Saturday 01 October

Saturday 01 October

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08:00 - 17:00

Pre-Course 1 - SUCCESS (1 day)
Survival Course Critical Emergency Skills for Young Doctors

Invited speakers: Lars LOMBERG (Hamburg, Germany), Thomas PLAPPERT (Fulda, Germany), Kostja STEINER (Nuremberg, Germany), Peter ZECHNER (Austria)
Pre-Course Director: Martin FANDLER (Consultant) (Bamberg, Germany, Germany)
The "Survival Course Critical Emergency Skills for Young Doctors" (SUCCESS) is based on a very simple concept - hands-on-training of critical skills needed for prehospital emergency doctors, in the emergency department, on ICU or even on the ward. The central theme of this full-day-course are the „4 Hs and 4Ts“ in Advanced Life Support. In short, focused and interactive presentations the main topics are covered, leaving much room for the practical hands-on-sessions, which include iv-access in difficult circumstances, intraosseous access, emergency ultrasound, finger thoracostomy, airway management with different methods including video laryngoscopy and alternative airways as well as the surgical airway. Theoretical sessions also include hypovolemia and shock including push-dose-pressor-use, hypoxia and airway, hyperkalemia, emergency toxicology, pulmonary embolism, pneumothorax and pericardial tamponade, ultrasound (focussing on eFAST).

This course has been „tested“ to great positive feedback at the German Emergency Medicine conference (DGINA) in Nuremberg 2014.

Saturday 01 October

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08:00 - 17:00

Pre-Course 4 - Ultrasound Beginner (1,5 day)

Presenter: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia)
Animator: Dr Joseph WOOD (Ultrasound instructor) (Phoenix, Arizona, USA)
Pre-Course Directors: James CONNOLLY (Consultant) (Newcastle-Upon-Tyne), Tomas VILLEN (Attending Physician) (Madrid, Spain)
Learning objectives

Develop basic skills and knowledge Learn how to develop Ultrasound in your institution and personal practice Techniques of basic US approach to limbs, chest, heart, abdomen
Recognition of basic US pathology
Basic US approach to cardiac arrest, shock, respiratory failure
Recognition of basic images and USartefacts
08:00 - 17:00

Saturday 01 October

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08:00 - 18:00

Pre-Course G1 - ESITrain (1,5 day)
Emergency Severity Index

Pre-Course Directors: Harald DORMANN (Germany), Harald EISENBARTH (FUERTH (BAYERN), Germany)
Schulung von Pflegekräften und Ärzten in der selbständigen ESI gestützten Ersteinschätzung von Notaufnahmepatienten.

Saturday 01 October

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08:30 - 17:30

Pre-Course 5 - Ultrasound Advanced (1,5 day)

Pre-Course Directors: Mike LAMBERT (Burr Ridge, USA), Christopher MUHR (Sweden)
Learning Objectives:
Technique: advanced US approach to head, neck, limbs, chest, heart, abdomen
Recognition of advanced US syndromes
US enhanced management of critical syndromes: cardiac arrest, shock, respiratory failure, acute abdomen, coma...

Saturday 01 October

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08:30 - 17:00

Pre-Course 6 - APEC (1,5 day)
Advanced Pediatric Emergency Care

Invited speakers: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh), Silvia BRESSAN (Moderator) (Padova, Italy), Liviana DA DALT (PHYSICIAN) (PADOVA, Italy), Santiago MINTEGI (Section Head. Pediatric Emergency Department) (Bilbao, Spain), Niccolò PARRI (Attending Physician) (Florence, Italy), Itay SHAVIT (Pediatric Emergency Physician) (Haifa, Israel)
Pre-Course Director: Said HACHIMI IDRISSI (head clinic) (Ghent, Belgium)
Objectives: To provide physicians participating in the course with both knowledge and advanced skills in recognizing and managing a wide spectrum of paediatric emergencies including trauma, both in the hospital and pre-hospital settings.

Saturday 01 October

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09:00 - 17:00

Pre-Course 3 - Non-Invasive Ventilation (1 day)

Invited speakers: Dr Anna Maria BRAMBILLA (Physician) (Milan, Italy), Dr Abdo KHOURY (PRATICIEN HOSPITALIER) (Besançon, France), Roberta PETRINO (Head of department) (Italie, Italy)
Pre-Course Director: Roberto COSENTINI (Head of Emergency Medicine) (BERGAMO, Italy)
At the end of the course, the participant will be able to:
evaluate the correct indications for NPPV
set both the ventilators and CPAP devices
critically analyze ventilator/patient interactions
evaluate intolerance and devise corrections

Saturday 01 October

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09:00 - 17:30

Pre-Course 8 - Disaster medicine (1 day)

Invited speakers: Matthieu LANGLOIS (medecin) (Paris, France), Luca RAGAZZONI (Scientific Coordinator) (Novara, Italy), Eric REVUE (Chef de Service) (Paris, France), Benoît VIVIEN (Adjoint du Chef de Service du SAMU de Paris, Responsable du SAMU Pédiatrique Régional IDF) (Paris, France), Dr Eric WEINSTEIN (Disaster Medicine Researcher) (Summerville SC, USA)
Pre-Course Directors: Pr Francesco DELLA CORTE (Speaker) (Novara, Italy), Dr Abdo KHOURY (PRATICIEN HOSPITALIER) (Besançon, France)
Mass Gun Shooting and Blast: how to deal with these new challenges
Sunday 02 October

Sunday 02 October

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08:00 - 12:30

Pre-Course 9 - Acute Pain Management (Half day)

Pre-Course Director: Fabio DE IACO (Chief) (Imperia, Italy)
Two main objectives:
- To lead the clinician toward choices that must be mindful, appropriate and effective,
- To create a patient-centred environment also in the Emergency setting

Sunday 02 October

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08:00 - 12:00

Pre-Course 11 - Airway Workshop (Half day)

Pre-Course Director: Sabine MERZ (senior consultant) (Villingen-Schwenningen, Germany)
Airway Management is a major topic in the Emergency Department. Anesthesiologists are not always available; therefore each member of the ED needs to be able to perform Airway Management. To secure the airway of a patient, it is necessary to know the different devices and techniques and also to consider, that the algorithm is different to the familiar pre-hospital and OR airway algorithm.

In this course, participants will learn about basic and difficult Airway Management. Furthermore, the technique of anaesthetization will be taught.

All participants will be able to train the different techniques and devices on intubation trainers.

Sunday 02 October

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08:00 - 13:30

Pre-Course 12 - ECGEM (Half day)
The European Course on Geriatric Emergency Medicine

Animators: Jay BANERJEE (Leicester, United Kingdom), Pr Christian NICKEL (Vice Chair ED Basel) (Basel, Switzerland), Fredrik SJOSTRAND (MD PhD) (Gustavsberg, Sweden)
Pre-Course Director: Pr Abdelouahab BELLOU (Research) (Boston, USA)
Overall objectives:
1- To be familiar with the concept of Geriatric Emergency Medicine (GEM).
2- To be familiar with the management of common and atypical clinical presentations of older patients in the ED.
3- To learn how to use comprehensive geriatric assessment in the ED.
4- To be familiar with ethical issues in older patients managed in the ED.

Sunday 02 October

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08:00 - 12:00

Pre-course PG6 - DGINA (Half day)
DGINA Führungsakademie: Führung- und Prozesskompetenz in der Notaufnahme

Invited speaker: Michael WÜNNING (Germany)
Pre-Course Director: Sebastian BENKHOFER (Germany)
Workshop für leitende Mitarbeiter (Ärztinnen und Ärzte & Pflegeleitungen) in der klinischen Notfallmedizin.

Sunday 02 October

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08:30 - 12:30

Pre-Course 10 - The 12-Lead ECG (Half day)
and Acute Myocardial Infarction: Improving Your Interpretation Skills

Pre-Course Director: Jerry W. JONES (USA)
The objectives of the pre-course are:

1. To be able to recognize subtle changes in the 12-lead ECG that are highly suggestive of acute ischemic episodes or actual myocardial infarction (ST deviation in aVR, inverted U waves, axis shifts)

2. To understand the difference between “reciprocal changes” and “ischemia at a distance”

3. To improve the recognition of “STEMI-equivalents”

4. To learn why some acute MIs are not always visible on the 12-lead ECG: cancellation of forces, electrically silent areas

5. To increase familiarity with new revelations regarding the true location of infarcting areas and the complexities of the vascular supply to the various areas of the heart

6. To increase knowledge of certain conduction disturbances that are classically associated with particular infarctions

7. Becoming more familiar with acute MI confounders: left ventricular hypertrophy, early repolarization, Takotsubo cardiomyopathy

Sunday 02 October

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11:00 - 18:00


11:00 - 18:00 #7088 - "e;Yound patient with right sided blindness: a case report"e;.
"e;Yound patient with right sided blindness: a case report"e;.

“Young patient with right sided blindness: a case report"

 Authors: [1] Dr. Srikrishna Vempaty, [1] Dr. Mahdi Alosert, Dr. Dan Ghiurluc,

 Sources: Hospital records.

Keywords: Periorbital swelling, Orbital compartment syndrome, Orbital USS.

Method: electronic engine research using Pubmed, Embase and Medline databases.


Orbital Ultrasound [USS] provides quick and non-invasive evaluation of the orbit. It allows the clinician to assess structures that may not be visible with routine ophthalmic examination of the swollen eye when swelling makes direct visualisation difficult.1


The use of ultrasound is well established in localisation and characterisation of orbital lesions, it provides a detailed cross sectional anatomy of the entire globe with excellent topographic visualisation and real time display of the moving organ.2

 Although this is a routine procedure, missed ocular pathology could be detrimental to a patient’s vision. Gross swelling of the Peri-Orbital tissues can make examination of the eye difficult.



28-year-old male, has no significant past medical history. Attended our emergency department [ED] for right orbital swelling, redness and pain. Symptoms developed 48-hours post right maxillary sinus elective polypectomy. 


After a thorough physical examination by the ED and ENT teams, a management plan has been established to treat it as post-operative peri-orbital/ orbital cellulitis for inpatient IV antibiotics. ED bedside orbital USS showed “Pre-septal and orbital collections with sonographic hyperaemia suggestive of orbital cellulitis”

 He remained clinically stable, waiting having orbital CT-scan and joint-assessment by ophthalmology team. 3 hours after the 1st ED bedside-orbital-USS, he developed right-sided blindness that required a 2nd ED bedside-orbital-USS [by the same operator] which revealed “a significant retrobulbar collection in comparison with the previous orbital USS”  

He was moved to the resuscitation-area where an emergency lateral-Canthatomy under local anaesthesia has been done then he was transferred to theatre for further surgical management as orbital compartment syndrome.


Ten patients presenting to ED with peri-orbital swelling were assessed using bedside-USS. They included patients with trauma, retrobulbar haemorrhage and Peri-Orbital cellulitis. Two patients were diagnosed with retrobulbar pathology, one with retrobulbar haemorrhage and another with a retrobulbar collection. Post-treatment and follow up scans were used to monitor progress. The remaining patients had preseptal cellulitis and orbital floor fractures. These motion scans were recorded and analysed.


Assessment and diagnosis of orbital pathology is both clinical and radiological. Acute retrobulbar pathology may not allow the luxury of time to organise computed tomography. This non-invasive procedure could be performed by ED doctors and frontline maxillofacial doctors following adequate training. Bedside-Orbital-USS is helpful in detecting and addressing ocular pathology. Use of ultrasound as an immediate investigation in the ED will help delineate and rationalise the treatment planning.





1        Kendall CJ, Prager TC, Cheng H, Gombos D, Tang RA, Schiffman JS. Diagnostic Ophthalmic Ultrasound for Radiologists. Neuroimaging Clin N Am. 2015 Aug;25(3):327-65

2         Nagaraju RM, Gurushankar G, Bhimarao, Kadakola B. Efficacy of High Frequency Ultrasound in Localization and Characterization of Orbital Lesions. Journal of Clinical and Diagnostic Research : JCDR. 2015; 9(9):TC01-TC06.

Mahdi ALOSERT, Srikrishna VEMPATY, Dan Lucian GHIURLUC (London, United Kingdom)
11:00 - 18:00 #7092 - 10-point plan to increase patient safety in A&E departments.
10-point plan to increase patient safety in A&E departments.

10-point plan to increase patient safety in A&E departments, particularly for geriatric patients - directly integrated SOPs and other procedures for each patient.

Agatharied Hospital, in Germany, has significantly improved A&E patient safety by successfully implementing the 10-point plan. The hospital’s primary care unit deals with 27,000 patients per year, with the largest age group being 70 to 79 year olds. The review and optimisation of processes and the implementation of supporting software using the 10 point plan, have resulted in improved patient safety, including areas such as the timely detection of a heart attacks to early identification of geriatric patients.
The measures taken related to both structural and technical and changes. The measures were developed in collaboration with the company ClinPath, and the SOPs and other procedures were integrated with the new software ERPath (ClinPath’s A&E Patient-management Software). The 10 points were directly integrated and implemented in the software’s pathway solution, based on patient-oriented diagnosis of symptoms and treatment pathways. The system is now deeply integrated into the A&E department’s workflow processes and the hospital’s IT infrastructure, including API’s to relevant systems.
The following 10 points were implemented:
1.) Issue: Undetected levels of treatment urgency
2.) Issue: Insufficient patient documentation
3.) Issue: Forgotten treatment steps or unknown side diagnosis
4.) Issue: Lost or forgotten patients in case of overload
5.) Issue: Uncertainty in the on-boarding of new employees
6.) Issue: Needs of elderly patients are missed under stress
7.) Issue: Medication errors due to misinterpretation of handwritten documentation
8.) Issue: Lack of use of SOPs/guidelines and uncertainty about the up-to-dateness of these
9.) Issue: Mortality and morbidity planning and management - lack of case discussion
10.) Issue: Resource scarcity during unpredictable peak loads

Bernhard FLASCH (München, Germany)
11:00 - 18:00 #7420 - 1000 consecutive ultrasound examinations in the emergency department: Indications, performer and documentation quality.
1000 consecutive ultrasound examinations in the emergency department: Indications, performer and documentation quality.


Ultrasound is an important tool in the emergency department (ED), which is already highly integrated in the routine work in the ED. Similar to other emergency departments, the implementation of new ultrasound techniques for different clinical questions is increasing constantly. Continuous medical education for advanced ultrasound techniques seem to be very high among emergency physicians. Data about the exact number of different examinations are lacking as well as indications, quality of documentation and level of experience of the performer.


We collected the data of 1000 Patients retrospectively, who received one or more Ultrasound-Exams during their stay in our ED. We analyzed the documents with regard to the number of certain exam techniques, the quality of documentation and performance.



In 1000 Patients who received ultrasound in the ED we could identify 1169 different exams. Especially, critical ill Patients receive up to 5 different exams like echocardiography, abdominal sonography, Doppler sonography, etc..

Abdominal Ultrasound contributed to 59,4%, lung ultrasound, venous duplexsonography as well as the focused Echocardiography to 8,5-11,4%. EFAST and ultrasound of fractures (including the ribs) with 3,6 and 4.8%, respectively, are also common procedures. The remaining exams consist of Ultrasound of Soft tissue, Arteries, Cerebral vessels, eyes and a singular area of Interest like assessing urinary stasis. 

Conclusion: Ultrasound Exams in the ED consist of a wide field of target areas. We showed that nearly every field of interest reachable by ultrasound is covered in our department, and sometimes even the bodyparts considered impenetrable by ultrasound like the lungs or bones. Improving quantity of ultrasounds in the ED via standardized and simplified documentation seems prudent and because of the wide range of possible implication, ultrasound should be more promoted and standardized in emergency medicine education, since our data show a very inhomogenous use of this tool.

Felix LORANG (Jena, Germany)
11:00 - 18:00 #8134 - 3-year review of unexpected deaths in a tertiary care emergency department: opportunities for improvement.
3-year review of unexpected deaths in a tertiary care emergency department: opportunities for improvement.

Introduction. The emergency department (ED) is a bustling, chaotic environment creating a milieu that poses a serious risk to patient safety. While clinical deterioration needs to be recognized early, supported by a timely response to optimize clinical outcomes, ED boarding places patients in a vulnerable position where the emergency physician (EP) may not be familiar nor the most responsible physician, thereby creating an error-producing perfect storm when called to the bedside of critically ill, deteriorating patients. We sought to describe ED deaths of patients who were stable upon ED presentation as part of a larger quality improvement and patient safety “code resuscitation” initiative.

Methods. A 3-year (March 2013-March 2016) retrospective review of deaths in the ED was conducted at a single, tertiary care centre. Patients were identified through the Emergency Department Information System. Inclusion criteria were: >18years, Canadian Triage Assessment Score (CTAS) 2-5 at presentation, non- and boarded admitted patients in the ED with a departure location of morgue. CTAS 1 was excluded as these represent the most unstable population requiring immediate resuscitative efforts. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by a staff Emergency Physician for inter-rater reliability. Outcomes were time-based from triage.

Results. 38 cases met criteria, 35 were assessed by an emergency physician and 3 were direct to service. Mean age 80.8 years (53-99), 22 (58%) males, 34 (89%) arrived by EMS. 37 (97%) were CTAS 2 with 34 (89%) triaged to “major” clinical treatment area. From triage, mean time to RN Assessment was 0:24hr (0:00-2:53hr) and EP Initial Assessment was 0:56 hr (00:00-5:22hr). Code status was documented in 36 (95%) charts: full code (6, 16%), DNR (30, 79%). 25 cases (66%) had a consult, with 14 (56%) having one consult, 9 (36%) two consults, and 1 (4%) had 3 consults. GIM (n=11, 44%) was most common initial consult service; 5 (20%) had ICU as their first consult, and 3 (12%) as second consult. 27 (71%) were admitted to a service at time of death in the ED, in which EPs documented being called to bedside for peri- or arrest care. Average time-to-death (ED LOS) was 6:05hr (0:45-22:00hr).

Discussion. Early recognition, timely response and optimal management of acutely, deteriorating patients is paramount in determining outcome. Despite a significant amount of work developing rapid response systems to improve morbidity and mortality in a variety of settings and support early identification for those at risk of clinical deterioration, none have been shown to be effective in the ED. While developing interdepartmental processes to support patient flow is fundamental to address ED boarding, implementing a protocol-driven system for goal-directed intervention through a "resuscitation huddle" in the ED has the potential to mobilize multidisciplinary resources and care earlier in the clinical course thereby potentially impacting mortality.

Melissa MCGOWAN (Toronto, Canada), Conor LAVELLE, Alina TOMA
11:00 - 18:00 #7278 - A 16-year old girl with impaired vision and instable gait.
A 16-year old girl with impaired vision and instable gait.


Dietary supplements may cause adverse events but are usually not listed on the patient’s medication list.  The current case report emphasizes the importance of asking about  these products.

Case report

A 16-year old girl presented to the emergency department with impaired vision, impairment of perception of depth and instable gait. She also complained of nausea, vomiting and abdominal and thoracic pain. 

She was currently treated for a (classical) Hodgkin lymphoma  with chemotherapy (ifosfamide, carboplatin and etoposide). Her current medication consisted of fluconazol, alizapride, lormetazepam and pantoprazol.

Clinical examination revealed a nervous girl who was giggling a lot. She was tachycardic (123 bpm) with a  normal blood pressure (140/74 mmHg). Her body temperature was normal (36.3°C) and oxygen saturation was 99%. On auscultation we found normal bilateral breath sounds. She  presented with a dry skin and conjunctival injection. Her walking pattern was unstable and she had difficulty maintaining her balance without signs of lateralisation. There were no coordination problems, but an ataxic gait was present.

A routine blood exam, an electrocardiogram  and urine toxicology screening were obtained. 

A history taken from the parents revealed that her last chemotherapy session was four days earlier after which she had complained of muscle ache (as usual). To relieve the pain, the patient’s mother had given her some drops of a herbal medicine she had ordered on the internet. A friend had advised her to buy this claiming that it would be highly effective in substituting minerals in patients undergoing chemotherapy. We were able to trace the  drops back to a Spanish company “Terapeutico Dandelions”. They consisted of an oily solution of  TCH (tetrahydrocannabinol) and CBC (cannabichromene), both derivates of cannabis. The company profiles itself as a 'naturalist shop' and promotes several drugs containing cannabis.

The results of the  technical examinations revealed no infection and no liver or kidney impairment. The electrocardiogram  was normal. Urine toxicology screening confirmed the diagnosis of acute cannabis intoxication.

Literature key points

A recent study estimated that in the United States 23000 emergency department visits per  year may be attributed to adverse events related to dietary supplements. Another study showed that nearly one in five young adults reported using dietary supplements.   Furthermore,  physicians do not ask after dietary supplements when performing a patient’s history. 


We report an accidental cannabis intoxication in a young girl caused by a dietary supplement. In a world where everything can be bought online without patients realizing what they are buying, emergency physicians need to remain  vigilant and ask their patients actively about any substitutes or food supplements taken. It is important to thoroughly  check the composition of  these supplements.

11:00 - 18:00 #8159 - A bite which went a bit too deep! ; A case report.
A bite which went a bit too deep! ; A case report.


Animal bites are common presentations to the Emergency Department. Commonly anticipated complications of animal bites are infections; here we present patient with severe necrotising fascitis caused by a rat bite 

Case Report:

A 25 year old man presented to Emergency department with pain, swelling and two distinct rashes on his forearm. He was previously healthy with no significant medical history. He gave history of being bitten by a rat couple of days prior to the presentation. He also complained of severe lethargy.  

On examination he had an abrasion surrounded by erythema over lower end of his fore arm. There were two distinct vesicular rashes over the ante cubital fossa and over the right nipple. The whole arm was grossly swollen limiting movements at elbow and wrist joints. The patient was septic from the infection.

Labs showed acute neutrophilia. Ultrasound with doppler studies of the arm were performed . It showed two haematomas in relation to the Brachio-radialis muscle causing compression of the radial vein. An MRI of the fore arm proved necrotising fasciits deep to the interosseous membrane with muscle necrosis and ischaemia. The patient was treated with Intravenous antibiotics and surigical debridement. He later had a skin graft and recovered satisfactorily.

Necrotoisng fascitis is a uncommon but severe complication of bites. Clinical suspicion and early agressive management is the key to get good results.


11:00 - 18:00 #8021 - A case of cerebral vein thrombosis.
A case of cerebral vein thrombosis.

Background: Cerebral vein and dural sinus thrombosis is less common than most other types of stroke, but can be more challenging to diagnose. Of all cerebral sinus thromboses, 5 to 20 % occur in connection with pregnancy or childbirth, or during the puerperium. The risk is highest during the first month following delivery.

Case presentation: A 23-year-old female patient with no history of illness was admitted to our hospital by ambulance after experiencing near syncope. Her blood pressure was 130/70mmHg, her pulse 76/minute, her oxygen saturation 99% and her fever 36.3 degrees Celsius. She had a Glasgow coma scale score of 15. One day before she had experienced loss of motor function on her right side. There was no evidence of pathology in her physical examination. She was only complaining about headache and weakness. One week before she had had a Caesarian section and she was now breastfeeding. Her blood panel and biochemical parameters were normal. There wasn’t any pathology in her cranial computed tomography. As a generalized tonic clonic seizure occured during her hospital monitoring, diffusion weighted magnetic resonance imaging was applied, and a diffusion limitation was detected on the left precentral gyrus. Because of the atypical localization, sinus venous thrombosis was considered as a prediagnosis. The Neurology Department was consulted and the patient was interned. The MR venography conducted in the Neurology Department showed no flow in the left vein of Trolard or in the superior sagittal vein.

Conclusion: In a postpartum patient with seizures, CVT should be considered as a differential diagnosis. Due to the widespread use of diffusion weighted magnetic resonance imaging in the Emergency Department, it is possible to detect and diagnose CVT early, which can be lifesaving for the patient.



Incifer KANBUR, Behlul BAS (istanbul, Turkey), Sila SADILLIOGLU, Hakan TOPACOGLU
11:00 - 18:00 #7267 - A case of dysarthria caused by Ricinus Communis tea.
A case of dysarthria caused by Ricinus Communis tea.

The castor oil plant, Ricinus communis, is a perennial scrub of the spurge family Euphorbiaceae. R.communis probably originates from Africa. Nowadays the plant grows wild in tropical and subtropical regions. Castor seeds are a rich source of oil which can be used as an inexpensive fuel for oil lamps and industrial raw material for lubricants, paints, coats and cosmetic products. Ricinus communis is considered to be less toxic in humans. The majority of intoxications were due to direct ingestion of seeds and the most common complaints were vomiting, diarrhea, abdominal pain, and dyspnea in general. But poisoning by water extracts of R. communis with neurologic symptoms have not been reported in the literature so far. Here we report a case of dysarthria caused by drinking tea brewed with R.communis in a 82-year old woman with manifestations of dysarthria. Water extracts of R.communis can cause toxicity and may cause neurological symptoms.

Pr Han Sung CHOI (Seoul, Korea, Republic of), Seo Kyong LEE, Junsoo SEOK, Kyounghwan KIM, Hyeonsong KIM, Sungkyoo KIM, Young Gwan KO, Seok Hoon KO, Hoon Pyo HONG
11:00 - 18:00 #7493 - A case of minitracheostomy for post of tracheostomy patient.
A case of minitracheostomy for post of tracheostomy patient.

Back ground . From the point of view for stenotic  change of trachea, cricothroyd puncture,such as minitracheostomy  is forbidden for posttracheostomy patient. However, we could  safely performed minitracheostomy under observation of bronchoscopy . Case 37-year old male.  He complained dyspnea,so he transferred to our emegency department. he underwent tracheostomy ,when he was 16 year-old due to cervical spinal cord injury.His ADL(activity of daily life)demonstrated ASIA(American Spinal cord Injury Association) impairment scale A (cervical 5 level).In daily,he moved by wheel chair.This time,he admitted due to bacterial pneumoniae. He underwent intubation due to worsening of poor excetion of sputum and hypoxia. Accidentally,the patient removed tracheal tube himself  after  5 day later, and he could not enoughly breath spontaneously without suctioning. But the patient will not allow us conventional tracheostomy or re-intubation,because he want to speak contrast of his willness,on the day 7th ,due to severe hypoxia, we had to intubate him.There is no standard guidelines concerning the indications, index of the intubation and extubation of this case.From the view of his willness,  Cricothroyd puncture as minitracheostomy has not recommended after tracheal  surgical procedure.But, this time ,we performed minitracheostomy safely under observation of bronchoscopy.On the day 13th,he could transferred to general ward,on the day 60th,he discharged.Discussion .There was no  complication of minitracheotomy. We may consider minitracheotomy for airway management after anterior cervical surgical within 2 weeks.Summary .From point of the view of airway management and vocal communication, we consider it may be useful that minitracheotomy for airway management afte r tracheostomy. Further study is needed.

Maeda YUJI, Kurihara MAKI (Kobe, Japan)
11:00 - 18:00 #7935 - A case of Myocarditis presenting with Hyperventilation.
A case of Myocarditis presenting with Hyperventilation.


Hyperventilation syndrome is a relatively common emergency department (ED) presentation in which minute ventilation exceeds metabolic demands. It is associated with a wide range of symptoms without a clear organic precipitant. Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentations, from subtle to devastating. It is caused by a wide variety of infectious organisms, autoimmune disorders, and exogenous agents,

Case report:

A 37 year old Egyptian lady who was 12 weeks pregnant presented to the ED with sudden onset of hyperventilation and chest discomfort. She also complained of numbness in the limbs but denied any other complaints. Clinically, she appeared well and her vitals were stable. Examination of heart and lungs was normal. ECG show normal sinus rhythm and ABG showed signs of hyperventilation (PH 7.54, PCO2 23mmHg, HCO3 20mmol/L and SaO2 99%). Chest x-ray was normal and bedside Echo did not show evidence of myocardial dysfunction, valvular abnormalities or massive pulmonary embolism. Troponin T was 426ng/L (normal < 30ng/L).


Diagnosing myocarditis is challenging in view of its varied presentations. There is no definite clinical feature that is diagnostic of myocarditis. It is typically seen in patients around age of 20-50 years and the variability in presentation reflects the variability in histological disease severity, etiology, and disease stage at presentation. Many cases go undetected because they are subclinical or present with nonspecific signs. Patients of myocarditis usually present with mild symptoms of chest pain, fever, sweats, chills, and dyspnea secondary to heart failure. This is a rare case where patient presented with shortness of breath which was not secondary to heart failure but only showed signs of hyperventilation of clinical examination and ABG.

Conclusion :

Emergency physicians treat young patients who present with shortness of breath secondary to hyperventilation/psychogenic dyspnoea. A high degree of suspicion is needed to diagnose myocarditis which can occasionally present with atypical symptom like hyperventilation.

Dr Amar SATYAM (Singapore, Singapore), Sohil POTHIAWALA
11:00 - 18:00 #7329 - A Case of Rheumatoid Arthritis and Multiple Myeloma.
A Case of Rheumatoid Arthritis and Multiple Myeloma.

Clinical case report


A 77-year-old female with sero-positive erosive rheumatoid arthritis (RA) presented with a one month history of fatigue, night sweats, nocturnal pruritis and spontaneous bruising with bleeding gums.  She denied weight loss, fever, epistaxis, haemoptysis, haematuria or recent infection. She was diagnosed with RA in 1985, on treatment with Methotrexate and Etanercept and her RA was in remission with no swollen and no tender joints.

On examination, she had a non-blanching, petechial, non-palpable, pruritic rash affecting her face and neck.  There was no hepatosplenomegaly or lymphadenopathy.  Vital signs and general examination were unremarkable.

Her routine bloods showed a normocytic anaemia (Hb 92g/l) and a new acute kidney injury (creatinine 249 µmol/L). White cell count, platelets and calcium were normal. Her CRP was normal but ESR had risen to 55mm/hour. She had significant proteinurea of 3g/l with no microscopic haematuria. Further blood tests revealed normal haematinics, fibrinogen and complement levels. An ultrasound of the abdomen was normal.

History and investigation suggested a paraprotenemia as the differential diagnosis. A myeloma screen identified an IGA lambda paraproteinemia with immunoparesis and raised B2 microglobulin. A skeletal survey was normal. She had a bone marrow trephine biopsy which demonstrated lambda restricted neoplastic cells consistent with a diagnosis of multiple myeloma. She was diagnosed with multiple myeloma and a myeloma kidney and started on dexamethasone, allopurinol and bortezomib. She responded well and her renal function recovered fully.



It is well recognised that patients with RA are at increased risk of developing lymphoma. So does RA increase the risk of developing multiple myeloma? A meta-analysis of 18 studies has shown that RA does not increase the risk of developing Multiple Myeloma.  Furthermore, is the RA treatment including biologic therapy a risk for multiple myeloma? A meta-analysis of 63 randomised controlled trials showed that the use of biologics does not increase the risk of malignancy.


 Conclusion and learning points


This case demonstrates that we should be cautious of ascribing symptoms to the chronic inflammatory disease as it is easy to attribute symptoms of lethargy and anaemia to a flare of the RA. Listening to the patient is of paramount importance and this lady was adamant that her symptoms were not due to a flare of the arthritis but a new condition. Pattern recognition is important as the new acute kidney injury and the lack of RA disease activity suggested a new disease process was occuring and prompted further investigation.

This case illustrates that diagnosis of myeloma is not straightforward especially on a background of chronic inflammatory disease. The new acute kidney injury suggested a new pathological process and a diagnosis of multiple myeloma was made with the patient making a good recovery.


1) Shen K, Risk of multiple myeloma in rheumatoid arthritis: a meta-analysis of case-control and cohort studies. Plos one, 2014, 9(3)

2) Dommasch BA, Is there truly a risk of lymphoma from biologic therapies? Dermatologic therapy, 2009, volume 9, p418-430







Rushabh SHAH, Raajul SHAH (London, United Kingdom)

47-year-old male with sudden onset severe abdominal pain after the ingestion of food. Profuse sweating, strong weakness, distal coldness and feeling of dysthermia. No nausea or vomiting. He denies chest pain.

Does not have medicine allergy or cardiovascular risk factors except smoking.


Physical examination:


Vital signs: BP: 60/40 mmHg, 99 bpm, Temperature: 36.7ºC

Conscious and oriented. Eupneic. Paleness with sweaty skin. Erythema in thorax with wheal skyn lesions.

Cardiopulmonary auscultation without pathological data.

The abdomen is soft, depressible, pain to hypogastrium palpation without peritoneal irritation signs. No hernias.


Complementary tests:


-       ECG: Sinus tachycardia of 103 bpm without data of interest.

-       Chest x-ray: whitout significant radiological findings.

-       Blood test: slight leukocytosis (16100) with predominance of neutrophils (81.8%), the rest of the hemogram is normal. Biochemistry: hyperglycemia (221) and slightly increase of Troponin I up to 0.23 (normal: <0.06).




Differential diagnosis:


In a clinical diagnosis compatible with shock we value different causes: hypovolemic, cardiogenic, obstructive or distributive.

The anaphylactic shock (distributive) is produced by the mast cells release, of sudden appearance, is characterized by low blood pressure, skin rash, urticaria, bronchospasm and digestive symptoms such as pain, vomiting and diarrhea.


Evolution and Discussion:


Initially treated with serum-therapy and administering of 0.5 mg of adrenalin improving clinically with BP 130/80 mmHg and rash disappearance.


Second Troponin of 0.46 (↑) again, reason for which suspected Non-ST-Elevation Miocardial Infraction (NonSTEMI) in the context of anaphylactic shock initiating treatment with dual antiplatelet therapy, and was admitted to hospital to complete the study: Normal Echocardiogram and coronary angioplasty without injuries in the coronary arteries. Obtained values of positive Tryptase and lgE specific for Anisakis. The final diagnosis was Kounis syndrome type I.


The Kounis syndrome is the simultaneous appearance of acute coronary events and anaphylactic allergy reactions. Through histamine and leukotrienes on smooth muscle can cause the onset of vasospastic angina.


Two subtypes I and II are distinguished: without coronary disease and with atheromatous coronary artery disease, respectively. A Type III postulates for patients with stents thrombosis produced by mast cells and eosinophils.


The diagnosis is clinical by the presence of signs suggesting an allergic reaction and a coronary event simultaneously. There are no pathognomonic tests and in case of suspicion of it, we must carry out: EKG to assess ST alterations in relation to vasospasm, blood test with Troponin and tryptase levels. Echocardiogram and cardiac catheterization allow to complete the study.


It should be noted that many of the drugs used separately in anaphylaxis or in ACS can present contraindications when both episodes appears simultaneously. The adrenalin that can aggravate ischemia of ACS and induce vasospasm. The drugs used in ACS can aggravate anaphylaxis: acetylsalicylic acid cause drug allergic reactions, nitrates are contraindicated in hypotension and tachycardia, and morphine can give rise to mast cell degranulation.


Kounis syndrome is infrequent and probably under-diagnosed. Unawareness can cause undesirable effects for the prognosis and evolution of patients that suffer it in case of present interactions between different drugs used in their treatment.

Sergio AZNAR (GUADALAJARA, Spain), Vanessa HERAS, Ezra Honan ROIZ, Gema ESTEBAN, Cesar BRIEGA, María Isabel CARRASCO, María José JIMENEZ
11:00 - 18:00 #7302 - A child's adventure in A and E.
A child's adventure in A and E.

A  guidebook to the children’s emergency department written for children by children


I am an emergency medicine consultant based in an inner city hospital which sees approximately 16 000 children/yr.


Most children’s experience of hospital is either of or involves the Emergency Department.


We have a general assumption that children may find these visits stressful. However I felt that it would be interesting to explore what they really thought and felt about the department and to explore what their hopes, fears and expectations were.


Also , due to its nature, visiting an emergency department is unplanned and unpredictable. We decided to create a guide to prepare both children and their parents for what they might expect or encounter.


I worked with children from Grafton primary school, their writer in residence Diane Samuels and artist in residence Tessa Garland.


Diane and I had sessions with the children during which they asked me anything they wanted to know and they also visited the department. They each selected an accident which they acted out in their drama class. Following this they attended and we role played the management they would receive including waiting.


Throughout they were encouraged to write about everything. From this large body of ‘raw work’ they selected what they wanted to tell other children. They wanted a booklet which had a magazine/comic feel to it.


They worked with artist Tessa Garland on the illustrations and also selected the layout design, font type etc with graphic designer Alex Anthony.


The result , A Child’s Adventure in A + E , is a guide book written for children by children.


During their time with us they became experts in the department having experienced it in a very real way. They noticed a variety of things which had previously escaped myself and other staff members or saw things from a whole different perspective. All of which has been captured in a ‘ Child’s Adventure in A + E ‘


I feel that this project gave us a very interesting insight into the experience of the department from a child’s perspective. Similarly in producing the booklet the children have captured this information in a fun format which will appeal to other children and hopefully improve their experience of the hospital.

Also most children’s experience of hospital is via the emergency department which, by its nature, is unplanned ; very little information/literature exists to prepare children for this experience.


The poster shows highlights from this guidebook all of which are the children’s own words and drawings.







Heidi EDMUNDSON, Louise BROWN (London, United Kingdom)
11:00 - 18:00 #8156 - A crucial case of surgical emergency in Aragon-Spain : idiopathic spontaneous hemoperitoneum.
A crucial case of surgical emergency in Aragon-Spain : idiopathic spontaneous hemoperitoneum.

Intraperitoneal bleeding is common in patients with abdominal trauma or in those with benign gynecologic diseases, but it is very rare to occur spontaneously. The purpose of this communication is to report a female patient with idiopathic spontaneous hemoperitoneum (ISH). Case presentation: A 28-year-old patient was admitted with 12-hour acute abdominal pain. Laboratory tests upon admission showed: Hb 9.0 g/dL, WBC 8.9 x 109/dL and negative immunologic pregnancy test. The ultrasound showed free intraperitoneal fl uid. She underwent exploratory laparoscopy with fi ndings of massive hemoperitoneum, which was resolved and, after a thorough exploration of the abdominal cavity, no evidence of the bleeding site was found. She was closely followed-up for 2 years without any recurrence or complications related to the ISH. An extensive review of the literature was performed. We conclude that ISH is a rare entity that usually presents as a surgical emergency and whose diagnosis is made in the absence of predispo-sing factors and excluding lesions in the abdominal blood vessels and organs. It warrants immediate intervention, which is crucial for patient survival.

11:00 - 18:00 #7979 - A diagnostic dilemma- Unknown case of oesophageal pericardial fistula.
A diagnostic dilemma- Unknown case of oesophageal pericardial fistula.

Oesophageal cancer is statistically the eight most common cancer worldwide with increased incidence in men than women. The prognosis is quite poor as most patients present late with advanced disease. Researchers are looking at genes, role of aspirin and photodynamic therapy apart from regular chemotherapy and surgery. 

We present a case of a 56years old male patient who attended our emergency department at east surrey hospital with acute episode of chest pain and mild shortness of breath which was relieved with analgesia in the deparment. His pain was retrosternal and did not radiate anywhere but was associated with nausea. Patient had a background history of  terminal oesophageal cancer which was stented previously. He also suffered from pancreatic and prostate cancer. His initial observations showed mild tachycardia  and low blood pressure which improved with fluids intravenously. He had no signs of respiratory compromise and was afebrile. His systemic examination was baseline with tenderness along the costochondral joints.His arteial blood gas and laboratory results were normal.His chest xry  did not show any new abnormality. He was observed in the department and as his pain improved he was discharged with a diagnosis of musculoskeletal pain. 

This patient was prioritised later that night into resus as a priority cardiac arrest. He was resuscitated with full life support protoccol despite his known medical condition but he did not survive. Autopsy later on revealed an Oesophageal Pericardial fistula as the primary cause of death despite his terminal cancer. 

Oesophageal Pericardial fistula is a rare clinical entity with a very dismal prognosis and is often a diagnostic dilemma. According to litreature review less than fifty( 50) cases have been doccumented so far. The clinical triad of symptoms include retrosternal chest pain, shortrness of breath and pyrexia. The commonest predisposing causes are oesophagitis, ulcer, foreign body, tuberculosis,iatrogenic, ingested caustic substances,oesophageal diverticula and oesophageal cancer. It can also occur in patients who have had radiofrequency ablation in atrial fibrillation. The common radiological findings are cardiomegaly, pneumomediastinum,pneumopericardium, hemopneumopericardium and pleural effusion. However it is a life threatening complication and diagnosis is often by radiology, surgery or at autopsy. 

Akhtar MUNAZAH (Redhill, United Kingdom), Babak DANESHMAND, Julian WEBB
11:00 - 18:00 #7624 - A different view to appendicitis with artificial intelligence.
A different view to appendicitis with artificial intelligence.

Introduction: Acute appendicitis, a etiology of acute abdomen, is a clinical concern for emergency physicians and general surgeons. With clinical scores risk calculations helps physicians to decide consultation and operation. Most of the patient have negative laparotomy though having a high risk scores. Lymphoid hyperplasia is very common in appendicitis etiology as well as obstruction by other causes. Mostly viral infection results lymphoid hyperplasia and may lead to recurrent or chronic right lower quadrant pain. Most of the emergency services have face diagnosing problems with insufficient stuff and equipment. Thus studies with diagnosing methods via machine learning techniques are recently popular and helpful.

Materials and Methods: One hundred thirty three patients with high risk scores and diagnosed as appendicitis are studied. Laboratory and pathological findings are reported, trained and tested.

Results: Success of machine learning techniques as K nearest neighbour, classification tree, Naive Bayes are all found higher in identifying appendicitis as lymphoid hyperplasia or other causes. Knn method is the successful among machine learning techniques with a accuracy of over 80%.

Conclusions: Patients with right lower quadrant pain and high risk of appendicitis can be classified as urgent or recurrent with the help of artificial intelligence methods. Thus may lower the waiting time to operation of the high risk patients.

References: 1.Xu, Yingding, et al. "Lymphoid Hyperplasia of the Appendix: A Potential Pitfall in the Sonographic Diagnosis of Appendicitis." American Journal of Roentgenology 206.1 (2016): 189-194.

2.Swischuk, Leonard E., et al. "Non-fecalith-induced appendicitis: etiology, imaging, and pathology." Emergency radiology 22.6 (2015): 643-649.

Acknowledgments: There is no conflict of interest in this study.

Goksu BOZDERELI BERIKOL (Istanbul, Turkey), Gurkan BERIKOL, Oktay YILDIZ, Mehmet Serkan YURDAKUL, Attila BESTEMIR
11:00 - 18:00 #7366 - A Fatal Case of Unintentional Colchicine Intoxication.
A Fatal Case of Unintentional Colchicine Intoxication.

Colchicine is widely used in the treatment of gout, Behçet’s syndrome and other disease. Colchicine intoxication, although rare, can cause symptoms ranging from mild gastrointestinal complaints to severe toxic conditions resulting in death. we reported a 32-year-old woman who had Behçet’s syndrome and presented to the emergency department after ingesting 30 tablets(18mg) of colchicine in attempt to alleviate her abdominal pain. Initially, she just complained of abdominal pain and nausea. Gastric lavage was performed and activated charcoal was administered immediately. On admission, The patient hematologic and biochemistry laboratory test result was normal. But she exhibited many progressing features of colchicine intoxication, such as gastrointestinal symptoms, colitis in CT scan, leukopenia, rebound leukocytosis, elevated liver enzymes, multiple organ failure and so on. Fifty hours after ingesting the colchicine, she complained of chest discomfort and dyspnea, and developed cardiac arrest immediately thereafter. Despite cardiopulmonary resuscitation, she was expired unfortunately. This case showed that overdose of colchicine is associated with rapid progression and sudden cardiac arrest. It is important that we have to know benefits and potential dangers of this drug. Careful prescription and explanation maybe needed.

Seo YOUNGWOO, Tae Chang JANG (Daegu, Korea, Democratic People's Republic of )
11:00 - 18:00 #8046 - A headache revealing hemophagocytic syndrome.
A headache revealing hemophagocytic syndrome.

Introduction :

Macrophage activation syndrome also called Hemophagocytic lymphohistiocytosis (HLH) is rare but potentially fatal. It is based on a number of clinical signs and laboratory findings. Five out of the following nine diagnostic criteria for HLH: fever, splenomegaly, cytopenias  (affecting two or more of three lineages in the peripheral blood), hypertriglyceridemia, hypofibrinogenemia, elevated ferritin, hemophagocytosis in bone marrow/spleen/lymph nodes.The causative agent, whether bacterial, viral, fungal or parasitic should be treated urgently.

Case report:

A 19-year-old man presented at our emergency departement with headaches and vomiting lasting for 5 days in a fever context. On admission, examination revealed that he was conscious, afebrile with a respiratory rate of 20 breaths/min, an oxygen saturation of 98% on air, and blood pressure of 100/60 mmhg. He was a jaundiced patient. Abdominal examination and elecrocardiogram were unremarkable. Biology showed acute renal failure (clearance : 14ml/min), cholestasis combined dominance 8N, cytolysis 2N, lipasemia 5N, hypertriglyceridemia, severe thrombocytopenia, hypochromic microcytic anemia 8.9. Cardiac ultrasound trans chest was unremarkable. Injected abdominal CT showed bilateral renal nephritis outbreaks. Hepatomegaly, intra abdominal effusion low abundance.


Infectious etiologies of HLH are many, predominated by viral infections. The severity of HLH prognosis requires an approach aggressive diagnosis and a multidisciplinary therapeutic management to determine the best options based on etiology found and the seriousness of the table.

Salwa AMRI, Salwa AMRI (villeneuve saint germain), Sarra JOUINI, Rym HAMED, Zied GUERMAZI, Asma ALOUI, Syrine JAOUANI, Bechir BOUHAJJA, Faten AMIRA
11:00 - 18:00 #6223 - A history to make history?
A history to make history?


National audits of the Paediatric Emergency Department have highlighted recurrent pitfalls in some areas during initial clerking. These include recognition and management of children in pain, response to abnormal vital signs and consideration of non-accidental injury.

In the local Emergency Department of Wexham Park Hospital it was identified that College of Emergency Medicine standards were not being met when it came to managing moderate pain in a timely fashion and re-evaluating pain. An initial audit examining management of children in pain looked at 50 children presenting to the Emergency Department, Wexham Park Hospital, with moderate to severe pain scores. It demonstrated pain management was below agreed standards from the College of Emergency Medicine. A pain pathway was designed to guide clinicians through appropriate pain assessment and prescribing of analgesia. After creation of the pain pathway a further 50 cases were identified and their management reviewed. This demonstrated an improvement in management of severe pain, but re-evaluation of pain and management of moderate pain remained poor. The repeat audit had failed to demonstrate significant improvement in practice, and highlighted that the pathway was not being utilised.

Non-accidental injury consideration is well documented electronically in Wexham Park Hospital Emergency Department because of a coded link which prevents discharging the patient from the system without completion. Written documentation in patient notes however is not often recorded.



A reconsideration of the clerking documents was commenced in order to improve the quality of the service provided. It was decided that the clerking document should be significantly changed from two blank sheets of headed paper. The new document would aim to encourage clinicians to use appropriate pathways and trigger appropriate responses to areas of previous poor performance. To reform the clerking documents it was decided to use signposting tools, check-points and diagrammatic aids to improve the quality of clerkings and management of patients.



At the top of the clerking document a signposting tool reminds clinicians to use the relevant pathway if one is available for the presenting complaint. Having to check a box of confirmation next to the signpost aims to encourage clinicians clerking the patients to take responsibility for this.

Check-points have been compiled for targets considered most important to patient safety and optimum care, based on audits highly recommended by the Department of Health. These include response to abnormal vital signs and management of children in moderate or severe pain.

Artwork was created specifically for the clerking documents by a doctor working in Ear, Nose and Throat surgical speciality. Diagrammatic representations of the mouth and tympanic membrane were included to encourage documentation of tonsillar and aural pathologies. The diagrams are designed to be anatomical aide memoirs and selected to serve as reminders to examine common sources of infection in the paediatric population.

The designed Paediatric Emergency Department clerking document introduced has been specifically designed to encourage optimum and safe care for patients. It is authorised by clinical governance and has been well received by clinicians.

Emily HIGNELL (Bristol, ), Jonathan LEWIN
11:00 - 18:00 #7541 - A New Immunomodulatory Drug, A New Adverse Effect; Adrenal crisis.
A New Immunomodulatory Drug, A New Adverse Effect; Adrenal crisis.

Background: Owing to the advancements in medicine, almost everyday, new information is obtained regarding cancer, and new antineoplastic agents are developed. Frequent use of these new pharmacological agents because of their promising properties propels emergency physicians to be vigilant about their side effects. We present a case of adrenal crisis in a patient with non-small cell lung cancer (NSCLC), caused by nivolumab, which is an immunomodulatory drug.

While adverse events are related to other immunomodulatory drugs have been reported in literature, our case is the first nivolumab-related adrenal failure to be reported.

Case: A patient with lung cancer presented to the emergency room(ER) with nausea and vomiting. The patient also had a seizure in the ED. Hyponatremia, hyperkalemia, persistent hypoglycemia led to the diagnosis of adrenal crisis. The patient was admitted into the ICU and externated after successful treatment.

Discussion: Immunomodulatory drugs are lately popular among new anticancer treatment agents. Having direct effect on the immune system, these drugs were claimed to be highly reliable and were chosen as the drug of the year in 2013. However, there is no reliable data on the side effect profile of these agents. In order to ensure early diagnosis and treatment of these cases, it should be kept in mind that life-threatening auto-immune reactions may occur, even though most side effects are mild.

Funda KARBEK AKARCA (Izmir, Turkey), Ozge CAN, Sercan YALCINLI, Yusuf Ali ALTUNCI
11:00 - 18:00 #7795 - A new point-of-care ultrasound workflow removing the middle man.
A new point-of-care ultrasound workflow removing the middle man.


Developing a seamless point-of-care (POC) ultrasound workflow has challenged frontline providers for years. Ideally, it would contain the fewest number of steps, allow for rapid examination performance and interpretation and perhaps most importantly become integrated into the electronic medical record (EMR).

Previously reports of workflow solutions have typically involved third-party “middle-ware.” These products add cost to the process and institution.

We developed a solution utilizing the EPIC EMR existing infrastructure to allow seamless order entry, worklist population and demographic entry, PACS integration, EMR results reporting and medical record billing. Prior to this implementation emergency department ultrasound images were not permanently stored as part of the medical record.


Physicians enter an application-specific order in EPIC as they would for any other diagnostic test. EPIC routes the order to an ultrasound modality worklist. On the modality the examination is selected and demographic information populates from the order. On study completion, the clinician ends the examination, sending images to PACS from the modality. In the radiology read worklist in EPIC, the physician associates the patient account number and enters a report using customized application-specific templates. The results, including a link to the PACS images, are immediately available to all providers with EMR access.


