Introduction

Acute vascular disease such as deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression to potentially fatal pulmonary embolism and recurrence. Approximately 1 in 1000 people are diagnosed with a DVT every year, with an annual population death from venous thromboembolism (VTE) being 0.1%. Traditionally the oral anticoagulant used is Warfarin but this is increasingly becoming superseded by direct oral anticoagulants (DOAC) as these are thought to improve the anticoagulant effect and reduce need for monitoring. Therapeutic efficacy monitoring of DOACs such as Rivaroxaban is problematic as no reliable test is currently available. A novel rheological biomarker developed at Abertawe Bro Morgannwg University Health Board/Swansea University, has focused on the measurement and quantification of clot microstructure as a biomarker of vascular disease and its treatment. Fractal dimension (d_f) has been shown to be a highly sensitive marker of changes in clot structure, quantifying acute vascular disease with both anticoagulation and antiplatelet therapy. This study aimed to investigate if d_f could quantity changes in clot microstructure in patients taking Rivaroxaban.

Methods

The prospective observational pilot study recruited patients being investigated for a DVT. Baseline blood samples were collected measuring d_f and standard markers. Upon diagnosis, a DVT and non-DVT group were created. The DVT group had three sample points in total, the baseline/pre-treatment sample and two additional sample points to measure the two different doses of Rivaroxaban. Sample points were at approximately 20 days with a dose of 15mg BD Rivaroxaban and finally at approximately 60 days following 20mg OD Rivaroxaban. The recruitment followed a strict inclusion and exclusion criteria with full ethical approval.

Results and Discussion

40 DVT patients (mean age 64 years [SD 14.8]; 23 male, 17 female) were recruited. Mean d_f on admission was 1.72 (SD 0.059). Rivaroxaban therapy reduced d_f to 1.69 (SD 0.051) after approximately 20 days, and subsequently increased to 1.71 (SD 0.061) at approximately 60 days. The non-DVT group of 178 patients (mean age 61 [SD 16.6]; 67 male, 111 female) had a mean d_f of 1.71 (SD 0.055). Despite the absence of significance in the differences in mean d_f at the three DVT timepoints, the trend observed suggests a measured and quantifiable reduction in clot strength associated with DOAC. Interestingly and of equal importance, analysis suggests a potentially gender based and personalised response to the DOAC. No difference between the DVT and non-DVT group suggests first time DVT may not be due to systemic clot microstructure changes. Furthermore, given the large potential difference in clot mass that changes in d_f represent, further studies with greater numbers are required to elucidate the effect of d_f during DOAC therapy in thrombotic disorders and its relationship to haemostasis and clot strength.

Background: Migraine is a primary headache disorder that presents in the emergency department (ED). Trials show that low-dose ketamine (0.1-0.5 mg/kg) provides analgesia for acute pain in the ED, but headache patients have been excluded from these studies. We sought to investigate analgesic efficacy of ketamine for treatment of acute migraine.

Objective: To evaluate and compare analgesic efficacy and safety of low-dose ketamine to saline placebo for treatment of acute migraine in the ED.

Methods: This prospective, randomized, double-blinded, placebo-controlled trial evaluated patients aged 18 to 65 in the ED with acute migraine. Patients were randomized to receive 0.2 mg/kg ketamine or normal saline intravenously. Subjects were assessed at baseline and at 30 and 60 minutes post-treatment for Numeric Pain Rating (NRS) scores, categorical pain, functional disability, side effects, and adverse events. The primary outcome was reduction in NRS score at 30 minutes. Secondary outcomes include categorical pain and functional disability improvement, rescue medication request, patient satisfaction, and adverse events. Side effects were evaluated using the Side Effects Rating Scale for Dissociative Anesthetics (SERSDA) model. 

Results: 35 subjects were enrolled (ketamine=17, placebo=18). The average subject was 35 years old (SD=12), Caucasian (66%) and female (77%). There were no statistically significant differences in demographics except age (ketamine=39 vs placebo=31, p=0.032). There was no statistically significant difference in NRS score reduction between arms. Median NRS score reductions at 30 minutes for ketamine and placebo arms were 1 [interquartile range (IQR: 0,3.00)] and 2 (IQR: 0,3.75) (p=0.590), respectively. Categorical pain and functional disability each improved at 30 minutes in 6 (35%) ketamine subjects, while 9 (50%) placebo subjects improved in categorical pain and 7 (39%) in functional disability. Rescue medication was requested at 30 minutes with similar frequencies in ketamine and placebo arms (71% vs 78%, p=0.820). Treatment satisfaction was similar in both arms (69% vs 65%, p=0.909).  Ketamine subjects had significantly higher SERSDA scores at 30 and 60 minutes for generalized discomfort with median scores of 4 [(IQR: 2,4) vs 2 (IQR: 0,3) in placebo arm, p=0.032] and 3 [(IQR: 2,4) vs 1 [(IQR: 0,2) in placebo arm, p=0.007], respectively. Ketamine subjects had significantly higher SERSDA scores for fatigue at 60 minutes with a median score of 2 [(IQR: 1,4) vs 0.5 (IQR: 0,1.75) in placebo arm, p=0.040]. All other differences in SERDA scores were statistically insignificant. No serious adverse events occurred.

Conclusions: IV ketamine at 0.2 mg/kg did not produce a greater reduction in NRS pain score compared to placebo for treatment of acute migraine in the ED. Generalized discomfort was significantly greater in the ketamine arm at 30 and 60 minutes, as well as fatigue at 60 minutes, but no other side effects showed significant difference.

Background: Emergency department (ED) overcrowding is a common problem in many countries and impacts on patient safety, quality of care, staff morale and cost. In England, many hospitals regularly fail to meet the national performance target of admitting or discharging 95% of patients attending ED within 4 hours. Existing evidence shows that factors external to ED (e.g. bed capacity within the hospital) can limit ED performance against this target. Our objective was to assess, for a UK hospital, the relative extent to which different external factors hinder performance against the 4-hour target and identify the scope for improving performance by reducing the time associated with key processes in the ED.

Methods: This study was conducted by a multidisciplinary embedded research team at University College London Hospitals (UCLH). Staff within the ED and related departments were interviewed and shadowed to identify key processes and flows of patients through ED and factors external to ED that were hindering performance. This informed the development of a mathematical model, based on a queuing network, that related the external factors to measures of ED performance (e.g. the 4 hour target). The model was used to determine the time evolution of the system (i.e. number of patients in each step of the ED process at any given time) and to measure performance against the 4-hour target under different scenarios of interest.

Results: The following external factors of interest were identified: patient arrival rates (number of patients arriving, and at what time during the day); delays due to unavailability of hospital beds for patient admission; delays due to unavailability of specialist clinicians from the main hospital to visit ED patients. The mathematical model was parametrised using data routinely collected in the ED and expert clinical input, and the impact on ED performance of these external factors and of reducing the time associated with key ED processes were quantified. For instance, we determined the extent to which delays accessing specialist clinicians and/or hospital beds currently limit ED performance and quantified performance gains attainable by shifting specialist/bed requests earlier in the patient journey. We studied the relationship between ED delays due to bed unavailability and the current pattern of inpatient discharges from the hospital during the day and used the model to quantify the gain in performance achievable by shifting inpatient discharges to earlier in the day.

Conclusion: The mathematical model enabled a better understanding of reasonable expectations for ED performance at UCLH given external factors that cannot be controlled by ED staff. The model results are being used to help ED staff prioritise interventions aimed at reducing the effects of overcrowding in the department. The study suggests that an improved synergy between different areas of the hospital could potentially lead to substantial gains in ED performance.

Objective: Ileus usually presents with acute abdomen and patients with ileus frequently need operation and hospitalization. High white blood cells (WBC) levels are associated with acute abdomen. The purpose of this study is to analyze the relationship between Neutrophil/Lymphocyte ratio and the time of hospitalization and the prognosis of the disease.

Material and Methods: The patients who applied to the Emergency Medicine Department of University of Health Sciences Ümraniye Research and Education Hospital between January 1st 2013 and December 31st 2015 with abdominal pain, diagnosed with ileus and hospitalized were scanned retropectively. The leukocyte, hemoglobin, neutrophile and lymphocyte counts, the time of hospitalization, the imaging technique used for diagnosis, the presence of malignity, and mortality rate were recorded. The relationship between NLR and the duration of hospitalization and the rate of mortality were studied in the patients who were diagnosed with ileus. 

Results: 251 patients were included in this study. 143 (57%) were male. WBC levels were studied in patient's presentation to the ED. The median WBC value of the deceased patients were 13 (9.07-15.90), and it was 10.90 (8.74-13.77) in patietns who survived which was statistically insignificant (p=0.201). Mean NLR of the patients who passed was 11.65 (3.29 - 18.83), and it was 5.21 (3.30 - 8.38) for patients who survived which was statistically significant (p=0.03, Man-Whitney U Test). A multiple linear regression was calculated to predict mortality. Age and NLR were significant predictors of mortality (p=0.014 and p=0.045, respectively). (Table 1) Clinical utility of NLR is shown in (Table 2).  In our study, the NLR was significantly higher in deceased patients (p=0.03). 

Discussion: Leukocyte level usually increases in the patients with acute abdomen but it is not specific and can be effected from other inflammatory diseases (1).Neutrophile and lymphocyte values in peripheral blood sample show variability in systemic imflammatory conditions (2). In recent studies, NLR is found useful for evaluating the degree of  the imflammatory response (3). In our study, the NLR was significantly higher in deceased patients (p=0.03). Also, mortality and duration of hospital stay was correlated. These results show correlation with other studies in the literature.

Conclusions:  NLR is a cheap and widely accessible laboratory test and can be used for predicting mortality in patients with ileus. More randomised studies in larger populations are needed for getting stronger evidence.

Background: Bone fractures are one of the three most important complications during accidents that fixation
and pain control are the most important management for these complications. The aim of this study was to
compare the effect of intranasal ketamine versus intravenous morphine in the treatment of pain in patients
with bone fractures.
Materials and Methods: In this double-blind clinical trial, 104 patients with bone fractures recruited from
the emergency department (ED) from 2015 to 2016 were randomly divided into two groups. Patients in the
ketamine group received 1mg/kg intranasal ketamine and patients in the morphine group received 0.1mg/kg
intravenous morphine. Then the severity of pain, hemodynamic parameters and side effects in the both
groups were measured for each 5 minutes.
Results: Results showed that the mean of pain score at different time intervals (from first 5 minutes until 20)
in the ketamine group were lower than the morphine group, of which in the 5th minute, in morphine group
was 5.19 and in ketamine group was 3.51 (P<0.001). Moreover, the analgesic effect of ketamine was started
faster, which was 2.36 min, hence in the ketamine group was 5.09 min (P=0.0034). Finally, we found that the
complications such as nausea and vomiting were significantly lower in patients receiving intranasal ketamine
(9.6% vs. 44.2%, P<0.001, and 3.8 % vs. 32.7 %, P<0.001).
Conclusion: Considering the results of our study and others’ experiences with intranasal ketamine, and its
benefits, including needle-free drug delivery, ease of use, non-opioid nature and ready access properties, this
novel medicine delivery method merits further research in patients with acute pain due to limb fracture.
Early application of low doses of ketamine following trauma-induced pain such as limb fracture may provide
acute pain relief and reduce the probability of chronic pain and merits further study.

