Background:

Establishing vascular access is one of the most common procedures carried out in the emergency department (ED) and a high priority for the care of a critically ill and unstable patients.

It is generally easy to realize, nevertheless, the difficulty or the impossibility of this access is a challenge of any emergency physician. Difficult venous access (DVA) can cause delays in diagnosis and treatment implementation in critically ill patients.

Methods:
This was a prospective, observational study conducted in the ED and in prehospital care which enroll adult patients undergoing intravenous (IV) placement. The primary outcome was DVA, defined as 2 or more IV attempts to establish IV access. Univariate analyze for factors predicting DVA was performed using Pearson's chi-squared test.

Results:

A total of 500 patients were enrolled, of which 90 (18%) met the criteria for DVA. In the univariate analysis, 5  conditions were significantly associated with DVA: elderly (p=0.015), history of chemotherapy (p=0.008), women (p=0.006), obesity (p=0.001), and cardiac arrest (p=0.006).

The most common alternative approach to DVA were: changing the operator (66 patients), change of site's puncture (85 patients), smaller IV catheter size (19 patients).

Discussion:
Difficult venous access is a common problem in the ED that can be frustrating for both patients and providers.  The prevalence of DVA was 18%, which is similar  to previous studies reporting a range of  from 10 to 40%.

Patients who are likely to present with challenges to peripheral intravenous line insertion often can be identified by certain risk factor (elderly, women, chemotherapy, obesity, cardiac arrest status). Several factors previously thought to be associated with DVA such as diabetes, IV drug abuse, sickle cell disease, dialysis, history of frequent  admissions in ED were not found to be significant in the current study. One issue with this finding is that these other conditions typically associated with DVA were not significant in our study. Future research is needed to confirm and expand these findings and to develop interventions to improve IV insertion skills and outcomes.

INTRODUCTION: Post-traumatic stress disorder (PTSD) is an adjustment disorder that can occur after exposure to potentially traumatic event. Joint headaches are often observed in the accompanying painful complaints. Since the relation between the association of headaches and a PTSD has not been insufficiently studied, our primary objective was to study the incidence and the impact of headaches in a PTSD; the secondary objective was to analyze the influence of the PTSD's treatment on these headaches.

MATERIALS: Prospective observational monocentric survey conducted between January 2013 and December 2015. Inclusion criteria: patients suffering from PTSD after exposure to situations with high traumatic potential (armed attacks, road accidents, etc.) and voluntary for the self-administered questionnaire. Study variables: epidemiological data, headaches and their type before and after the diagnosis of PTSD (ICHD scale), impact on the quality of life (HIT6 score), on mood (POMS scale), severity of the PTSD (PCLS scale) and treatments received. Statistics: Fisher's exact test and Chi² tests (qualitative variables), Mann-Whitney U-test (quantitative variables), Spearmans correlation (score comparison), all significant if p<0.05.

RESULTS: Over a period of 3 years, 101 patients (90% men) were included in 437 questionnaires sent (23.1%). The median age was 32 [27;39] years. The overall incidence of headaches was 54.5% (N=55) and the post-PTSD incidence was 36.6% (N=18). The HIT-6 score was 58.8 +- 8,3 with a major impact in 56.4% (N=31) of the cases. The severity of PTSD was correlated to PCLS scale same as the intensity of headaches on HIT-6 score (Spearman’s rho=0.35, p=0.009). In the post-PTSD time, tension headaches were predominantly found (45.5%, N=25). Associated head trauma was not an aggravating factor (p=0.3). Patients suffering from headaches were more often treated for PTSD (p=0.02). The pattern of mood, particularly anger and depression, showed a higher average score in headache patients (p=0.039).

DISCUSSION: Headaches should be recognized in the cohort of painful complaints that may accompany PTSD, as a potential indicator of its severity. Wartime’s pathology inviting itself particularly in the French territory after the attacks of 2015, the training and  multidisciplinary care approach by the health care givers are more than ever important and relevant.

Background: We designed this study to assess the validity of the Sequential ( sepsis - related) Organ Failure Assessment (SOFA) score of 2 points or more and quick SOFA (qSOFA) ≥ 2 for identifying emergency department (ED) infected patients with critical illness.

Methods: This prospective observational study will be performed in the ED university -affiliated tertiary care hospital. Adults patients will be included in this study if they had the following criteria: older than 18 years, present in our ED with infection probable or documented, are competent to give informed consent, and to be admitted to the hospital's service. Collected data includes age, sex, vital signs, origin of infection, SOFA and qSOFA score, and outcome. The primary outcome was the incidence of a critical illness defined as a stay in the intensive care unit of 72 hours or longer or hospital mortality. The ability of SOFA score ≥ 2 and qSOFA score ≥ 2 in predicting critical illness was evaluated by determining the sensitivity, specificity, positive and negative predictive values, and the area under the Receiver Operating Characteristics (ROC) curves. 

Results: We included 255 patients with a median age of 68 years (25 - 75% IQR: 59-79) who were admitted for infection. Pulmonary and urinary tracts were the most frequently infection. The frequency of patients with SOFA ≥ 2 AND qSOFA ≥ 2 were respectively 76% and 23%. The sensitivity of SOFA ≥ 2 for predicting critical illness was 93% (95% confidence interval (CI), 83% -98%) and the area under the ROC curve was 0.78 (95% CI, 0.71 - 0.85). The sensitivity of qSOFA was 49% (95% CI, 36% - 62%) and the area under the ROC curve was 0.76 (95% CI, 0.69- 0.83).

Conclusion: In ED the SOFA score was more sensitive than qSOFA for predicting critical illness.

Background. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis contributes to up to half of hospital deaths and is responsible for the utilization of a significant proportion of healthcare resources. Early diagnosis and quick interventions are associated with better outcomes. Early warning scores (EWS) are physiological monitoring systems that are used for detection of acutely deteriorating patients. The recently updated definitions of sepsis proposed the Quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) score in order to consider diagnosis of sepsis in the emergency department and on the wards. Physiological EWS including the National Early Warning Score (NEWS) and the Modified Early Warning Scores (MEWS) have been shown to predict mortality and escalation of care in patients admitted to hospital. SIRS criteria are usually criticized for their poor specificity. MEWS and the NEWS are commonly implemented in clinical practice outside the ICU. Our study sought to compare qSOFA, SIRS, NEWS and MEWS scores to identify high-risk septic patients in the Emergency Room (ER).

Methods. All patients admitted to the ER meeting criteria for suspicion of sepsis during 2016 September-December were included in the retrospective single-centre study. qSOFA, SIRS, MEWS and NEWS scores were compared for predicting death and ICU-stay.

Results. In total, 64 patients (38 male (59.4%), 26 female (40.6%) were admitted due to suspected sepsis during September – December of 2016. The mean age was 64.05 ± 18.63 years. 20.3% (n=13) patients died. Discrimination for in-hospital mortality or ICU-stay was highest for NEWS (AUC 0.738 [95% CI 0.612-0.841], p=0.001), followed by qSOFA ( AUC 0.686 [ 95% CI 0.557-0.797], p=0.003),  MEWS (AUC 0.654 [95% CI 0.523-0.769], p=0.027) and  SIRS (AUC 0.635 [95% CI 0.504-0.752], p=0.035) (p >0.05 for all pairwise comparisons). Using a patient’s highest non-ICU score, ≥2 SIRS had a sensitivity of 15.38% and specificity of 100% for the composite outcome compared to 7.69% and 96% for NEWS ≥8 and 0% and 98% for MEWS ≥5. And these results are in contrary to most of the studies. Highest sensitivity and specificity of MEWS was for >2 scores (38.46% and 76%), for NEWS - >4 scores (69.23% and 70%), for SIRS - >1 (84.62% and 40%). The mean time spent in ER was 287 min (IQR 188-403). The median hospitalization time was 12.5 days (IQR 8-18).

Discussion. Our study showed, that even though qSOFA showed higher discrimination for in-hospital mortality or ICU-stay than MEWS and SIRS criteria, NEWS criteria showed better one. On the other hand, the diagnostic test value is still poor, same as SIRS. Study needs further investigation in behalf of objection to other studies on this matter.

Mor Saban,  Efrat Dagan,  Aziz Darawsha, Rabia Salama

Background. A fast and correct identification of ST Elevation Myocardial Infarction (STEMI) in the Emergency Department (ED) significantly correlates to decrease morbidity, mortality and related complications in patients with chest pain. Yet, delayed diagnosis in patients with STEMI still represented a blind spot in the assessment of quality health care indicators.

Aim. To evaluate a 'fast-track' intervention intended to shorten Door-to-Balloon waiting times in patients presenting to the ED triage with STEMI.

Methods. In 2016, a 'fast track' intervention program for patients with chest pain was implemented in the ED at Rambam Health Care Campus. We determined a set of clinical guidelines for patients' assessment as follows: 15’ to triage, 10’ to ECG, 40’ for physician assessment, 60’ waiting time for decision and 90’ to catheterization lab (Door-To-Balloon-Time). The program was comprised of four steps: 1. Laying the patient immediately. 2. Marking the chart with a dedicated sticker 3. Assessing time-lags according defined clinical guidelines. 4. Signing the ECG and the dedicated sticker by a physician.
A retrospective-archive study was conducted between January 2015 and December 2016, to evaluate the intervention program achievements. We compared the adherence to clinical guidelines between all STEMI patients (n=140) who were attending to ED before (i.e during 2015, n=60) and after (i.e during 2016, n=80) implementing the intervention.  A lift chart and receiver operating characteristic
(ROC) curve were used to determine the optimal time lags in ED for achieving the objective of 60 minutes for evaluating the patients in ED.
Results. After implementing the intervention more patients have reached ECG evaluation within 10’ (57.5%) compared to pre- intervention (40%) (p=0.04); and more patients were stayed at ED less than 60’ (87.5% and 63.3%, respectively, p=0.01).
It clearly appears that post- compared to pre- intervention, less time lags (in minutes) were measured in patients who their clinical guidelines were not achieved before the program. This was found for physician assessment (70.25±30.24 vs. 52.86±13.51, respectively, p=0.05), for total waiting time in ED (126.18±59.63 vs. 72±9.67, respectively, p<0.001) and time to balloon (164.61±53.89 vs. 125±32.25, respectively, p<0.01). Interestingly, The ROC curve show that patients who were treated at ED according to the three clinical guidelines (15' for the nurse, 10' for E.C.G and 40'  for the Physician), had the largest probability to uphold the 60 minute waiting time in ED (AUC=0.98).
Conclusions. A ‘fast-track’ management for patients with chest pain providing early diagnosis of STEMI and shortened the waiting time for catheterization. The findings call for implementing programs for identifying patients at risk for STEMI in ED triage and programs’ interventions to reduce time lags for reperfusion for these patients at risk as fast as possible.

