultrasound-guided axillary vein placement catheter by Emergency Physicians. This approach is not widely used among emergency physicians. We set an objective to spread this technique among emergency physicians because of its safety features for the patient.

Material & Methods: a patient addicted to parenteral drugs, was admitted to the ER in septic shock condition.

Results: 52 year old woman addicted to parenteral drugs, stage C3 HIV with 2 weeks duration fever. On arrival had malaise, hypotensive, febrile, tachycardic... it was not possible to catheterize a peripheral vein we performed a central line cannulation: ultrasound-guided infraclavicular axillary vein. Less arterio-venous overlap and a greater distance between artery and vein and from vein to rib cage should provide an increased margin of safety for central venous cannulation. We will describe step by step, accompanied by images, the steps necessary to achieve infraclavicular axillary vein cannulation.

Conclusion: The ultrasound-guided axillary approach offers a number of potential advantages over others central line cannulation. The anatomy favours ultrasound guidance and less complications. Manual compression of the axillary artery or surgical access is possible if arterial damage is caused. The puncture site is further away from potential sources of infection in patients with tracheostomy, central chest wall burns or sternotomy wounds. Once mastered, this is a safe, useful, and reliable technique for central venous access, so the axillary vein is an alternative for central venous cannulation, as can be seen in the case presented, an effective alternative to US-guided IJV and SCV cannulation.

Introduction

Heterotopic pregnancy (HP) is diagnosed in the presence of simultaneous gestations at two or more implantation sites. It was first reported in the year 1708 as an autopsy finding. Its occurrence is rare in spontaneous conception with an incidence of 1:30,000, while in assisted reproductive techniques (ART), the incidence is found to be as high as 1%. We report a case of HP in a natural conception cycle that presented with tubal rupture.

Case presentation

— A 33 years old female presents to our Emergency department at 4:00 am with complaints of lower abdominal pain since 7-8 hours, nausea and 3 episodes of vomiting in that duration. She also complains of difficulty in passing urine and pain while passing stools. She was 6 weeks pregnant after which she experienced PV bleeding and was diagnosed as spontaneous abortion. Dilatation and curettage was done with uneventful post procedure and discharge of the patient. After a week she presented to our ED with above complaints. On general examination she was pale and alert but distressed with pain with pulse rate of 90/min and Blood pressure of 90/50mm Hg. Abdominal examination revealed diffuse, lower abdominal tenderness with significant guarding and rigidity. After initial resuscitation with intravenous fluids, she was further investigated. Her hemoglobin was 9 gm/dl with white blood count (WBC) of 15,320 and normal platelet count. Urine for HCG (human chorionic gonadotropin) was positive. FAST scan was done and was positive for all 3 views. Transvaginal sonography was done and was suggestive of multiple clots in pelvis predominantly in right adnexa (echogenic without vascularity), hemoperitoneum, and no obvious gestational sac noted. Emergency laprotomy was conducted and removal of all debris along with 1L blood in the peritoneal cavity was done. Post operatively she was given 1 unit of PCV and treated with I/v antibiotics, analgesics and other supportive measures. The post procedure stay remained uneventful and she was discharged in stable hemodynamic condition.

Background

Baclofen is a gamma-aminobutyric-acid-agonist (GABA-agonist) acting on the central nervous system (CNS). It is mainly prescribed to relieve spasticity and muscular rigidity in multiple sclerosis, spinal cord lesions and other diseases of the CNS that might result in muscular spasms. Recent clinical trials have shown that 30 to 300 mg/day oral baclofen can reduce alcohol caving, intake and relapse and it is actually used for alcohol withdrawal syndrome and cocaine addiction. Its use has therefore become increasingly popular, thus resulting in a soaring number of intoxication cases.

Case report:

A 23-year-old female with no previous medical history presented to the emergency department one hour after deliberate oral intake of 300 mg of baclofen. This medication was previously prescribed for her mother. On the initial examination, she was initially fully awake. Blood pressure was 120/60 mmHg, heart rate was 108/min, and temperature was 37.2°C. Respiratory rate was 16/min, pulmonary auscultation without abnormalities in two lung field and pulsed oxygen saturation was 98%. An attempt to perform gastric lavage was unsuccessful due to its poor tolerance by the patient. She was kept under clinical surveillance. Five hours later, she developed tremulations, vomiting, sinus bradycardia and hypotension. Her Glasgow Coma Scale dropped to 8/15. Fluid resuscitation with crystalloid solutions and mechanical ventilation were necessary. The patient was therefore transferred to intensive care unit (ICU) and further laboratory tests were carried out revealing rhabdomyolysis and hypokalemia. Treatment with atropine and 52 hours of mechanical ventilation was undertaken along with antibiotic administration for aspiration pneumonia and potassium supplementation. The outcome was favorable and the patient was discharged four days following ICU admission.

Conclusions:

Although baclofen intoxication cases are being increasingly reported, few studies have worked on setting precise thresholds for the toxicity spectrum of this drug. Lack of guidelines might result in the under-estimation of theoverdosage effects and treatment delays. Continuous ICU monitoring is mandatory in all cases.

Introduction

Bacteraemia related to catheters is the association of bacteremia occurring within 48 hours of catheter shrinkage and a significant culture of the catheter (> 1000 cfu / ml) or catheter insertion site culture that registers the same germ.

The objective is to determine the incidence of bacteremia related to catheters (BLC) in a medical resuscitation service, their microbiological profile and the risk factors associated with their occurrence.

Patients and methods

 Over a period of one year, spread between January 2015 and December 2015, all patients admitted to intensive care units and subjected to a central venous catheterization of more than 48 hours were included.

The BLC was selected on:

• Cultivation of the end of the catheter withdrawn positive according to BRUN BUISSON method> 103 CFU / ml

• The local and general signs present

The proportions of colonization and BLC were expressed as cumulative incidence (CI) of CLI.

Statistical analysis was performed using the univariate method.

Results

 The incidence rate was 6.78% with predominantly female 51.9%.Isolated microorganisms were represented by Gram-negative bacilli in 40.5% of cases, Gram-positive cocci in 35.4% of cases, and yeasts in 5% of cases.

Statistical analysis showed two main risk factors for colonization: prolonged catheterization and absence of systemic antibiotic therapy before catheterization.It is important to note that the lack of information in the medical files concerning the installation of the CVC is a weighing element on the follow-up of its infections indeed a checklist must be used like a memo tool that will make it possible to And to minimize risks related to human hazard.

 Conclusion

 The incidence of BLC was high, requiring reflection by the healthcare team to improve protocols and bundles for the prevention of these nosocomial infections.

 Bartholin’s gland abscesses are rare in females before puberty we report a case of Bartholin’s gland abscess in 10 month old female child along with review of the literature.

Key words: Bartholin’s gland abscess, children, incision and drainage.

Herpes zoster(HZ) is common in the elderly. The increased risk for developing Hz is associated with immunosuppression from chemotherapy for malignancy, immunosuppressive diseases such as AIDS, and most commonly with aging related deficiency of cell mediated immunity to varicella zoster virus. In approximately 20% of the cases, virus affects the first division of the trigeminal nerve, producing the characteristic and usually painful zoster rash on the forehead, periorbital area and nose. Hutchinson's sign that nasociliary skin lesions of virus was a powerful predictor of ocular inflammation and corneal denervation in herpes zoster ophthalmicus(HZO).

Our case was a 83 years old debilitated woman who came to our emergency service with a complaint of vesicles on the left side of his forehead and nose, accompanied by severe headache and ocular pain with edema. The physical examination revealed the presence of vesiculobullous lesions with erythema and crusted erosions on the left side of the forehead. Periorbital edema and bulbar conjunctival injection was obvious on her left side. Ophthalmologically, at presentation visual acuity, corneal sensation, detailed slit-lamp examination to detect anterior segment involvement and fundoscopy to detect posterior segment complications of Herpes Zoster Ophthalmicus were carried out in this patient. She was diagnosed with keratitis and iritis. The laboratory examination revealed mild liver dysfunction, mild leucocytosis and elevated levels of C-reactive protein. From these clinical and laboratory findings, she was diagnosed with HZO with iritis. Because of her severe iritis, 7 day intravenous acyclovir following 3 week po valacyclovir was used as treatment.