Background

Cardiopulmonary arrest is rare in children, but the survival rate is poor (0-27%). Training parents is of pivotal importance, especially for babies with high risk of cardiopulmonary arrest due to prematurity, congenital heart defects or chronic pulmonary disease. Our project aims to teach parents of high-risk babies admitted to our NICU on cardiopulmonary resuscitation (CPR) and foreign body ingestion maneuvers, before their infant's discharge.

Methods

Parents of high-risk babies, defined as prematurity, severe congenital heart defects, chronic pulmonary disease (including pulmonary hypoplasia due to congenital diaphragmatic hernia), gastrointestinal anomaly (including esophageal atresia), apnea spell, and need for tracheostomy, discharged from the DNMC of the Bambino Gesù Children’s Hospital between February and November 2016 were educated to perform CPR and foreign body ingestion maneuvres by certified instructors, following ILCOR 2015 guidelines, during weekly 2-hour courses. In a group of parents of babies with tracheostomy, home ventilation, airway management and tracheostomy care were also explained.  Parents completed a questionnaire to test attitudes towards CPR before and after training. The questionnaire was proposed again, by telephone call, 3 to 6 months after the course.

Results

Over the 10 month-period, 135 caregivers (71 mothers, 48 fathers, 9 grandmothers/grandfathers, 7 uncles/aunts) of 97 high-risk neonates were educated. Babies were affected by prematurity (62%), congenital heart defects (41%), chronic pulmonary disease (32%), gastrointestinal malformations (12%), apnea (10%), tracheostomy (6%). Parents were highly motivated to learn CPR. Among them, only 15% had previously performed a CPR course.  During the practical sessions, parents demonstrated good performances, in particular to heart massage with adequate depth and rate of the compressions faced to the foreign body ingestion maneuvres. The correct questionnaire rate was 30% and 85% before and after the course, respectively. In a subset of 60 parents, the survey was proposed again, by phone, 3 to 6 months later (average 4.5 months) to test skill retention. The prevalence of  correct answers decreased from 85% to 65%.

Conclusion

Based on our results, and consistently with other reports in the literature, a program of CPR for parents of babies with high risk of cardiopulmonary arrest should be planned in Neonatology and Neonatal Intensive Care Unit when the baby is going to be discharged home. Considering the decrease of the right answers to the delayed questionnaire, further evaluation should be done to establish the best interval for CPR training repetition.

Introduction: Hyperlactatemia has been found to be a risk factor for mortality in critically ill patients. Until now, no definitive research has been carried out into whether serial measurements or lactate clearance over time can be used as a prognostic marker in a clinically unwell population in the emergency department (ED).

Objective: To evaluate the predictive value of lactate clearance and to determine the optimal cut-off value for predicting short-term mortality in critically patients admitted in ED.Methods:  A prospective observational study was performed over 10 months. Inclusion of adult patients whose blood level of lactate was measured. Serial lactate levels in ED admission and 6 hours later were measured. Lactate clearance, percent decrease in lactate level in 6 h ((lactate admission – lactate 6 hours) x 100/lactate admission) was calculated. The main outcome measure was 7-day mortality.

Results: Inclusion of 170 patients. Mean age was 59 ± 21 years. Sex ratio = 1.53. The overall mortality at the seven day was 22%. The median admission lactate was 3 mmol/L [2,5]. Survivors compared with nonsurvivors had a lactate clearance of 30.2 ±69.9 vs. 21.8 ±40.6%, respectively (p=0.01). Based on Area Under the Curve in receiver operating characteristic analysis, lactate clearance have a significant inverse relationship with short-term mortality (0.65, 95% CI [0.47 to 0.81]), with a cut-off at 20%. Patients with a lactate clearance >20%, relative to patients with a lactate clearance <20%, had a lower short-term mortality rate (p =0.05).

Conclusion: Lactate clearance early in the hospital course may is associated with decreased mortality rate. Patients with higher lactate clearance after 6 hours (>20%) of ED intervention have improved outcome compared with those with lower lactate clearance.

Background: Procedural Sedation rates are rising exponentially in the Emergency Department and consequently measures have to be taken to stratify risk and avoid adverse events. Provision of safe sedation is an area of practice which benefits particularly from standard operating procedures and therefore the Royal College o Emergency Medicine (RCEM) published 7 standards in 2015. 

Aims: To ascertain whether the introduction of a mandatory sedation checklist and electronic database (Bamboo) following the 2015 audit has improved our documentation rates so far as to demonstrate high levels of compliance with the seven RCEM standards.

Methods: In 2015, data was collected from the procedural sedation logbook resulting in 50 consecutive patients between 27/07/2015 and 12/11/2015. 46 patients were included in the audit due to full data set availability. In 2016, data was extracted from all entries on the new trust electronic database resulting in 50 consecutive patients between 01/09/2016 and 13/11/2016. 

Results: ASA grade, anticipation of difficult airway and fasting status rose from 8.7%, 10.6% and 32.6% to 84%, 96% and 98% respectively. Consent was recorded in 98% of cases up from 21/7% the previous year. All team members were recorded as present 76% of the time, an increase from 56.5%: The most common missing member of the team on record was nurses. Patients were monitored with the required ECG/Capnography?NIBP and pulse oximetry in 98% of cases up from 39%. No specific information was recorded to demonstrate use of oxygen to the point of discharge. Fulfillment of discharge criteria was only documented in 39% of cases, down from 41% in 2015. 

Conclusions: Our documentation rate has significantly improved over the last year and consequently we are not far from adhering to the RCEM standards 100% of the time. 

Recommendations: All procedural sedation must be recorded on the electronic database with specific improvements to ensure extra details are documented: Patient consent, monitoring (specifically that it includes ECG/Capnography/NIBP and pulse oximetry and that nursing staff are present. As a matter of safety, we must add in the discharge criteria for all patients being considered for discharge and that we ensure that we meet these. 

Abstract

IMPORTANCE Use of calcium channel blockers (CCBs) has been found to improve sepsis outcomes in animal studies and one small clinical study. Whether the pre-admission use of CCBs would confer beneficial effects to patients with sepsis requires validation by a large population-based study.

OBJECTIVE To determine whether the use of CCBs is associated with a reduced risk of mortality in patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS We conducted a population-based cohort study using the National Health Insurance Research Database of Taiwan. From 1999 to 2011, hospitalized sepsis patients were identified by ICD-9 codes compatible with the sepsis-3 definition.   

EXPOSURES Use of CCBs or beta blockers. Beta-blocker was used as an active comparator, to examine the influence of healthy user bias. Propensity score (PS) adjustment and matching were used to adjust for unbalanced covariates between users of specific medication of and nonusers.

MAIN OUTCOMES MEASURES The primary outcome for the analysis is 30-day all-cause mortality. The secondary outcomes are 90-day all-cause mortality, septic shock, and acute respiratory failure.

RESULTS Our study identified 51,078 patients with sepsis, of which 19,742 received CCB treatments prior to the admission. Use of CCB was associated with a reduced 30-day mortality after PS adjustment (HR 0.94, 95% confidence interval, 0.89-0.99), and the beneficial effect could extend to 90-day mortality (HR, 0.95, 95%CI, 0.89, 1.00). In contrast, use of beta-blocker was not associated with an improved 30-day (HR, 1.06, 95%CI, 0.97, 1.15) or 90-day mortality (HR, 1.00, 95%CI, 0.90, 1.11). On subgroup analysis, CCBs tend to be more beneficial to patients with male gender, aged between 40 and 79, with a low comorbidity burden, and to patients with cardiovascular disease, diabetes, or renal diseases.

CONCLUSIONS AND RELEVANCE In this national cohort study, preadmission CCB therapy before sepsis development was associated with a 6% reduction in mortality when compared to patients who have never received a CCB. 

Background: In recent years lecture based learning (LBL) compared to Problem and case based learning (PBL-CBL) have been proven to be methods that improve training of residents. There are still not enough studies that analyze the importance of these methods in the medical Emergency area.

This study had as purpose to analyze the improvement in training given by the grades obtained in the Medical ER rotation of first year residents of family medicine comparing 2 course methods LBL group vs. PBL-CBL group.

Methods: Study type: Historical Cohorts. Universe of study: we analyzed the grades of the total of first year residents of family medicine that started their Medical ER rotation In HGUGM in the years 2012, 2013, 2014, 2015, 2016. We analyzed specifically the grades in the variable acquisition of theoretical knowledge, doctor-patient relationship, and rational use of resources. Statistical analysis was done with Excel, and SPSS (Pearson’s Chi-squared).

Results: In the years 2012, 2013, 2014 70 first year residents of family medicine received the LBL course, in the years 2015, 2016 50 first year residents received the PBL-CBL course.

In the grade variable of theoretical knowledge acquisition 88% of the residents in the PBL-CBL course obtained a grade of 2 (1-3 grading scale, being 3 the highest grade) compared to 60% in the LBL group. Being this difference statistically relevant (p < 0,01). In the Variable doctor-patient relationship 44% of the PBL-CBL course obtained a grade of 3 compared to 4.3% in the LBL group. Being this difference statistically relevant (p < 0,003). In the variable rational use of resources 68% of the residents in the PBL-CBL course obtained a grade of 2 compared to 39.1 % in the LBL group. Being this difference statistically relevant (p < 0,03)

Discussion: There was statistically relevant difference between the PBL-CBL group compared to the LBL group in the grades of the variables of theoretical knowledge acquisition, Doctor-patient relationship and rational use of resources. In this study we observed that the methodology of the PBL-CBL course had a favorable impact in the grades on the medical ER rotation, in the variable mentioned previously compared to the LBL course. The PBL-CBL group had an improvement probably due to the practical application of the theoretical knowledge, the simulation of real situations and how to overcome problems in doctor patient relationship, and due to the application of that knowledge to rationally use the resources they have for the purpose of solving problem and cases related to real patients. 

