Introduction

Laboratory blood tests are an integral part of the diagnostic investigation performed in patients presenting to emergency department (ED), but they are also widely recognized as a key form of potential waste in health care utilization. The aim of this study is to determine if a multilevel intervention based on optimization of test profiles and awareness of medical staff about costs and appropriate use of high cost tests (troponin Ic, D-dimer, procalcitonin and brain natriuretic peptide) could reduce the number of requested tests and costs without affecting ED performances.

Methods

A before-and-after study in an adult tertiary-referral teaching hospital ED was conducted. Laboratory test profiles used in pre-intervention period until 30th June 2016 (chest pain, sepsis, surgical, trauma, thromboembolism profiles) were modified, reducing profile to basic and major trauma and cutting by 50% the number of tests in each profile. All ED physicians were informed with one hour meeting about the expense of laboratory tests requested from ED and also about the appropriate use of the most frequent high cost tests in June 2016 and after six months in December 2016. The 8 months intervention period (from 1st July 2016 to 28th February 2017) was compared with the same 8 months in pre-intervention period (from 1st July 2015 to 28th February 2016).

Main outcomes were the total number of laboratory blood tests and the number of high cost tests ordered. The secondary outcomes were the cost of laboratory blood tests and ED performances. The costs in Euro were derived from the Tuscany region pathology public price schedule, the ED performance indicators considered in the study were waiting time from arrival to discharge or admission, number of death in ED and re-entry within 72 hours from discharge.

Results

There was no significant difference in patients presentation among intervention (61,976 pts) and pre-intervention period (61,154 pts). Total laboratory tests requests from ED decreased by 209,041 tests with a 347.4 tests/100 patients reduction (-37.1%) in intervention period compared to pre-intervention period (p<0.05). Total costs decreased of 608,079€ in 8 months with 1,026€/100 patients reduction (-30.6%) in the intervention period compared with pre-intervention period. High cost test requests decreased by 11,457 (-27.3%, p<0.05), participating in costs reduction for 197,206€ (367€/100 patients, -30.5%). No significant differences were found in the performance of ED indicators.

Conclusions

Multilevel intervention by modification of routine laboratory test profiles and educational meetings for ED medical staff is an effective method to reduce laboratory test ordering and costs in the ED without affecting ED performances.

Background: Kaizen, or continuous improvement, is a core principle in lean production. Healthcare organizations have sought ways to use this methodology in clinical practice to improve hospital quality and patient safety. Traditional deployment of lean process improvement plans (PIPs) relies on retrospective evaluations gathered from reiterative project lifecycles that often take months to years to complete. However, the Emergency Department (ED) operates under a fast-paced and unpredictable clinical environment. Thus, a real-time Kaizen model is needed to adjust to the ever-changing dynamics of the ED.

Methods: During a five week period, the ED at Aarhus University Hospital, Denmark was transformed into a live testing environment. Five test sessions were conducted to test PIPs aimed to optimize staff’s functional roles, patient intake flows, and ED space utilization. At the start of each session, the ED leadership team-including the department chair and head nurse, held an all staff meeting to introduce the PIP. Next, a five hour test phase was conducted to assess the PIP in live clinical production. For example, one PIP looked to streamline the patient intake process, where the secretary would accompany the nurse during patient rooming to minimize duplication of data collection. Another PIP introduced new responsibilities to the ED physician during trauma resuscitations. Each PIP was trialed for five hour as the leadership team performed real-time “gemba walks” around the ED to observe the change impacts. At the conclusion of the test session, all operation and clinical flow returned to normal, and a one hour debrief was held to gather feedback from participants and observers. Lessons learned from the first session would then be built upon during the next test. Each subsequent trial would increase in scale and complexity, involving more staff, patient care areas, and other specialty departments. Should an overall positive effect be determined at the conclusion of the 5 week test period, the PIP would then be officially implemented into daily practice.

Results: Change impacts captured from each PIP were organized onto a 2x2 matrix (expected vs unexpected findings, advantages vs. disadvantages). This enabled the ED leadership team to identify unexpected advantages that would have otherwise been missed without real-time testing in a live clinical environment. Furthermore, serial PIP trials allowed for targeted revisions with each subsequent session, thus greatly expediting the process improvement life cycle. Finally, the ED leadership team was on-site to witness the change impacts. This facilitated effective change management as it allowed key stakeholders to own and champion the PIPs from strategic planning to clinical implementation.

Conclusion: This adaptive Kaizen methodology allows for real-time assessment and implementation of process improvements in the dynamic clinical environment of the ED. 

