Introduction:

Severe trauma remains a major issue for public healthcare worldwide. Management of these polytrauma patients is mostly performed in intensive care units (ICU) that provide mutlidisciplinary care. The radiological evaluation is a vital part of their management and is essentialy based on performing a whole-body computed tomography (WBCT). However, less attention has been paid to the management of non-vital polytrauma patients in the Emergency Departments (ED). The aim of the study was firstly to evaluate the management of non-vital polytrauma patients who had a WBCT in our ED. We also performed this study to find predicting factors of severity at hospital admission.

Methods:

We present here a retrospective and monocentric study. We reviewed the chart of all patients who had a WBCT (for trauma) in 2014. We collected epidemiological, clinical and biological parameters and all therapeutic measures during the ED stay. A long-term survival follow-up was also performed. All patients directly admitted to the ICU were excluded.

Results:

A total of 210 patients were included for statistical analysis and 64% (CI95% : [57.8-70.8]) of them had one or more lesion(s) in the WBCT (36% normal WBCT). The mean ISS score was 10.1±8.8. 42 patients (20% ; CI95%: [14.6-25.4]) underwent urgent surgical procedures or were admitted to the ICU. We have defined these patients (n=42) as severely injured trauma patients. The mean ISS score for these patients was 16,1±10.8 compared to others 8,5±7.5 in the remaining cohort (p<0.0001). The mortality rate predicted by the TRISS model was 3,1% compared to 1,5% in the whole cohort (p<0.0001). The average length of stay in the ED was 5,4±2.9  hours for the severely injured trauma patients versus 7,2±4.6  hours for the other patients of the study (p=0.003) and the average lenght of stay was 16,2±18.9 days for the severely injured group versus 3,1±6.4 days for the non-severely injured patients (p<0.0001). In multivariate analysis, heart rate (>100/min) and Vittel score (³2 criterias) were related to the probability of belonging to the severely injured trauma group (p=0.03). The 24-hour mortality rate was 0.5% in the ED and the 30-day mortality rate was 1.5%.

Conclusion:

The development of a specific network in the ED hosting non-vital but severly injured polytraumas remains crucial. The primary goal of this future network will be to meet technical and time requirements and establish new in-hospital triage algorithms based on clinical variables (such as heart rate), in order to detect these patients at an early stage and offer them priority care in our overcrowded EDs.

Introduction. Traumatic brain injury (TBI) is very common in emergency department. Most of them are the results of mild head injury defined by a Glasgow coma scale score greater or equal to 13. In case of head trauma under antiplatelet agent, guidelines of the French Society of Emergency Medicine required to perform a CT scan to detect brain lesions. In this indication, 90% of CT scan are normal. The utility of CT is still debate given controversial and scarce number of studies.

Methods. We used the RATED registry (Registry of patient with antithrombotic agents admitted to an Emergency Department, NCT02706080) to assess factors of cerebral bleeding related to antiplatelet agent after head trauma. RATED is a monocentric, ongoing (from January 2014), observational registry of consecutive patients under antithrombotic drugs admitted to an emergency department. For this study, only patients under antiplatelet drugs at admission, with a head trauma who benefit a CT scan, were considered. Those under anticoagulants drugs were excluded.

Results. From January 2014 to December 2015, 993 patients under antiplatelet agent were recruited. Of these, 293 (29.5%) underwent a CT scan for trauma brain injury. Intracranial bleeding was found in 26 patients (8.9%). After multivariate analysis, these patients were more likely to have a history of severe hemorrhage (OR = 8.47, 95%CI: 1.56-45.82), a dual antiplatelet therapy (OR = 6.46, 95%CI:1.46-28.44), headache or vomiting (OR = 4.27, 95%CI: 1.44-2.60) and less frequently a glasgow coma scale of 15 (OR = 0.11, 95%CI: 0.03-0.35) than those without intracranial bleeding. The predictive model derived from these variables had a specificity of 98.9% and a Negative predictive value of 92%. The area under curves of the ROC curve was 0.85 (95%CI: 0.77-0.93).

Conclusions. Our study showed that the absence of a history of severe hemorrhage, dual antiplatelet therapy, headache or vomiting, and normal Glasgow coma scale score seems to predict a normal CT scan after trauma brain injury under antiplatelet. This founding need to be confirmed by prospective studies.

Background

Falls constitute a significant challenge in health care, particularly in the oldest age groups. We aimed to investigate the incidence of fall-related injuries among the older Finns.

Materials and methods

In this retrospective population-based study, we registered all consecutive emergency admissions due to fall-related injuries in a high-volume emergency department (ED) during a 2-year study period (January 2015 to December 2016). The catchment area of the study hospital exceeds 1 million inhabitants in tertiary care services, and it provides both primary and tertiary care ED services for a population of 226,696 inhabitants (10,991 aged 80 years or more). Patients were eligible for this study if they were 80 years or older. Patient demographics and diagnoses were retrieved from hospital records. The key factor under analysis was the incidence of fall related injuries.

Results

During the study period, 2,951 patients (median age 87, range 80-104; 73 % females) had 3,802 emergency admissions due to fall-related injuries (2.2% of all ED visits and 11% of all visits in this age group). The incidence of these injuries increased from 49/1,000/year in inhabitants aged 80-89 years to 87/1,000/year among those aged ≥90 years (p<0.001). The risk was also higher among females (p<0.001), the incidence was 60/1,000/year among females and 45/1,000/year among males. Typical injuries caused by falls included, fractured femur (21%), intracranial injury (19%, with intra-cranial hemorrhage in 5% of patients), open head wound (15%) and forearm fracture (7%). The number of injurious falls of all ED visits varied from 253-358 from month to month, with no association with time of year. Recurrent falls were registered in 39% of patients (range 1-5 falls). When single fallers and recurrent fallers were compared, older age and female gender were not associated with higher risk of recurrences (p>0.05). In community-dwellers, most injuries (64%) occurred in domestic setting. Ten percent of all patients were admitted to hospital from nursing homes.

Conclusions

The observed incidence of fall-related injuries is lower than in earlier reports. Nevertheless, these incidents cause a significant burden to emergency services. While the risk of single falls increased with age and was also higher among females, these risk factors were not associated with higher risk of fall recurrences.

 Introduction:

One of the most important factors for total morbidity and mortality in traumatized emergency patients is chest trauma; the complexity of injury in trauma patients makes it challenging to provide an optimal oxygenation while protecting the lung from further ventilator-induced injury to it. Ultrasound has a well-known established role in the diagnosis of a traumatic pneumothorax.

Case series: We are reported 46 patients with traumatic pneumothorax who require positive-pressure ventilation   recruited from Alexandria Main University Hospital Emergency Department who examined pre and post CT-Chest scanning by the same operator between November 2015 and September 2016.

Inclusion criteria: Any patient with either blunt or penetrating chest trauma regardless the age or gender who require positive-pressure ventilation.

Exclusion criteria: patients with open or tension pneumothorax.