The process allows for documentation and permanent EMR storage of POC ultrasound studies. The EPIC EMR allows consultants or providers throughout the health system to access a link within the report to review the PACS images. The advantage of using solely EPIC, rather than multiple interfaces, is that clinicians across specialties are able to view important clinical results;providers are also easily able to integrate this process into their workflow as they are accustomed to placing orders and navigating EPIC for all clinical functions. Continuity of care is improved as our patient portal allows the patient to access results and share with providers outside the health system. Additionally, by having the report in the standard results section of the EMR, providers do not have to search the chart for a separate clinical procedure note or flowsheet.

By placing the order for the ultrasound, completing the study (including sending the images to PACS), linking the registration account number in EPIC to the study, and the attending physician entering a report complete with the patient information, indications, findings and impression, the steps required to allow a professional and technical fee bill are complete. This also allows us to easily separate out billed official studies from educational studies, as the later are not ordered in the EPIC EMR. Also, the billers and coders do not need to dissect through notes or access additional systems, as all the elements for billing are stored within EPIC.


This novel workflow solution allows for a streamlined workflow with minimal interfaces with which the clinical sonologist and down-stream providers have to interact. This improves patient care and safety by allowing ultrasound to be used readily at the bedside and have that information available for the provider and as a permanent part of the medical record.

Christopher RAIO, Gerardo CHIRICOLO (Holmdel, USA)
11:00 - 18:00 #7950 - A parody- Anterior shoulder dislocation.
A parody- Anterior shoulder dislocation.

Acute shoulder dislocations are a common clinical correndrum/ presentations in our emergency departments worldwide. Statistics show that shoulder joint dislocations are 90% common with acute anterior shoulder diclocations accounting for 50% of cases. In our busy emergency departments it is important that we use a simple,reliable, less traumatic and time modulated procedure. Over decades we have seen various methods of anterior shoulder reduction procedures being implemented, which have been modified later as pain and time managemnt have always been an issue.

We have found a relaible and modified method of anterior shoulder reduction. Our first author implemented this technique initially with our support. it involves traction parallel to body ( either sitting or lying down position) with one hand and manipulation in affected axilla of humeral head into the glenoid cavity with other hand which leads to successfull repositioning of shoulder if adequate analgesia and muscle relaxtion have been achieved. The process is completed by internal rotation and placing a broad arm sling on the reduced shoulder.

Twenty (20)patients with acute anterior shoulder dislocations were evaluated between Januaury2014 till March 2016 at East Surrey hospital in United Kingdom . The patients were evaluated for the effectiveness of the procedure in achieving reduction, duration of reduction attempt and post procedural complications. The method was not compared with any other method.  However the exclusion criteria were polytrauma and fracture dislocations.

Our results wre quite encouraging as eighteen (18) out of twenty(20) patients achieved successfull redcution through this procedure in five minutes of attempt. However in two patients it was not successfull. There were no reported complications.

This method is in its initial stages and needs more research and time . it is a small  non-comparative study ,however  we feel it has paved a new way ahead. 

Asif MUSHTAQ, Julian WEBB, Akhtar MUNAZAH (Redhill, United Kingdom)
11:00 - 18:00 #8240 - A perforation history: still radiography.
A perforation history: still radiography.

Perforation of the gastrointestinal tract occurs for reasons such as peptic ulcer, trauma, iatrogenic, foreign bodies, appendicitis, inflammation and requires early diagnosis and timely surgical intervention. The main treatment is surgery. Today endoscopic and laparoscopic techniques instead of conventional laparotomy are used increasingly in the treatment stage. We report to case of perforation diagnosed after previous abdominal hernia operation.
A 47-year-old female admitted to the ED complaints of abdominal pain, nausea and vomiting and diarrhea. In physical examination defense there was defense and rebound. X-Ray showed free air under the diaphragm.Laboratory findings revealed Hb:6,9, Hct:21, WBC:9400, CRP:24,2. She was interned to general surgery clinic.
Despite advanced  scanning methods , conventional radiography is still important for diagnose of perforation due to cheap and easy method.

11:00 - 18:00 #6784 - A prospective comparison of bedside ultrasound and CT- scan of the chest for the diagnosis of traumatic pneumothorax.
A prospective comparison of bedside ultrasound and CT- scan of the chest for the diagnosis of traumatic pneumothorax.


In the United States, it is estimated that trauma is responsible for approximately 100,000 deaths annually.

Accidents (unintentional injuries) are the fifth most common cause of death.

Approximately 25% of deaths from blunt trauma arise from chest injuries.

Traditional imaging for a potential traumatic pneumothorax initially begins with chest radiography. However, due to the limitations of spinal immobilization in trauma patients, this examination often consists of anteroposterior (AP) supine films, in which radiographic features of pneumo thorax may be quite subtle. Computed tomography (CT) is much more sensitive for pneumothorax, but requires the patient to be removed from the emergency department (ED) environment and its resuscitative capability.

Bedside ultrasound become a very sensitive tool for the diagnosis of traumatic pneumothorax not only in detection of its presence but also in quantification of its size without the transportation risk and radiation exposure and with a lower cost.


The aim of this study is to evaluate the sensitivity and specificity of chest ultrasound in the detection of traumatic pneumothorax and quantification of its size in comparison to the CT-Chest as a gold standard diagnostic tool. PATIENTS

Exclusion criteria:

Life threatening pneumothorax.

Patients who do not undergo CT-Chest either for not being stable for transportation or do not met American college of radiology appropriateness criteria (ACR APPROPRIATENESS CRITERIA).


Patients with chest trauma presenting to our emergency department (ED) at Alexandria Main University Hospital will be examined according to the primary survey described by the ETC course and resuscitated as needed and the attending EM physician will perform the Extended Focused Assessment with Sonography for Trauma (EFAST PROTOCOL). The chest will be scanned (using the superficial probe 7.5 MHz type L7M-A of our CHISON device model ECO 2) at three lines and two views for each hemithorax as the following (1)anterior second through sixth intercostal spaces at the parasternal line, (2) anterior second through sixth intercostal spaces at the mid-clavicular line, (3) fourth through sixth intercostal spaces at the anterior axillary line,(4) fourth intercostal space at the mid-axillary line, (5) fourth intercostal space at the posterior axillary line, to assess for the presence of a sliding lung. Presence or absence of this sign will classify the patient either being negative or positive for pneumothorax. If positive for pneumothorax absent lung sliding in the 3 lines denotes small pneumothorax , absence of this sign up to view 4 denotes moderate pneumothorax and absence of lung sliding at the five views denotes massive pneumothorax (in spontaneously breathing patients or intubated patients after exclusion of right main bronchus intubation). Then the patient will be admitted to the surgical emergency unit where resuscitation is continued as required and the patient will be investigated including CT-Chest scanning if needed according to the ACR APPROPRIATENESS CRITERIA.

Then the result from both will be compared.


1.Sherry L, Murphy SL, Xu J, Kochanek KD, Jiaquan Xu, Kenneth D. Deaths: Preliminary Data for 2010. National vital statistics reports; Hyattsville, MD: National Center for Health Statistics. 2010; 60(4):4-5.

Dr Muhammad ABDULHALEEM (Egypt, Egypt)
11:00 - 18:00 #7627 - A Prospective Evaluation of Meritas Point-Of-Care Troponin I Assay.
A Prospective Evaluation of Meritas Point-Of-Care Troponin I Assay.

Background:  Troponin (cTnl) is of great interest to emergency and cardiology departments for rapid rule out of acute myocardial infarct (AMI) in chest pain patients.  Since turn-around-time is of paramount importance in ruling out AMI, point-of-care platforms makes it possible to provide the results rapidly to the clinical team.  The cTnI assay on the Meritas POC analyzer (Trinity Biotech) is an example of a point of care device offering the latest advancement in troponin testing.  Here we present our in-house data for the precision and feasibility of using this system in emergency department (ED) to rule out AMI in chest pain patients. 

Methods:  The precision of the test was assessed by analyses of 3 levels of quality control material (QC) by one operator on a single analyzer 5 times over 5 days.  In addition, two operators analyzed 6 AMI patient’s blood and plasma samples on two different analyzers 9 times each.  To assess whether the test was able to rule out AMIs, 149 subjects presenting to the ED were consented.  Their blood samples were collected in EDTA tubes for analysis of cTnI in both whole blood and in plasma.  Sequential samples were collected 2-4, 6-9 and 12-24 hours after presentation.  All test devices were made available by the manufacturer for this evaluation.  

Results: Out of the 149 chest pain patients consented in this study, 7 had confirmed AMI according to local diagnosis and 144 were ruled out.  The mean cTnI concentration at baseline and the second blood draw for whole blood in the ruled out AMI patients was 15.0 ng/L (SD=15.6) and 15.6 ng/L (SD=14.4), respectively.  The mean cTnI in the AMI subjects was 32.5 ng/L (SD=25.5) for the baseline and 110.5 ng/L (SD=130) for the second draw sample. 

As described above, we assessed the precision in two ways.  Analysis of the low QC by a single operator 5 times over 5 days resulted in %CV of 10.0, a mean of 63.7 ng/L (SD=6.4). The mid QC had a %CV of 7.1%, a mean of 174.2 ng/L (SD=12.4). The high QC had a %CV of 8.9%, a mean of 893.3 ng/L (SD=79.4).  The precision using the six AMI patients by two operators resulted in total CVs ranging from 5.3% to 13.5%.  

Conclusions:  The cTnI measured using a point of care format exhibited acceptable precision and performance for ruling out chest pain patients without AMI who presented to the ED.  The rise of cTnl from the baseline to the second blood draw 2 to 4 hours later in the clinical course is important for ruling in chest pain patients with myocardial infarction.


Keivan HOSSEINNEJAD, Shahab GHAFGHAZI, Stanislava PRATHER, Saeed A. JORTANI (Louisville, USA)
11:00 - 18:00 #7794 - A prospective feasibility trial of accucath™ 2.25” blood control intravascular catheter system with retractable coiled tip guidewire placed in difficult access patients in the emergency department.
A prospective feasibility trial of accucath™ 2.25” blood control intravascular catheter system with retractable coiled tip guidewire placed in difficult access patients in the emergency department.


The primary study objective is to evaluate insertion success rates.  Secondary objectives include user preference, patient satisfaction, complications, completion of therapy and dwell time of the novel AccuCath™ 2.25” BC Catheter System (FDA approved) placed in difficult access patients.



This is a single-arm feasibility trial evaluating the novel AccuCath™ 2.25” BC Catheter System in a convenience sample of difficult intravenous access patients defined as at least 2 failed initial attempts or a history of difficult access plus the inability to directly visualize or palpate a target vein.  The retractable coiled tip guidewire device is placed under dynamic ultrasound guidance after identification in the ED using a modified Seldinger technique.  All catheters are placed by EM physicians after a 30-minute training session which includes simulated procedures on ultrasound phantoms.  Patients are followed daily until catheter removal. Subject’s demographic (age, race, gender); admitting diagnosis, past medical history, baseline information (height, weight, systolic/diastolic blood pressure); and primary indication for intravenous line will be documented.

The following information is recorded for each subject enrolled:

  • AccuCath™ 2.25” BC catheter device gauge
  • Date, Time and Location of First IV Placement Attempt
  • Time and Location of Each Subsequent IV Placement Attempt
  • Use of USG With Each Catheter Attempt
  • Observation of Flashback With Each Catheter Attempt
  • Total Number of Venipuncture Attempts (each catheter insertion attempt)
  • IV Rating Scale with Factors Contributing to Insertion Difficulty for Each Catheter Attempt
  • Date, Time of Successful Catheter Placement
  • Patient Satisfaction at initial placement and upon removal using a 5 Point Likert Scale
  • Clinician Satisfaction at completion of study using a 5 Point Likert Scale
  • Safety outcomes anticipated to be similar to conventional catheters (Number and Severity of AEs)


Device Description

  • The AccuCath BC Intravascular Catheter System is designed to reduce blood exposure once at insertion. The catheter system consists of a radiopaque catheter with a valve mechanism delivered over a guidewire with atraumatic tip design; a notched needle to enhance flashback visualization, and a safety container that prevents sharp injuries.





120 patients enrolled and completed the study.  These patients had an average of 3.7 (95% CI 3.0-4.0) and median of 3 prior attempts at vascular access prior to Accucath placement by the ED registered nursing team.  Successful access was gained in 100% of the patients, 77% on 1st attempt and all within 3 attempts.  84% of patients completed therapy with no moderate or major complications in the other subjects.  The average patient satisfaction score upon removal on a 5-point Likert scale was highly positive at 4.6.



The AccuCath™ 2.25” BC Catheter System has excellent success rates in gaining vascular access in an extremely difficult patient population.  The device thus far has not led to any significant complications. Patients are also very satisfied with the procedure.


Christopher RAIO, Gerardo CHIRICOLO (Holmdel, USA)
11:00 - 18:00 #7974 - A PURPOSE OF A CASE: TOXOPLASMOSIS.


33 year old patient with a history of diagnosed HIV 10 years ago and has abandoned its retroviral treatment 4 years ago by intolerance. Currently do not follow controls by the infectious service.

Is brought to the emergency room by his family for presenting from a week ago picture of high fever accompanied by symptoms of respiratory infection, cough and dyspnea; with fluctuating disorientation, weakness of limbs, asthenia, anorexia and headaches.

Now concerns have suffered traumatic ciliary right without loss of consciousness or other added symptomatology.

The exploration tendency to sleep and low reactivity without clear foci. Analytically only highlights a discrete anemia with hematocrit of 32% and hemoglobin of 10.6 g/dl.

He is Rx thorax that is no evidence image of condensation.

Apply brain CT reporting as hypodense lesions associated with extensive vasogenic parietooccipital location perilesional edema

left, front left, right and left basal ganglia, frontobasal after administration of

contrast show enhancement in ring, as first possibility of toxoplasmosis given the

clinical context of the patient.

The occipital left along with extensive perilesional edema cause compression and displacement of the

occipital Horn ipsilateral and the left hemisphere associated edema also cause mass effect with

contralateral deviation from the centerline of 6 mm.

Intra or extraaxiales acute hemorrhagic lesions are not seen.

With this diagnosis starts m broad-spectrum antibiotic treatment (Sulfadizina, Pirimetadina and folinic acid).

The patient was admitted to the infectious being given high to his home unit.


11:00 - 18:00 #4546 - A rare case of a paratracheal mass requiring emergency interventions: An infected tracheal diverticulum.
A rare case of a paratracheal mass requiring emergency interventions: An infected tracheal diverticulum.

Recently, progression of radiological imaging has revealed various asymptomatic abnormalities than ever. Tracheal diverticula are relatively rare entities and found incidentally on radiological imaging such as CT scan. We present the case of an infectious tracheal diverticulum presenting as a paratracheal mass requiring emergency interventions.

A 65-year-old male nonsmoker presented with a fever, lower neck pain and aggravation of dyspnea for a week. His enhanced CT scan demonstrated that trachea was displaced by a paratracheal mass with a well-defined thin wall. His respiratory status was so urgent that emergency intubation was performed and surgical drainage of the abscess was carried out as well. His CT scan performed 4days after admission demonstrated the shrinking abscess and he was extubated and discharged 7days after admission without any complication.

We found out two important clinical issues. First, an infectious tracheal diverticulum can present as a paratracheal abscess impairing airway. Second, CT scans is helpful for the diagnosis of this condition. Most patients of a tracheal diverticulum itself have no symptoms. When symptoms occur (sometimes with infection), neck pain, chronic cough, dysphagia, odynophagia, hoarseness or hemoptysis are common. This is the first report describing an infectious tracheal diverticulum presented as a paratracheal mass impairing airway and required emergency interventions such as intubation or surgical drainage. The CT features of an abscess are low-attenuation masses with a well-defined thin wall that usually enhances after intravascular administration of contrast materials. His CT scan performed 4 years before obtained the proof that the mass was originated from a tracheal diverticulum. This is the first report describing a tracheal diverticulum can progress to an abscess on CT scan as well.

Though there are several differential diagnoses detected as a paratracheal mass, this case is clinically important that can require emergency interventions. Also, recent progression of CT scan has revealed various asymptomatic abnormalities including tracheal diverticula. This case also suggests follow-up of such abnormalities can be a clue to obtain the diagnosis.

Shota AKABANE (Kamakura, Japan), Jun KAWACHI, Ryuta FUKAI, Rai SHIMOYAMA, Hiroyuki KASHIWAGI, Hidemitsu OGINO, Kazunao WATANABE
11:00 - 18:00 #7905 - A rare case of Ramsay Hunt syndrome.
A rare case of Ramsay Hunt syndrome.

A 56-year-old man, with history of tonsillectomy, was admitted in the emergency department because of fever and skin lesions.

The patient had been well until 7 days before admission, when he began with fever, malaise, and sore throat, starting treatment with amoxicillin clavulanic. Five days later, fever persisted, and the patient developed skin lesions in form of papules and vesicles, affecting first face, scalp and oral mucosa, and then extremities and trunk. Dizziness, headache and loss of balance accompanied the skin lesions, so the patient went to our hospital.

On arrival at the Emergency Department, the patient appeared ill. On examination, the temperature was 37 ºC, and the blood pressure, pulse and oxygen saturation were normal. Vesicles and pustules in different stage of development involved all the skin, affecting also scalp and mucosae. In neurological examination, the patient was conscious and alert, with normal speech; rightbeat nystagmus was present, as well as mild dysmetria with left extremities and wide base gait. The remainder of the examination was normal.

Blood test revealed mild elevation of transaminases (GPT 66U, GOT 40U, GGT 118U) and PCR 2,8. Other results were normal.  Cranial computed tomography was normal. A lumbar puncture was performed; the opening pressure was 10cm of water, and the results of the cerebrospinal fluid showed 95 white cells (95% lymphocytes), glucose 69mg/dl and proteins 0.61g/l.

A diagnosis of suspected chickenpox with associated rhombencephalitis was made, and treatment with intravenous Acyclovir was initiated. Despite of the treatment, in the next hours the patient developed progressive left peripheral facial palsy, without affecting other cranial nerves, except of persistent nystagmus and tinnitus.

Suspected diagnosis: Ramsay Hunt syndrome due to Varicella-zoster virus (VZV) primoinfection.

Discussion: Ramsay Hunt syndrome typically includes facial palsy, ear pain and vesicles in the auditory canal due to VZV reactivation. Taste perception and hearing (tinnitus, hyperacusia) are usually affected, and vestibular disturbances (vertigo) are frequently reported, so this syndrome is usually considered a polycranial neuropathy. Nevertheless, peripheral facial palsy due to VZV primoinfection is a rare condition.  The pathogenesis of this peripheral neuropathy is not completely understood; it could be explained by a direct nerve lesion due to VZV, or to meningeal inflammation in the course of varicella meningitis. Treatment of this complication is also unclear, and should be individualized.

Our patient was transferred to Neurology department, and treatment with Acyclovir and Methylpredonisolone was administered. Magnetic resonance imaging of the brain showed enhancement of the left VII and VIII cranial nerves, with the remainder of the brain structures without lesions. Serologic test confirmed VZV primoinfection (positive IgM). The patient improved and was finally discharged, with completely recuperation of facial palsy. 


Introduction: Intestinal malrotation is a developmental anomaly of the midgut. It can be asymptomatic and generally diagnosed incidentally or during checking for atypical syptoms in adults. Intestinal malrotation can mimic other diagnoses as acute appendicitis.  

Case: We present a 23 year old man with having clinical syptoms indicating acute appendicitis in Adıyaman State Hospital. He had right lower quadrant pain and nause. He didn't discribe any alimentary tract symptoms in his history and there was no significant medical or surgical history. The patient operated with diagnosis of acute appendicitis and we saw a midgut malrotation with internal hernia behind the non fixed transverse colon. After hepatic flexure, colon was heading inferior and passing lateral site of assending colon with having omentum. Under the cecum, colonic segment was crossing over to the left side of abdomen. This crossing segment was mobile that not adhered to retroperitoneum. Appendectomy and fixation of colonic segment were applied and operation finished successfully. He was discharged postoperative 6th day with good recovery.

Discussion: Midgut malrotation presents usually in the first month of life. But some asymptomatic cases present in adulthood due to obstruction or other diseases redounded laparotomy. We can face with this diagnose rarely in adulthoods except for childhood or infants. This type of midgut malrotation with internal hernia, mimicking acute appendicitis, hasn’t been seen untill we operated this case.

Conclusion: We can be faced with midgut malrotation during examination or laparotomy. We have to be carefull and consider midgut malrotation in emergency services and surgery clinics.

Mesut YUR, Bünyami OZOGUL, Esra DISCI, Mehmet Ilhan YILDIRGAN ( ERZURUM, Turkey)



Serdar KAVAK, Aksaz Military Hospital, Marmaris, TURKEY

Introduction:Hemorrhagic otorrhea is known as blood coming  from de external auditory canal. The most commen causes of hemorrhage is trauma to the external auditory channel, trauma to middle ear, basilar skull fractures and barotrauma


Case Report

A 27-years-old female patient visited our emergency medicine department ( EMD ) with complaint of hemorrhage from the right ear.She has no other complaints of pain, hear loss or fever. The hemorrahage had began two hours before she visited the emergency medicine . She has no history of physcial and baro trauma and bleeding disorders.   She had an operation of tooth extraction( right lower impacted third molar tooth ) six hours before the visit. Her vital signs were in normal ranges.  The physical examination findings was blood in right the auditory channel and perforated tympanic membrane.After the detailed history the paitent told us that she had a ear pain six days ago. The pain reliefed one day later and purulant otorrhea occured for one day The source of bleeding was wound on the right mandibular region and while swalloving the salive, she swalloved  some amount of blood. By the retrograde action the blood came to midear and then cam outside to auditory channel. After the physical examination we advise her to follow up with ear throat nose spacialist about the perforated tympanic membrane. After one month follow up the tympanic membrane closed spontanously and her hearin tests were in normal ranges.

 Discussion : The most commen causes of hemorrhage is trauma to the external auditory channel, trauma to middle ear, basilar skull fractures and barotrauma. A detailed history must be taken from all the unusual situations. 

Serdar KAVAK (Marmaris, Turkey)
11:00 - 18:00 #7235 - A rare cause of pulmonar hemorrhage.
A rare cause of pulmonar hemorrhage.

Case Description: 77-year-old male with medical history of hypertension, sigmoid diverticulosis and chronic kidney disease (CKD) (diagnosed by Nephrologist as secondary to nephrosclerosis, without histologic diagnosis), was admitted at the Emergency Department because of hemoptysis and dyspnea with oliguria. He did not have hemoptysis before.

Exploration and additional tests: On physical examination the patient was afebrile with 88% oxygen saturation and blood pressure 100/60 mmHg. The pulmonary auscultation showed decreased breath sounds and crackles in both lungs. The blood tests showed: hemoglobin 8,8gr/dl, hematocrit 27%, creatinine 15,6mg/dl, urea 3,08 g/dl, pO2  in arterial blood gases 65mmHg. Torax X-ray: cardiomegaly, alveolar-interstitial involvement.

After hemodynamic stabilization, the patient was admitted in Nephrology Department to continue the study. To reach the final diagnosis, several complementary tests were requested:

-          Renal biopsy: rapidly progressive glomerulonephritis, with 100% of epithelial crescents

-          cANCA 1,04u/ml

-          pANCA 20,75u/ml

-          Anti-glomerular basement membrane antibodies: positive 3 times

Differential diagnosis: pulmonary-renal syndromes, such as Wegener´s granulomatosis, Goodpasture syndrome, Churg Strauss syndrome, polyarteritis nodosa and microscopic polyangiitis, systemic lupus erythematosus, Goodpasture syndrome, essential mixed cryoglobulinemia. We also should keep in mind as differential diagnosis infectious disease.

Diagnosis: Alveolar hemorrhage with rapidly progressive glomerulonephritis and anti-glomerular basement membrane antibodies is diagnostic of Goodpasture syndrome.

Conclusion: During admission in nephrology, the patient was treated with plasmapheresis and prednisone, with favorable evolution. Goodpasture syndrome is an autoimmune disease with glomerular basement membrane antibodies that mainly affects the kidneys and alveoli. It is a rare disease and a lower incidence is estimated at one case per million population. This case shows the difficulty of early diagnosis of reno-pulmonary syndrome in cases where there is only kidney clinical manifestations, as was our case before the debut with hemoptysis. Therefore it is very important a thorough medical history along with a detailed physical examination and appropriate complementary tests to make a correct differential diagnosis.

11:00 - 18:00 #8039 - A Rare Condition: Portal Vein Trombosis - A Case Report.
A Rare Condition: Portal Vein Trombosis - A Case Report.

Introduction: Abdominal pain has been shown in the general population to make up between 4.4% and 7.5% of primary care and emergency department visits.(1) In portal vein trombosis patients can present emergently with sudden onset of right upper quadrant pain, nausea, and/or fever. Portal vein trombosis usually associated with cirrhosis, liver transplantation, malignancies, inflammatory disorders, or hypercoagulable states.(2)                          

Case: A 74 years old female admited to ER with right upper abdomen pain. In patient’s medical history, she had a carsinoma of the ampulla vater. On physical examination, the patient was noted to be afebrile with a normal blood pressure and a heart rate of 71 per minute. Spesific examination findings were rebound tenderness over right upper and lower abdominal region. The abdominal pain was associated with meals, consisting of a significant increase in pain approximately 10 to 15 minutes after eating and intermittent post-prandial nausea and occasional vomiting. At laboratuary findings were white blood cell 10.48 10^9/l , hemoglobin level 7.6 g/dl, platelets 115 10^9/l, INR 1.5, AST 20 U/l, ALT 14 U/l, lactat 3.55 mg/dl. In hepatobilier ultrasound result’s  shows that at portalosplenic area 33*14 mm size, allowing blood stream trombus image. Dinamic abdomen CT showed no symptom of mesenteric ischemia. Enoxaparin started to the patient 1 mg/kg SC twice daily. The patient hospitalizated for further  examination and treathment.

Discussion: Portal vein trombosis is rare but should be considered diagnosis,  patients presented to ER with abdominal pain and malignancy history. Neoplasms,  hepatocellular carcinoma and pancreatic carcinoma causing most of these cases,  are second major cause, accounting for 21-24% of cases of portal vein obstruction. (3)

Yusuf Cankat BOZKURT, Burcu GULSEN, Onur TOKOCIN (istanbul, Turkey), Hakan TOPACOGLU
11:00 - 18:00 #7710 - A rare reason of sciatalgia: piriformis syndrome.
A rare reason of sciatalgia: piriformis syndrome.

Introduction:Piriformis muscle (PM) originates from the anterior part of the sacral 2-4. Vertebrae, runs through the greater sciatic foramen and ends on the trochanter major of the femur. PM crosses through the foramen ischiadicum majus with the neurovascular structures in the pelvic region. Piriformis syndrome (PS) is a rare clinical picture with sciatic pain caused by compression of the sciatic nerve in the foramen ischiadicum majus. Pyomyositis is the primary pyogenic infection in the skeletal muscle usually progressing to abscess. It is difficult to diagnose, because pyomyositis is deeply located in the pelvis with a non-specific clinical picture and rarely seen in the temperate climate. Pyomyositis is considered to develop secondary to injuries occurring in muscle during an asymptomatic and undiagnosed transient bacteremia. PM pyomyositis creates edema in muscles, causing irritation and compression in sciatic nerve. Classical sign of PS is pain, tingling or numbness beginning from the hips, extending down the length of the sciatic nerve. Because there is no definitive test for piriformis syndrome, the diagnosis is primarily established on clinic. Treatment of PS is directed to etiology. Methods used in treatment of PS include medical, physiotheraphy, acupuncture, therapeutic perisciatic blocks, botulinum toxin injections or surgical intervention.

Case report:A 18-year-old female patient presented to emergency department with severe pain and numbness  in the right hip, thigh and leg for 5 days and pain induced inability to walk. Vital signs of the patient at presentation were normal except fever (38.8°C). In physical examination, there was tenderness on palpation in right gluteal area, but no other signs of inflammation. Patient was easily bringing her right thigh to flexion and extension, but feeling severe pain during external and particularly internal rotation. Laboratory outcomes were WBC: 17000 and CK:500, while other values were normal. In pelvic tomography ordered for increased tenderness in the gluteal area of patient, there was heterogeneity in the right piriformis, gluteus maximus and minimus muscles, compatible with abscess. MRI was ordered to find source of abscess formation. In MRI; a lesion was observed in right gluteus maximus, minumus and pirifiormis muscles which was hypointense on T1-weighed images (AG) and showed marked signal increase on (WI) fat-suppressed T2-weighted images. The appearance was evaluated as piriformis intramuscular abscess. Piriformis symdrome was considered in the patient from piriformis intramuscular abscess. The patient was consulted to orthopedics clinic, a part of abscess could be drained with the guide of tomography and antibiotherapy was initiated. Staphylococcus aureus was isolated in abscess culture. The patient with complaints resolved at follow-up was taken to operation, abscess was cleaned and closed after insertion of drainage. Upon complaints of the patient were resolved, she was discharged at the 20th day of hospitalization.

Conclusion:Because piriformis syndrome is rarely encountered by physicians, diagnosis may be delayed, causing morbidity and unnecessary invasive examinations. We presented a piriformis abscess case which is a rare cause of piriformis syndrome and emphasized that piriformis syndrome should be kept in mind in differential diagnosis in patient presented with sciataalgia clinical picture. 

Mustafa UZKESER (Erzurum, Turkey), Ilker AKBAS, Orhan KARSAN, Alpaslan UNLU, Abdullah Osman KOCAK, Ihsan YUCE
11:00 - 18:00 #7748 - A rare type of fracture in a traffic accident: A case of isolated fracture of the hyoid bone.
A rare type of fracture in a traffic accident: A case of isolated fracture of the hyoid bone.

Background:  Excluding hyoid bone fracture during strangulation and hanging injuries, this type of fracture caused by blunt trauma is rare. In light of this, it may go unseen during physical examination, causing life-threatening airway obstruction. Thus, appropriate measures should be taken to carefully examine patients with blunt trauma. To date, few cases of hyoid bone fractures caused by trauma have been reported. In this study, we report the case of a young male with an isolated fracture of the hyoid bone as a result of blunt trauma. 

Case Report:  A 21-year-old male was admitted to our emergency department by an emergency ambulance crew following a traffic accident. At the time of the accident, he was sitting in the back seat of an automobile with his seat belt unfastened. As a result, he hit his neck on the edge of the front seat. On physical examination, his vital signs were stable and neck movements were unrestricted and painless. However, his right cricoid bone was tender during palpation.No pathology was detected from the anteroposterior or lateral cervical film.  A cervical computed tomography (CT) scan revealed a fracture within the right arch of the hyoid bone. Consequently, the patient was referred to the otorhinolaryngology department. Indirect transoral laryngoscopy was performed, but failed to detect any airway edema or laceration. The patient’s oral intake was stopped, and he was monitored for airway obstruction in the emergency department. In addition, he was treated with head elevation and a cold compress applied to his neck. His vital signs remained stable and he was discharged after 24 h, returning to the otorhinolaryngology department for a follow-up exam. 

Conclusions: A hyoid bone fracture should be suspected upon the detection of neck tenderness and pain following blunt trauma to the neck region. A delay in diagnosis may result in life-threatening airway narrowing. For diagnosis, CT examination of the neck is the modality of choice due to its high diagnostic accuracy. It is of great importance to closely monitor patients with an isolated closed fracture of the hyoid bone for a prolonged period to prevent airway obstruction. Patients who have no airway obstruction and a normal hyoid bone following indirect laryngoscopy can be conservatively managed.

Mustafa OZTURK (istanbul, Turkey), Ozgur SOGUT, Tuba EVRAN, Demet TAS
11:00 - 18:00 #8109 - A review of cycling injuries presenting to a suburban university teaching hospital in Dublin.
A review of cycling injuries presenting to a suburban university teaching hospital in Dublin.

Objective: The Central Statistics Office Ireland (CSO) reported following the 2011 census that there was a 9.6% increase in the number of people cycling to work compared with 2006. This ultimately leads to a higher prevalence of injuries and hospital attendances. The Road Safety Authority of Ireland (RSA) estimates from their provisional report that there were 12 pedal cyclist fatalities on Irish roads in 2014. There is little published data on cycling injuries in Ireland and the present study aims to describe the cycling related injuries presenting to the emergency department (ED) of a tertiary urban university hospital.

Methods: This is a retrospective review of patients with a cycling-related injury presenting to the ED of St.  Vincent’s University Hospital (SVUH) from 1st of January to 31st of December 2014. We used the ED Maxims © database to retrospectively review all cycling presentations to the ED in 2014. We searched for bike, cycling, bicycle in triage notes to identify patients that presented to the department following a bike-related incident. We also made use of Syngo © radiology database to access radiology reports for the same cohort of patients.

Results: There were 534 cycling related injuries presenting to the ED during the study period. 71.2% of the patients were male. 14.8% of patients presented following a collision with a motor vehicle. There were 2 mortalities during the study period with 5 patients sustaining an injury severity score greater than 15. 40 patients required admission to hospital following their injury with 6 of these patients spending time in the intensive care unit. 10 patients required transfer to other facilities for specialist care.

Conclusion: The Road Safety Authority in Ireland collates data regarding cycling injuries using police reports alone and does not use hospital data. Our study revealed that there was a significant number of cycling injuries presenting to this ED and that the majority of these injuries didn’t involve motor vehicles and therefore may not be reported by the police. Cycling injuries have a significant impact on EDs with significant use made of radiology, ED review and outpatient clinics and admission facilities. Cycling is now a very popular means of transport and exercise activity in Ireland and using hospital based data, it is possible that EDs may provide a vector for guiding injury prevention strategies in the future.

James FOLEY (Wexford, Ireland), John CRONIN, John RYAN
11:00 - 18:00 #7737 - A self pacemaker.
A self pacemaker.

The existence of myocardial infarction  with “normal” coronary arteries (MINCA), was recognized more than 30 years ago, however the etiology is not clear. It is supposed that exists for a multiple pathogenetic mechanisms like coronary vasospasm, thrombosis, embolization and inflammation, alone or combined, in presence of infarction, for example, endothelial dysfunction and myocarditis superimposed to non angiographically evident atherosclerosis, may be an underlying common feature predisposing to the acute event. MINCA typically occurs in the under-50s and it is usually no history of angina or previous myocardial infarction, Symptoms and electrocardiographic (ECG) findings are similar MI with angiographic coronary disease.

Here is the case of a 50 years old woman, with unknown drug allergies, smoking to 7 cigars per day,  from 16 years old, and drinking on weekends. Hipertension without phmacological treatment. She denied other drugs consume or medical or surgical dates. The patient consults in A&E (Emergency department) for servere crushing central chest pain radiating to the neck and jaw, associated  to nausea, vomiting and diaphoresis of 3 hours of evolution that didn´t stop with first step´s painkillers. She didn´t present dyspnea or syncope.The physical examination (PE) revealed normal blood pressure, heart rate and oxygen saturation. On heart auscultation was rhytmic, heart murmurs were no listened to. The rest of PE was normal. In additional tests, no radiological findings on chest X-Ray.At first, ECG complete AV block. ST 4 mm elevation in II, III and aVF leads. ST depression in V1 and V2.  Cardiac ultrasound: mediobasal posterior hypokinesia . Absence of valvular pathology. Given these dates, dual antiplatelet, GTN and analgesia therapy are started, getting pain free. Then, a new ECG was performed, it showing sinus rhythm with no repolarization abnormalities, and in  blood test was alterated with T us-troponine from 139ng/dl initial to 1197 at 12 hours later. Also GOT from 29 to 68, CK from 223 to 655. At Coronary angiography: no significant lesions in epicardial coronary. Images of thrombus laminar non-occlusive in right middle coronary suggestive of spontaneous recanalization of the thrombus. The patient continued improving, and she was discharged home a few days later.

MINCA is usually diagnosed in patients under 50 years old and the prevalence of this condition is 1–12%. It is difficult to find a cause because of the multifactorial mechanism present in that. So is important to the physician recognice that the espontaneous revascularization is possible in STEMI, and also, we have to know that the presence of complete AV block with an inferior STEMI associated is still a relatively common complication, which usually appears early and frequently develop the dilemma of implementing or not a temporary pacemaker, which may involve a delay in the administration of fibrinolytic.

11:00 - 18:00 #8164 - A serial of kidney injury playing football in Calatayud- Spain.
A serial of kidney injury playing football in Calatayud- Spain.

Introduction: Genitourinary trauma amount to an 8-10% of abdominal trauma with the kidney being the most affected organ in 50% of cases, especially the left one. The choice of treatment will depend on the kind of lesion found in the affected renal unit and on the patients clinical conditions.
Objective: The aim of this report is to determine the applicability of conservative treatment in major renal trauma and to assess the evaluation and emergence of possible complications.
Material and methods: We have analysed 3 cases of renal trauma detected in our emergency department, analyzing such variables as the etiology of the trauma, associated lesions in other organs, the therapeutic approach adopted as well as the presence of complications, both in the long and short run.
Results:the three cases were blunt renal trauma in Young men playing football in 2015. We have given a conservative approach in first case and the second was managed with partial nephrectomie,48-72 hours after the trauma.Third was carried out in the Emergency Room because of haemodynamic instability, being the total nephrectomy the definitive treatment.
Conclusions: According to our experience and in the light of the results obtained, we consider the conservative approach adequate for major renal trauma as long as the patient is haemodynamically stable.

11:00 - 18:00 #8270 - A silent bomb in the head; A Case Report.
A silent bomb in the head; A Case Report.

A 59-year-old male patient was brought to the emergency department with complaints  of sudden onset of weakness on his right foot and dizziness. The general appearence was medium and his consciousness was tend to sleep; GCS 14, BP: 138/78 mmHg, pulse:72/min, RR: 24/min with no fever respectively. It was learned that he had suffered balance problems and had a fall history four days ago but no cranial imaging had not been planned by admitted health institution. His medical history only revealed that his simple analgesic use due to recurrent unilateral headache since last year. On neurological examination, pupils were isochoric, spontaneous vertical nystagmus in both eyes and 4/5 right upper extremity strength while the left was 5/5 were detected. A ruptured dermoid cyst extending to silyvi fissure and middle cranial fossa in the right frontal lobe, causing 11 mm midline shift with calcification and fat density was seen on brain CT.  The images also showed widespread distribution of fat density throughout the other parts of cranial fossa and subarachnoid space due to rupture. The patient was consulted with neurosurgery department for hospitalization and operation. After the surgery, he was followed up in ICU post-operatively and discharged from the hospital at 7. day.

Dermoid cysts (DC) are originated from ectodermal cells at embryonic period. They are ectodermal inclusion cysts which are benign, slowly growing and sometimes show malignant transformation. Intracranially localized DC consist %0.2-%1.8 of primary intracranial tumors. Intracranial DC can reach very large sizes due to their slow growth rate without any symptom or sign. Clinical symptoms depend on the localization of the lesion and created adjacent parenchyma compression. However they may be acutely symptomatic in case of a rupture or an infection. Intracranial DC may rupture spontaneously or during a surgery and cyst contents may spread throughout subarachnoid space. When they ruptured, they may present with headache, nausea, vomiting, visual disturbances, dizziness, epilepsy, chemical aseptic meningitis, hemiparesis and changes in mental status. Both for Computed Tomography and Magnetic Resonance Imaging, images of fat particles in subarachnoid space as a result of a rupture or determination of fat content are typical.

The accessibility of brain CT and MR imaging may be vital in the diagnosis of patients with sudden onset of headache, dizziness or neurological diagnosis. 

Oğuz EROĞLU, Ertan CÖMERTPAY (Kırıkkale, Turkey), Mustafa KÖKSAL, Mehmet Faik ÖZVEREN, Figen COŞKUN
11:00 - 18:00 #7800 - A Survey of the Importance of Emergency Ultrasound in Prospective Practice Settings Amongst Emergency Medicine Residents.
A Survey of the Importance of Emergency Ultrasound in Prospective Practice Settings Amongst Emergency Medicine Residents.



Point of Care Ultrasound (POCUS) has been integrated into many community and academic emergency departments and is now a mandated skill for all emergency medicine (EM) residents according to the ACGME.  Current EM resident education includes US as a critical part of both life saving procedures and the bedside evaluation of critically ill. It is well accepted that approximately 80% of EM residents will practice in a community setting after completing their training.  Access to US in the community setting is variable and many sites have not secured credentialing to perform these examinations. We question whether current EM residents would be comfortable working in a clinical environment that does not include or has limited access to bedside US.




The goal of this study was to survey EM residents about their experience with POCUS and the importance of the accessibility of US in their future practice settings. This information is important to help set a foundation for the need of US infrastructure in the community setting.




FREIDA, an online residency resource, was referenced to obtain contact information for all current ACGME accredited EM residency programs. Each program was asked to distribute a 14-question survey to all residents currently in training at their site. The survey was accessed through




There were 381 responses from various residency programs around the United States. When asked how often they were using US, 80% said they were performing at least one scan per shift.

The residents were asked on a scale of 1-5, 1 being “absolutely will not” and 5 being “very likely”, How likely are you to take a job that:

Does not have POCUS available?
Has a machine solely for procedural guidance?

The weighted average of responses was 1.84 and 2.18 respectively.

When asked if they felt they could be able to perform quality EM without POCUS, 65% said no, 14% were unsure and 22% said yes.


65% of the respondents came from programs that have EM US fellowships.




Residents felt that procedural guidance, echo, early obstetric, FAST and AAA were considered to have the most utility in their future practice. The majority of residents felt that they were very unlikely to take a job at a site that did not have POCUS available.  It is clear that residents believe that in order to have quality EM performed at your institution POCUS needs to be available.

Chiricolo GERARDO (Holmdel, USA), Christopher MENDOZA, Christopher RAIO
11:00 - 18:00 #7064 - A two-pronged approach to improving efficiency of patient transfer from the emergency department to the ICU in an urban hospital setting.
A two-pronged approach to improving efficiency of patient transfer from the emergency department to the ICU in an urban hospital setting.

BACKGROUND: Emergency Department (ED) volumes have been rapidly increasing, with a 40% increase in annual patient visits in the US from 1995 to 2009. Crowding is a serious problem that can impact patient care, safety, and hospital efficiency. Delays in patient transfer from the ED to the ICU have been associated with higher patient mortality rates. This quality improvement project sought to improve ICU patient transfer from the ED by implementing strategies to decrease patient length of stay (LOS) in the ED.

DESIGN AND METHODS: This project was conducted in a 232-bed urban hospital in Bronx, NY. A two-pronged intervention was implemented to reduce patient LOS in the ED by: (1) removing the SMR’s (Senior Medical Resident’s) involvement from the throughput process and (2) implementing a pull-process of sending the patient directly up to the ICU for the face-to-face nursing handoff. Trained research assistants monitored each patient’s length of stay in the ED from documented patient arrival to exit according to the hospital’s electronic recording system. Average ED LOS was monitored over time to determine if the implementation of this ED-based intervention was associated with a decrease in average patient LOS in the ED. Sepsis data was monitored over time as a marker of healthcare outcomes.  

RESULTS: Average ICU patient LOS in the ED was collected over a 15-month time period (including six months post-intervention). Since the beginning of the two-pronged intervention, average ICU patient LOS decreased from 6 hours to approximately 3 hours and 48 minutes, an overall decrease of 2 hours and 12 minutes. The implementation of the intervention was associated with a clear decreasing trend of patient LOS in the ED. In addition, sepsis data showed a marked improvement on timely administration of several treatment measures. Percent adherence of timely administration of broad spectrum antibiotics increased from 27.8% to 81.8%, timely lactate level increased from 50.0% to 90.9%, and timely administration of vasopressor increased from 60.0% to 100%. 

CONCLUSION: A two-pronged approach to reducing ED patient LOS using multi-staff buy in can improve timeliness of ICU patient transfer. This result has positive implications for both hospital efficiency and patient safety. By utilizing the power of ED-based interventions to improve patient flow, ED management can create a safer, more efficient hospital experience for critically ill patients.

Yvette CALDERON, Uttara GADDE (Bronx, USA), Susan GULLO, Magdalena CHERRY, Daisy NANTA, Frederick NAGEL
11:00 - 18:00 #7306 - A young woman with severe heart failure.
A young woman with severe heart failure.

Introduction: Peripartum cardiomyopathy (PPCM) is one of the most severe cardiac diseases and is a leading cause of maternal death. PPCM is a non-familial form of peripartum heart failure, and is characterised as an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction in the absence of another cause of heart failure, close to the end of pregnancy or in the first months after the birth (1).

We present a case report of a young woman who suffered from dyspnoea, haemoptysis, and palpitations who was diagnosed with acute heart failure resulting from PPCM in the emergency department (ED).

Case Report: A 25 year-old female gave birth by elective Caesarean section at 40 weeks to her first child. She presented to the ED three days later with dyspnoea, haemoptysis, and palpitations. The patient’s initial vital signs were: blood pressure 125/83 mmHg, heart rate 140 beats/min, respiratory rate 20 breaths/min, temperature 36.1, and oxygen saturation 95% on 3-4L/min by oxygen mask. A plain chest film showed pulmonary oedema, and ECG on admission showed sinus tachycardia. Cardiac enzymes were within normal limits. An echocardiogram revealed mitral regurgitation, dilatation of left ventricle, and general hypokinesia with severe left ventricular dysfunction (i.e., ejection fraction of 30%), but no pericardial effusion or cardiac tamponade. The patient was diagnosed as having peripartum cardiomyopathy in pregnancy, based on the echocardiogram and clinical symptoms of congestive heart failure.

Discussion and Conclusion: The diagnosis of PPCM in the current patient was based on the following criteria previously described by Demakis et al and Hibbard et al. (2,3): development of heart failure in the last month of pregnancy or within five months postpartum, no history of pre-existing heart disease, unknown etiology for heart failure, and echocardiography findings that included a left ventricular ejection fraction of less than 45% and/or 30% M-mode fractional shortening, and an end-diastolic dimension of 2.7cm/m2.

PPCM should be considered in dyspnoeic female patients of childbearing age, and should be diagnosed early to prevent fatal consequences. In addition, PPCM should be excluded from other diseases associated with the reduced ejection fraction. PPCM is a rare disease, but due the risk of acute heart failure it should be considered in patients with suspect symptoms. Physicians should be appropriately educated with echocardiography on PPCM symptoms so that it can be diagnosed and treated early.  


1. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12(8):767-78.

2. Demakis JG, Rahimtoola SH. Peripartum cardiomyopathy. Circulation 1971;44(5):964-8.

3. Hibbard JU, Lindheimer M, Lang RM. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography. Obstet Gynecol 1999;94(2):311-6.

Adnan YAMANOGLU, Dr Sumeyye CAKMAK (İSTANBUL, Turkey), Ozgur SOGUT
11:00 - 18:00 #8246 - Abdominal pain: time for a second chance?
Abdominal pain: time for a second chance?

Objective Abdominal pain evaluation in the emergency department (ED) is difficult and sometimes we can´t find a precise diagnosis. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible process breakdowns.

Design We conducted a retrospective chart review of ED patients >18 years at an tertiary academic hospital. We reviewed patients admitted in ED in November and Dicember 2015. A computerised ‘trigger’ algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and(2) had a return ED visit within 10 days that led to a hospitalisation.

Results During the months of November and December 2015 19702 visits were recorded to the emergency room, within which, abdominal pain was the main complaint in 1653 visits (8.39%).820 visits (753 patients) with abdominal pain as presenting complaint were recorded in one month (analyzed period between 15 November and 15 December 2015). The average age of patients analyzed is 52.48 years (standard deviation: 21.7,minimum age 15 years,maximum age 104 years). During the period analyzed 82 patients (10.89%) were attended by abdominal pain in the first visit to the emergency room and later returned in a period ≤ 10 days Of this total, after the next visit, the final diagnosis was significantly changed in 40 patients (49%). Of the 82 patients who were evaluated in the ED in ≤10 days, 10 patients (12%) required emergency surgery after diagnosis on the second visit. Pathologies requiring surgery were: cholecystitis (4), Abscesses (3), Appendicitis (2), intestinal obstruction (1).Conclusions Abdominal pain continues to pose diagnostic challenges for emergency clinicians. In many cases, the differential diagnosis is wide, ranging from benign to life-threatening conditions.. Associated symptoms often lack specificity and atypical presentations of common diseases are frequent, further complicating matters.


Hector ALONSO-VALLE (, ), Andrea CERVERO, Francisco MATEOS, Enrique PERAITA, Luis PRIETO, Maria GONZALEZ
11:00 - 18:00 #7298 - Ability of emergency residents to identify and localize regional wall motion abnormalities in acute myocardial infarction.
Ability of emergency residents to identify and localize regional wall motion abnormalities in acute myocardial infarction.

Background: The ability of resident emergency physicians to identify regional wall motion abnormalities is unknown. We hypothesized that EM residents would show proficiency with limited training in identifying the presence as well as the location of regional wall motion abnormalities (RWMA) in AMI.

Methods: After reviewing a brief instructional module on RWMA, 9 EM residents analyzed 45 consecutive comprehensive echocardiograms on patients that were taken emergently to the cardiac catheterization suite for ST-elevation MI.  For each study, they responded to questions: 1) is there a RWMA present? (Yes, Maybe, or No) and 2) where is the RWMA located? (Anterior, Inferior, Lateral, Septal, or N/A).  They received 1 point for a correct “Yes” or “No” answer, and 0 points for an incorrect answer, for a total possible score of 90 points. An answer of “Maybe” was only considered valid if the resident localized the RWMA correctly.

Results:  Assuming a competency cut off of 70%, 7/9 ED residents posted a score demonstrating proficiency (Range 57-81%).  All 9 ED residents demonstrated proficiency in identifying the presence of a RWMA (Range 73-89%). 

Conclusion: EM residents with limited training are able to identify both the presence as well as the location of RWMA in patients that have sustained an AMI.  Their ability to identify the presence of a RWMA alone is even more favorable. Phase II of this trial is currently underway and aims to prospectively validate this educational intervention.


  1. A. E. Jones, V. S. Tayal, and J. A. Kline, “Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study,” Academic Emergency Medicine, vol. 10, no. 10, pp. 1054–1058, 2003.
  2. P. Sabia, A. Afrookteh, D. A. Touchstone, M. W. Keller, L. Esquivel, and S. Kaul, “Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction. A prospective study using two-dimensional echocardiography,” Circulation, vol. 84, no. 3, pp. I85–I92, 1991.

Acknowledgements: No conflicts of interest.

Peter CROFT (North Yarmouth, USA), David MACKENZIE, Strout TANIA, Samip VASAIWALA
11:00 - 18:00 #7875 - Aborted sudden cardiac death due to ventricular fibrillation in a patient addicted to supplements.
Aborted sudden cardiac death due to ventricular fibrillation in a patient addicted to supplements.

BACKGROUND: Sudden cardiac death (SCD) represents about one-fifth of all mortality in industrialized countries and still remains a major public health issue. Most of SCDs are caused by ventricular fibrillation (VF) and asystole. We experienced the case of ventricular fibrillation of walk-in visit patient while performing ECG examination. We introduce the case of VF due to hypokalemia induced by supplements abuse.