Background: To date, emergency medicine is not a formalized medical specialty in Denmark. Emergency medical care formerly fell under the provision of three separate entities: pre-hospital system staffed with board certified anesthesiologists, on-call primary care system provided by the general practitioners (GPs), and hospital inpatient departments comprised of various specialists. In 2007, the Danish National Board of Health recognized the need for a new emergency care model, which led to the mandate for 24 hour acute care coverage from 6 core specialties (internal medicine, orthopedic surgery, general surgery, anesthesiology, diagnostic radiology, and biochemistry), and for the designation of a single hospital-based unit for receiving acute patients, the emergency department (ED).  

Challenge: Aarhus University Hospital, a leading academic center in Denmark, is set to expand to become one of the largest and most comprehensive hospitals in Europe. The new medical campus is anticipated to be fully operational by 2020, and a new ED was included in the design to comply with the 2007 emergency care mandate. However, as acute patients were traditionally triaged directly to specialty departments, no prior ED model existed to facilitate the initial assessment and hospital management of acute patients. Thus, preparation in the transitional period was needed to redefine and reorganize the delivery of emergency medicine under a single hospital unit-the ED.

Prototype Design: A central call line was established in the new ED to receive all acute patient referrals from the GPs. This allowed the ED to become the single coordinator of acute patients in need of hospital management. However, because no specialty had the overarching core competency to manage all acute patients, triage of these patients were divided based on the training and medical background of the physicians. Dedicated full-time specialists were recruited onto the ED staff, such that board certified orthopedic surgeons managed acute injuries and board certified internists managed acute medical complaints. This reduced dependence on other departments to provide staffing resources and clinical expertise in the ED. Next, the organization of acute patients requiring overnight stays was designed to match the medical competencies of the nursing staff. For example, abdominal pain patients likely requiring surgical consults were grouped and staffed by nurses with prior experience caring for surgical patients. This ensured an appropriate level of quality and patient safety in a new ED actively undergoing the development of its staff. Finally, the new ED leadership team made special efforts to emphasis the guiding principles and mission of the new department. This allowed for effective change management.

Results and Conclusion:  The prototype ED allowed for the integration and centralization of emergency care under a new structural model that shifted away from traditional acute care practice.

Background: Distinguishing between acute coronary syndrome (ACS) and non-ischaemic heart disease (NIHD) or non-cardiac chest pain is a major challenge in emergency medicine. Patients presenting to the Emergency Department with chest pain are routinely triaged through a series of tests, such as an ECG, alongside lengthy diagnostic blood tests. However, in approximately 75% of patients, their chest pain is of a non-cardiac origin. The ability to detect ACS and rule-out NIHD earlier in some of these patients would have a positive impact on outcomes and save hospital resources. Magnetocardiography (MCG) is a non-invasive, highly-sensitive technique that has been extensively used to measure and map cardiac magnetic fields. A portable prototype magnetometer was recently developed for use in acute and routine clinical settings. We assessed the predictive capability of the magnetometer to differentiate non-cardiac subjects and patients whose chest pain had a non-ischaemic origin from those with ischaemic heart disease (IHD).

Methods: MCG data were collected from two studies. A clinical performance study was conducted in patients ≥25 yrs with suspected IHD and in healthy age-matched volunteers. A pilot clinical study was performed in patients ≥18 yrs with NSTEMI requiring hospitalisation for chest pain (≥50ng/L troponin 12h post-onset of chest pain) and in a control group with NIHD and chest pain. Study participants were grouped to provide greater statistical power to differentiate patients from controls: IHD patients (n=70), age-matched controls (n=69) and young (<30 yrs) healthy volunteers (n=37). MCG scans were recorded in an unshielded room. Between-group differences were explored by analysis of variance. The predictive capability of the magnetometer was assessed using logistic regression based on 10 potential predictive factors (termed ‘predictors’).

Results: Overall, 55/63 patients and 51/60 healthy volunteers were eligible for analysis in the clinical performance study. In the pilot clinical study, 15/21 patients with NSTEMI and 18/21 patients with NIHD were eligible. Of 10 potential MCG predictors, three showed a significant difference between the patient group and the age-matched controls (p<0.001) and eight showed a significant difference between the patient group and the young healthy volunteers (p<0.001). Logistic regression comparing patients with controls yielded a specificity of 36.4%, sensitivity of 94.0% and a negative predictive value for the rule-out of IHD of 97.2% (area under the curve 0.77).

Discussion: The portable prototype magnetometer effectively ruled-out approximately 35% of healthy subjects and patients whose chest pain had a non-ischaemic origin from those with IHD. The predictive capability of the device fills an unmet need for a test that can rapidly identify non-cardiac patients, thereby reducing the number of patients presenting with chest pain who currently have to go through unnecessary and costly screening procedures. 