The chest scanned (using the superficial probe 7.5 MHz type L7M-A of our CHISON device model ECO 2) at three lines and two views for each hemithorax as the following (1)anterior second through sixth intercostal spaces at the parasternal line, (2) anterior second through sixth intercostal spaces at the mid-clavicular line, (3) fourth through sixth intercostal spaces at the anterior axillary line,(4) fourth intercostal space at the mid-axillary line, (5) fourth intercostal space at the posterior axillary line, to assess for the presence of a sliding lung.

We analyzed 46 patients, 85% were men, with median age of 27 for the total number of patients. The results of ultrasound scanning of intubated patients’   pre CT scan in comparison to the result of ultrasound scanning after the CT scan of the chest to detect the behavior of traumatic pneumothorax. Six patient (13%) had expanding pneumothorax detected by CT chest and comforted by bedside US. One patient developed right tension pneumothorax after 6 hours, in which pre CT US scanning was Right minimal pneumothorax and Left minimal pneumothorax, post CT after 35 minute was Right mild pneumothorax and left minimal pneumothorax. Another patient developed massive left pneumothorax discovered accidental during CT abdomen, pre CT US scanning was Right mild pneumothorax and free left pneumothorax, post CT was Right mild pneumothorax and left minimal pneumothorax.                                                                                                                                                     

Conclusion: Bedside US lung could be used a predictive tool in detection of early expanding traumatic pneumothorax in-patient on positive-pressure ventilation.

M.D., PhD-student Egholm JWM^1,2, PhD Pedersen B^1,3, M.D. Oppedal K⁴, Professor M.D. Lauritzen JB⁵, M.D. Madsen BL⁶, Professor M.D. Tønnesen H^1,3

¹WHO-CC, Clin Health Promotion Centre, Bispebjerg-Frederiksberg Hospital, University of Copenhagen, Denmark; ²Orthopedic Dept, Hospital of Southern Jutland, University of Southern Denmark; ³Clin Health Promotion Centre, Dept Health Sciences, Lund University, Sweden; ⁴Alcohol and Drug Research Western Norway, Stavanger University Hospital, Norway; ⁵Dept Orthopaedic Surgery, Bispebjerg-Frederiksberg Hospital, University of Copenhagen, Denmark; ⁶Dept Orthopaedic Surgery, Hvidovre Hospital, University of Copenhagen, Denmark.

Introduction:

Patients with hazardous alcohol intake are overrepresented in emergency departments and surgical departments. In elective surgery, preoperative alcohol cessation interventions can reduce postoperative complications[1] but no studies have investigated the effect of alcohol cessation intervention at the time of surgery for acute fractures.

Purpose:

To evaluate the effect of the Gold Standard Programme for alcohol cessation intervention (GSP-A) for patients undergoing acute ankle fracture surgery regarding postoperative complications.

Methods

Our RCT design included a total number of 70 patients from Hvidovre and Bispebjerg Hospitals with an excessive intake of alcohol and an ankle fracture that required osteosynthesis. They were allocated to either standard care or a 6-weeks GSP-A aiming to complete alcohol abstinence peri- and postoperatively.

GPS-A involved a patient educating programme and weekly sessions at the orthopedic outpatient clinics. Furthermore, patients were provided with thiamine and B-vitamins, prophylaxis and treatment for alcohol withdrawal symptom and disulfiram to support abstinence.

Biochemical validation of alcohol intake was carried out. Follow-up took place after 6 weeks and 3, 6, 9 and 12 months.

The main outcomes were postoperative complications (requiring treatments), alcohol intake and cost-effectiveness.

Results:

In the GSP-A group 12 patients (34%) developed complications compared to 14 patients (42%) in the control group (p=1.0).

Interestingly, 14% in the control group versus 51 % in the in the GSP-A group had abstained completely from alcohol at 6 weeks follow up. (p=0.001).

Conclusion:

We found no statistically significant differences in the number of complications between the intervention and control group.

We are looking forward to evaluate the cost-effectiveness of the study to see if there is a difference between the two groups. Biochemical analysis is still ongoing.

However, the majority of the intervention group completely abstained from alcohol in the intervention period.

Contact information: julieweberegholm@gmail.com

Background

Head, neck, extremity, thorax and abdominal injuries are the main injury sites for trauma in Hong Kong. Return to work (RTW) status is an indicator of their outcome and an important element in their social reintegration. Besides physical recovery, RTW may be affected by the psychological characteristics of patients, available technologies that can assist their functional recovery and socioeconomic factors. Some of these are modifiable and may vary between injury sites.  The aim of this study was to compare the time to return to work (RTW) and time to reach Hong Kong norm of SF36 of patients who sustained moderate to severe injuries at these sites. This may help to identify the type of injury where research is most needed to bridge the gap between time to recovery and return to work.

Methods

This was a multicenter, prospective cohort study of patients entered into the trauma registry of the three regional trauma centres in Hong Kong. Patients were included if they were aged between 18 and 70, with an ISS³9 and were working or seeking employment before injury. Outcome measures included physical component summary (PCS) and mental component summary (MCS) scores in SF36 and their return to work status over 5 years. The Hong Kong norm for PCS is defined as >52.83 and that for MCS is >47.18.

Results

189 patients were recruited to the study from 1 January to 31 September 2010 (mean age 41.4 years; 80.4% male). 99 (52.4%) patients had head or neck injuries, 44 (23.3%) had extremity injuries, 39 (20.6%) had thoracic or abdominal injuries, and 7 (3.7%) had spinal or other body region injuries. 5-year mortality rate was highest in head injury patients (12/99, 12.1%, 95%CI 6.4-20.2%), followed by extremity injury (1/44, 2.3%, 95%CI 0.1-12.0%). There was no death in patients with injury in other parts of the body. For patients that are still alive at 5 year follow-up (n=87, 43 and 39 for head/neck, extremity and thorax/abdomen injuries respectively), Kaplan-Meier curves of time to RTW were different between the three principal injury sites (log-rank test p=0.041). Mean time to RTW for head/neck injury was 2.2 years (95%CI 1.6-2.8 years), 2.3 years (95%CI 1.5-3.1 years) for thoracic/abdominal injury and 3.6 years (95%CI 2.8-4.5 years) for extremity injury. However, Kaplan-Meier curves of time to reaching the Hong Kong normal PCS or MCS showed no significant difference between the three injury sites (log-rank test p=0.386 and 0.482 respectively; mean time to PCS>52.83 ranged from 3.3-4.0 years and mean time to MCS>47.18 ranged from 2.0-2.3 years).

Discussion

Among the factors that affect the RTW status besides health status, some of them are specific to extremity (limb) injuries. This may represent a specific group for targeted rehabilitation to shorten the time to RTW.

Funding

The study has been conducted with the support of the Health and Health Service Research Fund from Hong Kong government (HHSRF 07080261).

Background: whiplash Associated Disorders (WAD) are very frequent reasons for request of health care interventions in acute setting. They involve about 30-40% of people after a car accident, and they are a growing problem in terms of both health and insurance costs. The “gold standard” of WAD in acute management is not established and the application of cervical collar continues to represent a common practice, although it is known that it does not to improve the course of disease.