Objective: To develop a standardized high fidelity medical simulation (HFMS) training curriculum focusing on specific assessment and treatment of disaster-related severe injuries presenting to the emergency department.

Background: Evidence suggests that most prehospital and hospital providers are inadequately prepared to manage a multiple-casualty incident. For hospital healthcare providers, it is critical for them to develop competency in managing patients injured from disaster events. Unfortunately, some of these patients could be really critical, and understanding the pathophysiology of the injury progress is important for good quality care for the patients. Although existing disaster training systems emphasize non-technical skills, there has not yet been an in-depth analysis in identifying the competency of clinical skills for disaster personnel. HFMS is being used in rare but critical clinical events to enhance the competencies of healthcare providers.

Methods: The curriculum was developed using Kern’s 6-step approach. Problem identification, targeted needs assessment, goals, objectives, and educational strategies were developed according to evidence references and focused survey results. Five components of construct validation were used to validate the program: Content, Response process, Internal structure, Relationship to other variables, and Consequences. Contents were developed after reviewing all the related evidence references. And educational environment, setting, methods, instructor, and assessor were standardized. All checklists for assessment were validated using content validity index. And consequences were validated using pre- and post-intervention differences. The educational intervention consisted of a half-day workshop (lecture-HFMS-debriefing) for selected 24 emergency residents (6 teams). The objective of the scenario was to develop performance competency in managing critically injured patients in a disaster events, specifically, blast, radiation, and crush injuries. A checklist was developed to assess the performances of the participants. All pre-to-post differences within subjects were analyzed with paired t tests. The statistical level of significance was set at 0.05.

Results: The content validity index of performance checklist was 0.90. Pre- and post-intervention differences (percentage) for the 6 team performances were 67.7 to 84.6, 58.1 to 80.8, 51.6 to 84.6, 61.3 to 80.8, 51.6 to 65.4, 61.3 to 76.9, respectively. All results were statistically significant.

Conclusion: HFMS training program focusing on critically injured disaster victims positively affected performances of the participants.

Background: Evidence suggests that most hospital providers are inadequately prepared to manage a critically ill patient, especially patients in shock conditions. As the care of patients become more specialized, training the residents for general care of patients is becoming more difficult. The working hour limits of residents has restricted them to be exposed to critically ill patients. The objective of this project is to develop a standardized high fidelity medical simulation training curriculum, focusing on specific assessment and treatment of shock patients. Participation of healthcare providers in this program using self-assessment tools would positively affect knowledge, skills, and attitudes toward managing patient in shock conditions.

Methods: The educational intervention consisted of a full-day course for all new residents entering following departments: Internal medicine, General surgery, Pediatric, Obstetric, Chest surgery, Emergency medicine, and Anesthesiology. The day was composed of a summary lecture, followed by session comprised of learning psychomotor skills necessary for saving shock patients, which included airway management, and ultrasound-guided central line insertion. Simulation session consisted of 5 scenarios: Anaphylactic, Septic, Cardiogenic, Hemorrhagic, and Obstructive shock. To identify the differences in knowledge and self-confidence before and after course, all participants responded to the survey with a Likert scale. Paired t-test was used to compare the knowledge and self-confidence level on pre- and post-course. A descriptive analysis was performed to determine the general characteristics of subjects and the level of awareness of the importance of clinical competency in shock management.

Results: A total of 68 residents participated in the session (25 internal medicine, 9 general surgery, 12 pediatrics, 6 obstetrics, 1 chest surgery, 6 emergency medicine, 9 anesthesiology). All self-assessment questionnaires were scored out of 10 points. The mean score for overall course satisfaction was 9.3. For the face validity, the participants’ scoring for ‘realism of the setting environment’, and ‘realism of the scenario’ were 8.0, and 8.6, respectively. The score differences in pre-and post-course scores for competency in shock recognition, differential diagnosis, stabilization, intervention, skills, and crisis management were 4.5 to 7.6, 4.2 to 7.6, 4.3 to 7.5, 4.1 to 7.6, 4.5 to 7.5, and 4.4 to 7.5, respectively. The results were statistically significant.

Conclusion: The pilot course was satisfactory to the participants. The simulation session was able to improve the confidence and knowledge of the participants in managing shock patients. The scenario and simulation environment was able to assist the participants in recognizing the importance of patient in shock conditions, and also to self-assess competency in knowledge, skills, and attitudes towards shock patients.

Introduction

Acute bacterial skin infections are a usual cause of sepsis in the Emergency Department (ED). Mostly, the diagnosis is clinical. Globally, the most common pathogens are Streptococcus pyogenes and S. aureus. Our primary concern should be the use of a adequate antimicrobials therapy under guidelines. Before the spread and diffusion of bacterial resistances, empiric antiobiotics therapy (with a large spectrum β-lactam) was favoured. The rational is now to adapt the use of antibiotics to the local ecological situation. Monotherapy should be attempted (depending on the severity), Gram-negative coverage is mostly not empirically indicated, oral antibiotics are very effective and should be preferred if possible. The aim of this study was to evaluate the management of acute skin infections in an urban ED and the adherence to clinical guidelines.

Methods

We present here, a one-year (2015) retrospective and monocentric study conducted in a french teaching hospital. During the period of the study, we included all adult patients with the diagnosis af erysipelas. We collected and analyzed all clinical, biological, treatments and evolution datas during the stay in the ED. In fine, 127 patients have been included for statistical analysis.

Results

In the study population, mean age was 73.8±11.6 years old and the sex-ratio was 1.14. Penicillin G and Amoxicillin + Clavulanic Acid were the two most prescribed antibiotics (both 32%). Pristinamycin (15%), Amoxicillin (11%), Clindamycin (6%), Cloxacillin (4%) and others (2%) were the other used antimicrobials. Mean duration of therapy was 11.6±4.2 days. More than three quarter (77% (CI95%: [66-88%])) of them were hospitalized. IV administration was mostly used (78%) in the ED. Blood cultures came back positive in 14% of cases (mostly with S. pyogenes: 42% and S. areus: 14%). Antimicrobial therapy was given with a average time of 4.6±2.7 hours after ED admission. There was no difference in term of treatment duration (p=0.7), neither in term of antibiotics used (p=0.59) between out-patients and hospitalized patients. The mortality at Day28 was 2.3% (95% CI: [0.5-5%]) in this cohort.

Conclusion

Our study highlights the poor adherence to current guidelines. The management of acute skin infections in our ED remains heterogeneous. Penicillin G remains as a good choice in this indication but Amoxicillin + Clavulanic Acid should be preserved in the absence of bacteriological justification. As well as curbing the additional cost of non-guideline prescription, adherence to guidelines is essential in order to suppress growing resistances to antibiotic treatment. Pristinamycin and clindamycin could be appropriate alternative of Peni G in this area. The choice of antibiotic therapy should take in account various factors, including safety, interactions, patient profile (age), and possibility of permitting an early discharge (early switch-therapy, IV to oral at 48 hours) and thus minimizing the costs of hospitalization.

Emergency medicine (EM) was ranked the highest specialty in the 2016 GMC survey¹ for workload, intensity and fatigue. College surveys² have found that as many as 1 in 4 trainees may leave the specialty. Billions a year are spent on locums in the NHS.³

The 3 big questions to ask are : How can we recruit junior doctors into EM training posts and retain them? How can we inspire medical students into an EM career? And how can we deliver a cost effective service whilst providing quality training?

There is one solution: Fellows.

From August 2016, Brighton and Sussex University Hospitals (BSUH) created EM fellow posts. Each post consisted of 66% clinical time and 33% project time. The aim was to offer a better work-life balance and allow time to pursue other EM related interests. Applicants were required to be post foundation years. Fellowships were offered in education, simulation (both with a funded postgraduate certificate), leadership, trauma, toxicology and major incidents.

What do the fellows think of the job and does it make them want to do EM? We surveyed the fellows and 11/22 responded. 81% (n=9) agreed or strongly agreed that they had a good work-life balance and enjoyed the job. 91% (n=10) agreed or strongly disagreed that they had more time to participate in projects. 100% (n=11) would recommend the job to others. 72% (n=8) would consider a career in emergency medicine. Both of the registrar fellows who are EM trainees are continuing their training.

Every medical student on placement at BSUH ED this year was attached to an educational fellow. We aimed to encourage final year medical students to pursue careers in EM by providing a supportive and inspiring learning experience. How likely were they to consider emergency medicine as a career? We asked the students this question at the beginning of their EM placement and we asked them the same question after their placement with their dedicated educational fellow. The results were very positive. Answers were recorded on a 0-10 scale. Response rate was 100% of 39 students. The mean average before the placement was 5.3 and the mean average after the placement was 7.4. This is a difference of 2.13 (confidence interval 1.60-2.66).

And to answer the final question, these additional posts have enabled us to save £375,000 on locum spend already in the first half of this year.

We have shown how fellows can be a solution to recruitment, to retaining doctors whilst being cost effective. We are keen to explain the process further and share our successes and experiences with an international audience.

References in attachment

Background

UK ambulance services do not routinely receive information about what happens to patients following pre-hospital care. This impacts the ability of ambulance services to measure patient outcomes or evaluate care quality and performance. Measuring patient outcomes for ambulance service users has been identified as important through our consensus work with service users, service providers and service commissioners. In a Delphi study and patient and public consensus workshop, one of the highest priorities was to develop new indicators for measuring patient survival following ambulance service care. We present new survival indicators to measure survival for patients with serious emergency conditions, at multiple time-points.

Methods

We linked six-months patient level call and clinical data from one UK ambulance service with Hospital Episode Statistics (HES) Emergency Department (ED), admitted patient data and national mortality data. We identified a cohort of people who were admitted or died from one of 16 serious emergency conditions (conditions where death could potentially be prevented by a good emergency system). Multi-variable models (adjusting for age, condition and hospital effects) were created to calculate two survival measures. 1) Survival to hospital admission, within 7 days of the ambulance call; 2) For patients admitted to hospital, survival to 7 days from admission.

Results

Indicator 1: To identify the proportion of people with a serious emergency condition who survive to admission (within 7 days of ambulance contact). 11,264 of 187412 patients in our dataset met the inclusion criteria and had a serious emergency condition. Of these, 617 (5.5%) died and 10,647 survived to admission. The majority of pre-admission deaths occurred in older people and were within 1 day of the ambulance contact (87.8%). Pre-admission deaths were more likely for people with conditions such as ruptured aortic aneurysm, asphyxiation and meningitis.

