Monday 25 September
08:30
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A20
08:30 - 09:00

Keynote Lecture 1

Moderator: Senad TABAKOVIC (Zürich, SWITZERLAND)
08:30 - 09:00 Pitfalls in the management of older patients. Christian NICKEL (Basel, SWITZERLAND)
Trianti Hall
09:10
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A21
09:10 - 10:40

Pre-hospital (Cutting Edge)

Moderators: Christian NICKEL (Basel, SWITZERLAND), Jana SEBLOVA (Kladno, CZECH REPUBLIC)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
09:10 - 10:40 OHCA: Only the dispatcher can save lives!? Ondrej FRANEK (CZECH REPUBLIC)
09:10 - 10:40 Air support - Helicopter intervention in special situations. Carmen Diana CIMPOESU (Iasi, ROMANIA)
09:10 - 10:40 Airway Mangement - prehospital life-hacks you definitely need to know! Christian HOHENSTEIN (Jena, GERMANY)
Trianti Hall
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B21
09:10 - 10:40

Digitalisation in the ED
"Rage against the machine, the digital revolution in the ED"

Moderators: Catherine CHRONAKI (Brussels, BELGIUM), Tiziana MARGARIA STEFFEN (IRELAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
09:10 - 10:40 Digitalisation in the ED, the role of patient summary. Catherine CHRONAKI (Brussels, BELGIUM)
09:10 - 10:40 Digitalised health departments as part of a digitalised health community. Simon DE LUSIGNAN (Guildford, UK)
09:10 - 10:40 Panel discussion. Roberta PETRINO (Vercelli, ITALY), Catherine CHRONAKI (Brussels, BELGIUM), Simon DE LUSIGNAN (Guildford, UK), Tiziana MARGARIA STEFFEN (IRELAND)
Mitropoulos
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C21
09:10 - 10:40

Geriatric (Game Changers)

Moderators: Abdelouahab BELLOU (Boston, USA), Simon. P. MOOIJAART (Leiden, THE NETHERLANDS)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
09:10 - 10:40 Evidence-based medicine in older patients: why and how is it different from what you know. Simon. P. MOOIJAART (Leiden, THE NETHERLANDS)
09:10 - 10:40 Approach to the acutely presenting older patient. Jacinta A. LUCKE (Leiden, THE NETHERLANDS)
09:10 - 10:40 Geriatric Emergency Medicine – our new bread and butter. Suzanne MASON (UK)
Banqueting Hall
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D21
09:10 - 10:40

YEMD - Violence in the ED

Moderators: Monika BRODMANN MAEDER (Bern, SWITZERLAND), Basak YILMAZ (Ankara, TURKEY)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
09:10 - 10:40 The Hague Protocol: 'A succesful method for detecting Child Maltreatment at the Emergency Department'. Hester DIDERICH-LOLKES DE BEER (The Hague, THE NETHERLANDS)
09:10 - 10:40 Acute Behavioural Disturbance (ABD). Blair GRAHAM (Plymouth, UK)
09:10 - 10:40 Role of self protection and team training. Monika BRODMANN MAEDER (Bern, SWITZERLAND)
09:10 - 10:40 Interpersonal violence/ assaults towards healthcare professionals. Basak YILMAZ (Ankara, TURKEY)
Skalkotas
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E21
09:10 - 10:40

Paediatric
Telephone triage / Toxicology update

Moderators: Borja GOMEZ (Barakaldo, SPAIN), Henriette MOLL (Rotterdam, THE NETHERLANDS)
Coordinator: Henriette MOLL (Rotterdam, THE NETHERLANDS)
09:10 - 10:40 Improvement areas in the management of childhood poisoning exposures. Santiago MINTEGUI (Barakaldo, SPAIN)
09:10 - 10:40 Recognizing the sick child: the role of vital signs in triage. Joany ZACHARIASSE (Rotterdam, THE NETHERLANDS)
09:10 - 10:40 How risky is it to get up in the morning? Ian MACONOCHIE (UK)
MC-3
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F21
09:10 - 10:40

Free Papers Session 4

Moderators: Youri YORDANOV (Paris, FRANCE), Anastasia ZIGOURA (GREECE)
09:10 - 10:40 #10110 - OP028 Comparing outcomes between ICU patients referred directly from A&E, and those referred within 48 hours of admission to hospital.

Objective

To compare mortality, length of stay and cause for admission in adult emergency department (ED) patients at the Royal Infirmary of Edinburgh with a delay in intensive care unit (ICU) admission of up to 48h with a group of patients admitted directly from the ED to the ICU.


Background

There had been no study of the differences in patient cohort, or patient outcome between patients being referred directly for critical care support, or those being admitted from a ward within 48 hours. We aimed to identify a cohort of patients who had not been referred in ED, but who required critical care support early on during their hospital admission, and therefore may have benefitted from an earlier referral to ICU.

 

Sample & method:

We performed a retrospective cohort study in a 900-bed university teaching hospital over a 3 month period analysing data for all ITU admissions over the time period. One hundred and twenty-four adult emergency department patients admitted to the intensive care unit either directly from the emergency department (direct group) or within 48h of ward admission (delayed group) were identified.  The main outcome measures investigated were mortality, length of hospital stay and cause for admission to ITU. Exclusions included those transferred to the hospital directly to a ward, those who were admitted from recovery or theatres, and those assessed in the Primary Assessment Area.

 

Findings: 

  1. Mortality in the delayed group was 8% lower than the direct group (34% vs 26%).
  2. Length of hospital stay was 11.5 days longer in the delayed group compared with the direct group (25 days vs 13.5 days).
  3. Of the patients in the delayed group, 59% of the cohort presented with sepsis.

Conclusions

Our study showed that patients in the delayed group had a lower mortality compared with the direct group which we hypothesize to be secondary to a less critically ill patient cohort. We noted an almost double length of hospital stay in the delayed group, which holds significant implications for increased morbidity in that cohort. Of these delayed patients requiring ITU care, we noted that over half presented with sepsis. These results raised the question of whether our sepsis identifiers in the ED are being utilised appropriately and/or are clinically effective. There are two sepsis tools used: Systemic Inflammatory Response Syndrome  (SIRS) criteria “ and “Quick Sepsis Organ Failure Assessment” (qSOFA).

We performed further work to assess whether the sepsis tools of SIRS criteria and qSOFA would have helped identify the delayed patients with sepsis earlier. It identified that 60% of patients scored positive based on the SIRS criteria, but only 10% of patients scored positive based on the qSOFA criteria. It highlights that while there is a strong evidence base for qSOFA in risk stratification, it may be a poor indicator of the presence of sepsis in these patients and therefore should not be the sole sepsis screening tool within the department. 

Laura ELLIOTT, Kate EASTERFORD
09:10 - 10:40 #11316 - OP029 OXYGEN THERAPYIN EMERGENCY DEPARTMENT: IS IT OVERUSED?

Background: Though oxygen is one of the oldest drugs available, it is still the most inappropriately administered drug. It is a very commonly used therapeutic agent and is the treatment for hypoxaemia. There has been increasing criticism of the unrestricted use of O2 therapy over the past few years, and it is still controversial. This has led to over utilization of this very expensive resource.

Methodology:This was a cross sectional observational study done in the Emergency Department (ED) of a large tertiary care hospitals in South India. All patients who were administered oxygen over a 3 week period in April 2016 were included in the study. Details of oxygen administration and outcome were analyzed. Oxygen administered without hypoxia was considered as inappropriate.A basic cost analysis was also done. This study was approved by the ethics committee of Christian Medical College, Vellore and patient confidentiality was maintained using unique identifiers.

 

Results: 15.4 % (363/2356) of the patients presenting to the ED were administered oxygen. The mean age was 50.2 ± 17 years. There was a male predominance (66.4%). Majority (67.2%) were triaged as priority 1 patients. The common reasons for initiation of oxygen therapy were dyspnea (56.7%), low sensorium (14.0%), intubated elsewhere (11.0%), polytrauma (7.2%) and seizures (4.4%).The mean duration of Oxygen therapy was 7.3 ± 4.6 hours. 36.6% of patients were administered oxygen inappropriately. This resulted in wastage of 1376 euros in three weeks through treatment cost. 65.3% were admitted, 20.1% were discharged stable from ED and 11.8% left against medical advice. ED mortality rate was 2.8% and an additional 11.6% expired during hospitalization.

Conclusion:Oxygen is inappropriately administered in 1/3 of patients presenting to ED and increases the treatment cost for patients. Oxygen therapy should be strictly regulated to minimize its wastage.

Paul KUNDAVARAM, Acharya HARSHDEEP, Kumar SATISH, Selva BAGYALAKSHMI
09:10 - 10:40 #11763 - OP030 Sepsis-induced myocardial dysfunction: is it reversible?

Background: Sepsis-induced myocardial dysfunction (SIMD) is established in about 50% of septic patients; aim of this study was to assess if SIMD is a reversible condition by mean of strain echocardiography.

Methods: Unselected patients affected by severe sepsis and septic shock admitted consecutively to a High Dependency Unit from the Emergency Department between October 2012 and December 2016 were prospectively enrolled. An echocardiogram was performed within 24 hours from the diagnosis of sepsis (ECHO1). LVEF was calculated using LV volumes derived by LV planimetry by manual tracing (Simpson’s rule) and was considered normal if >55%. The global longitudinal strain (GLS) was evaluated from apical LV views, with a commercially available system (Philips Q-LAB ver. 8.1) and was considered normal if <-14%; RV systolic function was evaluated through Tricuspidal Annular Systolic Posterior Excursion (TAPSE). In a consecutive group of survivors we repeated an echocardiogram 3 months after hospital discharge (ECHO2).

Results: Among 177 patients who underwent an echocardiogram within 24 h from sepsis diagnosis, 127 (72%) survived at 28 days and 44 patients (35% of survivors) accepted to repeat an echocardiographic evaluation after three months and they represent our study population; no significant differences were found between participants and non participants in term of LV (LVEF: 54 ±14% vs 50 ±15%; GLS -12.9 ±3.7 vs -11.8 ±3.4, tutti p=NS) and RV systolic function (TAPSE: 2.1 ±0.5 vs 1.9 ±0.5, p=NS). ECHO1 showed an LV systolic dysfunction in 26 (59%) and RV systolic dysfunction in 9 (21%); at ECHO2 LV systolic function returned to normal values in 13 patients and RV systolic function in 7, but a new systolic dysfunction was appreciated in 2 patients for LV and in 7 for RV. Considering LVEF analysis, the prevalence of LV dysfunction at ECHO1 was 49% and dropped to 23% at ECHO2; according to GLS it fell from 59% to 29% p=0.010 between ECHO1 and ECHO2, p <0.001 between evaluation by mean of GLS or by LVEF). Overall 50% of patients presented at ECHO2 a mono- or biventricular systolic dysfunction: patients with persistent dysfunction did not have a higher prevalence of coronary heart disease (14 vs 9%) or, during the acute phase, they did not develop more frequently a septic shock (29 vs 20%) or needed high-dosage vasopressors (11 vs 9%, all p=NS). Biomarkers levels in the acute phase were comparable between patients with reversible or irreversible dysfunction (Troponine: 0.43 ±1.57 vs 0.83 ±1.61 microgr/L; NTproBNP 6615 ±6501 vs 7501 ±12785 pg/mL).

Conclusions

SIMD has a significant incidence and it persists beyond the acute phase of the septic process in a relevant proportion of patients, but we did not find any useful parameter to predict SIMD reversibility; strain echocardiography was superior to conventional methods in identifying systolic dysfunction. 

Valerio Teodoro STEFANONE, Eugenio FERRARO, Chiara DONNINI, Vittorio PALMIERI, Francesca INNOCENTI, Riccardo PINI
09:10 - 10:40 #11765 - OP031 Sepsis-induced myocardial dysfunction: which role for cardiac biomarkers in diagnostic and prognostic assessment?

Background: Left (LV) or right (RV) systolic ventricular dysfunction has been found in about 50% of septic patients. The aims of this study were:  1) to evaluate biomarkers’ diagnostic accuracy in identifying patients who develop SIMD; 2) to evaluate prognostic significance of biomarkers.

Methods: In 177 patients diagnosed with severe sepsis/septic shock and admitted in our ED-High Dependency Unit between August 2012 and December 2016; an echocardiogram was performed within 24 hours from admission. We evaluated LV systolic function using Global Longitudinal Strain (GLS) and Ejection Fraction (EF) measurement and RV systolic function with Tricuspidal Annular Plane Systolic Excursion (TAPSE). We divided our population in two subgroups:  patients who had a mono- or biventricular systolic dysfunction (D+) and those who hadn’t (D-). We referred to a GLS > -14% for LV systolic dysfunction and TAPSE <16 mm for RV systolic dysfunction. Biomarkers’ levels were measured both at the time of admission (T0) and after 24 hours (T1), considering them both as continue and dichotomized values (TnI: ≤0.1 or > 0.1 µg/L; NTproBNP: > or ≤ 6000 pg/mL). Day-7 and day-28 mortality were our primary end-point.

Results: Most frequent comorbidities were diabetes (27%), hypertension (55%) and neoplastic disease (31%); lung was the most common primary infection site (54%). One hundred twenty-seven patients (72%) showed an LV dysfunction and 54 (30%) a RV dysfunction; overall D+ group included 136 patients.

TnI T0 and TnI T1 levels were significantly higher in D+ patients compared with D- subjects (T0: 0.78 ±2.43 vs 0.15 ±0.29; T1: 1.00 ±2.60 vs. 0.19 ±0.48). T0 NTproBNP value was significantly higher in D+ than in D- patients (18292 ±34019 vs 9329 ±15616); dichotomized values did not show a significant different distribution between D+ and D- patients. ROC analysis showed an area under the curve (AUC)= 0.64 for T0

TnI,0.67 for T1 TnI, 0.60 for T0 NTproBNP and 0.65 for T1 NTproBNP.

Day-28 mortality was 28% (n=50). Biomarkers’ values did not show any significant association with an

increased mortality rate at univariate analysis; a more compromised value of GLS, TAPSE and EF was significantly associated with an increased day-7 and day-28 mortality; ; after adjustment for age and SOFA, an increased GLS was associated with an increased day-7 mortality (RR 1.18, IC 95% 1.04-1.35, p=0.010) while abnormal TAPSE and GLS were associated with increased day-28 mortality rate (respectively, RR 0.30, IC 95% 0.12-0.72, p=0.007 and RR 1.11, IC95% 1.01-1.25, p=0.041) while EF did not demonstrated any prognostic significance in a similar multivariable model.