Background: The management of pulmonary embolism (PE) has evolved over the past decade. Henceforth, outpatient treatment is an option for selected patients at low risk of complications. To assist clinician in identifying those patients, several rules have been proposed. The most validated to date are the Pulmonary Embolism Severity Index (PESI) or its simplified version (sPESI) stratifying patients according to their mortality risk and the the HESTIA rule based on a list of exclusion criteria, each one requiring inhospital care. Both strategies are used in clinical practice, but very few studies confront them.

Aim: To compare the proportion of patients eligible for outpatient management according to the sPESI and HESTIA rule.

Methods: This is a retrospective monocentric study. All patients with confirmed PE through CT scan or V/Q scan within 48 hours after Emergency Department admission were included. Medical records were retrieved to determine the sPESI score and HESTIA criteria at admission. Patients were considered suitable for outpatient management according to the sPESI if it was equal to 0, or if none of the criteria were met for HESTIA rule.

Results: 105 patients were included. HESTIA rule and the sPESI did not significantly differ on the proportion of patients suitable for outpatient management, respectively 45.7% [36.5-55.2] and 39.1% [30.3-48.6], p = 0.328. However, taking into account medical conditions not allowing outpatient management (severe comorbidities, social condition…) in addition to the sPESI score, the HESTIA rule significantly overtook the sPESI, with respectively 45.7% [36.5-55.2] and 26.7% [19.1-35.8], p = 0.004. Of note, the number of discordant results (suitable or not for outpatient management) between the two rules was 33.3% [25.1-42.8]. These conclusions were unchanged using the original version of the PESI.

Conclusion: sPESI score or HESTIA rule both identify a relevant proportion of PE patients suitable for outpatient care, but with a high level of discordance between the two rules. The HESTIA rule may select a higher proportion of patients when considering medical conditions requiring inpatient management despite a low-risk of death according to sPESI.

Introduction: The Netherlands is a densely populated country in Northern Europe. With several nuclear installations, a heavy petrochemical industry, transport of related products by road, rail or water and possible terrorist targets, the risk for CBRN incidents is eminent. In case of such an incident, ambulance personnel will be first to be confronted with victims but are they really prepared?  The Dutch Ambulance Academy shared this concern and organised an introductory day course on working in CBRN circumstances as pilot project in cooperation with the Defence CBRN Centre. A previous study revealed the gaps in preparedness. The course enhanced the scores of the participants but the practical knowledge however seemed to remain limited. Following this conclusions a 2-day course was designed with emphasis on practical training.

Material and methods: Participants of this new course completed an online survey on demographics, perceived knowledge, capability, willingness to work and training.  The reported answers were controlled with a set of theoretical/practical questions on the subject. Scores were compared with those of the pilot course and untrained ambulance personnel.

Results: Preliminary results reveal a mean age of 49 years, 44% has had any disaster training before. Eighty per cent works in the vicinity of a chemical risk installation and 20% near a nuclear installation. There was a higher estimated knowledge, ranging from 4.8/10 (vs. 2.9 in the untrained group and 3.6 in the pilot group) for nuclear incidents to 5.53/10 (vs. 4.46 and 4.59) in chemical incidents. Self estimated capability to deal with these incidents also scored higher, from 3.93/10 (vs. 2.28 and 3.59) in nuclear incidents to 4.67/10 (vs. 4.06 and 4.63) in chemical incidents. Up to 100% stated to be practically trained to use personal protective equipment (vs. 24 and 26%) with a clearly higher score on self estimated practical knowledge on this subject (7.53/10 vs. 3.35 and  4.22). A good practical training in decontamination was reported in 93.33% (vs. 27% and 43%) with also a higher score on practical knowledge (6.87/10 vs. 3.22 and 4.48).  The end score on the theoretical/practical test was also higher in the study group (7.47/10 vs. 4.65 and 5.98).  There was however no higher willingness to work, nor in nuclear nor in chemical incidents.

Conclusion: The preliminary data of this study illustrate how research has an impact on the evolution in training and enhances CBRN preparedness of Dutch ambulance teams. Further evaluation of participants of following training sessions seems mandatory.

BACKGROUND :

Approximately 150,000 strokes occur each year in France, but only 5 to 10% of patients have access to thrombolysis, mainly due to poor knowledge of stroke symptoms by the population. The main objective of our study was to evaluate the impact of a local information campaign on emergency medical services (EMS) call, for suspected stroke, in the Rhône area between September 2014 and October 2015, compared to a control area.

METHODS :

We carried out a controlled before and after study on 3 time-periods of 2 months to evaluate a multifaceted stroke awareness program deployed in the Rhône area (France), from October to December 2014. Key messages of the campaign were the recognition of stroke warning signs and the need to call EMS urgently, using multiple information media. We analysed all the calls to EMS for stroke suspicion, using databases of emergency health centers in the Rhône area and control area. To determine the impact of the campaign, we assessed the evolution of the number of EMS calls for stroke suspicions before the launch of the campaign (T0), at 3 months (T1) and 12 months (T2), compared to control area. We also studied the impact on the time between onset of symptoms and EMS calls and on the evolution of thrombolysis number.

RESULTS & DISCUSSION :

During these periods, we studied 707 calls (214 at T0, 234 at T1 and 259 at T2) to EMS in the Rhône area for stroke suspicion, compared with 519 (186 at T0, 174 at T1 and 159 at T2) in the control area. We found a 21% significant increase of EMS calls in the intervention area over the period studied (p <0.05). No significant effect was found on the secondary criteria.

CONCLUSION :

Our information campaign had an impact on the population, improving EMS call, but it remains limited and to be confirmed by other studies. The goal will be to develop better information campaign to improve access to reperfusion strategies.

Background:
Renal colic is a frequent reason for consultation in emergency department (ED). Its adequate analgesic treatment remains a preoccupation of the clinician. The aim of our study is to evaluate the tolerability and efficiency of the association of low doses of ketamine with morphine in the management of renal colic in ED.

Methods:

Prospective, randomized, double-blind study conducted at the ED in university hospital over a six-month period, including 62 patients admitted for renal colic with numerical pain rating scale (NRS)>5, randomized into three groups: standard group: receiving morphine 0.1mg / kg associated with placebo, group1: receiving morphine 0.1mg / kg associated with 0.15mg / kg ketamine and group 2: receiving morphine 0.1mg / kg associated with 0.3 Mg / kg ketamine.

Results:The demographic characteristics were comparable for the three groups with an average age at 38 ± 12 years, a sex ratio at 1.13.   51.6% of the patients didn't have previous diseases and 27.4% were known carriers of renal lithiasis. 53.2% of patients used analgesics prior to initiation of the protocol. The three groups were also clinically comparable with an initial mean NRS of 9.4. A significant decrease in NRS within 30mn is observed in the ketamine0.3 group compared to the other two groups (p= 0.01).  The analgesic effect, judged by the SPID, was better in group 2 compared to the 2 other groups with p <0.05.  The total dose of morphine consumed decreased significantly in the two ketamine groups with an average of 9.59 mg for group 1 and 7.55 mg for group 2 compared to the standard group which showed an average of 11.95 mg with p <0.01. Total patient satisfaction assessed via TOTPAR was better in group 1 compared to placebo (p = 0.22) and in group 2 compared to group 1 (p = 0.013) in group 2 compared to placebo (p < 0.01). Ketamine was globally well tolerated. There was no statistically significant difference in adverse events among the three groups (p = 0.806) with predominance of gastrointestinal adverse events in the placebo morphine group (p = 0.01) and neuropsychic adverse effects in the 2 ketamine groups compared to the morphine group alone (p = 0.04).

Discussion:The association of low doses of ketamine (at a dose of 0.3 mg / kg) to morphine is well tolerated and allowed a better analgesia, with greater patient satisfaction compared to morphine alone in patients suffering from nephritic colic.

Introduction

Managing unexpected situations such as mass casualties, disaster relief, and failure of dispatch software or equipment breakdown requires specific knowledge from both Emergency Medical Dispatcher (EMD) and dispatching physicians.

Both EMDs and physicians handle all incoming medical emergency calls in France and they need to work in close cooperation. Training sessions were performed in a pre-hospital emergency medical service for all professionals working at a dispatch center in order to reinforce this teamwork in unexpected situations. These half-day sessions consisted in different scenarios split in 2 situations: 1) mass casualty events (flood, building fire and mass shooting); 2) technical breakdown (computer aided dispatch system breakdown). Each session was composed of 2-persons teams: 3 EMDs working in partnership with 3 physicians. Each training session started with an evaluation of knowledge followed by evaluation after training.

The objective of this survey was to evaluate the added value of a training session that concerned unexpected situations in a medical dispatch center.