OBJECTIVE: This is a case of aborted sudden cardiac death due to ventricular fibrillation in emergency room. The purpose of this report is to heighten suspicion against not only prescribed drugs or illicit drugs but also on-the-counter supplements as a cause of ventricular fibrillation for all emergency physicians.

CASE REPORT: 56-year-old woman was presented to our hospital because of her continuous chest pain. She began to feel her chest tightened 3 years ago. She was diagnosed as vasospastic angina and followed up without medication. While her examination of ECG, a seizure was developed and ECG showed ventricular fibrillation. Cardiopulmonary resuscitation was started and successfully returned her spontaneous circulation after once of electrical cardioversion. Emergent coronary angiography was performed, found no significant coarctation. Blood examination showed hypokalemia of 2.8mEq/L, the cause of this hypokalemia was abuse of several supplements that claim a great effectiveness on constipation. Intracoronary acetylcholine spasm provocation test revealed the spasm of left anterior descending branch and the high lateral branch. There were no endocrine abnormalities, and serum potassium value was normalized by discontinuation of the supplements. She was discharged without any delayed effect, and she has not experienced the subsequent angina or fatal arrhythmia after discharge.

DISCUSSION and CONCLUSION: This was a case of aborted sudden cardiac death caused by ventricular arrhythmia due to addiction to supplements. In clinical practice, hypokalemia is a common electrolyte abnormality and known as one of the causes of lethal arrhythmia. The use of digitalis or coronary ischemia increases the risk of fatal arrhythmia in hypokalemic patient. In this patient, vasospastic angina was merged with hypokalemia associated with the addiction of supplements, resulting in triggering ventricular fibrillation. Hypokalemia can be critical in patients with heart disease, we should listen to the history, not only medications or illicit substances but also on-the-counter supplements as the cause of the hypokalemia and lethal arrhythmia.

Daisuke NISHIOKA (Nagareyama, Chiba, Japan), Keitaro GOTO
11:00 - 18:00 #7532 - Accidental Ingestion of Digitalis Tea.
Accidental Ingestion of Digitalis Tea.

It is not surprising that there are frequent cases of mistaken identity when amateurs decide to pick their own wild flora herbal remedies. It is also not common for these mistakes to be life-threatening. We present here a case of life-threatening accidental toxic ingestion in an urban environment.

Wild Comfrey (Symphytum officinale) grows in the UK and throughout Europe and temperate Asia. It is frequently used in herbal remedies brewed into a tea and has throughout history been thought to treat many ailments. It was actually named after its supposed ability to assist in bone healing (Greek symphis – the growing together of bones). Unfortunately, during Spring in particular, the thick leaves are very difficult to distinguish between Comfrey and the foxglove (Digitalis purpurea) the plant from which the cardiac glycoside, digoxin is extracted. Reviewing the literature this appears to be a more common problem in China where herbal medicine is more common. It is illustrative to examine the pictures of both plants.

Case report

MM a 53 yr old female presented to the Emergency Department complaining of 12 hours of severe lethargy and feeling presyncopal on standing. The patient had no prior comorbidities but had been suffering from insomnia and was advised by a friend to try a herbal tea made from Comfrey at night. MM duly picked the leaves as instructed and ingested the brewed tea in the evening.

MM was bradycardic at a rate of 40 to 70 and without heamodynamic compromise. Her ECG (shown here with patient consent) showed Mobitz type 2, second degree heart block with t-wave changes consistent with digoxin effect. Her serum digoxin level was 5.3 μmol/L (therapeutic range for digoxin is 1.2-2 μmol/L) and normal potassium.

Not all hospitals stock supplies of the Digoxin antidote, digoxin binding antibodies, and so there were significant delays acquiring the therapy. During this period the patient remained stable while supine without deterioration or improvement in her brady-arrhythmia. Following treatment with ‘Digi-fab’ the patient was in sinus rhythm by the next morning.


It is frequently easy to forget that in our urban environment that the wildlife can still be dangerous. This case report serves to highlight a few useful lessons: -

-          It would have been easy to miss or dismiss the herbal remedy part of the history, believing the patient had another cause of new onset arrhythmia.

-          Homemade ‘herbal remedies’ are not as benign as many believe. Especially when the identification and preparation is so easy to get wrong. It is also impossible to know what dose the patient has had.

-          Procuring digoxin binding antidote frequently takes prolonged period in the UK as it is not always stocked locally.

Matt EDWARDS (London, United Kingdom), Mathew VITHAYATHIL

Acute heart failure (AHF) is a common reason for consultation in the emergency services and the leading cause of hospitalization in the elderly. This leads to increased mortality, use of emergency services and health spending.

Knowing hospital mortality according to the type of heart failure in our emergency department.

Material and methods
It is a prospective, observational, descriptive study without intervention in patients who come to our emergency department in the period 2012-2014 choosing two randomized months per year, with a diagnosis of heart failure according to Framingham criteria. Within the inclusion criteria included patients older than 18 years with acute heart failure and give their signed consent. The study variables were: sex, type of heart failure echocardiography as previously described in your medical record (systolic, diastolic, mixed or unknown) and hospital mortality.

During 2012-2014 consulted selected from 119 patients with acute heart failure, of which 57 were women (47.9%) and 62 men (52.1%).
Depending on the type of cardiac dysfunction: 31 patients (26%) had systolic failure, 10 patients (8.5%) diastolic failure, 52 patients (43%) mixed failure and 26 patients (21.84%) of unknown origin.
The hospital mortality was 10.93% (13 patients: 6 men and 7 women), within this group, 2 patients had systolic dysfunction (15.38%), 2 diastolic (15.38%), 4 mixed (30, 77%) and 5 unknown (38.67%).
The hospital mortality compared to the total of all patients diagnosed with heart failure in our emergency department, it was observed that 20% had diastolic heart failure, systolic dysfunction 6.45% and 7.69% mixed dysfunction.

- Do not objectify a big difference in sex.
- Diastolic heart failure may be a risk factor for hospital mortality.
- Almost half of the patients with previous ultrasound, have a mixed heart failure.
- ICA-hospital mortality is 10.93%, still very low compared to total mortality.
- No differences in hospital mortality observed for systolic HF and mixed.

11:00 - 18:00 #7461 - Accuracy of Alert times in major trauma patients could save substantial amount of money!
Accuracy of Alert times in major trauma patients could save substantial amount of money!


In the management of major trauma time to the treatment is of utmost importance. This time starts from the time of injury to the time patients receive specialist care. Traditionally all these suspected major trauma patients are received by a trauma team consisting of multiple specialities. The idea of having trauma team is that patient receives best possible care and in timely fashion to improve the outcome.





To analyze the data of expected time of arrival (ETA) and actual time trauma arrives in Resuscitation room.   


To estimate the delay in ETAs, which in turn results in human resources unavailable, for clinical work.






We did a retrospective analysis of the notes from 1st July 2015 to 31st August 2015 at UHB.  All adult major trauma patients were included in the study.





We had a total of 198 patients presenting during this time but only 82 were included due to insufficient record on trauma alert sheet. We had 39 females (20%) and 159 male (80%) with mean age of 50years. The most common single body region involved was the head 23% followed by chest injuries 10% rest had multiple regions involved.

We had only 7% patients arrived within the expected time with 5 minutes margin. Rest of the 93% patients were delayed to a varying length ranging from 6 minutes to 65 minutes with the mean delay of about 36 minutes.




In the management of major trauma patients every minute counts. Based on the pre hospital information there might be a theater on standby or surgical team to delay their list, which has its own impact. In general the trauma team in our ED consists ED consultant, Trauma registrar, ITU registrar, Trauma SHO and Trauma HO and 3 nurses. Now a mean delay of 36 minutes in 81 trauma patients will add up to 121 man hours for each clinician and nurse. This in total will add up to 607 man-hours for clinicians and 363 hours for nurses while dealing with 81 major trauma patients, which have been unproductive. We see about 1000 major trauma patients per year and this will lead to 1000s of hours and thus thousands of pounds wasted which potentially can be saved. The above data is for 2 months only but if done over the whole year the results could look even more concerning. We believe in view of above figures the pre hospital team should endeavor to improve the accuracy of the alert times.

M Azam MAJEED (Birmingham, United Kingdom), Mohammed TUHIN, Asif NAVEED, Qasim ALI
11:00 - 18:00 #7344 - Accuracy of emergency physician renal ultrasound in the diagnosis of hydronephrosis : prospective study in comparison with radiologist ultrasound.
Accuracy of emergency physician renal ultrasound in the diagnosis of hydronephrosis : prospective study in comparison with radiologist ultrasound.


A renal ultrasound (RUS) is mandatory in renal colic (RC), acute pyelonephritis (AP) and acute renal failure (ARF) in search of a hydronephrosis because management would be different. Studies have explored performances of emergency physician (EP) renal ultrasound (EPUS) compared to computed tomography (CT) but not compared to radiologist ultrasound (RUS). The goal of this study was to evaluate performance of EPUS compared to RUS in the diagnosis of hydronephrosis. EP had different formations and experiences.

Patients and methods

Inclusion criteria

suspected RC, AP or documented ARF

Exclusion criteria

US almost done

absence of RUS

end of life


It was a non interventionist study which was approved by the Ethics committee. After inclusion and informed consent, an EPUS was performed. A RUS was then performed, the radiologist being blind to EPUS result. Only the RUS result was used for the management of the patients

The primary objective was sensitivity and negative predictive value (NPV). Secondary objectives were specificity, positive predictive value (PPV) and quantification of the hydronephrosis. The required number of subjects for sensitivity 0.9 with alpha risk 0.05 and beta 0.10 was 38.

Statistical methods

Values stored in Microsoft Excel were analyzed with Graphpad. Numerical data expressed as mean + SD were compared by a Student t test. Categorical data by a Khi2 test. P< 0.05 was considered significant.


55 patients were included, 5 excluded because of lack of RUS. Age was 47 + 22 years, sex ratio 1. There was 31 RC, 9 AP and 10 ARF. Sensitivity and NPV were 100% (CI95% [79.1-100%]) and 100% (CI95% [81.5-100%]) respectively. Specificity and PPV were 67.9% (IC95% [47.6-83.4%]) and 71% (IC95% [52.8-81.5%]), respectively. For 19 patients with hydronephrosis, measurement was done in 16, there was no difference (p=0.71)


In our department, sensitivity and NPV allow to not confirm the normal result by a RUS. However, in case of hydronephrosis found at the EPUS, a confirmation by a RUS or a non injected CT is warranted because of the lack of specificity. The absence of difference between hydronephrosis measurements could be due to a lack of power. Although non evaluate in this study, the time saving would be important in case of EPUS alone. Formation of the EP has to be improved to enhance the specificity.

Philippe LE CONTE (Nantes), François MOUNIER, Idriss ARNAUDET, François JAVAUDIN

Introduction: Patients with acute thermal injuries have physiological disorders that make difficult characterizing their acid-base status and identifying factors of poor prognosis.  Studies with non-conclusive results have being done on base deficit (BD) and a serum lactate.  Due to the complexity of the pathophysiological characteristics that define burn patients; the physic-chemical analysis of the acid-base status may hypothetically provide a higher accuracy in detecting metabolic and perfusion disturbances as well as in predicting bad outcomes than the other methods.


Methodology: We performed the acid-base analysis of 15 patients older than 15 years-old, with a burned body surface area greater than 20% that were admitted to a burn intensive care unit within 48 hours after the injury. The analysis was performed by using three methods: 1) Conventional method based on Henderson-Hasselbalch’s theory, 2) Anion-Gap (AG),and albumin-corrected AG, and 3) Physic-chemical approach of Stewart’s acid-base state theory.


Results: After using the Henderson-Haselbach’s method: 8 patients had metabolic acidosis, 4 patients had a low BD, 5 patients had medium BD, and 5 patients had severe BD elevations. When AG analysis was performed, only 5 patients showed an abnormal AG. In contrast, implementing the albumin-corrected AG it increased the number of patients with abnormal AG to 13 patients. Strong-ion difference was abnormally elevated in all the patients.


Conclusions:A higher agreement between abnormal acid-base statuses was observed when using the albumin-corrected AG method and Physic-chemical approach of Stewart’s acid-base state theory. 

Luis Arcadio CORTES-PUENTES (BOGOTA, Colombia), Gerardo LINARES-MENDOZA, Norberto NAVARRETE, Maria Victoria NIETO
11:00 - 18:00 #8243 - Activities of Croatian Nurses Society of Emergency Medicine.
Activities of Croatian Nurses Society of Emergency Medicine.

Croatian Nurses Society of Emergency Medicine (CNSEM) was established in 2014 on the initiative of nurses and medical technicians who work in emergency medicine service and emergency departments. The main objective of activities of CNSEM is focused on professional training of nurses and technicians in emergency medicine. Over the past two years CNSEM has organized numerous training in emergency medicine for EMS teams, education of triage in the department of emergency medicine in accordance with the standards of education prescribed by Croatian Institute of Emergency Medicine. Educational programs are designed to provide specific knowledge and skills needed for a work at emergency medicine system. In addition, there were two courses called school of emergency medicine on the topic cardiorespiratory diseases, and care of trauma patient. There are plans for another 4 modules of school. This year was organized the congress of emergency medicine with international participation, in cooperation with Croatian Medical Association Croatian Society for Emergency Medicine, which brought together 320 participants. CNSEM has almost 300 members who actively participate in society activities. The Society cooperates with Croatian Institute of Emergency Medicine, and with other professional associations from Croatia and Slovenia. Also CNSEM joined the European Society of Emergency Nursing, and it is open for collaboration with another Society from another countries. Activities that are done provide better care for emergency patients.

Damir VAZANIC (Zagreb, Croatia), Furdek DAVORKA
11:00 - 18:00 #8043 - Acute aortic dissection.
Acute aortic dissection.

Introduction :

Acute aortic dissection (AAD) is a medical emergency with a high mortality rate. It usually presents with severe, unrelenting chest pain of sudden onset.There are several different formats of classification for thoracic aortic dissection; the most commonly used is the Stanford Classification which divides the dissections into 2 types: A - dissection originating in the ascending aorta; B - dissection originating in the aorta distal to left subclavian artery.

Case report:

A 60 year-old man, presented to the emergency department of our hospital with complaints of sudden severe chest pain. His past medical history revealed uncontrolled essential hypertension and diabetes associated with noncompliance with medication and appointments. The pain was described as a retrosternal cramp without irradiation.

On physical examination, the patient was conscious, temperature and blood oxygen saturation were normal. Pulse and respiratory rates were 69/minute and 18/minute, respectively. Blood pressure was 100/50 mmHg in left arm and 150/90 mmHg on the right side. There was no jugular venous distension.His extremities were warm to the touch, with no pallor, finger clubbing or cyanosis. Pulses were symmetrical and there was no peripheral oedema. There was no femoral sound. The abdomen was soft without defence. The rest of the exam was unremarkable. Initial EKG showed a sinusal rhythm with signs of right ventricular infarct. An acute coronary syndrome was mentioned, but an aortic dissection couldn’t be eliminated. Therefore, the patient received the Nicardipine to control a systolic tension (less than 110 mmHg), a titration of Chlorydrate of Morphine and EKG monitoring. The patient’s clinical condition was unchanged, except for a pulse deficit on the left side of his body, a finger cyanosis in the left hand and the patient described a lump parasthesis. The EKG was dynamic with rhythmic alternation, axis changes and Nonspecific T wave modification. The diagnosis of acute aortic dissection was probable.

The Patient was subsequently planned for Computed Tomographic angiography, which showed normal coronary arteries but aortic dissection Stanford type A starting from the aortic valve to the iliac bifurcation and extending to the supra aortic trunks, coeliac trunk and to the superior mesenteric artery. The patient was planned for aortic root replacement with aortic valve conduit and reimplantation of coronary arteries, electively. The patient was urgently transferred to cardiovascular unit. There were no changes in his clinical condition during transport, but while being placed on the operating table, he went into cardiac arrest with unsuccessful reanimation.


Although aortic dissection is an uncommon entity, its outcome is frequently fatal and many patients with aortic dissection die before diagnosis. When left untreated, about 33% of patients die within the first 24 hours, and 50% die within 48 hours.

11:00 - 18:00 #8202 - Acute aortic dissection: unusual presentation in the emergency department.
Acute aortic dissection: unusual presentation in the emergency department.


Acute aortic dissection (AAD) is a critical disease state requiring immediate diagnosis and optimal treatment.  We describe a case of acute type A Stanford aortic dissection with an unusual presentation.


Case report:

A 70-year-old man with no medical history presented to the emergency department with agitation that occurred one hour before admission. There were no history of chest pain or dyspnea, no recent trauma and no toxic use. On physical examination, the patient was afebrile, his blood pressure was 100/60 mmHg in the left arm, and not detectable in the right arm without signs of acute ischemia. The pulse was 47 beats per min. Respiratory rate 20 times per min with an oxygen saturation of 98% on air room.  He was agitated, but there was no neurological impairment. His pupils were round, equal, and reactive to light and accommodation. Moreover,  a swinging right cervical mass was found. There were no signs of acute heart failure. The abdomen was soft, non-distended, and mildly tender without rebound or guarding. Electrocardiogram, chest x-ray and blood gas analysis were normals.

An ultrasound of the supra aortic arteries was performed and showed a dissection of right brachio-cephalic arterial trunck with floating membrane image and an obstruction of right sub-claviar artery.

Computed tomography (CT) scan confirmed a Stanford type A dissection with anevrysmal ascending  aorta. The patient underwent urgent surgery and experienced a successful outcome. He was discharged from the intensive care unit a week after his surgery.



Emergency physicians are especially challenged by diseases that require urgent treatment like aortic dissection. Misdiagnosis leads to delay of diagnosis, and exposure to inappropriate treatment. Emergency physicians should consider this diagnosis even in the absence of a typical presentation.



11:00 - 18:00 #7253 - Acute confusion: A case report.
Acute confusion: A case report.

Acute confusion is a clinical syndrome which is difficult to define exactly, but involves an enormity of thought, perception and levels of awareness.

It is typically of acute onset and intermittent. Both hyperactive and hypoactive delirium is rarely recognised and often patients exhibit features of both. Episodes of confusion with memory loss and temporary amnesia are frequent symptoms of brain disease and varied etiology.

Among the more common causes are: head trauma, senility and dementia, defused vascular disease of the brain, metabolic disturbances which effect the brain such as; hyperglycaemia, intoxication – such as acute alcoholics, alcoholism, psychomotor epilepsy and postictal state of seizures caused by brain tumour and other diseases.

We present a case of a 50 year old gentleman who presented to the emergency department with acute confusion. His friend found him at home; confused, disorientated and aggressive. He wasn’t communicating verbally, although he was his normal self the day before. He had past medical history of kidney stones, depression and anxiety. He was on Lamotrigine and Quetiapine.

On examination his airway was clear, his chest examination did not show any abnormality, respiratory rate was 15 per minute with oxygen saturation of 97% on air. Abdominal examination showed no abnormality. Pulse rate was 60bpm with BP 129/54. GCS of 12/15. Initial presentation was acute confusion state. A CT head and MRI head was performed which was found to be normal. His chest x ray was normal. His bloods were normal; urea 9.3, creatinine of 90 and Creatinine Kinase 1217.

He was diagnosed to be suffering from drug induced rhabdomyolysis, his medication was stopped. The patient improved and was discharged home.


Acute confusion may be caused by many reasons, but it is uncommon to find somebody developing rhabdomyolysis on Lamotrigine and Quetiapine. 

Inayat REHMAN, Mohammad ANSARI (Birmingham, United Kingdom), Ahmad ISMAIL
11:00 - 18:00 #7233 - Acute coronary syndrome presented with an only presentation of exertional headache.
Acute coronary syndrome presented with an only presentation of exertional headache.

Pain above the nose or below the navel is rarely cardiac in origin. Cardiac cephalalgia means that a case of headache is presented where the underlying cause was cardiac ischemia. This is a very rare syndrome and the mechanism is still unknown now. This time, we presented a case of acute coronary syndrome (ACS) with an only presentation of exertional headache of sudden onset.

Case report:
A 64-year-old female with past medical history of diabetes mellitus and end-stage renal disease under regular hemodialysis presented with severe headache of sudden onset while exercise for one hour prior to admission. Diaphoresis was noted at triage. She denied chest pain or tightness. She denied similar history before. Initial vital signs were T 36.5℃, pulse rate 90/min, respiratory rate 18/min, BP 103/59 mmHg. Physical examination showed no remarkable findings. Due to the suspicion of brain lesion, such as subarachnoid hemorrhage, emergent brain computed tomography (CT) was arranged. Emergent brain CT revealed no obvious intracranial lesion. Patient still complained of severe headache one hour after morphine 5 mg IM . Under the consideration of electrolytes imbalances or cardiac ischemia, ECG and blood exam were arranged. ECG revealed ST elevation of lead aVR and multiple ST depressions of lead I, II, III, aVF, and V2~V6. Previous ECG 2 months ago revealed normal sinus rhythm without ST-T changes. Laboratory data showed troponin I 1.05 ng/mL (Nromal: < 0.11). Coronary angiography was performed by cardiologist. The result showed 80% stenosis of right coronary artery (RCA) and 99% stenosis of left circumflex artery (LCX). Both percutaneous transluminal coronary angioplasty and bare-metal stent were applied for RCA and LCX. Her headache was relieved well after stenting. Then the final diagnosis was confirmed as severe headache of sudden onset due to ACS. She was under regular follow up at cardiovascular outpatient department without complications.

When the headache occurs as the only manifestation of an acute coronary event, the clues for suspicion are: (1) older age at onset, (2) no past medical history of headache, (3) presence of risk factors for vascular disorders, (4) onset of headache under stress.

Jiun-Jia CHEN (Taichung City, Taiwan, China)
11:00 - 18:00 #7390 - Acute epiglottitis in adults: Who needs airway intervention?
Acute epiglottitis in adults: Who needs airway intervention?


Acute epiglottitis is a potentially life-threatening condition as an airway emergency, therefore early diagnosis and airway management are essential.

Although laryngoscopy is the gold standard for the diagnosis of acute epiglottitis, this invasive procedure can be dangerous and sometimes hard to perform for emergency department (ED) physicians. In this context, we investigated how the clinical manifestations and X-ray findings can contribute to the diagnosis and proper airway management in patients with acute epiglottitis.



We conducted a retrospective chart review of patients with acute epiglottitis aged 18 years or above at the presentation who visited our ED between 2005 and 2014.

We evaluated the number of days between the onset and the ED visit, signs and symptoms (sore throat, dysphagia, salivation, dyspnea, muffled voice, and stridor), and examination findings (the width of the epiglottis (EW) on lateral neck X-ray and the degree of swelling of the epiglottis on laryngoscopy).



Out of the 47 patients identified in this study, 10 required airway intervention such as tracheal intubation, tracheotomy, or cricothyroidotomy. More than half of the patients visited the ED within one day of onset. Dyspnea was seen with higher frequency in the patients with airway intervention (90% in the airway intervention group vs 24% in the non-airway intervention group, p<0.01).All of those diagnosed with severe swelling of the epiglottis on laryngoscopy required airway intervention. Lateral neck X-ray was taken in 29 patients, 4 of whom required airway intervention. EW was 7mm or greater in 28 of them. The median value of the airway intervention group (4 patients) and the non-airway intervention group (24 patients) were 25.5mm (interquartile range (IQR), 22.3-30.25) and 11.2mm(IQR, 9.3-18) respectively, significantly greater in the airway intervention group (p<0.01).EW was 20mm or greater in all four patients with airway intervention who underwent lateral neck X-ray.



Patients without dyspnea on arrival are more likely to be treated without airway intervention. Lateral neck X-ray can be helpful both in the diagnosis of acute epiglottitis and in the prediction of those who require airway intervention.

Ryuhei IGETA (Fukui, Japan), Makoto SERA, Taizo NAKANISHI, Hideya NAGAI, Hideyuki MATANO, Shinsuke TANIZAKI, Shigenobu MAEDA, Hiroshi ISHIDA
11:00 - 18:00 #8260 - Acute ischemia of left lower limb and massive pulmonary embolism.
Acute ischemia of left lower limb and massive pulmonary embolism.

Man of 47 years old is brought by ambulance with paraesthesia at the shank and left foot, sudden feels dizziness. He has no previous medical history. As risk factors we have: smoking, caffeine user, stress, sedentary (truck driver).

At at primary evaluation in emergency department patient is conscious, responsive, AV = 98b / min, TA = 160 / 112mmHg, SaO2 = 98% TC = 36.6C, slightly anxious. Secondary evaluation highlights at the examination of the left lower limb following items: local paleness, cold, lack of pulse in pedia artery, posterior tibial artery, popliteal artery, femoral left artery and paresthesia. A few minutes after arrival clinical condition suddenly worsens, patient is showing : dyspnea, tachycardia (AV = 126b / min), paleness, TA = 120/104 mmHg, SaO2 = 86% D-Dimer> 5ug / ml and EKG BRD with SI QIII, TIII. Patient receives 5000 IU intravenous heparin bolus and CT angiography with contrast agent is performed (thorax and abdomen with pelvis) that highlights the pulmonary artery trunk of 31mm caliber, APD and APS 26mm caliber. Endoluminal thrombus in the pulmonary arteries, extended at the level of superior lobar arteries that are completely obstructed, extended also to the bilateral lower lobar and right middle artery with their branch segments almost completely obstructed. Aorta and collateral branches permeable of normal size. Common iliac artery, internal and external permeable with calcified atheroma and segmental stenosis in the internal iliac. Right common femoral artery permeable in the incipient segment with parietal thrombus occluding in a proportion of about 30%. Left common femoral artery shows an intraluminal clot wich completely obstructs. Retractile fibrous lesion in the right posterior sinus phrenic rib. Several nodules in the bilateral pulmonary area. Trachea and main bronchi free. Without fluid in the pleural cavity.

Conclusion: massive pulmonary embolism and acute ischemia of the left lower limb

Is administered intravenously thrombolytic (Actylise) with restore circulation in left lower limb and local,general and pulmonary symptom relief (warm skin; disappearance of paleness, paralysis, pain and mild paresthesia; SaO2 99-100%; without dyspnea and tachycardia). Patient is  hospitalized in coronary intensive care for therapeutic and clinical monitoring.

Florica POP (Arad, Romania), Monica PUTICIU, Johanna Elizabeth KATAI
11:00 - 18:00 #7750 - Acute liver failure, a diagnosis from Emergency Department.
Acute liver failure, a diagnosis from Emergency Department.

Male 25 years old attended the Emergency Department because of 10 days with fatigue, debility, abdominal swelling, fever and jaundice.

No epidemiological, food contact, history risk, travel abroad or consumption of toxic substances or drugs.

In the blood analyse we saw acute liver failure. The ultrasound of his abdomen not found any pathology. Hospitalisation on Digestive service is advised and general supportive measures should be employed.

During his stay in the service of Emergency he suffers repeated episodes of hypoglycemia with clinical deterioration and signs of hepatic encephalopathy.


Exploration: Normotensive, jaundice skin and mucous membranes. Eupneic. Bleeding active in areas venipuncture. Abdomen painful with hepatomegaly.


We decide to call to the ICU, “zero code transplant” was activated and a successful liver transplant performed at 5 days after admission.


Additional tests to filial the origin of failure were all negative (positive serology, toxic, Wilson disease, autoimmunity, liver biopsy, negative bone marrow puncture).

At 20 days after discharge came to the emergency by fever without any focus of it. On blood analyse we could see pancytopenia. And we look for the liver biopsy results, it was non-Hodgkin's B-cell lymphoma, Immediately we contact with hematologist who comes to treat starting QMT.After several cycles of QMT now he is free of disease.



NHL as a cause of fulminant liver failure is a rare presentation. Clinically the suspects of it is difficult because of the rapid and aggressive course. Also in this case show an atypical presentation, without lymphadenopathy or B symptoms except fever. Would he have been transplanted if he had NHL diagnosed before?

11:00 - 18:00 #4505 - Acute myocardial infarction in a young male with prothrombin gene mutation.
Acute myocardial infarction in a young male with prothrombin gene mutation.

G20210a mutation of prothrombin gene results in difficulty in degradation of prothrombin and favours a procoagulation state that increases the risk of thrombosis. Although it is a relatively frequent cause of venous thromboembolic disease, we present here a case report of myocardial infarction caused by coronary occlusion from a thrombotic clot in a patient with this mutation.

We received in the A&E department a 36-year-old male with previous history of knee injury followed by a pulmonary embolism. He was on acenocumarol and had the INR within normal limits. He complained of atypical chest pain of three-hour long. He had no changes in initial ECG, and blood samples and chest X-ray were performed following the initial examination. After a sudden worsening of his pain he suffered two episodes of cardiac arrest with ventricular fibrillation that were defibrillated with 200J discharge to defibrillate them, with ST elevation in the new ECG performed. The patient was trasferred to the Intensive Care Unit, where an episode of ventricular tachycardia was treated with IV amiodarone and magnessium sulfate. Cardiac catheterization was performed, finding an occlusion of the circumflex artery that was treated with a stent after previous administration of clopidogrel. He was discharged home 1 week later.

Luis Ángel MATEOS VEGA (Valencia, Spain)
11:00 - 18:00 #7098 - Acute myocardial infarction related Duchenne disease. How usseful are STEMI guideline?
Acute myocardial infarction related Duchenne disease. How usseful are STEMI guideline?

Background. Cardiac impairment and events are common to muscular dystrophy (Duchenne) patient, left ventricular remodeling and dilatation, heart failure, arrhythmias, but vascular disease in cardiac damage determinism is not a leading cause.

The aim of the paper are, firstly, to present an exceptional rare event in DMD – acute myocardial infarction, with atypical presentation in context and related diagnostic and therapeutic strategies implemented.

The second intention are to analyze how useful are STEMI guideline for pediatric patient with particular disease causing this event

Finally, we targeted obtaining the best explanation of the phenomenon determinism, how to differentiate aspects of myocardial damages and interpret clinical and paraclinical findigs.

Case presentation. We are presenting a 11 years old boy case with confirmed muscular dystrophy Duchenne, no history of cardiac events, moderate mental retardation, with beta – blockers and corticosteroids treatment, addressed in ED University County Hospital Craiova for upper abdominal pain and vomiting from 8h.

ECG -typical STEMI changes - postero inferior MI, minor RBB.

Troponin T initial level – 2000ng/ml, increasing to 17000 – 30000 ng/ml, decreasing later

NT – pro BNP – 1585pg/ml

Echocardiography –basal septum, posterior and inferior wall hypokinesis, reconnected after 3 days

Emergency coronarography - coronary artery with normal flow, no obstruction, no AMI confirmed

LVEF – under 35%

RMI - multiple cicatricial zones, specific DMD aspect cardiomyopathy

As therapeutic decision – with no guideline recommendation about trombolytic therapy regarding pediatric patient, primary PCI performed after immediate air evacuation to a reference pediatric cardiac center, under heparine subcutaneous administration.

ACE inhibitors (lisinopril) added to treatment

A double dosage of corticosteroids decided for medium period of time

Taking into account acute heart failure – beta blockers withdrawal


Some hypothesis where taken under consideration:

Accelerated apoptosis associate to maldistribution due to cardiomyopathy and decreased LVEF– the most possible hypothesis, well sustained by DMD stage of evolution, age of patient, RMI aspects

Arrhythmia event inducing hipodyastolic insufficiency – not documented

Long term corticosteroids therapy, collateral effects on vessels – not excluded as associate factor

Vasculitis - no founding inflammatory elements or coronarography evidences

Lerning points

Very rarely an acute myocardial infarction cited as a cardiac event related DMD. Evan when ACS confirmed, highly probability it that is not a coronary artery disease involved but, apoptosis events are commonly unpainfull

Cardiomyopathy, ubiquitary in DMD and associate with myocardial fibrosis, are not usually related to CAD

In that circumstances primary PCI strongly indicated

Special investigation (CT angiography, cardiac RMI, eventually Myocardial Late Gadolinium Enhancement MRI), inflammatory tests needed

No any arrhythmic events in this context.


1.Wagner KR, Lechtzin N, Judge DP. Current treatment of adult Duchenne muscular dystrophy. Biochim Biophys Acta 2007; 1772 (2): 229–37

2.Bushby K, Muntoni F, Bourke JP. 107th ENMC international workshop: the management of cardiac involvement in muscular dystrophy and myotonic dystrophy. Neuromuscul Disord 2003; 13 (2): 166–72

3.Daniel P. Judge; David A. Kass; W. Reid Thompson; Kathryn R. Wagner. Pathophysiology and Therapy of Cardiac Dysfunction in Duchenne Muscular Dystrophy. Am J Cardiovasc Drugs. 2011;11(5):287-294

Luciana ROTARU, Cristian BOERIU (Targu Mures, Romania), Letitia BOJIN, Virginia ARMEGA
11:00 - 18:00 #8031 - Acute Neuropsychiatric Syndrome Managed Like Status Epilepticus; Methylphenidate Intoxication.
Acute Neuropsychiatric Syndrome Managed Like Status Epilepticus; Methylphenidate Intoxication.

The authors describe a 2 years old boy presented to the emergency department (ED) about 2 h after accidentally ingestion of 3 Methylphenidate (SR) 18-mg tablets (54 mg Concerta(®)).  At admission he had neuropsychiatric signs and symptoms such as; severe agitation, hyperactivity, irritability and delusion. Physical examination revealed that his body temperature of 36.9C, pulse 200/min and blood pressure 140/100 mmHg. The patient also had hyperreflexia and his ECG showed sinus tachycardia. Beside neuropsychiatric signs cardiovascular effects include hypertension and tachycardia occured. Elevated cardiac troponin T has been detected on laboratory assesment with a value of 0.022 ng/mL (normal value < 0,013ng/ml). Since the present case evaluated as moderate to severe toxicity,  ingestion is recent, the patient is not vomiting, and is able to maintain airway activated charcoal was administered.  The goals of management this toxicity are to control agitation and prevent or limit end organ toxicity. To control CNS and cardiovascular stimulation, he received

received midazolam (0,1 mg/kg) without improvement in his symptoms. Multiple doses of intravenous

midazolam,administered  for a total of 1 mg/kg which provided some transient resolution of his symptoms. The child’s symptoms recurred within 6 hours after ingestion. Continuous midazolam  infusion (0,05mg/kg/h) was initiated  following loading dose with a 0.2 mg/kg.  The infusion was weaned by 0,01 mg/kg every hour to off.    He did not have any recurrence of symptoms with a normal cardiac troponin T level and was discharged after 36 h of observation.  

The authors describe a 2-y-old boy of methylphenidate intoxication in which continuous midazolam infusion was used successfully to abate both CNS and cardiovascular symptoms without respiratory compromise.

Ali YURTSEVEN, Mehmet Arda KILINÇ, Eylem Ulaş SAZ (Izmir, Turkey)
11:00 - 18:00 #7978 - Acute pancreatitis induced by cisplatin and etoposide.
Acute pancreatitis induced by cisplatin and etoposide.

Acute pancreatitis is an acute inflammatory process of the pancreas that may involve surrounding tissue and remote organ systems. The disease can range from mild inflammation to severe extensive pancreatic necrosis and multi-organ failure with mortality rates of 20% to 30% or higher. Most cases are mild with a mortality rate<1% and resolve spontaneously with supportive care.

Many drugs are reported to be associated with acute pancreatitis, but they account for only 1.4% to 2.0% of all cases.  This report describes a man who developed acute pancreatitis while being treated for lung cancer with the cisplatin and etoposide regimen.

Case Report: A 54-year-old patient presented to the ED with nausea, vomiting,  abdominal pain and swelling. In history he had been performed chemotherapy including cisplatin(100 mg) and etoposide (150 mg) before a week. On physical examination, the abdomen was distended and diffuse tenderness which was maximal in the epigastrium and no rebound tenderness was present. Laboratory data on admission showed increased serum levels of amylase (605 U/L; reference value <125 U/L), lipase (1143 U/L; reference value<78 U/L). Serum values of urea, creatinine, AST, ALT, alkaline phosphatase, triglycerides, cholesterol, calcium and bilirubin were normal. Abdominal ultrasound revealed that the head of pancreas was edematous and hypoechoic. The biliary tree was not dilated and no gallstones were seen. He was diagnosed with acute pancreatitis and  interned to gastroenterology clinic.

In conclusion we described drug-induced pancreatitis. Despite the low incidence of it, all patients of  acute pancreatitis  of unknown etiology should be carefully questioned about drugs possibly responsible for the induction of the disease.

11:00 - 18:00 #7251 - Acute Physicians in the Emergency Department reduce admissions in Hospital.
Acute Physicians in the Emergency Department reduce admissions in Hospital.


The National Health Service in the UK is under severe pressure for vacant beds in the hospital as the number of patients attending Emergency Departments keep increasing every year and the number of admissions increase on a daily basis. We are always looking for ways to decrease the number of hospital admissions. We decided to appoint Acute Physicians in our Emergency Department to see whether it had any impact in reducing admissions to hospital. Acute physicians were to stay in the Emergency Department between 8AM to 8 PM daily. They were to take care of the management of Emergency Medical patients on arrival to our Emergency Department.


This study was carried out at George Eliot Hospital, Nuneaton to see if appointing acute physicians in our hospital reduced hospital admissions.


We looked at the total number of patients attending our Emergency Department between the years 2013, 2014, 2015 and 2016. In the March to April of the year before and after the appointment of acute physicians and number of admissions during this period.


64163 patients were seen in Emergency Department in 2013 to 2014 and 14807 were admitted in the Hospital. 66536 were seen in 2014 to 2015 and 14915 were admitted. 700065 were seen in 2015 to 2016 and 14574 were admitted. There was a reduction of 8.88% in the month of December 2015. A reduction of 11.95% in admissions in the month of January 2016. A reduction of 11.21% in the month of Feb 2016 and a reduction of 6.8% in the month of March. There was a total overall reduction of 1.08% in admissions to the hospital for the whole year 2015 to 2016.


Emergency department waiting times are continuing to increase with figures of the third quarter of this year (October to December) showing that the number of people waiting longer than four hours has reached its highest level in over a decade The causes of this problem and the solution to address this problem are complex and multifactorial Many patients are waiting for long periods of time in the Emergency Department for a bed. The number of people admitted in hospital has increased overtime and the availability of beds depends on early discharge and less admissions from the Emergency Department.


Our results show that appointing Acute Physicians in the Emergency Department can significantly reduce admissions in the hospital.

Mohammad ANSARI (Birmingham, United Kingdom), Ahmad ISMAIL, Inayat REHMAN, Qazi ZAMAN, David FAROOGI
11:00 - 18:00 #6992 - Acute shoulder dislocation in the ED: Retrospective evaluation of pain management and a proposal for a standard operating procedure.
Acute shoulder dislocation in the ED: Retrospective evaluation of pain management and a proposal for a standard operating procedure.


Shoulder dislocation is a very common condition in the emergency department (ED). It’s one of the most painful medical emergency (VAS score, mean visual analog scale at the admission: 7.3) for which there is no specific recommendation supported. The main objective of this study was to analyze the management of pain in the ED. The secondary objective was to investigate the influence of seven clinical parameters on the choice of analgesic drugs.


We conducted a monocentric and observational study, on 238 patients who consulted for an acute shoulder’s dislocation from 1 January 2012 to 30 April 2015 in our ED admitted in the "lying-area” or in the "ambulatory-area”. We excluded all other patients who had already been reduced, who had shoulder prosthesis (dislocation or asymptomatic chronic dislocations with fortuitous discovery). Fifty-seven parameters reflecting the overall management were analyzed.


Descriptive analysis confirmed that acute dislocation shoulder, were reduced mostly in the ED (221/238: 93% of all dislocations). The main analgesics used were equimolar mixture of oxygen and nitrous oxide (nitrous oxide) (119/238: 50%), midazolam (11%), morphine (6%), nefopam (15%), tramadol (11%) and acetaminophen (25%). Ketamine and propofol were used in less than 1% cases. There was no trace of analgesic prescription in 22% of complicated fracture dislocation files. Admission’s VAS mean score was: 7.5/10 (95% CI: [7-8.1]) for all patients. The univaried analyzes show a significant relationship between the prescription of morphine and other two parameters: the place in the ED of patient care, for “the lying area” (p=0.035) and the presence of an associated fracture (p=0.05). Whatever, the level of analgesic considered, there was no statistical relation with admission’s VAS score (p> 0.05).


This study showed a very few use of strong analgesics and hypnotics despite high admission VAS score, even if there was an associated fracture. These findings highlight the importance of informations traceability in medical files. Our pain management standard operating procedure try to improve patients analgesics care especially during reduction maneuvers in the ED.

Oriane GUILLOT, Jean-Philippe STEINMETZ, Philippe KAUFFMANN, Pierrick LE BORGNE (Strasbourg), Charles-Eric LAVOIGNET, Claire KAM, Philippe ADAM, Pascal BILBAULT
11:00 - 18:00 #6436 - Adherence to guidelines for the diagnosis and management of acute prostatitis in the ED.
Adherence to guidelines for the diagnosis and management of acute prostatitis in the ED.

Introduction: Urinary tract infections (UTI) are common in the Emergency Department (ED) (male UTI prevalence: 2-9%). There is often a wide variation in the initial clinical presentation. The French guidelines (SPILF, 2014) have specified the management of this disease with an underestimated morbi-mortality risk. The main objective of this study was to assess the management of acute prostatitis in an urban ED. We also wanted to evaluate in our ED whether the existing guidelines were followed

Methods: We present hereby a retrospective and monocentric study, collecting all the patients who attended with a simple acute prostatitis in 2014 in our ED (University Hospital). Patients presenting with complicated urinary infection were excluded from the study. 38 parameters (clinical, biochemical, treatments, outcome…) have been analyzed. 72 patients have been included for statistical analysis.

Results: The median was 68 years (IQ: [50-77]). The initial clinical signs were mixed, 68% of the patients presented with functional urinary signs and only 30% with fever. Biochemistry and hematology revealed an inflammatory profile (mean leukocytosis: 12790/mm3 and mean CRP: 79mg/l). Urine was tested with dipstick in 86% of the patients and 92% had their urine sent for culture. PR examination was performed in only 50% of these patients; it was tender in half of the cases.  Escherichia coli remains the predominant uropathogen (63%). The bacterial environment also found was: 8% S. Epidermidis, 8% C.Koseri, 6% K. Pneumoniae and 15% of other uro-pahtogens. Fluoroquinolons were mostly prescribed (54%) and 33% of the patients were treated with 3rd generation cephalosporin. The median duration of treatment was 21 days (IQ: [15-23]). 20% of these patients were managed directly by the Urology Consultant in the ED. There was no significant difference in term of treatment duration (p=0.10), neither in term of antibiotics used (p=0.49) between physicians. 45% of the patients were sent for imaging (mostly ultrasound). Finally, 42% of the patients were admitted (95% CI: [27-58%]) (average hospitalisation duration: 6.3 days). For the ambulatory patients, a urology consultation was only offered for 61% of them. The mortality at Day28 was 3% (95% CI: [1-7%]).

Conclusion:Our study in the ED highlights the poor adherence to current guidelines. The management of male UTIs in the ED remains heterogeneous. The French guidelines suggest an interesting algorithm, which insists on the urine dipstick, UTIs with few symptoms, admission criteria and the appropriate use of imaging. As well as curbing the additional cost of non-guideline prescription, adherence to guidelines is essential in order to suppress growing resistances to antibiotic treatment.

Pierrick LE BORGNE (Strasbourg), Sébastien KIRSCH, Mihaela MIHALCEA-DANCIU, Hakim SLIMANI, Claude GERONIMUS, Claire KAM, Philippe KAUFFMANN, Pascal BILBAULT
11:00 - 18:00 #7265 - Adverse drug events in adult patients visiting emergency department in korea.
Adverse drug events in adult patients visiting emergency department in korea.

Adverse drug events (ADEs) didn’t unfrequently happen in both inpatient and outpatient. These events are a significant cause of morbidity and mortality, and results in increasing Institutional care, including and physician visits, and diagnostic tests, medication use, increased emergency department (ED) and hospital admissions. ADEs have been estimated that 5–25% of admissions are drug-related and have been studied mostly among hospital patients. However, ADEs occurring in treated in EDs receive less attention, though nearly 3-fold more patients are treated in EDs for ADEs compared to those admitted. In such a reason, we investigate to determine the prevalence, severity, and preventability of ADEs in patients presenting at EDs in Dongguk University Medical Center Ilsan Hospital for 2 years.

A retrospective registry study which was performed by using the spontaneous adverse drug effects reported data on an electronic medical record for adverse drug effects was conducted on a stratified random sample (n = 204) of adults (≥18 y) who presented to EDs from January 1, 2013 to December 31, 2014.The average age of patients with adverse drug effects in ED 42.6 ± 14.5 years, and Male gender were 35.3%. Drug combination was average 0.9 ± 1.2. Severity of symptoms were severe in 2.9% and non- severe in 97.1%. The reporter was nurses in 58.8%, doctors in 41.2%. The most common symptom was urticaria in 32.5% and the most common drug class was analgesics in 59.0%.   Using the spontaneous adverse drug effects reported data on an electronic medical record is worth noting. The future participation of more institutions needs additional study

Jeong Hun LEE, Han Seong LEE (Goyang, Korea, Republic of)
11:00 - 18:00 #7368 - After acupuncture: Acupuncture-associated pneumothorax.
After acupuncture: Acupuncture-associated pneumothorax.


Acupuncture is proven to be relatively effective in chronic pain treatment.[i] [ii] With its increasing popularity, Emergency Physicians (EPs) should be aware of its complications. We report 2 cases of acupuncture-induced pneumothorax presenting to our hospital emergency department in Singapore over a 2 week period.

Case 1

A 72 year-old lady presented with dyspnoea 20 minutes following acupuncture to the chest. She was a non-smoker with no pulmonary-related co-morbidities. On arrival to the Emergency Department (ED), the patient was tachypneic and had SpO2 of 98% on 2Litre oxygen. Other vital signs were normal.  X-ray showed a large right simple pneumothorax. A chest drain was inserted in the ED with symptom resolution and re-inflation of the lung on repeat x-rays. She was discharged the next day following removal of chest tube.

Case 2

An 81 year-old gentleman with no history of smoking or respiratory disease presented with chest tightness and dyspnea 1 hour after acupuncture to the back. He went to the acupuncturist for treatment of back pain from lumbar radiculopathy. He was hemodynamically stable. X-ray revealed a large right simple pneumothorax. Chest drain insertion was performed in ED. He, too had his chest tube removed after resolution of his symptoms and was discharged well the following day.


Common[iii] complications of acupuncture such as pneumothorax, penetrating injuries to other organs like the heart, haemorrhage, and infection can be life threatening. Since these patients often present to ED, knowledge and awareness of potential complications of alternative therapies like acupuncture is crucial. Furthermore, with increasing practice of complementary medicine worldwide[iv] [v], such knowledge also allows EPs to better manage, counsel, and educate patients.

Of the severe complications that arise from acupuncture, pneumothorax seems to be commonest[vi]. While the cases we reported were simple pneumothoraces with good recovery and outcome, extreme cases of bilateral tension pneumothoraces have been published[vii][viii]. In the medial scapular or midclavicular line regions, the lung surface is only 10 to 20 mm beneath the skin[ix]. This explains how improper needling of acupoints in this region could possibly lead to lung puncture. A review published by the World Health Organization reveals that most traumatic complications in China occurred after the sessions were performed in village clinics and rural hospitals, where acupuncturists rarely receive formal education in medical colleges[x]. This suggests that training may play a role in improving the safety profile of acupuncture.

More proper training programs are now available[xi] [xii] [xiii]  and this seems to be associated with increased safety[xiv] [xv]. In Singapore, the Traditional Chinese Medicine Practitioners Act passed in 2000 requires registration of practitioners with the government. This is an example of a step forward for better regulation and safety standards in the practice of complementary medicine. In future, with proper regulations and legislation, we hope that the practice of alternative medicine will become safer.

Wei Lin Tallie CHUA (Singapore, Singapore), Corinne LAU
11:00 - 18:00 #7080 - After cardiac arrest - dilemmas in a case of acute coronary syndrome by lupus vasculitis disease.
After cardiac arrest - dilemmas in a case of acute coronary syndrome by lupus vasculitis disease.

Background. CAD as an important cause of cardio respiratory arrest and sudden death, has however, specially to young peoples, so much particular faces to confirm for early and adequate management, some of these difficult to explore or implement during cardiac arrest.

Purpose of the study was to highlight the specific practical issues related to a special coronary artery occlusion etiology, outcome impact and subsequent prevention, for a cardiac arrest case occurring at a very young age women, caused by non usual coronary artery disease in systemic vascular inflammatory disease context

Case presentation – a 29 years women with sudden, in hospital, cardio respiratory arrest (refractory VF). No significant personal or family pathological history or prodrome.

Prompt resuscitation in scene by hospital resuscitation team. Early after ROSC, echocardiography suggests akinesis zone and mitral valve vegetation suggestive for endocarditis. ECG – anteroseptal acute STEMI. Low level of LDL, NT – proBNP – 421pg/ml, creatinine level – 0,9 mg%.

The coronarography identifies a myocardial necrosis area and vascular changes suggestive for autoimmune vasculitis, no elements for coronary artery atherosclerotic plaques or spasm. Completion of  imagistic (CT angiography and cardiac RMI) and laboratory tests reveal elements of confirmation of systemic lupus erythematosus disease with diffuse coronary artery vasculitis and  subclinical renal determinations. Anticardiolipin antibodies founded.

In terms of prompt and vigorous resuscitation, general anesthesia maintaining and immediately air evacuation to a interventional level I cardiology center, myocardial necrosis was restricted to a small apical territory. Evolution without cerebral sequelae, acute heart failure phenomena or signs of heart failure at 4 months.


1.      Focusing on differentiation causes of CAD to a young women without any risk elements for coronary artery atherosclerosis was from the begining a target

2.      Observing anterior mitral valve changes suggesting endocarditis has been the main reason for targeting primary interventional cardiology

3.      The main therapeutic dilemma was to refrain from the initial thrombolysis during resuscitation (INR 2.2 spontaneously) even with approximately 70' delay anticipation to primary PCI

4.      Lupus vasculitis disease existence generated a debate about type, therms, risks and benefits of antiplatelet agents use.