Conclusion: SIMD has a significant incidence and is associated with an increased mortality rate; the levels of biomarkers, commonly considered as a result of myocardial damage, are higher in patients who present ventricular systolic dysfunction than in others but the prognostic discrimination ability is poor.

Valerio Teodoro STEFANONE, Eugenio FERRARO, Chiara DONNINI, Vittorio PALMIERI, Francesca INNOCENTI, Riccardo PINI
09:10 - 10:40 #11768 - OP032 Echocardiographic assessment of fluid-responsiveness: a preliminary experience in a High-Dependency Unit.

Background: Aim of this study was to examine the feasibility and diagnostic accuracy of VCCI and velocity time integral variation after passive leg raising (PLR) in an unselected population of critically ill patients admitted to a sub-intensive clinical setting.

Methods: This is a prospective, observational, pilot study. Unselected critical patients admitted in an Emergency Department High-Dependency Unit (ED-HDU) were evaluated by transthoracic echocardiography to measure vena cava collapsibility index (VCCI) and aortic velocity (AoV)  variation during PLR. Conventional LV and RV diastolic dimensions and systolic function (LV ejection fraction, EF, and Tricuspid Annulus Systolic Posterior Excursion, TAPSE) were measured. According to VCCI, patients were considered fluid-responders when the value was ≥40%. According to AoV variation after PLR, a positive hemodynamic response was defined as an increase in AoV ≥ 10%. Whenever possible, both VCCI and AoV variation during PLR were evaluated. According to echocardiographic evaluation, three therapeutic options were considered: no intervention, administration of fluids or diuretics. Any change in the therapeutic strategy by the treating physician in the following 12 hours was annotated into the clinical records.

Results: we enrolled 53 patients, mean age 73±14 years; the two most frequent reasons for ED-HDU admission were sepsis (75%) and COPD re-exacerbation (8%); in 5 (10%) patients echocardiographic evaluation was not feasible. VCCI was feasible in 35 (66%) patients, while PLR could be performed in 33 (62%). Eighteen patients were managed according to VCCI: 13 were non FR, while 5 were FR and were treated with fluid boluses. In the following 12 hours, in 4 non FR patients and in 3 FR patients therapeutic strategy was modified (7/18, 39%). Thirty-one patients were treated according to PLR: among 18 FR patients, 16 received a fluid bolus while 13 non FR did not receive fluids and this therapeutic strategy was maintained in all but one FR patient in the following  12 hours (1/31, 3%, p=0.002). In the group of patients managed by PLR 18 also underwent VCCI evaluation which was discordant with PLR in 3 patients. Finally we compared LV and RV dimensions and systolic function between patients in whom VCCI correctly identified FR (n=26) or it did not (n=10): presence of LV dilatation  (LV diastolic diameter >55mm; 10% in both groups), RV dilatation (At least 2 of the three conventional RV diameter over normal limits; 62% in patients correctly identified vs 46% in patients not correctly identified), LV systolic dysfunction (LVEF <50%; 44% vs 33%) and RV systolic dysfunction (TAPSE

 Conclusions: we confirmed a poor diagnostic accuracy for VCCI independent to LV and RV dimensions and systolic function; VTI variation during PLR showed a very good diagnostic performance.   

Caterina SAVINELLI, Federico MEO, Salvatori MATTIA, Alessandro COPPA, Francesca INNOCENTI, Riccardo PINI
09:10 - 10:40 #11772 - OP033 MEWS and lactate dosage variation: which is the best time-interval for the prognostic assessment of septic patients?

Introduction: The aim of this study was to compare the prognostic value of MEWS (Modified Early warning System) score and lactate dosage absolute value and trend over 2, 6 and 24 hours after admission, in order to identify the most appropriate timing to evaluate score’s evolution.

Methods: In the period November 2011-December 2016, 269 patients enrolled in a prospective study aiming to find reliable biomarkers for an early sepsis diagnosis. Patients admitted to our High-Dependency Unit from the Emergency Department with a diagnosis of severe sepsis/septic shock were eligible. At ED-admission (T0), after 2 hours (T2), 6 hours (T6) and 24 hours (T24) from the initial diagnosis, we evaluated lactate and MEWS score; score differences over 2-hour (ΔMEWS-2H), 6-hour (ΔMEWS-6H) and 24-hour time interval (ΔMEWS-24H)were calculated. Lactate absolute values (analyzed as continuous values and ≤ or >2 meq/L) and lactate clearance (dichotomized as ≤ or >10%) were evaluated at the same time intervals. The primary end-point was in-hospital mortality.

Results: Mean age of the study population was 74±14 year, 59% male gender; main comorbidities were arterial hypertension (61%), diabetes (33%), neoplasia (22%) and chronic kidney disease (24%). The most frequent infection source was respiratory (45%) and 41% of patients developed a septic shock. Overall in-hospital mortality was 26%. Mews score was significantly higher in non-survivors compared with survivors at all evaluations (T0: 4.3±2.1 vs 3.6±2.0, p=0.028; T2: 4.1±1.6 vs 2.9±1.7, p<0.001; T6: 4.3±2.1 vs 2.6±1.7, p<0.001; T24: 3.9±2.6 vs 2.3±1.7, p<0.001); repeated measures analysis confirmed a significant difference within subjects (p<0.001) and between survivors and non survivors, with a continuous decrease in the first group and a flat trend in the second one. Score variation was negligible in non survivors (T2: -0.15±1.51 vs -0.71±2.03, p=0.062; T6: -0.19±2.15 vs 0.97±2.01, p=0.023; T24: 0.11±2.61 vs -1.31±2.01, p<0.001); after dichotomization of the score variation on the basis of the median value of this study population (≤ or >-1), only at 24-hour evaluation a variation>-1 was significantly more frequent among non survivors (60 vs 34%, p=0.004). Lactate dosage was significantly higher in survivors at all evaluations except for T2 (T0: 3.8±3.9 vs 2.7±2.5, p=0.043; T2: 3.5±3.8 vs 2.4±2.6, p=0.067; T6: 3.4±3.8 vs 1.7±1,3, p=0.003; T24 4.1±5.7 vs 1.4±0.9, p=0.002); a value>2 meq/L was significantly more frequent among non-survivors only at T24 (43 vs 19%, p=0.001). A lactate clearance >10% was significantly more frequent among survivors at T6 (71 vs 48%, p=0.006) and tendentially at T24 (67 vs 50%, p=0.053), not significant at T2 (59 vs 47%, p=.208).

Conclusions: Vital signs aggregated into MEWS score and lactate dosage were significantly worst in non-survivors compared with survivors at the moment of sepsis diagnosis; a 2-hour interval appears too short to allow a prognostic evaluation. 

Chiara DONNINI, Federico MEO, Camilla TOZZI, Maria Luisa RALLI, Michela ZARI, Irene GIACOMELLI, Francesca INNOCENTI, Riccardo PINI
09:10 - 10:40 #11774 - OP034 SOFA score variation: which is the best time-interval for the prognostic assessment of septic patients?

Introduction: The aim of this study was to compare the prognostic value of score trend at 6 and at 24 hours after admission, in order to identify the most appropriate timing to evaluate score’s evolution.

Methods :In the period November 2011-December 2016, 269 patients enrolled in a prospective study aiming to find reliable biomarkers for an early sepsis diagnosis. Patients admitted to our High-Dependency Unit from the Emergency Department with a diagnosis of severe sepsis/septic shock were eligible. Exclusion criteria included presence of severe cognitive impairment inducing associated with immobilization syndrome lasting from more than three months; age

Results: Mean age of the study population was 74±14 year, 59% male gender; main comorbidities were arterial hypertension (61%), diabetes (33%), neoplasia (22%) and chronic kidney disease (24%). The most frequent infection source was respiratory (45%) and 41% of patients developed a septic shock. Overall in-hospital mortality was 26%. SOFA score was significantly higher non-survivors compared with survivors at all the evaluations (T0: 6.1±2.7 vs 5.0±2.7, p=0.013; T6: 7.8±3.1 vs 6.1±2.9, p<0.001; T24: 8.5±3.5 vs 5.3±2.6, p<0.001). Discriminative analysis by ROC curves showed an improving prognostic stratification ability in following evaluations (T0: area under curve, AUC, 0.62, 95%CI 0.54-0.70, p=0.007; T6 AUC 0.67, 95%CI 0.59-0.775, p<0.001; T24 AUC 0.77, 95%CI 0.70-0.85, p<0.001). Based on ROC curve analysis, we identified the value 3.5 as that having a good sensitivity a specificity (98 and 74%): a SOFA score lower than 3.5 was significantly more frequent among survivors at all evaluation points (T0: 32 vs 17%, p=0.039; T6: 21 vs 6%, p=0.022; T24 26 vs 2%, p=0.001). ΔSOFA-T6 (1.8± 2.3 vs 1.1± 2.0, p=0.025) and ΔSOFA-24H (2.5±3.3 vs 0.3±1.9, p<0.001) were significantly higher in non-survivors compared with survivors. A ΔSOFA value at either evaluation point >1 (median value in our study population) was significantly more frequent among non-survivors (T6: 57 vs 35%, p=0.006; T24: 61 vs 28%, p<0.001). Patients with a SOFA score >3.5 and a score variation >1 showed a significantly higher mortality rate at either T6 and T24 evaluation, compared with patients who presented only one of the previous values or neither (T6: 57% vs 38% vs 6%, p=0.003; T24: 61% vs 37% vs 2%, p<0.001).

Conclusions: Prognostic value of SOFA score was modest at the moment of sepsis diagnosis; at a 6-hour interval, useful prognostic information could be obtained both from absolute score values and score variation, which were further confirmed at the 24-hour evaluation.

Chiara DONNINI, Federico MEO, Camilla TOZZI, Maria Luisa RALLI, Michela ZARI, Irene GIACOMELLI, Francesca INNOCENTI, Riccardo PINI
09:10 - 10:40 #10116 - OP035 Spanish Pediatric residents: Variability In Education and Research In Pediatric Emergency Medicine.

OBJECTIVE

To analyze the education in pediatric emergency medicine (PEM) given to pediatric residents and the research carried out by them in Spain.

 

METHODS

Descriptive cross-sectional study based on web surveys. First survey, regarding characteristics of PEM education and research in the Emergency Department (ED), was distributed to the directors of pediatric EDs included in the Spanish Society of Pediatric Emergencies. Respondents were asked to distribute a second survey to their residents and pediatric assistants. Only EDs with more than 30% of respondents were included for the descriptive analysis of all the variables.

Main outcome variables were the level of satisfaction within resident education (on a scale from 0 to 10) and the number of papers published in a peer-reviewed journal in the last 5 years. Multivariate analysis was made to assess associated factors between them.

 

RESULTS

First survey was sent to 83 directors and 42 (50.6%) answered it. In 33 (78.6%) EDs more than 30% of respondents fulfilled the second survey, including finally 376 (92.8%) for analysis (196, 52.1%, fulfilled by residents).

Median value of resident’s satisfaction with PEM training in each hospital ranked from 5 to 9. Factors associated with higher values were having education quality indicators, closer supervision of clinical practice and a structured evaluation of resident’s PEM skills when finishing the working shift or the rotation in the ED period.

In the previous 5 years, the average of research training activities by ED was 1 (IQR 0-3), with 11 EDs (33.3%) having no activity. Around 50% of respondents considered that research was not adequately supported at their EDs.

Level of resident’s satisfaction with research in PEM in each hospital are shown in figure 1. Sixty-eight respondents (18.1%) had published at least one paper on a peer-reviewed journal (residents, 17, 25%). Associated factors with having a paper published were the existence of a research director in the ED, having research quality indicators, self-perception of residents that the research was supported in the ED and having performed any research training activity in the previous 5 years.

Those residents with at least one paper published rated higher their education [mean= 8 (CI95% 7.34-8.66) vs those with no publications, 7.1 (CI95% 6.87-7.33)]

 

 

CONCLUSION

Significant variability in PEM education and the research was noted among Spanish pediatric residents. An adequate organization of the EDs seems to be essential to improve education and research. 

Roberto VELASCO, Santiago MINTEGI, Group For Study Of Education And Research Of Riseu .
09:10 - 10:40 #11675 - OP036 Comparison of two protocols of intravenous insulintherapy in the management of diabetic ketoacidosis.

Background:

Diabetic ketoacidosis (DKA) is an acute and potential life-threatening complication of diabetes mellitus. The mainstay in the treatment of DKA involves the administration of regular insulin. However, the route and the dose of insulin remains controversial. This study was designed to compare the safety and the efficiency of two protocols of intravenous insulin (IV): Protocol (A) Intravenous bolus of regular insulin 0,1UI/Kg followed by a continuous IV infusion at the dose of 0,1UI/Kg/H; Protocol (B) a continuous IV infusion of regular insulin at the dose of 0,14UI/Kg/H without bolus.

 

Methods:

Prospective randomized study of patients aged more than 18 years with moderate to severe DKA hospitalized in the emergency department. Patients were devised into two groups: Group (A) received protocol (A) and Group (B) received protocol (B). Standardization of:1) the fluid therapy with normal saline and 5% dextrose 2)the potassium replacement. Data on glucose level, pH, serum bicarbonate, anion gap, intravenous fluid administration, and length of stay were collected. Outcomes data were: time to recovery, time to glucose control (<250mg/l), insulin dose to recovery, occurrence of complications: hypoglycemia, hypokalemia, recurrence of DKA.