Method

5 training sessions from May 2016 to February 2017 were organized. 24 people (10 EMD and 14 physicians) answered a 26-item questionnaire that included 9 technical questions and 16 mass casualties’ questions before the training session and immediately after training. They answered to each assertion as true, false or did not know. A mark of 1 was assigned for each correct answer. Age, gender and seniority in the profession were also collected.

Analyses were presented as means and percentages. Each 26-item score was analyzed as a score, with 2 sub-scores concerning technical breakdown and mass casualty. Comparisons were performed with Ttests.

Results

2/3 of participants were female. 46% were younger than 40 years old and 12% older than 50 years old. 79% of them did work 5 years or less in a dispatch center.

Mean global scores were 11.66 (4.67 Standard Deviation – SD) out of 26 before the evaluation and 19.83 after the evaluation (SD: 3.34) (p<10^-3). The mean scores for mass casualty were 7.42 (SD: 3.10) out of 16 at first evaluation and 12.83 (SD: 1.90) after the session. The mean scores for technical breakdown were 4.13 (SD: 2.66) out of 9 at first evaluation and 6.54 (SD: 1.44) after the session. There were no differences in scores when comparing EMDs and physicians, but there were significant differences in the scores between first and second evaluation.

Discussion

These training sessions were very positive, with significant improvement of scores after the half-day sessions. Organizing training sessions for all professionals working in a dispatch center is essential, specifically concerning events that happen very rarely. Teamwork brought cohesion, which is critical in the first minutes of such unexpected events.

Objective

The first 2 links in the “Chain of survival”, and thus cardiopulmonary resuscitation training, are mandatory for a good patient outcome. Poor knowledge and skill retention following resuscitation training has been documented over the past 25 years.

We developed a basic life support training program for clinical nurses and we composed a six-stage plan based on the ERC algorithm for in-hospital resuscitation.

We defined two quality standards (which we had to modify, as the guidelines changed in 2010) to measure if there was an improvement in the resuscitation skills after four sessions.

Methods

The whole nursing staff (ca. 400 individuals) in our hospital had to register for a fourth obligatory basic life support session, with the consent of the Board of Directors.

The performance of the nurses was recorded on an Ambuman manikin (with Ambu CPR software version 2.3.9), lying in a hospital bed.

Several variables were recorded, e.a. the correct execution of the sequence of the six-stage-plan, the compression rate, the compression depth and the ventilation volume. Using two quality ‘standards’, we compared the results session.

Results

The attendance to those sessions is significantly lower when the nursing staff had to enrole themselves.

For the first two sessions (2005 guidelines), we saw a compression depth between 40mm and 50mm was achieved by 120 or 37% (vs 95 or 31% in first session) (p=0,09) (fig. 2); a compression rate between 80/min and 120/min was achieved by 254 or 79% (vs 221 or 72% in first session) (p=0,03) (fig. 3); a ventilation volume between 400ml and 700ml was achieved by 148 or 46% (vs 97 or 31% in first session) (p<0,001) (fig. 4).

Optimal resuscitation (defined as a combination of those three determinants) was achieved by 44 or 14% (vs 25 or 8% in first session) (p=0,03). Satisfying resuscitation (defined as a combination of a compression rate between 70/min and 130/min, a compression depth more than 35mm and a ventilation volume more than 300ml) was achieved by 228 or 71% (vs 98 or 32% in first session) (p<0,001) (fig 5.)

For the third, fourth, fifth, sixth, seventh and eighth session, we defined  optimal resuscitation as a compression depth >50mm, compression rate 100-120/min and ventilation volume between 400ml and 700ml. We defined satisfying resuscitation as a compression depth >45mm, compression rate 90-130/min and a ventilation volume more than 300ml. The 2017 session showed that 73% achieved a satisfying compression depth, 96% achieved a satisfying compression rate and 96% achieved a satisfying ventilation volume. This is, so far, our best result in 9 years.

Using Fisher exact test, we found a significant improvement (p<0,001) for ventilation volume and for satisfying resuscitation.

Conclusion & perspectives

We need to thank the team of BLS instructors for their efforts to keep the resuscitation knowledge of the whole nursing staff at this level. We will continue to support this project on director’s level.

Introduction: There is very little data in scientific literature regarding out-of-hospital cardiac arrest (OHCA) in pregnant women. This study aims to describe a group of pregnant women who experienced an OHCA and were treated by a pre-hospital Advanced Life Support (ALS) team, and to report the short-term outcome.

Materials and Methods: Retrospective observational study. Approval of the Ethics Committee. Inclusion criteria: pregnant woman > 18 years of age experiencing an OHCA, regardless of the stage of the pregnancy, treated by an ALS Team. Collected variables: age, term of pregnancy (weeks of gestation), location, presence of a witness, first documented rhythm, number of external electric shocks (EES) administered by an automatic external defibrillator (AED), use of an automated chest compression device (ACD), administration of drugs, and outcome (dead in the field, transport to hospital). Statistics: qualitative variables were expressed as a percentage, quantitative variables as a median [interquartile range, IQR]. The description was univariate.

Results: Over a period of 5 years, among 19,515 OHCAs, 17 concerned pregnant women. These 17 (100%) patients had a median age of 31 years (IQR [28-34]) and a median term of 20 weeks of gestation (IQR [9-32]) (6 missing data). Three (18%) OHCAs occurred in a public area and 14 (82%) took place at home. A witness was present in 12 (70%) cases, of which 6 bystanders initiated chest compressions (CC). The no-flow median time was 4.5 min (IQR [1-9]) and the low-flow median time was 42 min (IQR [30-70]). The cause of the OHCA was identified in 11 cases/17: 4 injuries (2 stab wounds, 1 hanging, 1 defenestration) and 7 medical causes (3 pulmonary embolisms, 2 myocardial infarctions, 1 hypoxia, 1 hypertrophic cardiomyopathy). Two patients (12%) received an EES by the first aid worker’s AED. Nine (53%) benefited from ACD. The median quantity of adrenaline injected was 10 mg (IQR [5-15]). One patient underwent thrombolysis and 6 were transported alive to hospital. Two patients were alive on day 30 following the OHCA.

Discussion : This is the first series of cases documented in medical literature. The diverse causes of OHCA were most often not related to the pregnancy. The rate of Ventricular Fibrillation was lower than for the general population. Of the 3 OHCA≥20 weeks of gestation, none survived. The recommendations for the treatment of OHCA in pregnant women are currently not applicable to the pre-hospital setting and are the subject of local consensus meetings aimed at producing a protocol adapted to these specific pre-hospital situations.

INTRODUCTION

Acute Dyspnoea is a common presenting complaint to the Emergency Department (ED). Studies have shown that acute decompensated heart failure (ADHF) is difficult to diagnose with standard modalities in the ED. The primary objective of this study is to estimate the accuracy of ADHF diagnosis in two Irish tertiary EDs.

METHODS

This is a retrospective multi-center study conducted in two tertiary university hospitals in Dublin. All patients who were discharged from the hospitals between 1st January 2016 to 30th June 2016 with a HIPE diagnosis of ADHF were included.

RESULTS

280 patients were found in the HIPE search. 61 elective patients were excluded leaving a total of 219 study patients. Of these, 95 (43.4%) were accurately diagnosed with ADHF by the Emergency Physician.  Of those who were not diagnosed in the ED (n=124, 56.6%) . 65 (52.4%) had a CXR which was normal or suggested an alternative pathology compared to 21 (22.1%) p<0.0001 in the accurate group. In the missed group, 57 (46%) had no previous history of CCF compared to the accurate group 43 (45.3%). Length of stay for the missed group was 13.2 days compared to 13.6 days (p=0.896) for the accurate group. Time to X-ray for both groups 

CONCLUSION 

With the currently available diagnostic strategies, our study suggests that the diagnosis of ADHF is difficult in the ED. Recent studies suggest that basic bedside lung ultrasound would improve the early diagnosis of ADHF by emergency physicians.

Rapid diagnosis of acute myocardial infarction (AMI) facilitates early disposition of chest pain patients presenting to the emergency department (ED). Point-of-care (POC) cardiac troponin testing may improve patient throughput but is currently discussed due to limited diagnostic accuracy. We compared the diagnostic accuracy of a novel cTnI test (Minicare cTnI, Philips), with a currently available POC cTnI (i-Stat cTnI, Abbott) and high-sensitivity central laboratory cTnI assay (Architect Stat High Sensitive Troponin-I assay, Abbott).

Methods: The clinical performances of these assays were compared in samples from 450 patients from an adjudicated outcome of AMI. The blood samples were drawn on ED admission and 3 h later. Bassink-Bablok regression analysis was used for comparisons between assays.

Results: Minicare cTnI correlated with Architect hs-cTnI (r²=0.85, p<0.0001) and I-Stat cTnI (r²=0.93, p<0.0001). Areas under the receiver operating characteristics curves were 0.87-0.91 at admission (p=ns) and 0.96-0.97 3h after admission (p=ns). The negative predictive value (NPV) at admission were 95% (92-97%, 95% CI) for Minicare cTnI and increased to 99% (97-100%) at follow-up testing, and were comparable to Architect hs-cTnI (98%, 96-100%), but higher than I-Stat cTnI (95%, 92-97%; p<0.01). Negative likelihood ratios (LR-) after 2-4h were 0.06 (0.02-0.17, 95% CI) for Minicare cTnI, 0.11 (0.05-0.24) for Architect hs-cTnI (p=0.02) and 0.28 (0.18-0.43) for I-Stat cTnI (p<0.0001). The clinical concordances between Minicare cTnI and Architect hs-cTnI were 92% (admission) and 95% (2-4h), with lower concordances among Minicare cTnI and i-Stat cTnI testing (83% and 78%, respectively; p=0.007).