5.      Immunosuppressive - corticoide therapy combination brings into question the subsequent coronary risk augmentation through the side effects of this therapy, even in conditions of vasculitis disease impact control, which, in turn, requires customizing imaging resources algorithm

6.      The recurrence risk of malignant arryhythmias remains high, leading to evaluate defibrillator implantation benefits

Lerning points

Young, healthy peoples developing an ACS  are strongly suspected to have special etiology of CAD, other than thrombotic

In that circumstances primary PCI strongly, early indicated

Special investigation (CT angiography, cardiac RMI),  endomyocardial biopsy, nuclear study,  inflammatory / immunologic tests, risk score assessment remains mandatory to direct therapy

There in unclear how antithrombotic therapy influences the late prognosis, or if thrombolysis during resuscitation (CAD with unknown etiology)  influences ROSC, or survival chance


Ali Karrar, Winston Sequeira, Joel A. Block Coronary artery disease in systemic lupus erythematosus: A review of the literature. Seminars in Arthritis and Rheumatism. June 2001, Vol.30(6):436–443, doi:10.1053/sarh.2001.23498

Luciana ROTARU, Cristian BOERIU (Targu Mures, Romania), Letitia BOJIN, Virginia ARMEGA
11:00 - 18:00 #7257 - After the bike he can’t take a hike.
After the bike he can’t take a hike.


After the bike he can’t take a hike


N S-Vainberg, F Mustafa, A Gleeson, P Gilligan


Bicycle and skate boarding injuries in young patients are a common presentation to the Emergency Department (ED). Not all injuries are obvious on initial assessment of the patient. Therefore, a thorough secondary survey of trauma patients is absolutely crucial to ensure adequate and appropriate management. We present a case of a teenager that had sustained trauma performing a stunt on his bike.

Case Report

A 17 year male patient was brought to the ED by ambulance in spinal precautions after landing on his head whilst undertaking a front-flip on his BMX bike. He had been wearing a helmet and shoulder pads and had fallen from a height of 2 meters on to his head and left shoulder while performing the stunt. He sustained a loss of consciousness of approximately one minute duration and was complaining of severe shoulder pain. He did not complain of any sensory deficit or weakness.

His primary survey was unremarkable.

He received analgesia and had x rays of his left shoulder, cervical, thoracic and lumbar spine. All x-rays were normal.

On further examination, the patient was noted not to have spinal tenderness but, when he was mobilised, he was noted to be Rhomberg’s positive and walked with a broad based gait. Further neurological evaluation revealed reduced co-ordination in his lower limbs, but no sensory or motor deficit. However, he had grade 3/5 weakness of C7 and C8, as well as grade 4/5 weakness for C4-6.

He was referred for an MRI of his cervical spine, which revealed a spinal contusion at C3-4.

He was admitted under the neurosurgical team for conservative management, physiotherapy and occupational therapy and is recovering well.


Spinal cord injury without radiographic abnormality (SCIWORA) refers to spinal injuries, with no identifiable bony or ligamentous injury on complete, technically adequate, plain radiographs or computed tomography. SCIWORA should be suspected in patients subjected to blunt trauma who report early (immediate) or transient symptoms of neurologic deficit or who have findings upon initial assessment. Treatment and prognosis are based upon neurologic presentation and MRI findings. 

It is important to remember that patients with blunt trauma who have a history of transient neurologic symptoms that have resolved by the time of initial evaluation may have a significant injury to the spinal cord and/or spinal column despite a normal physical examination and normal spine radiographs and/or CT.


Nikita SVIRKOV-VAINBERG, Farah MUSTAFA (Drogheda, Ireland), Aidan GLEESON, Peadar GILLIGAN
11:00 - 18:00 #7131 - Agreement of Point-of Care Test and Laboratory Lactate.
Agreement of Point-of Care Test and Laboratory Lactate.

Lactate is a useful prognostic marker in both sepsis and trauma. Point of Care Testing(POCT)for lactate is now readily available in many emergency departments. This study aimed to examine the agreement of the results of 23 blood specimens for POC lactate with the laboratory values in the Singapore General Hospital. Agreement between the 2 assays were analysed and showed good agreemnt of POCT vs lab lactate. 

Hence we conclude that POCT for lactate can be considered for further use in the emergency department to help in instituting early agressive reasuscitation of critically ill patients . 

Jean LEE (Singapore, Singapore), Siti Fatimah ISMAIL, Hm KANG
11:00 - 18:00 #7898 - Alcohol Withdrawal That Contains Severe Mental And Nervous System Changes: A Case Report.
Alcohol Withdrawal That Contains Severe Mental And Nervous System Changes: A Case Report.

AIM: Acute alcohol withdrawal syndrome leads to fluctuating changes in mental status and it is no uncommon to be reason of cardiovascular collapse and death. We report a patient who dies due to delirium tremens.
CASE: A 43 year old male patient with a history of reduction alcohol after prolonged intake was brought to our emergency service. The patient had no current medical history of epilepsy and had no any medication. He had a history of approximately twenty-year alcohol-use. He was admitted to our emergency service because of intractable seizures. The patient was monitored and airway was ensured. Despite positive inotropic agents, hypotension remained as it has already existed in emergency unit. After all these problems, cardiovascular collapse occurred and the patient didn’t respond to CPR administered for 45 minutes. Finally, he died despite all clinical interventions.
CONCLUSION: As a result, serious cardiovascular instability is no uncommon for DTs and to be aware of vital problems of DTs is essential for physicians.

Musa KAYA, Arif DURAN, Mansur Kürşad ERKURAN (Bolu, Turkey), Tarık OCAK
11:00 - 18:00 #7899 - Amlodipine Intoxication: A Poisoning Case Requiring Intensive Follow-Up.
Amlodipine Intoxication: A Poisoning Case Requiring Intensive Follow-Up.

AIM: Calcium channel blockers are drugs used in hypertension, arrhythmia and coronary heart diseases by blocking L type calcium channels. At high concentrations, calcium channels are blocked and calcium entry from L type channels is totally prevented.. In our study, we aimed to present the changes and the treatment approaches for the hospitalization period of a patient who applied to the emergency unit following the intake of high dose of calcium channel blocker, until the discharge
CASE: 18 year old female patient has taken 30 pieces of Amlodipin (5mg) at 18:30. After the patient was brought to public hospital at 20:00, gastric lavage and activated charcoal has been performed. The patient applied to our emergency unit at nearly 23:00 and she was conscious, cooperative and oriented. Vital signs were normal. Infusion of Dopamine, Dobutamine and Adrenaline was stopped in the fourth day in ICU because the blood pressure began to be normal. The patient was extubated and then discharged with recovery.
CONCLUSION: Mortal complications are inevitable unless intoxication is realized in early stages. Therefore, close hemodynamic follow up is essential for these patients in ICU.

Mansur Kürşad ERKURAN, Erhan DÜZENLI (Bolu, Turkey), Tarık OCAK, Arif DURAN, Hakan BAYIR
11:00 - 18:00 #8119 - An alternative method for increasing medical interns’ chest tube insertion skills: A display mannequin.
An alternative method for increasing medical interns’ chest tube insertion skills: A display mannequin.


Medical education naturally requires non-patient practical training sessions as much as theoretical training. Simulation-based training therefore plays an important role in this context. Chest tube insertion is a vitally important procedure in the emergency department. This study assessed the effect on intern physicians’ chest tube insertion skills of a low-cost chest tube simulation model developed by ourselves.


A dummy was prepared for training simulation using a display mannequin. Medical interns then received instruction concerning pneumothorax and the chest tube procedure. Each intern’s procedural skill was assessed using the “Chest Tube Application Skill Check List” prepared by the authors. Each item on the list was scored separately. A mean was then calculated for the total scores obtained.


All 63 interns taking part in the study reported that the simulation model we developed closely resembled reality. Interns’ mean procedural skill score was 40.9±1.3 out of a possible 42. The maximum score of 42 was achieved by 39.7% of the interns, while another 33.3% achieved a score of 41. Eighty-five percent of the participants succeeded in inserting the tube with an appropriate technique by achieving a score of 40 or more. 


The low-cost model prepared by us using a display mannequin was successful in terms of developing intern physicians’ chest tube insertion skills. This model can be used to improve the chest tube insertion skills of medical interns during medical training.

Ozgur TATLI, Suha TURKMEN, Melih IMAMOGLU (Trabzon, Turkey), Yunus KARACA, Mustafa CICEK, Metin YADIGAROGLU, Selen BAYRAK TAMER, Olgun ASIK, Murat TOPBAS, Suleyman TUREDI
11:00 - 18:00 #8008 - An Audit of Foot and Ankle Problems in Diabetic Patients presenting to the Emergency Department.
An Audit of Foot and Ankle Problems in Diabetic Patients presenting to the Emergency Department.

Title: An Audit of Foot and Ankle Problems in Diabetic Patients presenting to the Emergency Department

Introduction: Diabetic patients are at higher risk of foot and ankle problems especially if co-existant neuropathy is present. Even relatively minor injures could be the precipitating factor for serious problems such as a Charcot joint. It is recommended that diabetic patients have early access to appropriate foot clinics and podiatry services. We carried out a short audit to determine whether access to the foot clinic could be improved by undertaking a simple audit where we asked staff about the outcome of their patients including whether they were referred to the Diabetic Foot service.

Methods: A retrospective review of foot and ankle problems presenting to the ED combined with a prospective audit carried out after agreeing a protocol with the Diabetic Team to increase referrals to the Foot Clinic. In the retrospective audit patients were identified from the ED information system over a two week period. Non-diabetic foot & ankle problems were excluded. In the prospective audit over 2 weeks staff were asked to record the ID number of any diabetic foot or ankle problem seen in ED. Notes were subsequently reviewed to determine diagnosis & outcome

Results: In the retrospective audit  6 patients were identified, the diagnosis of a Soft Tissue Injury was made in 4 cases. All patients were discharged with no follow up. In the prospective audit 7 patients were identified . In this group 1 fracture was referred to orthopaedics and 6 others were noted to have soft tissue injuries however of these 3 were referred to the Diabetic Foot clinic.

Discussion: Patients with diabetes often present to the Emergency Department with relatively minor injuries or other foot and ankle problems. Inexperienced staff may be unaware of potential longer term problems e.g. ulceration, vascular insufficiency or Charcots joints. Following discussions with the Diabetic Team we have agreed that all patients who are known diabetics with foot and ankle problems should be able to access the Diabetic Foot service. The main limitation of the audit is that it was conducted by medical students on a short clinical atachment and as a result the numbers of patients studied were small. However if extrapolated over a year this would represent significant numbers of diabetic patients with foot and ankle problems presenting to the ED.  The improved referral rates reflect a classic Hawthorne effect of auditing clinical practice and making clinicians consider other discharge outcomes. We are now working on a patient information leaflet and hope to use smart media such as QR codes to facilitate greater numbers of podiatry referrals in the near future.

Katherine KELLY, Gordon MCNAUGHTON (Glasgow, United Kingdom), Alice UNSWORTH, Andrew CONNELLY
11:00 - 18:00 #7400 - An audit of procedural sedation in adults in the emergency department.
An audit of procedural sedation in adults in the emergency department.


Sedation is commonly administered in the Emergency Department (ED) to promote relaxation or sleep during painful or distressing procedures. Given correctly sedation can improve a patient’s experience of an unpleasant procedure. However sedative drugs can be unpredictable and if used incorrectly can cause unexpected complications and even death. The Royal College of Emergency Medicine (RCEM) designed the following audit to reflect the need to address safety before, during and after the administration of sedation for a procedure in the ED.


  1. To benchmark current performance in emergency departments against RCEM/RCOA (Royal College of Anaesthetists) and AoMRC (Academy of Medical Royal Colleges) clinical guidelines
  2. To allow comparison nationally
  3. To identify areas in need of improvement
  4. To provide a baseline for future comparison
  5. To develop a local document which outlines the fundamental concepts for delivering safe sedation which can also be used to document procedural sedation in patient notes.


  1. There should be documented evidence of the patient’s informed consent unless lack of mental capacity has been recorded.
  2. Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment 
  3. Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities 
  4. Sedation requires the presence of all of the below:
    1. A doctor as seditionist
    2. A second doctor or emergency nurse practitioner (ENP) as procedurist
    3. A nurse
  5. Monitoring during procedural sedation must be documented to have included all of the below 
    1. Non-invasive blood pressure
    2. Pulse oximetry 
    3. Capnography
    4. ECG
  6. Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area 
  7. Following procedural sedation, patients should only be discharged after documented formal assessment of suitability.


This was a retrospective case note audit from January 2015 to January 2016. The inclusion criteria, as defined by the RCEM, consisted of adult patients aged over 16 years, undergoing procedural sedation. Patients receiving Entonox (50% nitrous oxide/oxygen) only, opiates only or Entonox and opiates in combination were excluded. Our sample size was 50 patients.


Pre-procedure assessment of ASA grade was documented in 10% of cases, potential airway difficulty was assessed in 2% of cases and fasting status in 8% of cases. Most patients were sedated with a benzodiazepine but in 20% of cases the agent used was not recorded in the notes. Only 32% of patients had blood pressure monitored, 30% ECG monitoring, 20% capnography and 34% pulse oximetry. Only 28% of patients had oxygen during the procedure. Post sedation assessment was virtually completely unrecorded.


The results of this audit indicate that currently our department is not meeting the standards set by RCEM before, during or after the sedation. Whether this is because  the standards were physically met at the time of sedation but just not documented in the notes we cannot be sure. We plan to design and implement a document to be used for procedural sedation cases to improve patient safety and our documentation of clinical practice.

Eve FOLEY (Newcastle Upon Tyne, United Kingdom), Mark HARRISON
11:00 - 18:00 #7127 - An Evaluation of Patients with Carbon Monoxide Poisoning Using the TEMPS-A Temperament Scale.
An Evaluation of Patients with Carbon Monoxide Poisoning Using the TEMPS-A Temperament Scale.

Aim:  The purpose of this study was to determine whether patients diagnosed with carbon monoxide poisoning (COP) would differ in terms of temperament in the early and late periods using the “TEMPS-A temperament questionnaire.”

Materials and methods:Patients presenting to our emergency department with carboxyhemoglobin (COHb) levels of 10% or above and diagnosed with COP by our clinic, with no neuropsychiatric disease and aged over 18 were included in the study. Subjects presenting to the emergency department with nonspecific symptoms, with no neuropsychiatric disease and aged over 18 were enrolled as the control group. All patients’TEMPS-A temperament scale results were recorded.

Results:When the results of the TEMPS-A temperament scores of patients diagnosed with COP at first presentation to the emergency department were compared with the scores of the healthy volunteers, DT type scores were 7.5±3.96 and 5.69±3.39, respectively,(p=0.016), ST type scores7.01±4.29 and 6.71±4.19 (p=0.72), HT type scores 11.75±3.81 and 11.26±3.03 (p=0.484), IT type scores 5.16±4.07 and 3.73±3.36 (p=0.06), andAM type scores 6.52±5.72 and 3.88±4.09 (p=0.01). On the basis of these data, comparison of TEMP-A temperament scale scores performed when patients diagnosed with COP first presented to the emergency department with the results from the healthy volunteers revealed statistically significant differences between the two in terms of DT and AT types.

Conclusion: Illumination of the mechanisms behind the relationship between COP and temperamental characteristics, which are affected by the factors of low socioeconomic level and female gender, will be important in terms of preventive measures aimed at reducing the risk of encountering COP.

Oğuz EROĞLU (Kırıkkale, Turkey), Orhan Murat KOÇAK, Şadiye Visal BUTURAK, Figen COŞKUN, Turgut DENIZ
11:00 - 18:00 #6611 - An hour to save your life? Does intra-arrest extracorporeal membrane oxygenation application save life?
An hour to save your life? Does intra-arrest extracorporeal membrane oxygenation application save life?


Extracorporeal membrane oxygenation [ECMO] integrated Cardiopulmonary resuscitation [CPR] [E-CPR] has become one of the most promising advancement in the field of resuscitation medicine. Our aim is to conduct an independent meta-analysis combining all available high quality observational studies, in order to evaluate whether E-CPR can result in neurological intact mortality benefit as compared with conventional CPR.


A comprehensive search was performed in the following databases; Medline [1946 to present], EMBASE[1974 to present], CINAHL [1981 to present], BNI [1992 to present], AMED [1985 to present] andHealth Business Elite [1922 to present]. The literature search was supplemented with additional search of the following databases; Reference search and personal discussion with ECMO expert regarding grey literature.


5 high quality comparison observational studies were identified. E-CPR application to IHCA and OOHCA has an impressive association with short term neurological intact survival benefit. [OR 0.24 (0.14-0.44) p<0.0001] Surprisingly, the analysis indicates that OOHCA E-CPR [OR 0.196 (0.085-0.455) p<0.0001] has a better survival benefit as compared with IHCA. [OR 0.3 (0.13-0.66) p=0.003]. 


E-CPR is associated with neurologically intact survival benefit. The main limitation of this meta-analysis is that the combined data are all observational dates, hence causation of benefit is yet to be proven.

Jonathan LEUNG (Kent, United Kingdom)
11:00 - 18:00 #7545 - An interesting case of chicken pox in the elderly with Intestinal perforation and Prevertebral abscess.
An interesting case of chicken pox in the elderly with Intestinal perforation and Prevertebral abscess.


Chicken pox also known as Varicella is a highly contagious disease caused by Varicella Zoster Virus(VZV).
It is an uncommon inefction presenting in the elderly population which has more morbidity and mortality.
This case report is to present one such interesting clinical presentation of an elderly man with chicken pox and a set ofunusal clinical findings.

A 64 yr old chinese male was brought in by the family to the fever zone of the hospital with c/o vesicular rashes
and lowerlimb weakness for the past 3 days.
Pt was appropriately triaged and was isolated in the fever area of the emergency department.
Patient had no past medical issues.His weakness had started simulataneously in thelower limbs overpast week
and progressively worsened to the extent  he needed assistance to walk.

Physical examination revealed widespread vesicles over the limbs.
Neurological examination was significant for power 0/5  both lower limbs and 4/5  both upper
limbs.Pt was insensate below T2 sensory level and lax anal tone along with mild
tenderness in the RUQ.
x rays  revealed opacity in  rightlung apex and  free air under the right hemidiaphragm.
Pt was hypotensive on arrival from radiology and was uptriaged to resuscitation room and found tobe in ?spinal shock.
Urgent CT-Abdomen and pelvis  showed Pneumoperitoneum - site of perforation was likely greater curvature/fundus
of the stomach.He  had bilateral psoas abscess  with presence of gas within the fluid collection.
MRI cervical spine was done which showed C5-6 discitis with a large prevertebral abscess extending from C2 to T3.

Resulting mass effect contributed to central canal stenosis with possible cord compression at c5-6 and c6-7


Pt underwent exploratory laparotomy and omental patch repair  noted to have perforated D1 anterior duodenal ulcer of abouut 4cm diameter.
Pt developed refractory hypotension post operatively and required triple inotropes and 
activation of massive transfusion protocol.
Repeat CT showed ?subcapsular bleeding form liver and haemoperitoneum.Pt underwent another exploratory laporotomy and splenectomy.
Patient underwent ACDF-anterior cervical discectomy and fusion for prevertebral abscess extending from C3 to T1.
pt also underwent percutaneous drainage of psoas abscess .
His hospital stay was further complicated by disseminated MSSA bacteremia and  tracheostomy .


Chicken pox a common childhood disease is more severe in adults. This is because a key immune response – cell-mediated immunity
weakens with age.
This can lead to complications which are potentially fatal, especially among the elderly.
Presentation of multiple significant clinical findings in a previously healthy person should alert the physician about the likelihood of
immunocompromised states.

Chicken pox in elderly is a rare pesentation in A&E. So it is pertinent for a  doctor in A&E to be extra vigilant while handling such patients
It can lead to complications like Pneumonia and Encephalitis.
A high level of suscpicion and thorough investigations in patients of this group may benefit from early interventions and hence better outcomes.

Vetrivel RAMAR (Bournemouth, ), Irfan ABDULRAHMAN SHETH, Faizur Rahman MOHAMED MADEENA, Evelyn WONG
11:00 - 18:00 #7166 - An Italian version of the Ottawa crisis resource management rating scale: A reliable and valid tool for assessment of simulation performance.
An Italian version of the Ottawa crisis resource management rating scale: A reliable and valid tool for assessment of simulation performance.

INTRODUCTION:  Objective measurement of simulation performance requires a validated and reliable tool.  However, no published Italian language assessment tool is available.  Translation of a published English language tool: The Ottawa Crisis Resource Management Global Rating Scale (GRS) may lead to a validated and reliable tool.

 METHODS:  After developing an Italian language translation of the English language tool, the study measured the reliability of the new tool by comparison to the English language tool used independently in the same simulation scenarios.  In addition, validity of the Italian language tool was measured by comparison to a skills score also applied independently.

RESULTS: The correlation coefficient between the Italian language overall GRS and the English language overall GRS was 0.82 (Adjusted 95% confidence interval: 0.62 to 0.92).  The correlation coefficient between the Italian language overall GRS and the skill score was 0.85 (Adjusted 95% confidence interval: 0.68 to 0.94).

DISCUSSION:  This study demonstrated that the Italian language GRS has acceptable reliability when compared to the English language tool, suggesting that it can be used reliably to evaluate performance during simulated emergencies.  The study also suggests that the tool has acceptable validity for assessing simulation performance.

CONCLUSION:  The study suggests that the Italian language GRS translation has reasonable reliability when compared to the English language GRS, and reasonable validity when compared to the assessment of the skills scores.  Data suggest that the instrument is adequately reliable for informal and formative type examinations, but may require further confirmation before used for high stakes examinations such as licensing.

Dr Jeffrey FRANC (Edmonton, Canada), Manuela VERDE, Alba Ripoll GALLARDO, Luca CARENZO, Pier Luigi INGRASSIA
11:00 - 18:00 #7452 - An unusual case of central venous thrombosis after central venous catheterisation in a young patient with undiagnosed Behcet’s disease.
An unusual case of central venous thrombosis after central venous catheterisation in a young patient with undiagnosed Behcet’s disease.

Introduction: Behcet’s disease (BD) is a systemic small vessel vasculitis. Aneurysm formation and venous thrombosis are rare but life-threatening complications. We present the unusual case of central venous thrombosis in a young man under investigation for BD.

Case report: A 20-year-old-gentleman of Afro-Caribbean descent presents to the Emergency Department with severe right-sided neck pain unresponsive to intra-venous (IV) morphine plus sore throat and difficulty swallowing for 10 days.

He was under investigation for BD following infra-renal aortic aneurysm repair 5 weeks ago. Recovery on ITU had been uncomplicated aside from an incidental small non-occlusive thrombus in the right internal jugular vein (IJV) secondary to central venous catheterisation. He was discharged with a PICC line in-situ for IV antibiotics. On examination, the anterior border of right sternocleidomastoid was significantly tender and there was follicular tonsillitis with normal neck movements.

Vascular and ENT opinions were sought and the patient was treated for acute bacterial tonsillitis with meropenem and vancomycin since blood tests were consistent with infection (white cell count 14.7 and CRP 273).  After a few days, he developed marked head and neck swelling which triggered ITU admission for impending airway compromise. This responded well to a course of dexamethasone however antibiotics had been ineffective. CT imaging was therefore performed and revealed an occlusive thrombus in the right IJV extending cranially to the level of C2. This was significantly worse than before and there was new thrombosis in the right subclavian vein with extension into the origin of the left subclavian vein. Other findings were retropharyngeal oedema, bilateral prominent cervical lymphadenopathy and enlarged right axillary lymph nodes.  He received 5 days of anticoagulation before removing the PICC line to minimise the risk of dislodging the thrombus. Treatment was continued with warfarin. A lack of positive microbiological tests made it difficult to identify a source of infection however blood tests were later seen to improve on antibiotics. They were therefore stopped 24 hours after PICC line removal during which time he developed another thrombus at the site of a peripheral venous cannula in the left antecubital fossa. Unfortunately the patient subsequently underwent endovascular repair for a leaking pseudoaneurysm. Treatment for BD was commenced soon after discharge from hospital.

Discussion and conclusion: There are a handful of case reports for central venous thrombosis in BD.  They all present with swollen face, neck and upper limbs in the very first instance. This was different in that severe neck pain was the only presenting complaint and also complicated by signs and symptoms of tonsillitis. A referral to the vascular team was made because the level of pain was inconsistent with a diagnosis of tonsillitis. Both atypical head and neck presentations and risk factors should alert the emergency physician to suspect central venous thrombosis. Systemic vasculitis is another important consideration especially with central venous catheterisation.

Vittorio DECARO (Northampton, United Kingdom), Azam MAJEED
11:00 - 18:00 #8100 - An unusual presentation of aortic saddle embolism.
An unusual presentation of aortic saddle embolism.


An unusual presentation of aortic saddle embolism


Abstract type (please select only one):


1. ORIGINAL RESEARCH      2. CASE REPORT/CASE SERIES      3. OTHER (e.g. clinical governance, clinical audit, and quality improvement initiative) CASE REPORT

Author(s) Title (Dr., Mr., Ms., Prof. etc), Professional Grade, Department and Hospital (please underline name of presenter):

Dr G.  Nfila, SpR EM, BH

Dr O. Oginni, Reg EM, BH

Dr P. Gilligan, Consultant EM, BH


Contact e-mail address:


Contact telephone number: 0872483373


My preferred format for the presentation of this abstract is (please select only one):  Poster






Dr Galamoyo Nfila

Date: 16/05/2016



An unusual presentation of saddle aortic embolism



A saddle embolism of the aorta causes an acute ischemia of the lower extremities. In a third of patients, various degrees of sensory and motor deficits occur, but sudden paraplegia is seen rarely and its cause is unclear.




We report a case of an unusual presentation of saddle aortic embolism just above the bifurcation of the aorta



An 82 yr old woman with background history of CVA presented with sudden onset of lower back pain radiating to both legs and progressed to paralysis of both legs. ECG showed new onset AFIB, ABG revealed metabolic acidosis and lactate of 5.5

Her lower limbs were mottled, pale, cold with absence of pulses. She was paraplegic with reduce anal tone. CT angio reveal a large saddle embolism just above the bifurcation of the abdominal aorta,

She was given oxygen, intravenous fluids (saline), she was anticoagulated and transferred to vascular as appropriate.




Doctors must remember that the cause of lower back pain, paraplegia and loss of sensation doesn’t always represent caudal equine syndrome. In this patient, the cause of her paralysis and loss of sensation could be as a result of ischemia of the spinal cord from occlusion of arteries via branches from abdominal aorta or from ischemia of peripheral nerves


Olayinka OGINNI, Peadar GILLIGAN, Galamoyo NFILA (Dublin, Ireland)
11:00 - 18:00 #7849 - An unusual presentation of Intracranial Abscess.
An unusual presentation of Intracranial Abscess.

A fifty five year old patient was referred to the Emergency Department wit a diagnosis of hyponatremia.On assessment in the Emergency Department he was found to have a three day history of fever,headache,body aches and nexk pain.Although he was fully  conscious during initial he was found to have intermittent periods of delirium.An initial working diagnosis of meningitis was made and patient was started on IV antibiotics.LP was turbid and was consistent with bacterial infection .A CT scan and later an MRI scan showed multiple foci of abcesses in his cerebellar and thalamic region.

On further review of his medical file it was found that he was admitted a few months prior with lung empyema and required a thoracostomy at that point.This was an unusual case and it is presumed that the patient had thrown off several septic emboli to the brain.

We will intend to discuss ED presentations of intracranial infections and elaborate on investigation and treatment protocols as pertaining to managing such patients in the Emergency Department.

Omar GHAZANFAR (Abu Dhabi, United Arab Emirates), Saleh FARES
11:00 - 18:00 #7254 - An unusual presentation of Pulmonary Embolism.
An unusual presentation of Pulmonary Embolism.

We present a case of bilateral pulmonary embolism which presented to the accident and emergency department of George Eliot Hospital, Nuneaton following an injury to the patient’s chest.

Case report:

A 79 year old lady presented to the accident and emergency department after being unwell and found collapsed. She had a fall two days previously while she was visiting London. She injured the right side of her chest. She was seen in the local hospital and discharged with analgesia.

Two days later she collapsed. She felt light headed and dizzy and being very pale. An ambulance was called and when the paramedics arrived her pulse rate was 119bpm and her BP 85/48. Her past medical history included hypertension. She was on Lisinopril. She was fit and well, independent and self-caring.

On examination she was alert and orientated. The airway was clear. She was breathing spontaneously. Respiratory rate of 21.  We were unable to get her oxygen saturations on 15 litres. She had decreased air entry on the right base, and she as tender over the right chest wall. Abdominal examination showed tenderness over the right upper quadrant. By this time her pulse rate had risen to 127bpm with a BP 104/59. Clinical diagnosis of abdominal injury was made and she was referred to the surgical team. Her chest x ray was unremarkable.

Later on a CT scan of her chest and abdomen was performed, which showed bilateral pulmonary embolism (PE) and generalised fatty liver. She was treated with dabigatran for a period of six months for bilateral PE.

She was discharged home with a follow up appointment in an outpatient clinic. 

Inayat REHMAN, Ahmad ISMAIL, Mohammad ANSARI (Birmingham, United Kingdom)
11:00 - 18:00 #7651 - An Unusual Source For Nosocomial Infections Due To Multi Drug Resistant Acinetobacter Baumannii Complex: Emergency Department.
An Unusual Source For Nosocomial Infections Due To Multi Drug Resistant Acinetobacter Baumannii Complex: Emergency Department.

Introduction: The treatment and control of nosocomial infections due to multidrug-resistant Acinetobacter boumannii is a challenge. Many multi-problem patients were treated in critical care area of the ED for a long period of time. Therefore we aimed to investigate with this retrospective study the prevalence of multidrug resistant A. baumannii and ED related risk factors.

Methods: Patients who admitted between 1 July 2012 - 1 April 2016 to the ED and has a positive culture for A. baumanii were included to the study. Risk factors and patient history were recorded from the patient charts.

Results: Our new emergency department was builded three years ego. Fourty eight patients’ (29% female) who were hospitalized in our emergency deparment during the last three years, cultures were positive for Acinetobacter baumannii complex. Mean age was calculated as 70.04 +/- 13.43 years. A.baumanii complex were isolated from the cultures of peripheral blood, urine, sputum, deep tracheal aspiration, pleural fluid, tissue and wound swab with the numbers of eight, twenty four, four, three, one, two, one and five, respectively. Eleven culture positivities were not accepted as an infection and one of the culture couldn’t been evaluated. Emergency department was thought to be the source of infection for the total number of eight patients whose hospitalized for a long time or only had admission to the emergency department. The main complaints of the patients were fever, nausea-vomitting and confusion. Half of the patients (24/48) were confined to bed. Fourty two patients had a history of hospital or nursing home stay. Fourty one patients had comorbidities as a complicatory factor. Success rate of empirical treatment which was started according to initial complaints was only 50 percent (23/48). Avarage stay in the emergency department was 1.8 day. Twenty one patients were hospitalized and eighteen patients were discharged with oral treatments. Seven patients were transported to another hospital intensive care unit and two patients were accepted as exitus in our emergency department. Twenty one of the isolated Acinetobacters which were thought to be cause of infection were quite susceptible bacterias. Whereas, twenty seven of them were susceptible to colistin, amikacin and tigecycline but resistant to beta-lactams including widely used carbapenems, quinolones and trimethoprim-sulfamethoxazole. In one of the patients, there was also Pseudomonas positivity (colistin resistant) with Acinetobacter complex. In addition to this, vancomycin resistant enteroccus (VRE) was spotted in one patient and carbapenem resistant enterobactericae (CRE) was spotted in another one.

Conclusion: Nosocomial infections due to resistant gram-negative microorganisms are the important causes of mortality. The treatment choices are limited in Acinetobacter baumannii infections, especially if they are panresistant. The data presented in this study demonstrates that patients who have complicated factors and hospitalized before, should be considered carefully. Empirical treatments should be directed according to previous antibiotic history in these population. Maximum isolation measures should be taken even in the ED, because of spreading the isolates such as acinetobacter, pseudomonas, CRE, VRE from these patients to other ones and full compliance of these measures must be done. 

Pr Murat ERSEL (IZMIR, Turkey), Husnu PULLUKCU, Meltem TASBAKAN, Sohret AYDEMIR
11:00 - 18:00 #7116 - Anal abscess in a patient after multiple Emergency Room assists.
Anal abscess in a patient after multiple Emergency Room assists.

Case Report:

MAle Patient 80 years old with personal antecedents of atrial fibrillation, hypertension, benign prostatic hyperplasia and chronic obstructive pulmonary disease is treated with digoxin, Sintrom, doxazosin and inhalers.

He Comes to the emergency room for intense rectal pain one year of evolution that has intensified since one month that prevents the seated accompanied by fear of defecation and emission of liquid stools per day ago.

He Goes to the emergency room several times where he was diagnosed with hemorrhoids syndrome  continuously with no evidence of hemorrhoids thrombosed and not relieved after multiple treatments prescribed.


Affected by pain.

DRE with hypertonic sphincter. Ischiorectal red zone at 3 in the lithotomy position. No cracks or fistulas. Palpation endo-rectal mass, well defined, warm, fluctuating in the left posterior perianal area.

Complementary tests

Blood tests: highlights leukocytes: 14700 with neutrophilia and lymphopenia, thromboplastin time: 22%. INR: 3.2. Creatinine: 1,29. Remaining unchanged.

X-Ray: unchanged.

Pelvic CT: abscess with accumulation of purulent content of 4.7 x 1.5 cm and increasing your wall, located in the left and posterior perianal region affecting Ischiorectal left fossa and partially the ipsilateral levator ani muscle.

Diagnosis: anal abscess


It is discussed in General Surgery for evaluation and transfer is done at the university Regional Referral Hospital, for performing abdomino-pelvic CT scan which shows an anal abscess and testing for elective surgery is decided. We proceed to general ward with antibiotics and analgesia until the date decided.

During surgery, extraction is performed and emptying anal abscess without incident.

María Del Pino SALINAS MARTÍN, María Eugenia REYES GARCÍA (Málaga, Spain), Iván VILLAR MENA
11:00 - 18:00 #7824 - Analgesic treatment of ST-segment elevation myocardial infarction (STEMI). Characterization and outcomes of affected patients.
Analgesic treatment of ST-segment elevation myocardial infarction (STEMI). Characterization and outcomes of affected patients.

Introduction : analgesic treatment in coronary patients is recommended. Almost half the time, Morphine is used in almost half of the cases. Some recent interactions (ATLANTIC study) lead to raising questions about this practice.

Objectives : compare STEMI patients receiving  analgesic treatment to those who don’t.

Methods : Inclusion : data analyse of a regional registry including  all STEMI patients from 2004 to 2015. Secondary transfers were excluded from the analysis. Inclusion criteria: characterization, delay) for treatment, treatment and outcomes. Adjusted Odds Ratio (95% confidence interval, significant if p<0.05).

Results : 14892 patients have been analyzed. Factors associated with analgesic treatment administration were: male versus female gender, (0.81 [0.73-0.90] ; p < 0.0001), delay between chest pain and first medical care less or equal to 60 minutes (1.61 [1.46-1.78] ; p < 0.0001), high blood pressure (1.11 [1.01;1.22] ; p=0.037), dyslipidaemia  (1.13 [1.02-1.24] ; p = 0.0159).

Conclusion : patient receiving  analgesic showed different outcomes from the others. This should be taken into account in the interactions morphine / platelets aggregation inhibitor management.

Gilles LENOIR, Clément DERKENNE, Alexandre ALLONNEAU (Paris), Thévy BOCHE, Aurélie LOYEAU, François-Xavier LABORNE, François DUPAS, Mireille MAPOUATA, Yann-Laurent VIOLIN, Sophie BATAILLE, Frédéric LAPOSTOLLE
11:00 - 18:00 #5845 - Analysis correlation between different scales of severity assessment in acute pancreatitis: study in emergency department.
Analysis correlation between different scales of severity assessment in acute pancreatitis: study in emergency department.

Introduction: Acute pancreatitis is a disease characterized by severe form in 20% of cases, presenting a high mortality which is vital to predict its severity. At present there are different clinical and biochemical severity scales as Ranson, Apache II, Marshall and Bisap, which carry discrepancies when being compared to tomographic scales like Balthazar.

Objetive: Description of degree severity in acute pancreatitis according to Ranson, Apache II, Marshall and Bisap scales applied in patients at the moment of admission and correlate these outcomes with the results by Balthazar scale.

Methodology:Descriptive, observational and retrospective study. Population study were all patients admitted to the emergency department with acute pancreatitis between July to December 2014. The diagnosis of acute pancreatitis was established with the following criteria: severe abdominal pain and elevated amylase and/ or lipase more than three times the upper limit of normal. Patients who were not performed abdominal CT scan within 72 hours of onset of symptoms were excluded. A correlation between clinical scales (Ranson, Apache II, Marshall and Bisap) and Balthazar scale was performed based on the Pearson Correlation coefficient. Sensitivity, specificity, positive and negative predictive value of each clinical scales were calculated with respect Balthazar scale. The predictive capacity of every scale was measured by the area under the receiver-operating curve (AUC). Data were analyzed by SPSS v.10.

Results:The study included 90 patients with a mean age of 62,5 years (SD 17.5 years). 46,7% were women. The alcohol induced pancreatitis ocurred in 95 % of men and a only case in women. Most patients were hospitalized an average of 11 days (SD 6,029). The Ranson scale classified as severe 37,7% of patients compared to the Apache II scale that rises to 72,2%. Marshall and Bisap  scales classified to the patients similarly as mild approximately 80% and 20% severe. Balthazar classified as severe acute pancreatitis almost 70% of cases.  BISAP is the scale with the best Area Under the Curve (AUC) (0,609). BISAP presented the best Pearson´s corrrelation with respect Balthazar: 0,244 (p=0,010).

Conclusions: Acute pancreatitis is distributed equally in both sexes; alcoholic etiology is clearly more common in men. Ranson scale applied only one time to the admission of patients is not valid as predicted scale. Acute pancreatitis may have pancreatic and extrapancreatic complications so the scale of Balthazar CT should not be used as a benchmark, but as a complementary tool in risk stratification and prognosis of acute pancreatitis. Bisap is postulated as the most appropriate scale in our study showing high specificity and good Pearson´s correlation with Balthazar scale.

11:00 - 18:00 #7914 - Analysis of destination of patients presenting with acute heart failure in our emergency department after being cared.
Analysis of destination of patients presenting with acute heart failure in our emergency department after being cared.

Acute heart failure is a common reason for consultation in the emergency department (ED), and the leading cause of hospitalization in the elderly. With high mortality and reconsultations involving a large increase in health spending.

Objective: To assess the need for hospital admission depending on the type of heart failure assessed by echocardiography and destination at discharge from the emergency department.

Material and methods:
Prospective observational study without intervention in patients who come to our ED for acute heart failure (AHF) according to Framingham criteria in the period 2012-2014 choosing two randomized months per year. Inclusion criteria: age 18 years with ICA and give their written consent. The study variables were: Destination income (Cardiology, Internal Medicine, Short Stay Unit, other services and high direct from the Emergency Department Observation), type of heart failure (systolic, diastolic, mixed and unknown)

During the 2012-2014 selected 119 patients consulted by ICA of whom 57 were women (47.9%) and 62 men (52.1%). 31 patients (26%) had systolic heart failure, 10 patients (8.4%) diastolic, 53 patients (43%) mixed and not the kind of dysfunction was known in 26 patients (21.84%)
24 patients were discharged directly from the emergency department (20.19%) and 94 patients admitted to our hospital (79%) of which 24 had systolic HF (25.53%), 10 diastolic (8.5% ), 37 mixed (39.36%) and 23 unknown (24.45%).
77% of systolic dysfunction (24 patients) were admitted, 100% of the diastolic, 71% of mixed (37 patients) and 88.4% of type unknown origin (23 patients).
By Services: 17 patients were admitted to cardiology (14.2%), in Internal Medicine 61 patients (51.2%) in Short Stay Unit 13 patients (10,92) and other services 4 patients (3.36 %)


- 100% of diastolic heart failure were admitted to hospital
- More than 55% were admitted to Internal Medicine while only 14.2% were admitted in Cardiology
- Up to 20% of patients who come to our Service are discharged directly, without requiring hospital admission.

11:00 - 18:00 #6279 - Analysis of Patient with Burn.
Analysis of Patient with Burn.

Burn  has  been  an  important cause  of  trauma  trough human history.  Most  of  the

burn causes can be prevented by informing people and simple precautions but there is no

decline in the number of burn cases with tecnological advancements. Treatment  of burn

trauma is a long and costly process.  All around the world there are many researchs done

about burn treatment but there are limited researches about the cost of burn treatment. The

decrease in life quality after burn trauma effects patients’psychological health and financial

status. It has been shown because of these reasons, not only major burn trauma patients but

also simple burn patients should receive high quality healthcare service and this service

should be given by experienced helthcare providers. Because of this reason all the patients

that has come to emergency department with burn should be treated efficiently and with

low costs.

All admitted we aimed to analyze  age, gender, admittance   time, type  of  burn,

clinical prognosis, mortality, and percentage of burnsite, and total cost of treatment of the

patients presented with burn injury to the emergency department.

According to this purpose we have acquired the data of 264 patients who have been

admitted to Baskent University Emergency Department with burn injury between 2012 to

2014. We analysed age, gender,  time, months and year of admitance, causes of burn,

whether it is work related or not, self induced or not, if the treatment consists surgery or

admittance for follow up, burnsite, thickness of burn and the total cost of treatment. The

data has been collected from hospital patient registiration system.

In conclusion, it is shown that patients’condition, gender, admittance year, surgery,

burn cause, age does not effect cost of the treatment. On the other hand the main factors

that changes the cost are degree of burn and burn site.

Tolga ESER, Cemil KAVALCI (Ankara, Turkey), Afsin KAYIPMAZ
11:00 - 18:00 #8256 - Analysis of patients admitted to our hospital with pet bite wounds.
Analysis of patients admitted to our hospital with pet bite wounds.


Pet bite wounds, specially dogs, it isan important pathology in medical emergencies and sometimes can be very serious. The aim of this study is a quantitative and qualitative analysis in our hospital to assess the quality of care of these processes.


This paper presents a descriptive retrospective study of severe bite wounds by pets admitted in the Virgen del Rocío University Hospital during the years 2012-2015. The variables analized were: type of pet, age, sex, diagnosis, instituted treatment of patiens analyzed, hospitalization time, and final destination of the patients. Statistical programs inferences using chi-squared


Patients with animal bite wounds: 71; among them were men: 56 (/)%) and women 15 (21%) with minmun age of 0y and a maximun of 82y

In 2015 there were 33 patients admitted with dog bite wounds; among them there were women 5 (15%)

In 2014 were 15 and they were 4 women (27%)

In 2013 there were 9 patients, among them 4 women (44%

In 2012 there were 13 patients and 2 of then were women (15%). The diagnostics obtaines were cranial an facial fracture: 7 (10%), fractures in extremities 8 (11%), head injuries 6 (8%), wounds on limbs an trunk 34 (48%), eyebal injuries 1 (1,4%), finger amputation 1 (1,4%, liver trauma: 3 (4%), pulmonary trauma 2 (3%), septic shock 3 (4%) an exitus 0 (0%). The hospitalization time had a minimun of 1 day an a maximun of 60 days; with an average of 6 days. Surgical treatment was performed in the 100% of cases. In 2013 ungent interventions were 11 (85%) an scheduled 2 (15%). In 2013 urgent interventions in 7 (78%) an scheduled 2 (2%. Urgent interventios in 2014: 13 (87%) an scheduled 2 (13%). In 2015 urgen interventions: 22 (67%) and scheduled: 11 (33%). complications during admission: 7 (10%)


1)More than half of patients admitted to the Hospital with dog bite injuries were male (56%)

2)All patients admitted to the hospital required surgical treatment.

3)A high percentege of pa

4) 21% of bite wounds were associated with fracture.

5) 7% of the patients had serious injuries that couls jeopardize their life.

Pilar CONDE (SEVILLA, Spain), Jesus MORENO, Pilar MORENO, Alberto MORENO, Raul NEVADO
11:00 - 18:00 #7595 - Analysis of Prehospital Emergency Medical Service missions in Croatia for 2015.
Analysis of Prehospital Emergency Medical Service missions in Croatia for 2015.

At the end of 2012 new organisation model for Prehospital Emergency Medical care(PEMC) in Croatia has been finished. Instead of four models which existed by then, one unique model has been established for whole country. Today, PEMC is being provided by County Institutes of Emergency Medicine (21 in total) whish consists of two types of medical field providers (medical doctor units and medical technician units). Likewise, the Institutes employ medical dispatch units staffed with medical techniciansor, in case of four largest counties, medical technicians and physicians. Location of field teams and their distribution is defined by Emergency Medicine Network, as well as location of medical dispatch centers in each county (Official Gazette 71/2012). According to Emergency Medicine Network, currently there are 595 physicians teams on 99 locations and 229 medical technicians teams on 49 locations. On 44 locations PEMC is being provided by general practitioner on duty and on 22 locations by general practitioners on call.

In 2015 Prehospital Emergency Medical Service took care for 1.363.970 patients. Out of total number of interventions, 853.212 (40.14%) were field missions and 510.758 (59.86%) were walk in patients which have been examined in resuscitation rooms on team locations. Out of total inmterventions, 97.225 (11.40%) patients were prioritized as priority A (most urgent), 299.557 (35.11%) as priority H (urgent) and 456.430 (53.50%) as priority V (no need for PEMC). Out of total of 456.430 interventions dealing with priority V, 78.522 (17.20%) were field missions and 377.908 (82.80%) were walk in patients.

Since Emergency Medicine Network is designed to cover field missions and there are no teams designated to provide stationary medical care in County Institutes of Emergency Medicine for walk in patients, large number of non-urgent patients that utilize EMS can in future jeopardize EMS team response time and delay help for emergency medical patients.

11:00 - 18:00 #7182 - Analysis of Spontaneous Volunteer Response to 2013 Sudan Floods: Changing the Paradigm.
Analysis of Spontaneous Volunteer Response to 2013 Sudan Floods: Changing the Paradigm.

Study Objectives:
The role of spontaneous volunteers during the initial response to disasters remains controversial. In an attempt to resolve some of the debate, investigators examined the activities of a spontaneous volunteer group called Nafeer after the Sudan floods around the city of Khartoum in August of 2013.
This retrospective descriptive case-study involved: 1) interviews with Nafeer members that participated in the disaster response to the Khartoum floods; 2) examination of documents generated during the event; and 3) subsequent benchmarking of their efforts with the Sphere Handbook. Interviews were held with volunteers who held top administrative positions within Nafeer as well as individual members. Members who agreed to participate were requested to provide all documents in their possession relating to Nafeer. The response by Nafeer was then benchmarked to the Sphere Handbook’s six core standards, as well as the eleven minimum standards in essential health services.
A total of 11 individuals were interviewed (6 from leadership, and 5 from active members). Nafeer's activities included: food provision; delivery of basic healthcare; environmental sanitation campaigns; efforts to raise awareness; and construction and strengthening of flood barricades (Table). Its use of electronic platforms and social media to collect data and coordinate the organization’s response proved highly effective. Members of Nafeer came from diverse backgrounds, including employees of corporations and NGOs, medical practitioners, nurses, pharmacists, and university students. Nafeer adopted a flat-management structure, dividing itself into 14 committees. A coordination committee was in charge of liaising between all committees. The Health and Sanitation committee supervised 2 health days which included mobile medical and dentistry clinics supported by a mobile laboratory and pharmacy. A total of 613 patients were seen. The engineering committee managed to construct and maintain flood barricades. Nafeer used crowd-sourcing to fund its activities, receiving donations locally and internationally using supporters outside Sudan. It also received in-kind donations. Nafeer's total budget was $328,097 US; of which 12% was spent on administration. Nafeer completely or partially fulfilled all 6 core Sphere standards but none of the essential health services standards. Nafeer did not set specific objectives for itself based on which data elements would be identified and subsequently measured. Even though the Sphere Handbook was chosen as the best available gold standard to benchmark Nafeer’s efforts, it showed significant limitations in effectively measuring such groups. A specific template does not currently exist to evaluate community-led initiatives in disasters.
It appears that independent spontaneous volunteer initiatives like Nafeer potentially can play a significant role in the humanitarian response. Such organizations should be the subject of increased research activity. Relevant bodies should consider issuing separate guidelines supporting spontaneous volunteer organizations.

Acknowledgment: Dr. Albahari’s only financial conflict of interest is his donation of $100 to the Nafeer organization. Dr. Schultz reports no conflict of interest.

Amin ALBAHARI (Galway, Ireland), Carl SCHULTZ
11:00 - 18:00 #7719 - Analysis of the 12-Year Search and Rescue and Medical Evacuation Activities of Turkey Main Search and Rescue Coordination Centre.
Analysis of the 12-Year Search and Rescue and Medical Evacuation Activities of Turkey Main Search and Rescue Coordination Centre.

Introduction and Purpose

Turkey is a peninsula surrounded on three sides by the seas and that has Dardanelle and Bosporus, which have a strategic importance on the world. In this respect, Turkey is in the transit country position in marine transportation and marine trade. Therefore, she is a risky country for marine accidents. In order to efficiently, fast and actively intervene in marine accidents, national and international coordination are vital. This complementary study was made for determining the features of marine accident/incident and medical evacuations that were coordinated by Main Search and Rescue Coordination Centre between the years 2001 and 2012.

Material and Method

 This research is a descriptive epidemiological study. The population of study includes Main Search and Rescue Coordination Centre’s all accident/incident and medical evacuation reports between the dates 01.01.2001 and 31.12.2012. In this research, 1796 forms have been examined. The data in the registration forms have been input into a data base that was created in SPSS 15.0 programme and these data are evaluated statistically. In statistical evaluation, Frequency Distribution, Univariate and Bivariate Poisson Regression and non-metric Multidimensional Scaling Analysis are used. In frequency analysis, variables such as accident year, accident month, accident types, accident causes, accident area; the numbers of patients, people who were injured, dead, missing and evacuated, presence of environmental pollution and the units that joined the rescue operation have been examined. The research was performed between October 2012 and March 2014.


In inspected reports as part of the research, 2010 has the highest percentage of cases on year basis with an incidence ratio of 12.7% (228 accident/incident/medical evacuation), autumn is the first in distribution among the seasons with 22.7% (497 accident/incident/medical evacuation), between the hours 12:00 and 17:59 has the highest percentage according to occurrence hours with 30.0% (538 accident/incident/medical evacuation), Istanbul region is the region where the most accident happens with a ratio of 44,3% (795 accident/incident/medical evacuation). 58.7% of the cases (1054 accident/incident/medical evacuation) were responded by Coast Guard Command. Inspected reports as part of research between the years 2001 and 2012, total number of people  injured is 150, the number of people saved is 6042, total loss of life is 311, missing persons is 202 and the number of patients is 73. It has been stated in the reports inspected as part of research that the number of the people affected in marine accident/incident and medical evacuations in 12 years is 6778. 70,6% (n=48 hospital) of the patients and  the injured were taken to public hospitals. The number of accident/incident that caused injuries is significantly more in the international area in comparison with Istanbul (8.5 times more, 95% confidence limits 4.5-15.8).


In this research, it has been found that overturning, fire and explosion are the most seen types of accidents, comparing to others. Fire and explosion risks, in the tankers that carry petrol, gas and chemicals should be considered both for the people in the ship and the people near the ship must be considered.