Results:

We enrolled 164 consecutive DKA patients. Exclusion of 39 patients. The mean age = 39 +/- 18 years, sex ratio =0.97. DKA occurs more in type 1 diabetes n=87(47.6%) than in type 2 n= 64(39%) and was inaugural in 22 patients (13.4%). There were no differences between the two groups in clinical and biochemical data Group (A) versus Group (B) : mean age (37+/-17 vs. 37+/-17 years; p=0.95),sex ratio(0.84 vs. 0.88),Blood glucose level  (30.2+/-9.9 vs. 32.5+/-11.9 mmol/l; p=0.27), pH(7.14+/-0.13 vs. 7.15+/-0.12; p=0.7), anion gap (28.63+/ 5.74 vs. 28.9+/-7.21; p=0.8) ; also in outcomes data Group(A) vs. Group(B): time to recovery (17.6+/-13 vs. 17.4+/-21.5 hours; p=0.9), insulin dose to recovery (76.5+/-55.1 vs. 74.9+/-35.3 UI; p=0.8) length of stay in intensive care unit (28.3+/-18.2 vs. 32.4+/-20.3 hours; p=0.3),complications : hypoglycemia(n= 4 vs. 10; p=0.12 ) , hypokalemia (n= 32 vs. 31; p=0.33) , recurrence of DKA (n=1 vs. 7; p=0.31) .

 

Discussion:

 These two protocols of IV insulin infusion were safe and had a comparable efficiency without majoring the risk of complications.

 

Asma ALOUI, Sarra JOUINI, Rym HAMED, Hana HEDHLI, Alaa ZAMMITI, Aymen ZOUBLI, Badra BAHRI, Chokri HAMOUDA, Fatma HEBAIEB
Kokkali
11:10
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A22
11:10 - 12:40

Resuscitation (Cutting Edge)

Moderators: Clifton CALLAWAY (USA), Othon FRAIDAKIS (GREECE)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
11:10 - 12:40 Resuscitation from cardiac arrest. Clifton CALLAWAY (USA)
11:10 - 12:40 Optimized therapy for patients after ROSC. Wilhelm BEHRINGER (Jena, GERMANY)
11:10 - 12:40 Neurologic prognosis and withdrawal of life-sustaining therapy after cardiac arrest: if, when and how? Tobias CRONBERG (SWEDEN)
Trianti Hall
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B22
11:10 - 12:40

Prehospital (Game Changer)

Moderators: Steffen HERDTLE (Jena, GERMANY), Jana SEBLOVA (Kladno, CZECH REPUBLIC)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
11:10 - 12:40 EMS: fundamental for ED Lean Management? Eric REVUE (Chartres, FRANCE)
11:10 - 12:40 Rescuing the rescuers - necessary? Jana SEBLOVA (Kladno, CZECH REPUBLIC)
11:10 - 12:40 Do we really need an EMS-Physician for Stroke-Patients? Steffen HERDTLE (Jena, GERMANY)
Mitropoulos
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C22
11:10 - 12:40

Mental Health (Cutting Edge)

Moderators: Greg HENRY (USA), Christian HOHENSTEIN (Jena, GERMANY)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
11:10 - 12:40 Difficult patient or misinformed staff? Jim DUCHARME (Mississauga, CANADA)
11:10 - 12:40 Clearing patients in the ED for psychiatric admission. Greg HENRY (USA)
11:10 - 12:40 Physician burnout and suicide - Are you at risk? Julius KAPLAN (New Orleans, La, USA)
Banqueting Hall
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D22
11:10 - 12:40

YEMD - POCUS

Moderators: Adan ATRIHAM (USA), Jennifer TRUCHOT (Paris, FRANCE)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
11:10 - 12:40 The impact of ultrasound on the critical patient. Gregor PROSEN (Maribor, SLOVENIA)
11:10 - 12:40 Ultrasound and simulation: choosing the right teaching tool. Erden Erol UNLUER (TURKEY)
11:10 - 12:40 Ultrasound in the ED in 2017: an ethical imperative? Adan ATRIHAM (USA)
Skalkotas
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E22
11:10 - 12:40

Paediatric
Children as refugees

Moderators: Said HACHIMI IDRISSI (BELGIUM), Santiago MINTEGUI (Barakaldo, SPAIN)
Coordinator: Santiago MINTEGUI (Barakaldo, SPAIN)
11:10 - 12:40 Refugee children's health. Ruud NIJMAN (London, UK)
11:10 - 12:40 Health problems of refugee children: more than we think. Ozlem TEKSAM (Ankara, TURKEY)
11:10 - 12:40 Children among the refugees – (un)usual needs in unusual conditions. Zsolt BOGNAR (Budapest, HUNGARY)
MC-3
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F22
11:10 - 12:40

Free Papers Session 5

Moderators: Felix LORANG (Leipzig, GERMANY), Anastasia ZIGOURA (GREECE)
11:10 - 12:40 #9835 - OP037 Hygiene in the emergency medical service calls for attention.

Background     Contaminated environmental surfaces are known provide an important potential source for transmission of healthcare associated pathogens  and prehospital treatment have been associated to increased risk of infection. Nevertheless, few studies present and discuss prehospital hygiene, resulting in limited knowledge and understanding of related challenges. Our aim was to assess microbial contamination and influencing factors in order to assess the extent of the risks and illuminate eventual solutions.

Methods          A nationwide, semi-blinded, cross-sectional study was conducted in Denmark from August to November 2016. Using a combined swab/agar method, samples from environment, equipment and personnel were randomly collected from 80 ambulances and crew, in-between patient courses, after cleaning. Focus was on colony forming units (cfu) and healthcare associated pathogens. In addition, explanatory variables e.g. hours from last thorough cleaning, area of service (rural/city) and number of patient courses within the shift, were collected and used in bivariate analyses.

Results              800 sites, showed an average of 11.3 cfu/cm2 (environmental sites e.g. blood pressure cuff, patient harness and defibrillator 5.01 cfu/cm2, hands of the personnel 11.1 cfu/cm2 and uniforms 30.6 cfu/cm2). Staphylococcus aureus, Enterococcus and Enterobacteriaceae were found on 10, 3.4 and 0.5 % of the imprints, respectively. One imprint was MRSA, two were VRE but none was ESBL. Furthermore, we found no correlation between the explanatory variables and the degree of microbial burden.

Conclusion      Our study underlines that microbial contamination and related challenges in the EMS calls for further attention. As seen in prior studies, several sites were contaminated with healthcare associated pathogens.  However, neither time from cleaning, number of patients nor area of service were of influence on the degree of contamination, hence not contributing to an explanation. Future research on hygienic challenges and routes of transmission is recommended.

Heidi Storm VIKKE, Matthias GIEBNER, Hans Jørn KOLMOS
11:10 - 12:40 #11059 - OP038 Prehospital echocardiography during resuscitation impacts treatment decisions in a physician-staffed helicopter emergency medical service: a prospective observational study.

Background

Patients in cardiac arrest must receive algorithm-based management such as basic life support and advanced (cardiac) life support. International guidelines dictate diagnosing and treating any factor that may have caused the arrest or may be complicating the resuscitation. Ultrasound is recognized to be of potential value in this process. Also, it is shown to be feasible in a prehospital setting. We aim to determine the impact of prehospital echocardiography during cardiopulmonary resuscitation (CPR) and its impact on treatment decisions in a Dutch physician-staffed helicopter emergency medical service (HEMS).

Methods

We conducted a prospective, observational study from February 2014 through October 2016 of patients treated by the Nijmegen HEMS. Inclusion criteria were CPR irrespective of its cause and concurrent echocardiography. Echocardiography-trained physicians performed the examinations within the same time window where chest compressions are interrupted to analyze heart rhythm. Data collection included patient demographics; type of incident; CPR details and outcome; vital signs; ultrasound findings (ventricular dimensions; global myocardial function; any pericardial fluid); physician-reported image quality and ease of procedure; impact on treatment decisions. Outcome parameters were: impact on treatment decisions; characteristics of the population; feasibility of echocardiography in this setting.

Results

Of 6694 recorded scrambles and 3229 patients treated, 425 underwent CPR. In 56 patients 102 ultrasound examinations were documented. Treatment decisions were impacted in 49 patients (88% - CI 79.5-96.5%) and in 62 (61% - CI 51.5-70.5%) ultrasound examinations. Overall, we found 78 changes. They were termination of CPR in 32 patients (57%) and continuation hereof in 21 (38%). Other changes were related to fluid management (14.3%), adjustment of drugs and doses (14.3%), and choice of receiving hospital (5.4%). The causes of cardiac arrest were trauma (48%), cardiac (21%), medical (14%), asphyxia (9%), and other (7%). The ease of the entire procedure was scored a median of 7 (numeric rating scale 1-10) and image quality per examination good (59%), moderate (29%), or poor (12%).

Discussion

Ultrasound impacts management in 88% of patients. This is in accordance to results of (peri-) resuscitation studies by Breitkreutz (78%) and Shokoohi (12%-31% in different categories, overall unknown). Ultrasound images can help explain futile care to caregivers and relatives, even if the sensible decision already is to terminate CPR. Prehospital (traumatic) CPR is often impeded by stress, time pressure, environmental factors including a restricted workspace, and an inaccessible ultrasound machine. This likely explains the limited number of inclusions. In conclusion, prehospital ultrasound during CPR in our HEMS significantly impacts patient treatment. This suggests echocardiography should be a standard tool in every prehospital resuscitation.

Rein KETELAARS, Christian BEEKERS, Geert-Jan VAN GEFFEN, Nico HOOGERWERF
11:10 - 12:40 #11071 - OP039 Can additional ems call triage time improve resource utilisation?

Background

Time based standards have been used as a key performance measure for EMS internationally, despite a lack of evidence that they actually lead to good clinical care. Achievement of standards in an environment of rising demand potentially leads to operational behaviours that may be inefficient such as dispatching multiple vehicles before the problem is known.  In England, the Ambulance Response Programme is developing new operational models of care. One strategy has been to test if additional call triage time before starting the response interval clock start can lead to better use of resources and improved dispatching.

Methods

A controlled before and after time series analysis of a new intervention – Dispatch on Disposition (DoD)– comprising a short set of pre-triage questions to identify time critical emergencies needing immediate dispatch of a resource and up to 4 minutes to triage all other calls (compared to the existing 60 seconds). DoD was implemented in 6 of the 10 regional services in England and 4 services were control sites. We measured weekly trends in average resource allocation per call and resources on scene for different call types (life-threatening, emergency, urgent) for 1 year before and 7 months after implementation, and used time series regression models to compare changes between intervention and control sites adjusted for seasonality, call volumes and hours lost at hospital handover. We also conducted a survey of dispatch and operational staff.

Results

There was a statistically significant reduction in average resources allocated per incident of -0.1 for life-threatening calls, -0.06 for emergency and -0.12 for urgent, and a reduction in resources arriving on scene per incident of -0.006 for life-threatening calls and -0.02 for urgent in the intervention groups compared to control. Scaled up the resource allocation reductions will potentially produce an additional 10243 whole resources available to respond per week in England. Dispatch staff reported they were better able to manage call queues and allocate the right rather than any response. Operational staff reported a substantial reduction in calls where they were cancelled before arriving on scene.

Conclusions

Prior to DoD ambulance services in England had to dispatch a resource within 60 seconds of receiving an emergency call and in order to achieve a response time of 8 minutes for the most serious calls multiple resources could be sent before establishing if the call was serious. Allowing additional time to properly triage calls other than those likely to be life-threatening has created efficiencies by substantially reducing multiple resource allocations and freeing up vehicles for other calls. In an environment of increasing demand and diminishing resources this allows better use of existing resources.

Janette TURNER, Richard JACQUES, Annabel CRUM
11:10 - 12:40 #11172 - OP040 Improving data quality in a United Kingdom registry of Out-of-Hospital cardiac arrests through data linkage between the Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project and the Office for National Statistics.

Background: The Out-of-Hospital Cardiac Arrest Outcomes (OHCAO) project aims to understand the epidemiology and outcomes of out-of-hospital cardiac arrests (OHCA) across the UK. Significant variation exists between ambulance services in outcomes for patients with attempted resuscitation following OHCAs. Importantly, a great deal of the variability of reported outcomes can be traced back to the quality of data that results are based on.

This study is a sub-project of OHCAO and aims to establish the feasibility of producing a registry of OHCAs by linking OHCAO data to the Office for National Statistics (ONS) mortality data, via NHS (National Health Service) Digital, to improve data quality and establish accurate 30-day survival outcomes for OHCAs.

Methods: Data were collected from 1st January 2014 to 31st December 2014 as part of a prospective, observational study of all OHCAs attended by ten English NHS Ambulance Services. 28,729 OHCA cases had resuscitation attempted by Emergency Medical Services and were included in the study. Of these, a randomly selected sample of 3,120 cases (10% of total) were securely transferred to the ONS. This allowed OHCAO demographic data to initially be matched to NHS patient demographic data, using the NHS Digital list cleaning service to return previously missing data. Following this, cases were linked to ONS mortality data to provide accurate death dates where applicable to calculate 30 day survival.

Results: A total of 80.5% of OHCAO cases were matched to the ONS database. OHCAO collected complete demographic datasets on 868 (27.8%) cases. Using the linkage process, missing demographic data was retrieved for 72.7% of the 2,249 cases with incomplete data. Confirmation of 30-day survival improved by 37.6% with a reduction in unknown 30-day survival status from 46.1% to 8.5%. The most important data point required for linkage was the NHS number which provides a unique patient identifier. However, it was only retrieved by the OHCAO project for 31.7% of cases. This study found that if at least 3 other demographic data points were collected, the NHS number could be retrieved using the linkage process in up to 89.9% of cases.

Discussion: Ensuring high data quality is essential as this forms the basis of decisions that ultimately impact on changes in care and healthcare resource allocation. Data linkage was shown to successfully improve the quality of OHCA demographic data and survival status 30 days after OHCA. Importantly, this process has allowed the provision of demographic details to allow patients to be followed longitudinally, potentially to assess morbidity following OHCAs. The linkage process can be used to produce a registry of OHCAs and information gained from this can be fed back to institutions providing source data to improve OHCA outcomes.

 

Sangeerthana RAJAGOPAL, Scott BOOTH, Claire HAWKES, Chen JI, Terry BROWN, Samantha BRACE-MCDONELL, Sarah BLACK, Imogen GUNSON, Kim KIRBY, Niroshan SIRIWARDENA, Robert SPAIGHT, Gavin PERKINS
11:10 - 12:40 #11602 - OP041 Fire Medical Response Early Indications of Clinical Value.