The reported incidence of visual loss in HZO patients varies widely between 14% and 56% especially higher in immunocompromised patients. Immunocompetant patients receiving antiviral therapy show the best outcomes. Most studies have reported a definite reduction in the occurrence of visual loss with the use of antiviral therapy. The visual outcome was poorer in older patients. This could be attributed to the presence of preexisting senile cataracts. Chronic epithelial lesions can however cause severe visual loss and are often difficult to treat. Persisting loss or reduction of corneal sensation is in important factor in the occurrence of chronic epithelial lesions like neurotrophic keratitis. These patients should be counselled regarding the need for long-term follow up. Nasociliary nerve involvement indicated by the presence of Hutchinson sign was found to be a strong predictor for poor visual outcome and this concurs with other reports. It was also established that increasing rash severity was associated
with poor visual outcome.

Visual outcome in HZO patients treated with antiviral therapy is good. Hutchinson's sign and anterior uveitis were found to be strong predictors for poor visual outcome. Presence of these identified risk factors warrants close monitoring.

Background: Ischemic heart disease is still the leading cause of death in adults in developed and developing countries. Acute myocardial infarction (AMI) is a serious and dangerous presentation of acute coronary syndromes. AMI is defined as myocardial cell death and necrosis due to sever and prolonged obstruction in myocardial blood flow. AMI leads to several complications. These can be classified as two subgroups: electrical and mechanical complications.

 Ventricular free wall rupture (VFWR) after AMI is a serious and potentially life threatening mechanical complication. It may occur as early as a few hours after infarction up to 5 days. The clinical presentations of VFWR include prompt death, transient syncope, agitation, acute cardiogenic shock, pleuritic chest pain, recurrent emesis, dyspnea, etc. Risk factors associated with VFWR include advanced age, female sex, first time MI, anterior wall MI, ST elevation or Q wave development on the initial ECG, large infarct size and late or failed PCI. Emergent surgical intervention is the treatment of choice for this complication. Pericardiocentesis is indicated as an immediate temporizing intervention.

Case: A 64 years-old male with HTN and diabetic mellitus presented to emergency department with generalized weakness and drowsiness. He had experienced a syncope attack while walking an hour before coming to ED. On arrival, he was vomiting. He had no chest pain but dyspnea and orthopnea from 3-4 days ago.

VS: PR: 90/min,   BP: 70/50 mmHg (no significant difference between two arms), BS: 180 mg/dL,   SPO2: 89% in room air, RR: 28/min.

Heart sound was muffled with no increased neck veins. Lungs field was clear.

ECG showed an extensive ST-segment elevation MI with anterior, inferior and right side involvement. PCI was considered as a reperfusion therapy. But the patient condition did not change after initial fluid replacement therapy, so a vasopressor was initiated too. The portable CXR revealed a wide mediastinum (10 cm). In search for aortic dissection as a possible cause of these findings, we decided to do a bedside echocardiography in the ED. We found a large pericardial effusion and mild to moderate RV and RA collapse during diastole with no intimal flap or dilated aortic root. After consultation with a cardiologist and a heart surgeon, we decided to transfer the patient immediately to the heart surgery center for possible operation because of relative stability in patient condition. Left ventricular free wall rupture confirmed during cardiac surgery. Ruptured wall was repaired and the patient discharged home after a long time hospitalization.

Conclusion: signs of cardiac tamponade on ECG or echocardiography are suggestive of VFWR in the setting of acute or recent MI. VFWR is fetal, but prompt diagnosis followed by emergent surgery may be lifesaving. Echocardiography is crucial for the prompt diagnosis of this complication and can change the patient outcome dramatically in this sitting.

Purpose: The diagnosis of an aortic dissection by a bedside ultrasound. Aortic dissection is relatively rare, but may occur as a catastrophic condition for the patient's prognosis, so an early diagnosis and treatment is crucial to their survival. We used two systems of classification of this pathology, being the Stanford classification most frequently used in clinical practice: type A dissection, involves the ascending aorta; type B dissection involves the descending aorta or the arch without involvement of the ascending aorta.

Material & Methods: We studied the diagnosis of an aortic dissection type B of Stanford by a bedside ultrasound performed by emergency physician. We have an ultrasound-Sonosite M-Turbo, P21 probe of between 1 and 5 MHz, with and echocardiography software.

Results: A 76 years old male, admitted to the emergency room because he suffers intense, transfixing, oppressive central chest pain radiating to the back. He had normal vital signs. Analysis revealed a D-dimer 6222 µg/ml, with normal cardiac enzymes and electrocardiogram, but showing an aortic elongation mediastinal widening on chest radiograph, so the emergency physician performed an ultrasound scan that showed a double light in the abdominal aorta, until iliac. A thoracoabdominal computed tomographic scan was immediately performed with contrast confirmed type B aortic dissection, from the left subclavian to the iliac bifurcation, with false light in a posterior position, without involvement of supra-aortic arteries and visceral branches. The patient was admitted to the Intensive Care Unit, opting for traditional treatment, was discharged  without later complications.

Conclusions: The ultrasound has become in the last few years an indispensable tool for the emergency physician, and there is broad international supporting literature that recommends and requires that us, all the emergency physicians, use ultrasound for the benefit of our patients; but its use is not infallible, so performing the technique and interpretation by not medical experts, must be supervised by others with more experience to guide them so possible diagnostic errors are avoided.

Purpose: Intestinal pneumatosis (IP) defined as the presence of gas within the bowel wall and the presence of gas in the portomesenteric vein complex, a rare clinical condition that are typically associated with intestinal ischemia (II) and a fatal outcome. We present a case of IP, diagnosed at emergency room, through the use of US scanning by emergency physicians (EP).

Material & Methods: a patient with abdominal pain, with a final diagnosis of a IP assessing US, performed by EP.

Results: 82 year old woman, active and independent, who came to the ER with abdominal pain from 12 hours, which started about 2 hours after dinner. The patient presented malaise, affected by pain, hypotensive and tachycardic. Given the general malaise the patient underwent an abdominal ultrasound scan at the bedside of the patient showed many small echogenic mobile pictures that moved through the portal vein and its branches, and in the left hepatic lobe level we saw also multiple linear echogenic pictures in the portal branches with posterior acoustic shadows. Suspecting IP and gas in the abdominal venous complex portomesenteric urgent contrast CT was made, which confirmed the diagnosis.

Conclusion:

CT and US are the most commonly used imaging modalities in patients with acute abdomen and even if CT represents the gold standard in the evaluation of patients with II. However, there are some disadvantages associated with this technique, such as radiation exposure, potential nephrotoxicity and the risk of an allergic reaction to the contrast agents. Thus, not all patients with suspected bowel ischaemia can be subjected to these examinations. Despite its limitations, bedside ultrasound performed by EP could constitutes a good imaging method as first examination in acute settings of suspected mesenteric ischemia.

Ultrasonography by EP, can be a useful tool in cases with serious diseases. Incorporate ultrasound in the ER lowers overall service times, since the EP is more effective, efficient and dynamic management "time-dependent" emergency, providing greater clinical patient safety.