Conclusion: The Minicare cTnI POC assay tested on fresh whole blood samples demonstrated similar clinical performances to a current, high-sensitivite cTnI assay fort he diagnosis of AMI 3h after presentation. Minicare cTnI POC assay may be useful to aid in ruling-out of AMI in ED patients with suspicion of acute coronary syndrome using a guideline supported 0/3h testing protocol.

Introduction: The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) has recently been included in guidelines as a frailty indicator to identify patients for comprehensive geriatric assessment. Previous studies showed that the conventional cut-off score classifies a high percentage of patients as high risk incorrectly. We aimed to optimize the predictive value of ISAR-HP by using different cut-offs in older acutely hospitalized patients.

Methods: A prospective follow-up study was performed in two Dutch hospitals. Acutely hospitalized patients aged ≥70 years were included. Demographics, illness severity parameters, geriatric measurements and the ISAR-HP scores were obtained at baseline. The primary outcome was a combined end point of functional decline or mortality during ninety day follow-up.

Results: In total 861 acutely hospitalized older patients were included, with a median age of 79 years, of whom 276 (36.1%) experienced functional decline or mortality. The conventional ISAR-HP cut-off of ≥2 assigned 432/765 patients (56.5%) as high risk, with a positive predictive value (PPV) of 0.49 (95%CI 0.45-0.54) and a negative predictive value of 0.81 (95%CI 0.76-0.85). Thus, 51% of those whom the ISAR-HP denoted as high risk did not experience the outcome of interest.  Raising the cut-off to ≥4 assigned 205/765 patients (26.8%) as high risk, with a marginally increased PPV to 0.55 (95%CI 0.48-0.62).

Conclusion: The ISAR-HP with the conventional cut-off of ≥2 incorrectly identifies a large group of  patients at high risk for functional decline or mortality and raising the cut-off to 4 only marginally improved performance. Caution is warranted to ensure efficient screening and follow-up interventions. 

Background: Cardiac troponin I (cTnI) is widely measured in Emergency Department (ED) patients (up to14% of all) having any suspicion of possible Acute Myocardial Infarction (AMI). However cTnI can be elevated in a multitude of clinical scenarios other than the thrombotic occlusion of a coronary artery, such as tachycardia, heart failure, sepsis, pulmonary embolism, renal failure, stroke and others. The objective of this study was to determine how often elevated cTnI, at various levels, is associated with a final diagnosis of AMI.

Methods: Adult ED patients being evaluated for possible AMI were prospectively enrolled (from May, 2013 through April 2015) in a single urban center study in the United States (US). Exclusion criteria included acute trauma, distress requiring immediate life-saving intervention, cardioversion or defibrillation or receiving thrombolytic therapy within 24 hours, STEMI requiring immediate reperfusion, pregnancy or breast feeding, and if previously enrolled in the study. Serial cTnI (Siemens Ultra cTnI) measurements were obtained with values > 0.04 ng/ml (99^th %) considered to be elevated. The diagnosis of AMI was adjudicated by a cardiologist and an emergency medicine physician (with a 3^rd cardiologist available if there was diagnosis disagreement) in accordance with the 3^rd universal definition of AMI using all available clinical information obtained over the 30 days after the ED visit. The highest individual patient cTnI was utilized for the analysis and the cTnI values were divided into interquartile ranges.

Results: Of the 569 patients enrolled 116 (20.4 %) had at least one cTnI > 0.04 ng/ml. Of these 72 (62.1%) had a non-AMI diagnosis while 44 (37.9 %) had a final AMI diagnosis. Baseline characteristics of these 2 groups showed no significant differences with the exception of higher medical history of prior revascularization, congestive heart failure and emphysema in those with AMI. Patients with lower cTnI levels (0.05-0.06 ng/ml) were unlikely to have AMI and the incidence of AMI increased with higher cTnI values (p< 0.001). The highest individual patient cTnI values were divided into interquartile ranges. The number of individuals in each quartile with AMI were: 0.05-0.06; 1 AMI (2.3%), 28 non-AMI; 0.07-0.10; 7 AMI (15.9%), 21 non-AMI: 0.11-0.67; 12 AMI (27.3%), 18 non-AMI:  and >0.68 ng/ml; 24 AMI (54.5%), 5 non-AMI. There were very few 30-day deaths (4/569, 0.7%) out of which 3 were non-cardiac in etiology.

Conclusions: cTnI is a highly sensitive biomarker aiding in the detection of myocardial cell damage. However, the majority (62.1%) of ED patients being evaluated for possible AMI and having at least one elevated cTnI (> 99^th %) value did not have a final AMI diagnosis. However the incidence of adjudicated AMI diagnosis significantly increased with higher cTnI interquartile ranges. This trend will likely increase in the US with the current introduction of high sensitivity cardiac troponin assays.

BACKGROUND

Ultrasonography allows direct observation of the diaphragm. Its thickness variation has been recently used to assess work of breathing in ventilated patients. In children, only one study describing diaphragm ultrasound findings in healthy children have been performed. We aimed to assess the diaphragmatic function in infants with bronchiolitis.

METHODS:

Prospective study of infants with bronchiolitis (first episode, aged 1-12 months) evaluated in a tertiary level pediatric emergency room. Infants with life threatening disease requiring immediate intervention, preterms, infants with with cardiac diseases or comorbidities or genetical disorders or disability were excluded. Diaphragm thickness was measured in the zone of apposition and the thickening fraction (TF) was calculated as (thickness at inspiration - thickness at expiration)/thickness at expiration per 100 (therefore expressed as percentage); the higher the values, the higher the respiratory effort of the child, while values ≤ 20% indicated diaphragm dysfunction. Diaphragm excursion (DE), Ti/Ttot (time of inspiration divided by total respiratory act time – the lower the value the longer the expiration time)  were calculated.

RESULTS:

61 infants were enrolled (mean age 83 days, IQR 60.5 – 180, males 50.1%). Bronchiolitis score was mild in 43.1%, moderate in 48.3%, severe in 8.6% cases. 19.7 % children were discharged, 80.3 % were admitted for a median length of 4 days (IQR 2-6.5). Respiratory Syncitial Virus was the most common etiological agent (47.4% cases). 27 children required no oxygen delivery, HFNC were started in 25 cases, among these 7 required CPAP, of these 2 required mechanical ventilation.

Mean TF was 47% (IQR 28.6-64.7), mean Ti/Ttot was 0.47 (± 0.15), mean DE was 10.39 mm (± 4)

Infants with severe bronchiolitis had lower TF than moderate (P 0.03), indicating diaphragm dysfunction, while those with moderate bronchiolitis showed the highest respiratory effort (highest TF). All children with lower values of TF required HFNC and one of them required CPAP. There was a linear correlation between TF and oxygen saturation (P 0.013).

Children with severe bronchiolitis had higher DE and lower Ti/Ttot compared with those with mild bronchiolitis, even though statistically significant differences were not reached probably due to low numbers of patients evaluated.

The higher the eco score the higher DE (P < 0.05).

These parameters did not significantly correlate with length of admission and type of respiratory support, while correlated with length of HFNC support.

CONCLUSIONS:

For the first time to our knowledge, this study provides reference values for DE, TF and Ti/Ttot in otherwise healthy infants with bronchiolitis. TF seems a promising parameter to predict those infants that might require respiratory support. Further studies are needed to understand which one of these parameters may predict need of respiratory support and admission.

Background:

Sensitivity, specificity, and precision of the various commercially available troponin assays vary considerably. Sens-a-Heart is a novel rapid test using a combination of biomarkers, which provides a yes/no answer within 15 minutes using a single droplet of blood.

Aims:

The purpose of this study was to evaluate diagnostic accuracy of rapid Sens-a-Heart testing in patients with definite or possible ACS.

Methods:

The Sens-a-Heart test was performed in 191consecutive pts with definite or possible ACS admitted to departments of Hadassah Medical Center (Jerusalem) from 01.09.2015 till 31.03.2017. Initial troponin evaluation and simultaneous Sens-a-Heart testing were done under the ESC and ACC consensus guidelines.

Results:

Final diagnosis of ACS was established in 124 (65%), nonischemic heart disease documented in 3 (1.5%) and noncardiac disease in 64 (33.5%) of patients.

The Sens-a-Heart test was highly sensitive to coronary events. (77% of cases vs standard Hadassah troponin test which revealed 67% of cases).

The Sens-a-Heart test is also has high specificity for ACS. (96% vs 94% in Hadassah troponin test). Upon combining of both test results a higher sensitivity is achieved (86% sensitivity with specificity of 90%).

Table 1.

Roche ultra-sensitive troponin T test (Hadassah)

Sens-a-Heart Rapid Assay (Novamed)

Combined results (Sens-a-Heart + Hadassah’s Troponin)

Sensitivity

67%

77%

86%

Specificity

94%

96%

90%

Roche ultra-sensitive troponin T test (Hadassah)

Sens-a-Heart Rapid Assay (Novamed)

Combined results (Sens-a-Heart + Hadassah’s Troponin)

Sensitivity

67%

77%

86%

Specificity

94%

96%

90%

Conclusion: Novamed’s Sens-a-Heart Rapid Assay has prominent diagnostic sensitivity and specificity in patients with ACS in a very short time.

Introduction :

The quick sequential Organ Failure Assessment scores (q SOFA) may identify patients with infection who are at risk of complications .We determined the correlation between q SOFA scores and mortality in adult emergency department (ED) patients with and without infection.