 

Fire Medical Response Early Indications of Clinical Value

Background

In the UK, response to serious medical emergencies has been solely provided by the National Health Service (NHS), but UK Fire and Rescue Services (FRS) are increasingly establishing a presence as ‘Fire Medical Responders.’  FRS are highly developed organisations with the potential to offer a rapid response to medical emergencies. They also operate with ‘latent capacity,’ compared to health care resources, creating an opportunity to assist in meeting urgent patient need.  The aim of this study was to investigate the impact of FRS co-responding on the delivery of emergency medical response.’

Methods

An observational study generating data from 42/50 Fire & Rescue Services, FRS, during 2016 to assess current involvement in EMS co-response.  We have a) compared response time distributions between Fire and Ambulance services b) described the types of calls attended by FRS crews c) estimated the likely survival benefit based on optimal response time curves for successful defibrillation in out of hospital cardiac arrest and d) conducted an economic evaluation.

Results

There was a statistically significant difference in response performance between the Fire and NHS Ambulance Services, with FRS arriving first in 62% of cases, NHS Ambulance Service arriving first in 23% and no record of who arrived first in 25%.   For every 10% increase in the proportion of ‘whole time duty fire stations’ [stations with 24 hrs/day staffing], there was an 8.4% improvement in response time and mean 84 second shorter response time compared to stations using retained staff utilised via an “on call” system. The top 5 clinical categories attended by FRS were: cardiac problems/chest pain (23%); breathing problems (13%); unconsciousness (13%); cardio-respiratory arrest (9%), and fitting (9%).  From the response time improvement data, we have estimated a potential survival benefit of 1.2 Quality Adjusted Life Years (QALYs) gained.  Using NICE figures of £20,000 per QALY, there is a potential benefit of around £23,000 per critical medical event but this figure should be treated with caution as it is a theoretical extrapolation and the study was not designed to measure individual patient outcome.

Conclusions

Fire Medical Responding is a new development in the UK, having previously operated a strict demarcation between fire and ambulance services although it is well-established in some European countries and in other parts of the world, such as the USA.  This study found FRS can frequently respond more rapidly to medical emergencies than the ambulance service and that they can be appropriately deployed to time critical conditions. This offers an opportunity to employ an underutilised, potentially life-saving resource more widely at low cost.  There is a potential life-saving advantage in further developing and evaluating a Fire Medical Response capability.

 

Julia WILLIAMS, Andy NEWTON
11:10 - 12:40 #11971 - OP042 IMMIGRATION PROBLEM IN GREECE, The impact for Emergency Medical System in Attica Creece 2.

IMMIGRATION PROBLEM IN GREECE,

The impact for Emergency Medical System in Athens

 

INTRODUCTION

Over 10000 refugees have lost their lives in the Mediterranean since 2016 in their endeavor to reach the EU

In the first half of 2016 there were 2809 recorded deaths

Immigration today is one of the most important problems in the world and at the same time a purely anthropocentric challenge for all stakeholders, especially the EMS in GREECE (National Centre for Emergency care) (First responder)

SCOPE-METHOD

    In 2015 Greece became the main point of entry into the EU for refugees and immigrants from Turkey. It is estimated that 850,000 people attempted the dangerous passage of the Aegean Sea

Of these, more than 53,000 refugees remained in Greece Most of them (about 90%) come from Syria, Iraq, and Afghanistan. Among them are small children, people with severe health problems, pregnant women, and infants

Disease-related diseases (refugees) are often unexpectedly severe and complex (extreme age groups - infants, children, and the elderly)

To describe & estimate the effect on EMS/NHS

CHARACTERISTICS:

Children make up 48% of the refugees, while for adults, 30% of them are men and 22% are women

  • 10% of refugees in Greece are only 2 to 4 years old
  • 14% are aged between 5 and 9 years
  • 11% are aged 10 and 14 years old

There are camps that sheltered all these people in ATTICA 

 DATA for the present study are from the central Department of EMS & Na.H.O.C. archives

In the year 2016 they took place: more than 5000 records of emergency transportations from the above camps to Hospital through the Na.H.O.C. & EMS  

CONCLUSIONS:

  • The effect of migration problem in our country runs through every activity
  • EMS/NaHOC is responsible to manage the medical problems of the immigrants
  • This require resources from our country in a very difficult period to be available  
  • Although our country overcomes the present problems & reacts in the best practice 

 

Spyros PAPANIKOLAOU, Vasilis KEKERIS, Konstantina DIMITRIOU, Jimi JIANNOUSI
11:10 - 12:40 #10977 - OP043 Intoxications with prescription drugs at Tampere University Emergency department in 2014.

Background: Intoxications with prescription drugs are a common burden at emergency departments (EDs). Mortality associated with intoxication has been increasing. Intoxications are a common way to commit suicide, especially among women. Our study aimed to evaluate intoxication patients` psychiatric history and other clinical features.

Material and methods: We identified all patients with ICD10- code TX36 from year 2014 at Tampere University ED.  We collected the data on age, gender, arrival time and date from hospital records. We also collected patient-specific data such as psychiatric diagnoses, previous psychiatric care and suicide attempts, alcohol and/or drug consumption, difficulties in life (with relationships, money, work or with own or relatives` health) and somatic symptoms.

Results: There were a total of 372 patients with a slight female predominance (51,6 %).The median age was 38 years (1-92 years).  40% of cases arrived to ED between 6 p.m-12 p.m. The most used prescription drug was benzodiazepam (34%). 13% of patients had also used some type of illegal drug, for example cocaine, LSD and cannabis. Activated charcoal was given to 71 % of the patients. According to our data, 53% of intoxications were intentional/suicidal and in 18% of cases the feature of self-harm was not registered. 10% of patients had had one previous intoxication in the database of Tampere University Hospital during the previous two years, and 2% had had more than one intoxication during the same time. The most common difficulties in life were associated with interpersonal relationships (43%). 54% of the patients received psychiatric consultation and 66% were guided to psychiatric after-care.  The most common somatic complication of the intoxication was respiratory tract infection (7 %). Seven-day mortality was 0.8 % and one-year mortality 4.8 %.

Discussion: The results of our study were convergent with previous intoxication studies. Gastrointestinal decontamination was executed rarely but the number of complications, however, was low. This can be partly explained by effective and well-functioning treatment chains and settings. Understanding the associated features of intoxication patients is important for care guidance to these patients. As we could see in this study, many of the patients attempted suicide but only a minority of them were in danger of death.  These cases should be recognized as a cry for help. It is important for health care workers to identify high-risk patients and to guide them to psychiatric care as soon as possible, in order to prevent recurrent intoxications. This study shows that if the intoxication patient reaches the hospital, the prognosis is good. The mortality rate in this patient group is low.

Sini HEIKKONEN, Tiia MERKKINIEMI, Sami MUSTAJOKI, Sami PIRKOLA, Satu-Liisa PAUNIAHO
11:10 - 12:40 #11833 - OP044 BACLOFEN POISONING: AN EPIDEMIOLOGICAL RETROSPECTIVE STUDY IN A TUNISIAN INTENSIVE CARE UNIT.

  

Ben Jazia AMIRA, Fatnassi MERIEM, Khzouri TAKOUA , Khelfa MESSOUDA , Aloui ASMA, Fradj HANA, Blel YOUSSEF, Brahmi NOZHA
11:10 - 12:40 #11851 - OP045 Pediatric emergency department visits due to acute ethanol intoxication.

Background: Alcohol is one of the most frequently abused drugs. Alcohol exposure of pediatric population is gradually increasing all over the world thus leading to acute alcohol intoxication and its consequences. 

Objective: The aim of this study was to describe presentations and analyze demographic, clinical and laboratory characteristics of pediatric patients presented to the pediatric emergency department with acute ethanol intoxication.

Methods: We conducted a retrospective review of pediatric patients, who presented to a pediatric emergency department with any complaint and had serum ethanol level determined between January 2006 and December 2016. Patients with serum ethanol level below 50 mg/dL, patients with insufficient data and patients older than 18 year-old were excluded from analyses.

Results: Serum ethanol levels were determined for 917 patients. Among these, 229 patients were tested positive for alcohol abuse having serum ethanol levels >50 mg/dL. Nine patients were excluded because of having insufficient data so a total of 220 patients (Male 128; female 92) were included in the study. 53% patients were brought to the emergency department by emergency medical services. Mean age was 16.0±1.6 years. Most frequent complaints at presentation were decreased level of consciousness (29.5%, n=65), nausea/vomiting (21.8%, n=48) and trauma (14.1%, n=31). The median Glasgow Coma Score on admission to the emergency department was 15.  Only 5 patients had GCS ≤8. Minor injuries were identified in vast majority of patients with trauma. Most common injury type was falls (5.5%, n=12). 11.8% (n=26) patients consumed alcohol as part of a suicidal attempt. Serum ethanol level ranged between 50.8-341.2 mg/dl (mean: 157.9±57.9 mg/dl).  63% (n=140) patients had blood gas analysis. Among these 68.6% (n=96) had hyperlactinemia. 207 patients had biochemical investigations, which revealed abnormal kidney functions in 20.8% (n=43). Likewise, 19% (n=39) had hypokalemia (<3.4 mEq/L) while 17.6% (n=36) had hypophosphatemia (<2.7 mEq/L). None of the patients had hypoglycemia. However, 51.9% (n=95) had mild hyperglycemia (100-200 mg/dL). Blood glucose level and pH were correlated with serum ethanol levels (p=0.007, R2=0.053 and p=0.008, R2= 0.038, respectively). Vast majority of the patients (94%) received treatment in the pediatric emergency department.

Discussion: Acute alcohol intoxication in pediatric population is a preventable emerging problem. It is important to recognize that hyperlactatemia, hypokalemia, hypophosphatemia, mild hyperglycemia and abnormal kidney functions are common biochemical findings in children with acute ethanol intoxication. 

Damla HANALIOĞLU, Ahmet BIRBILEN, Aslı PINAR, Filiz AKBIYIK, Ozlem TEKSAM
Kokkali
14:10
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A23
14:10 - 15:40

Geriatric (Cutting Edge)

Moderators: Mehmet Akif KARAMERCAN (Ankara, TURKEY), Christian NICKEL (Basel, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
14:10 - 15:40 Implementation of a screening program for older patients visiting the Emergency Department; pitfalls and opportunities. Simon. P. MOOIJAART (Leiden, THE NETHERLANDS)
14:10 - 15:40 How to geriatrisize your ED. Simon. P. MOOIJAART (Leiden, THE NETHERLANDS)
14:10 - 15:40 Delirium. Christian NICKEL (Basel, SWITZERLAND)
Trianti Hall
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B23
14:10 - 15:40

Resuscitation (How To)

Moderators: Tobias CRONBERG (SWEDEN), Othon FRAIDAKIS (GREECE)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
14:10 - 15:40 To intubate or not to intubate during cardiac arrest. Clifton CALLAWAY (USA)
14:10 - 15:40 Glucose and Insulin during cardiac arrest. Roman SKULEC (Kladno, CZECH REPUBLIC)
14:10 - 15:40 33°C or 36°C after resuscitation from cardiac arrest? Wilhelm BEHRINGER (Jena, GERMANY)
Mitropoulos
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C23
14:10 - 15:40

Ultrasound (How to)
"Breaking the waves, new ways to use ultrasound in the ED"

Moderators: Gregor PROSEN (Maribor, SLOVENIA), Senad TABAKOVIC (Zürich, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
14:10 - 15:40 How ultrasound is going to influence decision making in the future. Eftychia POLYZOGOPOULOU (Patras, GREECE)
14:10 - 15:40 New ways to use ultrasound in the ED. James CONNOLLY (Newcastle Upon Tyne, UK)
14:10 - 15:40 How to teach ultrasound in the future. Gregor PROSEN (Maribor, SLOVENIA)
Banqueting Hall
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D23
14:10 - 15:40

YEMD - How to communicate in the ED

Moderators: Roberta PETRINO (Vercelli, ITALY), Basak YILMAZ (Ankara, TURKEY)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
14:10 - 15:40 How to communicate with other clinics. Oktay ERAY (Antalya, TURKEY)
14:10 - 15:40 How to communicate with hospital management. Greg HENRY (USA)
14:10 - 15:40 How to please patients and still practice good medicine. Adan ATRIHAM (USA)
14:10 - 15:40 How to build great ED staff. Roberta PETRINO (Vercelli, ITALY)
Skalkotas
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E23
14:10 - 15:40

Paediatric
Debate time

Moderators: Mark LYTTLE (Bristol, UK), Itay SHAVIT (ISRAEL)
Coordinators: Said HACHIMI IDRISSI (BELGIUM),Said HACHIMI IDRISSI (BELGIUM)
14:10 - 15:40 Fluid resuscitation in sick children: Yes-No. Tom BEATTIE (UK)
14:10 - 15:40 Fluid resuscitation in sick children: Yes-No. Ruth FARRUGIA (Malta, MALTA)
14:10 - 15:40 Tranexamic Acid in trauma resuscitation: Yes-No. David WALKER (Jackson Heights, USA)
14:10 - 15:40 Tranexamic Acid in trauma resuscitation: Yes-No. Said HACHIMI IDRISSI (BELGIUM)
14:10 - 15:40 Flumazenil for benzodiazepine overdose: Yes-No. Cathelijne LYPHOUT (Ghent, BELGIUM)
14:10 - 15:40 Flumazenil for benzodiazepine overdose: Yes-No. Lisa AMIR (ISRAEL)
MC-3
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F23
14:10 - 15:40

Free Papers Session 6

Moderators: Felix LORANG (Leipzig, GERMANY), Anastasia SFAKIOTAKI (Melbourne, AUSTRALIA)
14:10 - 15:40 #10117 - OP046 Differences in the use of skull radiography in children with minor head trauma.

Background: Minor head trauma is a major cause of emergency department visits. Head computed tomography (CT) is the reference standard for the emergency assessment of head trauma. A recent multicentre study of Research in European Pediatric Emergency Medicine (REPEM) network demonstrated that 30% of patients with a minor head trauma (MHT) underwent skull radiography (SR).

Objective: Describe the practice variation in the use of SR for MHT in a group of hospitals affiliated to REPEM.

Design/Methods: Subanalysis of a multicenter retrospective study, including 15 hospitals from 9 European countries. Patients up to 18 years with MHT, defined by Glasgow Coma Scale score (GCS) 14-15, evaluated in years 2012, 2013 and 2014 were included. Pediatric Emergency Care Associated Research Network (PECARN) rules were considered the standard to assess differences in management and to stratify the risk for clinically important Traumatic Brain Injury (ciTBI).