Introduction: There is currently conflicting evidence of the role of troponin testing in patients presenting to the emergency department (ED) after syncope. This study aims to assess the yield and utility of plasma troponin I testing during assessment of patients presenting to the ED after syncope.  

Methods: This is a retrospective cohort study being conducted at a single adult tertiary referral hospital. All adult patients presenting after syncope during a 3 year period from 1 January 2014 through 31 December 2016 are included. Patients were eligible for inclusion if ‘faint’, ‘syncope’ or ‘collapse’ was documented in triage notes or if diagnosed with ICD R55 (collapse or syncope) on admission or discharge. Patients were excluded if the syncopal episode was in the setting of seizure, severe trauma, change in baseline mental status and drug or alcohol intoxication. Troponin I, baseline demographics, vital signs, relevant clinical variables, length of stay and departure status were extracted using an explicit chart review.

Results: There were 3334 patients that presented with syncope during the study period and 1700 patients who had a troponin recorded eligible for inclusion in this study. Analysis to date reports on 215 patients with a mean age of 69.9 (16.0) years and 128 (59.5%) were male. Troponin was positive in 39 (17.2%) of patients. A history of structural heart disease (adjusted odds ratio 5.3; 95% CI: 2.1-13.3; p<0.01) and a presenting complaint of chest pain (adjusted OR 3.9; 95% CI: 1.4-11.3; p=0.01) were independently associated with an elevated troponin result. However, in patients without structural heart disease or chest pain, troponin was positive among 13 (8.5%) of patients.

Discussion: Troponin appears to be a useful investigation in the emergency department for assessment of patients with syncope. History and examination features cannot confidently rule out patients at high risk of adverse events. Ongoing analysis of the full sample size may inform high-risk variables associated with syncope and complete results will be presented. 

Background: Sudden cardiac arrest is one of the leading causes of death in Europe, with 84 cases per 100,000 inhabitants a year. Once cardiac arrest has occurred, early initiation of CPR and early defibrillation depends on bystanders and can lead to survival rates as high as 50-70%. This is a challenging activity that requires high levels of self-efficacy from the bystanders. In the field of cognitive theory, the term self-efficacy describes the way people choose to react during stressful situations - whether they decide to initiate challenging activities, which indicates high levels of self-efficacy, or they avoid implicating in such an activity, which correlates with low self-efficacy levels. Intervening in an incident of cardiac arrest is quite stressful and challenging. Training in CPR should include teaching techniques that ensure good knowledge retention and increase of self-efficacy.

Methods: Preclinical 3rd year medical students, in our University, participate compulsory in the BLS course, having no prior training in resuscitation. The course is organized according to the ERC regulations, including demonstrations and hands-on practice in groups, based on low-fidelity simulation scenarios. Participants are evaluated using continuous assessment. The 132 students that participated at the past year’s courses, were asked to complete an anonymous self-assessment questionnaire prior and immediately after their training. The questionnaire was designed using the Bandura’s “Guide for Self-efficacy Tests” and was modified using the Visual Analogue Scale. The questions had the form “I feel…” and included all basic steps of the BLS sequence: 1.Approach with care 2.Check for response 3.Check for normal breathing 4.Call the emergency services 5.Start chest compressions 6.Use an AED. The answers had the form: Not confident (0%) - Somewhat confident (25%) - Confident (50%) - Very confident (75%) - Extremely confident (100%) and had a colorized symbol according to the level of confidence represented, from blue – not confident to red – extremely confident.

Results: All 132 participants completed successfully the course, according to the continuous assessment performed by ERC certified instructors. The questionnaires analysis revealed enhancement of the self-efficacy levels in all steps of the algorithm after the course. The highest variation concerned the AED utilization with 89% feeling less than 50% confident prior to the session and 3% after the course. Another interesting finding was that even after the session, 30% of the students felt less than 75% confident to use an AED or to recognize a non-breathing victim.

Conclusion: Recognition of a non-breathing victim and AED use are regarded as the most challenging steps of the algorithm. The simulation-based hands-on BLS/AED course enhanced self-efficacy levels of preclinical medical students, implying that such courses can lead to more frequent initiation of the CPR algorithm during cardiac arrest events.

Introduction 

Quick and optimal management of pain is not only a daily challenge in the Emergency Department (ED), but also a quality marker who makes medical care easier. A nurse-initiated protocol for pain by triage nurses has been introduced in our ED and lets nurses administrate Acetaminophen starting at the entrance.

Methods

We present here an observational, monocentric and retrospective study led in the ED of an urban teaching hospital in France. In June 2015, we included during 48 hours all adult patients consulting in our ED. A total of 240 patients were included for statistical analysis.