Purpose: Pyonephrosis (PN) is an uncommon disease that is associated with suppurative destruction of the renal parenchyma in adults. Obstruction and upper urinary tract infection play a role in its etiology. Fever, shivering, and flank pain are frequent clinical symptoms. If the pus detected as a result of the investigations is not surgically drained, antibiotics may not be effective. Septic shock and death can occur if the disorder is not treated with urgent surgery. In this context percutaneous open nephrostomy or retrograde ureteral catheter insertion is appropriate, so it is a very serious disease and emergency physicians (EP) have a very important role in early diagnosis to start antibiotic treatment and early referral to surgery. We present a case of septic condition with PN developing due to a distal ureteral stone, diagnosed at ER, through the use of US scanning used by EP

Material & Methods: a patient with fever, right flank pain and septic condition, with a final diagnosis of a calculous PN.

Results: 56 year old male, was admitted to the emergency room by right flank pain and fever. On arrival had malaise, hypotensive, febrile, tachycardic... in septic shock condition. Bedside emergency abdominal US was performed by EP, demonstrating right moderate to severe pelvocaliectasis due to a distal right ureteral stone. The patient was started on empirical antibiotics and a retrograde ureteral internal stents was placed by urologist.

Conclusion: Identifying PN with early obstructive uropathy is clinically important in the emergency department because obstructive urolithiasis is an independent risk factor for inpatient death; so PN  is a life-threatening condition. Emergent bedside ultrasound can do that EP may dramatically increase their ability to identify those patients that need further investigation, consultation and ultimately increase patient safety in emergency department. In the case presented thanks to the implementation of emergency US by the EP came to a prompt diagnosis of the cause of septic shock, with a quickly drainage of the infection site, which it allowed rapid patient recovery.

Bifascicular (BF) block represents a particular form of intraventricular conduction disease.which is associated with a high incidence of progression.In some patients, this form of conduction disease progresse to high degree of atrioventricular ( AV)  block and accompany by syncope.

A 41-year-old man was admitted to the emergency department (ED) because of complete AV block and syncope.Until 4 years earlier, he visited the ED because of suddenloss of consciousness while running.There werw no whitnesses.He regained consciousness spontaneously and there were no postepisodic fatigue or weakness.He was brought to the ED but was discharged without a definitive cause of the syncope, and all relevant tests were negative except ECG showed BF block.

The management of BF block was determinated by the severity of symptoms and the degree of associated AV block.The guidelines recommended that the implantation of pacemakers is indicated in asymptomatic chronic BF block with intermittent third-degree of AV block, and type II segond-degree AV block.Pacing is also indicated in BF block with a markedly prolongated HV interval or syncope not proved to be due to a AV block.Pacing was not recommended in fascicular block without AV block and symptoms.

In summary, patients with BF block and syncope require more clinical attention.These patients had higher incidence of progression into complete AV block.In cases with BF block is symptomatic or associated with high degree AV block, pacemaker therapy is highly effective for the relief of symptoms.

 Blunt abdominal trauma patients requiring emergency laparotomy represent a challenging category of trauma patients with increased morbidity and mortality usually due to co-existing injuries.

A 14 year old patient was transferred to the emergency department, after he had sustained a traffic accident with a motorbike. The mechanism of injury involved high velocity deceleration on a fixed obstacle (wall).

During the initial evaluation, the patient exhibited good neurologic status (GCS:15/15)and ventilation (PO2:95%), Grade 1 schock (BP :105/65, 100 Bpm) as well as fractures of the right femur, the left ulna and radius and dislocation of the right elbow joint.

After the initial resuscitation he underwent emergency CT+IVC of the thorax and abdomen, that revealed a Grade 3 injury to the spleen, a Grade 1 injury to the right lobe of the liver as well as free intraperitoneal air, so emergency laparotomy was undertaken.

Additional findings at laparotomy  were a linear tear of the greater curvature of the stomach, hemoperitoneum due to active bleeding from the splenic injury and copious amount of undigested food in the abdomen. Splenectomy and primary repair of the gastric rupture were performed as well as thorough lavage of the abdomen and drainage through 3 soft tubes. The hepatic injury was managed with hemostatic gauze placement.

Internal fixation of the femur was also performed after 48 hours.

The patient was managed initially in the ICU, where pancreatitis was diagnosed on the 3^rd postoperative day, that improved gradually and the patient returned to the surgical ward on the 13^th postoperative day.

The patient’s recovery was complicated by spiking fever and cachexia due to early gastric filling and vomiting. Follow up abdominal CT+IVC revealed the presence of large multilocular retroperitoneal abscesses that were managed with CT guided percutaneous drainage of the 2 largest collections that revealed C. Albicans in the cultures.

There was a transient improvement of the patient’s symptoms for 48 hours but resurgence of fever mandated the re-exploration of the abdomen and surgical drainage of the abscesses on the 23^rd postoperative day.

The patient displayed impressive recovery after the 2^nd operation and was discharged in good condition on the 32^nd postoperative day.

The mycotic superinfection of the pancreatic phlegmon severely increased the morbidity and delayed the recovery of this multi-trauma patient.

Surgical drainage of retroperitoneal abscesses is mandatory when conservative measures fail.

CLINICAL HISTORY AND EVOLUTION.

A 70-year-old man who goes to the emergency department for a blurred vision of 10 days of evolution in both eyes. Initially, the patient is evaluated by Ophthalmology, which dismisses ocular pathology as the origin of the problem and is referred for evaluation by emergency physicians.

As a history of interest we emphasize that this patient is a diabetic and hypertensive patient and is on treatment with Metformin 850 mg twice daily and also takes Enalapril 5 mg every 24 hours and acidoacetylsalicilico 100 mg a day. After dinner you are given  1 mg alprazolam.

The patient is evaluated in the emergency room where a complete exploration by organs and devices is carried out without any alteration being objectified and without the existence of any neurological focal points.

Complementary tests are required, including blood and urine tests, chest x-ray, electrocardiogram and cranial Tac. Complementary tests are normal and the patient is referred home for follow-up and control by their primary care physician.

Days later the patient returns to the emergency department because symptoms persist and blurred vision is becoming more intense.

Again it is evaluated by ophthalmology on watch and then by the emergency doctor repeating all the complementary tests mentioned above that turn out to be negative again. On this occasion, a consultation is performed with the Neurologist on call who thinks it may be an episode of migraine with aura and prescribes medication for the control of symptoms: Rizatriptan 10 mg and quotes the patient for review in the specific consultation of migraines.

A week later the patient returns to the emergency department because the picture has worsened, at this time the case and all the complementary tests are reviewed again and it is commented on in a clinical session where it is lowered as one of the options the possibility of It was an adverse effect on medication that the patient took.

Metformin withdrawal was decided by improving the ad integrum chart one week later.

CONCLUSIONS

Adverse drug events constitute an emerging pathology with a great social and economic impact; However they are not yet assumed in most countries as a priority problem. In order to achieve this reduction, it is necessary that health professionals, scientific societies, agencies and institutions linked to health care and prevention, the pharmaceutical industry and patients themselves become aware of the importance of this problem and acquire the necessary culture to recognize and address targeted measures to reduce this problem.

Brain stem and visual evoked potentials in diagnosis of Central Demyelination in

Guillain Barre Syndrome

Dr. Geetanjali Sharma, Professor, Department of Physiology, Pt. B.D. Sharma Post-Graduate Institute of Medical Sciences, University of Health Sciences, Rohtak, Haryana, India

Aims: Guillain Barre Syndrome (GBS) is an auto-immune mediated demyelination polyradiculo-neuropathy. Clinical features include progressive symmetrical ascending muscle weakness of more than two limbs, areflexia, with or without sensory, autonomic and brainstem abnormalities. The purpose of this study was to determine subclinical neurological changes of CNS with GBS and to establish the presence of central demyelination in GBS.

Study design: a prospective study to find out early central demyelination in clinically diagnosed patients of GBS.

Place and duration of study: Department of Physiology, Pt. B.D. Sharma Post-Graduate Institute of Medical Sciences, University of Health Sciences, Rohtak, Haryana, India between January 2014 to June 2015.