Results: In the main study 13.266 patients (GCS 13-15) were included and 10.109 (76.8%) patients had MHT. The prevalence of ciTBI was 79/10109 (0.77%). SR was performed in 2.762 (27.3%) patients. The rate of SR varied between centres from 0.42% to 92% (figure 1).
Fifty-four (1.96%) had a skull fracture in the SR. In 27 (50%) a head CT confirmed a skull fracture or documented an intracranial lesion. Thirteen (48.1%) patients with skull fracture had other intracranial findings while 14 (51.9%) children had an isolated displaced skull fractures.
Three (11.1%) patients required surgery, due to intracranial lesions.
In 27 (50%) patients, the head CT did not demonstrate any fracture or intracranial lesion.
Twenty-one (77.8%) true positive patients would be classified as intermediate or high risk for ciTBI according PECARN criteria.
Focusing on children determined as low risk for ciTBI according to PECARN rules, SR was performed in 1.933 (28.9%) patients, and demonstrated a fracture in 12 (0.62%) patients. Three (0.16%) patients had an associated intracranial lesion.
Factors associated with the use of SR were grouped as intermediate or high risk for ciTBI according to PECARN rules and isolated scalp hematoma.

Conclusion(s): Although the low diagnostic value does not justify its use, SR is frequently ordered in management of MHT patients in a representative group of pediatric emergency department of the REPEM. We demonstrated a wide variation in the use of SR. These differences are mainly to be due to local or national guidelines and consolidated practices more than lack of adherence to validated prediction rules.

Roberto VELASCO, Niccolo PARRI, Carmel MOORE, Zsolt BOGNAR, Federica D'ELIA, Özlem TEKSAM, Santiago FERNANDEZ, Liviana DA DALT, Eveline SNOECK, Merel BROERS, Ricardo FERNANDES, Anaida OBIETA, Maider ALCALDE, Javier GONZALEZ, Sergi PIÑOL
14:10 - 15:40 #10905 - OP047 Cervical spine stabilisation in pediatric major trauma: a questionnaire of current practice.

Background

Cervical spine (C-spine) injuries in pediatric trauma are rare (0-2%)1, but can cause long-term morbidity. Recent Advanced Paediatric Life Support (APLS) guidance1 updated advice on management of suspected C-spine injury, not advocating routine use of hard collars. There are minor differences within existing national guidance on the same subject [National Institute for Health and Care Excellence (NICE)2, Joint Royal Colleges Ambulance Liaison Committee (JRCALC)3, Advanced Trauma Life Support (ATLS)4]. This study was undertaken to formally understand observed variations in C-spine stabilisation for pediatric trauma in the East of England (EoE) Trauma Network. 

 

Methods

An online questionnaire was sent to members of the EoE Trauma Network.  Respondents were presented with five hypothetical scenarios, reflecting changes in guidance, summarised as follows; 1) 4 year old (yr), high-speed motor vehicle collision, intubated, 2) 9 yr, 2 metre fall, GCS 14, chest pain, 3) 7 yr, bicycle collision, C-spine tenderness, for transfer to CT, 4) 6 yr, 4 step fall, GCS 13, combative, 5) 3 yr, rollover motor vehicle collision, asymptomatic.

Respondents chose whether C-spine protection was required followed by the type of protection required [‘Manual in-line stabilisation’ (MIS), ‘Collar’ or ‘Blocks and tape’ (B&T)] and ‘No protection required’. 

 

Results

A total of 163 responses were received from October 2016 to February 2017, mainly from paramedics (64%, 105/163) and 13% (21/163) from doctors.

  1. 77% (124/162) were unaware of recent changes in APLS guidance.
  2. The majority thought stabilisation was required in scenarios 1 to 4 [97% (161/166), 77% (130/168), 96% (158/164) and 82% (136/166) respectively]. However, opinion was divided in scenario 5 with 50% (81/162) choosing to stabilise, and 50% (81/162) otherwise. 
  3. The chosen method of stabilisation also varied, notably in scenario 2 [MIS; 44% (57/130), collar; 20% (26/130), B&T; 36% (47/130)]. Few chose collar for a combative child [scenario 4; 8% (11/136)].
  4. Of 666 total responses, collars were chosen least often [18% (118/666)], and MIS and B&T were selected equally [41% (274/666)].

 

Conclusions

The results suggest varying practice in C-spine stabilisation in the region, possibly reflecting variation in national guidelines. Encouragingly, appropriate protection was used majority of the time. Despite the limitations of this survey, it provides preliminary evidence of inconsistent practice, and hence requirement for clearer guidance and education.  More studies are needed to validate these findings, and ascertain whether they are representative of a national issue.

Lucy CROSSMAN, Shruti AGRAWAL, Helen BAILIE, Khurram IFTIKHAR
14:10 - 15:40 #10956 - OP048 How well do vital signs predict serious illness in children?

Introduction 

Vital signs are commonly measured during the first clinical assessment at the emergency department (ED). Usually, healthcare workers judge these physiologic measurements based on existing reference ranges and values below or above the pre-specified cut-offs are interpreted as abnormal. Many different vital signs reference ranges exist for use in children, but their diagnostic value is uncertain. Therefore, the aim of this study is to determine the diagnostic value of commonly used heart rate and respiratory rate reference ranges for the recognition of serious illness in children at the ED.

 

Methods

We assessed commonly used paediatric reference ranges for heart rate and respiratory rate, including those from guidelines, textbooks, medical literature and those provided in triage systems or early warning scores. The analysis is based on a observational cohort of children under 16 years of age, presenting to the ED of a university hospital in the Netherlands (2009-2012). Nurses routinely recorded patient data, vital signs and patient destination in the electronic health record. Missing vital signs were imputed 10 times using a multiple imputation approach. In a descriptive analysis we explored differences between the age-classification and cut-off values of the different reference ranges. Moreover, we assessed the diagnostic accuracy of these reference ranges for serious illness in children, defined as the need for ICU admission or hospital admission immediately after the ED visit

 

Results 

In our cohort, 15,099 children attended the ED during the study period, of whom 314 (2.1%) were admitted to ICU and 2681 (17.8%) to hospital. We identified 11 commonly used paediatric reference ranges for heart rate, respiratory rate, or both. These showed a large variation in age classification and corresponding cut-off values. Application of the different reference ranges in our cohort classified 2.4% to 58.0% of heart rate and 1.0% to 61.4% of respiratory rate values as abnormal. None of the individual vital signs had both a high sensitivity and a high specificity to detect serious illness in children, but the trade-off was very different for each of the reference ranges. Abnormal heart rate had a sensitivity ranging from 0.13 to 0.76 and a specificity ranging from 0.42-0.98 for ICU admission. For hospital admission, sensitivity ranged from 0.06 to 0.72 and specificity from 0.45 to 0.98. The diagnostic accuracy of respiratory rate also had a wide range, with sensitivity 0.05 to 0.69 and specificity 0.39 to 0.99 for ICU admission and sensitivity 0.02 to 0.68 and specificity 0.39 to 0.99 for hospital admission.

 

Conclusion

Several vital sign reference ranges for children exist and differences are large. It is important to be aware whether a certain reference range is better at ruling-in or ruling-out serious illness. Future research should aim at optimizing the cut-off of individual vital signs to improve existing reference ranges for children at the ED.

Joany ZACHARIASSE, Nienke HAGEDOORN, Henriëtte MOLL
14:10 - 15:40 #11026 - OP049 The value of routine blood pressure measurement in children at the emergency department: a prospective observational study.

Introduction

Blood pressure measurement is recommended in children at the emergency department (ED) because low blood pressure is considered a marker of serious illness. However, blood pressure measurement is time consuming and a burden for (young) children. Moreover, different reference values are available and little evidence exists about the diagnostic value of low blood pressure in children. This study aims to identify lower reference values for systolic blood pressure and to investigate the diagnostic value of routine blood pressure in addition to heart rate in children at the ED.

 

Methods

A systematic review was performed to define age-specific cut-off points for low blood pressure. Secondly, we used blood pressure cut-offs from two well-known international guidelines (APLS and PEWS) in a prospective cohort of children attending a university ED (2009-2013) in the Netherlands. To investigate the diagnostic value for these two blood pressure cut-offs, we performed multivariable logistic regression to assess the association of abnormal blood pressure with serious illness, adjusted for abnormal heart rate. Sensitivity and specificity for serious illness (hospital or ICU admission) according to abnormal blood pressure defined by the APLS and PEWS were calculated. To assess the additional value for heart rate, sensitivity and specificity were computed for tachycardia and for patients who had both tachycardia and abnormal blood pressure according to the two cut-offs.

 

Results

18 articles and 11 guidelines reported reference ranges. Only one guideline cited literature references. There was a large variation between the different age-related cut-offs for hypotension (differences ranging from 15 to 30 mmHg in age groups). In the observational study, 5467 children had complete data of blood pressure and heart rate. Frequency of ICU- and hospital admission was 5.5% and 34.7%, respectively. Abnormal blood pressure was significantly associated with hospital admission when adjusted for heart rate based on APLS (OR 1.32 95%CI 1.17–1.48) or based on PEWS (OR 1.76 95%CI 1.57–1.98). Similar associations were found with ICU admission. Abnormal blood pressure according to the APLS showed moderate sensitivity (67%; 61%) and low specificity (43%;45%) for ICU- and hospital admission. The PEWS demonstrated low sensitivity (55%;44%) and moderate specificity (64%; 68%). Tachycardia had low sensitivity (37%;30%) and high specificity (81%;85%) for ICU- and hospital admission. When combining tachycardia and abnormal blood pressure, the APLS showed high specificity (88%; 90%) and low sensitivity (21%;14%). The PEWS showed similar results.

 

Conclusion

Clinical references for blood pressure show large differences and are mostly not evidence based. Abnormal blood pressure showed an association with serious illness at the ED, but its diagnostic value is uncertain. However, the combination of tachycardia and abnormal blood pressure appears to be good at ruling-in serious illness. 

Nienke HAGEDOORN, Joany ZACHARIASSE, Henriëtte MOLL
14:10 - 15:40 #11068 - OP050 Are procalcitonin, C-reactive protein and absolute neutrophil count useful for predicting invasive bacterial infection in neonates under 21 days old with fever without source?

Background: neonates with fever without source (FWS) present a higher prevalence of invasive bacterial infection (IBI) than older infants. For this reason, it has been universally recommended performing a lumbar puncture and the admission with antibiotic treatment for any febrile neonate, even for those who are well-appearing. The “Step-by-Step” approach uses the 21-days-old cut-off point to identify high-risk patients. Our objective was to analyze the performance of the procalcitonin (PCT), C-reactive protein (CRP) and absolute neutrophil count (ANC) to identify IBIs among well-appearing neonates ≤21 days old with FWS.

Methods: a prospective registry-based cohort study including all the infants ≤90 days old attended in the Pediatric Emergency Department of a tertiary teaching hospital between September 2008 and August 2016 with FWS. We compared the prevalence of IBI (isolation of a pathogen bacterium in blood or cerebrospinal fluid) between those well-appearing patients ≤21 days old and >21 days old without leukocyturia in two groups: those with altered blood tests (PCT ≥0.5 ng/mL, CRP >20 mg/L or ANC >10000/mcL) and those with normal blood tests. We excluded those patients in whom the value of any of the three blood tests, the urine dipstick result or the blood culture result was not available.

Results: we included 1,762 of the 1,970 infants ≤90 days old with FWS attended (89.4%). Of them, 1,358 (77.0%) infants were well-appearing and had no leukocyturia in the urine dipstick. PCT, CRP and ANC values were normal in 126 of the 178 infants ≤21 days old (76.7%) and in 956 of the 1,180 infants > 21 days old (81.0%).

Prevalence of IBI in infants ≤21 days old was 3.2% among those with normal blood tests (vs 0.1% in infants >21 days old; OR 31.31 [IC 95%: 3.28-741.52]) and 5.7% among those with any of the three blood tests altered (vs 4.9% in infants >21 days old; OR 1.19 [IC 95%: 0.25-4.83]). Two of the four well-appearing infants ≤21 days old with normal blood tests who had an IBI were diagnosed with a bacterial meningitis.

Sensitivity and specificity of the three blood tests for identifying IBIs were 42.9% (15.8-75.0%) and 71.3% (64.2-77.6%), respectively in infants ≤21 days old and 91.7% (64.6-98.5%) and 81.8% (79.4-83.9%), respectively in infants >21 days old.

Discussion: PCT, CRP and ANC do not have a good performance to identify febrile infants less than 21 days old at low risk for IBI. In contrast to older infants, these tests cannot be used to identify patients suitable for a less aggressive management. Accordingly, neonates under 21 days old with FWS must be admitted with empiric antibiotic treatment after performing a lumbar puncture, regardless the general appearance and the results of the blood tests.

Borja GOMEZ, Haydee DIAZ, Alba CARRO, Javier BENITO, Santiago MINTEGI
14:10 - 15:40 #11306 - OP051 Antibiotic prescription in children with respiratory tract infections at EDs in The Netherlands.

Introduction

Fever is the main presenting symptom of children presenting at paediatric emergency departments (EDs) in Europe, with a majority related to respiratory tract infections (RTI’s). Despite a low rate of bacterial infections (5 – 10% of febrile children), we observe antibiotic prescription rates of 40-56% in children with RTI’s, with high variability among European EDs. This study aims to evaluate the association between clinical characteristics and antibiotic prescription rates in children under five with suspected lower respiratory tract infections at 6 Dutch EDs.


Methods

Prospective collected data of a multicentre study in 6 paediatric EDs in The Netherlands, both teaching and non-teaching. The population consisted of children aged 1 month to 5 years presenting at the ED with fever and cough or dyspnoea. We computed a risk profile for bacterial infection based on clinical characteristics, using a clinical prediction rule (Feverkidstool). Variation in risk profile and antibiotic prescription rate were assessed and associations tested.