Aim: the goal of this study is to assess whether the use of cervical collar in patients with WAD is associated to a higher risk of readmission within 90 days from trauma and the likely onset of post-traumatic associated syndrome

Methods: we retrospectively evaluated all the patients observed in the Emergency Department (ED) of the University Hospital of Verona for WAD, according to the Quebec Task Force definition. We considered only the patients with isolated WAD within 48 hours from a car accident, excluding those with associated head trauma. At the ED evaluation time we registered for each patient: the demographic and clinical features; the time and mechanism of trauma; the grade of WAD and if the application of cervical collar was performed or not. Moreover, we excluded the patients in case of rx assessment of cervical spine fracture (WAD 4). We carried out a multivariate analysis to verify the impact of the cervical collar on the outcome adjusted for grade of WAD. Finally, we submitted our series of patients to propensity score matching, in order to reduce the bias of a retrospective study, and then we repeated the statistical analysis on the selected cohort of patients.       

Results: from January 2013 to December 2014 we observed 2156 patients with WAD (grade 0 to 3). In most of the cases (85.5% of the patients) a cervical collar was applied. An overall number of 162 patients (7.5%) had a readmission within 90 days from trauma and 154 (7.1%) out of them used a cervical collar (p = 0.001). Cervical immobilization resulted to be a significant risk factor for readmission both in univariate (OR 3.663, 95% IC 1.684-7.122) and in multivariate analysis (adjusted OR 3.561, 95% IC 1.255-7.349). After the propensity score matching we selected 482 patients equally divided (50% with and 50% without cervical collar). Even in the selected series readmission rate was higher in patients with cervical collar (10.4% vs 2.9%, p < 0.001). The risk was confirmed both in univariate (OR 3.869, 95% IC 1.640-9.127, p = 0.002) and in multivariate analysis (adjusted OR 3.878, 95% IC 1.643-9.153, p = 0.001).

Conclusion: the application of cervical collar in WAD appears to be an independent risk factor for the onset of post-traumatic associated syndrome. These results are not related with the grade of WAD and they have been confirmed even when propensity score matching was performed.

Introduction:  Anaphylactic shock (AS) is a life-threatening condition in which blood circulation fails to meet oxygen demands of organs in the body. Restoring effective circulation is the major objective of treatment which can sometimes be resistant to conventional treatments available. We evaluated novel drugs targeting specific pharmacological pathways to define therapeutic alternatives or supplements to epinephrine. The role of potassium voltage-dependent channels (Kv) and hydrogen disulfide (H₂S), a potent vasodilator, was not explored in AS.

Objectives: Our objective was to demonstrate that the inhibition of Kv with 4 aminopyridine (4-AP) alone or combined with the inhibition of the production of H₂S with dl-propargylglycine (PEG) or betacyanoalanine (BCA) restores blood pressure and improves survival.

Methods: Rats were sensitized with ovalbumin (OVA, 1mg s.c), and AS was induced by i.v. injection of OVA (1mg) through jugular vein catheter. Experimental groups included NA=non-allergic rats (N=6); Controls=allergic rats (N=10); allergic rats treated with 4-AP (1 mg/kg) (N=10); epinephrine (EPI)=allergic rats treated with EPI (10 µg/kg) (N=10), allergic rats treated with PEG (N=10), allergic rats treated with BCA (N=10). Treatments were administered 1 minute after induction of AS. Mean arterial blood pressure (MAP), heart rate (HR) were measured through carotid artery catheter

Results: MAP, HR, and survival were measured for 60 minutes. MAP was normal in the NA group; severe hypotension and high mortality were observed in controls; normalization of MAP, HR, and increased survival were observed in 4-AP, DPG, BCA, 4-AP+DPG or BCA, and EPI groups. Survival time was: controls=22±3 min, EPI=59±1 min, 4-AP=60 min, DPG=49±5 min, BCA=44±7 min, 4-AP+DPG=58±2, 4-AP+BCA=60 min. All allergic 4-AP and 4-AP+BCA-treated rats survived after the induction of AS (p<0.05).

Conclusion: We demonstrated that the allergen-activation of Kv is a probably a new pathway involved in the vasodilation induce by AS in a rat model. It seems that H₂S is a major mediator released during AS in endothelial and vascular smooth muscle cells and could play a role in the induction of AS. Inhibition of Kv alone or combined with the inhibition of H₂S production improves significantly survival and restore blood pressure. 

Background: Inflammation and thrombosis are involved in the progression of acute aortic dissection (AAD). The aim of this study was to assess the prognostic significance of the Simplified Thrombo-Inflammatory Prognostic Score (sTIPS) in patients with early phase type B AAD.

Methods: We retrospectively reviewed 491 patients with type B AAD between November 2012 and September 2015. sTIPS was calculated using data obtained at the time of admission, and patients were assigned a score of 0, 1, or 2. Kaplan-Meier curves and multivariable Cox regression analyses were used to investigate the associations between the score and hospital survival.

Results: Of 491 type B AAD patients included in this analysis, 24 patients (4.9%) died while hospitalized. Compared to those with lower sTIPS, patients with higher sTIPS had higher rates of in-hospital mortality (P = 0.001). Kaplan-Meier analysis also showed that cumulative mortality was significantly higher in patients with higher sTIPS (P = 0.001). Multivariable Cox regression analysis further revealed that scores of 2 or 1 (versus 0) were strong predictors of in-hospital mortality (sTIPS 2: hazard ratio: 5.620, 95%; confidence interval [CI]: 1.320-16.167; P = 0.017; sTIPS 1: hazard ratio: 2.012, 95%; CI: 1.254-3.204; P = 0.043) after controlling for all of the confounding factors. Subgroup analysis showed sTIPS was also positively associated with the hazard of in-hospital mortality in patients with different therapies.

Conclusions: sTIPS was a useful tool for risk-stratifying type B AAD patients at admission for outcomes such as in-hospital mortality in the early phase.

Introduction. The morbidity and mortality of patients with pulmonary embolism is high with 8 to 23 deaths per 100,000. In order to make the diagnosis, the emergency physician uses clinical scores that involve the presence or absence of a tachycardia. The objective of our study was to assess the impact of beta-blockers on the heart rate of patient with a pulmonary embolism.

Methods. We performed a retrospective, observational, monocentric study from June 2014 to May 2015. All consecutive patients admitted to our department with an objectived pulmonary embolism were included.

Results. Among the 117 patients included, more than a quarter was under beta-blocker (n = 31). The mean age was 68+/-17 years. Patients with beta-blockers were older than those without (respectively, 76+/-11 vs. 66+/-18 years, p = 0.03). The mean heart rate was lower in patient with beta-blockers than in those without (76.714 vs. 90.719 bpm, p <0.001, respectively). Moreover, regarding the heart rate item in the revised Geneva score, those with beta-blockers were more likely to have a heart rate < 75 bpm (42% vs. 19%, p = 0.015, respectively) and less likely > 95 bpm (13% vs. 41%, p = 0.04, respectively) than those without. However, for the sPESI score, there was no difference between the mean score of those with and without beta-blockers (respectively, 1.2+/-0.9 vs. 0.9+/-0.8, p = 0.104). Interestingly, regarding the heart rate item of sPESI score, none of the patient with beta-blocker had a heart rate > 110 bpm whereas 9 (10.5%) of those without beta-blocker had it (p = 0.11).