Methodology: The patients were referred the department of Medicine to our department for electro-diagnostic evaluation. The study group comprised of 40 subjects (20 clinically diagnosed GBS patients and 20 healthy individuals) aged between 6-65 years. Brain stem and visual evoked potentials were done in both groups using RMS EMG EP Mark II machine. BAEP parameters included the latebcies of waves I to IV, inter-peak latencies I-III, III-IV & I-V while VEP included latencies of P100 waves.

Results: Statistically significant increase in absolute peak and inter-peak  latency in the GBS group as compared to the control group was noted. Prolongation of latency of P100 wave latency in both the right and left eyes was also recorded in the GBS group.

Conclusion: Results of evoked potentials reflect impairment of auditory and visual pathways probably due to focal demyelination in Schwann cell derived myelin sheaths that cover the extra medullary portion of the auditory nerves and also due to demyelination of optic pathways. Prolonged central conduction time in BAEPS & VEPS suggest the subclinical auditory and optical involvement in GBS. Early detection of the sub-clinical abnormalities is also important as timely intervention reduces morbidity and mortality.

Background

The Navigator programme, a novel intervention, was developed in response to the volume of patients presenting to emergency departments (ED) with injury or illness associated with violence, alcohol or drugs. Presentation to the ED is a frequent and recurring event for many patients with chaotic lifestyles and presents a ‘reachable’ moment (1).  Navigator is an opportunistic intervention operating within this moment that aims to reduce future ED presentations. The aim of this preliminary study was to determine the views of the ED staff on the Navigator service.

Methods

The study was performed at Glasgow Royal Infirmary. The ED has approximately 95,000 attendances annually with a case mix that reflects its location in an area of high socioeconomic deprivation. We conducted semi-structured interviews with a cross section staff within the ED to determine their views on the impact, benefits and direction of the programme. Interviews were recorded, transcribed and analysed using thematic analysis (2)

Results

During the first 12 months of operation Navigators provided support to 209 patients, 143 male and 66 female patients, with an age range of 15-80 years (median age 30 years). The main presenting issues for male patients were alcohol, drugs, violence and homelessness and for female patients were alcohol, drugs and domestic abuse. Seventy-seven patients presented with multiple issues.

Staff views on the service centred around three main themes.  Provision of support to patients both within and outside the ED. Secondly, an ability to connect with patients on their own level and to start to address the issues underlying their attendance; the ED staff spoke about their own lack of time. Thirdly, support to stabilise some of the chaos in their lives and a chance to break away from the cycle of violence.

Conclusion

We present a model of the Navigator programme describing the characteristics of the service group and ED staff views of the strategies Navigators implemented to achieve meaningful change for those patients. The programme was well received by ED staff and the Navigators were perceived as being a valuable addition to the service provided in the ED. Before consideration is given to further development and dissemination of the project to other tertiary EDs, further evaluation is underway to measure outcomes, impact and efficacy. 

References

1. Holdsworth et al (2012). Maximising the role of emergency departments in the prevention of violence: Developing and approach in South London. Public Halth 126: 394-396.

2. Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol 3:77–101

Background:

Brugada syndrome (Bsd) is a rare genetic disease.It causes sudden cardiac death by severe rhythm disorder occurring on a healthy heart. Prognosis is severe in symptomatic patients and is based on the prevention of sudden death by placing an implantable cardioverter-defibrillator (ICD).

CASE REPORT:

We report the case of a 24 years old man with no medical history who suddenly presented a cardiac arrest. Rescuers started immediately a cardiopulmonary resuscitation (CPR) until the transfer of the patient to the emergency department. After 15mn of CPR the patient had a ventricular fibrillation (VF) 3 successive external electric shock were delivered at an energy of  200 J in biphasic asynchronous mode followed by an intravenous cordarone injection at the dose of 300 mg .A sinus rhythm was achieved with a stable hemodynamic status.

An ECG showed a right bundle branch block with a persistent ST segment elevation suggestive of a type 2 Bsd without abnormalities in the echocardiography as well as the cerebral CT scan and the toxicological analysis .Two days after the patient was extubated with a favorable clinical and biological outcomes .Since then, he was followed up in the cardiology department.However, while waiting for diagnostic confirmation and implementation of an ICD, the patient died with the same clinical presentation. 

Discussion: Bsd is a rare but a fatal disease since it has a serious rhythm complications. A rapid and urgent in hospital medical strategy should be started immediately to prevent these complications and improve the survival of these patients. 

Introdcution :

Buprenorphine (Subutex) is a partial mu receptor agonist and κ receptor antagonist which was advocated as oral maintenance treatment for patients with opioid dependence. Although Subutex is safe and effective, parenteral abuse is an emerging phenomenon. The intravenous injection of pulverized buprenorphine tablets may produced various physical complications, such as abscesses, human immunodeficiency virus (HIV) infection, hepatitis B or C infections, respiratory depression, and tricuspid or pulmonary valve endocarditis. Both intravenous and intra-arterial injections of pulverized buprenorphine may cause peripheral limb ischemia.   In this observation we present a case report of patient who presented to the emergency department following complications of Subutex abuse.

Observation :

 A 36-year-old male drug user presented at the emergency department with fever, severe left extremity pain and warmth one week after the local intravenous administration of buprenorphine. On examination, the patient appeared acutely ill and the temperature was 37.7 °C. The thigh was swollen but not erythematous, and was exquisitely painful. Moreover, necrotic area was noticed on the homolateral limb.  On biology, markers of inflammation were rised. Radiography of the inferior limb showed subcutaneous air bubbles. We completed by a computerized tomography wich shows a liquid collection with air bubbles at the edge of the psoas muscle and, with a destruction of the homolateral coxo-femoral joint.  Patient was transferred urgently to the surgery ward.The diagnosis of necrotizing fasciitis was then  confirmed per surgery by explorating fasciectomy with extensive debridement.  Further bacteriologic cultures of necrotic tissues grew  staphylococcus.

Conclusion :

Few reports of Complications arising from buprenorphine abuse in the literature were documented probably because this drug has only been widely available in the last few years. For fear of legal prosecution, patients usually present late, greater public awareness and education regarding the dangers of parenteral abuse of Subutex should also help decrease the incidence of such complications 

INTRODUCTION
The daily practice of Medicine in the Emergency Department (ED)  involves a lot of challenges. In fact, in a short period of time,  ED workers have to make crucial decisions in order to improve the health of their patients.  These circumstances can lead a burnout syndrome in these professionals.
OBJECTIVE AND METHOD
We present a descriptive study that examined  29 nurses of the Emergency Department of a  public and urban hospital for the presence of burnout. During one week, they could answer a survey divided into two parts. In the first one, age, sex, marital status, time of working and employment situation were tested.  The second one was the Maslach Burnout Inventory (MBI) with its three components -Emotional Exhaustion( EA), depersonalization (DP) and reduced personal accomplishment ( PA)- which is currently widely used.  All of the respondents had worked at least during 6 months in the same workstations.  The participant was considered to meet the study criteria for burnout if they have a "high" score on at least 2 of the three dimensions of MBI.
RESULTS

Twenty-nine surveys were delivered and twenty-eight nurses answered (96.55%) which demonstrates the great interest of these professionals in the problem.
 The average age was  45.93 years  (Rank 34-59),  twenty-two of them were females and six were males.  Nine of them were singles and nineteen had a stable couple. The average time of working was 10.79 years  (Rank 1-30). Finally, fifteen nurses had an indefinite contract and four of them had a temporary contract.