Indicator 2:  For patients admitted to hospital, survival to 7 days from admission.

10,647 patients were admitted to hospital and 94% survived. The rate of survival decreased with age. People with septic shock, cardiac arrest, ruptured aortic aneurysm and heart failure were more likely to die, whereas people with falls age >75, road traffic accidents and asthma were more likely to survive. Most deaths occurred within one day of admission (47%).

Discussion

These indicators are part of a set of indicators developed by the Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) project, to measure ambulance service quality and performance. The indicators presented here are system indicators that monitor pre-hospital and post admission survival rates for people with a serious emergency condition and can be used to assess trends over time and differences between geographical areas.  For example, survival may improve through service developments, such as taking the right patients to the right specialist care.

Background

The Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) project is a five year NIHR funded research programme, which aims to identify, develop and test new ambulance service quality and performance indicators. During our 3 stage consensus research study, an important topic identified by patient and professional research participants was quality and safety of non-transport decisions. For example death or hospital admission following a non-transport decision. This is also important because the number of non-transported calls is increasing and there is huge service level variation for non-transport rates for different localities. Using our study patient-level linked ambulance and subsequent health event dataset, we developed a quality and performance indicator to identify potential missed opportunities to improve care related to prehospital non-transport decision making.

Method

Data for 6 months of 2013 was provided by one UK ambulance service and linked to national datasets (ED, hospital admissions, mortality) using NHS Digital’s data-linking service.  We excluded calls transported to ED, people who were dead on scene, untraced calls and end of life care calls. Calls were categorised into those receiving a paramedic response and not transported and calls receiving telephone advice only. We identified hospital admissions or deaths within 3 days of the original call as being potential missed opportunities to improve care. We calculated crude and standardised rates of admission or death within 3 days of the call and created predictive models to adjust for age, condition, call outcome and deprivation.

Results

84% of calls receiving a paramedic response and not transported were traced (42796/50894). Of these 6.3% were admitted to hospital within 3 days and 0.3% died within 3 days. Low tracing rates for telephone advice only calls (24%, 2514/10634) resulted in the possibility of bias, therefore we conducted a sensitivity analysis to identify a range of hospital admissions (2.5% – 10.5%) and deaths (0.006 – 0.24%) within 3 days of the original call. Using predictive models we assessed the results by county, clinical commissioning group, condition, in and out-of-hours calls, using traced and non-traced calls in the denominator, and presented standardised rates using funnel plots. We also assessed the impact of excluding hospital admissions < one day.

Conclusions

Quality and safety of non-transport decisions is important to service users and service providers, and can be measured using linked prehospital and subsequent health event data. We developed and tested a potential prehospital non-transport quality and performance measure. This can be used to monitor deaths and admissions following prehospital non-transport decisions and to provide information about the safety of non-transport decision making. This has potential as a system level indicator for all emergency and urgent care services where patients are not-transported to hospital.

Introduction: Syncope in the Emergency Department (ED) presents a dilemma between accurate diagnosis, recognition of risk-factors, and cost-effective management. Approximately 50% of the UK population will experience at least one syncopal episode in their lifetime, accounting for 3% of all ED attendances and up to 6% of hospital admissions. A comprehensive, evidence based pathway to aid decision making on whether to admit or safely discharge a patient with syncope could improve patient management and resource utilisation^.

Objectives: To collect data regarding the outcomes and risk characteristics of patients presenting to the emergency department with syncope to determine whether patients would benefit from the implementation of a syncope management pathway or dedicated syncope outpatient clinic.

Setting: Royal Alexandra hospital, Paisley, Scotland.

Results: 159 patients were included in the study after 12 were excluded according to set criteria. 99 (62.3%) were discharged and 60 (37.7%) admitted. The mean age was 35.7 years for those discharged and 71.4 years for those admitted. The two groups of most interest in relation to the aims were those stratified high-risk and discharged (HRD) and those stratified low risk and admitted (LRA). Of those discharged 23 (23.2%) were stratified as high risk, of those admitted 24 (40.0%) were stratified as low risk.

 When comparing these two populations LRAs were, on average, older than the HRDs (mean age 69.0 to 44.7). LRAs were more likely to attend hospital within 6 months for reasons other than syncope (29.2% to 13.0%), more likely to receive follow-up than low risk discharged patients (45.8% to 23.7%) and LRAs were more likely to receive head CT scans than HRDs (12.5% to 0%).

Conclusions: This study shows that there are patients presenting to the ED with syncope who are inappropriately admitted or discharged. Figure 1 outlines an example pathway helping to guide clinicians in decision making. Further research is required to identify exactly which patients would most benefit from referral to a specialist syncope clinic or from a management pathway to aid ED clinicians in assessing and directing care and whether its implementation is effective in real-world use.

TITLE A comparison of the timeliness and efficiency of two triage systems, the Manchester Triage System and Emergency Severity Index, in Midland Regional Hospital Tullamore and Royal Liverpool University Hospital

INTRODUCTION An effective triage system can ensure that an emergency department (ED) runs smoothly during periods of time where patient numbers are high and resources are sub optimal. The Emergency Severity Index (ESI) assessment is shorter than that of Manchester Triage System. The MTS is in use in the Midland Regional Hospital Tullamore (MRHT) and the ESI in the Royal Liverpool University Hospital (RLUH).

The aim of this study was to determine

1 the extent of the triage assessment used in each hospital.

2 the time elapsed between;

• patient arrival in the emergency department and time to triage.
• triage and patient information being available to the ED staff.
• patient information being available and first consultation with a Doctor.

3 if the availability of an advanced triage system improves waiting times

METHODS

A prospective observational study was undertaken in both EDs in Summer 2016. The time a patient entered triage was recorded and the process they underwent observed. The tasks undertaken by the triage nurse was noted. The time for notes to enter the boxes for doctor/ANP review was noted. The observed time and the duration of the  triage process as recorded on the IT system was compared if feasible. The advanced triage process (ie Bloods, ECGs etc) in each ED (formal in RLUH, adhoc in MRHT) was also observed and impact noted.

RESULTS

Data was collected on 217 and 204 patients in MRHT and RLUH respectively. The mean time for triage was 7mins 8secs and 9mins 36secs for MRHT and RLUH respectively. In both EDs, 1 in 5 patients needed no additional tasks at triage (19.8% and 20.6% respectively). A mean of 1.4 and 1.3 additional tasks were performed respectively at triage. 12.8% patients were discharged direct from triage to alternative services in RLUH. Availability of ED cards to medical staff was longer in RLUH than MRHT but time to medical review was longer in MRHT (113.9mins in MRHT vs 88.6mins in RLUH for Cat 3 patients)

CONCLUSION

In theory, the ESI should result in a shorter triage process than the MTS. In practice, this was not observed. Both systems require additional tasks to be performed at triage in the majority of patients, commonly recording vital signs and provision of analgesia. The formal advanced triage process in place in the RLUH resulted in longer delays to availability for doctor/ANP review. Due to the lack of IT systems recording the ED transfer of care to other specialties in RLUH, it is not possible to evaluate if the advanced triage process had benefits further along the patient journey.  Time until review by doctor/ANP for category 3 and 4 patients was longer in MRHT despite the longer advanced triage process in the RLUH, reflecting other factors that impact on efficient ED function eg lack of doctors or lack of cubicles.

Background:

The SAMe-TT₂R₂ score has been proposed to identify patients with non valvular atrial fibrillation (AF) who maintain a high average time in therapeutic range (TTR) on vitamin K antagonists treatment (VKA). This score has been validated in several studies; either monocentric or including very selected populations in a specialized setting. Our aim was to validate this score in patients attending an Emergency Room (ER). To our knowledge this is the first report describing this score in an Emergency Room setting.

Patients & Methods:

From January 2014 to June 2014, we included in this study patients with AF on VKA consecutively seen in our ER. The SAMe-TT2R2 score was calculated for each patient and so was the TTR using the Rosendaal method, following the international normalized ratio (INR) six months, after the admission in ER. Patients with SAMe-TT₂R₂TTR

Data Collection:

We enrolled 394 patients with AF seen in the ER for any reason. In 271 (68.7%) cases were on AVK thromboprofilaxis.

Results & Discussion:

A number of 271 (68.7%) cases were on AVK thromboprofilaxis. The mean SAMe-TT₂R₂ score was 1,6(0.70 SD) points. In 202(74.5%) patients the score was 0 or 1 points and 69(25.4%) patients received 2 or more points. Up to 211(77.8%) patients were followed 6 months with mean 4,25(4,75 SD) INR determinations in this period. A total of 79 (37.4%) patients had a TTR ≥65%. Comparing high TTR vs low TTR groups (table I) we found no differences bettween demographic and clinical variables. Comparing SAMe-TT₂R₂ groups with TTR values we found: SAMeTT₂R₂=0 43%, TTR(interquartile range(IQR)26-51). SAMeTT₂R₂=1 40%, TTR(IQR30-49). SAMeTT₂R₂=2 33% TTR(IQR23-48). SAMeTT₂R₂=3 31% TTR(IQR19-45). SAMeTT₂R₂=4 NA.

A linear correlation was found in the prediction of good TTR control with the SAMeTT₂R₂ scale. (Fig 1). A statistically level of significance (p <0.05) was observed for SAMeTT₂R₂ to predict good control by the Rosendaal method grouping the patients into a “likely to achieve a high TTR” group (SAMeTT₂R₂ <2) and “unlikely to achieve a high TTR” SAMeTT₂R₂ ≥2.

Conclusion & perspective:

In a "real-world" cohort of patients attending the ER we have meassured the value of the SAME-TT2R2 score for the identification of patients who would have poor-quality anticoagulation. Higher values have been significatively associated with worse TTR control.  Thus, rather than imposing a "trial of vitamin K antagonists" for such patients (and exposing such patients to thromboembolic risks), we can a priori identify those patients who can (not cannot) do well on a vitamin K antagonists. Such patients would benefit from additional strategies for improving anticoagulation control with vitamin K antagonists or alternative oral anticoagulant drugs.

Objectives: Previous animal studies reported that acute anticholinesterase pesticide (organophosphate and carbamate) poisoning (ACPP) may affect thyroid hormones. There is no human study investigating the association of hypothyroidism and ACPP, and therefore we conducted a retrospective nationwide population-based cohort study to delineate this issue.

Methods: We identified 10372 ACPP patients and matched 31116 non-ACPP patients between 2003 to 2012 in a 1:3 ratio by index date from Taiwan’s National Health Insurance Research Database for this study. We compared cumulative incidence of hypothyroidism between two cohorts by following up until 2013. Independent predictors for hypothyroidism were also investigated.

