Tuesday 04 October

Tuesday 04 October

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08:30 - 09:00

Keynote Session 2

Moderator: Wilhelm BEHRINGER (Director) (Jena, Germany)
08:30 - 09:00 How informatics is improving trauma care. John HOLCOMB (USA)

Tuesday 04 October

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09:10 - 10:40

State of the Art
Disaster & Biohazards

Moderators: Dr Abdo KHOURY (PRATICIEN HOSPITALIER) (Besançon, France), Luc J M MORTELMANS (PHYSICIAN) (Antwerp, Belgium)
09:10 - 09:40 Mass Civilian Shooting: The out of hospital phase. Amandine ABRIAT (urgentiste) (Paris, France)
09:40 - 10:10 Mass Civilian Shooting: The in hospital phase. Mathieu RAUX (Responsable d'unité) (PARIS, France)
10:10 - 10:40 Cooperation across Europe: European Medical corps and Emergency medical teams. Pr Francesco DELLA CORTE (Speaker) (Novara, Italy)

Tuesday 04 October

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09:10 - 10:40

Austria, Germany, Switzerland Invites

Moderators: Roland BINGISSER (Basel, Switzerland), Harald DORMANN (Germany)
09:10 - 09:40 GeriQ: Der geriatrische Notfallpatient - Qualitätsindikatoren. Harald DORMANN (Germany), Susanne SCHUSTER (Germany)
09:40 - 10:10 Patientenbefragung - Standards in der Qualitätssicherung der Patientenzufriedenheit. Martin PIN (Bornheim, Germany)
10:10 - 10:40 Notaufnahmeprotokoll/AKTIN Projekt. Martin KULLA (Senior physician) (Ulm, Germany)

Tuesday 04 October

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09:10 - 10:40

Philosophy & Controversies
P&C Cardiovascular 1

Moderators: Barbra BACKUS (Emergency Physician) (Rotterdam, The Netherlands), Ardavan KHOSHNOOD (Lund, Sweden)
09:10 - 09:40 What is an acceptable risk of missing an acute coronary syndrome? Barbra BACKUS (Emergency Physician) (Rotterdam, The Netherlands), Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, United Kingdom)
09:40 - 10:10 Should we cardiovert patients with stable atrial fibrillation in the ED? Hans DOMANOVITS (Austria), Pr Martin MOECKEL (Head of Department, Professor) (Berlin, Germany)
10:10 - 10:40 Do we need copeptin in the high sensitivity troponin era? Pr Martin MOECKEL (Head of Department, Professor) (Berlin, Germany), Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, United Kingdom)

Tuesday 04 October

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09:10 - 10:40

Infectious Disease & Sepsis

Moderators: Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia), Tobias SCHILLING (ÄD) (Stuttgart, Germany)
09:10 - 09:40 Quality of ED sepsis care: Process of care indicators, standardized mortality ratios or the Hawthorne effect? Bas DE GROOT (Amsterdam, The Netherlands)
09:40 - 10:10 q SOFA and other Sepsis Scores: Really helpful for the Emergency Physician? Tobias SCHILLING (ÄD) (Stuttgart, Germany)
10:10 - 10:40 Prehospital and early ED diagnosis of sepsis. Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)

Tuesday 04 October

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09:10 - 10:40

Eye Opener Quiz

Moderators: Riccardo LETO (Chief of ED) (Overpelt, Belgium), Basak YILMAZ (Faculty) (BURDUR, Turkey)
09:10 - 09:40 Part 1: bizarre medicine. Basak YILMAZ (Faculty) (BURDUR, Turkey)
09:40 - 10:10 Part 2: for the nerds. Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom)
10:10 - 10:40 Part 3: things you definitely shouldn't know. Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)

Tuesday 04 October

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09:10 - 10:40

EuSEM Nursing Track
Prehospital Emergency Nursing

Moderators: Luciano CLARIZIA (Italy), Yves MAULE (MANAGER DE SOINS) (LIEGE, Belgium)
09:10 - 09:40 Preparing for the disaster. Mark TYLER (Australia)
09:40 - 10:10 Prehospital trauma care: nursing interventions. Salvatore CASILLO (Italy)
10:10 - 10:40 Detecting child maltreatment based on parental characteristics. Hester DIDERICH-LOLKES DE BEER (policy officer family maltreatment) (THE HAGUE, The Netherlands)

Tuesday 04 October

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09:10 - 10:40

Oral Papers 31

Moderators: Al BEHCET (faculty speaker) (Gaziantep, Turkey), Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, Italy)
09:10 - 10:40 #5019 - OP064 Logging safeguarding concerns in paediatric emergency medicine: ticking the right boxes when going paperless.
Logging safeguarding concerns in paediatric emergency medicine: ticking the right boxes when going paperless.


NICE CG 89 ‘Child maltreatment: when to suspect child maltreatment in under 16s’ (1) suggests that health professionals should consider safeguarding issues in all encounters with children, gives guidance on when to suspect abuse, and stresses the importance of documentation. The Emergency Department is a place where this is of particular importance as children often present with injuries that could be indicative of maltreatment, such as burns or head injuries. Therefore, all attendances should have a record of a safeguarding assessment stating whether the possibility of child abuse has been considered or suspected. Previous audits (2) have shown that the level of documentation of safeguarding assessments in the ED was very high, with an excess of 90% of children having safeguarding considerations documented. This level was achieved following the implementation of a written prompt in the paper based patient record. Since the last audit in 2013 the hospital has introduced a new electronic system of patient records, Epic. This re-audit aims to assess whether the high levels of documentation have been maintained after the implementation of this new system the safeguarding section of which will be briefly presented.


Electronic patient records of all Paediatric ED attendances during the week 01/02/16 to 08/02/16 were reviewed and checked as to whether clinical staff completed the required documentation of safeguarding assessments and to gather information about those with absent safeguarding assessments. Sample size: 414. Results wre compared to the previous audit performed in 2013.


385 (92.1%) had a safeguarding assessment completed, in 29 (7.9%) cases the assessment was missing. Re-attenders (n=14) had no safeguarding assessment documented on the second attendance in 6 cases. Split into age groups, the percentage of assessments not completed ranged from 8.33% in the 6 - 10 year olds to 5% in the 1 - 5 year olds. 15 patients (3.6%) in whom safeguarding assessments were missing presented with diagnoses like burns, head or other injury.