Conclusions. Our study showed that 26.5% of PE patient admitted in an emergency department were under beta-blockers. Moreover, PE patient with beta-blockers had a lower mean heart rate than those without. This could have an impact on the different scores used by emergency physicians to diagnose PE. Thus, 42% of PE patients with beta-blockers did not obtain the point assigned to tachycardia in the revised Geneva score. This could therefore have an impact on emergency physician diagnosis which could underestimated the PE score of some patient with beta-blocker. This results should be validated by multicentric and prospective studies.

Introduction. The use of direct oral anticoagulants (DOACs) is increasing due to an easier used and a decreased bleeding risk. The objective of our study was to describe the clinical characteristics of patients under DOACs, the type of hemorrhage and their management.

Methods. We performed a retrospective, monocentric and descriptive study on patients under DOACs and admitted to our emergency department between January 2014 and June 2015. We used the RATED registry (Registry of patient with antithrombotic agents admitted to an Emergency Department, NCT02706080) which is a monocentric, ongoing (from January 2014), observational registry of consecutive patients under antithrombotic drugs admitted to an emergency department.

Results. Of the 357 patients under DOACs included, 51 (14.3%) were under apixaban, 109 (30.5%) under dabigatran and 197 (55.2%) under rivaroxaban. Atrial fibrillation was the most frequent indication for DOACs (79.3%) with an average CHA2DS2-VASc score of 3.9 ± 1.8. The mean age was 73 ± 15 years with 78 ± 12 years for apixaban, 74 ± 13 years for dabigatran and 71 ± 16 years for rivaroxaban. Our cohort identified 211 (59%) prescribing errors related to the combination of a treatment which could increase the bleeding risk (33.6%), a dose not adapted to the age of the patient (28.0%), a dosage not adapted to creatinine clearance level (15.9%) or an additional treatment with antiplatelet agent for more than 1 year (13.3%). Of the 357 patients under DOACs, 64 patients (17.9%) were admitted for hemorrhage with 23 major bleeding (6.4%). Bleeding occurred in 8 patients (15.7%) under apixaban, in 13 under dabigatran (11.9%), in 43 (21.8%) under rivaroxaban with, respectively, 2-5-16 major bleeding. The management of those with major bleeding (n=23) was transfusion for 9 (39%) of them (5 under rivaroxaban, 3 under dabigatran and 1 under apixaban), reversion by prothrombin complex concentrate for 1 (4.3%) under rivaroxaban or by FEIBA for 4 (17.4%) under rivaroxaban.

Conclusions. Our study showed that more than half of patients under DOACs admitted to the emergency department had a prescription error and that only 1 major bleeding over 5 were treated with a reversal agent. Even if DOACs are easier to use, clinicians must be aware of interaction and contraindication, and must improve the management of major bleeding.

Introduction: In the treatment of ST-segment–elevation myocardial infarction (STEMI), faster times to reperfusion result in better outcomes. Primary prehospital Helicopter Emergency Medical Service (HEMS) interventions may play a role in reperfusion therapy. We analyzed data from our Cardiologic Regional Interventional Observatory Registry involving patients with STEMI aimed at the evaluation of the potential benefit of HEMS interventions as compared with EMS ground transport with MICU (Mobile Intensive care Unit).

Materials and Methods:Retrospective multicentric study conducted from January 2014 to January 2015. All successive patients with STEMI eligible for percutaneous coronary intervention (PCI) were included. Access times were computed allowing the estimation of dispatch French System (SAMU) delay from emergency the phone call to admission to one of the 6 cath labs using standard data collection from the French region Centre Registry of Acute Coronary (CRAC). We analyze pre admission transport time (FMC-DTB) according to  distance between FMC to cath lab location and mode of transport (HEMS vs MICU)

Results: During the study period, 1699 patients with STEMI were included in the Registry.In the overall population, Mean age was 63,2 y-o, sex ratio male was 2,7. The mean time from the emergency phone call to the dispatch center (Number 15 or 112) to the ECG as the First Medical Contact (FMC) is 1h40 mn. Of these patients 82 % were transferred for primary PCI, 2% fibrinolytic therapy, 7% secondary angioplasty.The mean response time FMC to Door-to Balloon (DTB) time was longer using the helicopter HEMS (2h20 mn) than road transport with MICU ambulances (2h:06 min).For short distances (25-74 km) the median delay using road transport was shorter (1h: 54 min) whereas this time by air transport (2h: 12 min).The median transport delay gain was shorter (15 min) for distances over 75 km by using HEMS.

Discussion: In many European countries, patients with STEMI , guidelines have called for device activation within 90 minutes of initial presentation. Our results offer important insights of the impact of transfer time and mode of transport on achievement of guideline goals for D2D time in the treatment of STEMI patients as HEMS transport did not offer D2D time advantages for STEMI patients better than ambulances for short distances. Several explanations: (1) time for air transportation, (2) cases with more complexity (3) distance .In our study for patients with STEMI,  benefits of air transportation with HEMS are not significant for short (< 50 km) or long (> 75 km) distances and may encourage the dispatch center to use the MICU ambulances for a rapid access to PCI .

Conclusions In our CRAC registry for management of STEMI, strategy of decision was associated with longer DTB times with HEMS versus MICU ambulances.Our findings suggest the need for evaluation and continued systems improvement of the use of effective resources for transport of STEMI to the PCI.

 Background

The purpose of this study was to assess the prognosis for patients with suspected acute coronary syndrome (ACS) after the implementation of high sensitivity troponins (hstn). The first objective was to investigate if there had been a change in the incidence of  patients  diagnosed with ischemic heart disease and non-specific chest pain(NSCP) after the implementation of hsTn. The second objective was to determine the mortality in the NSCP group before and after hsTn and the third objective  to evaluate the prognosis and mortality in patients discharged with the diagnosis ACS, stable angina pectoris (SAP), other heart related conditions (OHC) and NSCP after hstn implementation.

 Method

This study is a register based prospective multicentre cohort study. All patients aged 18 and older in the region of southern Denmark with an acute contact to the emergency department or cardiology department in 2013 and who had at least one troponin measurement were included. Depending on their discharge diagnosis and the Troponin value, the patients were stratified into 4 groups, consisting of

a)      Patients with myocardial infarction and elevated Troponin measurement.

b)      Patients with other serious heart disease than ACS

c)      Patients with clinical assessed stable SAP and normal troponin

d)     Patients with normal troponin and without acute heart disease, who were discharged without an explanatory diagnosis of the chest pain, NSCP.

 Patients arewere identified by their troponin measurements from the biochemical system. Endpoint during follow up was obtained from the National Patient Registry and Civil Registration System. Endpoints were readmission with myocardial infarction, ventricular fibrillation/cardiac arrest and all-cause death. Endpoints were reported for one year follow up or until emigration.