Results: In total, 75 (0.72%) ACPP patients and 184 (0.59%) non-ACPP patients were diagnosed with hypothyroidism during follow-up. Cox proportional hazard regression analysis showed that ACPP patients had higher risk for hypothyroidism than non-ACPP patients (adjusted hazard ratio: 1.47, 95% confidence interval [CI]: 1.11-1.95) by adjusting age, sex, hypertension, malignancy, liver disease, renal disease, atrial fibrillation and flutter, thyroiditis, goiter, endocrine disorder, and mental disorder. Stratified analysis showed that ACPP patients had higher risk for hypothyroidism than non-ACPP patients in the subgroups of 40-64 years, female, past history of goiter, and follow-up of < 1 month. ACPP patients without atropine treatment had higher risk for hypothyroidism than non-ACPP patients (incidence rate ratio: 1.66, CI: 1.20-2.30), but ACPP patients with atropine treatment did not. Female gender, malignancy, renal disease, thyroiditis, goiter, mental disorder, and ACPP without atropine treatment were independent predictors for hypothyroidism in the all patients.

Conclusions: ACPP might increase the risk for hypothyroidism. We suggested that early evaluation of thyroid function for ACPP patients is needed, especially in the patients of 40-64 years, female, and past history of goiter. Further studies are warranted for the detail mechanisms.

Background

Ultrasound plays a significant role in emergency medicine protocols worldwide. It has proven to be a valuable tool, especially in patients subjected to blunt abdominal trauma. In a prehospital setting, ultrasound of the chest, abdomen, and pericardium is considered a valuable addition to physical examination and it guides patient management. Nevertheless, recent reviews conclude that a positive contribution remains controversial. We aim to determine the impact of prehospital abdominal ultrasound on treatment decisions in a Dutch physician-staffed helicopter emergency medical service (HEMS).

Methods

We conducted a retrospective review of patients who underwent abdominal ultrasound examination from 1 January 2007 through 31 December 2016 performed by the HEMS of Nijmegen, The Netherlands. It services an area of 10.088 square kilometers inhabited by 4.5 million. Physicians record data on every scramble and patient treated in a dedicated electronic database. The retrieved data included patient demographics, type of incident, abdominal ultrasound findings, impact on treatment decisions, and the physicians’ narrative report. Detection of hemoperitoneum with ultrasound was compared to computed tomography (CT) scan and laparotomy. Outcome parameters were: impact of ultrasound on treatment decisions, incident types leading to ultrasound examination, and its performance.

Results

Of 17077 recorded scrambles and 8699 patients treated, 1583 underwent 1631 abdominal ultrasound examinations. Male to female ratio was 3.54:1. Most suffered from traffic accidents and falls from height. After eliminating missing data, 1539 examinations lead to 193 (12.5% - CI 10.8-14.2%) impacted treatment decisions. Alterations were related to information provided to the receiving hospital (40%); mode of transportation, including physicians escorting patients (29%); choice of receiving hospital (13%); fluid management (13%); converting to a ‘scoop-and-run’ strategy (2%); administrating or withholding drugs (1%). Sensitivity of prehospital abdominal ultrasound for hemoperitoneum was 31.3%, specificity 96.7%, and accuracy 82.1%.

Discussion

Ten years of data on prehospital abdominal ultrasound showed management alterations in 12.5% of cases. Although comparable studies are scarce, a similar study showed a significantly higher impact on patient management but had an entirely different design. Sensitivity is low, likely due to the prehospital setting with many detrimental environmental factors, high stress, and time pressure. Also, accumulation of intraperitoneal blood is time-dependent and will be negligible at first. Furthermore, CT detects small quantities of free fluid, also in the retroperitoneal space associated with pelvic injury. In conclusion, prehospital abdominal ultrasound in our setting alters patient management significantly. It, therefore, is a valuable tool in the Dutch HEMS setting, and probably beyond.

The aim of this evaluation was to explore the impact, views and experiences of implementing an on-going initiative in Yorkshire Ambulance Service (YAS), utilising specialist triage by mental health nurses in the YAS Emergency Operations Centre (EOC).

An exploratory evaluation involved interviews with a range of staff (n=12) and analysis of computer aided dispatch (CAD) data.

Preliminary impressions of the intervention derived from this evaluation indicate that the triage nurses are increasingly managing patient’s issues over the phone to deliver ‘hear and treat responses’, thereby reducing unnecessary ambulance dispatch and conveyance to ED. Specialist mental health triage appears to deliver benefits from a patient and organisational perspective. These include improved responses that meet the needs of ambulance service patients experiencing a mental health crisis, reduced usage of ambulance resources and reduced conveyance to ED where not wholly appropriate.

Initial implementation was conducted quite rapidly and the approach was still evolving at the time of the evaluation. Perceived effectiveness of the mental health nurse triage scheme is attributed to the nurses’ established contacts and their ability to communicate inter-professionally with staff in mental health services. Staff reported an enhanced awareness of mental health issues, as well as improved working relationships and morale amongst those directly involved in managing patient calls since the introduction of mental health nurses. Staff in the frequent caller programme acknowledged the role that the nurses play in helping to manage patients with complex mental health needs.

The majority of the 3983 calls triaged by the mental health nurses (April - December 2015) were from Advanced Medical Priority Dispatch System (AMPDS) card categories 23 (overdose/poisoning) and 25 (psychiatric/ suicide).  As the number of calls triaged increased over the nine month period, the proportion of card 23 and 25 calls decreased, with more calls originating from across 22 ‘other’ AMPDS card categories. Analysis of available computer aided dispatch (CAD) data indicates that rates for (a) ambulance dispatch and (b) total cases conveyed were lower for calls triaged by the mental health nurses.

Further evaluation and research is needed to examine this intervention in more detail, including service user experiences and cost-benefits of implementing a mental health triage nurse intervention.

Full report available at: https://www.shef.ac.uk/polopoly_fs/1.647212!/file/YAS_Mental_Health_Triage_Report.pdf

Backround: The North Estonia Medical Centre is one of the top health care providers in Estonia. Each year, around 145,000 patients receive specialist medical care, a total of 36,000 of them are assigned to the hospital`s 1200 beds. The annual volume in the emergency department (ED) is approximately 80,000 visits. The number of ED visitis is constantly increasing over the past years. The causes for unscheduled returns to the emergency department (ED) within 72 hours of discharge at our hospidal are unclear.

Objective: To determine rate, common initial presentation and cause of unscheduled emergency department return visits within 72 hours at the North Estonia Medical Centre.

Methods: The study was conducted between 1 September 2016 and 30 November 2016. Data were abstracted from hospital electronic patient records, abstracted data included variables related to patient information, reason for visit, injury/poisoning, diagnosis and medications. The previous care variable was revised to collect data that includes three types of return visits; scheduled, unscheduled returns that are unrelated to the initial visit and unscheduled return visits related to the initial visit. For revisited patients, we identified the cause of the revisit, changes in diagnosis and/or treatment, diagnosis mistakes,  and final destination of the patient.

Results: There were 806 patients who had at least one scheduled or unscheduled 72 h return visit to the ED. These 806 patients made a total of 1781 initial and return visits, which accounted of 9.55 percent of the total number (18,655) of ED visits during the studied period.  Unscheduled visits constitute broadly half of these visits, which is comparable rate to ohter similar studies conducted in Europe and North America. The 72-hour return for admission rate, which is considered to be more critical measure was up to one third of unscheduled visits.

Discussion: The revisit rate in our ED is similar to other hospitals in Europe and North America. A relatively high percentage of revisited patients require to be admitted to the hospital. Further data analysis is needed to identify factors associated with unscheduled 72 h returns in the ED to serve as a basis for development of interventions to decrease unscheduled returns and improve quality of care and safety of patients.

More detailed data will be presented in tables and graphs.

Background: Mild knee trauma is a common reason for consultation in Emergency Department (ED). The Ottawa Knee Rules are used to determine if X-rays of the knee should be performed to find a fracture. Apart from bone injury, ligament and meniscal injury should be investigated. The diagnosis of ligament and meniscal injury of the knee is essentially on the questioning that allows to appreciate the mechanism of the trauma. As well as the clinical examination of the knee which makes it possible to test ligament and meniscal structures. In practice, evaluation of a knee trauma in the acute phase is difficult because of the painful phenomena, the functional impotence and often incomplete questioning about the fall. The objective of this study was to evaluate the initial and 1-month management of patients who had consulted for mild knee trauma in ED in order to improve their initial and post-discharge overall management. Methods: We conducted a prospective study in the Lariboisière hospital ED in Paris between February 2016 and June 2016. The patients included were any patient consulting for a mild knee trauma in ED who did not require initial surgical management or hospitalization. Patients had an initial evaluation when they were in the ED and were contacted by phone 30 days after discharge from ED for a final evaluation. The primary outcome was diagnostic concordance between initial diagnosis in the ED and final diagnosis 30 days after discharge from ED. Results: During the study period, 70 patients were analyzed. They came by their own means to the ED in 63% of the cases, following a fall (78%) with direct (50%) or indirect (50%) shock. Knee testing was performed in 69% of patients with laxity in 13% of cases. The only radiological examination performed was a radiograph of the knee in 98% of the patients. Emergency diagnosis was contusion (41.5%), ligament injury (47.1%), and meniscal injury (7.1%). Some patients were discharged from the ED with an external MRI prescription (51.4%). A clinical revaluation with a general practitioner, traumatologist or orthopedic surgeon was requested for 92.8% of patients. Finally, 75% patients were revaluated and 24% completed knee MRI. Knee MRI was justified for 60% patients showing ligament or meniscal injury. Thirty days after discharge from ED, diagnostic concordance was 52% for knee contusions, 27% for meniscal injury and 17% for ligament injury. Conclusion: Diagnostic concordance between initial diagnosis and diagnosis 30-days after discharge from ED was poor. A systematic revaluation could be beneficial for patients consulting with mild knee trauma in ED, especially when ligament or meniscal injury is suspected. The prescription of a MRI could be useful after discharge from ED if meniscal or ligament injury can not be eliminated.

Background: Antibiotic overuse has enabled growing rates of antimicrobial resistance and unneccessary adverse events. Antimicrobial stewardship programs (ASP) are effective in reducing antimicrobial use in inpatient setting. But Emergency Department (ED) is unique environment lends itself to challenges for succesful antimicrobial stewardship for outpatients. So, We want to evaluate the impact of our ASP.