Results

Pain scale was assessed in 89% (CI95%=[85-92]) of all patients. The majority of patients who were not evaluated by the triage nurse (11%),) were described as not evaluable for unclear reasons. 152 patients (63%, CI95%: [57-59]) declared having pain at the entrance of the ED. Mean declared Visual Analog Scale at the entrance was 4.8±1.7. Numeric pain scale was mostly used (88%). Only 15% of painful patients benefited of an analgesic according to the pre-established protocol. 43% benefited of second-line treatment (i.e medically prescribed analgesia) and 42% (CI95%: [34-50]) did not receive any analgesic despite the pain they first reported at admission. Only 1% of patients refused analgesics when proposed.

Conclusion

An initial assessment was made by the triage nurse in the large majority (89%) of patients of this study. Around two third (63%) declared having pain but only a half of them (48%) received treatment (vs 38% in a national cohort study in 2010). Meanwhile, initial assessment by the triage nurse is now routine in our ED, few protocoled analgesic administration is proposed. Although pain assessment and management are recognized as quality indicators in an ED and inscribed in a national plan (2013-2017), pain remains insufficiently treated and protocols delegating (to triage nurses) non-opioid analgesics or even narcotics are probably needed.

Background

The Pre-hospital outcomes for evidence based evaluation (PhOEBE) project is a 5 year research programme which aims to develop risk adjusted, patient focused performance and quality indicators for EMS. Consensus work identified a small number of potential indicators for further development. One high priority topic identified was pain management. We have explored the features of EMS pain management information and constructed a risk adjusted statistical model to measure mean reduction in pain in the EMS population.

Methods

We retrieved the computer aided dispatch and on scene electronic patient records for all 999 calls to one ambulance service in England for 6 months in 2013. We excluded patients who were managed by telephone advice, were under 2 years of age, died at scene or were unconscious. For included cases we conducted descriptive analyses of a range of variables including number of pain scores measures, age, sex, condition type and pre-hospital time. We then measured the correlation of these factors with reduction in pain score. Finally we constructed a multivariable linear model as a risk adjusted indicator of pain reduction.

Results

After exclusions 167,264 patient incidents were included. 27.7% had no pain score recorded, 23.7% had 1 score recorded and 48.6% more than one score. 35,749 patients (21.45%) had an initial pain score of ≤5 and 25.7% of these did not have a second score recorded. Cases were classified by conditions where pain may be expected or not expected. Of pain expected cases 23% had a pain score of 0 compared to 76.3% where it was not expected. Change in pain score was correlated with first pain score, age, total prehospital time, gender (male) and condition type. All of these variables were included in the final multivariable model with the specific conditions cardiac chest pain, trauma/injury and headache included.

Conclusions

Management of pain in the pre-hospital phase of care is an important outcome to patients. Our analyses have shown that around a quarter of patients have no pain score recorded and half have more than one pain score recorded. A number of patient characteristics are associated with mean reduction in pain score demonstrating that change in pain score alone is not a reliable indicator of clinical care. The risk adjusted indicator developed has the potential to be a more robust measure of EMS pain management that can more usefully used to monitor performance over time in a heterogeneous and changing population of patients.

Background & Aim:

Benign acute childhood myositis (BACM) is a self-limited illness that occurs during epidemics of influenza. It is characterized by leg pain and weakness with an isolated laboratory finding of elevated serum creatine kinase (CK).

Here we report 20 previously healthy patients who were admitted to our emergency (ED) department after developing myositis during/following the influenza-like illness.

Methods:

Prospective, observational, case series conducted at an urban, academic ED during two influenza season (January-March 2016-January-March 2017). Demographic characteristics clinical findings, laboratory, serological features and outcomes of the patients were evaluated. Serological evaluation tests were also taken for possible etiology of viral infections from patients identified as having BACM. A nasopharyngeal aspirate (NPA) was taken from 20 patients for testing.

Results:

A total of 20 children were included. The mean age was 7.96 (SD ±3.54) years and 16 (80%) were male. The most common symptoms were leg pain (95%), anorexia (65%) and sore throat (50%). No patient had abnormal neurological findings, hematuria, or developed renal failure. The mean CK level at presentation was 3804 IU/L (range, 1634–8644 IU/L). Serological tests was performed for 20 patients and 14 (70%) influenza [influenza A and B were 3 (15%), 11 (55%), respectively], 3 (15%) rhinovirus, 2 (10%) RSV agents were detected and one was negative. Five patients (23.8%) with BACM were admitted to the ward and one of them developed rhabdomyolysis. The rate of admission was higher in influenza A myositis when compared to influenza B (66.8% and 18%, respectively). Patient with rhabdomyolysis had influenza A myositis too. All patients discharged with a good outcome, and full recovery was achieved within 24 hours to 7 days.