Results

Results are based on 206 patients, 63% male, median age 16 months (IQR 7 – 32m). Median predicted risk of a bacterial infection according to the Feverkidstool was 9% (IQR 9 – 17%), ranging between centres from 5 – 15%. Overall antibiotic prescription rate was 42% (range 24 – 60% between centres). Children with a higher risk profile had a significantly higher prescription rate (Nagelkerke’s R2=23%). There was no association between prescription rate and centre. When stratified by clinical profile, antibiotic prescription rate was 13% in low-risk patients (predicted risk 0-5%), 34% in medium-risk patients (predicted risk 5-10%) and 65% in high-risk patients (predicted risk >10%).


Discussion

Antibiotic prescription rates are high among children with respiratory tract infections with variable rates among 6 Dutch EDs. Variability among centres is mainly explained by risk profile. Given the nature of lower respiratory tract infections, watchful waiting and follow-up in low and medium-risk patients could add to a reduction in antibiotic prescriptions.

J.s. VAN DE MAAT, D. NIEBOER, A.m.c. VAN ROSSUM, F.j. SMIT, J.g. NOORDZIJ, G. TRAMPER, C.c. OBIHARA, A. VAN WERMESKERKEN, G.j.a. DRIESSEN, J. PUNT, H.a. MOLL, R. OOSTENBRINK
14:10 - 15:40 #11489 - OP052 INTRANASAL KETAMINE FOR PERIPHERAL VENOUS ACCESS IN PEDIATRIC PATIENTS: A RANDOMIZED DOUBLE BLIND AND PLACEBO CONTROLLED STUDY.

Objectives: To verify the efficacy of intranasal ketamine as sedative agent for venous access in children.
Method: Randomized, double blind, placebo controlled study conducted at ER Hospital de Clínicas de Porto Alegre (Brazil) between November 2015 and August 2016. Children needing venous access were randomized to receive intranasal ketamine (4mg/Kg) or normal saline solution (Placebo group). Groups were compared regarding the time for venous access, facility for performing the procedure, adverse events, disturbances in vital signs and perception of the accompanying adult. The study was approved by the Local Ethics Committee.

Results: 39 children (21 Ketamine; 18 Placebo) were included without differences regarding to age, sex, weight, reason for hospitalization and professional experience. The median age was similar (19.8 x 15.8 months), as well as the median weight (10.0 x 11.3Kg). Ketamine reduced the length for venous access (23.0 x 67.5 seconds; p=0.01), and facilitated the procedure (p=0.00009). Ketamine induced sleepiness 15 minutes after its administration (p=0.003) and reduced the number of people for the child’s restraint (p=0.025). No difference was verified between groups regarding adverse effects or vital signs disturbance ́s. Side effects were observed in 29% of the children in the Ketamine group and 17% in the Placebo group, irritability being the most common for both. The accompanying adult reported that 81% of children in ketamine group were calm and quiet (p=0.0003).

Conclusions: Intranasal ketamine (4mg/Kg) reduces the time for venous puncture, facilitates the procedure to the nurse, decreases the number of people involved and provides a tranquil environment with low risk.

Patricia LAGO, Joao Carlos SANTANA
14:10 - 15:40 #11541 - OP053 Optic nerve sheath diameter measurement: a means of detecting increased ICP in traumatic and non-traumatic pediatric patients.

Introduction: Increased Intracranial Pressure (IIP) is a highly clinical mortality condition, which can be caused by various causes. It should be diagnosed rapidly, and its treatment should be done timely and correctly in emergency units. The procedures performed for the purpose of diagnosing and determination of etiology in patients with IIP are either invasive or cause radiation exposure. In this study, we aimed to determine the benefit of measurement of the optic nerve sheath diameter (ONSD) by ultrasonography (US) and power of the test in the evaluation of IIP.

Materials and Methods: After the primary treatment of the patient who was brought to our pediatric emergency department, transorbital ultrasonography was applied in the supine and neutral position as his/her eyes closed. Sonographic ONSD evaluation was performed using a SonoSite Edge ultrasound device with 6–13 MHz linear probe. The diameter of the optic nerve, which appeared as a hypoechoic two-sided line at a depth of 3 mm of globes which is determined as more sensitive to IIP alteration, was measured and recorded in both longitudinal and transverse sections.

Findings: Fifty-seven cases with IIP suspicion brought to our unit (31 males; 138 ±56 months old) and 35 controls (17 males; 151± 45 moths old)  were included in the study between June 2015 and December 2016. Thirty-one cases (54%) were trauma cases with the high probability of clinical signs of IIP. Others had headache, vomiting, altered consciousness, seizures. Eight of our patients had GCS <= 8. One patient died and 16 children were admitted to our intensive care unit. 19 of our patients were treated with anti-edema treatment. The ONSD value of the 38 patients without brain edema on CT scan was 4.8 ± 0.05 mm (Processing time: 2.8 ± 1 min). The ONSD of those with brain edema was 5.5 ± 0.07 mm (Processing time: 2.0 ± 1 min). The mean ONSD of all patients (5.0 ± 0,07 mm) showed significantly increased compared with the controls (3,9 ± 0,02 mm) (p<0.01). The ideal cut-off value of ONSD was found to be 4.9 mm when the cerebral edema detected in the CT scan was accepted as a reference (Sensitivity 84.2% and specificity 63.2%). Six patients had optic disc elevation (The median ONSD was 6 mm). The CT scan of all of these patients was compatible with brain edema.

Conclusions: CT examination and fundoscopy for diagnosing IIP are useful methods for middle/late stages of the IIP syndrome. As ONSD begins to expand within minutes when intracranial pressure begins to increase, ONSD measurement may be more sensitive in the acute stage and guide patient management in case of clinical suspicion of IIP.

Ozlem TOLU KENDIR, Hayri Levent YILMAZ, Tugsan BALLI, Ahmet Kagan OZKAYA, Sinem SARI GOKAY
14:10 - 15:40 #11676 - OP054 EFFECTS OF A CLINICAL PATHWAY ON ANTIBIOTIC PRESCRIPTIONS FOR PEDIATRIC COMMUNITY-ACQUIRED PNEUMONIA.

Background and aims: Italian pediatric antimicrobial prescription rates are among the highest in Europe. It is essential to identify efficient measures to improve antimicrobial stewardship (AS) programs. Since Clinical Pathways (CPs) have proven a promising tool to reduce antibiotic prescriptions in primary care and in-hospital settings, we hypothesized that their implementation in the Padua University Hospital Pediatric Emergency Department (PED) would decrease overall prescription of antibiotics, especially broad-spectrum (BS), for common infectious diseases such as Community-acquired pneumonia (CAP). 

Materials and methods: CP was implemented at the Department for Woman and Child Health of Padua on 01/10/2015. This is a pre-post quasi-experimental study comparing the 6-month period prior to CP implementation (baseline period: 15/10/2014-15/04/2015) and during the 6 months after intervention (post intervention: 15/10/2015-15/04/2016). We collected data from children aged 3 months -15 years diagnosed with CAP. We assessed differences in various measures of antibiotic prescription between pre and post periods including rates, breadth of spectrum, duration of therapy and, for inpatients, length of hospital stay. Chi-square, Fisher’s exact test and Wilcoxon rank sum test were used as appropriate. 

Results: 120 pre and 86 post-intervention clinic visits were associated with CAP. In regards to outpatients, we observed a decrease of BS regimens (50% vs. 26.8%, p=0.0215), in particular macrolides, and an increase of narrow-spectrum ones (amoxicillin). Children received less antibiotics (median DOT from 10 to 8, p=0.0001) for fewer days (median LOT from 10 to 8, p=0.0001). Physicians prescribed a narrow- spectrum monotherapy more frequently than BS combination therapy (DOT/LOT ratio 1.157 vs. 1.065). No difference in treatment failure incidence was reported before and after the implementation (2.3% vs. 11.8%, p=0.2862). Among inpatients we also noted a decrease in BS regimens (100% vs. 66.7%, p=0.0238) and the introduction of narrow-spectrum regimens (0% vs. 33.3%, p=0.0238). Admitted patients received less antibiotics (median DOT from 18.5 to 10, p=0.004), while there was no statistical difference in LOT (median LOT from 11 to 10, p=0.0629). In particular, children received a notably lower amount of BS days of therapy (median bsDOT from 17 to 4.5, p <0.001). No difference in treatment failure was reported before and after CP implementation (16.7% vs. 15.4%, p >0.999).

Discussion: Our study showed sustained changes in physicians' prescribing behaviors for CAP after implementation of a clinical pathway. Prescribing changes for CAP included an immediate increase in amoxicillin prescriptions with a concomitant reduction of BS antibiotic prescriptions, use of combination therapy and duration of treatment for CAP indicates effectiveness of CP for AS in this setting. 

Daniele DONÀ, Silvia ZINGARELLA, Andrea GASTALDI, Rebecca LUNDIN, Anna Chiara FRIGO, Silvia BRESSAN, Marco DAVERIO, Rana HAMDY, Theoklis ZAOUTIS, Liviana DA DALT, Carlo GIAQUINTO
Kokkali
16:10
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16:10 - 17:40

Analgesia and Sedation (Cutting Edge)

Moderators: Jim DUCHARME (Mississauga, CANADA), Christian HOHENSTEIN (Jena, GERMANY)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
16:10 - 17:40 Pain treatment in the addict. Jim DUCHARME (Mississauga, CANADA)
16:10 - 17:40 Ketadex, Ketofol or Dexofol – foolish sedation procedures? Christian HOHENSTEIN (Jena, GERMANY)
16:10 - 17:40 Sedating small adults - ketamine as the safe option? Santiago MINTEGUI (Barakaldo, SPAIN)
Trianti Hall
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16:10 - 17:40

Geriatric (How to)
Quiz Session!

Moderators: Jacinta A. LUCKE (Leiden, THE NETHERLANDS), Christian NICKEL (Basel, SWITZERLAND)
Coordinator: Senad TABAKOVIC (Zürich, SWITZERLAND)
16:10 - 17:40 Diagnosis and management of UTI in older patients. Roberta PETRINO (Vercelli, ITALY)
16:10 - 17:40 Sepsis in older patients. Abdelouahab BELLOU (Boston, USA)
16:10 - 17:40 Silver trauma, pre-hospital and in-hospital. James WALLACE (Northwich, UK)
16:10 - 17:40 Polypharmacy/De-prescribing. Jacinta A. LUCKE (Leiden, THE NETHERLANDS)
16:10 - 17:40 How to apply scientific evidence to older patients. Simon. P. MOOIJAART (Leiden, THE NETHERLANDS)
16:10 - 17:40 The unstable older patient. Mehmet Akif KARAMERCAN (Ankara, TURKEY)
Mitropoulos
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16:10 - 17:40

Resuscitation (Game Changers)

Moderators: Wilhelm BEHRINGER (Jena, GERMANY), Alice HUTIN (Paris, FRANCE)
Coordinator: Christian HOHENSTEIN (Jena, GERMANY)
16:10 - 17:40 Emergency Preservation and Resuscitation - not CPR: delayed resuscitation from traumatic death. Samuel TISHERMAN (USA)
16:10 - 17:40 Emergency Cardio-Pulmonary Bypass (ECPB) in the prehospital setting. Alice HUTIN (Paris, FRANCE)
16:10 - 17:40 Refractory cardiac arrest: Ethical dilemma? Tobias CRONBERG (SWEDEN)
Banqueting Hall
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YEMD - Prehospital

Moderators: Gerhard ADAMEK (Saint-Renan, FRANCE), Mohomed ASHRAF (Gzira, MALTA)
Coordinator: Basak YILMAZ (Ankara, TURKEY)
16:10 - 17:40 Controversy in Airway management. Sanela RADOSAVLJEVIC (Belgrade, SERBIA)
16:10 - 17:40 Debating between scoop and run versus stay and play in the pre-hospital setting. Gerhard ADAMEK (Saint-Renan, FRANCE)
16:10 - 17:40 Major incident/Disaster planning: how to manage resources and skills as a young doctor better. Michael SPITERI (Mosta, MALTA)
16:10 - 17:40 Being a HEMS doctor & how it has influenced my practice in the ED. Leonieke VLAANDEREN (London, UK)
Skalkotas
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Paediatric
Ultrasound scenarios

Moderators: Silvia BRESSAN (Padova, ITALY), Luigi TITOMANLIO (Paris, FRANCE)
Coordinator: Niccolò PARRI (Florence, ITALY)
16:10 - 17:40 Ultrasound scenario. Ron BERANT (Ramat-Gan, ISRAEL)
16:10 - 17:40 Ultrasound scenario. Niccolò PARRI (Florence, ITALY)
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Free Papers Session 7

Moderators: Agnès RICARD-HIBON (Pontoise, FRANCE), Anastasia SFAKIOTAKI (Melbourne, AUSTRALIA)
16:10 - 17:40 #11005 - OP055 Abdominal sonographic evaluation as a screening test to reduce the CT scans in trauma patients.

Computed tomography is the golden standard for evaluating haemodynamically stable blunt trauma patients. As a consequence, medical radiation induced cancers have been increasing exponentially. Ultrasound evaluation has been actively investigated as an alternative, but currently an ultrasound based algorithm for the investigation of blunt trauma patients cannot be supported. In this study instead of correlating ultrasound imaging findings to computed tomography imaging findings we correlate ultrasound imaging findings with patient clinical outcomes. This prospective clinical study took place in Nikaia general hospital Greece, between 6/2014 and 12/2014. We studied 60 (sixty) consecutive, haemodynamically stable, adult, blunt trauma patients, without injuries requiring immediate surgical intervention or hospitalisation, who met abdominal CT investigation criteria. All patients were initially investigated and treated according to current ATLS recommendations. An abdominal ultrasound evaluation was performed in all patients prior to the CT scanning. The ultrasound examination was performed by an ultrasound expert radiologist. We assessed the presence of free fluid as well as all solid abdominal organs for evidence of injury. Patients then underwent a formal trauma protocol abdominal CT. All patients were admitted to the surgical ward for a minimum of 48-hour observation, where they were closely monitored and investigated.  If there was no deterioration patients were discharged. In any other case patients were treated accordingly. In 21/60 patients, the ultrasound was negative for fluid and solid organ injury. A further 21/60 despite the presence of free fluid no solid organ injury was detected. Of these patients 7/42 were found to have some degree of solid organ injury at CT.  All 42 patients (100%) had an uneventful clinical course and were safely discharged. In 12/60 patients, ultrasound was positive for fluid and solid organ injury, all 12 patients had some degree of solid organ injury in the subsequent CT scan. Of these patients 25% were eventually treated surgically. In 6/60 patients, ultrasound was negative for free fluid but positive for solid organ injury. 5/6 of these patients had some degree of solid organ injury on CT. From this patient group 1/6 needed surgical intervention. This study provides evidence that abdominal ultrasonographic evaluation of trauma patients, when performed by an experienced professional can safely be used as a screening tool, since negative ultrasound findings correlate with 100% non-surgical clinical outcome and positive ultrasound findings correlate with a 100% positive CT findings and a 25% need for surgical intervention. Taking these results a step forward, it could be implied that blunt trauma patients can be safely discharged and followed up based on an ultrasound based algorithm.