Materials/methods: We performed a monocentric retrospective comparative study of all antibiotic prescriptions of patients who have been admitted to the adult ED without being hospitalized (or hospitalized les than 24H) before (Nov 2012-Nov 2013)/ after (june 2015-june 2016). Patients' files were rewied by 2 independant evaluators: an infectious disease specialist (IDS) and an ED physician. They assessed compliance of antibiotic prescriptions with national and international guidelines. Our ASP was driven by an IDS and ED physician, it included:

1) Educational course outlining ASP principles was given to ED residents every 6 months.

2) The on-call IDS was made available during regular work hours for ED consultations. ED physicians were encouraged to call him/her when uncertain about antimicrobial prescriptions.

3) One ED team member was identified as referent for antimicrobial usage and was present at everyday staff meetings. He/She raised awareness about optimized antimicrobial utilization during work hours

4) The ED physician and IDS porvided guidelines on the main infectious diseases encountered in ED. Theses guidelines were given to each resident and ED physicians as a pocket handbook

We compared the relevance and volume of antibiotics prescribed in both periods to assess the impact of our ASP.

Results:Before and after ASP, we recorded respectively 34671 vs 35925 consultations at ED, 25470 vs 26208 were outpatients. The number of antibiotics prescribed for them decreased significantly, 760 vs 580 (p<0.0001). Among these prescriptions, there was a significant decrease in non-compliant prescriptions 455 (59.9%) vs 255 (44%) (p<0.0001) of which:

- 197 (40.7%) vs 101 ( 17.4%) (p<0.001) had an unnecessary antimicrobial prescription

- 95 (19.6%) vs 54 (9.3%) (p< 0.05) had a prescription with too broad spectrum

- 87 (17.9%) vs 53 ( 9.1%) (p<0.05) had a prescription with an excessive treatment duartion.

Conclusions: Antibiotic prescriptions to outpatients in the ED are often inadequate. Thanks to ASP, antimicrobial use could be widely imrpoved, especially concerning the volume of prescribed antibiotics and prescriptions generationg the most resistances.

Objective: Demand for ambulances is growing. Nevertheless, knowledge is limited regarding diagnoses and outcome in patients receiving emergency ambulances. This study aims to examine time trends in demographic characteristics, diagnoses and mortality among patients receiving emergency ambulances.

Design: Population-based cohort study with linkage of Danish national registries.

Setting: The North Denmark Region in 2007-2014.

Participants: Cohort of 148 757 patients transported to hospital by ambulance after calling emergency services.

Main outcome measures: The incidence of emergency ambulance service patients, distribution of their age, sex, hospital diagnoses, comorbidity, and 1- and 30-day mortality were assessed by calendar year. Poisson regression with robust variance estimation was used to estimate relative risk and age- and sex-adjusted prevalence ratios for Charlson Comorbidity Index (CCI) to allow comparison of mortality rates by year, with 2007 as reference year.

Results: The annual incidence of emergency ambulance service patients increased from 24.3 in 2007 to 40.2 in 2014 per 1 000 inhabitants. The proportions of women increased from 43.1% to 46.4% and of patients aged 60+ years from 39.9% to 48.6%, respectively. The proportion of non-specific diagnoses increased during the years, whereas injuries declined. Proportion of patients with high comorbidity level (CCI>3) increased from 6.4% in 2007 to 9.4% in 2014, corresponding to an age- and sex-adjusted prevalence ratio of 1.27 (95% Confidence Interval (CI): 1.18 to 1.37). The 1- and 30-day mortality decreased from 2.40% to 1.21% and from 5.01% to 4.36%, respectively, from  2007 to 2014, which corresponds to age- and sex-adjusted relative risk of 0.72 (95% CI: 0.66 to 0.79) and 0.43 (95% CI: 0.37 to 0.50), respectively.

Conclusion: During the eight-year period, the incidence of emergency ambulance service patients, the proportion of women, elderly, and patients with non-specific diagnoses increased. The level of comorbidity increased substantially, whereas the 1- and 30-day mortality decreased.

OBJECTIVES: In a group of patients with acute respiratory failure (ARF), treated with noninvasive ventilation (NIV), we tested if an early evaluation through a validated scale, using variables easily obtained at the bedside, can identify patients at high risk of adverse outcome.

METHODS: This was a retrospective study including all patients with ARF requiring NIV over a two-year period (January, 2014-July, 2016), admitted in an Emergency Department High-Dependency Observation Unit (ED-HDU). Clinical data were collected at baseline, 1 hour, and 24 hours; HACOR score (previously employed only in patients with hypoxemic respiratory failure) was calculated before NIV and after 1 and 24 hours of treatment. For prognostic analysis, the score was evaluated as continuous value and as dichotomized value (≤5 or >5, as suggested in the validation study). The primary outcome was in-hospital mortality, need of ICU admission and NIV weaning at 48 hours.

RESULTS: The study population includes 348 patients, mean age 77±15 years, 53% male gender; 249 patients presented an hypercapnic respiratory failure. Most frequent admission diagnosis were pneumonia in 59% of patients, congestive heart failure in 34% and sepsis in 20%, which overlapped in some patients.  In-hospital mortality was 22%; 86 (25%) patients needed ICU admission while 167 (48%) patients were weaned from NIV within 48 hours. Admission SOFA score was 4.3±2.5; after 24 hours of HDU stay it decreased to 3.7±2.2. Compared with survivors, non-survivors showed  significantly higher  HACOR score before NIV (8.1±5.2 vs 6.2±4.0, p=0.006), after 1 hour (6.7±5.3 vs 3.8±3.3, p<0.001) and 24 hours (4.7±4.7 vs 2.0±2.2, p<0.001) NIV treatment; moreover, HACOR score reduction during the first hour of NIV treatment was significantly higher in survivors compared with non survivors (-2.5±3.5 vs -1.4±3.5, p=0.021). Analysis for repeated measures showed a score reduction significantly more marked in survivors compared with non-survivors (p<0.001). Compared with patients with HACOR ≤5, patients with HACOR score >5 showed a significantly higher mortality rate at every evaluation point (before NIV: 27 vs 16%, p=0.019; 1-hour: 36 vs 17%, p<0.001; 24-hour: 44 vs 17%, p=0.001).  When we took into account the end-point ICU admission and early weaning (<48H), only HACOR score after 24 hours was significantly higher in patients who were admitted to ICU (3.3±2.8 vs 2.3±3.1, p=0.021) or who needed a prolonged ventilation (3.0 ±2.1 vs 2.1±3.0, p=0.011).

CONCLUSIONS: HACOR score incorporates several variables easily obtainable at the bedside; in a population of unselected patients with acute hypoxic or hypercapnic respiratory failure, treated with non-invasive ventilation, from the beginning of treatment in-hospital non survivors showed significantly higher score values compared with survivors.    

Background:

Traumatic brain injury (TBI) is a major cause of morbidity and mortality. Hence severity scales are important adjuncts to trauma care to predict the prognosis in order to improve triage decisions and identify patients with unexpected outcomes. Traumatology scores have been investigated and found to be useful in major trauma patients. However, few studies have examined the contribution of  these scores and Prognostic scores in intensive care ICU severity scales as prognostic indicators in severe TBI.

Methods:

Retrospective study of patients 18 years and older, presenting in the emergency department with isolated severe TBI and requiring mechanical ventilation between January 2015 and January 2017. Collected variables included comorbidity data, Glasgow Coma Scale (GCS), vital parameters, imaging data, popular traumatology scores (GAP, MGAP, ISS and TRISS) and common ICU scores ( APACHE II and IGS II) at admission. Fischer exact test and T-test were used when appropriate to compare mortality groups.

Results:

Twenty-nine patients were eligible for the study. Males were represented more than femals (sex ratio = 6 ), the mean age was 42 +/- 18. The overall in-hospital mortality rate was 58%. Early mortality (<24 hours) was observed in 13.8% of cases. GCS (p=0.046; 5 Vs 7.5), APACHE II score (p=0.018; 16.56 Vs 11.52) and IGS II score (p= 0.006; 44.3 Vs 31.5) were significantly associated with overall mortality whereas TRISS, GAP and MGAP as well as age, Shock Index and the presence of brain edema at admission did not prove to be significant prognostic indicators. Elderly age (p=0.04, 60 vs 40), high glycemic level at admission ( p=0.025; 2.1 vs 1.5 g/L) , APACHE II score (p=0.018; 16.56 Vs 11.52) and IGS II score (p= 0.006; 44.3 Vs 31.5) were significantly associated with mortality occurring within the first 24 hours following admission. None of the above scores was associated with late mortality.

Conclusion:

Unlike the commonly used traumatology scores like GAP, MGAP and TRISS which did not prove to be significant prognostic factors in TBI, APACHE II and IGS II are significantly associated with early and overall in-hospital mortality. Their use in traumatology for prognostication should be investigated more thoroughly in future studies.

Background:

Traumatic brain injury (TBI) is one of the leading causes of death in traumatology. It is a very common pathology with a high mortality rate that usually affects young healthy individuals. Identifying patients who may progress to a poor clinical short-term outcome will encourage earlier therapeutic interventions in the emergency department.

Methods:

Retrospective study over 2-year period that included all patients aged 18 or more, presenting with isolated severe TBI and requiring mechanical ventilation. Demographics and comorbidity data, Glasgow Coma Scale, vital parameters, glycemia at admission and imaging data were collected. , popular traumatology scores (GAP, MGAP, ISS and TRISS) and common ICU scores ( APACHE II and IGS II) at admission were calculated. Fischer exact test and T-test were used when appropriate to compare short-term mortality group.

Results:

Twenty-nine patients were eligible for the study.  Mean age was 42 +/- 18 [16 – 82] and the sex ratio was 6. Two patients (6%) had diebetes history. %. Short-term mortality (<24 hours) was observed in 13.8% of cases. Advanced age (p=0.04, 60 vs 40), high glycemic level at admission ( p=0.025; 2.1 vs 1.5 g/L) , APACHE II score (p=0.018; 16.56 Vs 11.52) and IGS II score (p= 0.006; 44.3 Vs 31.5) were significantly associated with mortality occurring within the first 24 hours following admission. GCS of 3 at presentation, presence of bilateral fixed or dilated pupils, stress-induced hyperglycemia (non diabetic hyperglycemia) and presence of mass effect or early brain edema on initial computed tomography, traditionally associated with worse TBI outcomes were not significantly associated with short-term mortality in our study. Popular traumatology scores such as TRISS, GAP and MGAP as well as Shock Index did not prove to be significant prognostic indicators in severe TBI .

Conclusion:

Hyperglycemia, advanced age and high levels of APACHE II and IGS II scores are indicator of poor early outcome in severe and isolated TBI in the emergency department. 