Following the implementation of a new electronic system of patient record keeping and thus the removal of the previous ED paper based system with its well established prompts, documentation of presence (or absence) of safeguarding concerns in the Paediatric Emergency Department remains in excess of 90%. This is despite the fact that safeguarding assessments on Epic are not a compulsory documentation item, reflecting a positive culture of safeguarding awareness. Children who re-attended the ED were amongst those who were lacking safeguarding assessments when attending the second time but one coud argue that this may be appropriate in the vast majority of patients that re-attend within such a short time.  The current system is effective but still does not capture a proportion of patients that present with significant injuries.

Basia CHMIELEWSKA (Cambridge, United Kingdom), Peter HEINZ
09:10 - 10:40 #6184 - OP065 Do refugees pose a serious national public health threat? Incidence of communicable diseases amongst a representative cohort of 8.678 refugees in Germany.
Do refugees pose a serious national public health threat? Incidence of communicable diseases amongst a representative cohort of 8.678 refugees in Germany.


German immigration laws require refugees to undergo medical screening as part of the asylum application process. This consists of a self-reporting questionnaire, a physical examination and a tuberculosis screening. There appears to be some anxiety whether refugees pose a public health threat to the German population through higher than usual rates of communicable diseases. This study aims to assess the incidence of communicable diseases, i.e. head lice, scabies, hepatitis, HIV or tuberculosis amongst refugees.



We collected data on communicable diseases of refugees living in holding camps in the County of Lippe, Germany. All refugees not having undergone a medical screening examination or parts thereof underwent a medical screening examination as part of the weekly refugee medicine clinics run by the emergency department. Demographical data including age, gender and country/region of origin as well as any notable findings during the self-reporting questionnaire, physical examination and tuberculosis screening were recorded. Tuberculosis screening consisted of either chest radiographs, interferon-gamma immuno-assay or a Mendel-Mantoux skin prick-test, or a combination of these, depending on age and/or pregnancy status.



The County of Lippe operates 6 refugee camps with a capacity of 70-700 refugees each. From October 2014 until March 2016 altogether 9,992 refugees were registered for medical examination with 8,678 actually attending (86.8%). Of these, 69.3% were male and 30.7% female. The mean age was 24 years. Most refugees originated from Western Asia (41.8%), followed by those coming from Balkan states (21.7%), Africa (8.3%) and former Soviet states (6.9%).

As part of tuberculosis screening 3,327 refugees underwent chest x-ray in our clinic, whereas 3,096 were x-rayed elsewhere. 1,192 refugees received interferon-gamma immuno-assay and 769 children under the age of 6 years received a Mendel-Mantoux skin prick-test. Due to a lack of supply of Mendel-Mantoux serum from December 2015 onwards in whole Europe, 123 children did not receive any tuberculosis screening at all.

Overall, only 66 refugees were found to have scabies (0.76%) and 49 (0.56%) were tested positive for head-lice (0.56%). In contrast, 676 refugees had a non-communicable yet relevant medical condition (7.78%) requiring follow-up. We found 50 of 8,524 screened refugees to have an abnormal tuberculosis screening result (0.59%). Of these, only 7 were confirmed to have active tuberculosis requiring standard combination therapy (0.08%) and 3 refugees required isolation due to open tuberculosis (0.04%). Interestingly 27 refugees were known to suffer from viral hepatitis (0.31%) and 7 reported to be HIV-positive (0.08%).



This study is the first to describe the incidence of notifiable/communicable diseases and tuberculosis amongst a representative sample of refugees coming to Germany. Although only 0.8% of the total refugees entering Germany were included, the results appear to be fairly comparable to the overall refugee population. The incidence of tuberculosis amongst refugees appears to be 11 times higher than for the resident German population. Nevertheless, the projected overall number of approximately 500 new tuberculosis cases amongst refugees compared to an overall national incidence of 5,895 new cases in 2015 does not seem to pose any serious public health threat.

Patrick DISSMANN (Detmold, Germany), Felix KOEHRING, Florian FISCHER
09:10 - 10:40 #7076 - OP066 Hyperpyrexia as a predictor for serious bacterial infection (SBI) in children – a systematic review and meta-analysis.
Hyperpyrexia as a predictor for serious bacterial infection (SBI) in children – a systematic review and meta-analysis.

Importance: Fever is one of the most common symptoms in children. It is not clear if children with high fever are at increased risk for serious bacterial infection (SBI). 

Objectives: To systematically review and to perform a meta-analysis, in order to determine whether children suffering from high fever are at high risk for SBI.

Data sources: The following databases were searched from their inception until the last week of December 2014: Embase (via Embase.com), Medline (via OvidSP) and Pubmed.

Study selection: Cohort and case control studies comparing the incidence of SBI in children with a temperature higher than 410C,  with children with fever of 410C or less, and children with a temperature higher than 400C, with children with fever of 400C or less.

Data extraction and synthesis: Based on a preliminary review, two reviewers independently pooled studies for detailed review using a structured data-collection form. We calculated the odds ratio and 95% confidence intervals (CI) for SBI, assuming a random-effects model. A sub-group analysis was conducted based on age.

Main outcome and measures: SBI

Results: Ten studies met the inclusion criteria.  Only two studies compared children with temperature over 410C with children with lesser degree of fever. Children with temperature over 410C had higher risk for SBI (OR 1.96 95%CI 1.3-1.97). Nine studies reported on children with temperature over 400C. The summary end-point suggests an increased risk for SBI in children with high fever (OR 3.21 95% CI 1.67;6.22). When analyzing the studies reporting on young infants, the odds ratio for SBI in children with temperature over 400C was higher compared to infants with lower degree of fever (OR 6.3 95% CI 4.44;8.95). Four studies reported on older children; the odds ratio for SBI in children with high fever was only slightly higher than in children with lower degree of fever (OR 1.36 95% CI 1.16;1.61).

Conclusions and relevance: Young infants with temperature higher than 400C are at increased risk for SBI. Compared with children who have lower degree of fever, the risk of SBI in older children with temperature >400C is minimal.

Noa ROSENFELD-YEHOSHUA, Shiri BARKAN, Ibrahim ABU-KISHK, Meirav BOOCH, Ruth SUHAMI, Eran KOZER (Zerifin, Israel)
09:10 - 10:40 #7503 - OP067 Gender differences in paediatric emergency medicine: a multicenter prospective observational study.
Gender differences in paediatric emergency medicine: a multicenter prospective observational study.