Conclusion:

BACM is a predominantly benign disease and recovers completely. It may occur in epidemics mainly in the winter season. Although, it has been described as nonspecific viral myositis, our results demonstrated  that most of them had influenza myositis and influenza A  had more severe clinical course than B. 

Background

Worldwide, mobile Information and Communication Technologies (ICT) have been used in prehospital emergency care and emergency and disaster medicine. The use of the ICT in routine emergency care does not raise any concerns, but special application used in mass casualty incidents and disasters is still being discussed in Poland. Today we witness a lack of cooperation between the pre-hospital emergency and hospital ICT systems. However, following the computerization of hospitals and emergency departments, there is a new opportunity to integrate both systems.

Study

The main problem during mass casualty incidents is how to properly allocate patients in hospitals. Information coming from the scene of the incident is insufficient to make the right decision. What's more, information transfer from hospitals and information about available ambulances to the Command and Control Center is the insufficient, too. Only once you link and process these three pieces of information will you be able  to make  the right decisions at any time. The development of special model of allocation patients based on ICT solutions, is the aim of this study.

Methods

The study was based on the analyses of the local EMS database (Cracow Dispatch Center operation area) and simulations of mass casualty incidents (MCI) during “sand table drill”. The same MCI, the first, with ICT support, the second without it. The study measured the following aspects: triage on site, decision‐making model, effectiveness of EMS, information management, and criteria for deciding on a patient transport model and allocation in the hospitals.

A proper allocation of the injured was the case of the study. The exercise  involved  seventy injured (25 red code, 30 yellow code, 15 green code), local emergency departments and trauma center, 25 ambulances, dispatch center and external support (ambulances and hospitals). We wanted to know how we could use the EMS resources and hospitals with and without ICT support.

Results

Results after two the “sand table drill” exercises were completely different. The same database of  the seventy victims, the same scenario, but a different type of disaster management without/with the ICT support were used. Use of the potential of ICT support was changing the way decision-making. The victims' allocation was more accurate and more accurately used the capacity of hospitals.

Conclusion

The use of ICT improves the efficiency of allocation of the injured in hospitals. The monitored emergency medical care has proved greater efficiency of decision making with the ICT support than the traditional one.  The results allow to define new directions for the development of intelligent Command Support Systems for emergency management.

Title: The association between impaired cognition and adverse outcome in older patients presenting to the emergency department with minor trauma; the APOP study.

Authors: B.C.M. van den Berg*; MsC, J.A. Lucke*; MD, J. de Gelder; MD, C. Heringhaus; MD, B. de Groot; MD, PHD, S.P. Mooijaart; MD, PHD.

Introduction: A large number of older patients is discharged from the ED with minor trauma. Cognitive impairment may have a large impact on independent functioning, even in the case of minor trauma. The aim of this study was to investigate the impact of impaired cognition on functional status after 90 days in older minor trauma patients visiting the ED.

Methods: Analysis of the collected data from the APOP study (a prospective cohort study) of patients aged 70 years or older, presented to the ED. Cognition was measured using the 6CIT, using a cut-off of ≥11 as the definition of impaired cognition. Primary outcome was 1-point decrease in KATZ-ADL, new institutionalization or mortality after 90 days. The association between cognition and adverse outcomes was calculated using multivariable regression analysis.

Results: In this study, we included 125 (12.5%) of the 995 elderly patients who presented to the ED and were discharged home after a minor trauma. 30 (24%) of the patients with minor trauma had impaired cognition. In 13 (13.6%, 95% CI 7.8-19.4) patients with normal cognition and a minor trauma, there is functional decline, in comparison to 9 (30%, 95% CI 16.3-43.7) of the patients with impaired cognition (p = 0.004). These patients were four times more likely to have functional deterioration in comparison to an older patient with normal cognition independent of age, gender and educational level (OR 4.15, 95% CI 1.36-12.7). Injury type or location of a fracture were not associated with functional decline (p = 0.590).

Conclusion: Cognition is an independent predictor of functional decline. A patient aged 70 years and older with impaired cognition is 4 times more likely to suffer functional decline after minor trauma in comparison to a patient with normal cognition. On early recognition of this group at risk, additional information, preventive measures, care and support at home can be provided.

*authors contributed equally. 

Background: Emergency medicine as a new specialty has been introduced in Finland during the recent years. Along with this change, there is a trend towards “one-stop-shop”-type of emergency admissions, aiming at a specific diagnosis on the first visit. This may potentially increase unwarranted imaging. Hence, we wanted to evaluate the diagnostic yield of abdominal imaging at emergency setting.