Methods:

We performed a prospective and descriptive study of all adult patients admitted to the ED between February 2017 to March 2017. We calculated the qSOFA for all patients on admission .We study the correlation between q SOFA scores and inpatient mortality (intra hospital and 2 weeks mortality )

Results:

We included 153 patients. Mean age was 60±7 years old. 34 % were female and 66% were male. Hypertension and diabetes are the frequent associated disease (46, 2% and 37, 8% respectively) Different diagnosis are defined, the most frequent are coronary disease (35 %) and pneumonia (27%).  Septic patients are representing 43 % of patients .We studied the correlation between q SOFA scores and mortality. We find that when the q SOFA is less than 2 we have 1, 6% of mortality. and  when the q SOFA more than 2 the  mortality rate is  13% .We concluded a significant positive correlation between the Q sofa score and 2 weeks mortality ( p=0.04)

Conclusion:

QSOFA scores were associated with inpatient mortality, in adult ED patients likely to be admitted both with and without suspected infection and may be useful in predicting outcomes.

Objectives: Copeptin, Myeloperoxidase and Pro-adrenomedullin have emerged as potential biomarkers for diagnosis and prognosis of acute coronary syndrome. However, their applicability with chronic renal failures remains unknown as these patients were excluded from the previous studies. Our objective was to determine the superior novel cardiac marker to predict 30-day and 6-month adverse cardiac event (ACE) as defined as cardiac related death, myocardial infarction and ventricular fibrillation.

Methods: A prospective observational study was carried out. Patients were included if they presented to the ED with a chief complaint of chest pain and had chronic renal failure as defined as a serum creatinine of more than 130umol/L. Copeptin, Myeloperoxidase and Pro-adrenomedulin assays were performed. Occurrence of ACE was traced from review of the patients’ case records and checking of the registry of deaths.

Results: Seven hundred and twenty four patients were recruited with a median age of 67. 60.6% of the study population were male. 88.3% of the population had CKD stage 4 and 5, with 33.5% on dialysis. The rates of ACE at 30-day and 6-month were 15.1% and 21.7% respectively. All readings of the 3 biomarkers were not significantly different in patients with ACE compared to those without at both 30-day and 6-month. The AUCs for Copeptin, Myeloperoxidase and Pro-adrenomedullin are 0.53, 0.50 and 0.45 respectively (p all >0.05).

Conclusions: The performance the biomarkers was poor attributable to the lack of specificity for acute coronary syndrome as elevated levels could be due to other causes in patients with chronic renal disease. Routine testing cannot be recommended.

Background:
 In ischemic stroke caused by a thrombosis of a large brain artery, IV-thrombolysis (IV-tPA) appears ineffective, while mechanical thrombectomy (MT) is reported to be a powerful tool to open the occlusion (1). However, the favorable effect of recanalization is highly time-dependent (2). Previously validated and generally used stroke signs (face-arm-leg-speech-visual disturbance) recognize stroke in general. Furthermore, conjugate eye deviation (CED) is highly related to large vessel occlusion (LVO). Currently, patients with suspected stroke are transported to the nearest hospital with facilities for IV-tPA but not necessarily for MT. Hence, this can cause significant treatment delay.  We hypothesized that combining general stroke signs with CED will produce an easy-to-use prehospital stroke scale for prehospital use by emergency medical services (EMS), recognizing both stroke in general and LVO separately.  Thus, unnecessary visits to non-tertiary hospitals could be avoided.
Methods: We retrospectively analyzed n=856 consecutive patients with prehospital Code Stroke (thrombolysis candidate). National Institutes of Health Stroke Scale (NIHSS) was executed on patient arrival. Computed tomography (CT) was performed for all patients and CT angiography based on clinical decision. With random forest analysis and deviance analysis of the general linear model we confirmed superiority of NIHSS ‘Best Gaze’ over other NIHSS items in LVO detection.

Results: NIHSS ‘Best Gaze’ had the best predictive value of NIHSS items in detecting LVO of the anterior circulation. Based on this and generally used stroke signs we presented Finnish Prehospital Stroke Scale (FPSS) including dichotomized face drooping, extremity weakness, speech difficulty, visual disturbance and CED.  “Face droop”, “extremity weakness”, “disturbed speech” and “disturbance of vision” give each one point while “forged or partial conjugated gaze deviation to one side” gives four points. FPSS with combined score values of 1-4 indicates a thrombolysis candidate whereas values 5-8 indicate a thrombectomy candidate.   FPSS detected LVO with a sensitivity of 54%, specificity of 91%, PPV 48%, NPV 93%, and LR of 6.2 which are comparable to previous scales aimed to detect LVO only.
Conclusions: FPSS is simple to use and with dichotomized items, easily implementable for emergency medical services and emergency response centers. Furthermore, the high specificity of FPSS for LVO enables direct transfer of candidates for endovascular treatment to tertiary stroke centers. Containing a clear cut off point FPSS is convenient regardless of operational environment. Based on CED, FPSS can recognize LVO and on general stroke signs (face-arm-leg-speech-visual disturbance) stroke in general, thus aiding patient logistics in stroke management.

In emergent airway management, the laryngeal mask airway (LMA) have served as a bridge between endotracheal intubation and the face mask. For achieving the ideal anatomical position of the LMA, various trails, including insertion with the use of laryngoscope, have been described. Yet, except fiberoptic assessment, reliable tests for this technique of correct placement of LMA are not established.

Recently, oropharyngeal leak pressures are commonly performed with the LMA to indicate the degree of airway protection, the feasibility for positive pressure ventilation and the likelihood for successful supraglottic airway placement

The objective of this randomized prospective study was to assess the efficacy of insertion techniques, blind insertion and insertion with laryngoscope. The primary outcome was the measurement of oropharyngeal leak pressure with the two techniques. The secondary outcomes were the success rate on first attempt.

Method

Approval was obtained from the IRB, a prospective comparison of 100 patients divided into 2 groups (50 with blind technique and 50 with the laryngoscope technique) were evaluated. A standard anesthetic protocol without muscle relaxant was followed. After loss of consciousness, a LMA was inserted using the blind approach in blind insertion group or using laryngoscopy in laryngoscope group.

The oropharyngeal leak pressure was performed by closing the expiratory valve of the circuit at a fixed gas flow of 6 L/min and noting the airway pressure at which gas leaked into the mouth. The failure of first attempt insertion was recorded. Failed insertion was defined by any of the following criteria: failed passage into the pharynx; malposition; ineffective ventilation (maximum expired tidal volume < 6 ml/kg). We analyzed the data with SPSS version 17 (SPSS Inc., Chicago, Illinois, USA). Continous data were analyzed using Student’s t-test. Nonminal data were analyzed with x2 test. A p value less than 0.05 was considered significant.

Result

There was no significant difference between two groups on oropharyngeal leak pressure (18.4 ± 5.4 mmHg in blind group vs 20.6 ± 7.1 mmHg in laryngoscope group, p=0.16) and success rate on first attempt (89.2 % in blind group vs 94.5% in laryngoscope group, p=0.46).

Conclusion

In terms of oropharyngeal leak pressure, insertion with laryngoscope did not show any superiority compared to blind insertion. Blind insertion technique is easier and simpler method for insertion of LMA and has a reasonable success rate, so it is recommended to be used.

Introduction: Lumbar puncture (PL) is a common diagnostic procedure in the management of patients admitted to emergency departments. Its main indication is the search for an infection of the Central nervous system. Few epidemiological data are available in the literature concerning the use of PL, its efficiency and the populations benefiting from this review.

Purpose of Work: The objective of our work is to study the profiles of the patients benefiting from the lumbar puncture and to evaluate the predictive factors of its positivity, in order to propose a decision algorithm of the realization of the lumbar puncture in the emergencies.

Materials and methods: We carried out a retrospective study over a period of 4 years (between January 1, 2013 and December 31, 2016), within the adult emergency resuscitation department of the Ibn Rochd University Hospital Center. The inclusion criteria: Patient benefiting from a PL at the time of his/her management in the emergencies, taking into account the first effective PL carried out for the same patient during the same passage.  Excluded:   Patients who had CSF analysis by a technique other than lumbar puncture,Patients who had CSF analysis by PL without passing through the adultSAU.Epidemiological, clinical, biological, radiological and evolutionary characteristics were analyzed, according to a global descriptive study and a multivariate analysis and a univariate analytical study aiming at assessing the association between two variables.

Results: 590 patients received a PL after admission to the emergency room, representing 4.11% of patients admitted to emergency departments during study periods. Nearly 34.2% of the PLs performed were contributory and confirmed a diagnosis of meningitis (174 cases), meningeal haemorrhage (16 cases) or polyradiculoneuritis (12 cases). These contributory PLs were mainly related to infectious meningitis. The main diagnoses found in the presence of non-contributory PLs were related to neurological pathologies (convulsions and strokes) and infectious pathologies outside the central nervous system. In this work, it was found that a history of head trauma, presence of obliteration, clinical association of fever-headache, fever-meningitis stiffness, and fever-headache-meningeal stiffness are predictive factors, A positive lumbar puncture. Concerning cerebral imaging, 83.73% of patients with lumbar puncture had a CT scan. The importance of using the brain scan seems to be excessive, and the expectation of the result may be the cause of a delay in diagnosis and management leading to a situation prejudicial to the patient.

 Conclusion: A decision algorithm for performing lumbar puncture in emergency departments is proposed, based on the existence of factors predictive of CSF positivity, whether signs of gravity are present or not. And the key message is not to delay the administration of antibiotics to any suspected cases of community meningitis.

Background: The importance of early management of sepsis is well known and has led to increased efforts in improving the recognition of and response to septic patients in emergency departments    

Objectives: To evaluate the impact of utilising a Sepsis Pathway Program, aimed at improving recognition of and response to septic patients, in a metropolitan Emergency Department 

Method: Following the introduction of a Sepsis Pathway Program in June 2015, a review of patients presenting to the emergency department of Casey Hospital, Victoria from June to December 2015 with sepsis was conducted. Main outcome measures were: time to antibiotic administration and to lactate measurement; rate and duration of intensive care admission; in-hospital mortality, and total duration of hospital admission. Outcomes were compared to a retrospective review of septic patients presenting to emergency from June to December 2014.