 Results

6037 patients were eligible for final analyses. The group consisted of 2 513 patients before and 3 491 after the hstn implementation. Comparing the diagnosis before and after hstn, there was a relative increase in MI of 25% and OHC with 9%, NSCP and SAP decreased with 6% and 43% respectively. The 12 months-mortality for NSCP was 3.4% before hstn and 2% after. No significant difference was shown between in mortality before and after hstn. The prognosis for the four groups after implantation of hstn showed that MI had the highest risk of future MI with 4% event rate during one year. NSCP had 5 times lower risk of future MI compared to the MI group. No significant differences  in mortality was shown when comparing the MI group with the NSCP, OHC or SAP groups.

 Conclusion

The number of NSCP patients decreased after the hstn implementation and had a low risk for future cardiac events No significant differences in mortality was shown comparing the mortality rate in this group before and after hstn implementation. The risk of future MI is significantly lower in NSCP than in the MI group

Background

Atrial fibrillation (AF) increases the risk for stroke and other thromboembolic complications. Properly carried out anticoagulation (AC) is the most important treatment for AF patients in stroke prevention, and it has been found to prevent up to 60-70 % of strokes. In clinical practice, the need for anticoagulation in AF is estimated by using CHA₂DS₂VASc and HAS-BLED scores. CHA₂DS₂VASc score assesses the thromboembolic risk and HAS-BLED score the risk for bleeding.

According to recent national and international studies, anticoagulation is underused among AF patients. In particular, the Finnish FinFib study showed that as many as 29% of high risk patients did not receive anticoagulation (1). Therefore, we wanted to examine how well the AF treatment is carried out at Tampere University Emergency Department (ED).

Materials and methods

From 1 October 2014 to 30 November 2014 all patients with AF or atrial flutter (ICD-10 code I48) at ED were identified from hospital records. We collected the following data: age, gender, what type of AC was used and whether the diagnosis was new or previously existing. We also investigated if the CHA₂DS₂VASc and HAS-BLED scores were calculated during the patients stay. Additionally, we counted both scores for all the patients, regardless of whether they were calculated during the ED visit. For this purpose, we collected data on all patients with any type of risk factors. Finally, we investigated whether the bridge therapy was started with warfarin, and furthermore, what were the INR values of all the patients on warfarin therapy.

Results

A total of 470 patients with 537 unique ED visits were included in the study. Patients had a mean age of 70 years (range 21 -100 yrs). Out of the unique ED visits, CHA2DS2VASc and HAS-BLED scores were calculated in 19% and 3% of the cases. 87% of all the high-risk and 72% of new high-risk AF patients had AC therapy when leaving the ED. 57% of the patients on warfarin had an INR in therapeutic range (2.0-3.0). Furthermore, only 53% of patients with newly diagnosed AF referred to cardioversion had received bridging AC therapy with small molecular heparin (LMWH).

Discussion:

We found that although CHA₂DS₂VASc and HAS-BLED scores were calculated in a minority of the cases, relevant AC therapy for high-risk patients was well executed. However, over every fourth of the high-risk patients with new onset AF did not receive AC therapy when leaving the ED. Furthermore, only half of the patients who began warfarin therapy were prescribed to use bridge therapy with LMWH. Based on these results, we have developed a standardized treatment protocol for AF patients. This protocol includes evaluation of the optimal treatment (rhythm or rate control) and execution of suitable AC treatment for each patient. We have also developed a special program to our ED’s patient data system in which the CHA₂DS₂VASc and HAS-BLED scores shall be filled in for each patient.

Introduction: The HEART score is a validated risk score for chest pain patients presenting at the Emergency department (ED). The HEART score  consists of five elements; history, ECG, age, risk factors and troponin. All of the elements are scored zero, one or two points, depending on the severity of the abnormality. Two of its elements, history and ECG, are subjective for interpretation by the ED physician. Little is known about the interobserver variability of history and ECG scoring and how this influences the interobserver variability of the final HEART score. The purpose of this study is to assess if the HEART score can be calculated reliably by different physicians.

Methods: For this study data from 125 patients was used. Each patient was scored by two cardiologists, two emergency physicians and two residents. Each physician scored the history and ECG of the 125 cases independently and blinded for the other elements of the HEART score. Interobserver agreement was measured by calculation of the intraclass correlation coefficient (ICC), using R statistics.

Results: Mean HEART score was 4.7 (95% CI 0.7-8.7). The analysis of the separate components yielded an ICC of 0.617 (range 0.0-1.0) for the history and an ICC of 0.512 for the ECG. On top of that, the agreement of the total HEART score between physicians was even higher, with an ICC for the HEART score of 0.888. The ICC for the total HEART score was 0.887 for the cardiologists, 0.882 for the emergency physicians and 0.986 for the residents.

Conclusion:  This study shows a very high ICC between different physicians at the ED, demonstrating a very high interobserver reliability of the HEART score. This supports the use of the HEART score by  several physicians. 

Abstract

Purpose: The purpose of the study is to detect whether using modified valsalva maneuver (VM) be more effective than standard VM in terminating SVT. 

Material and Method:This prospective randomized control trial, was conducted in an emergency department with patients who diagnosed SVT between 01.12.2015 - 31.12.2016. Participants were divided into two groups, randomly as standard VM or modified VM, as the first treatment with two-dimensional permutation blocks; in the order of arrival of the patients. The randomization was performed by envelope method. In both groups; the determined procedure for standard or modified VM were repeated up to three times in unresponsive patients. In both groups; if the maneuver is unsuccessful after three attempts, rescue medication with anti-arrhythmic treatment used. The primary outcome was defined to compare the success rate of achieving sinus rhythm after standard VM and modified VM.

Results: Totally, 56 patients were included randomly to this study; 28 were assigned to the standard VM, and 28 were assigned to the modified VM. Three of 28 patients(10.7%) in VM group and 12 of 28 patients(42.9%) in modified VM group were returned to sinus rhythm after intervention (p=0.007). Number of patients who need rescue treatment was lower in modified VM group, 16 (57.1 %) of 28, than in standard VM group, 25 (89.3%) of 28 (p=0.007).

Conclusion: Modified VM therapy is more effective than standard VM for terminating of SVT. It also indirectly reduces the need for anti-arrhythmic medication and indirectly causes fewer side effects. Therefore, we believe that modified VM can be considered as a first line treatment option in management of SVT according to results of this and previously studies. 

Background

Chest pain is the most common reason for emergency hospital admission, although the majority could be avoided with improved diagnostic technology. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid ‘rules in’ and ‘rules out’ acute myocardial infarction (AMI) with one blood test at the time of arrival in the Emergency Department (ED). T-MACS estimates the probability of AMI using basic data about a patient’s symptoms, signs, electrocardiogram and a single concentration of high sensitivity cardiac troponin (hs-cTn), a central laboratory assay.

Successful validation with a point of care (POC) cardiac troponin (cTn) assay would reduce turnaround time, helping to unburden crowded EDs. We aimed to prospectively validate T-MACS with a contemporary POC cTn assay.