Hüseyin KOÇAK (Çanakkale, Turkey), Kerim Hakan ALTINTAŞ
11:00 - 18:00 #8184 - Analysis of the pain assessment practice by the medical team of Jeanne de Navarre Hospital Center.
Analysis of the pain assessment practice by the medical team of Jeanne de Navarre Hospital Center.

Title: Analysis of the pain assessment practice by the medical team of Jeanne de Navarre Hospital Center

Authors: Boukhalfa.I, Ouedraogo.L, Kodzin.MJ, Fiani.N

Hospital Center Jeanne de Navarre, Château-Thierry, France


The proper management of patients' pain requires an efficient assessment. Mastering this practice by the medical team, based on protocols using validated and adapted rating scales, is the only guarantee.

Participants and Methods

To analyze the practice of pain assessment by the medical staff at the Jeanne De Navarre Hospital Center of Chateau-Thierry, we conducted a prospective and a cross-sectional study using a self-administered questionnaire to all of the staff members during the month of March 2016. The results were analyzed using Microsoft Excel software.


We collected 149 questionnaires: 47% nurses, 26% care-assistants, 20% doctors and 5% obstetric nurses. 60% were aged between 30 and 50 years and 42% were under 10 years of experience. 80% took courses on the pain management and only half was entitled to ongoing training. 87% said they know about the different analgesic medicines for pain and 40% ranked them according to OMS levels and yet 15% have confused the auto and straight assessment scales. Despite the presence of a protocol in each service, 82% were aware and only 70% applied it. The VAS (visual analog scale for pain) was the most used scale in adults and children and ALGOPLUS for the elderly. 54% assessed the pain in less than one minute and 30% couldn’t do anything for against pain without prescription. 65% of physicians do early prescription for the pain treatment. 38% of staff recognized the difficulty of pain assessment especially in demented and non-communicative patients. In total 67% consider the pain assessment  as good.


Although the majority of the staff in our hospital adheres to the pain management protocols, some of them remain not aware of this practice. It is essential to ensure continuous training and organizing awareness days to improve the current situation.


Imene BOUKHALFA (Bizerte, Tunisia), Louis OUEDRAOGO
11:00 - 18:00 #7371 - Analysis on the regulating activity of psychiatric files. Do they last so long?
Analysis on the regulating activity of psychiatric files. Do they last so long?


At the EMS call centre, management of phone calls for psychological or psychiatric distress seems often complex and tend to monopolise a lot of the resources of the regulating team regulation team. We present here the results of our analysis of this activity.

Material and method

Retrospective analysis of the files entered in the call centre from 2011 to 2014. Selection of files related to psychiatric cases such as psychoses, neurosis, addiction, intoxication... comparative analysis to other cases. taking into account their evolution during this time period using as criteria: number of files, their regulating duration (i.e. period of time between the start and the end of a call), identification of the physician regulator and decision Comparison via Chi-2 tests for the qualitative variables and with mean of Wicoxon[CDa1] 's tests for the regulating duration.


On 671.421 files (167.855 files per year), 4,8% were identified as a psychiatric distress. Their annual number has increased by 50% between 2011 and 2014, while the global activity did increase by only 7%. The median duration of the regulation was 50 min for psychiatric files against 34 min for the other files (p<0,0001). This median duration [CDa2] of regulation had constantly decreased while it had been relatively stable for the non-psychiatric files (respectively between 55 and 35 min in 2011, 47 and 34 min in 2014). In 2011, 0,3% of the psychiatric files did not have any identified regulator physician against 10% in 2014 (p<0,0001). In 2014, while 26% of the studied cases (25% for the non-psychiatric) ended in a simple advice to the callers, 63% of them were taken to hospital (52% for the non psychiatric p<0,0001).

Discussion and conclusion

Calls to the EMS call centre for psychiatric distress had clearly increased during the the past few years, requesting a new distribution of this workload among the different actors of regulation. Those call cases generated a meaningful time of regulation, even if the trend was decreasing. Some improvements could come through actions such as organising the call flow, training the teams, establishing networks, writing procedures, switching to others operators (psychologist, nurse...), which all may reduce the impact of this activity on the EMS call centre.

Roger KADJI (Corbeil-Essonnes), Stephanie POLINI, Jean-Pierre ROSSI, Anne Sophie FURET-PIGNON, David SAPIR, Jean Christophe ROBART, Aurelia ROCHEDREUX, Francois-Xavier LABORNE
11:00 - 18:00 #7391 - Anemia expression of upper gastrointestinal hemorrhage.
Anemia expression of upper gastrointestinal hemorrhage.

Anemia expression of upper gastrointestinal hemorrhage


Virgiliu Cezar Bologa (1) ; Denisa Elena Vintila(1) ; Ramona Ganea(1); Francesca Iulia Paius(1);

1. Emergency Department, UPU-SMURD Sibiu, Sibiu, Romania


Keywords:  anemia, gastrointestinal bleeding, ulcer, esophageal varices  

Speaker : Denisa Elena Vintila



The upper gastrointestinal bleeding is 5 times more frequent compared to the lower one.  UGIB has a prevalence of approximately 170 cases per 100.000 inhabitants per year!!!

The present study aims to evaluate the incidence and etiology of the upper gastrointestinal bleeding at the patients who arrived at the Emergency Department of Sibiu County Clinical Emergency Hospital as well as their hospitalization according to the hospital’s departments.



The study was performed through a retrospective observational method on a number of 190268 cases emerged in the Emergency Department of Sibiu County Clinical Emergency Hospital between 01.01.2013 – 31.12.2015, out of which 848 were diagnosed with UGIB.



Out of the total number of cases registered at the Emergency Department of SMURD Sibiu between 01.01.2013 – 31.12.2015, 848 were UGIB, which represents 0.4 %.

The distribution of the 848 cases of UGIB emerged at the Emergency Department of SMURD Sibiu for the studied period was as follows: 316 (37.26%) in 2013, 276 (32.54%) in 2014, 256 (30.18%) in 2015.

Out of the total number of UGIB cases, 141 (16.62%) were cases where patients have associated severe anemia, and 707 (83.37%) were cases where patients have shown mild and moderate anemia.

According to the etiology of UGIB, the following values were registered: 28 (3.30%) cases of esophageal varices, 67 (7.9%) cases of gastric and esophageal neoplasms, 753 (88.79%) cases of gastric and duodenal ulcer.

The distribution of hospitalizations of patients with UGIB according to the hospital’s departments was the following: Gastroenterology - 80.42%; Surgery - 2.12%; Medical - 7.42%; Oncology - 0.4%; refused hospitalization - 9.43%.



Between 2013 – 2015 the percent of patients diagnosed with UGIB, hospitalized at the Emergency Department, decreased: 2013 -37.26%, 2014 –32.54%, 2015 –30.18%.

Out of the total number of UGIB cases, 141 (16.62%) were cases where patients have associated severe anemia, and 707 (83.37%) were cases where patients have shown mild and moderate anemia.

The majority of UGIB cases were caused by ulcer: 753 (88.79%) registered cases, the rest being represented by gastric and esophageal neoplasms (7.9%) and bleeding esophageal varices (3.30%).

Out of a total number of 848 patients diagnosed with UGIB, the hospitalization according to the hospital’s departments was as follows:  Gastroenterology - 80.42%; Surgery - 2.12%; Medical - 7.42%; Oncology - 0.4%; Discharged - 9.43%.


Ramona GANEA, Virgiliu Cezar BOLOGA, Denisa Elena VINTILA (Sibiu, Romania), Dr Francesca Iulia PAIUS


Angioedema (AE) is a vasodilatation phenomenon associated to edema in deep dermis and subcutaneous tissue, without well defined contours, painless and elastically, that can be observed  in any area of the body.


We presented a  case of an 75-year-old men with no history of allergies, arterial hypertension and paraplegic due to a spinal cord injury in a traffic accident and secondary neuropathic pain. Usual treatment is omeprazol 40mg/24 hours, lactulosa 5ml/8 hours, acetyl salicylic acid 100mg/24 hours, pregabalin 150 mg/12 hours, enalapril 10 mg/24 hours and metamizol 575mg/8 hours.

She consulted in the emergency department for facial erythema and edema of the tongue from her awakening without dysfagia, difficulty in breathing, rash or pruritus. On physical examination she showed erythema and edema of the tongue without injuries in neither her thorax, nor her limbs. Her blood analyses findings were impaired serum creatinine (2 mg/dL).

We suspected AG secondary to enalapril, which was suspended, and methylprednisolone plus dexchlorpheniramine therapy was initiated. Clinical improvement was clear after 6 hours. Subsequently Icatibant was administered with clinical improvement by  4 a.m.


Angiotensing Converting Enzyme Inhibitor (ACEI) is the treatment of choice for arterial hypertension, heart failure and diabetic nephropathy with proteinuria. Dizziness, cough, migraine, hypotension and renal failure are the most frequent side effects. Angioedema Secondary to ACEI appears in 0,2 % of the treated individuals. A progressive incidence is estimated because of new therapeutic indications. AE should not be related with neither the administration nor the dose.


AG may vary from facial and tongue edema as well as in the supralotic area, worse conditions than other presentations, such as hands, feet and visceral edema.

Bradikinine is the nonapeptid and proinflamatory vasodilator in the physiopathologycal mechanism. Nevertheless, in AG secondary  to ACEI an allergic reaction should not be considered and in some cases it can be refractory to the treatment with antihistaminics and steroids, being necessary the introduction of new therapies in the emergency department.

11:00 - 18:00 #8080 - Angioedema. Nasal vestibulitis.
Angioedema. Nasal vestibulitis.


Male 69 years referred pain in the right nasal vestibule 24hours evolution with declines during the last hours, spread to appreciate holofacial eyelids edema and fever up 39'5ºC and shivering.

From the previous days it presents box progressive facial swelling. The family reports that in the previous days food material by nostrils, with further manipulation by the patient, presenting from the last 24 hours swelling, redness, and blisters fluctuation around the facial bones, with pain on palapción

AP: severe COPD. Iª chronic renal. Permanent AF anticoagulated with rivaroxaban. Lung carcinoma with liver metastases in trataminto with palliative chemotherapy.

Physical exploration:

Purulent nasal area in both halls, columella and upper lip philtrum.

Facial swelling from chin to glabela associated with redness, heat and intense tenderness. Lobby with purulent nasal discharge erythematosus. Great bilateral palpebral edema preventing eye opening.



Blood tests: Blood count: Leukocyte 35100, neutrophilia 92%. Hb 7'9, Platelets 293000. Coagulation: PT activity 78.6%. Venous blood gases: pH 7.11. Biochemistry: glucose 379, urea 52, creatinine 1.74, normal ions, PCR 245, Procalcitonin 6.71.

TAC skull and sinuses: mucosal thickening of both maxillary sinuses with partial occupation of the left and anterior ethmoid cells for soft tissue density material, as well as thickening of the mucosal lining of the left maxillary sinus. Significant increase in thickness and density of soft tissue to diffuse facial level, which could be related to inflammatory-infectious process. focal bone defect with cortical thinning and front right supraorbital level.

Final diagnosis:

Facial cellulitis in immunocompromised patient


Admission is decided in observation area given the severe sepsis box of origin in skin and soft tissue facial and cervical region, starting treatment with ceftriaxone, cloxacillin and methylprednisolone.

Given the proper evolution during the first 24 hours admission is decided in charge of Internal Medicine discarded surgical approach given the palliative stage of his previous illness.

After almost a month of hospitalization, and after adding to valaciclovir intravenous treatment is decided discharged home after progressive improvement of the infection with facial and cervical recovery.




However minimal possible entry must take special precautions in cancer patients being immunocompromised and complications that might entail.

Juan Antonio RIVERO, Enrique CARO (MALAGA, Spain), Daniel FERNANDEZ VARGAS, Eduardo ROSELL, Pedro ARRIBAS, Francisco TEMBOURY
11:00 - 18:00 #7270 - Anisakis, an unusual cause of anaphylaxis.
Anisakis, an unusual cause of anaphylaxis.

CASE REPORT: A 48-years-old man with any antecedent of interest, presented to the Emergency Department (ED) complaining an episode of 12 hours of evolution of a periumbilical and epigastric pain of moderate intensity without irradiation and associated with malaise. He did not refer fever. In the last hours, he presented as well skin lesions as an urticaria in armpit and abdomen. When the patient arrived to the ED, it highlights hypotension (85/40 mmHg), tachycardia (110 beats per minute), low oxygen saturation (90% baseline) and erythematous lesions in abdomen and armpits, not scaly and confluent. On abdominal examination, it highlights epigastrium pain, without sings of peristonism. With the initial suspicion of anaphylaxis, treatment was initiated with intramuscular adrenaline, antihistamine and corticosteroid and intensive intravenous fluid therapy. Clinical situation was stabilized disappearing itching and skin lesions but not abdominal pain. Analytical results were normal, except for the presence of mild eosinophilia. Due to the persistence of abdominal pain, ultrasound was performed demonstrating the presence of free liquid perisplenic and perihepatic fluid and no evidence of biliopancreatic or anyother alterations. The study was extended by abdominal Computed Tomography (CT), with evidenced thickening of gastrics folds suggesting gastric inflammatory process (Figure 1).

DIFFERENTIAL DIAGNOSIS: complicated hydatid cyst, episode of histaminergic intestinal angioedema, food-induced anaphylaxis, parasitic gastritis, eosinophilic gastritis.

EVOLUTION: Following the findings in abdominal CT, new oriented anamnesis was performed, and the patient recognized intake unfrozen fish (anchovies in vinegar) prior to the start of abdominal pain. Anisakiasis was suspected, and urgent gastroscopy was requested, watching live parasites in the gastric mucosa, predominantly in the body and fundus (Figure 2). Endoscopic removal of all parasites displayed was performed and the patient showed progressive improvement with final disappearance of pain.

FINAL DIAGNOSIS: Anisakis anaphylaxis

DISCUSSION: The Anisakis simplex, the main species causing human anisakiasis complex, has an extensive distribution. It is transmitted to humans by eating raw or undercooked fish. In Spain, the main responsible fish are fresh anchovies, but they have also involved other species: hake, sardines, cod ... Anisakiasis is an underdiagnosis disease in our area, so its actual prevalence is probably higher than documented in the literature. It is produced by the local action of the parasite on the stomach, after a latency period of 24-48 hours from the ingestion of parasitized fish. The most common forms of presentation are gastric, intestinal and gastro-allergic. In the stomach, the parasite attaches to the mucosa, producing local irritation that cause intense epigastric pain, nausea, vomiting and fever within a few hours after that ingestion. It may be accompanied by skin rash. The diagnosis of this parasitosis can be difficult, especially if the history of intake of raw or undercooked fish is not taken into account. The analytical and radiological findings are very unspecific. Endoscopy is diagnostic and therapeutic because it allows the extraction of the parasite and the consequent improvement of symptoms.

11:00 - 18:00 #7170 - Another causes of acute coronary syndrome: Kounis Syndrome.
Another causes of acute coronary syndrome: Kounis Syndrome.

Clinic history:

 63 years old woman with hypertension and osteoporosis that after eating a chocolate begins with erythema and itching in upper extremities and oppresive chest pain accompanied by sweating. On physical examination, the patient has blood pressure 174/98, heart rate 85 and temperature 36º; erythema and wheals on trunk and upper extremities, lip edema. The blood count and biochemestry have no notable changes. In the initial electrocardiograma ST is decreased in V4, V6 and II. After treatment with nitroglycerine and antihistamines drugs, improves the pain and the ECG changes. At 12 hours the patient begins again with chest pain and LBBB in ECG then activating the myocardial code. Catheterism is performed without coronary lesions objectified. The pain improves again after administrataion NTG, metilprednisolone and antihistamines drugs. At no time myocardial enzymes rise.


The association between coronary events and allergic reactions  are recognized for years. The first case was described in 1950 after allergic reaction to penicillin. In 1991 Kounis and Zayras describe Kounis syndrome establishing two types: Type I , patients with cardiovascular risk factors and coronary spasm with normal coronary arteries . Type II, with atherosclerotic plaques in the coronary arteries that are broken during the allergic reaction.

In coclusion an allergic reaction can lead to cardiovascular events ACS on arteries with or without angiographic lesions being the pathogenic mechanism vasospasm produced by mediators delivered in anaphylaxis as histamine and leukotrienes that act as a potent vasoconstrictor. Facilating factors are the presence of cardiovascular risk factors and the existence of atherosclerostic plaques. 

11:00 - 18:00 #7946 - Another Life Saved. Integrated use of Ultrasound In pulse pause of Adult life support.
Another Life Saved. Integrated use of Ultrasound In pulse pause of Adult life support.

Diagnosing and treating a cause of cardiac arrest has been challenging for Emergency physicians for years since clinical signs of most reversible causes (4H and 4T) are either absent or difficult to interpret in noisy Resus and often due to continuous chest compressions . Use of integrated Ultrasound has helped Emergency Physicians to solve this clinical dilemma.

We are reporting an unusual case of cardiac tamponade and pleural effusion in a 77years old female who was diagnosed and drained during PEA cardiac arrest in our resusitation /emergency department. Integrated Ultrasonographic approach was used to get  satisfactory images and to insert drains during pulse pause of Adult life support.Successful drainage of 200mls of pericardial fluid and 1500mls of pleural fluid lead to return of spontaneous circulation(ROSC). Patient was sucessfully resusitated and stabilised and transferred to intensive care unit for furthur management. She was consecutively discharged after 18days of hospital admission. However on furthur imaging it was revelaed that she had Adenocarcinoma of the lung which was the primary cause of her disease process.

Our case report highlights the importance of training and skills required by Emergency Physicians to perform Integrated Ultrasound during Life support scenarios which aid us in diagnostic management of patients. We demonstrate that acquiring such skills are life saving.

Asif MUSHTAQ, Akhtar MUNAZAH (Redhill, United Kingdom), Julian WEBB
11:00 - 18:00 #7072 - Antibioprophylaxis in nonsurgical facial trauma in the ED.
Antibioprophylaxis in nonsurgical facial trauma in the ED.


Facial fractures are a frequent cause of emergency department (ED) visit. The indication for surgery is rare. Antibiotic prophylaxis is frequently introduced in not requiring urgent surgery patients. Infectious complications of theses fractures are unusual. The indications and modalities of this antibioprophylaxis are not well codified in the literature and are based mostly on empirical habits. Any antibiotic provides bacterial resistance. We aim to determine what proportion of patients are treated with antibiotics in non-surgical trauma of the face. We also wanted to discuss the modalities of such an antibioprophylxis in our ED.


We conductes a single-center and retrospective study for 3 months (from June to August 2015) in the ED of an urban teaching hospital. All patients with 1 or 2 facial fractures without urgent surgical indication were included. The existence of antibiotic therapy and its modalities (molecule, dosage, duration) were sought. Patients with a fracture requiring urgent surgery, or with multiple fractures were not included.



105 patients were enrolled in this study for statistical analysis. Antibiotic treatment was introduced in 44 patients (41.9%, [CI: 32.6-51.4%]). The amoxicillin-clavulanic acid association was used in 43 cases (97.7%) with an average of 6.14 days of treatment (SD: 1.87 days).


Antibiotics are prescribed in nearly 40% of injuries in the non-surgical facial trauma whereas real indications are rare.  In the current climate of increasing bacterial resistance and concern, interest of antibiotic prophylaxis in nonsurgical trauma of the face should be discussed taking into account the risk of selecting resistant bacteria, or encourage late infection with resistant organisms. When antibiotic treatment indication was laid in prophylaxis, especially in fragile patients and in situations with increased risk of infectious complications, the use of amoxicillin-clavulanic acid combination is a possibility. However, the environmental consequences of its widespread use should be considered. Pristinamycin and clindamycin may constitute interesting alternatives in this non-surgical trauma situation. The duration of treatment should not exceed 48 to 72 hours.

Charles-Eric LAVOIGNET, Pierrick LE BORGNE (Strasbourg), Carmen HAMMANN, Céline RENFER, Sarah UGÉ, Philippe KAUFFMANN, Hakim SLIMANI, Pascal BILBAULT

Chronic obstructive pulmonary disease (COPD) is a lung disorder It characterized by the existence of an obstruction of the airways usually progressive and irreversible. The exacerbation of COPD (COPD exacerbations) is defined as a sustained worsening of respiratory symptoms, beyond its daily variation, and its most frequent infectious cause. The frail elderly or high risk is one that has a high probability of suffering an adverse process and therefore have higher morbidity and mortality. In them, strict control of COPD exacerbations is, if anything, more important.
Evaluate the use made of antibiotics in acute exacerbation of COPD exacerbations of infectious origin in patients over 75 years discharged from the emergency department.
descriptive, observational and retrospective study General Hospital Universitario Reina Sofia. 1172 patients diagnosed with COPD by spirometry who came to the emergency department of HGURS from January 2012 to June 2015 were included.
1172 patients of which 643 (57.67%) were older than 75 years were analyzed. 592 (92%) were discharged home with a diagnosis of respiratory infection. Of these, 151 (28.9%) were prescribed antibiotic from the Emergency Department.
529 (42.33%) patients were younger than 75 years, of which 495 (93.58%) were discharged from the emergency department with a diagnosis of respiratory infection. Of these, 157 (31%) were Standard antibiotic from the Emergency Department.
Patients over 75 are considered high risk when severe complications from infectious diseases, so that, if necessary, appropriate infection control is essential to prevent further complications. For prescribing antibiotics should stick to the criteria ruled by experts. In our case, we can see that the differences in prescribing in older or under 75 years are not significant so the fragility based on this almost age does not seem to be a criterion to be taken into account by EPs when antibiotic treatment prescribed at discharge from the Emergency Department.


Chronic obstructive pulmonary disease (COPD) is an irreversible, progressive disease characterized by chronic airflow obstruction. The use of antibiotics in exacerbations of COPD (COPD exacerbations) has precise indications reflected in the latest Clinical Practice Guidelines, although there is controversy.

Analyze the antibiotic treatment at discharge from the Emergency Department patients with COPD exacerbations and the relationship between antibiotic prescribing and the severity level.

Material and methods
observational, retrospective study conducted at the University General Hospital Reina Sofía. patients diagnosed with COPD were included by spirometry for COPD exacerbations attended between January 2012 and July-2015. antibiotic treatment prescribed at discharge and its relation to gravity Stadium was analyzed according GOLD (FEV> 80% mild, moderate 50-80%, 30-50% severe and <30% very severe).

1029 patients with COPD exacerbations value. They received antibiotic treatment 35% of patients with FEV> 80% (20 patients), 33.8% with FEV 50-80% (290 patients), 31.2% with FEV 30-50% (446 patients) and 23.4% with FEV <30% (273 patients). 9.6% was discharged with amoxicillin clavulanate, Moxifloxacin 6.7%, 13.7% Levofloxacin, Ciprofloxacin 1.5%, 0.9% Cefditoren, Ceftriaxone 0.2%, 0.9% versus active Cephalosporin Pseudomonas and 3% with other antibiotics and the rest were discharged without antibiotic or were admitted.

The Levofloxacin was the most used antibiotic, amoxicillin clavulanate followed, corresponding largely as described in the Clinical Practice Guidelines.
In response to gravity, we note that in the case of patients with severe very severe stage (FEV <30%) and (FEV 30-50%) only treatment prescribed at discharge in 23.4% and 31.2% of cases respectively. This could be explained by the fact that most patients with advanced stage disease are admitted, being discharged only those with a stable clinical condition and, in principle, no criteria antibiotic therapy. It would be interesting to extend the study to assess these results.


Exacerbations of COPD (COPD exacerbations) represent today the main reason for consultation in the emergency of these patients. The use of antibiotics have precise indications but no longer in dispute.

Evaluate the use made of antibiotics in patients with COPD exacerbations of infectious origin according to the criteria Anthonisen.

Material and methods
Observational, retrospective study in a General Hospital with an area of 200,000 inhabitants and 275 urg / day. The medical records of patients with a previous diagnosis of COPD exacerbation had consulted January 2012 to July 2015 were reviewed.

A total of 1027 were included with COPD exacerbations. Of the 1027 patients studied 283 (27.6%) did not meet the criteria Anthonisen and 744 (72.4%) did the meet. Of those who did not present criteria Anthonisen 83 (29.3%) went with antibiotic therapy at discharge and 200 (70.3%) left without antibiotic therapy at discharge. Of the patients who were Anthonisen criteria were with antibiotic therapy at discharge 224 (30.1%) and 520 (69.9%) left without antibiotic therapy at discharge.

Over 70% of patients with COPD exacerbations presented criteria for the use of antibiotics. Our results reveal that the use of antibiotics in the Emergency Department is independent of the criteria Anthonisen because we use exceeds 30% of cases where it would be justified if their use.
It seems that if we better leave without antibiotic treatment to those who have no criteria where only prescribe antibiotics to 29% of patients.
These results should make us reflect on this aspect that is really improved in accordance with the recommendations.

11:00 - 18:00 #7466 - Anticoagulant-Induced Intramural Intestinal Hematoma: Report of two Cases.
Anticoagulant-Induced Intramural Intestinal Hematoma: Report of two Cases.

Introduction: Spontaneous intestinal hematoma is a rare and severe complication of anticoagulant therapy.

Cases: we reported two cases of intramural and submucosal small bowel hematoma resulting from warfarin administration. The first patient presented with abdominal pain, had intramural hematoma at jejunum, the most common site of intramural small bowel hematoma. Another patient who had submucosal duodenal hematoma presented with epigastric tenderness . Typical findings on abdominal computerized tomography yielded the diagnosis. All patients rapidly improved after conservative treatment.

Conclusion: The history of anticoagulant use with prolonged INR value in patients presented with abdominal pain should alert physicians to search for this entity. It is extremely important to recognize this syndrome in order to avoid an unnecessary operation since the outcome is usually excellent after conservative treatment

Mohamed Ali CHERIF, Asma BEN ALI, Farah RIAHI (Belfort), Mohamed MEZGHENI, Rim BEN KADDOUR, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7361 - Aortic dissection in the Emergency Department.
Aortic dissection in the Emergency Department.

Dissection of the aorta is a condition that usually occurs suddenly, and in most cases, arise from an incidental finding, during a secondary abdominal pain or acute chest assessment. This condition is not as common as other causes of chest pain, but it is essential to maintain a high index of suspicion based on adequate knowledge of this entity.

 The objective of this study is to describe the prevalence of this disease in our population and thus identify risk factors and demographic characteristics thereof with special interest in the timely diagnosis. Based on this we propose an algorithm of action in the ED. Methodology: Transversal, retrospective descriptive study on the epidemiological, clinical, with special attention to the presentation, diagnosis in the emergency department at our center.

 The importance of this study is to propose an early diagnosis for better patient outcomes. Within our sample, 77.77% of patients were male. The most common symptom that led to emergency room patients was chest pain by 100%. The initial clinical suspicion, after making history and examination was 11.1% for dissection prior to any diagnostic, in other cases another diagnosis was assumed, so the patients were admitted to hospital, diagnosed with "chest pain in study" in a 9.09%.

The 66.6% of patients were operated. The hospital mortality was 22.2%.

 The sudden onset of severe, retrosternal or interscapular chest pain, sometimes referred to as tear and subsequent progression downward or toward the back region would typically wait picture. 100% of the cases had chest pain related to the range described in the literature (14-55%).

The use of complementary diagnostic tests, differs markedly from a serious to others, explained by the availability depending on the center and experience in use, varying from one center to another and even from staff is on call in the emergency services .

 So an algorithm care is proposed to these patients from the perspective of the emergency department, integrating the most important data of clinical and suggesting the most simple and effective guidelines for care before chest pain suggestive of aortic dissection applicable to all emergency  services..

Cruz SALEME (Mexico, Mexico), Karla HERNANDEZ, Hector MONTIEL
11:00 - 18:00 #7889 - APHER: Analyzing Acute Pyelonephitis Handling in Emergency Hospitalary Room: observacional study.
APHER: Analyzing Acute Pyelonephitis Handling in Emergency Hospitalary Room: observacional study.

Acute pyelonephritis (APN) is a frecuent infection that mainly affects to sexually active healthy women. APN represents a 3% of the urological patients attended in the Emergency Hospitalry Room (EHR) wich prevalence is around 12% in women and decreases to 2-3 % in men. APN encompasses both renal parenchyma and collecting system and it presents with 3 key symptoms: fever, lowerback pain and voiding syndrome. However, a high amount of the APN are uncomplicated. It´s of a vital importance to know the patient epidemiological characteristics, reason for consultation and therapeutic management in order to achieve a quick and safe handling in HER.

Observacional descriptive study enrolled patients with APN diagnosis made in EHR during a 5 moths period. Medical histories, current complaints, labortory test results and prescribed hospitalary and ambulatory treatment were recorded to all patients, as well as final destination and analyzed with SPSSv17 stadistical programme.

43 patients were included with an average age of 38.4 ± 15.9 years, being 93 % women. The total incidence for APN was 1.7 ‰. No risk factors for developing APN were detected in most of the patients. The 86 % of the patients showed fever as the most prelavent symptom in association or not with renal fossa pain and sickness. More than the 90 % had urinary sediment altered, with a 74.4 % presenting leukocytosis and neutrophilia. A 53.3 % of the abdominal ultrasounds made were pathological. Urine culture, recorded in 35 patients, were positive in 30.2%, with Escherichia Coli as leader pathogenic agent and antibiogram sensivity test positive for nitrofurantoin and fosfomicyne. Empirical intraveous antibiotic therapy was performed with ceftriaxone in association with tobramicyne(67.1%) and discharged home with oral cefuroxime and cefditoren treatment. More than a half of the patients required hospital stay in Urology or Intensive Care Unit.

Discharge home from the EHR is therefore justified after an observation period less than 24h in which a first pal antibiotic dose is administered(ceftriaxone+tobramicyne) and an appropriate oral antibiotic is chosen. The patient should be warned about possibility of the persistence of some symptoms and referred for appropriate outpatient follow-up.

Virtually all the patients were women with no risk factors. E. Coli was the most common patohenic agent, with high rate of resistance, particularly to trimethoprim-sulfamethoxazole and ampicillin. Therefore we can afirm that our results are similar to other studies consulted

11:00 - 18:00 #7442 - Aplasia of the posterior arches of the atlas: a rare cause of acute neck pain in emergency departement.
Aplasia of the posterior arches of the atlas: a rare cause of acute neck pain in emergency departement.

Introduction: Cervical pains are a common reason for visit in emergency department. About 20% of the population had at least one episode of neck pain in her life [1-2]. The cause can be traumatic, postural, inflammatory, infectious, tumor or secondary to bone deformities. Agenesis of the posterior arch of the Atlas is a rare cause.

Observation: We have reported the case of a young woman, aged 25, basketball player who has consulted in the emergency for isolated neck pain, lasting for two days. On physical examination, the patient was  non-febrile , mobility was preserved and painful and there was no sensory-motor deficit. The rest of the examination was without abnormalities. Radiography of cervical spine showed agenesis of the posterior arch of C1. The patient benefited from a symptomatic treatment based on anti-inflammatory and analgesic drugs and she was sent to the orthopedic consultation to complete the exploration by an MRI of the cervical spine.

Conclusion: malformations of the cervical spine are a rare cause of neck pain. Their clinical expression may remain asymptomatic for a long time and their discovery is often fortuitous.

Dorsaf BELLASFAR, Mouna TITEY (tunis, Tunisia), Jihene AOUEM, Saloua HOUIMLI, Abdelmajid BEN ROMDHANE
11:00 - 18:00 #8179 - Apparent insect bite that ends in finger amputation.
Apparent insect bite that ends in finger amputation.

Introduction: A patient presented with a suspected insect bite ends up having his finger amputated. This case report include a brief review of the literature about necrotising soft tissue infections. Case report: A 47 years-old male, presented to the Emergency department with mild itching and pain on his left index finger.He initially denied any trauma but observed a erythematous patch on the dorsal aspect of the finger. Two hours after the ED consultation re represented hours after patient consulted by increasing of pain and required opiates to relieve the pain Upon arrival she showed mild erythema and Oedema only in the finger. Labs showed leucocytes at 22 000. He was treated as a cellulitis by possible insect bite and empirical antibiotic therapy was initiated. Few hours later he presented with lymphangitis in the arm and signs of necrosis in the finger. A venous Doppler ultrasound of left upper limb done and was normal. He underwent surgical debridement but developed necrosis and later ended up having amputation of the finger. Blood culture showed Streptoccocus pyogenes. Two weeks later patient report he remembers injury the finger with a rose thorn the day before initial presentation. Necrotising cellulitis presents with pain and swelling, the onset is gradual, but the process may spread rapidly with systemic toxicity. Early surgical exploration and debridement are required to prevent spread of infection in the different planes of tissues References: 1. Demain JG. Papular urticaria and things that bite in the night. Curr Allergy Asthma Rep 2003; 3:291. 2. Siljander T, Karppelin M, Vähäkuopus S, et al. Acute bacterial, nonnecrotizing cellulitis in Finland: microbiological findings. Clin Infect Dis 2008; 46:855. 3. Leppard BJ, Seal DV, Colman G, Hallas G. The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. Br J Dermatol 1985; 112:559. 4. Woo PC, Lum PN, Wong SS, et al. Cellulitis complicating lymphoedema. Eur J Clin Microbiol Infect Dis 2000; 19:294.

11:00 - 18:00 #7422 - Application of qSOFA score compared with Modified early warning signs for predicting 24-hours-in-hospital cardiac arrest : A retrospective review.
Application of qSOFA score compared with Modified early warning signs for predicting 24-hours-in-hospital cardiac arrest : A retrospective review.


Quick SOFA (qSOFA) is a newly purposed simple screening tool to predict in hospital mortality from sepsis and it should also be used to predict mortality from other causes too. But the role of this score for predicting overall in hospital cardiac arrest in 24 hours is not known. Modified early warning signs (MEWS) was a widely used score for predicting in hospital mortality from any causes now but recent studies showed that low MEWS score still cannot ruled out in hospital mortality. So the aim of our study was to determine the role of qSOFA and comparison to MEWS score in predicting 24-hours-in hospital cardiac arrest.


This is a single-centre retrospective study. The study included adult in-hospital-cardiac-arrest (IHCA) patients who were monitored and resuscitated by a medical emergency team in the emergency department, on the general ward or ICU. They were enrolled in this study between January to December 2015. qSOFA and High risk MEWS score (MEWS: ≥5) were calculated for the highest score tracing back to 24 hours before cardiac arrest. Timing before IHCA, ROSC rate and survival-to-discharge rate were collected.


Preliminary results were reported from 50 patients. Out of 50 patients, 40.6% had a return of spontaneous circulation. And 18.8% of the patients had survival until discharge. After tracing back until 24 hours before they had IHCA event, there were 53.1% and 59% IHCA Patients who have qSOFA ≥2 and High risk MEWS respectively. The mean time that qSOFA ≥2 was presented was 3.2 hours before cardiac arrest. While for high risk MEWS was 2.9 hours. There was no statistical difference reported in any elements.


As our preliminary results showed, there were no differences in using qSOFA for predicting 24 hours-IHCA compared with high risk MEWS. We supposed that this result will also be presented in the final result of this study and qSOFA should be able to use as an early predictor for IHCA of any causes.

Wisarut BUNCHIT (Bangkok, Thailand), Veerapong VATTANAVANIT
11:00 - 18:00 #8124 - Application of telemedicine between primary care and emergency department of the Hospital of Barbastro.
Application of telemedicine between primary care and emergency department of the Hospital of Barbastro.


The application of new communication technologies for the realization of medical consultation between the different services of emergency primary care and reference hospital, allows the advice from doctors hospital emergency of the patient without the need to scroll to hospital and can offer different options for the correct diagnosis of pathological conditions and provide early therapeutic response, optimizing time and quality of care.1,2,3


Describe the process of medical care for patients with urgent health problems using new technologies of medical consultation between primary care and hospital emergency doctors.


Prospective study of medical interconsultations made through videoconferencing and / or calls between the emergency department of the Hospital of Barbastro and its different primary care centers over a period of 12 months (01/01/2016 - 31 / 12/2016).

At the present time obtained a sample of 35 interconsultations, it will proceed to the final analysis of statistical data through SPSS


Pending final results at the time of shipment. At the current time of sending present work it has obtained a sample of 35 interconsultations, all of which have been phone calls. Only 10 patients were sent for evaluation and hospital admission. The rest was followed by his primary care doctor. The most frequent reason for consultation with 42% was questions of interpretation of diagnostic tests, followed with 28%  dyspnea in patients with chronic obstructive pulmonary disease.


With the data obtained is too early to draw reliable conclusions but it can be noted that the time has facilitated communication between professions Primary care and emergency departments, reducing uncertainty professional must make a medical decision in a short period of time optimizing of this form the medical care of the patients.


  1. “Telemedicina”,, última visita 8 de diciembre de 2015
  2. “Las TIC En la sanidad del futuro”,, Última visita 4 De diciembre de 2015.
  3. “La telemedicina: ¿ciencia o ficción?”,, última visita 8 de diciembre de 2015.
11:00 - 18:00 #7216 - Application of the Canadian C-Spine Rule and Nexus low criteria and results of cervical spine radiography in emergency condition.
Application of the Canadian C-Spine Rule and Nexus low criteria and results of cervical spine radiography in emergency condition.

Background: The Canadian C Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (Nexus) low criteria are well accepted as guide to help physician in case of cervical blunt trauma. We aimed to evaluate the application of these recommendations in our emergency department. Secondly we analyzed the quality of cervical spine radiography (CSR) in an emergency setting.

Results: 281 patients with cervical blunt trauma were analyzed retrospectively. The CCR and the NEXUS rules were respected in 91.2% and 96.8% of cases respectively. No lesions were found in 96.4% of patient. A lesion was present in 1.1% of patient and suspected in 2.5% of patient. The quality of CSR was adequate in only 37.7% of patient. The poor quality of CSR was due either to the lack of C7 vertebrae visualization in 64.6% or other lower vertebrae in 28%. Other causes included the absence of open mouth view (8%), the absence C1 vertebrae visualization (3.4%), artifact in 2.3% and the absence of lateral view in 0.6% of patient.

Conclusions: CCR and NEXUS are widely used in our emergency department. The high rate of inadequate CSR reinforces the debate about it’s utility in emergency condition.

William NGATCHOU, Jeanne BEIRNAERT, Daniel LEMOGOUM, Cyril BOULAND, Pierre YOUATOU, Ahmed Sabry Elsaeid RAMADAN (BRUXELLES, Belgium), Regis SONTOU, Maimouna BOL ALIMA, Alain PLUMAKER, Virginie GUIMFACQ, Claude BIKA, Pierre MOLS
11:00 - 18:00 #7091 - Appropriate use of CT Pulmonary Angiography at a Brisbane Hospital - An analysis of ordering D-Dimers in the Emergency Department and the potential for improvement.
Appropriate use of CT Pulmonary Angiography at a Brisbane Hospital - An analysis of ordering D-Dimers in the Emergency Department and the potential for improvement.



The symptoms and signs of a pulmonary embolism (PE) are extremely varied and thus a clinical diagnosis of PE can be unreliable. A robust way to stratify a patient’s risk of PE is to use one of the validated clinical decision tools such as the Wells score. 1 Using these tools, a patient can be stratified into a low, moderate or high pretest probability of PE. The addition of a d-dimer test provides a pathway to determine if a patient requires imaging to exclude a PE. 2


The d-dimer is a breakdown product of crosslinked fibrin and occurs coincident with activation of the coagulation cascade. The d-dimer level may be elevated in the presence of a clot that embolises to the lungs causing a pulmonary embolism (PE). The d-dimer level should be used in patients with a low to moderate pretest probability for PE. 3


Methods and Materials:


A retrospective audit was performed of patients who underwent CT Pulmonary Angiography (CTPA) for suspected PE from the emergency department in January 2016. IMPAX search parameters:


Study Dates = 01/01/2016-01/03/2016.

Study Description = “CT Pulm”

Request = ED Clinician and/or location ED.


Using these studies a more detailed review of the available documentation including d-dimer result, a recent chest x-ray, vital signs and clinical history were used to produce a retrospective Wells PE probability score.




The first 100 CTPAs performed were analyzed. 13% of the patients had a positive CTPA for PE. 98% of patients were of low to moderate pretest probability for PE. 15% of these patients had a d-dimer requested prior. 12 (92%) of the patients who had a confirmed PE were of low or moderate pretest probability. It was noted, one patient with low pretest probability of PE, who had a negative d-dimer, still continued to have a CTPA which was also negative.




The positive CTPA rate for PE was 13% - less than the rate recommended by the Royal College of Radiologists of 15.4-37.4%. 4 Only 15% of the low and moderate pretest probability patients had a d-dimer requested. If the d-dimer test was utilized appropriately, it could have conceivably avoided up to 71% of the CTPAs. . Education sessions and emphasis on the diagnostic imaging pathway would save cost, reduce exposure of patients to ionizing radiation, the risk of contrast complications and would improve patient turn over in the emergency department.




  1. Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011;155:448–60.
  2. Department of Health, Government of Western Australia. Diagnostic imaging pathways – respiratory. Available at: [Accessed 28 March 2016].
  3. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276–315.
  4. Duncan K, Howlett D. Appropriateness of usage of computed tomography pulmonary angiography investigation of suspected pulmonary embolism. 2010. Available from:
Amit CHACKO (Brisbane, Australia), Carl DUX
11:00 - 18:00 #8127 - Are patients with asthma that arrive in emergency department treated following the recommendations?
Are patients with asthma that arrive in emergency department treated following the recommendations?

Introduction: Asthma is a highly prevalent disease that presents commonly to the emergency department (ED) in acute exacerbation. Recent Spanish Ashtma Management Guide(GEMA) has set the management for both regular therapy, with 6 therapeutic steps, and exacerbation therapy.
Objetive: To determine whether patients with asthma treated in the emergency department for exacerbations had a previous treatment, had been treated in the emergency room, and have been discharged with treatments that followed the
recomendations of the Spanish Ashtma Management Guide(GEMA)
Method: Prospective study of patients treated in emergency for exacerbation of asthma, checking pretreatment, during emergency admission and discharge fitted the guidelines.
Results: We studied 117 clinical reports of patients treated for asthma exacerbations in the ED of our Hospital during 2015. 6 patients were in the first therapeutic step, 11 in the second, 45 in the third, 37 in the fourth, 11 in the fifth, and 7 in the sixth. Only 35% of the patients were recieving treatment according to the GEMA guidelines, 23% were overtreated, and 42 were not recieving enogh treatment. In emergency admission 85% of the patients (99) were treated according to the guidelines, and 15% (18) were overtreated, with 0 patients not recieving enough treatment. 27 patients were admitted to the hospital ward. Of the 90 patients discharged, 66% were prescrieved treatment according to the guidelines, 12% were not recieving enough treatment and 22% were overtreated.

Conclusion: low compliance is found in the application of clinical guidelines in patients with asthma so it is necessary to find tools to improve the correct application of the recommendations of clinical pathways.

11:00 - 18:00 #7122 - Arrhythmogenic dysplasia evidenced after food poisoning.
Arrhythmogenic dysplasia evidenced after food poisoning.

Case Report

Patient presenting with symptoms of vomiting and diarrhea after dinner last night. He goes on his own picture described referring to hospital and decay.
No known drug allergies. Hypertension, chronic renal insufficiency. Treatment: Olmesartan 20 mg.

Physical Exploration:

Conscious. Oriented. Feeling disease, mucocutaneous pallor, mild dehydration of mucous. Ausculatacion cardiorespiratory: rhythmic tones, 120 beats per minute, no murmurs or extratonos. Preserved vesicular murmur without superadded noise. Abdomen soft and palpable, no palpable masses or organ enlargement, no signs of peritoneal irritation. Increased peristalsis. Preserved distal pulses, no signs of deep vein thrombosis.

Additional tests

Rx thorax and abdomen without interest.
Analytical requested with gases and proceeds to channeling to start intravenous fluid and enters observation for stabilization.


On admission observation was continually monitored displayed on TV monitor sustained monomorphic, with hypotension when it comes to electrical cardioversion with 200 J shock after which happens to sinus rhythm.
He turns to interrogate the patient acknowledges occasional episodes of palpitations with exercise dominance for which he had never consulted.
In analytical results highlights decompensation previous renal function (creatinine 3.5 no other findings).
After entering picture stabilization plan of Cardiology. Finally, during admission was diagnosed with arrhythmogenic right ventricular and proceeds to implantation of implantable cardioverter defibrillator (ICD).

CONCLUSION: Sometimes considered banal pathology can afford the casual diagnosis of serious latent disease.

David NÚÑEZ CASTILLO, María Eugenia REYES GARCÍA (Málaga, Spain), José Ignacio VALERO ROLDÁN

Medical history:
Male 72 years old witha history of atrialfibrillation, severeaorticinsufficiency and hypertension treatedwith anticoagulantsandACE inhibitors, which came due to have increasedtheirabdominal perimeterandoliguriainthe previous two weeks. Blood presure 105/85,157bpmheart rate,tachypneic. Flapping++.IY+AC:panfocalrhythmicsystolic murmurgradeII-III.AP:hypophonesiswidespread. Abdomen:globular,significant increase inabdominal circumference,signwave+.peneoescrotaledema.EEII:edemawithfovea+tothigh.Analytical:2.3ureacreatinine119regularrest.AcxFAECG157. Bilateralpleural effusiononchest X-ray. Due to an importantpenoscrotaledemaand presentinginability tobladdercatheterization, bladder size was carried out despite beinganticoagulated, because of this punctureascitic fluid was discarded. Treatment was initiatedwithSegurilat maximumdoseand Digoxin, and as oliguria and elevated heart rates persisted was necessary to add Amiodarone to the treatment. InEchocardiographywas observed dilated cardiomyopathywith severe systolicdysfunctionand ejection fractionof 45%. Moderate mitral regurgitation. Moderatepulmonary hypertension. Having suspicions of dilated cardiomyopathy andAnasarca, he hospitalized in Cardiology,wherecontrolEchocardiographywas performedat 24 hoursobjectifyingserious deteriorationwithejection fraction20%and significantpericardial effusion. Severe pulmonary hypertension. Severe mitral-aorticinsufficiency. Because ofthe poor performanceand poor generalcondition of the patient,  the family agreed alimitationof the therapeutic effort, passing awaya few hours after.
Dilated cardiomyopathy isa disease of theheart muscle thatcauses theheart becomes enlarged and cannot pump blood efficiently. The causesare uncertainand varied:viral, autoimmune, alcohol abuse,coronary artery disease, hypertensionand valvulardisease, which may triggerheart failure and, inthe worst case, may becongestive causing edema, pleuraleffusion, ascitesandanasarcainfinal stages. The most reliable diagnostic test is  the echocardiogram and the treatmentis based onthecontrol of heartrate and blood pressureanddiuresisreinforcement. In very advanced cases orwhen there are severe arrhythmias, themost appropriateoption is usuallycardiactransplantor placement ofICDs. The probabilityof deathin the final stagesis high.
11:00 - 18:00 #7481 - Assessing accuracy and inter-rater reliability of the emergency severity index in triage in the al-rahba emergency department: A cross-sectional observational study.
Assessing accuracy and inter-rater reliability of the emergency severity index in triage in the al-rahba emergency department: A cross-sectional observational study.

Background: The Emergency Severity Index (ESI) is a five-level triage scale used by the vast majority of emergency departments (ED) in the United States (US) and a growing number of EDs globally. The scale was developed and validated within the US, and there is little data to support its use in other settings where clinical training, resource availability, and cultural norms vary. ESI relies heavily on operator experience and intuition, and accurate triage designation is dependent on rapid assessment of illness severity and accurate prediction of clinician treatment decisions. Reports of ESI performance in countries where emergency medicine (EM) is a relatively young specialty suggest sub-optimal performance of ESI in these settings.

The purpose of this study was to assess triage accuracy, variability, and self-perception among formally trained nurses performing ESI triage at Al-Rahba Hospital (ARH) in Abu Dhabi, United Arab Emirates. We hypothesized that ESI user performance would be lower than has been previously reported in the US, and there would be greater variability in triage decisions.  

Methods: We utilized twenty-five standardized triage cases from the ESI Handbook to evaluate accuracy and inter-rater reliability in ESI score assignment in a cross sectional cohort of ESI-trained ED nurses at Al-Rahba Hospital in Abu Dhabi. The gold standard of accuracy was the ESI handbook answer key.

The survey data was analyzed with Krippendorff’s alpha to assess for inter-rater reliability. Accuracy was calculated for each question and broken down based on ESI triage level and scenario type (medical, trauma, or pediatric case). We also determined percent “under-triage” and “over-triage” overall and for each case, and assessed self-perception of triage level assignment accuracy among nurses.

 Results: Thirty-five ED nurses from ARH participated in the study. Overall accuracy in triage scale assignment was 58.7%, with 28.8% of cases under-triaged and 12.3% over-triaged.  Range of accuracy by individual scenario was 2.9% to 100%. The lowest accuracy was observed for pediatric cases, with 48.9% of all scenarios scored correctly (range by individual scenario: 2.9% to 94.3%). Accuracy was slightly higher for adult trauma (56.2% overall accuracy, range 40% to 85.7%) and adult medical cases (overall accuracy 66.2%, range 28.6% to 100%). Overall inter-rater reliability was moderate (Krippendorff’s alpha = 0.78), and self-perceived accuracy among nurses was either “moderately confident” (40%) or “very confident” (60%).

Discussion: We observed low accuracy in ESI score assignment and significant case-to-case variability for these standardized cases, yet nursing self-perception of performance was high. Nurses scoring these cases had 5 or more years of experience, were formally trained in ESI, and undergo regular triage performance assessments. While more work is required to determine causality, we believe that practice environment has a significant impact on ESI user performance, and that this triage scale, which relies heavily on provider experience, intuition and predictive capacity for treatment decisions, may not be suited to all practice environments.  Future directions include semi-structured interviews with nurses to assess for barriers to using ESI in real-time and repeating this study at other sites globally. 

11:00 - 18:00 #7552 - Assessment of antibiotic prescription in the Emergency Department.Prospective study (about 100 patients).
Assessment of antibiotic prescription in the Emergency Department.Prospective study (about 100 patients).

Introduction: sepsis is associated with high mortality worldwide. It is now accepted that the precocity of the treatment is related to a significant prognostic improvement. Antibiotic therapy which is the specific treatment is usually started in emergencies. Furthermore, there is a consumer increasing use of antibiotics in emergency services generating some reservations for its justification. In this work, we tried to evaluate antibiotic prescription in terms of justification, relevance and compliance.

Materials and Methods: This is a prospective study over 5 months that enrolled 100 patients admitted to the unit of hospitalization of the emergency department for sepsis. We used our local registry of sepsis. We collected Clinical, biological, microbiological, the final diagnosis and characteristics of antibiotic therapy for each patient. An evaluation of antibiotic prescription was conducted by two experts blindly regarding 3 items: justification, relevance and the compliance (of doses and the route of administration) of the antibiotics.