Results: The review included 171 patients in 2014 and 130 patients in 2015. The median time to antibiotic administration was significantly shorter in the post-intervention group (102 minutes vs. 190 minutes, p<0.05. The time to lactate measurement, number and duration of intensive care admissions, in-hospital mortality and total length of stay was not significantly different between the two groups.  

Conclusion: Implementation of the Sepsis Pathway Program resulted in earlier administration of antibiotics in septic patients presenting to the emergency department. Although a significant difference in secondary outcomes were not observed in this study, further evaluation in a larger multi-centre study may be warranted.

Introduction

The aim of this study was to assess differences in population, management and outcome of children with respiratory complaints in 5 different European emergency departments

Methods

This study was part of the TrIAGE project, a prospective observational study consisting of a large cohort of children visiting the emergency department (ED) in 5 different hospitals in 4 European countries (UK, Austria, Portugal, the Netherlands). Data collection consisted of routinely recorded patient data, automatically extracted from electronic medical records. Data harmonization and quality checks were performed.  We included all children aged The associations between population (age, hospital, triage urgency, vital signs) and management (lab, imaging, inhalation medication and hospital admission) were assessed using a logistic regression model.

Results

In total, 13.552 children with shortness of breath were included. Of those, 55% (8.560) were categorized as urgent. This ranged from 13% in a low-urgency setting to 80% in a high-urgency setting.
The majority of children was below the age of 5 years (77%, range 73-84%).

Regarding vital signs, 41% of the total population had an abnormal respiratory rate according to APLS normal values, 9% had an abnormal oxygen saturation and 53% showed increased work of breathing.
Lab tests were performed in 16% of children (range between hospitals: 8-32%, adjusted odds ratio 5.6, 95% CI 4.0-7.9) and an X-ray was performed in 19% (range: 8-33%, adjusted odds ratio 8.6, 95% CI 6.4-11.6).
Forty-six procent of all children were treated with inhalation medication (range: 21-61%, adjusted odds ratio 0.5, 95% CI 0.3-0.7) and 19% was admitted (range 8-47%, adjusted odds ratio 0.1, 95% CI 0.1-0.2). Two hundred and five children (1.5%) were admitted to the ICU (range: 0.1-9%, adjusted odds ratio 43.4, 95% CI 13.4-140.7).

Patient characteristics (age, gender, urgency, presence of fever, abnormal vital signs) could explain part of the observed differences in management. However, after correcting for these population characteristics, we still observed substantial differences between hospitals concerning the management of these children.

Conclusion & discussion

European EDs differ substantially regarding the management of children with respiratory complaints, even when correcting for triage urgency or age. Possible explanations might be other aspects of patient characteristics such as underlying problem or comorbidity, or differences in local practice and use of different guidelines. 

The complex pathophysiological mechanisms behind coagulopathy that occurs after traumatic brain injury are multifactorial and remains poorly defined  , but many studies have shown the progression of parenchymal lesions particularly in patients with coagulopathy . Disorders of coagulation may be amenable to treatment  , adequate and prompt intervention may prevent secondary complications and poorer outcome.

Objectives : The purpose of this study is to evalute the association of coagulopathy and isolated traumatic brain injury as regard its frequency and outcome for patients who developed coagulopathy .

Patients : this prospective study was conducted to include 60 patients with isolated traumatic brain injury admitted to the emergency department of Alexandria main university hospital within 24 hours of trauma . Patients with known coagulopathy , on anticoagulants therapy , or those with intra abdominal collection , hemothorax or other injuries that affect coagulation were excluded from the study.

Methods : Primary survey and secondary survey were done for those patients . Radiological investigations were done including CT brain to exclude other sources of bleeding which can lead to coagulopathy . This also includes laboratory tests to asses coagulation as INR , platelet count , PTT and FDP for those who showed abnormality with the previous three tests .

Results : The frequency  of coagulopathy among those 60 patients was  8.3% . In this study 80% of cases who developed coagulopathy had severe traumatic brain injury and 20% had moderate TBI , but non of the  cases who developed coagulopathy had mild TBI .  Brain edema was the most common CT finding in patients with coagulopathy following TBI as it was present in 80% of cases . Acute Subdural hematoma is the second most common CT  finding in those who developed coagulopathy occured in 60% of those patients . Intra ventricular hemorrhage and hemorrhagic contusion occured in 40% of cases .All patients with coagulopathy had FDP > 10 mic/ ml and INR >1.3 , while PTT> 34 seconds in 80% of cases who developed coagulopathy.  Platelets count  < 100,000 cell/mm3 was present only in 40% of patients who developed coagulopathy . As regard outcome in ED  80% of cases who developed coagulopathy had deterioration of their GCS, while only 40 % of those who developed coagulopathy had disseminated intravascular coagulopathy .Also 80% of those had progressive hemorrhagic lesion on follow up CT  brain .

 Conclusion : coagulopathy occurs frequently after TBI . Coagulopathy is much more pronounced in patients with severe TBI than in patients with mild or moderate TBI .  Brain edema and acute subdural hematoma ate the most common CT finding in patients with coagulopathy after TBI . Not all cases of TBI  that had high levels of FDP had disseminated intravascular coagulopathy. 

Introduction:

Severe head trauma is a common reason for patient’s admission to the intensive care unit and it is the leading cause of death in young adults. The outcome of these patients depends on many factors such as cerebral hypoxia. Pulmonary contusion can cause an acute respiratory failure that aggravates head trauma.

Study objective:

To evaluate the impact on morbidity and mortality of pulmonary contusion in patients admitted for severe head trauma.

Patients and methods:

This was a retrospective study performed in the emergency and intensive care department in the regional hospital of Zaghouan. The patients were recruited during 3 years, from January 2013 to December 2015. All adult patients admitted for severe head trauma (Glasgow coma score (GCS) ≤ 8) were included and evaluated by quantified injury severity scores including APACHE2, GCS, ISS, TISS. The diagnosis of pulmonary contusion was based on the history of blunt chest trauma and the appearance of four types of lesions on chest CT scans. Hospital length of stay, mortality rate, incidence of adverse events including pneumonia, ARDS and shock were recorder and compared into the tow groups (with or without pulmonary contusion).

 Results:

During the study period, 104 patients were included. The diagnosis of pulmonary contusion was retained in 34 patients (32.7%). The two groups were compared for age, genre, APACHE 2 and GCS. There was a significant difference in the ISS and TISS (p <0.001). Patients with pulmonary contusion had significantly lower PaO₂/FiO₂ ratio (240 [range, 160-380]) vs. 430 [range, 210-590]; p = 0.009); and significantly higher PaCO₂ levels (43.5 mmHg [range, 38-52 mmHg] vs. 38 mmHg [range, 32-40 mmHg], p < 0.001). The number of cases of pneumothorax and hemothorax were significantly higher in the group of pulmonary contusion (p = 0.003, p = 0.021; respectively). Likewise, The occurrence of pneumonia and ARDS was significantly higher in the group of pulmonary contusion (p = 0.031, p = 0.023; respectively) with a shorter length of time between ICU admission and the occurrence of such complications; (6 days [range, 6-10 days]) vs. 13 days [range, 8-16 days]; p = 0.024) and (6 days [range, 2-8 days]) vs. 10 days [range, 8-10 days]; p = 0.016), respectively. No significant difference was observed with regard to the number of cases of shock (p = 0.174). The length of hospital stay was significantly higher in the group of pulmonary contusion (13.44 ± 6 days vs. 12.44 ± 4 days; p < 0.001). The overall mortality rate was 11.5% in pulmonary contusion group and 7.7% in the other group (Odds ratio, 4.22; 95% confidence interval, 1.527 to 11.703; p = 0.004).

Conclusion:

In this study, pulmonary contusion alters gas exchange and appears to increase the morbidity and mortality in patients with severe head trauma.

Background: Trauma is a leading cause of mortality in young people aged under 40 years. Early assessment of prognosis is a cornerstone in the management of severe trauma. Several prognostic scores have been proposed in the literature during last decade. The aim of this study was to evaluate the prognostic value and to compare five trauma scores in terms of mortality at day 30 in severe trauma patients admitted to the emergency department.     

Methods: This was a prospective, observational study with inclusion of severe trauma admitted to the emergency department during a 20-month period. We focused on the predictive value of 5 specific trauma scores in terms of mortality in severe trauma admitted to the resuscitation room. Five scores were included: The Injury Severity Score (ISS), the New NISS, The Emergency Trauma Score (EMTRAS) and the GAP and M-GAP scores. Multivariate analysis of mortality at day 30 post-trauma was conducted with comparison of ROC curves.

Results: We included 298 patients. Median age was 40 (15-80) years. Sex ratio was 4,5. Clinical characteristics: n (%): GCS ≤ 8: 62 (21); PAS <90 mm Hg: 32 (11) and pulse oximetry <90%: 44 (15). The median ISS was 17 (0-75) and 176 (59%) trauma patients had a score ISS ≥ 16. The global mortality  was 21.5%. Independent predictors of mortality after multivariate analysis were respectively : EMTRAS score ≥ 3 (adjusted OR 1.80, 95% CI [1.05-3.08], p = 0.0033), ISS ≥ 16 (adjusted OR 2.05; 95% CI [1.26-3.46],p = 0.002),GAP <20 (adjusted OR 1.92, 95% CI [1.268-2.92], p = 0.002) 1.74, 95% CI [1.17-2.592], p = 0.005). After comparison of the 5 scoring tools, the GAP score showed the best AUC= 0.811 followed by the EMTRAS with an AUC of 0.789.