We found high leves in EA in the  32.1% and 42.9% in DP and low leves in 10.7%  in PA.  In 7 of them (25%) we found 2 or 3 pathological subscales. Burnout was more frequent in men, unmarried, under 40 years, with occasional work and with less than 20 years in the current workstation nevertheless there wasn´t  significant difference between groups.
CONCLUSION
The nurses of the Emergency Department show  a moderate  level of burnout.  Administrators should be aware that symptoms of burnout constitute potential precursors of more severe impairment  and should implement  interventions in order to improve the career satisfaction and prevent burnout

Study objective: Burnout syndrome (BOS) associated with stress has been documented in health care professionals in many specialties. The pre-hospital healthcare services are highly stressful environments. Little is known about the BOS in critical care nursing staff. The objective of the study is to compare the incidence of BOS and its three domains, namely, emotional exhaustion, depersonalization and reduced professional accomplishment, in two cohorts of critical care nurses: a pre-hospital emergency service with an internal psychological support service and a pool of “classic” pre-hospital emergency services (without this additional service).

Methods: A survey using a questionnaire (the Maslach Burnout Inventory-General Survey, MBI-GS), among nurses of four Italian emergency services has been performed. One of these is in a Regional Hospital with a mean of 75770 interventions/year and has a dedicated psychologist who supports the nurses (PHES-Psy). The other 3 pre-hospital emergency services make a mean of 44562 interventions/year and don’t have a psycologic support service (PHES).

Results: All 68 nurses surveyed (51% female) filled the questionnaires. BOS-related symptoms have been identified in at least 85% of the nurses in the entire study  population. In the PHES group (n=52) BOS-related symptoms have been identified in 88% of the respondents. Among the PEHS-Psy nurses (n=16), BOS-related symptoms have been identified in 75% of the respondents. A medium-high emotional exhaustion was found in the 46% of the respondents in the PHES group and 62% in the PEHS-Psy (p=0.2). 60% among the PEHS nurses and 75% among PHE-Psy nurses soffered a medium-high depersonalization (p=0.8). 63% and 58% respondents had a medium-high reduced professional accomplishment respectively in the PEHS and the PEHS-Psy populations. Moreover, the likelihood that a nurse had a severe BOS, that is at least one degree of high burnout or ≥2 degrees of medium burnout, is 75% and 63% respectively in the PHES-Psy and the PHES group (p=0.4). However the frequency of severe BOS in the group of the PHES-Psy is lower than the same rate found in a previous (2014) survey (75% vs 90%, p=0.2). Taken into account that two important determinants of BOS are the amount of interventions and the years of work, we can speculate that the incidence of BOS in PHES-Psy is well controlled during the last two years.

Conclusion: More than two-thirds of critical care nursing staff had a severe BOS. The use of a psychological support service seems to limit the incidence and the grade of BOS among PHES-nurses. Further interventional studies are needed to better investigate this potentially preventive strategy.

BACKGROUND

   Pupillary laterality does not always indicate cerebral herniation (CH) in traumatic brain injury (TBI), because its cause ranges from CH to cranial neuropathy or pupillary sphincter muscle injury. The aim of this study was to clarify whether anisocoria could be a predictive factor of CH in trauma.

METHODS

   Clinical records of all trauma patients with anisocoria,  admitted to the Hyogo Emergency Medical Center between January 2011 and December 2016, were retrospectively reviewed. Anisocoria was defined as difference in pupillary size of 0.5mm or above. Those patients were divided into the cerebral herniation (CH) group or the control (C) group, according to their initial head computed tomography images evaluated by board certified neurosurgeons. Systolic blood pressure, pulse rate, Glasgow coma scale (GCS), and presence of hemiplegia on admission were obtained. Patients were classified by GCS score into a low GCS (8 or lower), a moderate GCS (9 to 12) or a high GCS (13 or higher). The Abbreviated Injury Scale of head, face and surface, and the Injury Severity Score were graded. Single variable  (Chi-square test) and  multivariate logistic regression  were used for statistic analyses.

RESULTS

   During the study period, 123 trauma patients had anisocoria, and 39 of 123 had CH. In the H group, there were 33 cases in a low GCS, 5 in moderate GCS, and 1 in high GCS. In the C group, there were 21 in a low GCS, 21 in a moderate GCS, and 42 in a high GCS. The single variable analysis revealed there was a significant difference between the C and the H group (P<0.05) in a GCS classification and hemiplegia(16 in H, 12 in C). A multivariate logistic regression analysis identified  GCS classification as an independent risk factor for CH (OR 2.06 [95%CI 1.21-3.53], P=0.008).

CONCLUSIONS

Only 30% of cases had CH among trauma patients with anisocoria. Although a GCS classification was an independent predictor, 21 of 54 (39%) cases did not have CH even in a low GCS. Anisocoria cannot be a reliable predictor for CH.

Introduction: There are no obvious guidelines for therapy of elevated blood pressure (BP) in the emergency department (ED). Diastolic BP is probably more difficult to control compared with systolic BP.

Aim: This study aim was to characterize patients who respond with a significant decrease in diastolic BP in the ED, whether treated or not.

Methods: In this retrospective cohort study, all patients attending a tertiary care ED with elevated BP were evaluated.  Clinical characteristics of patients in whom diastolic BP decreased ≥ 20% were compared with those in whom diastolic BP decreased < 20%.

Results: Overall, 391 patients were included in the final analysis (64% females), of which diastolic BP of 106 (27%) patients decreased ≥ 20%. Patients in whom diastolic BP decreased ≥ 20% were older [70.1±13 years vs. 65.9±16.7 years, P=0.011] and had a history of ischemic heart disease (IHD) and cerebrovascular disease (CVA) prior to the ED visit [30 patients (28.3%) vs. 45 patients (15.8%) for a history of IHD, P=0.005 and 16 patients (15.1%) vs. 21 patients (7.4%) for CVA respectively, P=0.02]. 

Conclusions: A history of cardiovascular disease  was associated with a higher decrease in diastolic BP irrespective of the use of medical treatment during the ED visit .

Background

A major commitment in an ED is to identify the most sick. Several systems exist, most rely on vital sings, and thus require these to become abnormal to reliably identify patients at risk. But when vitals sings deteriorate, it becomes difficult to treat. What if we could find the patients who are not only sick right now but also the patients with an increased mortality risk within the next 30 days.

A recent observational study from our group, using infrared thermography, investigated if the temperature difference between the inner canthus of the eye (representing core temperature) and either the tip of the third finger, the tip of the nose or ear lope could predict 30-day all-cause mortality. This study included 198 patients and found a significant association between the temperature gradient and mortality.

With this study, we aim to investigate if we, using the temperature gradient between central and peripheral temperature from infrared thermography, can identify patients at increased risk of short term mortality. We also wish to compare the predictive capability of infrared thermography with individual vital signs, an early warning score and clinical assessment by doctors.

Methods

In this prospective observational study, we included consecutive adult medical patients from the Emergency Department at the Odense University Hospital (October 2016 to May 2017). Using the unique Danish personal identification number, we had complete follow up at 30 days.  We excluded patients unwilling or unable to give informed consent as well as patients in the highest triage category.

Approximately 30 minutes after arrival (and no later than 3 hours), we took a standardized infrared thermographic image of the face and hand. We calculated the temperature gradient between the core temperature (inner canthus of the eye) and peripheral temperatures (tip of 3rd finger, ear lope and tip of nose). We also asked the treating physician of estimate short term mortality using clinical intuition on a scale of 0-100%.

The association between the measurements and the end point was assessed as the area under the receiver operating characteristics curve (AUROC). Our primary endpoint was 30 day all-cause mortality. The need for approval by the regional ethics committee was waivered by the committee.

Results

We screened a total of 936 patients and 678 (72%) were included. Some 306 have been analyzed thus far.

Median age was 63 (range 18-101) years and 49% were male. 60 (20%) were in the 2nd highest triage category, 161 (53%) in the 3rd highest and 75 (25%) in the 4th highest. One (0, 3%) patient died within 7 days, 2 (0,6%) within 14 days, 8 (3%) within 14 days and 11 (4%) within 30 days.