The influence of gender on health and disease is increasingly being recognized. In emergency medicine, sex-specific differences are well described in adults, including the acute presentation of certain conditions, the epidemiology of illnesses and injuries, and the effects and side-effects of medications. Beside physiologic and biologic factors, gender-specific biases are found to influence physician’s treatment decisions. So far, little is known about how gender affects emergency care for children. The aim of this study was to assess the role of gender in presenting problem, disease management and outcome in children attending the emergency department(ED).

This study is part of the TrIAGE project, a prospective observational study in five ED’s in four European countries (the Netherlands, United Kingdom, Austria, Portugal). Data collection consists of routinely recorded patient data, automatically extracted from electronic medical records. Study sites are instructed in data collection and a minimum set of required variables. Data harmonization and quality checks were performed.  We included all consecutive children aged

In total, 84,747 children under the age of 16 were included in the study, and 54.2% were male. In all 5 hospitals, the proportion of boys visiting the ED was higher than girls, ranging from 52.0 to 58.4%. The proportion of boys decreased with age, from 56.5% (range 52.3-61.4%) in children 12 years. Boys presented more often with trauma and limb problems (22.0% versus 19.7%), presented more often with high-urgent problems according to the Manchester Triage System (12.9% versus 10.6%) and were more often admitted (11.9% versus 10.6%). When adjusted for clinical parameters, diagnostics and therapy, and patient disposition, some differences between boys and girls remained. Girls were triaged less often with a high urgent triage category (OR 0.85, 95%CI 0.81-0.89). Moreover, in girls significantly more lab tests were performed in case of medical problems (OR 1.09, 95%CI 1.04-1.14) and more radiologic tests in case of trauma (OR 1.16, 95%CI 1.09-1.24). Girls were less likely to receive inhalation medication (OR 0.72, 95%CI 0.68-0.77), while overall there was no difference in oral or intravenous medications administered.

In childhood, boys attend the ED more often than girls, and this trend decreases with age. When adjusted for potential confounders, girls were triaged less often to a high urgency category. Moreover, some gender-based differences were found in diagnostics and management. Further research is needed to explore whether these findings are caused by differences in disease type, disease presentation, symptom severity or whether gender subconsciously plays a role in management decisions in children. 

Joany ZACHARIASSE (Rotterdam, The Netherlands), Dorine BORENSZTAJN, Claudio ALVES, Paulo FREITAS, Frank SMIT, Johan VAN DER LEI, Ewout STEYERBERG, Ian MACONOCHIE, Susanne GREBER-PLATZER, Henriëtte MOLL
09:10 - 10:40 #7598 - OP068 The first emergency physician driven diagnostic algorithm for acute vertigo showed very high negative predictive value for acute brain injury: the STANDING prospective study.
The first emergency physician driven diagnostic algorithm for acute vertigo showed very high negative predictive value for acute brain injury: the STANDING prospective study.


Vertigo and unbalance are frequent complaints in emergency department (ED), often due to a benign disease. However, the possibility of an acute brain disease is not remote and vertigo assessment is usually time and resource consuming. We aimed to investigate the diagnostic accuracy of an ED driven diagnostic algorithm.


Consecutive adult patients presenting with vertigo/unbalance to a third level university hospital in Florence, from October 2015 to March 2016, were considered for the study. The STANDING is a four steps algorithm, which includes the discrimination between SponTAneous and positional Nystagmus, the evaluation of the Direction of the nystagmus, of the head Impulse test (HIT) and of the standinG position. Reliability of each step was analysed in a subset of patients by Cohen’s k calculation. The reference standard (central vertigo) was a composite of acute brain injury at initial head imaging or a diagnosis of stroke, demyelinating disease, neoplasm or other new-onset brain disease during 3 months follow-up, adjudicated by an independent panel of experts in vestibular disease and neuroimaging.


Three hundred and fifty one patients were included with a mean age of 57.6±18 years, with a slight prevalence (59.5%) of females. We found an incidence of acute brain disease of 11.7% (95% CI 8.5%-15.5%). The leading cause was ischemic stroke (68.3%) followed by neoplastic disease (24.4%). Each step of the STANDING algorithm showed e good reliability; the second step, the analysis of the direction of nystagmus, showing the highest (0.95) and the HIT test the lowest (0.83) agreement. The overall accuracy of the test was good (87%, 95% CI 84-88%) showing good specificity (86%, 95% CI 84-86%), high sensitivity (95%, 95% CI 83-99%) and very high negative predictive value (99%, 95% CI 97-100%) for acute brain disease.


The STANDING diagnostic algorithm showed good reliability and high accuracy in excluding acute brain disease in the emergency setting. 

09:10 - 10:40 #7633 - OP069 A NEW CATHETER FOR LARGE VEINS: A NEW WAY.

Background Availability of venous access for administering drugs and fluids in critically ill patients is a cornerstone of modern Emergency Medicine. In patients with difficult peripheral venous access, alternative techniques, such as the placement of a central venous catheter, require expertise and are invasive, expensive, time-consuming and prone to serious adverse events. The attempt to obtain vascular access placing a peripheral venous catheter under ultrasonographic guide has been sometimes performed in clinical practice, but only a few case reports are presented in literature. Despite an easy placement and absence of complications, insufficient length of the classical PVC (45mm) led to frequent early displacement. For these reasons, we plotted a new venous catheter (JLB®, Deltamed Inc.) to cannulate large bore veins and lead an observational convenience sampling study to test the security of device and eco-guided bedside technique of insertion, the cheapness of the catheter, the handiness of learning and use of it.

Study  We led a multi-center observational convenience sampling study to evaluate safety and effectiveness of JLB®. Patients were enrolled in 3 EM units, 2 ICU, 1 Internal Medicine ward. Data were collected from July 1st 2015 to April 15th 2016. Inclusion criteria were: age≥18, impossibility to obtain peripheral access, need for inotropes/TPN or patient's preference. The procedure was performed by attending physicians or EM residents under US guidance. We enrolled 250 patients; at present data were analyzed in 158 patient: 91 women, mean age 74,5 years ± 16,2 SD. 130 patients (82,3 %) had not any other peripheral access, 33 (20,9 %) need inotropes/TPN infusion, 6 (3,8 %) express preference. Mean procedure time (from disinfection to securing) was 207,7 s ± 12,4 SD. Early complications (<24h) occurred in 2 (1,3 %) patients, consisting in 1 soft-tissue hematoma and 1 atrial tachyarrhythmia. No major complications (such as PNX, major arrhythmia, infection) were reported. Mean duration time was 132,1 h ± 67,6 SD, occlusion/dislocation occurred in 11 cases (6,9 %).