Methods 

In this multi-centre prospective diagnostic accuracy study nested within the Bedside Evaluation of Sensitive Troponin (BEST) programme, we recruited patients with suspected cardiac chest pain presenting to nine EDs. Patients with another medical condition requiring hospital admission and those whose symptoms peaked >12h ago were excluded. Ethical approval was obtained and all participants provided written informed consent. 

Blood samples drawn on arrival were analysed for cTnI using the POC i-Stat assay (Abbott Point of Care, New Jersey, 99th percentile 80ng/L, LoD 20ng/L). The primary outcome was a diagnosis of AMI, which was defined in accordance with the Third Universal Definition based on central laboratory cTn analysis. To provide an adequate reference standard, the protocol required that all patients also undergo serial central laboratory cTn testing over at least 3 hours (for high sensitivity assays) or at least 6 hours (contemporary assays). 

T-MACS was computed using the original reported formula. We calculated sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios.

Results 

A total of 622 patients were included in this analysis, of which 78 (12.5%) had AMI. Key results are summarised in Table 1. With a single POC cTn test, T-MACS would have ‘ruled out’ 41.6% (n=259) patients with a sensitivity of 97.4% (95% CI 91.0–99.7%) and a negative predictive value of 99.2% (95% CI 97.0–99.8%). Two AMIs were missed based on serial laboratory cTn concentrations. One patient did not receive a clinical diagnosis of AMI, received no treatment, did not undergo further investigation and had no adverse events within 30 days.

T-MACS would have ‘ruled in’ 7.1% (n=44) patients with a specificity of 99.2% (95% CI 98.0–99.8%) and a positive predictive value of 90.9% (95% CI 78.5–96.5%).

Conclusions

To our knowledge this is the first successful validation of a single test ‘rule out strategy’ using a POC cTn assay. Its use could enable almost immediate reassurance and discharge for >40% of patients with suspected cardiac chest pain.

BACKGROUND: In the last two decades we have observed a dramatically increase of the CT scans use at the emergency department (ED). As a result, there has been growing concern around the increase of medical radiation exposure and cancer. The positive rate of head CT in non-trauma patients presenting to the ED is low. Currently, indications for imaging are based on the individual experience of the emergency physician, which contributes to overuse and variability in imaging indication. In adult patients with syncope, without cranioencephalic trauma and with no alarm signs, there is variability and inadequacy in deciding to request a CT scan. The aim of this study is to ascertain the predictors of a positive head CT scan in patients with syncope and demonstrate the feasibility of clinical decision rule (CDR) to improve the adequacy.

METHODS: A systematic search for evidence was made based on a PICO question (Haynes pyramid). After the search PubMed and Embase (2005-2014) was consulted. Four reviewers reviewed all citations and select eligible ones for inclusion. Two authors independently appraised the quality of the studies and their degree of recommendation (GRADE). All disagreements among reviewers were discussed and resolved by a third independent reviewer. After the systematic review CDR was developed and included in the Electronic Clinical Record System at the Emergency department. We retro/prospectively reviewed all ED syncope patients 6 months before and after implementing the CDR. Medical records were assessed for analyzing the adequacy of the CDR and a telephone call was made after 30 days from discharge, in order to ensure that a related event had not occurred.

REUSLTS: The CDR has 5 items (alarm signs) and if any of them was present the CT scan should be performed. The items were: abrupt/severe headache after vigorous exercise, neurological focus, alteration of the level of consciousness, meningism and hypertension emergency. Both in the pre and post-implantation groups, 10% of the syncope had alarm signs. From patients with alarm signs, 10% had a positive CT result. In the cases that did not show alarm signs (90%) an evident differentiation was detected resulting in the Pre-CDR group being 46% unsuitable indications, compared to 7.6% after the CDR implantation, which shows that the goal of adapting CT indications was achieved. None of the patients that were discharged from the emergency department without a CT scan had a new event related with the syncope (CDR had a safety of 100%). Finally, a cost analysis was carried out. We found a reduction of total expenditure of CT scan from 50% to 20% post-intervention, which accounts a total of 85,848 euros savings annually.

DISCUSSION: We can conclude that, the implementation of the CDR for the indication of a CT scan, being the reason of the consultation the syncope at the emergency department, is safe and increases the adequacy reducing not only the costs but also the medical radiation exposure.

Background

Approximately 2300 in-hospital cardiac arrests (IHCA) occur annually in Sweden and the prognosis for those affected is poor with 29% survival to hospital discharge. A do-not-attempt-resuscitation (DNAR) order is issued when it is against the wishes of the patient that cardiopulmonary resuscitation (CPR) is performed, or when CPR is considered medically futile; that is when the chances of good quality survival are minimal. Emergency physicians are required to address the question of futility in the emergency department, but scientific support to fulfill this task is sparse. The Good Outcome Following Attempted Resuscitation (GO-FAR) score was developed in 2013 and has not been validated on a population basis outside the index population. The GO-FAR score is a summed score consisting of 13 prearrest variables with values ranging from -15 to 11 points reflecting the likelihood of good neurological survival at discharge measured as CPC 1 (patient is alert, able to work and lead a normal life, may have minor psychologic or neurologic deficits). A prearrest prediction tool for good outcome after IHCA would substantially contribute to daily clinical practice and reduce barriers for discussing DNAR orders. 

Methods

This validation study is based on a retrospective cohort of adult IHCA in Stockholm County 2013 to 2014 identified through the Swedish Cardiopulmonary Resuscitation Registry (SCRR). SCRR provides patient and event characteristics, personal identification numbers and CPC score at discharge. Data for the GO-FAR variables was obtained from manual review of hospital electronic patient records. The model performance was evaluated by quantifying discrimination and calibration, calculating the area under the receiver operating curve (AUROC) and evaluating the calibration plot with calibration-in-the-large and calibration slope.

Results

The final cohort included 717 patients with a 30-day survival of 27.5% and survival with good outcome at discharge of 22.3%. 61.9% were male, mean age was 72 years (SD 14 years) and 22.1% presented with ventricular fibrillation or ventricular tachycardia. In complete case analysis (526 cases) AUROC was 0.82 (95% CI 0.78 to 0.86) indicating good discrimination. The calibration slope was 1.38 (95% CI 1.08 to 1.68) and calibration-in-the-large -0.84 (95% CI -1.05 to -0.63) indicating that the GO-FAR score systematically underestimates the probability of good neurological survival.

Conclusion

The GO-FAR score shows satisfactory discrimination but dissatisfactory calibration in a cohort representing a Swedish population. It has the ability to distinguish a patient with good outcome from a patient with adverse outcome, but good outcome is systematically underestimated. Recalibration of the GO-FAR score is suggested before taken into clinical practice in Sweden.

Background

Triage systems have been implemented in most emergency departments (EDs) worldwide to minimize crowding and treatment delays that may adversely affect outcomes in acutely admitted patients. Triage systems are designed firstly to identify patients in need of immediate care, and second to provide risk stratification and ensure the optimal distribution of resources.

However, pre-existing triage systems are time consuming, supported by limited evidence, and could potentially be of more harmful than beneficial.

This trial prospectively compared a new simplified triage system with emphasis on clinical judgement with a traditional triage system with focus on clinical endpoints.