Dimitrios TSIFTSIS, Panagiotis KAZAKIDIS, Anthimos CHATZIVASILIOU, Vasilios STOUKAS, Pavlos IOANNIDIS
16:10 - 17:40 #11300 - OP056 Discordance between Emergency Physicians (EP) and Radiologists (RA) interpretation of chest X ray: prospective observational study on 402 patients.

Introduction

Chest X ray (CXR) is the most frequent imaging exam in the Emergency Department (ED). However, its interpretation is frequently difficult; thus, CXR based clinical decisions might be harmful. We investigate discordance (DI) between EP and RA on CXR interpretation prescribed for a non-traumatic indication.

Patients and methods

inclusion criteria

patients older than 15 years old

non traumatic indication

exclusion

pregnancy,

method

This observational study was conducted in the ED of a teaching hospital with an annual census of 75000 patients. During a 3-month period, EP and ED residents completed a reporting form for a convenience sample of patients with CXR. It included clinical features, a CXR systematic analysis and a conclusion. A similar form without clinical features was completed by RA being blind to the EP interpretation.

The main objective was DI between EP and RA. Secondary objectives were performance of EP interpretation, therapeutic and orientation impact induced by all CXR, therapeutic errors induced by a wrong interpretation and potentially serious illnesses missed by EP. RA interpretation was considered as the gold standard.

Statistics

For a DI 0.1, with alpha risk 0.05 and beta 0.1, the required number of patients was 196. Qualitative data were expressed as percentage and 95% confidence intervals. They were compared by a Chi2 test, p < 0.05 being significant.

Results

417 patients were included, 15 were excluded for lack of clinical informations. Age was 61 + 15 years old, sex ratio 1.09. CXR quality was assessed as good for 266 for EP and 136 for RA (p < 0.0001). DI was 23% [19-27%]. Sensitivity, specificity, negative predictive value, positive predictive value were 87% [82-86%], 64% [54-71%], 80% [72-85%] and 75% [69-80%] respectively. Therapeutic and orientation impacts of all CXR were 44% [39-49%] and 19% [15-23%], respectively. Due to wrong EP interpretation, 42 antibiotics and 31 diuretics were mistakenly prescribed. Eight suspect opacities were missed.

Discussion

DI in our ED was comparable to other published studies. The main limit was a selection bias since only 20% of all prescribed CXR during the study period were included. Despite a rather bad quality and a DI affecting 23% of CXR, therapeutic impact of CXR remains high. Training of EP and ED residents to CXR interpretation has to be organized. However, intrinsic diagnosis qualities of this exam remain poor even with good realization and interpretation.

Implementation of lung Point-of-Care Ultrasound which has demonstrated far better performance might be interesting. This diagnosis procedure is inexpensive, radiation free, performed on the patient’s bedside and with immediate result.

Sarah-Lou GUYOT, Amal KENZI, Olivier MORLA, Eric BATARD, Philippe LE CONTE
16:10 - 17:40 #11565 - OP057 Assessment of left ventricular ejection fraction by the emergency physician versus the cardiologist: A concordance study about 52 cases.

Introduction

Transthoracic echocardiographic examination (TTE) that is performed at the patient’s bedside in emergency departments has several recognized important indications.

 

Objective

 The purpose of our study is to evaluate the agreement of the estimates of left ventricular ejection fraction (LVEF) obtained by emergency physicians with the findings obtained by cardiologists in patients admitted to emergency departments.

 

Material and methods

This randomized prospective study was carried out in the emergency department of the military hospital of Tunis (Tunisia) over a period of 6 months going from September 2015 through February 2016, and involving patients aged > 16 years whose condition required an emergency TTE.

The patients included in the study had to undergo a double echocardiographic examination:

1-An initial investigation that was performed in the emergency department by an emergency physician who had previously received a three-month training in Doppler echocardiography.

2-A subsequent echocardiographic examination that was performed by an echo-Doppler proficient cardiologist.

Left ventricular ejection fraction was evaluated by both readers using the following methods:

1-the global visual estimation (GVE) method,

 2-Teicholtz’s method in time movement mode (TM)

3-and Simpson Biplan method (SB).

We excluded from the study patients with:

1-segmental kinetic disorders

2-or with hearts out of alignment.

The findings thus obtained were compared using the inter-class concordance coefficient of Cronbach’s alpha.

 

Results 

Fifty-two patients were involved in the study. Mean age was 55 + 11 years; sex-ratio was 7 males/4 females.

-For the GVE method, the findings obtained by the emergency physician were similar to those obtained by the cardiologist: alpha = 0.72 (IC 95% = [0.68-0.78]; p<10-3).

-The findings obtained by both operators by Teicholtz’s method were as follows: alpha = 0.94 (IC 95% = [0.80-0.95]; p<10-3).

-The concordance of the findings obtained by the emergency physician and of those obtained by the cardiologist for their assessment of LVEF by SB method was shown by alpha=0.91 (IC95% = [0.80 – 0.98]; p<10-3).

 

Conclusion

Global visual estimation of LVEF can be performed similarly by an emergency physician or by a cardiologist provided they are sufficiently experienced. The results yielded by both other methods (Teicholtz’s method and SB method) were very similar indicating an excellent concordance independently of the degree of deterioration of the left ventricle contractility. Biplan Simpson’s method is, however, a time-consuming procedure.

Bassem CHATBRI, Mehdi BEN LASSOUED, Ala ZAMMITI , Mounir HAGUI, Yousra GUETARI, Rim HAMMAMI, Maher ARAFA, Ghofrane BEN JRAD, Ines GUERBOUJ, Olfa DJEBBI, Khaled LAMINE
16:10 - 17:40 #11825 - OP058 A systematic Review and Meta-analysis of the Management and Outcomes of Isolated Skull Fractures in Children.

Objective: Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim was to evaluate the short-term clinical outcomes of children with isolated skull fractures.

Methods: We performed a systematic review and meta-analysis of studies indexed in EMBASE, MEDLINE and Cochrane Library databases through August 2016 reporting on short-term outcomes of children ≤18 years with linear, non-displaced, isolated skull fractures (i.e. without intracranial injury on neuroimaging). Two reviewers independently reviewed identified articles for inclusion, assessed quality and extracted relevant data. Our primary outcome was emergent neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeat neuroimaging.  We calculated a pooled estimate of each outcome by fitting a random-effects model and then tested for heterogeneity across studies.

Results: Of the 385 studies screened, the 21 that met our inclusion criteria, included 6646 children with isolated skull fractures. One child needed emergent neurosurgery and no children died [pooled estimate: 0.0%, 95% confidence interval [0.0-0.0%]; I2 =0%]. Of the 6280 children with known emergency department disposition, 4914 (87%, 95% CI 78-95%; I2 = 98%) were hospitalized.  Of the 644[SB1]  children that underwent repeat neuroimaging, six had a non-operative intracranial hemorrhage (0.0%, 95% CI 0.0-0.1%; I2 = 79%).

Conclusion:Children with isolated skull fractures were at extremely low risk for emergent neurosurgery or death, but were frequently hospitalized. After careful consideration of non-accidental trauma, clinically stable children with an isolated skull fracture could safely be managed outpatient.

Silvia BRESSAN, Luca MARCHETTO, Todd LYONS, Michael MONUTEAUX, Liviana DA DALT, Lise NIGROVIC
16:10 - 17:40 #11888 - OP059 THE IMPACT OF CLINICAL PATHWAYS ON ANTIBIOTIC PRESCRIBING IN THE EMERGENCY DEPARTMENT.

Background and Objectives

Italian pediatric antimicrobial prescription rates are among the highest in Europe. To date it has not been paid adequate attention on how to implement and improve the antimicrobial prescriptions. As a first step for antimicrobial stewardship (AS) implementation, clinical pathways (CP) outlining standard of care for acute otitis media (AOM), and group A streptococcus (GAS) pharyngitis were developed and implemented on 1 October 2015 at the Pediatric Emergency Department in collaboration with Children’s Hospital of Philadelphia.

The primary aim of this study was to assess changes in antibiotic prescription before and after CP implementation for AOM e GAS pharyngitis; secondary aims were to compare treatment failure and to assess the change in the total antibiotics costs before and after CP implementation.

Methods

Pre-post quasi-experimental study comparing the 6-month period prior to CP implementation (baseline period: 15/10/2014-15/04/2015) and during the 6 months after intervention (post intervention: 15/10/2015-15/04/2016).

We assessed differences in various measures of antibiotic prescription appropriateness, including type and breadth of spectrum prescribed, using chi-square and t-tests as appropriate. We also assessed the total cost and the cost for each class of antibiotics comparing the two groups and relating it to 1000PD.

Results

295 pre- and 278 post-intervention clinic visits were associated with AOM. After CP implementation there was an increase in “wait and see” (21.7%vs.33.1%,p<0.01) and a decrease from 53.2% to 32.4% (p<0.01) in overall prescription of broad-spectrum (BS) antibiotics. The total cost was significantly reduced (8.033,08€/1000PDvs. 5.878,30€/1000PD), with a decrease especially in BS antibiotics, above all cephalosporines, and a slight increase in the cost for amoxicillina. 151 pre- and 166 post-implementation clinic visits were associated with GAS pharyngitis, with decrease in BS prescriptions (46.4%vs.6.6%,p<0.01). The total cost was reduced (9.337,68€/1000PDvs. 6.247,23€/1000PD), with a sharp decline in the cost for BS antibiotics and an increase in the cost for narrow spectrum antibiotic contextually to the increase in its use.

Discussion

Our study showed sustained changes in physicians' prescribing behaviors for AOM and GAS pharyngitis after implementation of a clinical pathway. Prescribing changes for AOM included an immediate increase in “observation with close follow-up” approach and amoxicillin prescriptions with a concomitant decrease in BS antibiotic prescriptions. Complying with the CP, a dramatic increase of amoxicillin prescriptions for GAS pharyngitis was documented with a concomitant decrease in BS antibiotic use. In summary, our data show that clinical pathways for AOM and GAS pharyngitis are associated with reduced rates of antimicrobial prescription and cost for antibiotics purchase with no significant change in treatment failure rates.

Daniele DONA', Maura BARALDI, Giulia BRIGADOI, Rebecca LUNDIN, Marco DAVERIO, Silvia BRESSAN, Rana HAMDY, Theoklis ZAOUTIS, Liviana DA DALT, Carlo GIAQUINTO
16:10 - 17:40 #10738 - OP060 An insight into the patient’s perspective of trauma care using point of view glasses.

Background:

Trauma patients are particularly vulnerable to negative experiences of healthcare. The psychological effects of trauma and restricted movement from cervical spine immobilisation combine to heighten a patient’s fear and anxiety. One factor identified to reduce anxiety amongst spinal immobilised patients is eye contact, however this has been neglected from communication tools used within emergency medicine. One explanation for this is the relative challenge of objectively assessing eye contact between doctor and patient using traditional methods.

New wearable technologies offer a way of addressing this blind spot in assessing doctor-patient communication. We subsequently set out to examine the use of point of view glasses as a method of objectively assessing the frequency and location of eye contact between a spinal immobilised patient and doctors in high fidelity trauma simulation.

 

Methods:

This study was integrated into an emergency medicine module for clinical medical students. High fidelity trauma simulations requiring cervical spinal immobilisation were recorded using covert point of view glasses and ceiling mounted cameras. The simulation footage was analysed, examining the frequency of paired verbal communication and eye contact at five predefined locations around the patient (the foot of the bed, bellow the waist, above the waist, above the shoulders and at the head of the bed).

Results:

110 communication events and 29 eye contact events were observed during six high fidelity simulations. There was a significant difference in the number verbal communication events and eye contact events below the waist, above the waist and above the shoulders (p=0.0312, 0.0156 and 0.0312 respectively). Verbal communication at the head of the bed achieved the greatest eye contact on 95% of occasions (p=0.500).

 

Conclusion:

Whilst methods for assessing communication skills have been validated for emergency medicine, they have neglected non-verbal communication that can only be assessed from the patient’s perspective.

Using new point of view technologies this study demonstrates an objective method for the identification of non-verbal doctor-patient communication and highlights the poor attainment of eye contact amongst medical students when managing trauma patients. Although this cannot be extrapolated to clinician’s, greater awareness of body position when communicating with spinal immobilised patients, especially in the absence of an anaesthetist, will help to improve eye contact with patients.

Whilst the priority for trauma patients will always be managing their medical condition it is important to give consideration to the patient’s experience, especially for vulnerable groups such as trauma patients. With this awareness and incorporation into current communication tools we aim to provide further feedback for learners during simulation, improving communication and thereby the patient’s experience of trauma care.

 

Samuel MAESE, Andrew ARMSON, Anna WOODMAN
16:10 - 17:40 #11526 - OP061 Predictive factors for the failure of high flow nasal cannula therapy in children with bronchiolitis in pediatric emergency department.

Background: Bronchiolitis is a lower respiratory tract infection affecting principally the small airways. The disease is the most common cause of infant hospitalization during the winter months. High flow nasal cannula therapy is recommended in patients with severe disease. The aim of the study was to determine the parameters associated with high flow nasal cannula therapy failure in children with bronchiolitis in pediatric emergency department.

Methods: The patients were aged between 6 weeks and 24 months presenting to the pediatric emergency department of the Health Sciences University, Tepecik Teaching and Research Hospital with acute bronchiolitis between 01.01.2014 and 31.12.2015 were evaluated retrospectively. Vital signs and clinical findings were determined before interventions such as suctioning, antipyretic medication, oxygen support, and I.V. fluid. We included the patients with bronchiolitis treated with high flow nasal cannula therapy. Patients were divided in two groups: High flow nasal cannula therapy responders and non-responders. High flow nasal cannula therapy failure (non-responders) was defined as the need for escalation to another ventilation support: non-invasive ventilation or invasive mechanical ventilation. 