Conclusion Our bedside device revealed to be fast to place. This new catheter is also safe since no major complication or clinical device-associated infection occured. Moreover, placement of this device doesn't need CXR to confirm placement and exclude PNX because is unlikely, but this task can be easily performed using US. Our device can represent an ideal technique for DIVA not needing advanced vital monitoring and in emergency settings.

Brugioni LUCIO, Elisabetta BERTELLINI, Marco BARCHETTI, Pietro MARTELLA, Vivoli DANIELA, Serena SCARABOTTINI, Francesca MORI (MODENA, Italy), Davide Maria Francesco LUCCHESI, Francesco LUPPI, Francesco BORRELLI, Mirco RAVAZZINI, Elena CARELLA, Sergio CAMPANALE, Angelo TRICOLI, Antonella LANOTTE
09:10 - 10:40 #8051 - OP070 A Review of Emergency Department Patients with a Very High D-Dimer Level.
A Review of Emergency Department Patients with a Very High D-Dimer Level.

TITLE:  A Review of Emergency Department Patients with a Very High D-Dimer Level




In a low risk patient a negative D-Dimer (DD) can be used to rule out suspected venous thromboembolism (VTE) and avoid advanced imaging tests.


Clinicians tend to view the DD result in a binary fashion - positive or negative. However DD is a fibrin degradation product and as such can correspond to clot burden. Therefore it is logical to suppose that we should not view a DD of, for example, 0.95mg/L the same a 9.5mg/L. In our study we analysed patients with very high DD results.




This is a retrospective cohort study of patients who had a D-Dimer requested by the ED between September 2014 and July 2015.  We studied patients who had a D-Dimer result over 10 times upper limit of normal (i.e. >5mg/L). The parameters analysed were age, DD value, diagnosis, the presence of new/old malignancy and 6 month mortality.




2,060 patients had a D-Dimer sent during the study period, 104 had a result of >5mg/L. There were no notes available for two patients and there was one duplication. The overall positive diagnostic rate for VTE was 46.5% (47/101). In those patients with DD between 5-10mg/L, the incidence was 40.6% (24/59) and in those >10mg/L it was 54.8% (23/42). There were higher rates of proximal DVT (64% vs 50%) and bilateral/multiple PEs in the DD- >10mg/L versus 5-10mg/L groups. 22 patients had a known malignancy prior to testing,  there was a new diagnosis of malignancy in 3 patients. 6 month mortality rate was 19.8% (20/101), half of these had a known malignancy.




Our results indicate that in those patients with a higher D-Dimer, there appeared to be a correlation between D-Dimer level and clot burden.  A very high result should give a clinician a higher index of suspicion to consider larger VTEs and possibly a more serious underlying diagnosis. 

David MONKS (Dublin, Ireland), Neha SIDDIQUI, Precious NWAFOR, John CRONIN
09:10 - 10:40 #8154 - OP071 The burden of genetic diseases in a French pediatric emergency department.
The burden of genetic diseases in a French pediatric emergency department.


The prevalence of children with complex chronic conditions in pediatrics is increasing and their management is an important part of hospitalizations, emergency room visits and pediatric healthcare costs. Some of them are suffering from genetically determined diseases. Both group of diseases share part of their problems. In the literature, the impact of genetically determined diseases on pediatric emergency services is unclear.



The objective of this study was to determine the prevalence of genetically determined diseases in a pediatric emergency department and describe the features of their management.



This was a prospective observational study performed in the pediatric emergency department of a French university Hospital receiving over 60,000 children annually. All children under 18 years old, visiting our pediatric emergency department for a medical complaint were included during five consecutive days in September 2014. Chronic diseases or malformations were classified according to the classification proposed by McCandless et al. Am J Hum Genet. 2004;74:121‑7. The study was reviewed and approved by the Ethics Committee of Necker-Enfants Malades Hospital. One family refuses to participate to the study.



Of the 454 children included, 39,5% of them had a disease or malformation genetically determined (categories I to IV, n = 179), of which 4.4% had a chromosomal or single-gene disorders such as sickle cell disease, hemophilia (IA), 6.4% had a multifactorial/polygenic disorder such as spina bifida, autism (IB), 7.1% had a disease or abnormality of heterogeneous cause, often genetic such as mastocytosis, migraine (IC) and 20.7% had an acquired chronic disease with genetic predisposition such as diabetes, asthma (III). Of these 179 patients, 83 (46%) visited the pediatric emergency department with a chief complaint related to their chronic condition. We observed more biology tests (40% versus 18%), more imaging test (32% versus 20%), longer length of stay (mediane 123 minutes versus 88 minutes), and higher hospitalization rate (32% versus 9%) in children with underlying conditions with strong genetic basis (IA + IB + IC). Similarly, the hospitalization rate was higher (37% versus 9%) in children with an acquired chronic disease with genetic predisposition.



These results highlight the high frequency of patients suffering from complex chronic conditions, especially genetically determined diseases, in a pediatric emergencies department and the impact of such conditions on the care provided. These patients had particular characteristics that should lead to specifics treatments, and then a comprehensive and global approach of children with genetically determined diseases in pediatric emergencies is needed. This should be based on several axes of improving: training of professionals, scientific research, pharmacogenetics, support of families, the quality of care, and patient identification.

François ANGOULVANT (Paris), Béatrice SIMONNARD, Agathe APRAHAMIAN, Névine EL KHATIB, William CURTIS, Rémy CHOQUET, Gérard CHÉRON
09:10 - 10:40 #8157 - OP072 Prognostic value of bnp, ddım, mmp-9 and s100β levels of stroke patients in emergency department.
Prognostic value of bnp, ddım, mmp-9 and s100β levels of stroke patients in emergency department.

Background: Ischemic stroke is the leading cause of long term morbidity and mortality, which affects several hundred thousand people per year. Various biomarkers indicating neurologic damage have been developed. The biomarkers indicating neurologic damage will reduce the need for neurologist or radiologist consultation in emergencies, enabling to follow a more reliable way  in order to set the true diagnosis and determine treatment options in patients at risk. In addition, neurologic examination is not objective and may differ depending on a person's experience. With determination of an objective marker, a more accurate and reliable way will be followed in the diagnosis and treatment of stroke. It is believed that, a fast, simple and low-cost biomarker which provides information about brain tissue damage would be extremely beneficial. For this purpose; S100 calcium-binding protein B (S-100β), d-dimer (DDIM), matrix metallopeptidase 9 (MMP-9) and brain natriuretic peptide (BNP) that show cerebral damage have been studied in early period stroke patients. The primary objective of this study is to measure the correlation between clinical severity and serum/plasma concentration of neuronal injury biomarkers in stroke patients.