Methods

The Copenhagen Triage Algorithm (CTA) study was a large prospective, two-center, cluster-randomized, parallel, cross-over, open trial comparing CTA to a traditional triage system, Danish Emergency Process Triage (DEPT), which is a local adaptation of the internationally used ADAPT system.

All patients ≥17 years admitted to the ED in two large hospitals in a 10-month period were randomly cluster allocated to either CTA or DEPT triage with subsequent crossover. Based on vital signs and a subsequent clinical assessment by the ED nurse, CTA stratifies patients into 5 acuity levels. 

The study had a non-inferiority design with 30-day all-cause mortality as the primary endpoint. The non-inferiority margin was set at 0.5%. As a secondary endpoint, the study aimed to assess if CTA was superior in predicting 30-day mortality as assessed by C-statistics.

Results

A total of 45,977 patient visits were included. Of these 23,415 (50.9%) visits were triaged using CTA and 22,562 (49.1%) visits using DEPT.  Patients were well matched on baseline characteristics. The non-inferiority criteria was met, with the 30-day mortality among patients triaged with CTA and DEPT at 3.35% and 3.28%, respectively (p=0.68), a difference of 0.07% (95% CI: -0.26-0.40). Comparable results were observed for mortality at 48 hours (0.63% and 0.68%, p=0.58 using CTA and DEPT, respectively) and at 90 days (6.18 % and 6.36 %, p=0.41 using CTA and DEPT, respectively).

The triage level of patients in the CTA group was significantly lower (P<0.001) and CTA was superior in predicting 30-day mortality with an AUC of 0.670 (95% CI 0.650-0.690) compared to 0.638 for DEPT (95% CI 0.618-0.659) (P=0.03). Still there was no significant increase in mortality among low risk patients. A sensitivity analysis including vital signs, age, and sex showed no added risk among patients in the CTA arm for mortality at 48 hours (HR 1.07, 95% CI 0.97-1.18), 7 days (HR 0.98, 95% CI. 0.98-0.99), 30 days (HR 0.98, 95% CI 0.89-1.08) or 90 days (HR 1.03, 95% CI 0.96-1.1).

Conclusion

A new triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm with regards to mortality and superior at predicting 30-day mortality. 

Terapat Chantawong*, Pilaiwan Sawangwong*, Warawut Khangmak*, Chaiyaporn Yuksen MD,  Yuwares Sittichanbuncha ,MD. Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.

 Backgrounds: Out of hospital cardiac arrest (OHCA) is one of the main causes of death in Thailand. Chest compression in narrow space may occur in ambulance or aircraft. Straddle chest compression is one of the technique to help the stability of chest compression.

Objective:  To compare the quality of chest compressions and exhaustion of healthcare provider between straddle chest compression and conventional chest compression in manikin model.

Methodology: This is an experimental study randomization into two different group, by using the SNOSE and block of four randomization by dividing them into group A (Straddle chest compression) and group B (conventional chest compression). Each participants were performed maximum 4 minutes hands only compression, quality parameters were recorded: compression rate and depth. The blood pressure, heart rate and respiratory rate of each participant were recorded both before and after chest compression.

Result: 124 participants (mean age 25.8 years and 27.6 percent are male, 40), the rate of chest compressions in conventional CPR and straddle CPR (126.2±17.1 and 127.0±21.0, p = 0.811), the average depth (43.8±9.6) and 43.4±9.0), p = 0.830). The blood pressure, heart rate and respiratory rate before and after chest compression in both method was no clinical significantly. 
  
Conclusion: The quality of straddle chest compression was as good as conventional chest compression. The exhaustion of healthcare provider between Straddle and conventional chest compression was no clinical significantly.

Background: Trauma is a main cause of death among young adults worldwide. Patients experiencing a traumatic cardiac arrest (TCA) certainly have poor prognosis but population-based studies are sparse.

Aim: Primarily to describe characteristics and 30-day survival following a TCA as compared with a medical out-of-hospital cardiac arrest (medical CA).

 Material and methods: A cohort study based on data from the nationwide, prospective population-based Swedish Registry for Cardiopulmonary Resuscitation (SRCR) between 1990 -2015. The definition of  a TCA in the SRCR is, a patient who is unresponsive with apnoea where cardiopulmonary resuscitation and/or defibrillation have been initiated and in whom the Emergency Medical Services (EMS) reported trauma as the aetiology. Outcome was overall 30-day survival. Descriptive statistics as well as multivariable logistic regression models were used.

Results: In all, between 1990-2015, 1 710 (2,4%) cases had a TCA and 69 123 had a medical CA. Overall 30-day survival gradually increased over the years and was in total among TCAs 3,8% compared to 8.0% following a medical CA (p<0.01). Factors associated with a higher 30-day survival were bystander witnessed TCA and having a shockable initial rhythm (adjusted OR 2.65, 95% C.I. 1.13–6.21 and OR 9.38 (4.44-19.85, respectively) while those given adrenaline had a poorer survival (adjusted OR 0.40, 95% C.I. 0.19 - 0.83).

 Conclusion: Even if the prevalence of TCAs is low and survival is poorer than in medical CAs, many affected individuals are young. Therefore, resuscitation in TCAs should not be seen as futile, but rather an area considered for improvements.  

Objective:

To determine which factors had the most impact on outcomes after pediatric out-of-hospital cardiac arrest (POHCA) now that protocol guidelines have become more aligned with those for adults, including emphasis on quality CPR.

Methods:

In an EMS jurisdiction using a comprehensive Utstein-style database, all POHCA cases over the previous 5 calendar years (1/1/12 through 12/31/16) -- since implementation of the latest international guidelines -- were analyzed to identify current predictors for return of spontaneous circulation (ROSC), hospital admission (HA) and survival to successful hospital discharge (SURV). Logistic regression models of traditional predictors were performed using JMP 12.0 for Mac.

Results:

Of 133 consecutive POCHA cases studied (61 % male), the interquartile range (IQR) for response intervals was 16 to 47 minutes (range: 0-490). As traditionally predicted, shorter times from arrest to EMS arrival were associated significantly with ROSC, HA and SURV (all p<0.0001) whereas witnessed arrest cases (only 13%) were not (p=NS). Still, in 95% of cases, the arrest was identified by a bystander prior to EMS arrival and, contrary to previous studies, chest compressions were performed by bystanders in 59% of cases. While the earlier CPR was provided by EMS personnel was itself significantly associated with ROSC, HA and SURV (all P<0.0001), some form of treatment before EMS arrival was provided in 54% of cases and such actions were strongly associated with ROSC, HA and SURV (p<0.0001 for all) whereas AED placement (50% of cases) was not.

Conclusion:

Whereas witnessed arrests and AED placement were not identified as contributing factors in this subpopulation of arrests, 1) shorter elapsed intervals from the moment of arrest to EMS arrival, 2) performance of CPR prior to EMS arrival and, in fact, 3) any treatment provided before EMS arrival, resulted in significantly higher rates of ROSC, hospital admission and survival beyond hospital discharge.

Goal: The aim of this study was to assess the survival of victims of out-of-hospital cardiac arrests due to ventricular fibrillations of three successive cohorts over a 10 years’ period.