We still have not analyzed the association between the measurements and outcome.

Conclusion

With this study, we wish to show the association between infrared thermography and short term mortality as an alternative to vital signs, early warning scores and clinical assessment.

Background: A number of global studies suggest that approximately 10% of patients admitted to hospital suffer some kind of harm. With these staggering statistics, there have been calls to develop techniques to combat medical error. One such method is simulation-based medical education (SBME) - an education tool which can mitigate errors and allows students to hone their skills in a safe learning environment, thus increasing their confidence to deal with patients in real life. Numerous studies have demonstrated that students who were taught in this manner reported higher levels of confidence in managing patients compared to their peers who did not receive simulation teaching. 

Aims: To ascertain whether carrying out simulated ABCDE scenarios for medical students can improve their confidence in managing an acutely unwell patient in the Emergency Deparment (ED). 

Methods: Data was collected from 29 3rd and 5th year students from Brighton and Sussex Medical School during their Emergency Medicine placement. They were asked to fill in a feedback form using a 10 point Likert scale (1=not confident at all, 10 = extremely confident) stating how confident they felt managing an acutely uwell patient PRIOR to the simulation session and AFTER the simulation session. They were also asked to record how useful they found the teaching and feedback elements of the simulation (1=not useful at all, 10 = extremely useful). 

Results: The mean score for students' confidence levels prior to the simulated scenarious was 5.86. This increased to a mean of 8.67 after the simulated scenarios. For all the students there was an increase of at least 1 point following the sessions with some increasing their confidence by 5 points in the Likert scale. The mean score for the usefulness of the teaching was 9.21 and the feedback was 8.93. 

Conclusions: SBME plays an increasingly important role in the education of medical staff, particularly students. Carrying out simulated ABCDE scenarios appears to subjectively improve the confidence of medical students to manage an acutely unwell patient in the ED by an average of 3 points on the Likert scale. The teaching element of the simulation was deemed the most useful aspect of the exercise by all students. 

Patients with cervical spine injury sometimes need ventilation and tracheotomy because their respiratory muscle are palalysis and it is difficult to take out sputum. So we investigate to find common thing in the patients who was done tracheostomy. A retrospective review of patients with acute cervical spinal injury admitted to Tottori University Hospital from 2010 to 2016 was performed.

There were 30 patients (26 male and 4 female) who had cervical injury by trauma and whose ASIA score were below C. The age was from 33 to 94 (average 69). 9 patients had a tracheostomy. Patients remained ventilator 1patients were died after injury.

The result is that the stay of the patients who had tracheostomy is longer and older and  patients weren’t removed intubation more than 1 week after admission.

And all the patients of ASIA A were done tracheotomy and we investigate the reason whether the patients of ASIA B or C were done tracheotomy or not.

A case of a 27 years old female with right elbow fracture is presented here. She came to the Emergency department with history of fall on right flexed elbow one day earlier. On examination there was mild right elbow edema with no obvious injury. Tenderness present mainly on the lateral aspect of elbow. Movements were severely restricted in extension, she could not extend beyond 30 degrees, pronation and supination is almost not possible and forearm is in mid prone position. Sensations were intact in right forearm with radial and ulnar pulses palpable. X-ray right elbow was done which showed displaced Bryan and Morrey type I fracture of capitulum with mild joint effusion. Open reduction and internal fixation of capitulum was done with headless screws. Patient recovered uneventfully and discharged after three days with physiotherapy follow up.

Background
The critical relationship of EtCO2 monitoring and clinical decision making in the tracheally intubated patient is well-documented. The rationale and benefits from applying EtCO2 monitoring in the non-intubated cohort is, however, not well documented and guidelines and recommendations for its application are sparse. The aim of this systematic review was to investigate the possible benefits of capnography to clinical decision making in the spontaneously breathing, non-intubated emergency patient and thereby provide recommendations for its use.

Methods
A systematic search of studies comparing capnography monitoring and non-capnography monitoring in the spontaneously breathing, non-intubated emergency patient, published in the MEDLINE, SCOPUS, Cochrane, Academic Search Complete, and CINAHL databases from 1st of January, 1990 up to 24th of February, 2016 were performed. In total 409 studies were identified of which 11 (1 meta-analysis, 2 randomised controlled trials, 8 cohort studies) met pre-specified inclusion criteria, involving 1450 study subjects.

Results
The retrieved literature suggests capnography beneficial to clinical decision making in the investigated population. The included studies were, however, found to be of variable quality and strength with several risk of bias, methodological and technical limitations which led to questionable and inadequate conclusions.

Conclusions
This review found some sporadic benefits to clinical decision making when applying capnography to the spontaneously breathing, non-intubated emergency patient.
Until more evidence from high-quality studies are available, capnography in the investigated cohort should be utilised with a critical approach as it is not possible to adequately scientifically support recommendations and guidelines for its use.

Background: cellular metabolism produces carbondioxide while the lungs eliminate it. End tidal carbon dioxide (EtCO₂) refers to the graphical presentation of carbon dioxide partial pressure in mmHg at the end of expiration. EtCO₂  gives a clinical clue aboutr pulmonary pathophysiology.

Methods: 23 cardiac arrest patients admitted to Alexandria Main University Hospital were enrolled in the present study. All patients were resuscitated according to the Advanced Life Support (ALS) guidelines 2015. Chest compressions were started once cardiac arrest was confirmed. Endotracheal intubation was done by emergency resident with at least 2 years experience in emergency medicine. All patients were monitored using mainstream waveform capnography. The number of CPR cycles done and the average time consumed to obtain the first reading of EtCO₂ were recorded. the duration of a single CPR cycle is 2 minutes according to the ALS guidelines. The first reading of EtCO₂ was taken as a method to confirm correct endotracheal intubation. Further EtCO2 values were r3ecorded during CPR and the average of these values during CPR was recorded for each case. The relation between the mean value of EtCO₂ during CPR and the patient outcome was studied.

Results: All patients enrolled in the study suffered Out of Hospital Cardiac Arrest (OHCA). The first reading of EtCO₂ was obtained after 3 CPR cycles in 13 patients (56.5%), after 2 CPR cycles in 9 cases (39.1%) and  after 4 cycles in only 1 case (4.3%). The mean time to obtain the first EtCO₂  was 353.9 ± 69.3 seconds, and this was also the time consumed to confirm correct endotracheal tube placement. The value of the first reading of EtCO₂ ranged between 8 -15 mm Hg with a mean value of 12.43 ± 2.79 mmHg. while during CPR the value of EtCO₂ ranged between 8 -25 mmHg with a mean value of 17.96 ± 7.61 mmHg, at the end of resuscitation, the value of EtCO₂ ranged between 0-45mmHg with a mean value of 21.3± 21.01 mmHg. 12 cases of the studied population had successful resuscitation efforts and return of spontaneous circulation, where11 patients (47.8%) were admitted to the ICU and 1 patient (4.3%) was transferred to the operating theatre. 11 patients (47.8%) had unsuccessful resuscitation efforts and died. There was a significant relation with significant p value <0.001 between the patient outcome and the value of EtCO₂ obtained during CPR, where the value of EtCO₂ in patients who had return of spontaneous circulation ranged between 20-25 mmHg with a mean value of 24.09 ± 2.02 mmHg, while the value of EtCO₂ in the cases who died ranged between 8-15 mmHg with a mean value of 10.27± 1.68 mmHg. 

Discussion: The benefits of continuous EtCO₂ monitoring during cardiopulmonary resuscitation outweigh correct endotracheal tube placement. Continuous waveform capnography monitoring during CPR can give a clue regarding efficiency of chest compressions in addition to its prognostic value regarding successful reuscitation efforts. 