Material & Methods: This prospective study was initiated with 63 patients having pre-diagnosis of stroke, but then 15 patients were excluded due to various reasons. All patients were undergone the necessary  laboratory and radiological examinations and treated in accordance with guidelines. Blood samples were collected at the first admission and after 48 hours, and S-100β, DDIM, MMP-9 and BNP values were measured.

Results: Of patients, 45.8 (n=22) were female with median age 70 (min=25, max=85). There were previous SVO in 25% (n=12), DM in 12.5% (n=6) DM, atherosclerosis in 31.3% (n=15), hyperlipidemia in 25% (n=12), COPD in 16.7% (n=8), renal failure in 2.1% (n=1), smoking in 37.5% (n=18) and alcohol abuse in 8.3% (n=4). On ECG ordered, 30 (62.5%) patients have sinus rhythm and 18 (37.5%) atrial fibrillation. Patients were hospitalized in the neurology clinic between 1-60 days (median: 9 days). From the patients followed-up, 11 (22.9%) died and  37 were (77.1%) discharged from the neurology clinic. Impairment of consciousness was more common in the patients who died (72.7%; n=8 vs. 35.1%;n=13, p=0.04). GCS was significantly lower in patients who died (n=11; mean=11.2±2.7) compared to those discharged (n=37; mean=13.3±2.8) (p=0.01). BNP (died:783.3±778 vs. discharged:268.7±377; p=0.002) and DDIM (died:2565.4±1512 vs. discharged:1547.2±1341.7; p=0.036) studied at the hour 0 were found to be significant in determination in-hospital mortality. Whereas, no significant difference was found in the parameters studied at the hour 48. MMP-9 values at the hour 0 were positively correlated with the days of hospitalization (pearson correlation:0.291; p=0.045).

Conclusion:In this study, we demonstrate that BNP and DDIM as markers of prognosis at the time of first admission in patients with ischemic stroke. MMP-9 level was significantly correlated with hospitalization time, although no significant difference was found in terms of mortality. 

Mustafa UZKESER (Erzurum, Turkey), Abdullah Osman KOCAK, Lutfi OZEL, Mucahit EMET, Ilker AKBAS, Sahin ASLAN

Tuesday 04 October

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09:10 - 10:40

Administration management
Patient Safety & Risk Management

Moderators: David BROWN (USA), Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
09:10 - 09:40 Major mistakes for which you will pay. Greg HENRY (USA)
09:40 - 10:10 You can't fix what you don't measure: Improving care in the ED and beyond. Karin RHODES (USA)
10:10 - 10:40 Mitigating Risk in ED Patient Hand-offs. David BROWN (USA)

Tuesday 04 October

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10:45 - 11:05

Poster Highlight Session 4 - Screen 1

10:45 - 10:50 #7189 - Traumatic diaphragmatic injuries: 12 year experience from a tertiary trauma centre: A retrospective cohort study.
Traumatic diaphragmatic injuries: 12 year experience from a tertiary trauma centre: A retrospective cohort study.

Introduction: Traumatic diaphragmatic injuries (TDIs) are clinically challenging. We aimed to review TDIs treated in a tertiary trauma centre.

Materials and Methods: We performed a 12 year, single-centre retrospective review of adult patients with TDIs. Primary outcomes were survival, mortality rates and injury severity scores (ISS) associated with each TDI subtype. Secondary outcomes included proportions of TDIs diagnosed radiologically, operatively or at autopsy. We compared TDI subtypes with their mechanism of injury, mortality rates and median ISS. Data was analyzed using descriptive statistics. P values < 0.05 were considered statistically significant.

Results: We recruited 46 patients with acute diaphragmatic herniation (14/46 or 30.4%), tears (22/46 or 47.8%) or contusions (10/46 or 21.8%). The survival and mortality rates ranged from 0.0 to 64.3% and 35.7 to 100.0% respectively among the TDI subtypes. The ISS among survivors and deaths ranged from 22.0 (interquartile range [IQR] 6.5) to 34.0 (IQR 23.0) and 53.5 (IQR 16.0) to 66.0 (IQR 28.5) respectively among these subtypes. Chest X ray revealed 2/33 (6.1%) while computer tomographic scans detected 6/13 (46.2%) patients with TDIs. All survivors (n=21) and deaths (n=25) underwent open surgery or autopsy respectively that confirmed their TDIs. Blunt and penetrating trauma was more frequently associated with acute herniation and tear respectively. There were statistically significant differences among the TDI subtypes with their mechanism of injury, mortality rates and median ISS of survivors.

Conclusions: TDIs had a predictable pattern with mechanism of injury and were associated with significant mortality rates. Pre-operative imaging had limited diagnostic use.

Lim BENG LEONG (Singapore, Singapore), Teo LI TSERNG, Chiu MING TERK, Asinas-Tan MARXENGEL, Seow EILLYNE
10:50 - 10:55 #7295 - Directing massively and simultaneously numerous terrorist victims in a hospital provided with all surgical specialties: An adapted answer.
Directing massively and simultaneously numerous terrorist victims in a hospital provided with all surgical specialties: An adapted answer.

Study objectives: On the 13th of November 2015, Paris was targeted by multisite terrorist attacks. Triage principles on the field have been applied in order to adapt patients care needs to hospital capacities. The important number of victims forced the first responders to direct simultaneously a tremendous number of patients to few hospitals provided with all surgical specialties. The main objective of our study was to assess if this orientation strategy was adapted or if many secondary transfers have been needed shortly after receiving victims to our center.

Methods: We conducted a monocentric retrospective study in our academic hospital on all attacks victims brought to us during the first 24hours following the attacks. The wounds description and health care resources utilization during the first 48 hours have been collected through the analysis of medical charts. Patients presenting a single psychotrauma have been excluded. Our primary endpoint was the proportion of transfers to another hospital in the first 48 hours du to exceeded capacities. Data are given in n, percentages and mean + standard deviation.