Results: hundred patients were enrolled. The average age was 62 years. The sex ratio was 1.04. The most common sites of infection were urinary and pulmonary in 43% and 28% of cases. Among our patients there were 46 cases of sepsis, 49 cases of severe sepsis and 4 cases of septic shock. 99 patients received antibiotics. The most used drug was cephalosporin in 83.83% of cases (in association in 71.08% of cases) followed by Quinolone in 52.52% of cases. The antibiotic therapy was considered justified in more than 95% by the two experts. A mismatch was noted between the two experts regarding the relevance and compliance (Kappa=0,34). However our choice of antibiotic was deemed appropriate in 53% of cases (expert 1: 53.7%, expert 2: 80.8%), the largest rate relevance concerned the pulmonary pathology for both experts. The administration route was deemed compliant in more than 76% of cases (expert1: 76.8%, expert 2: 100%). There was an agreement between the two experts regarding the unit dose and the spacing of doses (the compliance rate has exceeded 80%).

Conclusion: The assessment of prescription of antibiotics is important. Some disparities were noted in our practice. An available guide for antibiotic prescriptions in emergency case is essential to ensure the quality of prescriptions.

Ibtissem CHAIEB, Asma ZORGATI (tunisia, Tunisia), Naouefel CHEBILI, Houda BEN SALAH, Khaoula BELHADJ ALI, Riadh BOUKEF
11:00 - 18:00 #8144 - Assessment of community acquired pneumonia with fine’s score and a radiological score.
Assessment of community acquired pneumonia with fine’s score and a radiological score.

Introduction: Community acquired pneumonia (CAP) is a frequent leading cause of hospital admission worldwide. Through this study we investigate the accurancy of Murray radiological  score (RS) associated to Fine score (FS) as a triage tool for CAP in the emergency department.  

Methods: a prospective observational study including patients admitted in an emergency department of a general teaching hospital for a CAP. FS and RS were calculated on admission and we analysed the rate of hospitalization and outcome at 30 days and analysed  the correlation between the two scores. Statistical analysis were based on Chi 2 test with significant statistical difference (SSD) if p < 0,05.

Results: 174 CAP, 104 men and 70 women, mean age = 57,5 ± 17,7 years. RS was 3 ± 0 in FS class I (n = 6), 3.6 ± 1.4 in class II (n = 46), 3.54 ± 1.5 in class III (n = 40), 4.1 ± 2 in class IV (n = 67) and 4.33 ± 2 in class V (n = 15).  Among patients who were hospitalized in medical ward, 60% of them belongs to class I, 83.3% to class II, 53.4% to class III, 15.1% to class IV and 16.6% to class V. 17.5% of patient hospitalized in ICU had a fine score class III , 52.8% had a class IV and 41.1% had a class V. Checking out  was possible for 40% of patients in class I, 13.9% in class II, 22.6% in class III and 11.3% in class IV. Mortality ranged from 2.8% in class II to 41.7% in class V.

We found an association  between FS and RS (r=0.16, p=0.034). The RS in survivors versus  not survivors in the FS categories was respectively 3.46± 1.3 vs 5±1 in class II, 3.25 ± 1 vs 5 ± 2.4 in class III, 3.7 ± 1.7 vs 4.8 ±2.3 in class IV and 4 ±1.3 vs 5 ±2.5 in class V. There was a SSD only in category II (p = 0.01).


Conclusion: Radiological score may improve Fine score. Further studies with larger cohort are necessary to show better results.


Majed KAMEL, Mohamed Amine KALLEL (tunis, Tunisia), Zaouche KHEDIJA, Baccouche RAMLA, Khelil MOHAMED HASSENE, Maghraoui HAMIDA, Modhafer MOHAMED, Hammouda CHOKRI, Borsali NEBIHA
11:00 - 18:00 #7886 - Assessment of passive leg raise by thoracic electrical bioimpedance in spontaneously breathing volunteers, a pilot study.
Assessment of passive leg raise by thoracic electrical bioimpedance in spontaneously breathing volunteers, a pilot study.

Background: While Intravenous fluid resuscitation is common in emergency departments (ED), existing standard monitoring techniques are relatively poor indicators of fluid responsiveness (FR). Passive Leg Raise (PLR) creates a reversible haemodynamic response similar to fluid challenge. Thoracic Electrical Bioimpedance (TEB) is a non-invasive cardiac output (CO) monitoring technology which can be used to quantify the cardio-haemodynamic response to PLR.[1, 2]

Objectives: To study the haemodynamic response to PLR measured by TEB (Niccomo, Medis, Germany), assess the feasibility of the test and the reproducibility of the findings.

Methods: A prospective observational study was conducted on healthy volunteers (≥18 years old). Blood pressure was recorded and TEB device was used to record continuous data of heart rate (HR), CO and stroke volume (SV). Subjects were placed in head-up position for 3 minutes followed by 3 minutes lying flat with legs elevated (PLR1). Subjects were returned to semirecumbent position for 5 minutes, then the procedure was repeated (PLR2). FR was defined as a rise in CO by more than 10% during the test.

Results: Fifteen volunteers were enrolled. Median age was 35 (interquartile range [IQR] = 28 – 47) and 8 were males. Median mean arterial pressure was 100 (IQR = 90 – 107). FR was observed in 11 subjects during PLR1 and 14 subjects during PLR2. Median change of CO during PLR1 was 13.9% (IQR = 11.2 -18%) and 15.2% (IQR = 13.4 - 18.2) during PLR2. Repeated FR testing showed fair agreement (Kappa = 0.328; 95% confidence interval [CI] = -0.175 to 0.832). In the 30 PLR tests CO and SV responses showed weak correlation (rs = 0.45, CI = -0.08 to 0.78).

Conclusion: These initial data suggest that PLR-TEB test is a promising tool to predict FR in ED. The test showed fair repeatability, however this should also be established in a patient group. The weak correlation between CO and SV responses suggests that the response to increased preload is more complex than the current literature recognises. Additional patient data will allow us to determine the CO response to PLR-TEB test with more confidence and to establish the limits of agreement of repeated PLR-TEB. The next step will be evaluating the accuracy of this test to predict FR to a fluid bolus.


1. Cherpanath TG, Hirsch A, Geerts BF, Lagrand WK, Leeflang MM, Schultz MJ, et al. Predicting Fluid Responsiveness by Passive Leg Raising: A Systematic Review and Meta-Analysis of 23 Clinical Trials. Crit Care Med 2016; 44(5):981-91.

2. Summers RL, Shoemaker WC, Peacock WF, Ander DS, Coleman TG. Bench to bedside: electrophysiologic and clinical principles of noninvasive hemodynamic monitoring using impedance cardiography. Acad Emerg Med 2003; 10(6):669-80.

Acknowledgements: We would like to thank the Ministry of Higher Education – Missions Sector, Egypt and the British Council for their support through Newton-Mosharafa Fund.

Dr Mohammed ELWAN (Leicester, United Kingdom), Ashraf ROSHDY, Assem KHAMIS, Eman ELSHARKAWY, Salah ELTAHAN, Timothy COATS
11:00 - 18:00 #7297 - Assessment of the epidemiology and the management of the patients with acute heart failure diagnosis in Emergency department.
Assessment of the epidemiology and the management of the patients with acute heart failure diagnosis in Emergency department.

Background: Majority of acute patients are admitted to the hospital through the emergency department (ED). Acute heart failure (AHF) is a frequent cause of presentation to the ED and increase with age. Emergency physician suggests a potential case to the cardiologist who decides to accept it or not.

Objective: To describe epidemiology and outcome of patients with acute heart failure diagnosis in ED.

Methods: A prospective, observational, monocentric, study was carried out over a 6 weeks period. All patients with AHF diagnosis were included.

Results: From 14/10 to 25/11/2014, there were 4873 emergency department admissions and 55 patients (1%) had AHF diagnosis: 32 (58%) women, 23 men. The average age and median age was respectively 83.7 and 87 year old (58 – 101). Sixty-four percent of patients had conserved autonomy and no cognitive decline. 71% were older than 80 years. The mean and median time elapsed from arrival and medical consultation was respectively 31 and 18 minutes. 41 patients (75%) had AHF only, 14 patients (27.3%) had combined with sepsis pathology.  The cardiologist would be called for 36 patients (65%) with mean age 80 year old, among them 5 had combined pathology, 30 had no functional impairment and no dementia. 20 patients (36%) were older then 90, cardiologist would be called for 6 of them. All the patients were hospitalized:  49% in a cardiology unit, 18% in geriatric unit and 33% in medicine department. All the patients with AHF diagnosis at ED had the same diagnosis at discharge. The mortality was 10% (5 patients).

Discussion: Emergency physician’s assessment selected patients to propose to the cardiologist.  Age, dementia and functional impairment are limited factors to cardiology department hospitalization.  

Conclusion: A high proportion of patient with AHF are aged more than 80 years. The diagnosis is commonly associated with sepsis. Cardiologist call and hospitalization in a cardiologic unit are motivated by absence of comorbidity, functional impairment or cognitive decline.

Dr Christelle HERMAND (PARIS), Jennifer SOBOTKA, Ines LEUNG, Clement TOURNON, Dominique PATERON
11:00 - 18:00 #8118 - Association between acute phase course of systolic blood pressure and early neurological improvement in stroke patients treated with rtPA.
Association between acute phase course of systolic blood pressure and early neurological improvement in stroke patients treated with rtPA.


The relation between systolic blood pressure (SBP) and neurological outcome in acute ischemic stroke is not well understood in spite of research for more than a decade. Conflicting results of the previous studies may be attributed to the difference in methodological design and passing over the potential effect of blood pressure course on stroke outcome. This study aimed to evaluate the relation between SBP tendency during acute phase of ischemic stroke and early neurological outcome in patients treated with intravenous thrombolysis.


A total of 155 ischemic stroke patients who received intravenous recombinant tissue plasminogen activator (rtPA) were retrospectively examined. Blood pressures were measured every 15 minutes for the first 6 hours from the administration of rtPA (0–6 h), then every 30 minutes for the next 6 hours (6–12 h). Time course was divided into 4 phases by every 3 hours. The average, standard deviation, coefficient of variation (standard deviation / average x 100) of SBPs during the periods of 0–3 h, 3–6 h, 6–9 h, and 9–12 h were calculated. Data on baseline demographics, vascular risk factors (hypertension, diabetes mellitus, atrial fibrillation, dyslipidemia, and obesity), pre-stroke disability (using the modified Rankin Scale score), stroke severity (using the National Institutes of Health Stroke Scale score), time of rtPA administration, and laboratory parameters were collected. Early neurological outcomes were assessed at 24 hours after thrombolytic therapy. To determine independent predictors for early neurological improvement (National Institutes of Health Stroke Scale score of 0–1, or of decrease ≥8-point), a multiple logistic regression analysis fitted with backward stepwise selection procedure was performed. Two-way repeated-measures analysis of variance was used to compare the 12-hour SBP course between the patients with and without early neurological improvement.


Patients with early neurological improvement (n=43) showed higher frequency of dyslipidemia, higher triglyceride level, lower HDL-cholesterol level, and lower SBPs during the periods of 3–6 h, 6–9 h, and 9–12 h, in univariate analysis. On a multiple logistic regression model, atrial fibrillation and mean SBP during 6–9 hours were independently associated with early neurological improvement after adjustment of covariates. Comparing the time course of SBPs, mean SBP values in patients with good outcome constantly reduced until 9 hours after thrombolysis, whereas those without neurological improvement showed plateau pattern in their SBP course.


The tendency of average SBP level during 3–12 hour after rtPA therapy was predictive of early neurological outcome at 24 hours in ischemic stroke patients.

Junsoo SEOK (Seoul, Korea, Republic of), Kyounghwan KIM, Sungkyoo KIM, Hyeonsong KIM, Ki Young JEONG, Jong-Seok LEE, Young Gwan KO
11:00 - 18:00 #7132 - Asthma is not the only cause of dyspnea in young patients.
Asthma is not the only cause of dyspnea in young patients.

Objective: The description of this case is due to the rarity of this clinical entity and its semiotic diversity that implies a high level of suspicion for a correct and quick diagnosis.

The case describes a 17-year-old male who presented to the A&E department complaining of odynophagia and cervical pain from 2 days ago. He also complained of haemoptysis in the last 24 hours. He started with shortness of breath, mild in severity, and several bouts of intense cough 5 days ago after touching a rabbit His GP doctor prescribed him antihistaminic and dry powder inhalers, which didn’t improve his respiratory symptoms. No fever, no shivering. He denied any similar symptom in the past.

Past medical, social, surgical and family history

He also denied any use of illicit drugs or any history of trauma. He had a history of asthma but he was on no prescription medications and participated in sports without any difficulty. He did not smoke or drink alcohol.

Physical examination

Blood pressure was 133/79 mmHg, HR 95 bpm, temp. 36.4ºC and RR was 24/min, SpO2 97% on room air.

He was well developed but in mild respiratory distress.

HEENT: crepitance felt in the right supraclavicular area. Otherwise unremarkable. Trachea was in the middle.

Chest: clear to auscultation bilaterally. No stridor

Heart: No murmurs, rubs or gallops. Regular rate and rhythm.

Abdomen: no remarkable

No pedal edema was appreciated.

No focal findings of neurological deficits.

Next step in the management of this patient

A PA chest X-ray (posteroanterior and lateral view) was done, which showed a slight layer of air surrounding the cardiac silhouette, right chest wall and extensive subcutaneous emphysema in supraclavicular area.


Spontaneous pneumomediastinum


He was admitted to the hospital, followed up of a chest X-ray within 12-24 hours to detect any progression or complications. Treatment included analgesia, rest, and initial oxygen therapy. He was discharged on the 5th day of hospitalization and there were no signs of recurrences.


The diagnosis of spontaneous pneumomediastinum in an acute hospital setting can present as a challenge. Pneumomediastinum should not be confused with other pathological conditions such as interstitial emphysema, pneumothorax and pneumopericardium, which mostly require specific types of management. Spontaneous pneumonedistiinum is rare in adults, with young male being the most frequently affected, with a male/female ratio of 8/1. Based on previous studies, the prevalence of spontaneous pneumomediastinum ranging from 1 per 800 to 1 per 42,000 patients presenting to a hospital emergency department. Of these cases, approximately 1% has a history of asthma. The natural course is for the pneumomediastinum to spontaneously resolve.




Patricia BAZAN (Madrid, Spain), Elena AZNAR, Marta MERLO, Raquel CASERO, Virginia ALVAREZ
11:00 - 18:00 #7194 - Asymptomatic ruptured of abdominal aortic aneurysm in a patient with COPD presented in Emergency Department.
Asymptomatic ruptured of abdominal aortic aneurysm in a patient with COPD presented in Emergency Department.

Ruptured abdominal aortic aneurysm (AAA) is one of the most fatal surgical emergencies, with an overall mortality rate of  90%.The classic triad consists of abdominal or flank pain, hypotension and a pulsatile abdominal mass, but only manifests in 50% of cases at best. AAAs can be symptomatic without acute rupture as well. We present the case of a 67 years-old-man with COPD, active smoker, hypertensive, brought by ambulance in the Emergency Department with mild dyspnea, cough and hemoptysis. Physical examination revealed a pulsating abdominal mass. Laboratory investigations showed mild anemia. Abdominal ultrasound revealed an infrarenal aortic aneurysm. Un urgent angioCT was performed, which showed un infrarenal aortic aneurysm with minimal extravasation of contrast. Rupture of an abdominal aneurysm is a catastrophic complication with a high mortality rate. In this case, the aneurysm rupture was asymptomatic and only a thorough clinical examination identified a pulsatile mass which raised the suspicion of aortic aneurysm.

Vasile GAVRILA, Gabriela FILIP (TIMIS, Romania), Alexandru Nicolae CARSTEA, Rodica Daniela GAVRILA
11:00 - 18:00 #7715 - Atmed eTriage System, new model of EMS triage in the structure of the Smart City.
Atmed eTriage System, new model of EMS triage in the structure of the Smart City.

Study/ objective

Worldwide, Information and Communication Technologies (ICT) and telemedicine have been used more often in prehospital emergency care and emergency and disaster medicine. In Poland, the use of ICT in routine emergency practice does not raise any concerns, but its application in mass casualty incidents and disasters is still  being discussed. The development of intelligent management systems in particular “SMART CITY” project requires an adequately intelligent medical emergency management system for EMS. Atmed eTriage System (AeTS) is a new concept of triage for routine emergency care and disasters.


The study was conducted based on the analyses of the Kraków EMS database and field simulations of mass casualty incidents (MCI). The study measured the following aspects: the kind of management and decision-making model, the effectiveness of EMS (the response time and the appropriate management medical staff), the effectiveness of triage, the information flow to/from the command and control center, the criteria deciding on a patient transport mode and the adequate allocation of patients in hospitals. The observation concerned the period 2009-2016.


Within the scope of research, ICT monitoring emergency medical care proved greater effectiveness of the ICT model rather than the traditional one. Moreover, ICT lets take decisions that could not be taken within the traditional model due to lack of current feedback from the incident analysis and hospital database. ICT provides new management possibilities.


The use of etriage based on ICT in EMS contributes to more effective management. The initial research results allow to define new directions for development of  intelligent EMS management systems.  


Arkadiusz TRZOS (Krakow, Poland), Katarzyna DŁUGOSZ
11:00 - 18:00 #7247 - Atraumatic limp in children presenting to a tertiary paediatric emergency department (PED): time for change?
Atraumatic limp in children presenting to a tertiary paediatric emergency department (PED): time for change?

AIMS: To retrospectively review the investigations and outcomes of all children with atraumatic limp presenting to a tertiary paediatric emergency department in 2014 to assess whether the current management protocol, advocating blood tests and ultrasound for all, was necessary.

METHODS: All patients who had a hip or knee ultrasound scan ordered from the PED were identified and their electronic patient records accessed with relevant consent to retrieve the following data: age, duration and nature of symptoms, examination findings including ability to weight bear, blood results (white cell count, absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate), pyrexia preceding or documented during PED attendance, duration of symptoms, examination findings, clinical diagnoses and outcomes. 

RESULTS: 535 patients had hip and/or knee ultrasound scans in 2014, of which 492 were performed for atraumatic limp and were therefore included in the analysis. Age range was 10 months-15 years (median 4.5 years). Three hundred and twenty seven patients (66%) had a diagnosis of transient synovitis, three patients had septic arthritis and osteomyelitis respectively (0.6%), four patients had Perthes disease (0.8%) and one had slipped capital femoral epiphyses (SCFE), 0.2%.  Twenty three percent had no formal diagnosis recorded (but no significant later diagnoses emerged in any) and there were small numbers of overuse, soft tissue and fracture injuries aswell as single patients with rheumatological or neurological causes.  All the patients with septic arthritis were young (18 months or younger) and a febrile history and raised inflammatory markers. All the patients with osteomyelitis were diagnosed on MRI scan. Two had mildly raised blood inflammatory markers, none were pyrexial. The positive predictive value and sensitivity of WCC, neutrophils, CRP and ESR were universally poor in identifying septic arthritis and ostemyelitis though negative predictive values, as expected, were very high (>0.99).   Slipped capital femoral epiphyses was identified in a 10 year old who had a pelvic xray (as per the existing protocol) as were the Perthes disease patients, who had more protracted histories ranging from 5 days – 4 months.  The laboratory cost of performing FBC, CRP and ESR in this cohort was £3,956 and Consultant Radiologist time to perform the hip/knee USS was in excess of 40 hours (estimated at 5 minutes per scan).               

CONCLUSIONS:  The majority of children who are well and afebrile presenting with atraumatic limp can be safely managed at first presentation without blood and radiological investigations given the extremely low incidence of infective pathologies in this population. Bony abnormalities such as SCFE and Perthes must be considered in older children or those with atypically lengthy histories and a plain xray is the investigation of choice. Our protocol has been redesigned to reflect this with attention to rigorous safety netting in the form of written caregiver information leaflets and PED Consultant review in 3-5 days at which time further investigations including blood tests and imaging might be considered in the patient who has not improved.      


Jennifer Kate SMITH (Edinburgh, ), James CARR, Gordon WHITE
11:00 - 18:00 #7446 - Atrial fibrillation in the Wolff-Parkinson-White syndrome: a challenging arrhythmia.
Atrial fibrillation in the Wolff-Parkinson-White syndrome: a challenging arrhythmia.

Background: Wolff-Parkinson-White syndrome often represents a diagnostic and therapeutic dilemma for emergency physicians especially if it’s associated with atrial fibrillation. It is life-threatening because of the fast ventricular response and the possibility of degeneration to ventricular fibrillation.

Case report: We report the case of a 25 years-old man, with a medical history of hypertension, presented to the emergency room for loss of consciousness with palpitation and dizziness. Clinical examination found a clammy patient with a Coma Glasgow Scale of 15, a blood pressure about 100/60 mmHg and a pulse about 200 bpm. Admission electrocardiogram showed irregular wide QRS complex tachycardia. Intravenous amiodarone was administrated at a dose of 300 mg. With the persistence of the same arrhythmia an electrical cardioversion was performed with success. A sinus rhythm and a delta wave were shown in the post cardioversion electrogram. Then, the patient was transferred in the department of cardiology for radiofrequency ablation of the accessory pathway.

Conclusion: Clinical clues to the diagnosis of atrial fibrillation occurring in the setting of the Wolff-Parkinson-White syndrome include essentially medical history and electrocardiogram signs. An irregular wide QRS complex in a young patient with palpitations, dizziness or syncope has to lead to this diagnosis. treatment depends on the initial hemodynamic status.

Dorsaf BELLASFAR (tunis, Tunisia), Karim OUNALLI, Saloua HOUIMLI, Mouna TITEY, Ghania Fetiha AOUADI, Amel AMAMOU, Jihen AOUEM, Fatma BEN SALEM, Ben Romdhane ABDELMAJID
11:00 - 18:00 #7891 - Atypical presentation of abdominal aortic aneurysm complicated with shock.
Atypical presentation of abdominal aortic aneurysm complicated with shock.


    Abdominal aortic aneurysms (AAAs) contribute significantly to disease burden in developed countries. Ruptured abdominal aortic aneurysm (rAAA) is characterized by the presence of blood outside the adventitia of the dilated aortic wall. Free rupture, with egress of blood into the peritoneal cavity, is distinct from covered rupture, in which there is less blood loss because the periaortic hematoma is enclosed by retroperitoneal tissue.


Case Report

    A 77-year-old male patient was brought to our emergency department by emergency medical services (EMS) a history of short of breath, ECG showed sinus tachycardia. Laboratory studies with Artery Blood Gas analysis revealed metabolic acidosis (PH:7.165, HCO3:10.9mmol/L),WBC:12500/uL,Lactate:12.2mmol/L, a normal Hemoglobin and normal troponin level . His BP initially was 50/41mmHg and dyspnea.

    In the absence of abdominal pain, a chest CT scan with contrast scan was arranged to confirm the diagnosis of pulmonary Embolism. The CT scan revealed rupture of abdominal aortic aneurysm with massive hematoma in the para-aortic and left retroperitoneal space. He was transferred directly to operation room.

    During operation, we found abdominal aortic aneurysm 8 cm in diameter rupture with shock and bilateral iliac artery stenosis post PTA (percutaneous transluminal angioplasty) procedure. The patient made a recovery and he was admitted to SICU of following respiratory insufficiency.



     For someone with unknown reason of shock, rAAA should be kept it in mind. 

Ching-Fang CHAO (Changhua, Taiwan, China)
11:00 - 18:00 #8010 - Audit of the management of buckle fractures of the wrist in the paediatric emergency department.
Audit of the management of buckle fractures of the wrist in the paediatric emergency department.

Buckle (torus) fractures of the wrist account for one third of all wrist fractures in children. These fractures are stable and heal well. Traditionally they have been treated in a Plaster of Paris with orthopaedic review.

Critical appraisal of the evidence revealed splints to be as effective as Plaster of Paris in pain control and healing as well as resulting in improved physical function, patient satisfaction and significant cost savings. Based on this we developed a new policy for the management of buckle fractures in children.

The aims of the policy were to improve management of buckle fractures, improve functional outcome, improve patient and parent satisfaction, reduce fracture clinic appointments and reduce the cost of treatment.

An audit of the changes made revealed that 35% (227) of all wrist injuries seen in the Emergency Department were buckle fractures. Of these 126 were treated in removable splints and 119 did not attend fracture clinic. Of those who were treated in a splint the re-attendance rate was 7% compared to 21% for those in a Plaster of Paris.

A Plaster of Paris costs £6-£7 per patient and requires 15-20 minutes of nursing time to apply, splints cost £2 and can be applied in seconds at the end of the consult. In addition these patient did not require a review appointment in the fracture clinic and demonstrated a marked reduction in re-attendance in the in the emergency department for Plaster of Paris complications. The result was a reduction in work load for the emergency department staff, a reduction in waiting times for affected patients, reduction in hospital attendances and a reduction in fracture clinic appointments. In addition the savings for treating patients with a splint for one year were an estimated £11,500.

A significant cost saving has been demonstrated in the reduction of fracture clinic appointments. Further adjustments to the policy will result in an estimated £20,000/year saving and better patient satisfaction. This policy demonstrates how a well-run journal club with critical appraisal can directly affect service provision and quality of care.

Tudor OMAN (Belfast, United Kingdom)
11:00 - 18:00 #7944 - Aurora Bridge Bus Crash review of a mass casualty event pre-hospital and hospital response, lessons learned.
Aurora Bridge Bus Crash review of a mass casualty event pre-hospital and hospital response, lessons learned.

At 11:11 on September 24, 2015, an amphibious DUKW (a two-ton vehicle, was refurbished in 2005 for tourist use) with 37 people on board lost control due to a catastrophic left front axle mechanical failure.  The vehicle crossed the center line into oncoming traffic and struck a charter bus transporting 50 members of an international college group including students and staff.[i]  This event occurred on an urban bridge with heavy traffic.  A Mass Casualty Incident response was activated at the levels of EMS, the inter-hospital coordinating system: Disaster Medical Control Center (DMCC), the regional inter-hospital coordination group Northwest Healthcare Response Network (NWHRN) and the City of Seattle.

There were 62 reported injuries, however this number might be low due to reported delayed self-directed medical attention care seeking after the event.  The incident had many unique features that affected the incident response including: location on a bridge with limited access points, involvement of an amphibious DUKW vehicle, involvement of two commercial vehicles mandating investigation of the National Traffic Safety Board, and large numbers of foreign nationals.  This mass casualty event demonstrates the challenges to a complex mass casualty response and how many aspects of our disaster response system met those challenges.

There were four victims pronounced dead on the scene and another victim died three days later of his injuries.  A total of 51 victims were triaged and transported via the EMS system to 8 area hospitals.  These included 12 triaged red (emergent), 11 yellow (urgent) and 28 green (delayed).  The four on scene fatalities were triaged stripped (expectant).  A pre-hospital county issued EMS MCI triage tag was used to help patient tracking. 

Many small but not irrelevant elements were in play that made this tragic accident unfold in a manner that maximized healthcare and good outcome for the patients as well as a supportive and informed environment for the victims’ families and the general population of Seattle.  Years of coordination and collaborative agreements and planning, as well as drills came to play as patients were appropriately managed in the field, distributed appropriately to area hospitals who were aware of and prepared for their arrival, their whereabouts were tracked and available to public officials who were able to inform and support family and the public.  Several elements also contributed to the event in a negative manner.  As a commercial tourist vehicle and a commercial transportation vehicle neither vehicle was required to or had seat belts.  The DUKW vehicle, having been involved in prior mass casualty accidents, does not meet current safety standards, and concerns over the vehicles size, shape, blind spots and buoyancy have also been raised.[ii][iii][iv]  Despite the robust response of our community’s EMS, city and hospital based emergency services, it is likely many of these injuries and fatalities may have been averted with improved safety guidelines and implementation.

[i] Preliminary Report National Transportation Safety Board: HWY15MH011,







Stephen MORRIS (seattle, USA), Andrew MCCOY, Joshua JAUREGUI
11:00 - 18:00 #7831 - Autopsic examination of injured bicyclists due to disease.
Autopsic examination of injured bicyclists due to disease.

The objective of this study was to clarify the relationship between injury severity in bicyclists involved disease. Autopsic records were reviewed for all cadavers from 1995 to 2014 in Shiga University of Medical Science and from 2003 to 2014 in Dokkyo Medical University School of Medicine. The mechanism of injury, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) of the patient were determined. A total of 26 cadaver’s records were reviewed. The mean patient age was 62.2 years. The average ISS was 6.6, with an average maximum AIS (MAIS) score of 1.7. The mean chest AIS scores were as high as 1.3, with head ones were 0.9. This study provides useful information for emergency physicians who suspect disease in bicyclists involved in the traffic accidents.

Satoshi FURUKAWA (Otsu, Japan)
11:00 - 18:00 #7797 - B-Mode Ultrasound Signs in Ovarian Torsion and Normal Doppler Blood Flow: Masses, Cysts, and Follicular Ring Sign - A Potential Diagnostic Algorithm.
B-Mode Ultrasound Signs in Ovarian Torsion and Normal Doppler Blood Flow: Masses, Cysts, and Follicular Ring Sign - A Potential Diagnostic Algorithm.

Background: Ovarian torsion is a surgical emergency for which ultrasonography is the gold standard imaging modality. Absence of blood flow is diagnostic, but blood flow may be visualized in the setting of torsion.  B-Mode signs may be sufficient to establish torsion in the presence of blood flow.   Ultrasound finding of masses or cysts, as well as, “Follicular Ring Sign” (FRS), a prominent hyperechoic ring around the antral follicles of the affected ovary, have been identified in patients with ovarian torsion.

Objective: To determine if the presence of ovarian mass, cyst, or FRS can predict the diagnosis of ovarian torsion, when Doppler blood flow analysis is nondiagnostic.

Methods: A retrospective chart review was done for patients diagnosed operatively with ovarian torsion at a large community, teaching hospital from January 1, 2011 to January 1, 2015. Preoperative pelvic ultrasounds from these cases were examined for the presence or absence of Doppler flow, ovarian mass or cysts, and FRS.

Results: 63 patient charts were reviewed. 43 patients were found to have preoperative ultrasounds and surgically confirmed ovarian torsion. In total 46 scans were reviewed. 34 were radiology scans (RAD), and 12 were point-of-care scans (POCUS) performed in the ED.

Doppler flow was done in 44 of 46 scans. 19/44 (43%) had normal arterial and venous Doppler flow. 25/44 (57%) had abnormal or absent arterial flow. 15/44 (34%) had abnormal or absent venous flow and 15/44 scans (34%) had abnormal or absent arterial and venous flows.

The presence of ovarian mass alone had sensitivity of 28%, specificity of 100%, PPV of 100% and NPV of 77%. Ovarian mass or cyst had sensitivity of 84%, specificity of 79%, PPV of 80% and NPV of 83%.

Of the 46 ultrasounds reviewed, ovarian follicles were seen in 30 scans. The presence of FRS was assessed in these 30 scans (22 RAD and 8 POCUS). Overall FRS had a sensitivity of 60%, specificity of 83%, PPV of 78% and NPV of 68%. For RAD only, FRS had a sensitivity of 50%, specificity of 82%, PPV of 73% and NPV of 62%. For POCUS only, FRS had a sensitivity of 88%, specificity of 88%, PPV of 88% and NPV of 88%.

Conclusion: 43% of the patients with ovarian torsion had normal arterial and venous blood flow.  The presence of ovarian mass was found to be 100% specific for the diagnosis of ovarian torsion.  FRS alone does not appear to be highly sensitive or specific for the diagnosis of ovarian torsion. The sensitivity and specificity of the ED POCUS scan is higher compared to the Radiology Department scans.

An algorithm starting with Doppler flow and, when present, progressing to ovarian assessment for mass, cysts, and FRS may have high predictive value.

Chiricolo GERARDO, Christopher RAIO (Dix Hills, USA), Harinder SINGH
11:00 - 18:00 #8047 - Bacterial meningitis in Syrian refugee pregnant women.
Bacterial meningitis in Syrian refugee pregnant women.

Introduction: Altered mental status is one of most important and complicated issue for an emergency medicine doctor. Enfectious diseases is rare for  that patient groups. Enfectious diseases in 5th place patient with altered mental status causes acording to Kanich et al. Because of the norologic status sometimes sedoanelgesia should be used for diagnosis. Propofol(category B) could be use safetly for sedoanelgesia in pregnancy. In some rare situation  like immigrants (language barrier etc.) differential diagnosis even more harder.

Case: A 18 year old pregnant (38 weeks) Syrian refugee patient was admitted to ER with delirium and altered mental status. Because of the communication problems with patient and her relatives, patient’s medical history was not taken at all. Patient had lack of cooperation and orientation. She was hurting herself and agitated. Glaskow coma score evaluated as 14/15.

 She was examined as low blood pressure (70/40 mmHg), tachycardic (110 bpm), tachypneic (28 bpm). The patient’s fever was 36.7 C and sO2 was %97. Respiratory and cardiac examination was normal.  Pupillas were seen isocoric and with intact light response. Four ekstremity reflexes were normal. Nuchal rigitidy and other neurological examination couldn’t evaluated properly. There weren’t any rush at patient’s body. IV fluids resutation was started. As lab results were; WBC 42.03 10^9/L, HGB 10.7g/dl, NEU 39.17 10^9/L, Lactat 3.4 mg/dl, Blood Glucose 114mg/dl, AST 24U/L, ALT 10U/L. Spot urinary test showed no leukocyturia, no proteinuria. In brain MRI there was no intrcranial mass, other focal brain lesion, bleeding area or infarction.Because of the white blood cell count was elevated, with a shift to right and  confusion, we tought bacterial menengitis as a prediagnosis and ceftriaxone was applied 2 gr twice daily.

The patient was consultated with gynecology and obstetrics clinic for fetal distress and emergent C-section. NST was showed decelerations. After the sedation with propofol (0,1 mg/kg/min) lomber puncture was performed to patient then patient transfered to gynecology and obstetrics clinic for emergent C-section. Cerebro-spinal fluid was cloudy. Gram strain positive, >%80 PMN, pandy test +++, Glucose(CSF) 50mg/dl, protein(CSF) 296.2 mg/dl. Antibiotherapy was set ceftriaxone 2grp twice daily and vancomisin 500 mg four times per day by enfection and microbiology clinic. After C-section patient admitted to ICU. After a week of antibiotherapy; patient’s vital signs, mental status and lab results were seen normal. Patient‘s medical treatment has ended and was discharged.


Conclussion: Bacterial meningitis is a rare, life-treatining and important reason of altered mental status. Lumber puncture is the main procedure to establish a final diagnosis of meningitis. Main medical theraphy is ceftriaxone. Sometimes sedoanelgesia is necessary for examination and prosedures. In pregnancy , propofol(category B) is reliable agent for prosedural sedation. Emergency cesareans are sometimes further classified by degree of urgency like an immediate threat to life of the mother or fetus is present. Early antibiotherapy and emergent C-section can provide an improvement of maternal and fetal health status as seen as in our case.

Yusuf Cankat BOZKURT, Aziz VATAN, Burcu GULSEN, Emine GAFFARI, Onur TOKOCIN (istanbul, Turkey), Hakan TOPACOGLU
11:00 - 18:00 #7767 - Bad mood after a long flight.
Bad mood after a long flight.

We present the case of a 27 year-old woman with no relevant medical history

The symptoms began 8 hours before admission to the Emergency Department. After landing from a ten hours flight, she began with malaise,  weakness, nausea, vomiting and strange behavior.

She is taken to the Hospital by her husband, who tells that during the holidays and flight her behaviour was totally normal and that most of the time in the flight back to Spain she was sleeping with her head over his shoulder.

They have stayed in Cuba for a week celebrating their honey moon. Her husband said she did not consume any type of drugs during the holidays or the flight.

At the general examination no fever, normal blood pressure and no tachycardia, but although she had a Glasgow Score of 15, the neurological exploration showed some abnormalities: she was in an unlike mood, with unmotivated laughter, disoriented with inappropiated answers to the doctor's questions. No visual problems, no loss of strength or sensitive afection. Reflex exploration was also normal. She could walk properlly and no signs of meningeal or cerebellum disorders were found at the first examination.

Laboratory tests were taken, including chest and abdominal radiography, pregnancy test and study of different types of toxics , being all of them normal and negative. 

A Computerized Axial Tomography of the brain was taken that showed  an hypodense lession in the frontal right part of the brain, suggesting ischemia in the territory of the right anterior cerebral artery

Just five hours after admission, her clinical condition got worsed, decreasing her level of consciousness, vomiting, and with more abnormalities in the neurological examintaion as dysphasia, paresis of the right central facial nerve and right hemianopia. As time went by also paresia of the right hemisphere with positive Babinski appeared, so treatment with intravenous anticoagulation was prescribed suspecting a progressive ischaemic stroke.

She was admitted to the Stoke Unit. During admission, a Magnetic Resonance Imaging  was performed, reported a stenosis of the cervical segment in the left internal carotid due to a dissection with also affection in both frontal hemispheres.

The final Diagnosis was Bifrontal and Left parietal ischaemia with spontaneous dissection of  left carotid artery.

She continued with anticoagulation treatment, with progressive improvement of the neurological condition and after thirty-two days of admission, she had a nearly complete resolution of symptoms, remaining just some attention problems.

A month later, she could manage to do normal life without any help.

As always in Medicine, the most important thing to do is a good clinical history and physical examination before jump into wrong conclusions.

As in this case, we must ruled out potentially serious illness, before attributing the cause of the wrong behaviour to a toxic or psychiatric origin.

Luz Tamara VÁZQUEZ (MADRID, Spain), María CUADRADO, Luis YUBERO, Isabel FERNÁNDEZ, Luis PÉREZ, Santiago BERMEJO, Francisco JIMÉNEZ, Manuel GIL
11:00 - 18:00 #8048 - Be careful! It may be emphysematous cystitis.
Be careful! It may be emphysematous cystitis.

Introduction:Urinary tract infections are a large share of emergency servise visits. Although most of the them are outpatient, complicated urinary infections are hospitalized. Besides it is an etiology of abdominal pain and sepsis, one of the complication of urinary tract infection is emphysematous cytitis. Emphysema is seen in bladder wall and lumen and also can results with a air embolism in vena cava.

Case report: Our patient is 87 year old woman applied to emergency department with abdominal pain, fever with unstabil condition. She has hypertension, diabetes mellitus, hyperlypidemia, chronic renal disease, coronary artery diseases. In her physical examination the blood pressure was 90/60 with sinus tachicardia of 120/min. Her temperature was 38.5C, arterial oxygen saturation estimated by pulse oxymetery was 95%, respiratory rate was 14/min and blood glucose was 290mg/dl. The lungs were clear oscultation. The heart sounds were normal with no murmur. Lower of abdomen was distanded and tender. There were positive peritoneal irritation signs and bowel sounds were alleviated. Laboratory findings are respectively; WBC:14,400/µl, CRP:40,3mg/dl Creatine:1,3mg/dl, Urea:65,9mg/dl. Urinary catheterisation was applied but no urine output occurred in the first hours of visit. Her abdominal computer tomography was done and air-fluid level in bladder, gas bubble accumulation in bladder wall and lumen, air bubbles in vena cava inferior lumen were seen. While observation, she had cardiac arrest. She was resuscitated for 45 minutes and was not responded to CPR.

Discussion: Emphysematous cystitis with venous air embolism is rarely seen in emergency services. It can be a mortal complication of urinary tract infections in patients with predispositing factors like diabetes mellitus as our case. The pathophysiology is has not identified yet, but the accepted mechanism is accumulation of carbondioxyde and hydrogene by infected microorganisms. Computer tomography demonstrates the gas accumulation not only in bladder wall and lumen but also in vena cava inferior. An accelerated process was occurred in our patient resulted with mortality. The management of emphysematous cystitis is drainage and antibiotherapy sensitive to organism. In conclusion, the emergency physicians should keep this complication with differential diagnosis of abdominal pain in mind.

References: 1.KARASHIMA, E., EJIMA, J. I., NAKAMURA, H., KOIKE, A., KANEKO, T., & OHMURA, I. (2005). Emphysematous cystitis with venous bubbles. Internal Medicine44(6), 590-592.

2.Yokokawa, R., H. Tsuka, and K. Muranaka. "[Emphysematous cystitis with air bubbles in the vena cava]." Nihon Hinyokika Gakkai zasshi. The japanese journal of urology 105.1 (2014): 22-25.

Acknowledgments: There is no conflict of interest in this study.

Attila BESTEMIR, Goksu BERIKOL (Istanbul, Turkey), Mehmet Serkan YURDAKUL
11:00 - 18:00 #7323 - Bedside Percutaneous Cecostomy, a Candidate Treatment Option for 'Acute Tension Megacolon’ at ED: a Case Report.
Bedside Percutaneous Cecostomy, a Candidate Treatment Option for 'Acute Tension Megacolon’ at ED: a Case Report.


The treatment of Ogilvie’s syndrome begins with usual conservative treatment of ileus followed by neostigmine administration and/or colonoscopic exsufflation, with surgery as the last choice. We report a case, for which bedside percutaneous cecostomy, a rarely utilized method, was tried at ED.

Case presentation

A 20-year-old, uncommunicable, bed-ridden male patient with cerebral palsy and epilepsy on levetiracetam presented at ED. According to the caregiver, his abdomen began to distend 3 days ago with constipation. The next day, he vomited twice. One day ago, fever developed. Nothing was given via the PEG since then. He had undergone mediastinal tracheostomy and percutaneous endoscopic gastrostomy (PEG) for aspiration tendency.

He looked acutely ill, slightly drowsy, and cachexic (168cm, 36kg). Vital signs were 129/76mmHg-140/min–20/min-39.0°C. Abdomen was distended, tense, and hyper-tympanic on percussion. Metallic sound was heard. PEG drained brown to dark green fluid. There were no pressure ulcers. Chest x-ray was non-specific. Abdomen x-ray revealed megacolon. Routine laboratory findings were normal except leukocytosis (15.31*103/µl) and high CRP (22.2mg/dl).

Suspecting ileus-related sepsis, we initiated full hydration and empirical antibiotics (ceftriaxone and metronidazole). PEG was naturally drained. A rectal tube was inserted. Abdomen CT revealed megacolon (maximum diameter: 11.5cm) without obstructing mass, free air, or meaningful peritoneal fluid. On consultation, with possible laparotomy in mind, the general surgeon inserted a 40mm-long, 22 gauge needle vertically at 3cm above the umbilicus, where the megacolon abutted abdominal wall. He compressed abdomen very gently for 10 minutes for the gas inside the megacolon to come out. The width and height of abdomen, at the umbilicus level, decreased from 26.0cm to 22.0cm and from 22.5cm to 19.0cm, respectively. The patient looked comfortable and was admitted to a general ward with stabilized vital signs: 118/68mmHg-90/min-20/min-37.8°C.

Colonoscopic exsufflation was also performed. However, the patient got unstable and received oxygen and meropenem from the 2nd hospital day (HD). Two days later, he underwent right hemicolectomy. The remarkably dilated ascending colon showed ulcer and perforation at its right lateral aspect with generalized peritonitis and adhesions. (The needle decompression puncture site, far from these lesions, was undetectable.) Despite intraabdominal abscess, which was drained percutaneously for 3 weeks (14th-36th HD), he has improved steadily and will be sent home soon as of the 50th HD.


As no obstruction nor colitis caused megacolon, this case could be defined as Ogilvie’s syndrome, acute colonic pseudo-obstruction (ACPO). In case of ACPO, supposedly caused by decreased parasympathetic activity, neostigmine and colonic exsufflation are recommended additionally. For this bed-ridden patient with malnutrition, surgery was to be delayed, if possible, considering high postoperative mortality rate (40%). Bedside needle decompression, which has been reported for treatment of ACPO, was tried initially. Although surgery was performed finally, percutaneous cecostomy seems to have delayed the septic process. It remains to be answered whether a retention catheter placement might have obviated the need for surgery.


1. Pereira Pet al. Ogilvie's Syndrome-Acute Colonic Pseudo-Obstruction.J Visc Surg. 2015;152(2):99-105

2. vanSonnenberg E et al. Percutaneous Cecostomy for Ogilvie Syndrome: Laboratory Observations and Clinical Experience. Radiology. 1990;175(3):679-82

Sung-Bin CHON (Ras Al Khaimah, United Arab Emirates), Intaek LEE
11:00 - 18:00 #8185 - Benzylglycinamide abuse: a new psychoactive substance analytically-confirmed case.
Benzylglycinamide abuse: a new psychoactive substance analytically-confirmed case.

Objective: We present a case of analytically-confirmed consumption of benzylglycinamide, a phenyl derivative of glycinamide and an analogue of milacemide (1,2) in a patient with a suspected intoxication by New Psychoactive Substances (NPS).

Case report: A female patient, 21, with a history of addiction was admitted to the psychiatric ward with a suspected NPS intoxication. She showed reduced emotional expression, dysphoria, restlessness and denied any consumption of drugs of abuse. Her mother referred about some episodes of “absence” during the previous month. Standard toxicological screening in urine, neurological examinations, standard and sleep-deprived EEG and MRN tested negative. Urine sample and a powder found by the patient’s mother were sent to our laboratory for NPS screening. The analysis of the powder performed both in gascromatography-mass spectrometry (GC-MS), full scan mode and in 1H-NMR proved it was benzylglycinamide. The benzylglycinamide transitions (precursor ion 165.05; quantifier transition 90.95, qualifier 120) used for the analysis in Liquid Cromatography-Tandem Mass Spectrometry, Multiple Reaction Monitoring mode, were obtained through the tuning of the powder, being a certified standard of benzylglycinamide difficult to purchase from our supplier companies. 1ml urine, additivated with dosulepin as internal standard, was extracted with a mixture of exane:ethylacetate (3:1) at pH14 and analysed by the LC-MS-MS system. The analysis resulted positive for benzylglycinamide (230 ng/ml). Urine was also submitted to the screening for NPS (3) that involves: a generic analysis for basic, non-volatile substances by GC-MS; a screening by LC-MS-MS for NPS belonging to the classes of cathinones, benzofurans, 2C-family drugs, other amphetamine-like substances, dissociative anaesthetic and two immunoassays for synthetic cannabinoids in urine. No positivity emerged. Buprenorphine, LSD, and ecstasy tested negative, too.

Conclusion:Benzylglycinamide was never commercialized and no data about its pharmacokinetic and pharmacodinamic in human is available. The evidence presented here is concerning with a warning of N-benzylglycinamide as a possible NPS whose effects are almost completely unknown.


References: 1. Sussan S, Dagan A, Blotnik et al. The structural requirements for the design of antiepileptic-glycine derivatives. Epilepsy Research 1999;34:207-220: 2. O’Brien E M, Dosterrt P, Pevarello P et al. Interactions of some analogues of the anticonvulsant milacemide with monoamine oxidase.1994 Biochem Pharmacol;48:905-914; 3. Papa P,  Rocchi L,  Rolandi L, Valli A et al. Research and identification of new psychoactive substances in cases of suspected intoxication in Italy. 2014 Italian Journal on Addiction;4:50-56

Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy), Antonella VALLI, Eleonora BUSCAGLIA, Pietro PAPA, Loretta ROCCHI, Laura ROLANDI, Marcello DI TUCCIO, Massimo SERRA, Davide LONATI, Valeria Margherita PETROLINI
11:00 - 18:00 #7865 - Beware: unexpected heart reaction.
Beware: unexpected heart reaction.

INTRODUCTION: Brugada syndrome (BS) is classified as an channelopathy, whose consequence is the predisposition to arrhythmias. SB prevalence is around 5 in every 10,000 people, although it is estimated that there is also a large percentage of the population with silent forms of the disease and, therefore, there are people who are undiagnosed. Between 17% and 42% of them present syncope or sudden death due to ventricular arrhythmia during mostly, the third or fourth decade of life. SB patients have an increased risk of suffering atrial arrhythmias, especially atrial fibrillation (AF) risk. The incidence of atrial fibrillation in patients with Brugada syndrome is 10 to 20% and, in turn, the presence of AF was associated with a severe presentation of disease and increased risk of ventricular fibriliación. AF is the arrhythmia most common presentation in the Emergency Departments (ED), so it is crucial to know all the possible etiologies of the AF for proper patient management, minimizing the risk that the patients would suffer adverse events.

OBJECTIVE: Recycling and update training for the management of Brugada syndrome in the context of tachyarrhythmias that are handled in the usual emergency practice.

METHODS AND RESULTS: A case report: Male, 42 years without allergies, smoker ten packs / year, without family or other personal factors of structural heart disease. He arrived to Hospital in an ambulance with well tolerated palpitations, that started 2 hours ago. He refers previous episodes that are self-limiting in recent years, with electrocardiogram (ECG) without pathology when he is seen. Upon arrival, hemodynamically stable, the ECG shows a narrow QRS tachyarrhythmia with left axis and morphology of Incomplete Right Bundle branch block compatible with AF to 130 bpm. The chest X-ray shows no findings. The patient is not with chest pain and there are not signs of heart failure, so we proceed to cardioversion pharmacologically with intravenous flecainide. After 5 minutes, the patient reported being "dizzy", while retaining hemodynamic parameters. We repeat ECG, that confirms us became to sinus rhythm (SR), although with alterations in repolarization of V1 to V3 compatible with BS type I.

The patient has hemodynamic and clinical stability, and being asymptomatic, so he goes to observation area, where he recovered the ECG original morphology of repolarization, and remaining in SR in the following 6 hours. Serial tests of markers of myocardial necrosis are made more than 12 hours of onset of symptoms, and there is not evidence of an ischemic event. The patient is valued by Cardiology, and due to the clinical presentation and evolution (Asymptomatic, BS morphology type I after blocking sodium channels drugs, and without family history of sudden death), the patient is discharged from hospital to continue the study and monitoring by the Arrhythmia Unit. 

CONCLUSIONS: Although the BS has a low prevalence, the high incidence of AF and its management in Emergency Departments, must motivate us to have a proper recycling in the etiology of atrial arrhythmias, to ensure patient safety and proper integrated management in the ED.

11:00 - 18:00 #7900 - Bilateral Perforating Eye Injury during Mole Hunting.
Bilateral Perforating Eye Injury during Mole Hunting.

AIM: Trauma of eye can cause significant morbidity and effects on human life. Perforating eye injuries due to trauma are almost always unilateral. In this case report, bilateral eye perforation is caused by a primitive tool, a mole gun.
CASE: A 63-year-old male patient applied to the emergency service after the mole gun, a pistol used to trap moles, accidentally discharged and caused eye injury. He was conscious, cooperative and his vital signs were stable. On examination, both eyelids were edematous. Several buckshot inlet holes and gunshot residue were present on his face and eyelids. Serious subconjunctival edema (chemosis) and subconjunctival hemorrhage findings were determined. The operations which the patient underwent were correction of the perforation of the right eye, posterior vitrectomy and removal of the intraocular foreign object. The left eye wasn’t operated because, there was no any expectation for vision.
CONCLUSION: Bilateral eye perforation, which has a very low incidence, may lead to serious morbidity. Increasing work safety and refinement of training programmes about consciousness-raising will reduce a considerable part of eye traumas.