Conclusion:  Severe trauma is a dynamic process with high rate of morbidity and mortality. The need to an accurate evaluation of the prognosis remains a challenge for the emergency physician. Many scoring tools were proposed. In our study, all scores were able to predict mortality but physiological GAP score showed the higher AUC and so that could be proposed as safe to be used at the early stage for evaluation in the ED.

Introduction :

Early detection of at-risk trauma patients remains a challenge for emergency physicians and guides both triage and making decision. In this context, biological tools were proposed within the last decades such as lactate – rapidly available in the emergency department (ED) and widely correlated with severity and mortality. This study aimed to compare the lactate prognostic value in terms of early and delayed mortality with the anatomical Injury Severity Score (ISS), a reference score proposed worldwide in the litterature but obtained after completing explorations in trauma patients.

Methods:

It was a single-center prospective study (12 months). Inclusion of severe trauma patients over 18 years admitted to the emergency resuscitation room at the ED. Arterial lactate at admission was drawn on a point-of-care sample gaz before any resuscitation attempts. ISS were calculated after completed explorations and assessment. Mortality at day 7 and 30 was colliged with comparison of the ROC curve’s characteristics of both lactate and ISS towards mortality.

Results:

We enrolled 190 trauma patients with median age (min, max) = 34 years (18,85) and sex-ration= 4. Road traffic accident was the predominant cause of trauma in 140 cases (74%). Average ISS (SD)= 20 (12) with ISS >= 16 in 122 patients (22%). Mortality rate was respectively 26% at day-7 and 29,5% at day-30. Median lactate (IQR) =2,4 mmol/l (0,4- 10,9) and lactate >=2,5 mmol/l was found in 118 patients (62%). ISS and lactate were significantly higher in non-survivors than in survivors; p<0,001. Moreover, ISS was superior to lactate in predicting mortality. The ROC curves characteristics were respectively :  Mortality at Day-7  (ISS: AUC = 0,930; CI95% [0,895-0,964]; p<0,001) vs (Lactate: AUC =0,704; CI95% [0,622- 0,786]; p<0,001) and mortality at Day-30 ( ISS: AUC 0,951; CI95% [0,924- 0,978]; p<0,001) vs (lactate: AUC 0,700 ; CI95% [0,621-0,779]; p<0,001).

Conclusion :

In this study, indeed ISS remains a higher tool for predicting mortality but is difficult to calculate and is late to obtain with the need of exhaustive morphologic injury assessment. Lactate showed a good predictive value for both early and delayed mortality with strong significative AUC. Moreover, lactate is  rapidly available in few minutes after admission at the ED and so that can be proposed for early  accurate assessment in severe injured patients. Our study was single-center with a limitation of small size sample. Enlargement of the size and conducting multi-centric study in the future could improve sensitivity and predictive value of lactate biomarker.

Introduction

Methodological evaluation of interventional studies conducted via emergency medical call centres has not previously been performed.

Objective

To describe in both quantitative and qualitative terms interventional research performed in medical call centres.

Methods

Study: Systematic review.

Search engines: PubMed, World of Science, Cochrane Methodological Register, OMS Register and ClinicalTrials.

Inclusion criteria: Studies evaluating therapeutic or organisational interventions, directed by call centres, enacted by responding physicians, paramedical teams or bystanders, in the context of situations judged to be emergencies by callers.

Exclusion criteria: Studies focussed on call management for general practice or non-healthcare agencies.

Parameters collected: Delay to publication, general characteristics of the study, study population (patients, mannequin based training, experimental modelling), number of patients included, theme or pathology targeted by the study, primary and secondary outcome measure(s), funding, ethical approval, quality criteria evaluated according to the risk of bias scale (ROB) or the Newcastle-Ottawa scale (NOS). For NOS, scores of 0-3, 4-6, and 7-9 are regarded as low, moderate, and high quality respectively.

Methodology: Extraction of parameters by two independent investigators. In cases of disagreement, a third expert investigator was consulted.

Results

Our search terms yielded 3896 articles. After examining abstracts, 47 articles were retained. The median delay to publication was 36 weeks (IQR: 30-48). Thirty-three of the studies were clinical trials (70%) and 14 (30%) were before-after trials. Studies were monocentric in 33 (70%) of cases and 32 (70%) used randomisation. The models used were simulation training, patient based or experimental studies in 26 (55%), 17 (38%), and 3 (6%) of articles respectively. The median number of subjects included was 147 (IQR: 74-1271). The theme most commonly targeted was cardiac arrests (n=36, 77%), with outcome measures of CPR quality and dispatch assistance. Other themes included triage in the call centre, management of pathologies such as myocardial infarct, severe trauma, cerebrovascular accidents, and analysis of the transmission of information. Ethical committee approval was declared in 38 (81%) of cases. Funding was reported by 26 (55%) of studies. Among the randomised-trials, selective reporting was high for 24 (75%) studies, blinding of outcome was low for 28 (88%) and incomplete outcome was low for 23 (72%) studies. Regarding non-randomised studies, quality was high, intermediate and low respectively in 7 (50%), 6 (43%) and 1 (7%) of cases.

Conclusion

Few interventional studies have been carried out in call centres. Those that exist principally describe simulation studies, and often focus on cardiac arrest. The quality of studies needs improvement in order to allow a better recognition and understanding of emergency medical call control.

Introduction

Mesenteric ischemia/reperfusion (I/R) injury is a serious clinical condition. There were a lot of experimental studies performed in the treatment of I/R injury. In our knowledge, this is the first experimental study with effects of sesamin on I/R injury model. We aimed to investigate the protective effect of sesamine on mesenteric I/R injury model.

Materials and methods

A total of 32 male Sprague-Dawley rats were divided into four groups. Control group: superior mesenteric artery (SMA) exposed without clamping. I/R group: SMA was clamped for 60 minutes and then reperfused for 2 hours. Sesamin group (S): 30 mg/kg sesamin were given for 5 days, and SMA exposed without clamping. I/R+S group: 30 mg/kg sesamin were given for 5 days, SMA was clamped for 60 minutes and then reperfused for 2 hours. We studied plasma and tissue oxidant parameters and histopathological evaluation was performed.

Result

Plasma and tissue TAS levels were significantly higher in I/R+S group compared to the rest (p<0.005). The plasma TAS levels in I/R group was significantly low. The highest tissue TAS levels were detected in I/R+S group. The high levels of plasma and tissue TOS were found in I/R+S group. Plasma and tissue OSI levels were significantly higher in I/R group. Histopathologic evaluation showed that; the mean level of intestinal tissue injury score in I/R group was 2,75 and was 1.38 in I/R+S group. 

Conclusion

Sesamin helps to protect the intestinal tissue at the cellular level by reducing the oxidative stress and inflamation at both the plasma and tissue levels in the experimental I/R model.

Introduction

Electroencephalography is regularly used in the emergency department, but its relevance and value are actually difficult to assess, despite clear guidelines from the Société de Neurophysiologie Clinique de la Langue Française (SNCLF). The purpose of this study was to evaluate the relevance of EEGs in the emergency department by comparing actual indications and clinical practice.

Method

Monocentric, retrospective study over a 6 months period, from 01/01/2014 to 31/06/2014 at the emergency department. The EEGs performed were classified as recommended and non-recommended, as regards to the guidelines from the SNCLF.

Results

476 EEGs were performed over this period. 389 were used for statistical analysis. Mean age was 62.6 +/- 20.3 years, with a sex ratio of 1.2 (M:F). 30.8% of EEGs were recommended. The clinical symptoms that led to an EEG were varied and often linked. We noted 57.5% of confusion and 50.8% for generalized tonic-clonic seizures in the recommended group. In the non-recommended group, 40.9% of EEGs were performed for funny turns and 28.3% for altered mental states. The recommended EEGs lead to the final diagnosis in 24.4% of the generalized tonic-clonic seizures and 6.2% of altered mental states. For the non-recommended group, rates were 4.8% and 9% for these clinical presentations. 19.2% of recommended EEGs had a therapeutic impact VS 5.9% for non-recommended. The duration of hospitalization was 4.54 days for the group of recommended EEG VS 8.45 days for the non-recommended.

Discussion

Our study demonstrates that the EEG has a greater diagnostic and therapeutic contribution when the guidelines of the SNCLF are followed. Concerning altered mental states, diagnostic value of the EEG is weak and almost equivalent in both groups. This suggests that EEGs should not be performed in this indication. Half of the hospital stay for patients with recommended EEG was also reduced.

Conclusions

Although the indications of the EEG in the emergency department are clearly established, its relevance remains uncertain. Indeed, our study shows that non-recommended EEGs are equivalent in diagnostic value regarding altered mental states, reaffirming the premise that any paraclinic examination should be requested after a thorough clinical examination. 

Background: Traumatic brain injury (TBI) is the leading cause of death and disability among young adults worldwide. Difficulties in clinical assessment and triage of TBI patients in the prehospital phase results in numerous precautionary hospital admissions of mild TBI patients and treatment delay due to mis-triage of moderate and severe TBI patients. Early knowledge on biomarker values is suggested key to improvement of patient outcome as it may guide clinical-decision-making already in the prehospital phase.

Aim: To investigate the potential of early biomarker measurements in prehospital management of TBI patients.

Methods: 3 Prospective, observational studies were designed to investigate ROC characteristics of S100B, GFAP and NSE in relation to clinically relevant endpoints. 690 adult patients suffering mild, moderate and severe TBI in Central Denmark Region will be included from February 15 2017 - June 15 2018. Blood samples are drawn in the ambulance, on admission and repeatedly during the first 12 hours past trauma. Blood samples are stores in a biological bank and batch analysis will be done after 6, 12 and 18 months during the period og inclusion. An endpoint adjutication comittee of senior researchers will review patient causes blinded to biomarker values in relation to endpoint of the relevant study:

PreTBI I:Diagnostic Potential of S100B and GFAP in Prehospital Rule-Out of Intracranial Lesions in Patients suffering Mild TBI.