Material and methods: Consecutive patients admitted to a high-volume, collaborative emergency department (ED) undergoing either abdominal computed tomography (CT) or ultrasonography (US) during a one-year study period (1.1.-31.12.2016) were included in the study. Gravid women and patients requiring urinary tract-related imaging were excluded. Patient demographics, diagnoses (ICD-10 classification) and radiological studies were retrieved from hospital records. Based on the diagnostic distribution and performed radiological studies, we evaluated whether these studies were appropriate or not.

Results: Out of a total of 88,481 ED admissions, 3,508 patients (4.0%; median age 61 years, range 0-101 years; 52% female) underwent either abdominal CT or US examinations (n=4,058) and were thus included in the study. A total of 2,257 CT (56%) and 1,801 US (44%) studies were performed. Contrast-enhanced CT (n=1,923, 56%) was preferred over non-contrast-CT (n=334, 8.2%), and upper abdominal US (n=815, 20%) was the most often used of US modalities. During the study, 8.2% (n=286) of the patients were readmitted to ED with a need of a new radiological examination (range 1-6 studies/patient), and in 5.7% of emergency accesses (n=201) more than one radiological study was required to reach diagnosis.
Of the study patients, 37% were diagnosed to suffer from specific, acute diseases of the digestive system, most commonly acute appendicitis (7.0%), cholecystitis (6.8%), diverticulitis (6.4%), pancreatitis (3.1%) and intestinal obstruction or ileus (2.9%). In addition, pyelonephritis (2.6%) was among typical post-discharge diagnoses. However, one third (38%) of the patients were discharged without a specific diagnosis, even though they underwent emergency radiological imaging. Among the patients discharged without a specific diagnosis US, contrast-enhanced CT and non-contrast CT were performed in 46%, 34% and 26%, of the cases, respectively. 12% of patients were later diagnosed to suffer from extra-abdominal conditions; e.g. pneumonia was diagnosed in 1.7% of these patients.

Conclusions: Studies performed by a radiologist are often necessary to distinct an acute abdominal condition requiring surgical care from non-specific symptoms. However, we found that the percentage of patients discharged without a specific diagnosis after CT or US was quite high, 38%. Again, as extra-abdominal conditions in these patients were not uncommon, thorough clinical examination of the patient should still be at focus, prior to the use of costly and resource-intensive radiological studies.

Introduction

Vertebrobasilar ischemia accounts for 3-5% of vertigo presenting to emergency departments (EDs) and its diagnosis is challenging. The role of vertebral artery extracranial color-coded duplex sonography (VAECCS) in patients presenting with vertigo is unknown. The aim of this prospective study is to evaluate the diagnostic accuracy of a standardized VAECCS examination performed in patients presenting to ED with vertigo. 

Methods

Consecutive adult patients presenting to ED with vertigo and with suspected vertebrobasilar ischemia underwent VAECCS. VAECCS was performed by one of six sonographers according to a predefined protocol. The exam was considered abnormal when one of the following alterations were detected in V2 segments: flow not present in a segment or in all vertebral artery, flow detected but with an abnormal spectral waveform compared with opposite vertebral arteries (focal high peak systolic velocity, > 60cm/sec, high resistance pattern velocity, low velocity flow or post-stenotic flow pattern) or presence of flow inversion. Patients were followed up for 3 months and the final diagnosis established by a panel of expert composed by an emergency physician, a neurologist and an expert vestibologist based on all clinical and instrumental data except for VAECCS results. Acute cerebrovascular disease was diagnosed when an acute brain ischemic lesion congruent with symptoms was detected by neuroimaging.

Results

Among 126 patients included in the study, 28 (22%) were diagnosed with vertebrobasilar ischemia. VAECCS was abnormal in twenty patients (16% of all cases) and in 15 cases (75%) the final diagnosis was vertebrobasilar ischemia. In 106 (84% of all cases) patients VAECCS resulted normal and 13 of them (12%) had a final diagnosis of vertebrobasilar ischemia. The sensitivity and specificity of VAECCS were 54% and 95% respectively and detecting an abnormal flow pattern at VAECCS significantly increase the risk of vertebrobasilar ischemia (Odds ratio 21). The most important alterations related to vertebrobasilar ischemia were absence of flow and high resistance pattern velocity (odds ratio 9.3 and 22.7 respectively). 

Conclusion

VAECCS could be a useful bedside screening tool in patients presenting to ED with vertigo of suspected ischemic origin and predict vertebrobasilar ischemia. 

Objective: The aim of our study is to compare ultrasonography and plain radiographs to evaluate the sensitivity and specificity of ultrasonography in the diagnosis of nasal fractures and availability of USG for detecting nasal fractures in the emergency department.