Tarık OCAK (Bolu, Turkey), Arif DURAN, Mesut ERDURMUŞ, Ümit Yaşar TEKELIOĞLU
11:00 - 18:00 #7113 - Bilateral pneumoperitoneum in patient with vomiting.
Bilateral pneumoperitoneum in patient with vomiting.

Case Report:

50 year old male, smoker 1.5paquetes / day, benign prostatic hypertrophy

The patient comes to the emergency department with vomiting for two days of evolution, has barely tolerated referred liquids and abdominal discomfort right upper quadrant and right flank,

Exploration / Development

Upon arrival to the emergency department presents a blood pressure 125/63. Heart rate 95 beats per minute (bpm) and temperature 36.5 ° C.

Signs of dehydration in mucosal disease strikes, skin pallor, abdominal examination to tenderness in abdomen RH signed Murphy + and voluntary muscular defense; When thinking about possible disease of the bile duct or kidney disease, blood test request, urine, abdominal radiography and peripherally administering channeled Pantoprazole + Metamizol IV.

After 40 minutes of arrival, Nursing warns us for worsening of the patient, which is rescanned and presents an abdominal palpation with widespread pain, belly "on board" with signs of peritoneal irritation; he moved to radiology and abdominal radiography in which dilated small bowel loops and absence of distal gas and chest radiography in principle is performed in supine for patient comfort in which no pathological images are seen seen is performed, but in the diagnostic impression drilling is performed seated chest, appreciating imgen of "bilateral pneumoperitoneum."

It contacts the service of Digestive Surgery and treatment is initiated with antibiotics (piperacillin / tazobactam 4 mg).

Then they proceed to surgery and they appreciate a sharp stomach ulcer with pyloric perforation 3 cm long axis and chemical peritonitis with involvement of the 4 quadrants 


Chest x-ray: No pictures of pneumonic infiltrates are seen.

Blood test: 13.92 leukocytes with 75% neutrophils, creatinine 0.79, normal liver profile and PCR 56


After surgery, the patient is admitted to plant antibiotics Surgery


It is important to the successful completion of certain diagnostic tests in suspected acute abdominal pathology

11:00 - 18:00 #7808 - Bleeding after change anticoagulation.
Bleeding after change anticoagulation.


Male patient 66 years after change of anticoagulant therapy makes a 20días (taking rivaroxaban and initiated acenocumarol) refers bleeding episodes at several levels: bleeding gums, epistaxis and from the previous day hiposfagma with hematoma infraorbitario left without trauma or eye clinic. Refers dyspnea with moderate effort, without fever or infectious clinic.

AP: Permanent Atrial Fibrillation. IHD. Mellitus diabetes. HTA.


Physical exploration:

REG. BHyP. TA 120 / 80mmHg. Sat O2 99%. Afebrile.

ACP: arrhythmic and audible tones. No murmurs. MVC with some isolated roncus.

Left Eye: left infraorbital hematoma, hiposfagma with conjunctival edema.


Supplementary tests:

CBC: Hb 12.2. Platelets 330000. Leukocyte 9200.  Coagulation: INR 10'7. Biochemistry:Glucose 33. Urea 82. Creatinine 0'9. Na 136. K 4'6

Rx thorax: alveolar-interstitial infiltrate bilateral.



After the analytical results, the patient was admitted to observation area where prothrombin complex is administered, achieving figures of INR in range.

He later joined by pulmonology for development of pulmonary hemorrhage.


Updates pharmacopoeia helps prevent complications of older drugs such as acenocumarol complications and difficult INR control.

Valentina MORELL, Enrique CARO (MALAGA, Spain), María Carmen RODRÍGUEZ CASIMIRO, Juan Antonio RIVERO, Eduardo ROSELL, Antonio Ramón BOSCÁ CRESPO
11:00 - 18:00 #7782 - Bleeding in anticoagulated patient: report of a rare case.
Bleeding in anticoagulated patient: report of a rare case.

79 year old woman patient, diabetic, hypertension, ischemic heart disease with triple bypass and pacemaker carrier, treated with acenocoumarol, atorvastatin, enalapril and metformin. Go to emergency room for nausea, vomiting and abdominal pain 12 hours of evolution, previously serviced by ambulance and treated coin antiemetics and sulpiride, without improvement. Not refer other symptoms.
Physical examination: neurological examination, abdominal and cardiorespiratory auscuktation within normal limits.
Blood tests, urine and abdominal radiographs are requested. Sulpiride is intramuscular regimen, without improvement.
- Analytical discrete neutrophilia, PCR <1, INR 2'3. Rest within normal limits.
- Urine: neutrophilic leukocytosis.
- Radiography abdomen without pathological images.
During the stay in the ER, suffers clinical worsening, with dizziness and convulsion, why is serviced in Box CPR.
Immediately, the patient is monitored, stabilized and ECG and CT scan are requested. While performing cranial CT suffers ventricular fibrillation episode objectified in monitor, so electric shock is applied with 150 J and permeability of the airway is maintained with self-inflating bag and oropharyngeal cannula.

Results cranial CT: acute parenchymal hematoma in left cerebellar hemisphere of 2.5 x 2.5 cm, with perilesional edema without mass effect on the fourth ventricle or other infratentorial parenchyma.
It warns Intensive Care Unit and the neurosurgeon. Vitamin K and prothrombin complex are administered. Analytical requested magnesium levels. Neurosurgery discarded surgical approach. Intensive Care indicates tell if clinical worsening. The patient remains in watching ER. It is reported relatives of the patient.
Analytical stands glucose 288 mg / dL, magnesium 1'1 mg / dL.
After the replacement of magnesium, neurological patient monitoring and maintaining the Glasgow score 15 without objectified hemodynamic deterioration, it is admitted by Neurology.

Faced with a suggestive picture of vertigo resistant to treatment, we must suspect a central source. In this case, since the patient is anticoagulated, it is important to perform a CT scan to rule out bleeding. We know the management of hemorrhage in the anticoagulated patient, since the reversal of INR help control bleeding and therefore clinical worsening. It is also important to know the classification of bleeding in anticoagulated patients: minor bleeding, severe bleeding and severe bleeding with life-threatening. In our case, this is a hemorrhage of the third kind, since it is symptomatic intracranial hemorrhage (debuting with vomiting, dizziness and seizure). In severe bleeding in anticoagulated patient with acenocumarol we must administer vitamin K and prothrombin complex to reverse the anticoagulant effect of the drug as soon as possible.

Marina BUFORN, Enrique CARO (MALAGA, Spain), Carmen Adela YAGO, Andrés BUFORN
11:00 - 18:00 #7479 - Blood products wastage in major traumas.
Blood products wastage in major traumas.


The major haemorrhage protocol (MHP) is frequently activated in major trauma (MT) cases and consequently blood products wastage becomes inevitable.


Since Aintree University Hospital became a Major Trauma Centre (MTC) in June 2012 there have been 349 MHP activations for traumas alone.

Code Red (CR) activations were introduced at Aintree University Hospital in October 2014 whereby the MHP could be activated prior to patient arrival in the Emergency Department (ED) in anticipation of massive transfusion requirements.

Not all blood products that are ordered and issued are appropriately used or returned to the laboratory, resulting in avoidable wastage and extra costs. From November 2015 to March 2016, at Aintree University Hospital, there was £2,942 worth of wasted blood products on trauma cases.



To review the wastage of blood products when the MHP is activated in MT cases and to see if this has changed following the introduction of CR activations in October 2014.



Data from MHP activations as a result of MT was collected and collated.

A 3-month period was chosen and data prior to the introduction of CR activations (June to August 2013) was compared with data after its introduction (June to August 2015) and analysed.



There were a total of 26 MHP activations as a result of MT from June to August 2013 and also 26 activations from June to August 2015.

There were 3 units RBC (O-negative), 18 units FFP and 1 unit of platelets across 6 cases wasted from June to August 2013 compared to 2 units RBC (O-negative), 12 units FFP and 1 unit Cryoprecipitate across 5 cases (3 were CR cases) from June to August 2015.



This audit demonstrates that blood products are wasted in MT cases when the MHP is activated. Reasons cover blood products that are collected, not used and then returned out of their controlled temperature (>30 minutes post collection) to the laboratory or blood products that are ordered and issued post MHP activation but then no longer needed nor returned to the laboratory.

Interestingly the wastage of blood products did not significantly change following the introduction of CR activations for this cohort of data.

This wastage of blood products can be potentially avoidable. This audit highlights the need for the introduction and reinforcement of clear protocols within the ED for effective blood product management in MT cases to reduce blood product wastage and associated costs.

Tom BARKER, Abdo SATTOUT (Liverpool, UK, United Kingdom), Michael HICKEY
11:00 - 18:00 #7751 - Both renal infarction and renal colic.
Both renal infarction and renal colic.

INTRODUCTION: Acute renal infarction is a serious medical emergency. The diagnosis is often delayed or missed as it is not common.Hence, the exact incidence of acute renal infarction is not known. Failure to consider renal infarction in the initial differential diagnosis results in a delay in diagnosis and treatment, which in turn leads to permanent loss of renal function. We present a case of acute kidney infarction that was initially treated as renal colic.
CASE: A 45-year-old man presented to the emergency department with left flank pain and right lower quadrant abdominal pain. In his medical history, left side renal stone and suffered cerebrovascular accident were detected. Physical examination revealed right costavertebral angle tenderness. His pain continued despite NSAID and narcotic drugs. The CT scan revealed wedge style cortical and medullar hypodens areas accordance with renal infarct on level of the central and upper pole of the right kidney. Renal angiogram confirmed to infarct. He was interned to interventional radyology.
CONCLUSION: Acute embolic renal infarction is an entity that is often misdiagnosed as a renal calculus because of similar presenting symptoms. This leads to delay in the initiation of treatment and to increased morbidity.

11:00 - 18:00 #8063 - Breaking Bad News: the Take five program.
Breaking Bad News: the Take five program.


For many years, bad news delivery’s impact on patients or their relatives, as well as physicians’ stress has been a major concern. On the basis of studies emphasizing the potent efficacy of training courses to help physicians delivering such news, many protocols, like SPIKES, BREAKS or SHARE, have been developed worldwide. However, training to such protocol might be time-consuming and not suitable with junior doctors or trainees’ turnover. Indeed, there is currently no teaching program validated to date. We hypothesised that a short simulation program (the TAKE 5 program) could improve bad news delivery performances, reaching a level comparable with longer course programs. We therefore designed the present study to evaluate the potential impact of this standardized 5-hours training program.

Participants and methods

This preliminary study was conducted in the Emergency Department of a tertiary care academic hospital accounting for 90 000 ED census per year, 16 attending emergency physicians, 10 junior residents, and 5 trainees per month. Data were extracted from a 5-months period between November 2015 and April 2016.

The study included three phases over 4 weeks. Video recorded individual role-playing sessions happened the first (T1) and the fourth (T3) weeks. A 3-hour theoretical training group session happened the second week  (T2), introducing the basic principles of therapeutic communication and delivering bad news based on the SPIKES protocol. Each role-playing session lasted approximately 1 hour with 10 minutes briefing and medical case acknowledgement, 10 minutes role-plays and 40 minutes group debriefing. We created an 8 scenarios database (paediatric with severe asthma attack, road accident, intracranial bleeding) for the role-playing sessions.

Bad news delivery performance evaluation was based on a 14 points retrospective assessment tool (1). We collected data about the status and impact of a stressful event at 3-days using the french version of the IES-R scale (2). We applied Student t-tests for statistical analysis.


A total of 14 volunteers (10 trainees and 4 junior emergency physicians) were included in the study. On average, bad-news delivery process took 9’45’’ at T1 and 10’20’’ at T3. Form T1 to T3, bad-news delivery performance increased significantly for both the junior emergency physicians and trainees (p=0.0003 and p=0.0006, respectively). Further analysis revealed that most relevant increases concerned the “situation” (p<0.001), “presentation” (p=0.009), “knowledge” (p=0.037), “emotions” (p=0.01) and “summary” (p=0.001) steps. Interestingly, we also found a significant decrease of the impact of bad-news delivery on trainee physicians’ stress (p=0.006).


These preliminary results indicate some potential for this new standardized course of breaking bad news delivery.  Apart from allowing physicians increase their communications skills, we believe that this simple 5-hour simulation-training program could alleviate physicians’ stress when they happen to break bad news.


1. Brunet, A. et al. (2003). Validation of a French version of the Impact of Event Scale-Revised. Can J Psychiatry, 48(1), 56-61.

2. Park, I. et al. (2010). Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. J Emerg Trauma Shock, 3(4), 385-388.

Aline GILLET, Isabelle VAN CAUWENBERGE (Mechelen, Belgium), Rebecca TUBES, Alexandre GHUYSEN
11:00 - 18:00 #7620 - Broken or not? nuchal ligament ossification: case report.
Broken or not? nuchal ligament ossification: case report.

Introduction: The nuchal ligament extends from the external occipital protuberance on the skull and median nuchal line to the spinous process of the seventh cervical vertebra in the lower part of the neck. It is responsible for providing the stabilizing of the head and maintaining the lordotic alignment of the cervical spine during the movement of the neck. The pathogenesis of this condition is not clear, as a result of mechanical factors and repetitive trauma, calcifications occurs at the nuchal ligament. This calcification often round or ovoid structure, uniformly bounded. They are seen as parallel to longitudinat axis. They are seen usually in a single bone. The most frequent localizations are C5-6 and C6-7. They occur in almost 7.5% of the population, with a male predominance of 3:1.

Case Report: A-66-year-old male patient was admitted to head and neck pain after hitting his head and fall down. The patient had no systemic diseases known. Vital signs were normal. On physical examination, there was dermabrasion head in the frontal region and nasal dorsum. Neck movements were normal. There was no neurological deficit, other system examinations were normal. Because of trauma, skull and neck radiographs was performed. Lateral radiographs of the cervical spine was shown two opaque lesions which was present at the level of C5 between spinous proces, in bone density, had longitudinal elongation. CT was performed to exclude avulsion fracture. CT was shown well-defined, ovoid, longitudinally extending parallel parts, in different sizes, 2 bony structures. These structures were considered as the nuchal ligament ossification. The patient was discharged with analgesics.

Conclusion: Age-related changes and the anatomical variations can be easily confused with pathological conditions, particularly at direct graphics. When clinicians have knowledge of such anatomical variations, that will help in patient assessment.

Ilker AKBAS (Erzurum, Turkey), Abdullah Osman KOCAK, Esra KADIOGLU, Mustafa UZKESER
11:00 - 18:00 #8111 - Bronchodilator treatment of patients with COPD at home in the emergency department and at discharge. Are clinical practice guidelines followed?
Bronchodilator treatment of patients with COPD at home in the emergency department and at discharge. Are clinical practice guidelines followed?

Chronic obstructive pulmonary disease (COPD) is a health problem of great magnitude and intensification is a major cause of morbidity and mortality. Consumes many resources with increased incidence foreseeable in the immediate future.

Rate track clinical practice guidelines (CPG), analyzing bronchodilator treatment they receive at home in emergencies and at discharge.

Material and method
descriptive, observational and retrospective study General Hospital with population of 200,000 and 275 emergency / day. 1167 patients treated with COPD exacerbations from January 2012 to July 2015 with FEV1 <70% were included proven. home treatment in emergency and high: the variables were collected.

Of the 1167 patients who met criteria for inclusion in the study, home treatment bronchodilator which were prior to the aggravation was: b2 inhaled short-rescue action in 285 (24.5%) patients, b2 inhaled long-acting 71 (6.1%) and 5 (0.4%) nebulized. 87 (7.5%) were receiving anticholinergic (AC) inhaled short-acting, 815 (69.8) AC long and 25 share (2.1%) nebulized. 855 (73.3%) were receiving inhaled corticosteroid treatment and 5 (0.4%) nebulized.
After evaluation in the emergency room, treatment was initiated in boxes with inhaled b2 in 19 (1.8%) patients and 781 (67%) nebulized. 131 (11.2%) patients were treated with inhaled anticholinergic and 854 (73.2%) with nebulized. 121 (10.4%) patients received inhaled corticosteroid, 440 (37.7%) nebulized and 838 (71.8%) Intravenous corticosteroid. Of the patients who consulted, 371 (36.1%) were discharged without income and bronchodilator prescribed treatment was: b2 inhaled short acting in 259 (22.3%) patients, b2 inhaled long-acting 50 (4.3%), b2 inhaled rescue 112 (9.6%) and 41 (3.5%) nebulised. 79 (6.8%) patients treated with short-acting inhaled AC, 212 (18.2%) AC long and 50 share (4.3%) with nebulized. In 252 (21.6%) were prescribed oral corticosteroids, 246 (21.1%) inhaled and 49 (4.2%) nebulized.

Against the GPC, where the main treatment are bronchodilators, in our series only 65-75% received bronchodilators (beta2 or anticholinergics). The use of systemic corticosteroids was largely as indicated by the GPC. We think that despite being a known disease requires training and dissemination of GPC for better management of this patients in the emergency room

11:00 - 18:00 #7667 - Brucellosis back pain as cause of acute emergencies.
Brucellosis back pain as cause of acute emergencies.

An 74 year old woman with a history of arterial and diabetic hypertension independent and active life, which refers in the last two months, multiple emergency room visits for lumbosacral pain of inflammatory and mechanical characteristics, which radiates to gluteal and lower limb right associating dysesthesia and gradually you have finished prostrating in bed in the last 7 days. It has repeatedly been diagnosed lumbosciatica right. She lives in an urban environment and eat dairy and meat supermarket. It has been treated with analgesics and anti-inflammatories several null responders them. Associated asthenia, hyporexia and weight loss. After being removed all anti-inflammatory medication, for mild renal impairment in a visit to the emergency room 48 hours prior to admission, begins with fever, reason leading to perform several differential diagnoses to symptoms of fever, acute low back pain.

On examination patient collaborator, overweight, fair general condition, fever 39.4Cº, on a stretcher. .Eupneic, Normotensive. Well hydrated and perfused.

 Auscultation and regular rhythmic tones, aortic systolic murmur IV / VI, hypoventilation in both bases. Mamas without findings.

Abdomen: globular, symmetrical, soft, depressible without mass or organ enlargement. Pain on deep palpation in the right iliac fossa, without peritoneal irritation.

Lower extremities signs of chronic venous insufficiency. No edemas.

Neurological examination: no focal neurological deficits of cranial nerves or sensory-motor pathways. No meningeal signs.

Locomotor: slight deformity of both knees in relation to degenerative changes. Acupressure pain of lumbar spinous dorsal distal and proximal movement Arcos de coxofemorales diminished by pain. bilateral negative fabers. bilateral negative brush with limited flexion no signs of arthritis or knee or ankle or metatarsophalangeal. bilateral flexor plantar skin with no signs of spasticity. Lassegue and positive Bragard Left 40 Cº.

Analytical hemoglobin 10 Leukocyte 6790.

Simple Thorax Radiography: costophrenic grip both breasts.

Radiography lumbosacral spine: listesis L5 and decreased joint space of the right sacroiliac joint.

 Rose Bengal test: positive.

Final diagnosis: right sacroiliitis with spondylodiscitis L5-S1 brucella source.

Evolution: The patient was admitted to the Infectious Diseases, evolve Doxycycline more favorably after start streptomycin.

 Discussion: Brucellosis is a disease transmissible to humans and capable of affecting various organs and tissues zoonoses. The most common in the human species is Brucella melitensis, whose main reservoir is cattle. The main mechanism of transmission is oral for dairy products. In our case we had to make several differential diagnoses as: degenerative causes, structural changes, infectious, inflammatory changes, tumors, metabolic bone diseases, gynecological problems, kidney or intra-abdominal. It should detect the so-called symptoms and signs of "alarm": the realization fever, toxic shock syndrome, weight loss, previous history of cancer, steroid use, age greater 50 years nocturnal severe pain that does not subside, pain exacerbated supine and standing.

The incidence rate in Andalusia Brucellosis is 7.17 cases per 100,000 inhabitants. Malaga is endemic Brucella infection.

Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #8079 - Buckingham Medical Students' Community First Responder Scheme.
Buckingham Medical Students' Community First Responder Scheme.

The Buckingham Medics’ Community First Responder (BMCFR) Scheme was started in August 2015, and was created by medical students following some research into average medical service response times, and the population demographic of the town.

The scheme allows medical students to complete additional training to enable them to respond to potentially life threatening cases on behalf of South Central Ambulance Service. The response is always within a ten-minute driving radius, and encompasses a range of ailments from minor injuries to cardiac arrest. Within the first 3 months, over 100 calls were attended and a much larger interest has been drawn; with hope to extend responder hours to 24/7 within the next few months.

This scheme helps the local community by providing first response medical cover, and it helps medical students to use and apply their knowledge first hand, which seems to be beneficial to the students are cursory data of OSCE performance between responders and non-responders suggests those who are responders do better in first year exams. More data is being collected to conduct a clinical audit by the end of 2018, looking at first hand clinical experience and examination performance.



Andrew NEVES (Buckingham, United Kingdom), Matthew BECK
11:00 - 18:00 #7258 - C is for confusion and consider CT.
C is for confusion and consider CT.


C is for confusion and consider CT.


F Mustafa, N S-Vainberg, P Gilligan


Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is said that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder on investigations. Unfortunately, in the Emergency Department (ED), the clinicians often face the challenge of not having a detailed history available, and the diagnosis, investigations and management of the patient are very dependent on the clinical gestalt of the physician.


We present a case of a confused, withdrawn young female patient that presented to the ED with no clear history available but she admitted to taking paracetamol.


A 24 years old female patient was brought in by ambulance to the ED with a suspected paracetamol overdose. She presented on her own and there was no clear history or collateral history available. She appeared withdrawn and had a GCS of 14/15.

A toxicology screen was sent with routine investigations that all came back normal. At this stage, a friend of hers arrived to the ED expressing concerns that he had contacted the ambulance after not hearing from her for more than 2 days and confirmed that the patient’s family was away. In the context of her confusion and altered mental state a  CT scan of her brain was performed which showed significant intracranial hemorrhage in left parietal and temporal lobes with significant surrounding edema, mass effect, sulcal effacement, compression of lateral ventricle and midline shift.

A CT venogram demonstrated thrombotic occlusion of the intracranial venous system from the level of the left internal jugular vein including left sigmoid and left transverse sinus.

Further evaluation and assessment revealed that the patient had admitted taking paracetamol to relieve the headache she had had for the last 2 weeks.

The patient’s subsequent management and progress are described in detail.


Cerebral venous thrombosis (CVT) is an uncommon presentation to the ED. CVT is believed to be more common in women than in men. In a study, 61% of women with CVT were aged 20 to 35 years. This difference may be related to pregnancy or the use of oral contraceptives.

Not having a history available, poses particular difficulty for EM clinicians to reach a diagnosis. Medical imaging used appropriately in conjunction with clinical gestalt can help significantly in investigating and managing patients.


  1. Ameri A, Bousser MG. Cerebral venous thrombosis. Neurol Clin. 1992 Feb. 10(1):87-111.
  2. Galarza M, Gazzeri R. Cerebral venous sinus thrombosis associated with oral contraceptives: the case for neurosurgery. Neurosurg Focus. 2009 Nov. 27(5):E5.
Farah MUSTAFA, Nikita SVIRKOV-VAINBERG (Dublin, Ireland), Peadar GILLIGAN
11:00 - 18:00 #7450 - C2 fracture with absence of neurological signs.
C2 fracture with absence of neurological signs.


Falls are a common presentation to the Emergency Department (ED). In some cases, the symptoms and clinical examination may not correlate with the severity of the injuries sustained.



An 81 year-old male was brought to our ED after tripping on a loose carpet and falling forward down 12 stairs. There was no loss of consciousness and he was able to mobilise with no limitations after the fall. He was immobilised by the ambulance crew based on the mechanism of injury.

Examination revealed tenderness to the left aspect of the neck, no midline cervical spine tenderness, a GCS of 15 and no neurological deficit.

In accordance with NICE guidelines, an urgent computed tomography (CT) scan of head and neck revealed a displaced fracture through the base of odontoid process with significant anterior and left lateral subluxation and dislocation of the body of C2 in relation to C1. There was surrounding haematoma with a degree of spinal canal compromise at C1-C2 level.

Due to the severity of the fracture and preserved neurology, the patient was transferred urgently to the regional neurosurgical unit for posterior C1-C2 fixation. He made good post-operative recovery and was discharged 5 days later with an Aspen collar to be worn for 8-12 weeks.



Cervical spine injuries account for 3.7% of all trauma patients with an estimated incidence around 11.8 per 100,000 per year. Falls (60%) are the commonest mechanism of injury followed by motor related accidents. Involvement of the C1-C2 complex accounts for 19-25% of all cervical spine fractures with odontoid process accounting 55% of these.

Odontoid fractures are classified as Type I (upper tip of the odontoid process only), Type II (through the base of the odontoid process) or Type III (body of C2).

Patients usually complain of neck pain and inability to actively move the neck with a sensation of instability. Examination findings can be as severe as quadriplegia with respiratory involvement but more commonly (up to 79% of cervical spine fractures) no neurological deficit is identified.

Diagnosis relies on clinical examination and radiological imaging (plain X-rays or CT scans). However, NICE suggest that, as a minimum, CT scans should cover any areas of concern or uncertainty from X-rays or clinical examination. MRI may add important information about ligament and disc injuries.

Treatment for Type I fractures is immobilization with a hard-collar for 6-8 weeks whilst Type II and III fractures can be managed either conservatively or surgically (external immobilization with a halo vest, internal fixation/ odontoid screw fixation or posterior C1-C2 arthrodesis).



Significant cervical spine injury can be present with minimal signs and symptoms. Patients demographics (especially the elderly) and mechanism of injury should always be considered when deciding on choice of investigations.

Tom BARKER, Abdo SATTOUT (Liverpool, UK, United Kingdom)
11:00 - 18:00 #7802 - Can an “Ultrasound First” policy reduce incidence of CT scan use and radiation exposure in pediatric patients presenting to the Emergency Department for Evaluation of Abdominal Pain?
Can an “Ultrasound First” policy reduce incidence of CT scan use and radiation exposure in pediatric patients presenting to the Emergency Department for Evaluation of Abdominal Pain?



Abdominal pain is a common complaint in presentation to the Emergency Department and acute appendicitis is the most common condition requiring emergent abdominal surgery. Early diagnosis to minimize the incidence of perforation is important to a successful outcome, however diagnosis can be challenging in the pediatric population who frequently do not have a classic presentation and to whom radiation exposure is a concern. 


The American Academy of Radiology recommends ultrasonography as the initial imaging modality of choice for children in whom appendicitis is suspected (1). The principles of as-low-as-reasonably-possible (ALARA), an approach to minimizing radiation exposure, suggest ultrasound be used in suspected cases of appendicitis, followed by CT only if the ultrasound results are equivocal.


In January 2013, New York Methodist Hospital instituted an “ultrasound first” policy for the evaluation of abdominal pain in patients presenting to the emergency room ages 18 years and younger.  All patients presenting with abdominal pain undergo an ultrasound examination performed by an ultrasound trained Emergency Medicine attending physician or an ultrasound performed by the radiology department prior to obtaining a CT scan.




To demonstrate that a formal policy recommending ultrasound prior to CT scan in the diagnostic algorithm for acute appendicitis is effective at reducing CT usage and radiation exposure in the pediatric population.




A retrospective chart review was done of all pediatric patients who presented to the emergency room between January 1, 2013 and January 1, 2015 for abdominal pain and underwent an appendectomy. The rate of ultrasound use and CT use was compared to prior ultrasound and CT rates at our institution.




In 2009, prior to the availability of POCUS at our institution, 116 cases of acute appendicitis were analyzed.  Four patients went to the OR solely based on clinical exam findings (3.4%). 10 of 112 (8.9%) cases of acute appendicitis underwent an ultrasound examination prior to CT and 3 of these went to the OR based on ultrasound alone (2.7%)

In 2011, after the introduction of POCUS, 140 cases of acute appendicitis were analyzed.  Six went to the OR based on clinical findings (4.2%). 36 of 134 (26.8%) underwent ultrasound prior to CT and 15 of these went to the OR based on ultrasound alone (11%).

From Jan 1 2013 to Jan 1 2015, there were 104 cases of acute appendicitis. None went to the OR based on clinical findings. 97 of 104 (93.2%) underwent ultrasound prior to CT and 38 of these went to the OR based on ultrasound alone (39.2%).

Introduction of bedside ultrasound followed by implementation of an “ultrasound before CT” policy in our ED has raised the rate of risk avoidance from 2.7% to 38.9%.




Implementation of an “ultrasound first” policy for the evaluation of acute appendicitis for pediatric patients presenting to the ED is associated with a significant reduction in CT utilization.  By decreasing CT use in the ED in the workup of acute appendicitis, it is reasonable to conclude that medical radiation exposure has decreased.

Chiricolo GERARDO (Holmdel, USA), Christopher RAIO, Lindsey BEHAN
11:00 - 18:00 #7073 - Can clinical evaluation determine the need for pelvic x-ray in awake and stable blunt trauma patients?
Can clinical evaluation determine the need for pelvic x-ray in awake and stable blunt trauma patients?

Aim: Pelvic fractures is common and can be potentially life threatening.  The early diagnosis of pelvic fractures resulting from blunt abdominal trauma traditionally relies on the anterior-posterior pelvic radiograph although sometimes it may not give a definitive diagnosis of pelvic fractures. So reliability of pelvic x-ray has been questioned and ways of removing pelvic x-ray from the ATLS protocol are being observed on the basis of finding the reliability of clinical examination in finding out pelvic fractures in alert and awake, hemodynamically stable patient and also to avoid the unnecessary exposure of radiation and reduce the financial burden.

Methods: This is a cross sectional study conducted in the department of surgery, Aga Khan University Hospital, Karachi. This study included patients with blunt trauma mainly the road traffic accident victims presenting the emergency department with GCS of 15, hemodynamically stable and alert and awake. Clinical examination of pelvis of these patients were done on three different examination maneuvers and assessment of pelvic made which was then compared to routine pelvic x-ray findings.

Results: Total of two twenty one (221) of blunt  trauma patients were reviewed having mechanism of injury being road traffic accident and history of fall. Of these 221 patients thirty two (32) were not entered in the study as they had GCS of < 15, fifteen patients were not included as they have abdominal tenderness, fourty one (41) patients had associated lower limb injuries. So the final of one thirty three (133) patients were included in our study. Of these 133 patients majority of patients were male around 91.7% and 8.9% were females. Mean age of patients included in this study 37 with standard deviation of +/- 14.2. Fourteen patients were positive for pelvic fracture on clinical examination and positive on PXR categorized as true positive (TP), fourteen patients were positive for pelvic fracture on clinical exam but negative on PXR and categorized as false positive (FP), two patients were negative for pelvic fracture on clinical exam but positive on PXR categorized as false negative (FN), one hundred and three patients were negative for pelvic fracture both on clinical exam and PXR and were labelled as true negative (TN).

Sensitivity, Specificity, Positive predictive value and Negative predictive value were calculated by using two X two table. Sensitivity of clinic examination was found to be 87.5%, Specificity 88.03%, Positive Predictive Value 50% and Negative predictive value 98.09%.

Conclusion: In relation to above mention findings new protocol can be advised for alert and awake patients and pelvic x-ray can be avoided helping in reducing the financial burden to patient, reducing emergency hassle and unnecessary radiation.  

Muhammad Asad MOOSA (Karachi, Pakistan), Hasnain ZAFAR, Raza SAYYED, Iqra JANGDA
11:00 - 18:00 #7840 - Can Failure Mode and Effects Analysis (HFMEA) improve the door to needle time in patients suspect of ischemic cerebral accident?
Can Failure Mode and Effects Analysis (HFMEA) improve the door to needle time in patients suspect of ischemic cerebral accident?


The door to needle time (DNT), defined as time between arrival of an ischemic stoke patient and the deliver of the thrombolytic agent, is considered to be an important indicator of quality of care. Considering only one out of seven ischemic stroke patient leaves hospital with fully regained functions, it is paramount to deliver the agent to the right patient as fast as possible. Acceptable norm of door to needle time is considered to be within 1 hour. The DNT in Radboud university in 2014 was 41 minutes.  

Failure Mode and Effects Analysis (HFMEA) is systematic techniques for failure analysis. It was developed by reliability engineers in the late 1950s to study problems that might arise from malfunctions of military systems. It is often the first step of a system reliability study.



The current thrombolysis procotol is revised by utilizing HFMEA and the involvement of department of neurologie, radiologie and emergency medicine.


Patients who are suspect of stroke presented at our ED between 1/1/2015 and 31/12/2015 are included in the study. The time between arrival of ischemic stoke patients and deliver of alteplase is recorded and compaired to the same patient group in 2014.


There are 359 stroke patients presented at our ED in 2015. 275 with ischemic stroke, 42 have hemorrhagic stroke and 42 with transient ischemic accident. The DNT in 2015 is 25 minutes compares to 41 minutes in 2014.


Failure Mode and Effects Analysis is able to identify and eliminate de delays in the thrombolysis protocol and effectively shortens the door to needle time by 40%.

Abel WEI (Cuijk, the Netherlands, Netherlands Antilles), Frank Erik DE LEEUW
11:00 - 18:00 #7148 - Can risk factors predict the likelihood of successful reduction of displaced wrist fractures in the emergency department?
Can risk factors predict the likelihood of successful reduction of displaced wrist fractures in the emergency department?

Background: The majority of displaced isolated wrist fractures in Australia are reduced in the Emergency Department (ED) and followed up as outpatients. Previous research has identified a number of risk factors for fracture instability.  Our aim was to describe the prevalence of instability risk factors, the rate of successful fracture reduction according to previously defined radiological criteria and whether the number of risk factors was associated with success of fracture reduction.

Participants and methods: This was a retrospective study performed by medical record review. All adult ED patients coded as having an isolated wrist fracture in 2014 were screened for eligibility. Data collected included demographics, history of osteoporosis, mechanism of injury and radiological features on initial and post-reduction x-rays.  Outcomes of interest were the prevalence of previously defined risk factors, the proportion of patients with good radiological outcome according to pre-defined criteria and any association between the number of risk factors and successful reduction.

Results: 2048 patients were screened for eligibility; 319 met inclusion criteria and had full data. Median age was 62 (IQR 48-74) and 77% were female. Most fractures (73%) resulted from a fall from level ground or height <30cm.  The median number of instability markers was 4 (IQR 3-5); 63% of patients had ≥4 risk factors. Good radiological position according to pre-defined criteria was achieved in 206 patients (65%; 95% CI 59-70%).  The number of instability markers was associated with success of reduction – the higher the number the less likely successful reduction (AUC 0.66, 95% Ci 0.59-0.72; p<0.0001). The previously suggested cut-off for number of risk factors to predict poorer outcome (≥4) had sensitivity of 67%, specificity of 57% and negative predictive value of 52%.

Conclusion: Instability markers are common in patients undergoing fracture reduction in ED. The number of risk factors is only moderately associated with successful reduction however the previously suggested cut-off of ≥4 risk factors had poor sensitivity, poor specificity and negative predictive value for successful fracture reduction in ED. 

Alyza GOSSAT, Amar WINAYAK, Klim SHARON, Jenny COOPER, Peter RITCHIE, Wei LIM, Anne-Maree KELLY (Melbourne, Australia)
11:00 - 18:00 #7577 - Can single dose of duloxetine induce hyponatremia in a middle-aged male patient? A case report.
Can single dose of duloxetine induce hyponatremia in a middle-aged male patient? A case report.

Can single dose of duloxetine induce hyponatremia in a middle-aged male patient? A case report


Introduction: Duloxetine is a serotonin/norepinephrine reuptake inhibitor, used for treating major depressive disorder, diabetic neuropathy, fibromyalgia, generalized anxiety disorder and chronic musculoskeletal pain.[1] The cases of hyponatremia induced by duloxetine have rarely been reported. We report a case of hyponatremia induced by duloxetine developed rapidly after a single dose medication in a middle-aged male with somatic symptoms.

Case: A 28 years old male patient presented to the Emergency Department (ED) with fatigue and dizziness. The patient declared that he had a single dose of duloxetine which was he was prescribed for somatic complaints. A routine laboratory work-up showed a significantly low sodium level (Na= 121 mg/dl). The patient had no known predisposing factors for hyponatremia. Vital signs and physical examination, including neurological evaluation, were normal. The patient’s presentation complaints were completely resolved after duloxetine was ceased and normal saline treatment was given.

Discussion: When treating patients with depression and somatic symptoms, close monitoring for clinical and laboratory evidences of drug related adverse and side effects, such as hyponatremia, are essential. 

11:00 - 18:00 #8163 - Can suPAR add prognostic value in the assessment of surgical patients by predicting mortality and postoperative complications?
Can suPAR add prognostic value in the assessment of surgical patients by predicting mortality and postoperative complications?


Risk assessment of surgical patients is in Denmark based on the American Society of Anesthesiologists (ASA) Physical Status classification. Routinely, no biochemical component is used in the prediction of mortality and postoperative complications.

In acute medical patients, studies have found soluble urokinase plasminogen activator receptor (suPAR) to be an independent predictor of 30-day mortality and adverse outcomes, such as readmission, admission to ICU, and longer admissions. Whether suPAR adds prognostic value to the customary preoperative risk assessment by predicting post-operative outcome in unselected patients in need of acute surgery has not been investigated.

In this study, we aimed to determine whether preoperative suPAR levels were able to predict mortality, postoperative complications, and reoperation in surgical patients.


Between 5 September 2013 and 7 December 2013, suPAR was measured in all patients admitted to the emergency department (ED; n=6,383) at Hillerød hospital, Denmark. Among these, 714 patients underwent various surgical procedures within 90 days from admission to the ED, and follow-up was 90 days. Of these, patients with missing suPAR (n=45) or minor, insignificant, and endoscopic diagnostic procedures (n=145) were excluded.

Complications and reoperations were registered by reviewing medical records of included patients. Complications included various types of pulmonary, thromboembolic, cardiac, renal, infectious, and neurological genesis. Furthermore, death was registered.

suPAR values are presented as medians with interquartile range (IQR), and statistical analysis was performed using Kruskal-Wallis test and receiver operating characteristics (ROC) curve analysis, presented as area under the curve (AUC) values with 95% confidence intervals (CIs).



A total of 524 included patients (283 women (54%); median age 63.4 years, IQR 43.5 – 76.4) underwent significant surgery within 90 days after admission to the ED. Median suPAR for the entire population was 4.5 ng/ml (IQR 3.5 – 6.2).

Median suPAR for the general surgical patients was 4.2 ng/ml (IQR 3.2 – 5.5, n=215), for orthopedic surgical patients 5.2 ng/ml (IQR 3.9 – 6.6, n=201), and for all other surgical patients 4.4 ng/ml (IQR 3.3 – 5.8, n=108).

Out of all included surgical patients, 147 (28.1%) developed one or more complications during follow-up. These patients had significantly higher suPAR compared with patients without complications (5.8 ng/ml (IQR 4.1 - 8.1) vs. 4.2 ng/ml (IQR 3.3 – 5.5), p<0.0001). 71 patients (13.5%) were reoperated, and these patients had significantly higher suPAR compared with patients not reoperated (5.7 ng/ml (IQR 4.0 – 7.7) vs. 4.4 ng/ml (IQR 3.5 – 6.0), p<0.0001).

ROC curve analyses of suPAR for predicting development of complications or reoperation yielded AUCs of 0.69 (95% CI 0.64-0.74) and 0.64 (95% CI 0.57-0.72), respectively.

Results regarding mortality will be presented at the EuSEM 2016.



Among surgical patients, those who developed one or more complications or were in need of reoperation during follow-up had significantly higher suPAR levels, than those with no complications. These results suggest that suPAR may have a preoperative predictive value for development of complications in acutely admitted surgical patients. 

Morten Alstrup and Jeppe Meyer contributed equally to this work.

Morten ALSTRUP, Jeppe MEYER (Copenhagen Ø, Denmark), Line Jee Hartmann RASMUSSEN, Martin SCHULTZ, Jesper EUGEN-OLSEN, Kasper IVERSEN
11:00 - 18:00 #8098 - Can the efficiency of WBC be Increased by Using Hematologic Inflammatory Parameters on Acute Appendicitis Diagnosis?
Can the efficiency of WBC be Increased by Using Hematologic Inflammatory Parameters on Acute Appendicitis Diagnosis?


Purpose: The rate of negative appendectomy in patients suspected of appendicitis is still high. Here, we evaluated the efficiency of parameters like white blood cell(WBC), Neutrophil Leukocytes Ratio(NLR), Mean Platelet Volume(MPV) and Red Blood Cell Distribution Width(RDW) in decreasing the negative appendectomy ratios.

Material and Method: 804 operated acute appendicitis patients in seven years were examined retrospectively. The patients were divided into 2 groups according to the pathology reports (Group AA: Acute Appendicitis, Group NA: negative appendectomy). The age, gender, preoperative WBC, NLR, RDW and MPV values, intraoperative findings, postoperative pathology results and etiologies were recorded.

Results: Of the patients, 58.2 were male and mean age was 30.8±11.9. Logistic regression analysis using enter method and taking age, gender (dichotom) and NLR showed that being female (wald: 6.284, OR: 1.77, 95%CI: 1.133-2.765, p=0.012) and having high NLR (wald: 4.541, OR: 1.057, 95%CI: 1.004-1.111, p=0.033) were independent parameters for negative appendectomy. Area under the curve (AUC) for WBC and NLR to diagnose negative appendectomy patients among patients with prediagnosed appendicitis were 0.598 (95%CI:0.535-0.660; p=0.003) and 0.621 (95%CI:0.556-0.685; p<0.0001), respectively. 

Conclusion: Using WBC together with NLR might decrease Negative Appendectomy rates. 

Sukru ARSLAN, Erdem KARADENIZ, Mucahit EMET, Bunyami OZOGUL (Erzurum, Turkey), Sabri Selcuk ATAMANALP
11:00 - 18:00 #7586 - Can We Use High Sensitive Troponin T as a 30 Day Mortality Predictor in Pulmonary Embolus in Emergecnt Medicine Department?
Can We Use High Sensitive Troponin T as a 30 Day Mortality Predictor in Pulmonary Embolus in Emergecnt Medicine Department?

Introduction: Pulmonary Thromboembolism, almost (%90) originated from deep femoral veins as a complication of separated thrombus or fragments from deep vein thrombosis. PTE is second common, sudden and unpredictable cause of mortality who come to outpatient clinics. We aimed to investigate the predictive power of hsTnT in 30 day prognosis of PTE diagnosed patients.

Material and Method: This prospective cross-sectional clinical study has been carried out between 01.04.2012 and 31.03.2013 in Gazi University, Faculty of Medicine, Department of Emergency Medicine. High Sensitive Troponin T test was performed in all patients in Pulmonary Thromboembolism.

Results: Patients which had high mortality in 30 days were significantly tachycardia, tachypnea, lower pulse saturation and malignancy history (Mann Whitney U test, respectively p:0,041, p:0,002, p:0,027 and p:0,011). Patients that high levels of hsTnT were good correlation about 30 days mortality prediction. (correlation coefficient: rho: + 0,567). HsTnT has 88% sensitivity and 28% specificity about prediction of 30 days of mortality.

Conclusion: HsTnT can be used in patients that diagnosed a PTE,  which can predict right ventricle dysfunctioning.  HsTnT is easy applicable, repeatable and short duration test. Given the advantages of hsTnT, it seems to be appropriate for use prediction of bad prognosis which patients diagnosed a PTE. 

11:00 - 18:00 #7255 - Cannabinoid hyperemesis: An unusal cause of digestive symptoms.
Cannabinoid hyperemesis: An unusal cause of digestive symptoms.

Cannabinoid hyperemesis: An unusal cause of digestive symptoms

 Cannabis has been used recreationally for a long time  and is the third most commonly used drug after tobacco and alcohol. The therapeutic potential of cannabinoids has been recognized and utilized as anti-emetics. However, the  Cannabinoid hyperemesis syndrome has been described characterized by a paradoxical effect of hyperemesis in some susceptible chronic cannabis abusers. The etiology of cannabinoid hyperemesis is not known but some authors propose that the central effects of long-term cannabis use on the hypothalamic-pituitary-adrenal axis might play a major role in the development of CH.

It  would be essential for the diagnosis the regular use of cannabis for years, cyclic nauseas and vomiting , abdominal pain  and resolution of symptoms after stopping cannabis use. Compulsive hot baths with symptom relief would support the diagnosis.


We present  a case series  of 7 patients, admitted in  the Emergency Department of our hospital from May 2009 to May 2015, all of them  with long-term cannabis use and recurrent nausea, vomiting, abdominal pain  and, some of them, relieved with hot water bathing.

All patients, 2 females and 5 males,  were under 44 years of age and reported using of cannabis for more than 2 years before the  symptom onset. Two patients used it for 20 and 30 years.

The average attendance in the emergency department was 15.85. In one case, we counted 31 times.  In  3 of them  we found another drugs in urine (Heroin, cocaine).  5 reported weekly use of alcohol.

Diagnostic studies were performed in most patients and generated  negative results for  alternative diagnoses. These studies included complete blood cell count, glucose level, liver biochemistries, pancreatic enzyme level, abdomen X-ray and in two cases, abdominal computed tomography and upper endoscopy.

Standard treatment was used with fluid therapy, antiemetic  and proton-pump inhibitor in all of them, thus  achieving improvement in all cases after more than 12 hours of stay in the emergency room.  5 patients reported relief of symptoms with  hot baths or showers. 

The clinical improvement was confirmed in four patients  after cessation of cannabis use. The rest continue going to the emergency room  at the time of writing this article.


Because  of  the high prevalence and increasing consumption of Cannabis, it is likely that we will see an increased  number of patients with this syndrome in the Emergency Departments . Therefore,  it is necessary to collect the medical records of all patients who come with nausea and vomiting that are refractory to standard therapy but  improved  with hot baths. Cannabinoid hyperemesis should consequently be considered in these patients.


Rosario PEINADO (BADAJOZ, Spain), Miguel Angel RUIZ, Concepcion DE VERA, Alvaro MARTIN
11:00 - 18:00 #7685 - Cannabis-induced acute coronary syndrome.
Cannabis-induced acute coronary syndrome.

Introduction :

Smoking cannabis is a rare trigger of acute coronary syndrome but several cases of myocardial infarction have been increasingly reported during the last few decades. The physiological  pathway involves a coronary vasospasm but remains uncertain.

Observation :

We report the observation of a 20-year-old young male, regular cannabis smoker and alcohol consumer with no other medical history, who presented to the emergency department after complaining of paroxysmal recurrent episodes of retrosternal isolated chest pain occurring at rest and lasting longer than 20 minutes. The patient reported the use of cannabis during the three days before admission on ED with last consumption 12 hours before the beginning of chest pain. On examination : The patient was conscious; the blood pressure was 130/80 mmHg in both arms; The pulse rate was regular = 59 beats per minute and the evaluation of the pain was estimated over 30 mm. Otherwise, there were no  vascular left signs nor clinical findings of heamodynamic instability. The electrocardiogram at admission showed a regular sinus rythm at 60 bpm with an early repolarization in the inferolateral territories. The patient was admitted to the emergency ward for further decision clinical making  and therapeutic options. The evolution was marked by a dynamic T-wave negativation during the EKG monitoring and positive points of hypersensitive Troponins : 194 ng/ml to 452 ng/ml. A Non ST Elevation Myocardial Infarction diagnosis was made and the patient was transferred to the cardiology unit for further explorations. Echocardiography was normal. The coronary angiography revealed thight thrombotic stenosis of the proximal anterior interventricular artery with TIMI-3 flow and a  general spastic coronary system.

Discussion and Conclusion :

Several Cases of acute coronary syndrome due to the use of cannabis have been reported in the literature, especially among young people. However, the pathophysiological mechanism remains not completely understood with multiples hypothesis involving vasospasm, increased demand oxygen and decreased supply and plaque rupture. Actually, myocardial infarction may be more frequent than recognized by the literature. The medical taking history is the hallmark of the decision making.

Imen MEKKI (Tunis, Tunisia), Hamed RYM, Feten AMIRA, Ryef AMMAR, Bassem CHTABRI, Rym HAMMAMI, Bouhajja BÉCHIR
11:00 - 18:00 #7376 - Carbon monoxide poisoning due to water pipe smoking: case series.
Carbon monoxide poisoning due to water pipe smoking: case series.

Introduction:Hookah is a different form of tobacco consumption. In recent years, hookah usage has become increasingly widespread. The thought that it is less harmful than cigarettes increases its usage. Long-term exposure to high carbon monoxide (CO) levels due to hookah consumption may cause CO poisoning.

Case reports:A-18-year-old male patient admitted to emergency room. His complaint was syncope. He sat for 3 hours with friends in a café for hookah smoking, but he had to use hookah. After he had left the café, he said he had had head pain and dizziness then he could not remember what happened. He was described syncope lasted about 5 minutes. His physical examination and vital signs were normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 18,7% (normal range:0,5-1,5%) and other laboratory values were normal.

A-21-year-old male patient was admitted to emergency room with head trauma. At his anamnesis, he said he had felt dizziness after smoking hookah and bumped his head.  His physical examination and vital signs were normal. His cranial CT scan was normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 29,2%.

A-29-year-old male patient admitted to hospital with nausea, vomiting, dizziness and palpitation. At his medical history, the complaints had started after smoking hookah. His physical examination and vital signs were normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 34,1%.

A-28-year-old male patient was admitted to hospital by relatives due to confusion. Vital signs were normal. His Glasgow Coma Scale point was 12 (E: 3, V: 4, M: 5). He had no neurological deficit. Other systems were normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 35,5%. His cranial CT scan was normal.

All patients were administered a session of hyperbaric oxygen therapy and normobaric oxygen therapy during follow-up in the emergency room. After recovering their clinical status, they were discharged.

Conclusion:Hookah consumption is the most observed form of tobacco consumption in the Eastern-Mediterranean Region, and second in the US. Although it’s considered that all toxic agents are filtered while hookah smoke passes through water, hookah consumption increases levels of carcinogen, CO, nicotine, and tar in the blood compared to smoking. It’s striking that COHb values of our cases are as high as, even higher than stove poisoning cases. It must be kept in mind that non-specific symptoms following hookah consumption may be symptoms of CO poisoning.

Abdullah Osman KOCAK, İlker AKBAS, Zeynep CAKIR (ERZURUM, Turkey)
11:00 - 18:00 #7713 - Carbon monoxide poisoning in children during the years 2006-2015.
Carbon monoxide poisoning in children during the years 2006-2015.