Results: A total of 84 infants (median age: 5 month; 25-75 percentile: 2-10 month; minimum: 6 weeks – maximum: 19 months; female/male: 25/59) with bronchiolitis were treated with high flow nasal cannula therapy. 23 of them (27.4%) were in non-responders group; 19 of them were intubated and mechanically ventilated. Underlying chronic disease, prior hospitalization due to bronchiolitis, prior admission to the pediatric intensive care unit, significant tachycardia (0-12 months> 160 / min, 12-24 months: 150 / min), physical examination findings of significant dehydration (5% or more), pH <7.30 and high pCO2 level (>45 mm Hg) were found more frequently in non-responders group (p <0.05). In the logistic regression analysis, underlying chronic disease (p: 0.031; OR: 4.677; 95%CI: 1.148-19.062), significant tachycardia (p: 0.015; OR: 5.088; 95%CI: 1.369-18.910), and significant dehydration (p: 0.038; OR: 3.811; 95%CI: 1.079-13.459) were the most significant parameters.

Conclusion: The presence of underlying chronic disease, significant tachycardia, and significant dehydration were the most powerful predictors of high flow nasal cannula therapy failure in children with bronchiolitis.

Murat ANIL, Yuksel BICILIOGLU, Fulya KAMIT CAN, Ayse Berna ANIL, Esin ALPAGUT GAFIL, Gamze GOKALP , Emel BERKSOY
16:10 - 17:40 #11716 - OP062 High flow nasal cannula therapy in the pediatric emergency department; a prospective pilot study.

 

Background and Objectives: High-flow nasal cannula (HFNC) is a reliable method of respiratory support that has demonstrated large utility in the pediatric population. HFNC may be able to avoid intubations in patients with respiratory distress. There is limited data about its use in the pediatric emergency department (PED). The aim of this study was to evaluate whether the use of HFNC therapy is associated with reduced respiratory distress and a decreased need for intubation in patients presenting to the PED.

Methods: This was a single –center prospective observational study conducted over six months  (October 2016 - March 2017) on children with severe respiratory distress (SRD) who commenced HFNC therapy in our PED. Baseline demographic and clinical data, as well as respiratory variables at baseline and various times after HFNC initiation during 24 h, were recorded. Therapy failure was defined as clinical deterioration in respiratory status after that requiring another form of non-invasive ventilation (nasal positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP)) or invasive ventilation (intubation) within 24 hours from the time of HFNC initiation. The rate of intubation, admisson to pediatric intensive care unit, therapy failure and predictors of therapy failure were also recorded.

Results: A total of 115 children commenced on HFNC therapy in PED during the study period. The median age was 12 months and 70% patients were male. The most common diagnosis was acute bronchiolitis (n=73, 63.5%) followed by pneumonia (n = 23, 20%) and asthma (n = 18, 15.7%). Seven-teen   patients (14.8%) failed HFNC therapy;10 required secondary invasive mechanical ventilation and 7 BiPAP.  Children who had higher initial respiratory score (RS)  and comorbodity were more likely to fail the HFNC therapy (p=0.001, p=0.039). HFNC significantly reduced the respiratory rate, heart rate and (RS) at 2 hours of admission (p<0.05). These improvements were observed as early as 15 min after the beginning of HFNC for respiratory rate and heart rate.

Conclusion: HFNC has a beneficial effect on clinical signs and respiratory score in PED patients with acute severe respiratory distress. It also significantly reduced the respiratory rate and heart rate at the beginning.

Ali YURTSEVEN, Caner TURAN, Eylem Ulas SAZ
16:10 - 17:40 #11757 - OP063 HACOR score to predict in-hospital mortality for patients with type I and type II acute respiratory failure treated with non-invasive ventilation.

OBJECTIVES: In a group of patients with type I and type II 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 hour 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 in a 48-hour time interval.

RESULTS: The study population includes 348 patients, mean age 77±15 years, 53% male gender. Most frequent admission diagnosis were pneumonia in 59% of patients, congestive heart failure in 34% and sepsis in 20%, which overlapped in some patients. Ninety-eight patients presented a Type I ARF and 250 a Type II ARF. In-hospital mortality was 33% in Type I ARF patients and 19% in Type II patients (p=0.012).  Compared with survivors, Type I non-survivors showed  comparable HACOR score before NIV (7.3±5.5 vs 5.9±2.9, p=NS), but higher score after 1-hour (6.8±6.4 vs 3.4±3.3, p=0.025) and 24-hour (6.2±5.0 vs 3.0±2.6, p=0.022) NIV treatment; moreover, HACOR score reduction during the first hour of NIV treatment was significantly higher in survivors compared with non survivors (-2.7±3.2 vs -0.7±3.7, p=0.016). Analysis for repeated measures showed a significantly more marked score reduction  in survivors compared with non-survivors (p=0.001). Compared with survivors, Type II non-survivors showed  higher HACOR score before NIV (8.5±5.0 vs 6.3±4.2, p=0.005) and after 1-hour (6.7±4.7 vs 3.9±3.3, p<0.001) and 24-hour (3.8±4.3 vs 1.7±2.0, p=0.002) NIV treatment. Analysis for repeated measures showed a significantly more marked score reduction  in survivors compared with non-survivors (p=0.001). Compared with patients with HACOR ≤5, Type II patients with HACOR score >5 showed a significantly higher mortality rate at every evaluation point (before NIV: 68 vs 48%, p=0.026; 1-hour: 55 vs 26%, p<0.001; 24-hour: 18 vs 5%, p=0.009); analysis with dichotomized values did not show significant differences among patients with Type I ARF.     

CONCLUSIONS: among patients with Type II respiratory failure , a Hacor score value >5 was significantly associated with an increased mortality rate; among Type I ARF patients, patients with adverse outcome showed significantly worst score value compared with patients with a good prognosis. 

Laura GIORDANO, Simona GUALTIERI, Arianna GANDINI, Lucia TAURINO, Monica NESA, Chiara GIGLI, Alessandro COPPA, Francesca INNOCENTI, Riccardo PINI
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A25
17:40 - 18:40

Award Ceremony

Moderators: Tom BEATTIE (UK), Felix LORANG (Leipzig, GERMANY), Youri YORDANOV (Paris, FRANCE)
17:40 - 18:40 #11133 - OP121 Home treatment of patients with pulmonary embolism: comparison of the performance of three clinical rules in daily clinical practice.

Background  

Recent guidelines suggest home treatment for patients affected by pulmonary embolism (PE) judged to be at low risk of adverse clinical outcome. Several clinical rules have been proposed but studies aimed to compare their efficiency and safety in daily clinical practice are lacking. 

Objectives  

We evaluated the efficiency and safety of PESI, sPESI scores and Hestia criteria in the identification of PE patients candidate to home treatment and compared them with clinical gestalt.  

Methods  

Consecutive adult patients with objectively diagnosed PE were prospectively included in the study. All data requested in PESI, sPESI and Hestia scores were collected prospectively. Patients were managed according to the clinical gestalt of the attending physician, independent of the results of clinical rules. The primary outcome was a composite of all-cause mortality, venous thromboembolic recurrence with or without hemodynamic collapse or major haemorrhage within 30 days from inclusion. Efficiency was the prevalence of low risk patients and safety the incidence of primary outcome in the low risk group according to each stratification model. 

Results  

We included 277 patients with a median age of 75 years, 52.7% were females. After initial assessment, including right ventricular dysfunction evaluation, 123 (44.4%) patients were judged to be at low risk and discharged within 48 hours from presentation. Six (4.9%, 95% CI 1.8-10.3%) of these patients reached the primary outcome.  

Similarly to clinical gestalt, Hestia criteria identified 121 (43.6%) low-risk patients, whereas both PESI and sPESI identified a significantly lower proportion of low-risk patients (24.9% and 19.1% respectively, p< 0.05 for both). Primary outcome incidence was 7.3% (95% CI 2.4%-16.1%), 7.6% (95% CI 2.1-18.2%) and 4.1% (95% CI 1.4-9.4%) in PESI, sPESI and Hestia low-risk groups respectively, without significant differences among prognostic models and in comparison to clinical gestalt.  

Conclusions 

In our cohort, Hestia criteria showed higher efficiency and similar safety in identifying low-risk patients when compared to PESI and sPESI scores. Clinical rules did not show better performance than clinical gestalt in identifying PE patients candidate to home-treatment. 

Valerio STEFANONE, Peiman NAZERIAN, Cosimo CAVIGLIOLI, Michele BAIONI, Chiara GIGLI, Gabriele VIVIANI, Stefano GRIFONI, Simone VANNI
Top scoring Abstract 1
17:40 - 18:40 #11370 - OP122 Impact of using the HEART score in chest pain patients at the emergency department: a stepped wedge, cluster randomized trial.

Background: The HEART score is a simple instrument to stratify chest pain patients according to their probability of having an acute coronary syndrome, but its impact in daily practice is unknown. The HEART-Impact trial was designed to measure the impact of its use on patient outcomes and use of health care resources.

Methods: In a stepped wedge, cluster randomized trial, chest pain patients presenting at emergency departments (ED) were included in nine hospitals in the Netherlands  between 2013 and 2014. All hospitals started with “usual care” and over time hospitals consecutively switched to “HEART care”, during which treating physicians calculated the score for each patient to guide patient management. For safety, a non-inferiority margin for major adverse cardiac events (MACE) was set. Other outcomes included use of health care resources, quality of life, and cost effectiveness. Trial registration: ClinicalTrials.gov 80-82310-97-12154 (closed).

Results: A total of 3,648 patients were included, 1,827 receiving usual care and 1,821 HEART care. Six-week incidence of MACE during HEART care was 1.3% lower than during usual care (upper limit one sided 95% CI: +2.1%, not exceeding the non-inferiority margin of +3%). In low-risk HEART patients, incidence of MACE was 2.0% (95% CI: 1.2 to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits or visits to general practitioner were observed.

Conclusion: Using the HEART score during initial assessment of chest pain patients is safe but the impact on health care resources was limited possibly due to non-adherence to management recommendations. Physicians were hesitant to refrain from admission and diagnostics in patients classified as low-risk by the HEART score.

Judith POLDERVAART, Johannes REITSMA, Barbra BACKUS, Erik KOFFIJBERG, Rolf VELDKAMP, Monique TEN HAAF, Yolande APPELMAN, Herman MANNAERTS, Jan-Melle VAN DANTZIG, Madelon VAN DEN HEUVEL, Mohamed EL FARISSI, Benno RENSING, Nicolette ERNST, Ineke DEKKER, Frank DEN HARTOG, Thomas OOSTERHOF, Giske LAGERWEIJ, Eugene BUIJS, Maarten VAN HESSEN, Marcel LANDMAN, Roland VAN KIMMENADE, Luc COZIJNSEN, Jeroen BUCX, Clara VAN OFWEGEN-HANEKAMP, Jacob SIX, Maarten-Jan CRAMER, Pieter DOEVENDANS, Arno HOES
Top scoring Abstract 2
17:40 - 18:40 #11731 - OP123 Addition of magnesium sulphate to the femoral block: preliminary results.

Introduction:  Due to its N-methyl-D-aspartic (NMDA) receptor antagonist effect in peripheral neurons, some studies suggest the potential analgesic effect of magnesium sulphate (Mg2+).On the other hand, according to our daily practices, the classic femoral block seems to have a short duration of action.The objective of our study is to show the potentiating effect of the addition of SMg to the xylocaine in the WINNI’s femoral block in traumatology. Methods: A prospective study including all patients aged> 16 years and suffering from a medio-diaphyseal femoral fracture or a knee wound. After patient consent, randomization was carried among 3 groups: A (15 ml xylocaine 2% + 5 ml SMg 10%), B (15 ml xylocaine + 5 ml S.Phy 0.9%), C (15ml SMg + 5ml S.Phy 0.9%). The severity of the pain was assessed using EVA at 0 min, 15 min, 30 min, 40 min, 50 min, 60 min and then every 60 min until the first six hours after the femoral block. If  EVA> 5 after 15 min local anesthetic injection, titration of morphine as a rescue analgesic is recommended.  Jujement criteria are the duration of the sensory block, the duration of tolerance of pain, the rate of failure of analgesia and the appearance of side effects.  Results:  We included 28 patients (39.3%  are men) with a median age of 71.4 +/- 16 years. The most frequent occurrence of the fracture was the fall (68%). The average duration of the sensory block was 220 + /- 70 min, 125 +/ - 70 min, 14.5 +/ - 28.3 min respectively for group A (n =10), B (n =8) and C (n=10) with a significant difference.  The average duration of tolerance of pain was 274 +/ - 103min, 148.74 +/ - 92 min and 18 +/ - 6.3 min respectively for group A, B and C with a significant difference. During the study we did not note any side effect. Conclusion: Mg sulphate appears to have a potentiating effect on the duration and efficacy of the WINNI’s femoral block without added side effect.

Rabiaa KADDACHI, Chawki JEBALI, Asma ZORGATI, Wael CHABAANE, Achref HAJ ALI, Riadh BOUKEF
Top scoring Abstract 3
17:40 - 18:40 Introduction of Falck Foundation and Top scoring Pre-Hospital Abstract. Rune ANDERSEN (Arhus C, DENMARK)
17:40 - 18:40 Sophus FALCK Prize abstract presentation.
17:40 - 18:40 EUSEM YEMD Fellowship presentation. Riccardo LETO (BELGIUM)
17:40 - 18:40 YEMD Fellowship certificate hand-over.
17:40 - 18:40 EUSEM Best Abstract announcement and certificate hand over.
17:40 - 18:40 EMERGE EBEEM announcement. Ruth BROWN (London, UK)
17:40 - 18:40 European Board Examination of Emergency Medicine diplomates ceremony.
17:40 - 18:40 Best performance EBEEM Part A certificate.
17:40 - 18:40 Best performance EBEEM Part B certificate.
17:40 - 18:40 EMDM Diploma ceremony. Francesco DELLA CORTE (ITALY)
Trianti Hall