BACKGROUND:Severe pneumonia remains a major cause of death. Acute respiratory distress syndrome (ARDS) and pneumonia are closely correlated in the critically ill patient and ARDS was described as an independent predictor factor of mortality in case of pneumonia. Recent research suggests that host factors have a major bearing on the development of ARDS. Other studies suggest sepsis as the principal link between pneumonia and ARDS. The aim of the study was to identify factors that predict the occurence of ARDS during severe pneumonia. 

METHODS:

Retrospective study over 2-year period that included patients 18 years and older, presenting in the emergency department with severe pneumonia diagnosis. ARDS was defined with the Berlin criteria. Fischer exact test and T-test were used when appropriate to compare ARDS group.

RESULTS: N=24.The mean age was 69 + 14 years with a sex ratio of 2. Medical history: hypertension (29,8%), diabetes (37,7%) and tobacco (60,9%). chronic respiratory failure (33,3%), chronic heart failure (12,5%), immunosuppression (32%), patients had cumulated more than three comorbidities in 46 % of cases. The mean PSI score was about 124 +39, class V: 43,5%, the CURB 65 score was greater than or equal to two in 74% of cases, the mean value of APACHE II score was 32,  IGS II score was 69  and SOFA score was 11. The only Predictive factor of ARDS was the presence of immunosuppression (p=0,01) and the APACHE II score was correlated with the risk of development of ARDS  (p=0,000; 24 vs 14). The sepsis was not a predictive factor for the occurence of ARDS during severe pneumonia in this study.   CONCLUSION: The pulmonary infection is the most frequent cause of ARDS. Immunosuppression seems be the principal predictive factor in the occurrence of ARDS in severe pneumonia patients. The APACHE II score was correlated with the risk of development of ARDS and his use in pneumonia patients for severity and prognosis assessment should be investigated more thoroughly in future studies.

Background:

Diabetic ketoacidosis (DKA) is a frequent acute metabolic complication of diabetes mellitus. Cerebral edema (CE) is a rare therapeutic complication but it is known as the major cause of mortality and long-term morbidity in DKA patients, especially in children and young adults. Until yet, the mechanism of this severe complication remains poorly understood and guidelines for management of DKA can never be considered entirely safe.

Purpose:

To describe the incidence of CE after standardization of DKA therapy according to the recommendations of American Diabetes Association (ADA) published in 2009.

Methods:

Prospective descriptive study over 2-year period including patients aged > 16 years admitted to the emergency department for moderate to severe DKA. Standardization of DKA management occurring to ADA recommendations: fluid replacement, insulin therapy and replacement of electrolytes.

Cerebral edema was defined as deterioration in conscious level with imaging, histopathological or therapeutic confirmation (improvement after osmotherapy or assisted ventilation)

Results: 

We enrolled 106 consecutive DKA patients. The mean age was 36+/-16.5 years with a sex ratio of 0.63. Medical history, N (%): type 1 diabetes, 61 (57.5); type 2 diabetes, 31 (29.3); inaugural, 14 (13.2). Usual treatment, N (%): insulin, 90 (81.1); biguanides, 8 (7.5); sulfonylureas, 8 (7.5). Time to glucose control was 6.5 +/- 4 hours, time to resolution of acidosis was 13 +/- 7 hours, insulin dose to recovery was 66 Units (0.95 U/Kg). The length of stay in intensive care unit was 29 hours and mortality rate was 0.9%.Therapeutic complications were (N;%): hypoglycemia (58; 54.7), hypokalemia (21; 19.8) and Hyperchloremic acidosis (27 ; 25.7). No case of cerebral edema was documented during this study.

Conclusions:

Using the DKA standardized protocol improved several clinical outcomes with reducing time to resolution of acidosis and length of stay in intensive care unit and understating the incidence of fatal complications especially cerebral edema.

Intoduction:

Chronic obstructive pulmonary disease (COPD) is the fifth cause of morbidity and mortality worldwide. Exacerbation of COPD is a sustained worsening of the patient's condition.The Global initiative for chronic Obstructive Lung Disease (GOLD) 2016 is the main recommendations document for diagnosis and management of COPD exacerbations.

The aim of our study was to evaluate the management of patients admitted to the emergency department (ED) for COPD exacerbations using international guidelines.

Methods:

Prospective observational study over four months period. Inclusion of adult patients admitted to the ED for COPD exacerbations. Collection of epidemiological, clinical and para-clinical characteristics. Treatment management was standardized using GOLD2016 guidelines. All the medical staff was asked to carry out the same protocol.

Results:

Inclusion of 198 patients. Mean age: 67±11 years. Sex ratio = 3.95. Comorbidities n(%): hypertension 39(20), diabetes 33(17), tobacco 137(69), atrial fibrillation 15(8), dyslipidemia 13(7), chronic heart failure 11(5). ABCD classification of COPD n(%): C group 19(10) and D group 112(64). COPD Assessment Test more than 10 n(%):  145(81). Symptoms n(%): cough 148(76), dyspnea 140(71), sputum production 138(72), asterixis6(3) and cyanosis10(5). Physical examination n(%): wheezing 150(75), crepitates27(13,5%) and CPC 6(3)

Short-acting inhaled beta2-agonists (SABA) were prescribed in 158 patients (80%). Nineteen patients (10%) had short-acting anticholinergics bronchodilators in addition to the SABA. All patients received systemic corticosteroids (mode of administration n(%): oral route 131(66) and intravenous 67(34)).

Non-invasive ventilation was required in 37 patients (19%). Six percents (n=12) of patients were admitted to the intensive care unit for mechanical ventilation.

Main causes of exacerbations n(%): infection 74(38), treatment cessation 46(23), acute heart failure 17(9) and pulmonary embolism 12(6).

CONCLUSION:

The goal of treatment in COPD exacerbations is to minimize the impact of the current exacerbation and to prevent the development of subsequent exacerbations. A protocolized protocol at the ED helps to improve management and thus to decrease complications.

Background: Noninvasive ventilation (CPAP/NIPPV) is widely used to treat acute respiratory failure (ARF) in the Emergency Department (ED). Its use seems challenging also for patients who are not eligible for endotracheal intubation (ETI) both to treat ARF due to reversible causes and to relieve symptoms in end stage ARF. 

Methods: INVENT (Italian Noninvasive Ventilation in Emergency National Trial) is an observational prospective multicentric study whose aim is to outline the use of CPAP/NIPPV in Italian Emergency Departments. It involves 19 EDs and it is promoted by the SIMEU (Italian Society of Emergency Medicine) Study Center. Enrollment started in May 2015 and went on until February 2017. Data about patients treated with CPAP/NIPPV during four weeks/year, one for season, were collected.

We focused on the subgroup of patients for whom ETI was considered not indicated (Do Not Intubate: DNI) to outline the main features of DNI patients and to analyse the impact of DNI status on hospital mortality. 

Results: among 245 patients, 72 were considered DNI (29,3%). Patients with a DNI status were older (78,5±12,6 vs 73,2±13,7 years, p:0,004) and were more likely to have dementia (25,0%vs 8,2%, p<0,001) and solid tumours (31,9% vs 8,8%, p<0,001). They were less likely to have COPD (36,1% vs 56,7%, p:0,003), diabetes (18,7% vs 35,7%, p:0,012) and obesity (10,0% vs 22,9%, p:0,021). DNI patients were more likely to have ARF due to pneumonia than other causes (33,3% vs 13,5%, p<0,001).

Hospital mortality was higher in the DNI group (34,7% vs 14,6%, p<0,001). 

Among patients with a DNI status, the dead  had higher lactate levels (7,2±11,1vs 2,8±3,7, p: 0,022), lower diastolic blood pressure (DBP) levels (69,4±14,7 vs 78,8±19,2, p:0,025) and were less likely to have history of COPD than the dead. No ARF cause significantly affected hospital mortality. In the first hours of treatment, survivors showed an improvement of: DBP (77,9±19,6 to 71,1±13,0 mmHg, p:0,011), respiratory rate (RR) (29,9±6,4 to 24,7±6,7 bpm, p<0,001), pH (7,31±0,11 to 7,36±0,09, p:0,001), paCO2 (62,6±23,7 to 55,2±20,9 mmHg, p:0,001), paO2 (64,9±32,8 to 100,6±61,9 mmHg, p:0,001). 

Conclusion: DNI patients represented almost one third of those treated with CPAP/NIPPV for ARF in the ED, according to our data. They have higher hospital mortality and they are more likely to have ARF due to pneumonia. Dementia, solid tumours and an older age correlate with DNI status, while COPD patients are more likely to be not-DNI. Among DNI patients, higher lactate levels  and lower DBP levels correlate with survival rate. 

Although hospital mortality is higher in DNI patients, CPAP/NIPPV seems to be appropriate to treat ARF and to relieve symptoms of dyspnoea

Background: Noninvasive ventilation (NIV) is widely used to treat acute respiratory failure (ARF) in the Emergency Department (ED), in particular in acute cardiogenic pulmonary edema (ACPE) and  acute exacerbation of chronic obstructive pulmonary disease (AECOPD); its use has been described for other pathologies, such as pneumonia, pulmonary contusion or neuromuscular disorders, though evidence about these indications is still controversial.

Methods: INVENT (Italian Noninvasive Ventilation in Emergency National Trial) is an observational prospective multicentric study promoted by the Italian Society of Emergency Medicine (SIMEU) Study Center and involving 19 Italian EDs. it’s aim is to describe the reality of NIV use in Italian Eds, considering both Continuous Positive Airway Pressure (CPAP) and Non-invasive Positive Pressure Ventilation (NPPV). Patients treated with NIV were enrolled during 7 periods lasting one week from may 2015 to February 2017, 1 period for every season.

Results: We collected data from 245 patients, 138 males (56,3%), average age 74,8±0,87 years.

The indication for NIV was ACPE in 67 patients (27,3%),AECOPD in 56 (22,9%), pneumonia in 47 (19,2%), neuromuscular disorders in 6 (2,4%). 45 patients (18,3%) were treated because of a mixed indication: 13 (5,3%) had ACPE and AECOPD, 14 (5,7%) had ACPE and pneumonia and 18 (7,3%) had AECOPD and pneumonia. 47 patients (19,2%) were treated with NIV because of a mix of other pathologies. 

The initial modality of ventilation chosen was CPAP in 65% of patients with ACPE, 17,6% of patients with AECOPD, 51,9% of patients with pneumonia, and 1,67% of patients with neuromuscular disorders. The other patients were started firstly on NPPV.