Background: Carbon monoxide is an important cause of poisoning in children. We performed this study to clarify the epidemiology and clinical characteristics of patients with CO poisoning.

Methods: Retrospective analysis of medical records of patients hospitalised into Tallinn Children’s Hospital with suspected CO poisoning from 2006 -2015.

For the same time period, data of paediatric deaths from CO poisoning was acquired from Estonian Causes of Death Registry.

Epidemiological and clinical data were collected and analysed.

Results: A total of 97 children with suspected CO poisoning were admitted during the years 2006-2015.

Patient ages ranged from 1 month to 17 years. House fires were the most common cause of intoxication (46%), improper wood stove heating caused 27% of the cases, improperly ventilated exhaust produced by gas-fired water boilers caused 8%,  inadequately ventilated motor vehicle exhaust caused 7%, and 12% of the sources of the poisoning remained unknown.

62% of the events occurred during cool season.

Severe poisonings with loss of consciousness made up 11% of the cases. From other symptoms, the most common were nausea and vomiting (37%), headache (30%), dizziness (28%), and vertigo 11%.

Of the children admitted, 7.8% had CoHb levels over 20%, which is considered high. These high intoxication levels were mainly found to be caused by improperly ventilated gas-fired hot water boilers. None of the patients received hyperbaric oxygen therapy.

No mortality was seen in these hospitalised children. No neurological sequelae or pneumonitis were detected.

During these years, according to Estonian Causes of Death Registry data, 22 children died from carbon monoxide poisoning in Estonia, all of them were due to fires.


Conclusion: Children with CO poisoning had good outcomes in this series. Although improperly ventilated gas-fired hot water heaters were not the most common factor of carbon monoxide poisoning in children, it caused the most severe CO poisoning seen during that time.

Ulle UUSTALU (Tallinn, Estonia), Triin PERKSON, Gleb DENISSOV
11:00 - 18:00 #8218 - Cardiac arrest team or medical emergency team?
Cardiac arrest team or medical emergency team?

In Arad County Hospital, resuscitation team is a  cardiac arrest team from Emergency Department which is called only when a cardiac arrest is recognised. We evaluated this intervention during 2015 on neurology, internal medicine, haematology, gastroenterology, surgical, orthopaedic and paediatric fields.

Resuscitation team was called for 123 cardiac arrest situation, from which 111 were cardiac arrest while the other 12 were not.

 46 patients were resuscitated (41,44%) whereas 65 (58,55%) didn’t respond to the resuscitation measures. The initial cardiac rhythm was ventricular fibrillation in 28 cases (25,23%) and asystole and pulseless electrical activity in 83 cases (74,77%).  Patients’ rate of survival to hospital discharge after in hospital cardiac arrest was only 1,8% (2 patients).

Referring to those who were not in cardiac arrest (12 patients), the rate was higher: 6 of them (50%) survived and left the hospital. The number of discharged patients (alive) from the 123 interventions was 8 (6,5%).



  1. Emergency medical team must be called not only for cardiac arrest situation, but also for deteriorating patients who are evaluated within early warning score.
  2. A strategy of recognising patients at risk of cardiac arrest may prevent some of these arrest.
  3. In order to prevent futile resuscitation attempt for those who are unlikely to benefit from Cardiopulmonary Resuscitation, a do-not-attempt-resuscitation (DNAR) policy should be implemented.


Monica PUTICIU (Arad, Romania)
11:00 - 18:00 #8059 - Cardiopulmonary resuscitation by emergency medical technicians in Austria - Results from the AURORA-registry (Austrian registry of resuscitation by ambulance-crews).
Cardiopulmonary resuscitation by emergency medical technicians in Austria - Results from the AURORA-registry (Austrian registry of resuscitation by ambulance-crews).

Out of hospital cardiac arrest (OHCA) is a leading cause of death in the western world, and an important field of operation for emergency medical services (EMS). EMS in Austria is organized as a two-tier system, with emergency medical technicians (EMTs) with basic training, many of them volunteers, usually arriving on scene first, and emergency physicians providing follow up-care on-scene later on. Currently, there is no nationwide acquisition of data on EMS-efforts in OHCA in Austria.

The AURORA-registry was designed to prospectively collect data on resuscitation by EMTs of the Austrian Red Cross (providing the vast majority of EMS in the nation) according to Utstein-criteria. In addition, country-specific details on EMTs' level of training were recorded.

From January 2014 to September 2015 a total of 1,544 cases were recorded (546 (35%) female, mean age 71 +/- 17 years), 1,064 (69%) of them were observed cardiac arrests. A traumatic cause was evident in 103 (7%) cases. Bystander-CPR was provided in 596 (39%) cases, and a public access defibrillator was used in 21 (1.4%) cases. Upon arrival of EMS, a shockable rhythm was identified in 661 (43%) cases.

Regarding EMTs, 881 (57%) were volunteers, 1234 (80%) had only basic training ("Rettungssanitäter"), 307 (20%) had advanced training ("Notfallsanitäter"), including venous puncture and the use of drugs. For initial airway management, a laryngeal tube was used in 1019 (66%) cases, bag-valve-mask ventilation in the rest of cases.

Any return of spontaneous circulation (any ROSC) could be achieved in 319 (21%) cases. Rate of survival to hospital was 165 (11%).

We present the first nation-wide data on OHCA from Austria. Outcomes of our volunteer-based, two-tier system are comparable to other similar countries.

Dominik ROTH (Vienna, Austria), Lukas LEHER, Wolfgang SCHREIBER
11:00 - 18:00 #7209 - Cardiotoxicity after overdose of korean medicine, Kyushin.
Cardiotoxicity after overdose of korean medicine, Kyushin.

Kyushin (Chinese, meaning "saving heart") pill, manufactured by Boryung pharmaceutics, Republic of Korea, is a dark brown pill with a unique scent and taste including toad venom 0.83 mg. Toad, Bufo venom, found in granular glands of the skin, parotid glands and eggs of some species of toads (Bufo gargarizans, Bufo stejnegeri in Korea) contains several toxins and bioactive alkaloids, such as bufadienolide (bufotenin and bufogenine, etc.), digoxin-like cardiac glycosides. We report a case of Bufotoxin intoxication in 87-year-old female patient who showed signs of digitalis intoxication and recovered from tachy-bradyarrhythmia and pulseless electrical activity cardiac arrest. 

81-year old, female patient presented in the ED with decreased mental status, occurred 3 hours ago. 2 hours 30 minutes before to ED presentation, a medical crew in a nursing facility found the patient in decreased mental status and empties of Kyushin next to the patient. Glasgow coma scale was 8 points, Systolic blood pressure was 104mmHg, heart rate 142 per minute, respiratory rate 24 per minutes and body temperature 36.0°C with IV dopamine infusion. The first 12-leads electrocardiogram on patient's arrival showed sinus tachycardia with heart rate 142/min and right bundle branch block. PR interval was 218msec, corrected QT interval was 429msec. After 3 minutes, suddenly heart rate dropped to 20s per minutes with SBP 96mmHg. IV atropine 1mg bolus was injected, IV dobutamine infusion started and activated charcoal of 50g was applied via nasogastric tube. 

After 30 minutes when patient arrived, ventricular fibrillation on ECG monitor was detected, cardiopulmonary resuscitation was started, defibrillations with energy of 200J were delivered 6 times, IV magnesium 2g and amiodarone 300mg and 150mg were injected. After 6 cycles of cardiopulmonary resuscitation, patient's of spontaneous circulation had returned, SBP was 134mmHg, ECG showed complete AV block with ventricular rate of 43/min. Mechanical ventilator and external cardiac transcutaneous pacing with 130mA, 60/min were applied. 

Plasma toxicologic test revealed the serum concentration of digitoxin 66.90 ng/ml, digoxin 0.76 ng/ml. 

After 9 hours of ED presentation, cardiac transcutaneous pacing was removed, SBP was 115 mmHg and mental status came to be alert. ECG showed sinus bradycardia with rate of 57/min, PR interval 413 msec and QRS interval 98 msec. After 10 hours of presentation, the patient had been weaned and transferred to the nursing facility according to the willing of guardians. 1 week later, the patient's recovery from arrhythmias without any serious complication was confirmed by telephone.

Kyushin overdose can cause serious arrhythmias similar to digitalis intoxication. 


1. Ko, R. J., et al. (1996). "Lethal ingestion of Chinese herbal tea containing ch'an su." West J Med 164(1): 71-75.

Byung Hak SO (Suwon, Korea, Republic of)
11:00 - 18:00 #7609 - Care with fever in the psychiatric patient!
Care with fever in the psychiatric patient!

CASE REPORT Reason Query: 38 Patient brought to the ER for attempted suicide Personal history:

Mental and behavioral disorder opiate (methadone ), with dependence criteria , use of benzodiazepines , cannabis and cocaine dependence criteria . Personality Disorder Dissocial Chronic Treatment : Bupropion , Lormetazepam , Lorazepam , Olanzapine , pregabalin, Agomelatine . He went to the emergency room the last week, referred by his family doctor, by autolytic ideas. Rated by resetting Psychiatric treatment increases the dose of olanzapine and discharged .

Present Illness : Males 38 referring the family that has been missing 2 days and they find it in your hectic home , with 4 empty blister Olanzapine 5 mg , 4 of pregabalin 150 mg, one of   bupropion and  , lorazepam. Brought by the emergency outpatient service sedated with midazolam and  chlorpromazine and mechanical restraint
Upon arrival to emergencies:   Presure blood: 99/71 Temperature 35.4 ºC.  Well hydrated skin and mucous membranes, well perfused. Neurological Exploration: impossible to do on arrival at the emergency room for be the mechanical containment and patient sedated.
Complementary tests: Glucose 114, Urea 30, Creatinine 1.2, 25700 leukocytes (neutrophils 91%), hemoglobin 18.2 . . Platelets 310000 venous blood gases . 7.4 pH , pCO2 42.7  Toxic Urine positive for methadone and benzodiazepines
The patient was sedated and mechanical restraints, so passing observation area.
6:00 a.m. (5 hours after arrival to the emergency room ) Call from observation area for important psychomotor agitation and fever of 39 º. Come to assess the patient, further objectifying rigidity, diaphoresis , tachycardia 13o  and disorientation . Analytical requested in CPK and Procalcitonina. We started of intravenous midazolam perfusion and  administration of paracetamol and  saline Cranial CT is requested . We suspected neuroleptic malignant syndrome versus infectious process , are advised to intensive care unit, which decides admission to its Service
Physical exploration : Glasgow 13 Neurological examination : No nuchal rigidity, no meningeal signs Analytics : CPK 16627 , Procalcitonin 0.37 Cranial CT : No significant alterations lumbar puncture: clear liquid Leukocytes 2/mm3 , Glu 69, 34.8 Proteins
EVOLUTION: In intensive care unit te patient is stable, maintaining normal renal function despite frank rhabdomyolysis. Hyperthermia with physical measures and antipyretics, not objectified infected focus possession. Gradually infusion of sedatives with appropriate adaptation to the environment is suspended, so it is discharged with the diagnosis of neuroleptic malignant syndrome.
Conclusion: Thee is a serious complication of the use of neuroleptics, should be suspected. in a patient who uses such drugs ( olanzapine in our patient was the cause ), to present: hyperthermia, rigidity and impaired consciousness (all present in our case). They may be associated with rhabdomyolysis secondary leukocytosis and elevated CK . The differential diagnosis must be made with: lethal infectious process nervous system, lethal catatonia , heat stroke and malignant hyperthermia. Although rare , it is very severe with high mortality in untreated cases early, so early diagnosis is important and appropriate treatment in mild cases: maintaining hemodynamic stability, hydration and monitoring may be sufficient.

11:00 - 18:00 #7705 - Case report – hypothermia after accidental intake of an antipsychotic agent and a tricyclic antidepressant.
Case report – hypothermia after accidental intake of an antipsychotic agent and a tricyclic antidepressant.


Intoxications with antipsychotics and tricyclic antidepressants are recognized as a cause of hyperthermia in the setting of an anticholinergic syndrome. In this case report we describe an adult patient with an accidental administration of levomepromazine with clomipramine and furosemide, presenting with somnolence, hypotension and hypothermia.


Case description

A 55-year old, mentally retarded, woman was brought to the Emergency Department by ambulance with somnolence and hypotension. Five hours earlier, she had been accidentally given medication that belonged to another patient in her nursing home – levomepromazine 25mg (phenothiazine, antipsychotic agent), clomipramine retard 75mg (tricyclic antidepressant) and furosemide 40mg (loop diuretic).

One hour after administration of the medication, she became more somnolent than usual, with shaking hands and a hypotension (95/60 mmHg).

Her medical history consists of said mental retardation due to perinatal asphyxia, an anemia, obstipation and gastroesophageal reflux when supine. Her prescribed medication consists of cholecalciferol 400IE 1dd1, domperidone 10mg 3dd1, hydrochlorothiazide 25mg 1dd1, magnesium hydroxide 724mg 1dd1, omeprazole 40mg 1dd1, macrogol 1dd1 and dalteparin 2500IE 1dd1. Her usual dose of domperidon, hydrochlorothiazide, magnesium hydroxide and macrogol had not been given that day due to the accidentally administrated medication.

She had no known allergies.


On physical examination the patient was somnolent, with an Glasgow Coma Scale of E2M5V1, hypotensive (82/38 mmHg) with a bradycardia (56/min), and hypothermic (31 °C, rectally). Her respiratory rate was slow, with a SpO2 of 94% without supplementary oxygen. Her ECG showed a mild sinusbradycardia with a first degree AV-block, a small QRS-complex and a QTc of 0,51sec. Laboratory testing revealed a respiratory acidosis.


The patient was admitted with the diagnosis of intoxication with levomepromazine, clomipramine and furosemide. Aggressive fluid resuscitation was initiated, while the patient was simultaneously internally and externally warmed. Based on her history, current state and in consultation with her legal representative a DNR order was agreed upon. During admission, no further complications occurred. After two days, the patient was discharged to her nursing home in her previous condition.



Thermoregulation is controlled in the preoptic area of the hypothalamus through regulation of shivering, peripheral vasodilation and diaphoresis - with serotonin and dopamine being the most important neurotransmitters. While the exact mechanism of action in this matter is not understood, both phenothiazines (levomepromazine) and tricyclic antidepressants (clomipramine) interact with these neurotransmitters and may promote hypothermia.

In this patient, multiple factors may have contributed to the development of hypothermia. Besides said medications, the perinatal asphyxia and consequent cerebral damage in this patient in combination with her somnolent state may have lessened her ability to shiver.



Although antipsychotics and tricyclic antidepressants are known for their abilities to cause hyperthermia, these agents should also be considered as a possible cause in patients presenting with hypothermia.

Laura ESTEVE CUEVAS (Dordrecht, The Netherlands), Eva SLAG, Barendina BAKKER
11:00 - 18:00 #7842 - Case Report.
Case Report.

4 patients presented to the ED with ingestion of Unknown Plants. They are from Nepal and one of them brought that plant from the forest in Nepal. They used it for headache, body pain, and flu symptoms (herbal). After ingestion, 3 of them started to vomit with abdominal pain.. They presented with hypotension, relative bradycardia, tingling sensation, and dizziness. The most critical patient has fluctuating rhythm (multi-focal PVCS, runs of non-sustained VT, R on T phenomena, PACs, change in the amplitude of the complex), hypotension, salivation, active vomiting, deep rapid respiration, GCS is 13/15, compensated metabolic acidosis. The 2nd one had the same presentation but milder and better ECG, GCS is 15/15. The 3rd one has no cardiac manifestations but hypotensive, less vomiting. The 4th one is asymptomatic. They have a piece of its root with him. All of them showed normal LAB. Results

difficulties are (language barrier, unknown poisoning, non-famous in the current community, resemble the manifestations of other toxidrome like cholinergic effect, multi-causality with only 1 senior staff, Unknown mechanism of action so difficult to decide about the use of any supportive medication)

By translator with some language barrier, safety to the patient from legal issues given to allow them to explore more about the nature of the plants As it is unbelievable that all of them have headache at the same time. Then they admitted that it was for energetic effect. Then I discovered the plant which is Aconitum Napellus and it was the root

Amoidarone given to control the arrythmias followed by ICU admission

Aconitum Napellus contains (Aconitine and mesaconitine)


The cardiotoxicity and neurotoxicity are due to their actions on the sodium channels of the cell membranes of  he myocardium, nerves, and muscles. they bind with high affinity to the open state of the voltage-sensitive sodium channels at site 2, causing an activation of the sodium channels, which become refractory to excitation. The arrhythmogenic properties are due to its anticholinergic effects mediated by the vagus nerve. Aconitine has a +ve inotropic effect by prolonging sodium influx during the action potential. It has hypotensive and bradycardic actions due to activation of the ventromedial nucleus of the hypothalamus. they can induce strong contractions of the ileum through acetylcholine release from the postganglionic cholinergic nerves.


Patients present with paresthesia and numbness of face, perioral area, and the four limbs, muscle weakness in the four limbs. hypotension, chest pain, palpitations, bradycardia, sinus tachycardia, vent. ectopics, VT, and VF. nausea, vomiting, abdominal pain and diarrhea. The main causes of death are refractory ventricular arrhythmias and asystole and the overall hospital mortality is 5.5%.


supportive, close monitoring of blood pressure and cardiac rhythm. Inotropic therapy is required if hypotension persists and atropine for bradycardia. vent. arrhythmias are often refractory to direct current cardioversion and antiarrhythmic drugs. Amiodarone and flecainide are reasonable first-line treatment. maintaining systemic blood flow, blood pressure, and tissue oxygenation by the early use of cardiopulmonary bypass.

more information are available but no place here.

Abdelmonim ELHAKIM (Jeddah, Saudi Arabia), Adeeb BUKHARI
11:00 - 18:00 #7619 - Case report: a rare cause of acute abdomen polyarteritis nodosa.
Case report: a rare cause of acute abdomen polyarteritis nodosa.


Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis involving the small and medium arteries, that resulted in decreased the blood supply and ischemic damage. Middle-aged men are more frequently affected.  Clinical manifestations of PAN resulted from involved systemic and affected organs, for example, skin, kidneys, abdominal organs, nervous systems and heart. The level of disease severity is from mild to severe. There is no diagnostic laboratory test for PAN. The American College of Rheumatology(ACR) has established 10 criteria for the classification of PAN in a patient with a vasculitis. The sensitivity and the specificity for the diagnosis of polyarteritis is 82% and 87%, respectively. Arteriography and cross-sectional imaging, such as computed tomography (CT) and magnetic resonance (MR), can be used as alternatives to tissue biopsy for the diagnosis. The optimal therapy of PAN remains uncertain. We report a case of PAN presenting with abdominal pain.

Case report:

This 56-year-old woman with the past history of hypertension presented to our emergency department(ED) because of acute onset periumbilical and right flank pain for 1 day. The visual analog scale of pain was 9/10. Vital signs are as follows: blood pressure 159/104 mmHg, pulse rate 85/minute, respiratory rate 16/minute and body temperature 36.9 ℃. There was no fever, nausea, vomiting, diarrhea or abdominal operation history. Physical examination revealed soft abdomen without definite tender point and peritoneal sign. A hemogram and biochemical test results were as follows: white blood cell count 10.09×103/μL (3.04 to 8.54×103/μL), neutrophilic differential 64.4%, creatinine 0.77mg/dL(0.6 to 1.0mg/dL), total bilirubin 0.6mg/dL(0.2 to 1.0 IU/L), aspartate transaminase 17 IU/L (15 to 37 IU/L), and lipase 117 IU/L (73 to 393 IU/L). Because of the pain out of proportion to examination, implying the possibility of mesenteric ischemia, abdominal contrasted CT was done. It showed wall thickening with adjacent fat stranding along the superior mesenteric artery, which was indicated to vasculitis (Figure 1,2). Subsequently, she was admitted to our rheumatology ward for treatment.


Polyarteritis nodosa is a rare, but potentially life threatening, inflammation of the blood vessels. The emergency physician should keep this in mind. A high index of suspicion and prompt management should avoid catastrophic outcomes.

Pei-Shan WU (ROC, Taiwan, China), Po-Liang CHENG, Yi-Kung LEE
11:00 - 18:00 #7401 - Case report: Massive pulmonary embolism in pregnancy – Intra-arrest thrombolysis and resuscitative hysterotomy.
Case report: Massive pulmonary embolism in pregnancy – Intra-arrest thrombolysis and resuscitative hysterotomy.


Massive pulmonary embolism is a leading cause of maternal death and may require intra-arrest thrombolysis as well as resuscitative hysterotomy.


Case Report

The case presented is that of a 35-year-old primigravida at 28 weeks gestation. The patient was brought to the Emergency Department in cardiac arrest with cardiopulmonary resuscitation (CPR) ongoing with a paramedic ambulance crew. Initial rhythm was PEA; return of spontaneous circulation (ROSC) was obtained following one cycle of the Advanced Life Support (ALS) protocol and adrenaline bolus. Spontaneous circulation was not sustained; episodic CPR with adrenaline boluses was required. Resuscitative hysterotomy was performed intra-arrest. The baby was given to the neonatal arrest team; it had no output and did not survive despite resuscitation attempts. Echocardiography was performed during maternal resuscitation using the Focused Echocardiography Evaluation in Life Support (FEEL) protocol revealing a grossly dilated right heart. The patient was thrombolysed intra-arrest with 100mg Alteplase. ROSC was obtained post thrombolysis and output was maintained thereafter. Inotropic support was initiated and surgical haemostasis was achieved in the resuscitation room. Repeat echocardiography showed good biventricular function. The patient was transferred to the Intensive Care Unit where despite improved cardiovascular status subsequent computed tomography (CT) brain revealed catastrophic irreversible hypoxic injury. Treatment was withdrawn with the support of family members. Post mortem examination confirmed massive pulmonary embolism as the cause of death.



Intra-arrest thrombolysis can significantly restore and improve cardiovascular status in cardiac arrest caused by massive pulmonary embolism. Thrombolysis is not contraindicated in maternal resuscitation where resuscitative hysterotomy may also be required.

Ngua CHEN WEN (CARDIFF, United Kingdom), John TAYLOR, Matthew CARWARDINE
11:00 - 18:00 #7760 - Cellulitis Audit.
Cellulitis Audit.

In our clinic We use to treat patients with cellulitis. It is important that every Doctor follows the same criteria in every pathology. 

The aim of this audit is to establish the current standard of treatment provided to patients with cellulitis.


This is a retrospective audit of patients with cellulitis coming to the clinic from 11th to 30th September 2015.


1-If patient afebrile and otherwise healthy, flucoxacillin 500mg QDS 7-14 days may be used as single drug treatment.

         -Number of patients including in audit without fever.

2-If febrile and ill send to Hospital for IV Treatment.

3-In facial cellulitis use co-amoxiclav 625mg TDS 7-14 days.

4-If penicillin allergic. Clarithromycin 500mg BD 7-14 days or Clindamycin 450mg QDS 7-14 days.

*Initial Standard Setting

-At least a minimum 80% of patients afebrile and cellulitis will have flucoxacillin treatment 500mg QDS 7-14 Days.

-At least a minimum 90% of patients febrile and ill send to Hospital for IV Treatment.

-At least a minimum 90% of patients with facial cellulitis use co-amoxiclav 625mg TDS 7-14 days.

-At least a minimum 90% of patients with penicillin allergic, Clarithromycin 500mg BD 7-14 days or Clindamycin 450mg QDS 7-14 days.

*Analysis and Findings

There were 23 patients aged 1-89 years old diagnosed with Cellulitis, and 2 patients excluded because, one of them had Pilonidal Abscess and the second one had an infected wound.

In 6 cases of 21 the temperature were not in the records.

1.- Criteria:In regards to the chosen antibiotic, patient afebrile and otherwise healthy, flucoxacillin 500mg QDS 7-14 days ,12 patients (71%) were prescribed with  Flucoxacillin, only 1(6%)was prescribe with  2 antibiotics:flucoxacillin and calvapen.

But 4 patient, that  flucoxacillin was prescribed the temperature is not  in the records.

2.-Criteria:In febrile and ill, send to Hospital for IV Treatment.

Only 2 patients were sent to A&E(28%), one of them was ill and without temperature in the records and the other one had fever.

But, I included 5 patients in which the temperature was not checked, because we do not know if they had fever or not(72%)

3.-Criteria:In facial cellulitis use co-amoxiclav 625mg TDS 7-14 days.

Only one case of facial cellulitis was reported and treated with co-amoxiclav

4.-Criteria:If penicillin allergic. Clarithromycin 500mg BD 7-14 days or Clindamycin 450mg QDS 7-14 days.

The are no patients penicillin allergic treated with Clarithromycin or Clindamycin. (0%) There is only one patient penicillin allergic treated with Erythromycin.

It´s always necessary to check temperature if there is a cellulitis because depends on this we will send patients for iv antiv¡biotics to A&E.

In the audit there are 6 patients without checked the temperature and then we don´t know how it is.

We need to see in the records that the patient is allergic to penicillinIf we have to give other antibiotic.

*Conclusions and Reflections

- In cellulitis we need to check vitals and temperature.

- If temperature is normal, no penicillin allergic : flucoxacillin 500 mg QDS 7/14 days

- If fever/ill :send to A&E for iv antibiotics

Maria Angela CANAS BARRANCO (Malaga, Spain), Enrique CARO VAZQUEZ, Maria Del Carmen RODRIGUEZ CASIMIRO
11:00 - 18:00 #8050 - Cerebral oedema in diabetic ketoacidosis : case report.
Cerebral oedema in diabetic ketoacidosis : case report.



cerebraloedema is a rare but potentially lethal complication of diabetic ketoacidosis (DKA). It is more common among children with DKA than with adults.


Case report:

A 23-years-old male patient presented to the emergency department (ER) for asthenia, vomiting, drowsiness and (high sugar blood level/hyperglycemia). He had no medical history. Diabetic ketoacidosis state has been confirmed. Correction with continuous itra-venous insulin and fluids rescucitation has been started. 2 hours after, he altered his state of consciousness. His vital signs were as follow GCS of 3, blood pressure of 70/40, pulse rate of 45 beats/min, respiratory rate of 10 breaths/min. his laboratory tests were pH at 7.09, lipase level at 60 times the normal and albumin level at 19,3. Abdominal computed tomography (CT) showed acute pancratitis grade E of Balthazard scoring. Cerebral CT showed cerebral oedema with bilateral Uncal herniation. The patient has been intubated. He received mannitol and catecholamine. He deceased 48 hours later.


Brain swelling can be revealed when a major sign occurs but it has to be suspected when minor signs such as drowsiness and vomiting are presented. Cerebral oedema for this patient can be enhanced by hypovolemia caused by ketoacidosis, pancreatitis and hypo albuminea.


Cerebral oedema in DKA can be suspected and confirmed rapidly by cerebral CT. however, it remains difficult to mamage and its mortality remains high.

Houcem OUNI (tunis, Tunisia), Mohamed Ali CHERIF, Ons ANDOLSI, Khaled SAIDI, Youssef Zied EL HECHMI, Mohamed MEZGHENI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #8072 - Cerebral thrombophlebitis following head injury: a case report.
Cerebral thrombophlebitis following head injury: a case report.


Cerebral venous thrombosis is a rare complication of head trauma which is sometimes difficult to diagnose. We report a medical observation who presented post-traumatic cerebral venous thrombosis revealed by signs of intracranial hypertension and psychiatric disorders.

Case report

A 24-year-old man presented to the emergency department (ED) one hour after a head traumatic injury. He had head and chest trauma and lost consciousness for undetermined period after a bicycle accident. At physical examination, he was conscious with no neurological abnormalities. He could not move his left arm because of shoulder dislocation. Computed tomography, performed 6 hours later, showed right fronto-temporo-parietal acute subdural hematoma without midline shift, right temporal petechial contusion, displaced fracture of the occipital condyle and non-displaced fracture of the scapula. There was no need for neurosurgery and the shoulder dislocation was reduced.

The patient was admitted in the emergency observational unit and was discharged after 24 hours. Two days later, he complained severe headache and multiple episodes of vomiting, dizziness and visual illusions. Computed tomography scan of the brain with contrast injection revealed left lateral sinus thrombosis extending to homolateral internal jugular venous. The patient was given anticoagulation and admitted in the neurology intensive care unit.


Repeating CT scan of the head is recommended in the management of traumatic brain injury if there is a worsening of neurological disturbances and a contrast injection may be required to rule out cerebral venous thrombosis which requires specific treatment.

Majed KAMEL, Mghirbi ABDELWAHEB (Tebourba, Tunisia), Zaouche KHEDIJA, Kilani MOHAMED, Khelil MOHAMED HASSEN, Maghraoui HAMIDA, Modhaffer MOHAMED, Hamouda CHOKRI, Borsali Falfoul NEBIHA
11:00 - 18:00 #7119 - Cervical cancer prevention in a family planning consultation of urban health center.
Cervical cancer prevention in a family planning consultation of urban health center.


Evaluate the data record in the clinical records of patients attending family planning consultation according to the integrated cervical cancer care protocol. 


Cross-sectional retrospective


A total of 97 patients attending family planning consultation during 2010 in a health center, single randomly chosen were assessed. This sample size allowed us to study the main objective of the research with an accuracy of 0.09 with a confidence level of 95%


The variables age, record of PAI of cervical cancer registry sampling, communication record results, anamnesis, physical examination and compliance with the timing of cytology as risk factors were evaluated.


Of the 97 patients evaluated, 16 did not attend your appointment cytology. Of the remaining 81 the average age was 38 years. Only 5% were derived gynecology by pathological cytology. The largest deficit record occurred in variables anamnesis (not registered in 37% of cases, if 63%), physical examination (not collected in 47% of cases, if 53%). The sequential implementation of smears according to PAI was correct in 75.3% of cases.


Despite the decline in the incidence of cervical cancer, a deficit in medical uptake (16%), especially in people over 65 with FR, with little awareness on the part of patients still persists. The collection of data on clinical history is scarce, mainly in the anamnesis (FR) and physical examination.

If we improve the recruitment and data collection will improve the quality of the care process.

11:00 - 18:00 #7379 - Changes in urine biomarkers of acute kidney injury among amateur long-distance runners: a prospective cohort study.
Changes in urine biomarkers of acute kidney injury among amateur long-distance runners: a prospective cohort study.

Running is associated with a healthy lifestyle and improves quality of life. The “Weir Venloop” is a yearly running event and several collapsed runners were admitted to our Emergency Department. Studies with (ultra)marathon participants have shown that long-distance running can be associated with exertional rhabdomyolysis and acute kidney injury (AKI). The level of neutrophil gelatinase-associated lipocalin (NGAL) in urine has shown potential for use as an early biomarker of AKI. The aim of this study was to investigate AKI among amateur long-distance runners by analyzing urinary biomarkers and if these parameters can be related to performance.

In this observational prospective study we collected urine samples of participants of the 10km and half marathon competing the “Weir Venloop 2015”, immediately before and after the finish. An urine dipstick analysis of hemoglobin, glucose and ketones concentrations was directly performed. Furthermore, the levels of albumin, creatinine, uric acid, sodium and NGAL were measured on the Architect® c8000 and i2000 analyzers. Race times were documented.

A total of 35 urine samples (18 male, 17 female) from the 10-km participants and 45 samples (21 male, 24 female) from the half marathon participants were collected. Significant increase in creatinine, albumin, hematuria (dipstick) were found after the race. Urine levels of albumin, hematuria, creatinine and uric acid showed significant correlation with the race times, i.e. exertion. Urinary NGAL significantly increased in male participants, most pronounced after running a half marathon, and uNGAL showed significant correlation with race times but only in the male participants.

Long-distance running was found to be associated with microalbuminuria and hematuria among both male and female participants. A significant increase in uNGAL and significant decrease of sodium was only found in male runners. With this knowledge, we can take better care of the collapsed runner in our ED.

Monique VAN DER LUGT (Venlo, The Netherlands), Rick VAN DER DOELEN, Nathalie PETERS, Loes JANSSEN, Jos LE NOBLE
11:00 - 18:00 #7924 - Changes of emergency department workers’ perceptions of effectiveness and reported compliance of infection control measures after middle east respiratory syndrome outbreaks.
Changes of emergency department workers’ perceptions of effectiveness and reported compliance of infection control measures after middle east respiratory syndrome outbreaks.

Emergency department workers’ perceptions of effectiveness and reported compliance of infection control measures after middle east respiratory syndrome outbreaks 

Purpose : Middle east respiratory syndrome (MERS) outbreaks occurred in Korea on 2015 with 186 patients in relatively short time. The epidemiological pattern in South Korea was hospital-associated. Infection control plans for all hospitals was implemented to stop the spread of MERS infection and to protect healthcare workers from infections. Enhanced guidelines for infection control measures might affect healthcare workers. The purpose of this study was to determine changes of tertiary emergency department healthcare workers’ perception and compliance to hand hygiene and personal protective equipment (PPE) before and after MERS outbreaks.

Methods : A written questionnaire was administered to members in the emergency department at the Samsung Medical Center. Participants were asked to rate the combined overall effectiveness of hand hygiene and PPE and to report compliance on a 5 point scale. This survey conducted during 11-26 September 2015.

Results : The number of participants was 123. Perception of effectiveness before and after MERS outbreaks was that hand hygiene (4.05 vs 4.44, p<0.05), N-95 mask (4.02 vs 4.44, p<0.05), gown (3.03 vs 3.53, p<0.05), eye protection (2.98 vs 3.70, p<0.05), glove (3.30 vs 3.87, p<0.05) and surgical mask (3.65 vs 3.68, P=0.714). Respondents showed statistically higher compliance with hand washing and PPE after MERS outbreaks, specifically, hand hygiene (3.79 vs 4.50), surgical mask (3.37 vs 4.43), N-95 mask (2.23 vs 4.06), gown (2.12 vs 4.45), eye protection (1.72 vs 4.28), glove (2.61 vs 4.09). Compliance with hand hygiene and PPE depending on patient symptoms - only fever or fever with upper respiratory symptom compared to no fever and no respiratory symptom – reported statistically increased except surgical mask. The most highly rated reason for doing hand hygiene and using PPE before and after MERS outbreaks was to protect oneself from respiratory infectious disease, which was 50.41% and 82.11%, respectively. Protection guideline of hospital was secondly rated reason, which decreased 39.80% to 11.80% after MERS outbreaks. But regarding reference source for choosing specific infection control measures, hospital guideline was 89.43% and individual decision was 9.76%.

Conclusion : Infection control measures except surgical mask was perceived to be more effective than before MERS outbreaks. Emergency department’s workers reported increased compliance on hand hygiene and PPE except surgical mask. Even though reported compliance for eye protection was statistically higher after MERS outbreaks, its compliance rate was relatively low compared to other PPE measures. 

Gabyong JEONG (Seoul, Korea, Republic of), Tae Rim LEE, Min Sub SIM, Sung Yeon HWANG, Won Chul CHA, Tae Gun SHIN, Ik Joon JO, Keun Jeong SONG, Joong Eui RHEE, Yeon Kwon JEONG
11:00 - 18:00 #7260 - Chaperones in the emergency department – an audit of clinical practice.
Chaperones in the emergency department – an audit of clinical practice.


Chaperones in the emergency department – an audit of clinical practice.


The Royal College of Emergency Medicine, UK has established best practice guidelines for chaperones in the Emergency department, summarised as follows:

  1. The presence of a chaperone should be offered to all Emergency Department patients undergoing a "Sensitive Area Examination", regardless of patient or practitioner genders.
  2. The presence or absence of a chaperone should be appropriately documented. 
  3. If an Emergency Department patient declines a chaperone, the fact that one was offered and declined should be documented in the ED record.

We present an audit of clinical practice in our ED regarding the use of Chaperones.


We conducted the first cycle of the audit over a 3 month period with 12359 attendances out of which 476 patients needed “Sensitive Area Examination”.

After analysing the results of the first cycle, we are presenting the findings to the medical and nursing staff in the ED, and are reiterating the importance of the presence of Chaperones as well as the importance of clear documentation of the presence or absence of a Chaperone and/or if one was offered but declined by the patient. We are using the delivered lectures and electronic medium for educating the staff in ED and will proceed to complete the audit cycle.


The results of the first cycle of the audit showed a very poor compliance of documenting the presence or absence of a chaperone and/or if the patient had declined one for “Sensitive Area Examination”. We are in the process of educating medical and nursing staff in the ED currently to improve practice and will complete the audit cycle shortly.


The Emergency Department is an environment in which the entire range of physical examinations may be clinically necessary, and so a hospital should recognise the need for a clear chaperone policy tailored to the Emergency Department setting. With the help of this audit, we have tried to improve our current practice relating to the management of patients that require “Sensitive Area Examination” in our dept.


The Royal College of Emergency Medicine best practice guideline – Chaperones in Emergency Deparments. C--inetpub-wwwroot-medical-cem-Upload-documentz-CEM8291-Chaperones in EDs

Farah MUSTAFA (Drogheda, Ireland), Andrew CASEY, Peadar GILLIGAN
11:00 - 18:00 #7990 - Characteristics of and the Factors Affecting the Morbidity and Mortality of Malignancy Patients Presenting to the Emergency Department: A Prospective Epidemiological Study.
Characteristics of and the Factors Affecting the Morbidity and Mortality of Malignancy Patients Presenting to the Emergency Department: A Prospective Epidemiological Study.

Objective: Death due to malignancy is the second cause of mortality after cardiovascular system diseases. Because technological developments allow early diagnosis and new treatment modalities extend follow-up periods, emergency department presentation of malignancy patients with disease- and treatment-related complications has been rising. The objective of this study is to identify the clinical characteristics of the patients with malignancy, who constitute the majority of the emergency department admissions, and to increase the quality of care and raise awareness of rapid targeted-therapy.

Materials and Methods: Cancer patients 18 years of age and older who presented to the Istanbul University Cerrahpaşa Medical School Emergency Department between October 6, 2014 and May 6, 2015 were evaluated prospectively. Patients’ demographics, vital signs, characteristics associated with malignancy, examinations performed and their results, treatments and length of stay were evaluated.

Results: A total of 1283 patients and 1522 presentations were recorded. In nine patients, the initial diagnosis of cancer was made in the emergency department. 51.99% of the patients were male (mean age: 57.52±13.12), and 48.01% were female (mean age: 69.05±15.15). The overall mean age was 63.05±14.08. The most prevalent symptom was dyspnea (17.94%), and the most common type of cancer was lung cancer (16.23%). In male patients, the most prevalent complaint was fever, and the most common type of cancer was lung cancer (34.63%) (p<0.001). In female patients, the most prevalent complaint was dyspnea, and the most common type of cancer was breast cancer (35.25%) (p<0.001). Distant metastasis was present in 64% of the patients. The influence of mean arterial blood pressure, pulse, hemoglobin levels, uremia and hypoalbuminemia on mortality and ICU admission was significant (p<0.001). Overall, 41.46% of the patients were hospitalized, and 1.05% of the patients died. The average length of stay was 4.64±6.73 days. The average length of stay in the emergency department until the patient was admitted to the relevant department was 3.04±1.91 days.

Conclusion: Patients with malignancy constitute a significant portion of the emergency department admissions. Promoting the emergency physicians’ insight into and experience on oncological emergencies would contribute to decreasing the mortality and morbidity of these patients. 

Onur TOKOCIN, Afsin IPEKCI, Deniz Necdet TIHAN, Fatih CAKMAK, Didem CEYLAN, Mehmet Necmettin SUTASIR, Canturk EMIR (istanbul, Turkey), Ozgur DANDIN, Merve TOKOCIN, Ibrahim IKIZCELI

The chest compression is a key of High-quality cardiopulmonary resuscitation (CPR), for this reason the current Guidelines for Cardiopulmonary Resuscitation recommends ensuring chest compressions of adequate rate, adequate depth, allowing full chest recoil between compression and minimizing interruptions. Apparently feedback methods could improve the quality of chest compressions, however, subjective analysis showed poor accuracy to qualify adequate rate and depth of chest compressions, and a more complex methodology for evaluation is necessary. Physiological parameters such as quantitative waveform capnography or arterial pressure monitoring could assess the response to treatment and guiding interventions to improve the quality of CPR. In our work we measured the peak systolic velocity of femoral artery (FPSV) by ultrasound during chest compressions, as an indirect indicator of cardiac output and a quantitative measure of the quality of chest compressions.



Determine if is possible to measure the FPSV produced by chest compressions during CPR



In 6 cases of cardiac arrest the conditions to perform the measurement were obtained. Patients were younger than 75 years and had nontraumatic cardiac arrests, patients with signs of abdominal vascular diseases were discarded. The FPSV measurements were performed in the common femoral artery,  at the beginning and 30 seconds before the end of the compression cycle. Additionally a description of chest compressions quality was performed during each measurement.



45 measurements were obtained, 9 were discarded due to poor quality of ultrasound view. The highest FPSV was 145 m/s, adequate chest compression techniques were associated with an average measurement of 110 m/s (range 90 to 120 m/s), most FPSV decreased to 90 m/s  (range 80 to 100 m / sec) at the end of each cycle. Poor quality techniques were associated with FPSV between 60 to 80 m/s. One resuscitator with a history of elbow trauma, performed a poor quality compressions according to quantitative evaluation, however the FPSV during chest compressions resulted greater than 90 m / s



Measurement of FPSV is possible during CPR and could provide quantitative information about the quality of chest compressions, even provide a real-time feedback to improve the technique. Further studies are needed to confirm these findings

Luis Arcadio CORTES-PUENTES (BOGOTA, Colombia), Gustavo Andres CORTES-PUENTES, Gerardo LINARES-MENDOZA, Carlos Hernan CAMARGO MILA
11:00 - 18:00 #5128 - Chest pain and risk stratification in the emergency department.
Chest pain and risk stratification in the emergency department.


Chest pain is a commonly presenting symptom in the emergency department with multiple aetiology. The need to distinguish between life threatening conditions and the less severe is critical. In many cases history and clinical examination can provide only limited information and most patients will undergo further investigations into the cause of their symptoms. We looked at a sample of 92 patients attending the emergency department and have analysed outcome associated with individual risk-profile.


92 patients presented to the emergency department (43 male, 49 female) between June-October 2014. In total, 33 patients described symptoms of cardiac chest pain (as described by NICE 2010 guidelines) with 59 patients presenting with non-cardiac chest pain. Of all patients, 34 presented within four hours of onset - of which 18 were from the cardiac chest pain group. The majority - 25 of cardiac chest pain patients had cardiovascular risk factors and were admitted to hospital. In addition most of those deemed low risk were also admitted for further investigation. None of the patients presenting with non-cardiac chest pain had a positive troponin and the majority were discharged from the emergency department. Only a small number of patients - 3, were deemed suitable for referral to the ambulatory care day unit (ACU) to await a second assessment, and all were eventually discharged.


The majority of patients attending the emergency department with symptoms of cardiac chest pain presented within four hours of onset and were associated with cardiovascular risk factors. Of those admitted most had serious underlying pathology ruled out by repeat troponin and were later discharged. Most patients with non-cardiac chest pain presented later and had cardiac aetiology ruled out by negative troponin. The use of the ambulatory care unit in management of chest pain was limited as patients were often admitted to a medical bed for a repeat blood test and suitable patients for the ACU would often present out of hours.


All patients admitted with chest pain should have cardiovascular risk factors clearly documented. A clear pathway for low-risk patients would be of benefit and could avoid unnecessary admission. With many patients describing cardiac-like chest pain presenting early there may also be benefit of the use of newer high-sensitivity troponin assays for early diagnosis or exclusion.

Craven HENRY (London, United Kingdom)
11:00 - 18:00 #7423 - Chest pain in young man after car accident.
Chest pain in young man after car accident.

Mediastinal hematoma with compressive effect on cardiac cavities is a rare and serious complication of blunt chest trauma. For a man of 21 years, with no history of interest who suffers an accident by frontal crash at 50 km / h, occupying the passenger seat with the seat belt it is presented. He went to the emergency room for their own reporting a central chest pain of moderate intensity.
At that time, constants and physical examination were normal, with the only data of pressure pain on the lower third of the sternum. A study of plain radiography were performed, appreciating posterior dislocation of the xiphoid process, an electrocardiogram showed sinus rhythm with an incomplete right bundle branch block, and an analytical, resulting normal blood count and levels of troponin not high. Three hours after his arrival to the emergency room, the patient presented a progressive malaise, with pallor, and hypotension. A chest scan was performed finding a voluminous anterior mediastinal hematoma with compression effect on right heart chambers due to active bleeding from the left internal mammary vein. The patient underwent emergency VATS with bleeding vessel closure and placement of pleural drainage, presenting a favorable evolution. Mediastinal hematomas are caused by injury of mediastinal vessels, sometimes secondary sternal or vertebral fracture. In severe cases can lead to cardiac tamponade extrapericardial origin, a potentially fatal complication. In the early stages, symptoms and physical examination may not be relevant, in the absence of symptoms of both acute bleeding and cardiac tamponade classics (bradycardia, jugular venous distension, paradoxical pulse).
The case highlights the importance of maintaining a high degree of suspicion of mediastinal hematoma, despite an initial period of hemodynamic stability, in a patient with blunt chest trauma. Regarding our case, it should also remember the relationship between the use of seat belts and sternal fracture. Early diagnosis facilitates rapid handling of this potentially serious situation.



11:00 - 18:00 #7146 - Chest pain, syncope, hypotension and left hemiparesis, all in one diagnosis: aortic dissection.
Chest pain, syncope, hypotension and left hemiparesis, all in one diagnosis: aortic dissection.

Acute aortic dissection (AD) is a surgical emergency with a high mortality rate, that requires quick diagnosis and emergency surgical intervention. This disease was first described by Morgagni in 1761. Aortic rupture is catastrophic and has an 80% mortality. We present a 58-year-old woman with history of chronic hypertension, brought to ED by ambulance with a one-day history of chest pain and syncope. Shortly after presenting to ED, the patient developed a transient episode of left hemiparesis and aphasia. On physical examination her blood pressure in the right arm was 95/55 mmHg and in left arm was 70/40, pulse 110/per minute. She had tenderness on palpation over the upper abdomen, especially in the epigastrium. Electrocardiogram showed minor transient right bundle branch block, but no acute ischemic changes. Abdominal ultrasound did not detect free fluid in the abdominal cavity, no cardiac tamponade, but echocardiography showed enlargement of the ascending aorta. CT angiography of thorax was performed which showed a Stanford type A aortic dissection, with doubled lumen extending from ascending aorta to aortic bifurcation. Emergency physicians must be aware of atypical presentations of acute aortic dissection. Association of chest pain, syncope, hypotension and neurological signs may be suggestive of aortic dissection.

Vasile GAVRILA, Alexandru Nicolae CARSTEA (Timisoara, Romania), Rodica Daniela GAVRILA, Gabriela FILIP
11:00 - 18:00 #7534 - Child abuse and neglect in the emergency department of a northern Taiwan community hospital.
Child abuse and neglect in the emergency department of a northern Taiwan community hospital.


Emergency department(ED) is one of the most important port for child abuse and neglect (CAN) victims to seek medical attention. As CAN would recur, an ED mandatory CAN report system was implemented in Taiwan in a hope that timely intervention can prevent avoidable mishaps. Though previous studies revealed that nursing training in CAN reporting may not be adequate, the efficacy of the report system was not widely reported. The purpose of the study was to explore the demographic characters of CAN cases reported from the ED of a northern Taiwan community hospital. The compliance of ED nurses-oriented report was examined.


Child abuse and neglect (CAN) cases who presented to the ED of a northern Taiwan community hospital in 2015 were retrospectively examined. The report was either by a social worker or by an ER nurse. During office hour, while the patients with suspected CAN being evaluated in the ED, the social worker will be notified to come to the ED and evaluate the patients. The CAN report will be completed with 24 hours. When the patients presented during the hours when social workers are usually not on service, the ED nurses will complete the report as the system required.


The CAN reported cases numbers in 2015 was 93. Compared to the annual patients visit number of 60,458 in the same year, the CAN repot cases constitute only a small fraction of total visits. Among the victims, 57 cases (61%) were male, while 36 (39%) of them were female. The age distribution spanned all the pediatric group, yet almost half of the patients (49%) were younger than 6 years old. Thirty-five cases (38%) were reported by ED nurses, while 58 cases (62%) were reported by social workers. The report form compliance, either by ED nurses or social workers, was satisfactory.


Child abuse and neglect (CAN) is a serious threat to the children and the whole society. It carries not only immediate mortality and morbidity to the victims, the long term negative impact may be even difficult to estimate. The study revealed   satisfactory CAN report compliance by both ER nurses and social workers. However, it is far from concluding that the current report system was satisfactory. It can be easily identified that if the symptoms and signs of a CAN case is missed in the front line, the social worker and even the report mechanism will not be activated.  Although the magnitude of missed CAN cases is difficult to assess, these vulnerable patients deserve more of our devotion.

Po-Sheng CHIH (Taipei, Taiwan, China)
11:00 - 18:00 #7509 - Children and adolescents presenting to pediatric emergency department with chest pain.
Children and adolescents presenting to pediatric emergency department with chest pain.

INTRODUCTION: Chest pain is a common presenting symptom in pediatric practice but, unlike in adults, the cause is rarely cardiac. The aim of this study was to assess the etiology and various factors related to childrens’ and adolescents’ visits to pediatric emergency department (PED) due to a chest pain.

METHODS: Retrospective hospital based study was conducted during one year - all visits to the PED because of a chest pain, recorded in a hospital database, were analyzed. For data analysis descriptive statistics and Fisher exact two tailed test were used.

RESULTS: Of 12.068 admitted children, the chest pain was presented in 138 patients (1.14%): 79 boys, 59 girls; age range 3-18 yrs, mean 12.4 yrs. There was no significant difference in age between the boys and girls (12.47±3.82 vs. 12.37±3.55 yrs; t=0.149, p=0.881). Most of them arrived as an emergency (81%), while 19% were sent by their primary pediatrician.

Most of the patients arrived between 14-22 hrs. The boys arrived more frequently at night and during the morning but the differences were not statistically significant (Fisher two-tailed test p=0.288). During the school year 2.85 child per week reported chest pain, and only 1.81 per week during vacations. Attendance was relatively more frequent during the weekend. Pain occurred mostly at rest (82%), less frequently during and immediately after physical activity (18%).

Out of all diagnostic procedures, the only significant gender difference was in ECG, which  was performed more often in  boys (p<0.05).

After the pediatrician’s exam, 44% were sent to another specialist: cardiologist (21%); pulmonologist (commonly because of asthma attack) and gastroenterologist (both 5%); orthopedic surgeon (4%) and seldom to others. Most of the children were released home (69%), while 20% were kept in day hospital. Only 12% (17/138 patients) were hospitalized, mostly at the Cardiology Unit (15/17); only five diagnoses (5/138; 3.6%) could be potentially life-threatening: pneumothorax, cardiac arrhythmia, myopericarditis, chest trauma and electr