 Methods: Six hundred and thirty-six patients visited Dr. Lütfi Kırdar Kartal Training and Research Hospital Emergency Medicine Department with nasal trauma between 10.02.2015 and 01.09.2015 were included in this study. USG was performed by emergency medicine resident / specialist whom had advanced USG training beforehand and identified nasal fractures were recorded. Patients consulted to Ear, Nose and Throat (ENT) specialist with lateral nasal radiographs for confirmation. Nasal fracture was determined by examination of ENT specialists. The sensitivity, specificity, positive predictive value, negative predictive values of ultrasonography and plain radiographs were determined.

Results:

Compared with ENT examination in detecting the nasal fractures USG sensitivity was 97.8%, specificity 100%, positive predictive value was 100% and negative predictive value was 98.8%, and the plain radiography sensitivity 80.3%, specificity 99.5%, positive predictive value 98.9%, negative predictive value was 90%. Under the age of 5 years old children, in detecting the nasal fracture, negative predictive value of USG was 97.2%. The elderly population over age 65, in detecting the nasal fracture; sensitivity, specificity, positive and negative predictive value of USG was 100%.

 Conclusion: On the diagnosis of nasal fracture it was found that USG is superior to plain radiographs. It’s harmless, fast, easy to apply with ability to make the right diagnosis.

Background: Laryngeal attacks may be fatal without prompt and effective treatment. Icatibant is a bradykinin B2 receptor antagonist used to treat hereditary angioedema (HAE) type I/II attacks in adults. We analysed characteristics and outcomes of icatibant-treated laryngeal HAE attacks in a real-world setting.

Methods: The Icatibant Outcome Survey (IOS; Shire, Zug, Switzerland [NCT01034969]) is a prospective, international observational study that monitors the safety and effectiveness of icatibant treatment. Retrospective descriptive analyses of laryngeal HAE type I/II attacks were performed (July 2009-February 2017).

Results: Of 4541 icatibant-treated HAE type I/II attacks (517 patients), 239 were laryngeal (120 patients; 62.5% female): 170 (71.1%) attacks affected the larynx only and 69 (28.9%) multiple sites. Of evaluable attacks, 162/214 (75.7%) and 52/214 (24.3%) were treated with self- and healthcare professional (HCP)-administered icatibant, respectively. Of the 52 attacks treated with HCP-administered icatibant, emergency room physicians administered treatment for 10 (19.2%) attacks. 127/207 (61.4%) attacks were severe/very severe and 63/239 (26.4%) were in patients on long-term prophylaxis (LTP). Of 51 icatibant-treated attacks in patients receiving LTP, androgens were LTP in 33 (64.7%) attacks and C1 inhibitor (C1 INH) was LTP in 7 (13.7%) attacks. 41/239 (17.2%) attacks were treated with concomitant or rescue medication. 216/235 (91.9%) attacks did not require C1 INH rescue medication, of these 194/216 (89.8%) attacks received one icatibant injection,  17/216 (7.9%) received two icatibant injections and 5 (2.3%) received 3 icatibant injections. C1 INH was used as a rescue medication in 19 attacks treated with one icatibant injection. Median (IQR) time to treatment was 1.0 (0.3, 3.5) h (110 attacks), median (IQR) time to resolution was 6.0 (2.0, 23.3) h (109 attacks), and median (IQR) attack duration was 8.8 (3.7, 24.0) h (92 attacks). For 6 evaluable attacks treated with a second injection, the median (IQR) time between first and second injection was 5.5 (1.3, 10.0) h; for 5 evaluable attacks, median (IQR) time from second injection to symptom resolution was 4.0 (2.0, 6.8) h.

Conclusions: Most laryngeal HAE type I/II attacks were successfully treated with a single, self-administered, icatibant injection; a second injection or other medication was only needed in a minority of cases. Patients on LTP may experience breakthrough laryngeal attacks resolved with icatibant. Emergency physician administration of icatibant was reported in a minority of HAE laryngeal attacks.

Sepsis is characterized by an innate immune response and the following immune dysfunction which can increase the emergence of secondary infections. Ethyl pyruvate (EP) has multiple immunoregulation functions in several serious illness models, such as burn injury, severe sepsis and acute respiratory syndrome. However, little data was shown the effect of EP administration to the immunosuppression post-CLP and the following secondary infection. Using a model of cecal ligation and puncture (CLP) infected by Pseudomonas aeruginosa (PA), we characterized the immune response of two-hit model of sepsis. We assessed the survival rate, lung damage and lung bacterial clearance in vehicle or EP treatment group to demonstrate the lung response to pseudomonas aeruginosa of septic mice and the effects after EP treatment. Then cytokines, apoptosis of splenic immune cells and Foxp3 expression on splenic regulatory T cells (Tregs) were studied to demonstrate the mechanisms of EP administration on two-hit mice. We found that the susceptibility of septic mice to Secondary Pseudomonas aeruginosa pneumonia could be down-regulated by ethyl pyruvate treatment and the protective effects of EP may via altering the expression of cytokines, inhibiting the function of Tregs and relieving the apoptosis of splenic immune cells. The “immune paralysis” post-sepsis still remains a rigorous challenge for curing sepsis, our study may aid in the development of new therapeutic strategies to this problem.