The preferred interface using CPAP was the oronasal mask (66,4%), followed by the Helmet (33,9%), the full face (4,4%) and the nasal (0,9%) masks. For NIPPV the oronasal was still the most used interface (75,7%), followed by the full face mask (24,3%). In a few patients more than one device was used due to intolerance. CPAP was stopped because of intolerance in 10 patients (10,2%), while NIV in 11 patients(7,5%). Sedation was needed in 28 patients (11,4%).

19 patients (7,8%) underwent endotracheal intubation.  72 patients (29,4%) were considered not eligible for endotracheal intubation (DNI) by the treating physician.

Overall in-hospital mortality was 20,4% (50 pts), while it was 16,3% in ACPE patients (15/92), 10,6% in AECOPD patients (9/85), 31,2% in pneumonia patients (24/77) and 33,3% in neuromuscular disorder’s patient.

Conclusion: NIV is used in Italian EDs for many pathologies. CPAP is preferred in patient with ACPE, while NPPV is the ventilatory support of choice in AECOPD. The preferred interface in our study was the oronasal one. The mortality rates are consistent with the value found in literature.  These are preliminary data of an ongoing study, further investigations are needed to investigate this topic.

Intravenous Lipid Emulsion Treatment: Review of the effect on Lipophilicity

Background: Although the action mechanism of intravenous lipid emulsion has not been fully elucidated yet, its use in liposoluble drugs intoxications. Mechanism of effect is suggested that lipid sink theory, cardiotonic effect and positive inotropic effect by increasing the calcium level via the calcium channels. The aim of this systematic review is to investigate the relationship with the lipophilic feature (log p values) of drugs and the success rate of ILE therapy in poisoned patients.

Methods: We reviewed 765 cases published in PubMed between 1966 and June, 2015. After applying exclusion criteria, totally 141 cases ingested single substance and received ILE therapy with 20% ILE solution were included in present study. Amount of lipid solutions given and the results were recorded. Success rate was statistically assessed according to log p values of the substances taken and the amount of lipid emulsion used.

Results: 141 patients were involved in this study; log p values were calculated for all drugs regardless of the success of ILE therapy. Amount of ILE therapy given was ≤500 mL in 87 (61.7%) (≤100 mL in 14 (9.9%)) and >500 mL in 54 (38.3%) of the cases. The success rate was 85.1% in patients received ILE therapy≤500 mL, whereas the same rate was 92.6% in patients that received ILE therapy>500 mL. There was no significant difference between groups received ILE therapy≤500 mL or >500 mL (p=0.142). When amount of lipid emulsion given was below 500 mL (1-500 mL), the log p value, especially the ALOGPS and ChemAxon data, becomes more important. In cases that received ILE therapy≤500 mL, the ALOGPS and ChemAxon log p values were higher in the group with successful outcome than those observed in cases, in which ILE therapy was failed (p values are 0.043 and 0.008). In addition, Experimental log p value was higher, indicating a trend towards statistical significance (p=0.071). Thus, we can argue that log p value has significant effect on treatment success when amount of lipid emulsion is equal or below 500 mL. But, there is no significant effect of treatment outcome when amount of lipid emulsion is higher than 500 mL

ILE therapy under the amount of 100 mL failed to achieve successful outcome. ALOGPS and ChemAxon log P values were higher in cases, which received ILE therapy ≤500 mL and showed successful results. It was found that log p value had no contribution to the treatment success in the group received ILE therapy >500 mL.

Conclusions: It was found that ILE therapy500 mL, and that liposolubility had no significant contribution to treatment success. It could be thought that additional action mechanisms other than lipid sink phenomenon are more active in ILE therapy.

Background: Recently, the number of ambulance dispatches has been increasing in Japan and it is, therefore, difficult to accept emergency patients to hospitals smoothly and appropriately because of exceeding the hospital capacity. To facilitate the request for patient transport by ambulance and hospital acceptance, the emergency information systems using information technology (IT) has been built up and introduced in various communities. However, its effectiveness has not been insufficiently revealed in Japan. Herein, we developed a smartphone application system that enable the emergency medical service (EMS) to share information about ambulance and hospital situation in 2013. The aim of this study was to assess the implementation effect of this application for EMS system in Osaka City, Japan.

Methods: This study was a retrospective study with population-based ambulance records of Osaka Municipal Fire Department. This study period was six years from January 1, 2010 to December 31, 2015. In this study, we enrolled emergency patients that on-scene EMS personnel conducted the hospital selection for them. The main endpoint was difficulty in hospital acceptance at the scene. The definition of difficulty in hospital acceptance at the scene was to make >=5 phone calls by EMS personnel at the scene to each hospital until a decision to transport was determined. The definition of using smartphone application is the period of 2013-2015 after the introduction of this application since in 2013, and we assessed the effect of using smartphone application with multivariable logistic regression model.

Results: A total of 600,526 emergency patients who EMS personnel selected hospitals were eligible for our analysis in this study. There were 300,131 cases (50.0%) without using the smartphone application in 2010-2012 and 300,395 cases (50.0%) with using the smartphone application in 2013-2015. The proportion of the difficulty in hospital acceptance without using smartphone application was 14.2% (42,585/300,131) and that with using smartphone application was 10.9% (32,819/300,395), and the difficulty in hospital acceptance significantly decreased by the introduction of the smartphone application (adjusted odds ratio; 0.730, 95% confidence interval; 0.718-0.741, P<0.001).

Conclusion; Sharing information between ambulance and hospital by using IT was associated with decreasing the difficulty in hospital acceptance. Our findings may be considerable useful for developing emergency medical information system with IT in other areas of the world.

Motivation of employees in pre-hospital and in-hospital emergency care in Bulgaria.

Desislava Katelieva MD, phD; Lora Georgieva MD, phD, ass.prof.

Key words: emergency care, Bulgaria, motivation

Background: The shortage of personnel in emergency care in Bulgaria is a serious problem. Regardless of subsequent wage increases in recent years, the system has a fluctuation and insufficient number of specialists.

Methods: A research was conducted by semi-structured questionnaire in 2016 to identify attitudes, reasons for leaving or staying in the system. The data was processed by descriptive statistics, nonparametric chi-square test, correlation analysis (Spearman's coefficient) and regression analysis (linear regression). The study involved 291 participants: 149 (51,2%)  of outpatient care centers and 142 (48,8%) from emergency departments. The average age of respondents was 47,7 +/-9,2 years. According to their qualification the participants were: 97 physicians (33,3 %); 76 feldshers (26,1%); 93 nurses (32,0%) and 25 drivers (8.6%).

Results: 210 of the respondents (72,2%) do not intend to leave – 66,7% of whom like their job, and 5,5% cannot find professional realization elsewhere. Respondents who intend to leave state as reasons: their intention to work outside of medicine (6,6%); to work abroad (9,6%); to work in another medical facility (8,95%). The leading motive for staying in systems is the satisfaction of saving a human life for 190 (65,3%) of those surveyed, followed by free time between shifts-178 (61,2%) and reduced working time - 114 (39,2%). According to 232 (79,7%) salary is not a motivating factor to work in the system of emergency aid. According to 244 (83,3%) of respondents career development opportunities are not satisfactory. A statistically significant difference between satisfaction with career development and qualification of the respondents (chi² = 2,410, p = 0,566) is not established. As possible incentives to remain in the system of emergency aid respondents indicate: measures to restrict aggression (67,4%); the introduction of clear rules (60,1%); more opportunities for further training (59,1%); the introduction of triage (51,5%).

In recent years, emergency teams are increasingly subjected to physical and verbal aggression. Among the respondents, 81,1% were subject to physical aggression, while 93,5% - to verbal aggression. Mostly physicians are victims of physical aggression (r = 0,153, p = 0,009). A causal link between the frequency of unfounded calls and surveys and frequency of physical aggression (B =-0,349, p = 0,001) is found through linear regression.

Discussion: In order to solve the problem with staff fluctuation and shortage of specialists in emergency assistance, it is essential to seek the reasons behind their departure. The motivation factors include: decent pay, good working conditions, measures against the physical and verbal aggression, and opportunities for career development.

Application of telemedicine in prehospital emergency care in Bulgaria

Desislava Katelieva MD, phD; Atanas Mitkov MD; Dimitar Shandurkov MD

Keywords: telemedicine, telemedicine consultation, Center for outpatient emergency care

Background: The lack of nearby hospitals and doctors in Bulgaria, requires the introduction of telemedicine in emergency care. In January 2014 a pilot project was launched to introduce a multifunctional system monitoring, defibrillation and telemedicine in remote, hard-to-reach regions, operated by emergency crews without a doctor. This device has an integrated defibrillator and monitor of the vital indicators (the blood pressure, pulse, O₂, CO₂, body temperature), transmitted in real time over the Internet to the Center for telemedicine consultation. The pilot project starts with a peripheral device, used to train teams in Krumovgrad. The consultations are carried out by physicians in the coordination headquarters of outpatient emergency aid. The Ministry of health has purchased the first two peripheral devices for out-patient centers of emergency in Krumovgrad and Ardino in February 2015

Metods: Analysis of telemedicine consultations was carried out in Krumovgrad according to age, gender, the need to set hospitalization and diagnoses of patients for the period 22.02.2015. - 22.02.2017. The center for outpatient emergency aid in Krumovgrad covers 19907 people on a territory of 843 km². and is situated 47 km. from the regional hospital.

Results: A total of 135 telemedicine consultations for patients (65% are male and 45% female) were conducted for the research period. According to their age patients are: children-1 (0,2%); young people up to 30 years - 3 (2,2%); people with an average age of 30-60 years- 43 (32%) and over 60 years- 88 (66%). The diagnoses set after consultations, are mainly cardiac – ACS 27 (17%); pulmonary tromboembolism 7 (5%); rhythm-conduction disorders 26 (19%); arterial hypertension 34 (25%); respiratory failure 19 (14%) and clinically healthy 22 (16%). After consultation with physicians the emergency teams hospitalized 34 patients (25%). Telemedicine consultations during the first year were only 36, and in the second year they have increased 2,7 times. The relative amount of hospitalizations during the first year was 28%, in the second year decreasing to 24% due to increasing telemedicine consultations.

Discussion: After positive experiences from Krumovgrad, in September 2015 the State equipped more than 18 outpatient center with 22 new peripheral devices for telemedicine. Unfortunately a single center for telemedicine is still missing. The increase in emergency teams without doctor requires the application of medical control over their activities. A good and secure communication between emergency teams and doctors in hospitals is needed. Telemedicine guarantees patients, served by a team without a doctor, with competent and timely physician advice and reduces hospitalizations.

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.

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.