Background : 

Carbamazepine (CBZ) poisoning is clearly increased because of the wide use of CBZ for treatment of simple or complex partial or seizures, trigeminal neuralgia, and bipolar affective disorder. It is also increased during the last 10 years, particularly as addicted drug in our country. We aimed to study is there any correlation between neurological signs and carbamazepine serum level.

Methods :

This was a retrospective observational study spread over 88 months from January 2010 to April 2017 including all patients admitted to our ICU for carbamazepine poisoning. 

Results :

201 patients aged of 29.5 years (12 ; 67) were eligible. They were 82 male and 119 female with a sex ratio was 0.7. A history of psychiatric disease was noted in 56% of cases, epilepsy in 15% and long term treatment with carbamazepine in 57% with a median duration of carbamazepine treatment of seven years.

The supposed ingested dose was 4.3 g (0.4 ; 20) and the delay between ingestion and hospital arrival was 5.7 hours (1 ; 26). 

Thirty three per cent of CBZ poisoning was associated to another drug coingestion. Physical exam showed coma 36% of cases (n=73), agitation in 26% (n=52) and seizures in five patients (2.5%).

The analysis of correlation between neurological signs and serum level CBZ on admission showed a low correlation between carbamazepine serum level and coma both for patients who ingested carbamazepine alone (r² :0.016) and also for patients with multidrug poisoning (r² :0.14)

Discussion:

Carbamazepine serum measure on admission doesen’nt appear to predict the severity of CBZ poisoning. It is better thow to study the serum CBZ kinetics then to emphasize on the CBZ serum level on admission.

Background: Narghile (waterpipe, hookah) is a traditional method of tobacco use. In recent years, its use has increased worldwide, especially among young people. Compared to cigarettes, narghile smoking can result in a greater exposure to several volatile compounds, including carbon monoxide (CO). We evaluate the waterpipe-related CO-poisoning to assess the severity of the intoxication. Methods: All cases referred to our Poison Control Centre in a height-year-period (April 2008-April 2016) for CO intoxication were retrospectively reviewed, and narghile-related cases were selected and evaluated for (i) patient data, (ii) clinical manifestations, (iii) carboxyhemoglobin (HbCO) level at admission, (iv) treatment and (v) outcome. Results: Sixteen patients (M/F 13/3), aged from 17 to 47, were identified as waterpipe-related CO poisoning. Height patients had smoked alone, while in the other eight cases the patients smoked with other people. 15/16 patients had smoked tobacco, while only one had smoked hashish. Ten patients referred to an emergency department because symptomatic: syncope (5/10), headache (7/10), dizziness (2/10), vomit (3/10), diarrhea (1/10), dyspnea (3/10). HbCO level of symptomatic patients at admission ranged from 5,3 to 23,2% (average 14,2+/-7). Six patients were asymptomatic and undergo medical evaluation just because they smoked together with symptomatic patients: nevertheless, their HbCO levels at admission were positive ranging from 5,6 to 18,3% (average 8,4+/-5). Five of six asymptomatic patients were discharged in twelve hours after cardiac evaluation and normobaric oxygen treatment. Eleven patients were hospitalized for further clinical evaluations and for normobaric (7/11) or hyperbaric oxygen treatment (4/11). All patients were discharged without sequelae. A forty-day clinical follow-up was performed. The symptomatic patient who smoked hashish manifested syncope with short pseudo paresis of limbs; his HbCO level was 11,5% three hours after smoking. Conclusion: Narghile smoking exposes to the same harmful substances of cigarette smoking (CO included), although in greater quantity due to the duration of smoking/inhalation (approximately 5 minutes for cigarettes, 50 for narghile) and to the combustion temperature. The amount of CO in smoke is mostly related to waterpipe size and tobacco type. Moreover, waterpipe smoker inhales CO as a result of the charcoal combustion. CO intoxication, even severe, may occur, and it’s reasonable to believe that this cases are underestimated. This diagnosis should be considered in case of non-specific neurological symptoms.

INTRODUCTION :

The clinical importance of cardiovascular consequences resulting from cerebral injury has been well studied. However, interactions between the brain and the cardiovascular system are not well understood and their importance for the management of patients suffering from acute brain injury is underestimated. This study was conducted to evaluate cardiovascular consequences of cerebral injury relying on serum levels of the High-sensitive troponin (hsTnT).

METHODS :

We conducted a prospective study in the emergency departement (ED) in which we included all the patients presentend to the ED with cerebral agression ( cranial trauma, stroke, subarachnoid hemorrhage, seizures). All patients had troponin (hsTnT) test and electrocardiogram. We excluded patients with chest pain or coronary history.

RESULTS :

We enrolled 170 patients. The mean age was 56 ± 15. The sex ratio was 1.39. 55 patients (32%) had cranial trauma, 66 patients (38%) had a stroke, 33 patients (19%) had a seizure and 16(9%) patients had subarachnoid hemorrhage.

Troponin elevation was noted in 97% of  patients with subarachnoid hemorrhage , chez 20% of patients with seizure 8%  of patients with stroke. ECG abnormalities like ST/T changes were noted in 33% of patients with subarachnoid hemorrhage and in 3% of patients with stroke.

Conclusion :

Cardiac troponin release occurs frequently after brain injury and specifically after subarachnoid hemorrhage and has been associated with a neurogenic form of myocardial injury.

Objetive: Give importance to the correct exploration and study of patients with nonspecific symptoms

Method: A 51-year-old female patient who came to the emergency room for perioral paresthesias and carpopedal spasms during two hours. She is accompanied by her family who relates symptoms to low mood due to personal problems and reports that they have already consulted their doctor for the same reason and started treatment with antidepressants because of anxiety. In addition it refers catarrhal disease in previous days as well as weight loss due to anorexia related to depressive syndrome. Diazepam 5 mg is administered sublingually by the profuse symptomatology on arrival. Clinical examination: Tubal murmur in right base pulmonary auscultation. Hemogram was performed, with anemia (Hb: 9 mg / dl), hypokalemia (K. 2.8 mEq / L), hypocalcemia (6.8 mg / dl) and hypomagnasemia (0.8 mg / dl). In gasometry Respiratory alkalosis. Torax X-ray:condensation in the upper right lobe of the right atelectasia. Entered by Internal Medicine for Hypocalcemia and Pulmonary Mass to study.

Results: CT scan of thorax, PET evidencing Pulmonary mass of Hipermetabolic compatible with neoplastic lesion confirmed with Biopsy and Hypocalcemia by Hypovitaminosis D from carencial origin. After intravenous treatment, normalization of analytical data and improvement of the clinic was achieved.

Discussion: The reasons for consulting the ER are, in many cases, nonspecific and suggestive of banal pathologies but a correct clinical examination and systematic study can perform diagnoses of important clinical entity.

Introduction

Total talus dislocation is a rare injury due to excessive supination or pronation of the ankle joint. Only a few case reports have been published and no concrete data regarding incidence rates for this injury.This case report describes a patient with an open talus dislocation associated with medial malleolus fracture that was treated with early surgical intervention and stable fixation.

 Case Report

A 30 yo man was transported by the prehospital EMS for multiple trauma after being involved in a motor vehicle accident with an oncoming car..He was conscious CGS 15 complained of severe pain in the right ankle. Examination revealed a severe head trauma, multiple wounds on a right leg, left hand and total talus dislocation with the talus being exposed with a contaminated wound at the anterolateral side of the ankle. Neurovascular integrity was not compromised. ISS Score 48. The total-body computed tomography scanning (TBCT) confirmed a total talus dislocation with an associated displaced medial malleolus fracture.

The patient was admitted for immediate intravenous antibiotic therapy and surgery .

The talus was reduced and screw fixation of the medial malleolus was realized, an external fixator was applied to maintain stability of the ankle.  