Results: n=41 patients (77.3% of all patients brought to the hospital) were brought to our center, 70.7% with gunshot wounds. Sex ratio was 1.2. Patients were 37,9 ±9,6 years old. They were brought to the hospital between 1:15 and 3:15 AM. Pre hospital services had advised 13 (31.7%) Absolute Emergencies and 28 (68.3%) Relative Emergencies but only 19.6% of our patients had written medical charts with prehospital parameters. When arriving in the Emergency Department (ED), a triage was done and 30 (73.1%) patients were kept in the ED area whereas 11 (26.9%) were brought to Intensive Care. Patients were presenting wounds (90.2%), mainly on members of the body (83.8%) with projectile for half of the cases (48.6%). 29.7% had an open fracture. 30 (73.2%) patients were admitted to the hospital (mean length of stay: 11.8 days [1;101]. 65.8% of all patients have had surgery in our facility in the first 48 hours including 88.9% for orthopedics. At last, all patients needing a surgery had it performed in the first 48 hours including 3 patients needing to be transferred because of exceeded capacities in our hospital. Our proportion of transfers was 7.3%. These transferred patients had members’ orthopedics surgeries. Due to spontaneous arrival of senior colleagues in the ED, the medical workforce has increased of +300%. There has been no in-hospital death.

Conclusion: The triage strategy on the field followed by directing massively and simultaneously victims to a hospital provided with all surgical specialties seems to be an adapted answer in front of an important number of patients. A technical platform associated with workforce mobilization allowed us to provide care to almost all victims brought to our hospital from the terrorist attacks. Only 3 patients out of 41 have been transferred to another facility for a minor surgery. No death was to deplore.

Florent FÉMY (Paris), Anne-Laure FÉRAL-PIERSSENS, Arnaud FOLLIN, Philippe JUVIN
10:55 - 11:00 #7317 - Is Whole Body Non-Contrast Computer Tomography Useful in Blunt Abdominal Trauma? Retrospective Study in Blunt Liver Trauma.
Is Whole Body Non-Contrast Computer Tomography Useful in Blunt Abdominal Trauma? Retrospective Study in Blunt Liver Trauma.

Background and Introduction: The estimated percentage of liver injury in multiple trauma patients is about 1% to 8 %. The Focused Assessment Sonography of Trauma (FAST) could be used in the survey of blunt abdominal trauma popularly and the whole body computer tomography (CT) is promoted in the recent papers when the patient is under severe trauma. When patients arrive in the emergency room the renal function result of patients is not usually available. We try to find that the usage of non-contrast CT can be more efficient method in the diagnosis of liver trauma. 

Participants and Methods: The results of liver trauma patients are collected from July 2001 to March 2016. There are 118 patients are included in this review study. Patients belong to liver trauma to be included and these patients are confirmed by abdominal CT and graded with Abbreviated Injury Scale (AIS)-90. The FAST examination is performed at the scene of emergency room. Our doctors which are in charge review the finding and take ultrasound reports in the medical history. We review our liver trauma cases and present the different results between FAST, non-contrast abdominal CT and contrast abdominal CT.  

Results: Within 118 patients of liver trauma the FAST is performed in 83 patients. In FAST group there are 43.4% patients with negative finding. In cases of negative-liver trauma on non-contrast abdominal CT we find there are 38 cases belonging to grade II liver injury scale after contrast injection. The negative predictive value of non-contrast CT is 52.5% (62/118) in liver trauma. Besides in 36 patients presenting liver trauma on non-contrast CT 9 cases are negative finding on FAST examination. The liver injury scale belongs to grade II and grade III.

Discussion and Conclusion: The CT should play more important roles in diagnosis of major trauma. The FAST scan has limitations at liver trauma diagnosis. The miss diagnosis rate is 25 % and non-contrast CT provide us higher diagnosis rate than FAST but we find that this result is still not satisfactory in clinical usage. The negative predictive rate is so high and usually is under estimated . Combinations of other clinical findings such as biochemical study, vital sign and mechanisms may be most useful. If liver trauma is highly suspected the contrast CT still has be performed.


  1. Gerrit Matthes, Dirk Stengel, Julia Seifert et al  Blunt Liver Injuries in Polytrauma: Results from a Cohort Study with the Regular Use of Whole-body Helical Computed Tomography World J. Surg. 27, 1124–1130, 2003
  2. Daniel K. Nishijima, David L. Simel, David H. Wisner, James F. Holmes Does This Adult Patient Have a Blunt Intra-abdominal Injury? JAMA, 307(14),1517-1527, 2012

Chia-Hsi CHEN (Chiayi, Taiwan, Taiwan, China), Wai-Bun CHAN, Tak-Yee WONG, Jui-Fang HUANG, Su-Lan WU
11:00 - 11:05 #7333 - The Nomogram is a pre-CT scan clinical tool to predict and stratify the individual risk of intracranial lesion after Minor Head Trauma.
The Nomogram is a pre-CT scan clinical tool to predict and stratify the individual risk of intracranial lesion after Minor Head Trauma.

Background: The management of patients observed in the Emergency Department for minor head trauma (MHT) remains controversial. Up to now all the main decision rules, NOC and CCHR, are focused to identify the risk of intracranial lesions suitable for neurosurgery in selected patients, those with loss of consciousness and/or amnesia. As a consequence, a clinical tool able to stratify for every patient the individual risk of all intracranial lesions, either neurosurgical or not, still lacks.

Aim: The aim of our study was to create a predictive tool able to estimate the risk of intracranial lesion after MHT: the nomogram. This would be a fast and reliable tool to stratify the individual likelihood of traumatic sequences in every patient observed in Emergency Department. 

Methods: We considered 3538 patients consecutively observed for MHT and the submitted to CT scan in the Emergency Department of the University Hospital of Verona (Italy) between January 2014 and June 2015. All baseline features, common risk factors and CT findings of every patient were collected and then registered. First step was directed toward the construction of nomogram. All the risk factors associated in the univariate analysis with the outcome (CT scan positive) were candidates for the multivariate analysis. The final model was then used to explain the nomogram. Second step was the validation of the nomogram on an independent dataset, after discrimination (C-index, ROC curve) and calibration (calibration plot) were verified.

Results: The eleven risk factors significantly associated with all intracranial lesion in the multivariate model resulted to be: suspect of skull fracture (OR 69.56 IC 95%  19.88 – 243.35), dangerous mechanism (OR 4.61 IC 95%  3.04 – 7.00), vomiting (OR 3.97 IC 95%  2.35 – 6.71), GCS < 15 (OR 5.85 IC 95% 3.83 – 8.94 ), post-traumatic LOC (OR 3.23 IC 95%  2.09 – 4.96), previous neurosurgery (OR 3.79 IC 95%  1.61 – 8.92), focal neurological deficit (OR 5.55 IC 95%  2.48 – 12.45), amnesia (OR 2.25 IC 95%  1.56 – 3.48), age over 65 years (OR 2.26 IC 95%  1.45 – 3.50), visible signs of trauma (OR 1.72 IC 95%  1.17 – 2.52), antiplatelet therapy (OR 1.93 IC 95%  1.29 – 2.89). The nomogram gave each risk factor a likelihood rate of intracranial lesion and the individual risk level was defined by the amount of risk factors reported in every patient. The predictions of the nomogram appeared to be accurate and to have good discriminatory abilities, since it generated an area under ROC curve of 0.85. As matter of fact, the nomogram achieved a high predictive negative value (0.96) in low risk patients (< 5%), while high specificity (0.92) in high risk ones (> 20%).