Materials and methods: This was a retrospective observational study that compared three successive cohorts. The study was approved by an ethics committee. Inclusion criteria were: non-traumatic out-of-hospital cardiac arrests due to ventricular fibrillations shocked by an automated external defibrillator, and having benefited from prehospital advanced life support by a team managed by an emergency physician. Collected variables were: the period of occurrence of the cardiac arrest (1^st period = P1 - September 2005 to March 2007, 2^nd period = P2 - June 2011 to December 2012, 3^rd period = P3 - June 2014 to December 2015), the patient’s age and gender, the location of the cardiac arrest, the presence of a witness, the initiation of chest compressions by a bystander, the number of external electric shocks delivered by the automated external defibrillator, and the number of adrenaline injections administered by the advanced life support team. The primary endpoint was the hospital discharge. The secondary endpoint was the admission to the hospital with a palpable pulse. We used a logistic regression model to estimate the relationship between hospital discharge and the variables that were collected. We show the median [interquartile range] or the rate (%) according to the quantitative or qualitative nature of variables.

Results: A total of 2,648 patients (843 for P1, 830 for P2, 975 for P3) were included (62 years-old [51–74]; 1,608 (60.7%) men). Patients admitted to the hospital with a pulse during P1, P2, P3 were respectively 361 (43%), 464 (56%), 555 (57%) (p < 0.001). Patients discharged from the hospital during P1, P2, P3 were respectively 101 (12%), 166 (20%), 204 (22%) (p <0.001). In the multivariate analysis, factors associated with hospital discharge were: being a woman, a younger age, the occurrence of the cardiac arrest in a public area, and chest compressions by a witness. The rate of witnesses who performed chest compressions increased considerably over time (28% of cases for P1, 50% for P2, and 67% for P3). Adjusted odds-ratio associated with hospital admission were respectively: 1 for P1, 2.3 [1.8–3.0] for P2, and 1.8 [1.4–2.3] for P3.

Discussion: The survival of out-of-hospital cardiac arrests due to ventricular fibrillations shocked by an automated external defibrillator has improved over the past ten years. The increase of the rate of victims who benefited from chest compressions provided by a witness is one of the explanatory factors.

Conclusion: Efforts undertaken to improve the chain of survival, especially the early recognition of out-of-hospital cardiac arrests, an early cardiopulmonary resuscitation, and an early defibrillation must be continued.

Background: In the case of out-of-hospital cardiac arrests, 50% of ventricular fibrillations reoccur at least one time, mainly after the resumption of chest compressions. The aim of this study was to identify factors associated with the time between the resumption of chest compressions and the recurrence of the ventricular fibrillation (“CC-VF”). 

Materials and methods: We conducted a retrospective observational study. Collected variables were: patients’ age and gender, the presumed origin of the cardiac arrest, its location, the presence of a witness, the initiation of chest compressions by a bystander. We extracted from automated external defibrillators the rate of chest compressions, the time and length of each chest compressions’ interruption, the time between external electric shocks and the resumption of chest compressions (“EES-CC”), and “CC-VF”. Inclusion criteria were: out-of-hospital cardiac arrests, being over 18 years-old, one or more recurrences of a ventricular fibrillation shocked by an automated external defibrillator of basic life support teams. We performed a univariate analysis followed by a multinomial regression on repeating data; only variables associated with “CC-VF” with p < 0.2 in the univariate analysis were included in the multivariate analysis. We show the median [interquartile range] or the rate (%) according to the quantitative or qualitative nature of variables.

Results: Between 2010 and 2013, we recruited 266 patients (62 years-old [51.5–76]; 212 (80%) men) for a total of 1,047 episodes of recurrent ventricular fibrillations. A witness was present in 129 (48%) cases and performed chest compressions in 57 (21%) cases. The number of external electric shocks by automated external defibrillator ranged from 1 to 19. Concerning recurrences of ventricular fibrillations, 342 (32.7%) episodes occurred before the resumption of chest compressions, 129 (12.3%) were concomitant of the resumption of chest compressions, 170 (16.2%) occurred between 2.5 and 10 s after the resumption of chest compressions, and 406 occurred more than 10 s after the resumption of chest compressions. In the univariate analysis, factors associated with a shorter “CC-VF” were: being a male, an older age, a presumed cardiac origin of the cardiac arrest, the presence of a witness, a longer “EES-CC”, faster chest compressions’ rates, and greater chest compressions’ ratios. In the multivariate analysis, an older age and a faster rate of chest compressions were associated with a shorter “CC-VF”. A longer time between the first alert to the dispatch center and the initiation of chest compressions was associated with a longer “CC-VF”.

Discussion: This is the first study to identify factors associated with the time between the resumption of chest compressions and the recurrence of a ventricular fibrillation. If preliminary results presented above are confirmed, new approaches could be suggested to deal with the recurrence of ventricular fibrillations.

Background: Circadian variation in occurrence of out-of-hospital cardiac arrest (OHCA) is an observation which has been reported from several parts of the world. Mostly, diurnal variation was shown exhibiting low incidence of OHCA at night and a two daytime peaks, in the morning and late afternoon. However, this variation can be related to geographical regions and the validity of the results is extremely dependent on the quality of the data collection. Therefore we have analyzed the Czech and Slovak data from the EuReCa ONE study to investigate whether there is any local significant variation of OCHA events treated by Emergency Medical Services (EMS) in time and if so, whether it depends on geographic variables.

Methods: In an international clinical study EuReCa ONE (European Registry of Cardiac Arrest), data on all EMS treated OHCA events were collected from the entire territory of the Slovak Republic (5421352 inhabitants) and several administrative regions of the Czech Republic (4350000 inhabitants) in the period from 1.10.2014 to 31.10.2014. Data were processed and analyzed for circadian and infradian variability.

Results: For the selected period, a total of 659 cases of confirmed resuscitated OHCA events was reported. Significant circadian variation was observed, with very low occurrence in the night (approximately 2% of all episodes each hour) followed by three peaks in the daytime, in the 9^th, 16^th and 20^th hour (8.2, 6.4 and 7.4 % of all episodes, respectively, p<0.05). During the week, OHCA events were the most frequent on Fridays while the least common on Tuesdays (16.8 versus 12.1 % of all events, p=0.019). In the Czech Republic, OHCA was more frequent at weekends than in Slovakia (31.2 versus 22.4 % of all episodes, p=0.013). The lowest thirty-day survival or survival to hospital discharge was observed in OHCA events that occurred on Tuesdays, while highest in episodes that occurred on Thursdays (6.2 versus 20.6 %, p=0.011). Time dependent variation of survival patterns were We did not found any differences between the Czech and Slovak republics in survival variation.

Discussion: In the selected regions and time interval we have identified a marked circadian and infradian variability of OHCA events occurrence and of their survival as well. While the variability of the events in time was partly country-dependent, survival was not. Further investigation of this phenomenon may lead to a better understanding of the circumstances leading to cardiac arrest and improve prevention of this cardiovascular catastrophe.

References: Gräsner JT et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: Aprospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation 2016;105:188-95.