PreTBI II:S100B and GFAP in Prehospital Prediction of Need for Neurosurgical Observation or Intervention in Patients suffering Moderate TBI.

PreTBI III: Prognostic Potential of S100B, GFAP and NSE in Patients suffering Severe TBI.

Perspectives: To underline the potential of prehospital biomarker measurements for effective rule-out of low risk patients and rule-in of high-risk patients in order to minimize treatment delay, secure optimal resource consumption and streamline patient courses for patients suffering neurotrauma. Ultimately to elucidate the need for development of a point-of-care analysis.

Background and Objectives: Nights and weekends represent a potentially high-risk time for pediatric cardiac arrest (CA) patients in emergency departments (EDs). Data regarding night or weekend arrest and its impact on outcomes is controversial. This study performed to determine the relationship between cardiopulmonary resuscitation (CPR) during the various ED shifts and survival to discharge.

Methods: We conducted a retrospective, observational study in which patients who had visited our ED for cardiac arrest from January, 2013 to December 2015. We examined survival from cardiac arrest in hourly time segments, defining within working hours as 8:00 AM to 17:00 PM, out of working hours as 17:00 PM to 7:59 AM and weekend as 17:00 PM on Friday to 7:59 AM on Monday. Medical records and patient characteristics of 54 children with cardiac arrest were retrieved from patient admission files.

Results: The median age was 3 years, 59% were male and 17 patients were younger than 12 months. A total of 26 cases of cardiac arrest admitted at working hours to ED and 28 cases admitted at out of working hours. Rates of survival to discharge 30.8% (n=8) within working hours vs out of working hours 3.6% (n=1). Among in cardiac arrests presenting to ED, survival was higher on working hours than out of working hours (p=0.01). Rate of return of spontaneous circulation within working hours was higher than out of working hours (54% vs.18%) (p=0.009).  Patients older than 5 years had poor outcome, whereas better outcome was associated with in-hospital cardiac arrest (p<0.05). The first documented rhythm at our group was more frequently to be asystole (92%).

Conclusion: Survival rates from pediatric cardiac arrest are lower during out of working hours.  The outcome has also been related to duration of CPR, age and location of CA.

Purpose: Hydroquinone (HQ), a major metabolite of benzene, exists in many plant-derived food and products. Although many studies have addressed biological properties of HQ including the regulation of immune responses and antioxidant activity, neuroprotective effects of HQ following ischemic insults have not yet been considered. Therefore, in this study, we examined neuroprotective effects of HQ against ischemic damage in the gerbil hippocampal cornu ammonis 1 (CA1) region following 5 min of transient cerebral ischemia.

Methods: To elucidate the neuroprotective effects of HQ against ischemic damage, the gerbils were divided into 8 groups (n = 7 in each group), as follows: 1) vehicle-treated sham-operated group (vehicle-sham-group), 2) vehicle-treated ischemia-operated groups (vehicle-ischemia-group), 3) and 4) 50 and 100 mg/kg HQ-pre-treated sham-operated groups (pre-HQ-sham-groups), 5) and 6) 50 and 100 mg/kg HQ-post-treated sham-operated groups (post-HQ-sham-groups) 7 and 8) 50 and 100 mg/kg HQ-pretreated ischemia-operated groups (pre-HQ-ischemia-groups), 9 and 10) 50 and 100 mg/kg HQ-post-treated ischemia-operated groups (post-HQ-ischemia-groups). HQ was purchased from Sigma (St. Louis, MO, USA) and dissolved in saline. For pre- and post-treatment, HQ or saline was intraperitoneally administered once at 30 min before or after ischemic surgery, respectively. Sham-operated animals were subjected to the same surgical procedures except that the common carotid arteries were not occluded.

Results: We found that pre- and post-treatments with 50 and 100 mg/kg of HQ protected CA1 pyramidal neurons from ischemic insult. Especially, pre- and post-treatments with 100 mg/kg of HQ showed strong neuroprotective effects against ischemic damage. In addition, pre- and post-treatments with 100 mg/kg of HQ significantly attenuated activations of astrocytes and microglia in the ischemic CA1 region compared to the vehicle-treated-ischemia-operated group.

Conclusion: Briefly, these results show that pre- and post-treatments with HQ can protect neurons from transient cerebral ischemia and strongly attenuate ischemia-induced glial activation in the hippocampal CA1 region, and indicate that HQ can be used for both prevention and therapy of ischemic injury.

Background Costs of healthcare services are difficult to determine. Accurately allocating costs of healthcare services to activities would enable better policy decisions on subjects such as optimal care venues, spending priorities, and staffing. Current cost-per-patient systems (kostnad-per-patient, KPP) consolidate Emergency Department costs for some patient encounters with inpatient costs, obscuring the true costs of ED care. Standard cost accounting allocates all costs to current patients, creating the appearance of cost increases with decreased utilization. We developed the Patient Encounter Cost (PEC), a method for more accurately assigning costs within a regional emergency department (ED) care system to account for excess capacity.

Methods We used data from Region Halland, Sweden, a county of 300,000 people over 5,500 km². We analyzed 2015 records of the entire population of 88,132 ED visits across 2 ED sites in the region.  We calculated total costs incurred of 212 million Swedish Crowns (SEK), or approximately 25 million USD. Time spent per visit was determined from prospectively recorded ED records and adjusted by published weighting factors for nursing care by triage acuity level. Total capacity was determined based on available nursing and physician staff time. We developed the PEC using time-driven activity based costing (TDABC) methods to determine unit-time costs for ED care. Unit-time costs were then used to determine total ED patient-care costs for the year 2015.

Results In 2015, Region Halland spent 212 million SEK on its emergency departments, incurring unit costs of 1,787 SEK per nursing hour. The average ED visit service cost 2,363 SEK (95%CI 2,273-2,453), ranging from 460 SEK (454-466 SEK) for triage level 5 patients to 4,507 SEK (4,505-4,509 SEK) for triage level 1 patients. Total costs spent on direct patient care accounted for 191 million SEK, showing a utilization of 81% of available capacity. The average ED visit service cost 2,363 SEK using PEC techniques compared to 2,865 SEK using traditional health care cost accounting techniques.

Conclusion PEC can be used to allocate costs down to the individual patient encounter level within a regional emergency care system using readily-available data. This method has the potential to contribute to policy decisions regarding appropriate excess capacity and allocation of scarce healthcare resources, as well as more closely aligning costs with prices in systems without a single payer. Next steps include refining the model for greater granularity of cost assignment to patient care visits.

Background: There has been an increasing number of emergency department visits due to synthetic cannabinoid use. There is little information about the structural and functional damage caused by the use of synthetic cannabinoids. This study aims to evaluate the serum S100B levels to predict neuronal damage and clinical poor outcomes associated with the use of synthetic cannabinoids.

Method: Thirty patients with synthetic cannabinoid user and 30 healthy controls were included in the study. The S100B levels were measured with a Human ELISA kit. Serum S100B levels were compared to healthy controls with synthetic cannabinoid users. Among the users of synthetic cannabinoids, patients with the following outcomes were considered to have a composite outcome: the need for endotracheal intubation due to hypoventilation and decreased GCS; seizures; the need for intensive care unit admission; and in-hospital mortality. Clinical and laboratory findings associated with composite clinical outcomes were examined.

Results: We found significantly increased S100B levels in patients with synthetic cannabinoid use. The mean serum S100B level was 19.32 ± 4.92 pg/mL in patients with synthetic Cannabinoid user, and 15.94 ± 2.43 pg/mL in the control group (p = 0.001).  In patients with and without composite clinical outcomes, the mean serum S100B level was measured as 24.13 ± 5.48 pg/mL, and 17.58 ± 3.38 pg/mL, respectively (p = 0.001). With the cut-off value for S100B set at 20 pg/mL based on the highest sensitivity; the sensitivity, specificity, positive predictive value, and negative predictive value for S100B were 89.9%, 52.0%, 44.4% and 91.9%, respectively.

Conclusion: Our data suggest that serum S100B levels are elevated in patients using synthetic cannabinoids. But the role of high S100B level in determining neuronal damage and clinical poor outcomes was limited. These results show that S100B can help clinicians to exclude neuronal damage and possible poor outcomes. 

Background: Severe traumatic brain injury (TBI) is considered a time-critical condition. Relevant emergency medical response must be commenced, which makes dispatch key. Danish ambulance dispatch is criteria-based depending on main symptom or incident, but no separate dispatch criteria exist for head trauma or suspected TBI. Dispatch are graded level A to E according to severity of emergency call.

Aim: To investigate which dispatch criteria are assigned patients with severe TBI (confirmed intracranial lesion), if the highest level (A) of emergency response are commenced and to examine related 30-day mortality.

Methods: Population-based follow-up study of emergency medical calls in the Central Denmark Region from October 1 2011 - December 31 2014 concerning patients subsequently diagnosed with severe TBI according to ICD-10 codes from Danish National Patient Registry. For patients with confirmed intracranial lesion odds of receiving the highest level of emergency response was investigated in a logistic regression model.

Results: Of 76,009 emergency medical calls, 1382 patients were subsequently diagnosed with TBI (1.8%) of which 216 patients suffered severe TBI with intracranial lesion. Patients were assigned 14 different dispatch criteria. Level of emergency response was dependent on assigned dispatch criteria: 11 of the 216 severe TBI patients were assigned the lowest level of emergency response (telemedical advice). 30-day mortality was 1.5% (95% CI 1.0-2.0%) for overall TBI and 8.8% (95% CI 5.7-13.3%) in severe TBI.

Conclusion: Severe TBI patients are assigned different dispatch criteria. Highest level of emergency response varies within subgroups of dispatch criteria. Patients suffering intracranial lesions have a high 30-day mortality.