Conclusions: Risk factors can be combined into risk profile to predict the likelihood of traumatic sequences. This predictive tool, the nomogram, can be used to stratify all the minor head trauma patients according to a growing risk of intracranial lesions.

Gianni TURCATO, Dr Antonio BONORA (VERONA, Italy), Alice DILDA, Gabriele TAIOLI, Massimo ZANNONI, Domenico VERALDI, Giorgio RICCI, Mariano BELLONI, Claudio PISTORELLI, Francesco BUONOCORE

Tuesday 04 October

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10:45 - 11:05

Poster Highlight Session 4 - Screen 2

10:45 - 10:50 #7656 - Herpes simplex encephalitis: top priority diagnosis and treatment in emergency department.
Herpes simplex encephalitis: top priority diagnosis and treatment in emergency department.

Introduction: Herpes simplex encephalitis (HSE) is a sporadic, endemic but devastating viral infection. In general it is due to a reactivation or a reinfection by herpes simplex virus 1 (HSV1) while herpes simplex meningitis (HSM) is due to HSV2. Objectives: a. to analyze their clinical presentations, complementary exams, treatment (TT) and patient’s outcome; b. to retrospectively evaluate a diagnostic score of encephalitis (IEC, International Encephalitis Consortium 2013). Material and method: Observational retrospective study of all patients admitted in the emergency department (ED) between May 2005 and May 2015 with final diagnosis of HSM or HSE. Results: inclusion of 32 patients over 10 years: 12 HSM and 20 HSE. Patients with HSE were older (average age: 65.6 years). The clinical consultation deadline was ≤ 84h for 75% of patients (average time: 67 hours). Patients with headache had a poor risk of HSE, whereas those with confusion and/or neurological signs had a higher risk of HSE. The IEC score retrospectively permitted to differentiate HSM and HSE by considering results “possible” as HSM. The lumbar puncture was positive for viral meningitis in 93.8% of cases. An EEG was always abnormal in HSE (100%), with a statistical significant difference between HSM and HSE. Brain CT scan did not differentiate HSM and HSE. An abnormal brain MRI (gold standard) statistically signed a HSE, and its average delay time was > 24 hours for 75% of HSE patients. Regarding TT all patients had received acyclovir, and its average duration in HSE was 21 days. No patient having HSM presented neurological sequelae compared with 65% of HSE patients. Discussion: PCR results should not delay the treatment start time. Brain MRI is the exam of choice if suspicion of HSE. Conclusion: The HSE need top priority diagnosis and treatment related to the risk of neurological damage. Score IEC had an excellent sensitivity and specificity in the HSE diagnosis and could thus be used to differentiate MH and MEH clinical presentations on ED admission.

Paul GAYOL (Strasbourg), Eleonore SEUVIC, Ruxandra COJOCARU, Manana POTOCNIK, Fadi KHALIL, Eric BAYLE, Syamak AGHA BABAEI, Pascal BILBAULT
10:50 - 10:55 #7674 - Prognostic significance of left and right ventricular systolic dysfunction during sepsis.
Prognostic significance of left and right ventricular systolic dysfunction during sepsis.

Background: In sepsis, organ failure is used for risk stratification, myocardial dysfunction is common, but abnormal left ventricular (LV) ejection fraction (EF) does not predict outcome . We sought to evaluate frequency and prognostic impact of biventricular dysfunction in patients with severe sepsis or septic shock independent to standard assessment of organ failure.

Methods: Consecutive septic patients admitted between October,2012 and March,2016 to a High-Dependency medical unit were enrolled. Sepsis-related Organ Failure Assessment (SOFA) score was assessed along with LV and right ventricle (RV) dimensions and systolic function by echocardiography within 24 hours from the admission (T1).  LV systolic function was evaluated also by bi-dimensional speckle tracking modality. Mortality was evaluated in the short (day 7, D7) and intermediate follow-up (day 28, D28).

Results: In 143 patients (85% of the consecutive candidates) mortality was 17% at D7 and 28% at D28. Non-survivors were significantly older than survivors (D7: 80±15 vs 72±12 years; D28: 79±14 vs 71±13, all p<0.01); SOFA score was comparable among survivors and non-survivor at both follow-ups (D7: 8.3±2.8 vs 7.2±2.8; D28: 7.8±2.9 vs 7.2±2.6, all p=NS). LV diastolic diameter (4.6±0.8 in non-survivors vs 4.7±0.8 mm in survivors) and RV basal diameter (3.7±0.7 in non-survivors vs 3.6±0.6 mm in survivors; midventricular diameter 2.7±0.8 in non-survivors vs 2.7±0.9 mm in survivors; longitudinal diameter 7.4±1.1 in non-survivors vs 7.7±1.1 mm in survivors, all p=NS) did not differ according to outcome. LVEF was only slightly lower in non-survivors compared with survivors (D7: 42±21 vs 51±15%; D28: : 44±19 vs 51±15%, all p=0.06); Tricuspid Annular Systolic Posterior Motion (TAPSE) only tended to be lower in the short term while it was lower in non-survivors compared to survivors (D7: 1.7±0.4 vs 1.9±0.5, p=0.05; D28 1.6±0.4 vs 2.0±0.5, p=0.002). LV global longitudinal peak systolic strain (LVGLS) was significantly less negative, i.e. indicative of more pronounced impairment of LV contractility , in non-survivors than in survivors (D7: -9.0±4.1 vs -11.0±5.3, p=0.002; D28 -10.0±4.0 vs -11.5±3.4, p=0.009)indicating a more pronounced impairment of LV contractility. Overall, 20 patients showed normal LV and RV systolic function, 77 showed either LV or RV systolic dysfunction (LV systolic dysfunction: LVGLS >-14%; RV systolic dysfunction: TAPSE<)

Conclusions: A significant proportion of septic patients developed a LV and/or RV systolic dysfunction, but LV systolic dysfunction assessed by LVGLS was the strongest prognosticator of outcome both in the short and intermediate follow-up.