After 3 months of follow-up the patient had a osteochondritis and an evolutive algodystrophy on his right leg, knee and ankle. 2 years after the accident the patient had a relative excellent recovered evolution with a limitation of 50 % lateral movements of his ankle.

Discussion: Total talus dislocation occurs when the talus is entired detached and dissociated from the tibiotalar, talonavicular and subtalar joints. It results from a high energy motor vehicle accident or fall from height. Total dislocation of the talus is usually associated with fractures of the malleoli or the talus itself.. Total extrusion involves disruption of vascular supply to the talus, predisposing to osteonecrosis. Infection, avascular necrosis and post-traumatic arthritis are the most major complications.

Orthopedics surgical recommendations suggest wound debridement, early reduction and fixation to avoid infection, provide early revascularisation, and to preserve the normal ankle anatomy. Based on previous reports, the role of the Emergency Physician is relatively complex : clean and the talus still attached, keep the environment close to the original biological state encouraging early revascularisation. However, development of post-traumatic osteoarthritis is still possible and may present years after initial injury.

Background:

Because CMC joints are very stable related to strong transverse dorsal ligaments and longitudinal volar ligaments, dislocations of these joints are rare. These injuries present in less than 1% of hand injuries and are associated with high energy trauma, mainly related to motor bicycle accidents. Dorsal CMC joint dislocations are more common than ventral CMC joint dislocations.

Because patients with high energy trauma often present to the emergency department with other more obvious traumatic injuries, CMC joint dislocations can be missed in up to 30-50%.

In addition, dislocations of the CMC joint can be missed in patients who present with subtle findings on physical and radiographic examination at initial presentation on the emergency department.

With this report of an untypical presentation of a punching injury we will increase the awareness that CMC joint dislocations can also be related to a low energy trauma.

Case summary:

A 30 year old man without any significant medical history presented to our emergency department several hours after beating a brick wall in a state of emotional stress. He complained of pain in his dominant right hand.

On examination the right hand was deformed with a soft tissue swelling on the dorsal and ulnar side of the hand. The patient was unable to move his wrist related to pain and kept the hand in a neutral position. There was no neurological or vascular impairment and no additional injury. There was no obvious rotational deformity of the fingers.

To exclude a fracture or luxation an x-ray of the right hand was performed. The x-ray study showed a fracture of the proximal fourth metacarpal bone with fragments between the base of the third and fourth metacarpals. Furthermore, there was a dorsal dislocation of the third and fourth metacarpals.

For preoperative planning  a CT scan of the right hand was performed which showed a luxation of the fourth and fifth carpometacarpal (CMC) joints with a dorsal and proximal dislocation of approximately 1 cm and a fracture of the base of the fourth metacarpal with multiple bone fragments.

The consulted trauma surgeon performed a closed reduction of the CMC joint dislocation and internal fixation with Kirschner wire and an additional short arm cast.

Conclusion:

CMC dislocations are rare hand injuries and normally related to a high energy trauma. In this case the CMC dislocation was related to a low energy trauma. Careful hand examination and radiographic assessment including anterior-posterior, lateral and posterior-anterior oblique views with a systematic approach of both intercarpal and CMC joints are necessary to avoid missed diagnosis of CMC joint fracture dislocation. A CT should be performed for preoperative planning but even if in doubt about a possible dislocation. When left untreated or treatment is delayed, these injuries can lead to chronic pain, stiffness and posttraumatic arthritis. Delayed treatment will also increase need for open reduction.

Introduction:

Weapon wounds represent 1% of victims in prehospital care. Located in abdomen or thorax area, these penetrating injuries are serious life-threatening conditions. In particular, heart wounds represent a lethal condition with high mortality rates (60-90% of patients die on the scene or during transport). This situation requires an urgent, rational and adequate treatment to improve patients' prognosis.

Case report:

We report the case of a 24-year-old man, victim of thoracic stab wound. The EMS team arrived 5 minutes later in the scene. The patient was in a cardiac arrest with a wound at the 5^th left intercostal space. Chest compressions have been started by a witness.  Monitoring showed asystole. Advanced cardiopulmonary resuscitation was initiated. The patient was intubated and adrenaline injection given every 4 minutes. The possible causes of cardiac arrest were checked: hypoxia was treated by oxygen,  no massive pneumo or hemothorax were excluded, hypovolemia by haemorrhage was evoked and controlled by fluids.  Cardiac tamponade was strongly suspected because of jugular vein distension. Percutaneous pericardiocentesis was  practiced  by subxiphoid approach after 20 minutes of CPR which allowed the aspiration of  60 ml of blood. Twenty minutes later, the patient return to sinusal rhythm and recovered spontaneous circulation. He was transferred to operating theatre. Two wounds were repaired in the right ventricular with a good circulatory and neurological evolution in intensive care unit  allowing  withdrawal of ventilatory support and patient's discharge from hospital 3 days later alive and in good health.

Discussion:

Cardiac wounds are dominated by right ventricular wounds (45% of lesions), then the left ventricle (32%), the atria (15%) and finally the pericardium (9%). There is no unique symptoms for these heart stab wounds but they frequently induce tamponade in 80% to 90% of cases.  Location of the wound at the 5th left intercostal space at the sternal border was very suggestive of a direct cardiac injury with pericardial effusion.  Presence of a witness who started CPR and optimized resuscitation with optimal control of reversible causes in prehospital care (tamponade, hypovolemia...) were determining for recovery of spontaneous circulation and good outcome. Fast et concise alert of anaesthesiologists and cardio surgeon team, by the medical regulation, allowed optimization of adequate management of this cardiac wound and the haemorrhage's control.

Conclusion:

The improvement of recovery rates and outcome of traumatic cardiac arrest involve  optimization of every link of the survival chain: from the first witness to  post-resuscitation care. Optimal management in prehospital care is primordial. Every reversible cause might be evoked and eventually treated to allow recuperation

Introduction: Colonoscopy is a widely-used procedure evaluating, diagnosis and treatment of gastrointestinal diseases. That’s why its complications are well diagnosed. We present a rare and interesting complication following diagnostic colonoscopy.

Case: A 41 years old female admitted to our Emergency Department with pain in the neck. At the physical examination, there was crepitation and swelling on the right side of the neck that extends along 2^nd rib. In her history, it was learned that nearly before 3-4 hours she had have diagnostic colonoscopy for etiologic research of constipation and diagnostic polypectomy was performed from rectosigmoid junction. Although the abdominal examination and X-rays were normal, considering perforation, computerized tomography was taken and retroperitoneal air images, subcutaneous emphysema from right cervical area to chest and pneumomediastinum were seen. The patient given to the surgery due to the diagnosis of perforation. After the primary repair the patient was hospitalized for 8 days and discharged.

Discussion: In America 14,2 million colonoscopies were performed in 2002¹. Perforation is a rare but threatening complication of this procedure. Its rates range from 0,003-0,12%^2,3. There are some risk factors of perforation following colonoscopy like advanced age, male sex, low volume endoscopic service, significant comorbidity, obstruction as an indication for colonoscopy and performance of invasive interventions⁴. Three mechanisms are responsible from perforation; mechanical perforation, overzealous air insufflation or barotrauma and after therapeutic procedures such as polypectomies and biopsies⁵. Patients with intraperitoneal perforation usually may present with abdominal pain, peritoneal irritation signs and rarely respiratory symptoms. Retroperitonal air can move upwards to the mediastinum from the hiatus aorticus and IVC, continue along facial planes into the neck resulting in cervical subcutaneous emphysema⁶. Treatment of perforation following colonoscopy is simple and safe for patients without peritonitis. Alternatives of the modalities are conservative treatment with nasogastric catheter and antibiotics and surgical treatment like primary repair or resection⁷.

Conclusion:  By the increase of colonoscopy rates for colorectal cancer screening, the incidence of colonic perforation rates is expected to rise. For the patients care physicians should be aware of the rare signs of perforation beside common ones.