Background and Objectives: One of the most common, and most dangerous, of adolescents’ risky behaviors is using illicit drugs in many countries. Drug-related visits to emergency departments (ED) have continued to increase in Turkey. We aimed to determine the frequency of substance abuse among adolescents who presented to our ED. We also tried to identify potentially relevant biological, psychological and socio economic characteristics of the adolescents. 

Methods: We conducted a retrospective study of all patients, aged 13–18 years, presenting to our emergency department (ED) with complaints related to recreational drug use and having a positive urine drug screening from January, 2013 to December 2015. To minimize the missing data, a telephone interview was done by the first author. Baseline demographic data (age, gender) and clinical data (admission date, cause of presentation) were obtained.

Results: During the study period there were 10350 adolescent visits. Urine toxicology screen was positive for illicit drugs in 83 (0.8%) patients. The rate of substance users to total adolescent admissions by years were respectively 17 / 2837 (%0.6) in 2013, 27/3476 (%0.8) in 2014, 4037 and 39 (%1) in 2015. Male adolescents were (60%) more likely than their female counterparts to use illicit drugs. The median age was 16 years in our study. Majority of substance users (64%) were more likely to present by neuropsychiatric complaint. Amphetamine (60%) was the most commonly used substance in our cohort, followed by cannabis (25%), benzodiazepine (8%), synthetic cannabinoid (4%) and opiate (3%). The frequency amphetamine use in female adolescents was 74%. Telephone interview was performed only in 37(46%) parents.  Rate of cigarette and alcohol use in this adolescent group was respectively 95% and 62%. This group also had some specific features such as smoker parents (92%), low income (62%) and single‐parent family (52%). Multi organ failure developed in a boy and "Ecstasy"-related fatality occurred.

Conclusion: Since the high rate of illicit drug use among youth has been steadily increasing adolescent substance use needs to be identified and addressed as soon as possible.  The most common identified substance was amphetamine. 

Acute exposure to air pollution and atrial fibrillation: the Emergency Department perspective

Introduction and objective:

Several studies suggest that exposure to air pollution may leads to atrial fibrillation (AF) onset. However the association of AF onset to particulate matter (PM) remains still unclear. On the other hand, AF is the most common cardiac arrhytmia in clinical practice especially in the Emergency Department (ED).

Methods:

We performed a retrospective study on AF admitted to our ED from Jan 2011 until Dec 2016. The association of AF onset was correlated with air particulate matter PM (PM ₁₀ and PM_2.5) levels. Incidence of cases was associated with PM concentration levels on the day of onset (lag 0-day) and on the next 3-days moving levels (lag 3-days) following PM increase. Veneto Regional Agency for Prevention and Environmental Protection (ARPAV) provided PM air levels were provided from local monitoring data, classified accordingly with EU air quality standards for pollutants in air (25 µg/m³ for PM_2.5 and 50 µg/m³ for PM₁₀).

Results:

826 AF were admitted to the ED in the study period: 376 (45.5%) were male (mean age 70 years; range: 21-98) and 450 (54.5%) were female (mean age 77 years; range: 36-102). We did not observe any difference when comparing AF incidence with PM₁₀ levels. PM_2.5 air concentration over the EU safety limits revealed to be associated with a higher incidence of AF (+32%) compared to AF cases admitted on the within the EU standards PM_2.5 level days. Gender distribution was similar to the study population one (M 43% vs F 57%) with an older female population (M 70 years vs F 77 years). Lag 0-day exposure to high PM_2.5 accounted to 60% of the cases with a slight increase in the male group (M 66% vs F 60%). Lag 3-days exposure accounted for the remaining AF cases (M 34%, F 40%).

Conclusions:

AF, the most common cardiac arrhytmia, increases the risk of stroke and death. Only few studies, in the recent years, reported association between air pollution and AF. Our data show an association of exposure to PM_2.5 concentration exceeding the EU safety threshold and AF incidence. It is likely that AF, associated with stroke and cardiovascular disease, contributes to the adverse effects of air pollution observed in clinical studies.