Valerio Teodoro STEFANONE (Florence, Italy), Chiara DONNINI, Vittorio PALMIERI, Francesca INNOCENTI, Riccardo PINI
10:55 - 11:00 #7762 - Identification of septic patients at risk of complications in emergency department.
Identification of septic patients at risk of complications in emergency department.


Early  identification of septic patients at risk of developping  severe sepsis syndrome (SSS) is crucial.  An intensive care unit (ICU) cohort study identified simple clinical criteria to predict patients requiring immediately intensive care management (Am J Respir Crit Care Med 2005). 


To identify factors associated with the occurrence of a SSS (severe sepsis or septic shock) in patients with non complicated documented infection in the emergency department (ED).


Prospective study conducted over six months. Were included:  patients aged ≥18 years with suspected infection associated with two or more criteria of the systemic inflammatory response syndrome (temperature ≥38 ° C or ≤36 ° C,  heart rate> 90 bpm / min, Respiratory Rate > 20 / min or PaCO2 <32 mm Hg or WBC > 12,000 cel / mm3 or <4,000 / mm3), with a systolic blood pressure (SBP) > 90 mmHg and a lactate levels < 4 mmol / L. Epidemiological, clinical, therapeutic and outcome criteria were collected. APACHE 2 score was calculated. Occurrence of organ failure define severe sepsis, Persistent hypotension (SBP <90 mmHg) or signs of hypoperfusion (lactate ≥4 mmol / l, oliguria) despite fluid resuscitation define septic shock. Multivariate analysis to identify factors associated with the occurrence of the SSS was performed.

Results : Inclusion of 120 patients. SSS: n = 41, 34%. Mean age = 62 ± 18 years.

Sex ratio = 0.85.  Site of infection: intra-abdominal (45%) and respiratory (32%). Mean APACHE 2 score = 13 ± 11.  Multivariable logistic regression identified the following parameters  as associated with occurrence of SSS: a SBP <110 mmHg, an SpO2 <90% in ambient air (AA) and a lactate level ≥3 mmol / l with Odds Ratio (OR) and confidence interval (CI) 95% respectively to 5,54 [2,37-12,92], 2,2[1,67-5,7] and 2,6 [1,54-4,71].


A SBP <110 mmHg, a SpO2 <90% in AA and a lactate level ≥3 mmol / l were associated with the occurrence of a SSS. Early identification of patients with SSS may help the emergency physicians for better management and better outcome.

Aymen ZOUBLI, Hanen GHAZALI, Wided BOUSSELMI, Rania JEBRI (Lyon), Anware YAHMADI, Ahmed SOUYAH, Farah RIAHI, Wided BAHRIA
11:00 - 11:05 #8054 - Thirty-day mortality and predictors of death among patients with early-identified sepsis in an emergency department.
Thirty-day mortality and predictors of death among patients with early-identified sepsis in an emergency department.

Background: New guidelines for the early identification and treatment of patients admitted with sepsis have been implemented in recent years. Our aim was to report 30-day mortality and predictors of death among all sepsis patients admitted to an Emergency Department (ED) and treated in accordance with these guidelines.

Patients and Methods: A historical cohort study was conducted among prospectively registered patients admitted to a single-centre ED from 1 November 2013 to 31 October 2014. All patients identified with sepsis were included in the study. Data for systemic inflammatory response (SIRS) criteria and initial treatment in the ED were obtained from a standard sepsis admission form. Baseline clinical data and data for survival were obtained from patient records and The Danish Civil Registration System. Logistic regression analysis was used to adjust for potential confounders and to determine whether the risk factors for death in the crude analyses were independently associated with 30-day mortality.

Results: A total of 429 patients were admitted to the ED with sepsis. Fifty six (13.1%; 95% confidence interval [CI], 9.9-16.1%) patients died. The mortality rate among patients with severe sepsis or septic shock (SS/SS) was 38.2% (95% CI, 24.9-51.4%). Patients without SS/SS had a mortality rate of 9.4% (95% CI, 6.4-12.3%). Age (odds ratio [OR], 1.49; 95% CI, 1.11–2.00%), lactate value on admission (OR, 1.36; 95% CI, 1.11–1.67%), Charlson Comorbidity Index (OR, 1.26; 95% CI, 1.03–1.53%), creatinine (OR, 1.03; 95% CI, 1.01-1.06%) and platelet counts (OR, 1.05; 95% CI, 1.02-1.07%) were associated with mortality. Urinary tract infections (OR, 0.19; 95% CI, 0.05-0.64%) and increasing systolic blood pressure (OR, 0.87; 95% CI, 0.81-0.93%) were associated with a lower risk of death.

Conclusion: The 30-day mortality rate among all sepsis patients was 13.1%. Approximately 38.2% of the patients with SS/SS died. Factors present on admission and associated with death were identified.

Dr Osama Bin ABDULLAH, Johannes GRAND, Petrine NIMSKOV, Astha SIJAPATI, Finn Erland NIELSEN (Slagelse, Denmark)

Tuesday 04 October

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10:45 - 11:05

Poster Highlight Session 4 - Screen 3

10:45 - 10:50 #4525 - Critical incident debriefing after failed paediatric resuscitation and childhood death: a review of the literature.
Critical incident debriefing after failed paediatric resuscitation and childhood death: a review of the literature.

Critical incident debriefing after failed paediatric resuscitation and childhood death: a review of the literature


Dr Craig Swinburne, Department of Paediatrics, Wishaw General Hospital, Wishaw, Scotland, UK.



Approximately 6000 children and young people aged between 0 and 19 years die in the UK annually, with approximately two thirds of deaths occurring in infancy.  Although childhood death in the UK is a rare event, the resuscitation and death of a child remains one of the most stressful critical incidents encountered by healthcare staff.  Critical incident debriefing aims to reduce the adverse sequelae associated with such events while also enhancing patient care.



To review current practices in critical incident debriefing following failed paediatric resuscitation and childhood death.


Materials and Methods

A literature search was performed using OVID, Web of Science, MIDIRS, CINAHL and EMBASE databases.  A total of 21 papers were identified, 5 of which were deemed relevant and included in the literature review.  A further 13 papers were identified independently of the literature search and were included for review.



This literature review explores current practices in critical incident debriefing following failed paediatric resuscitation and childhood death.  The review focuses on the aims of debriefing, debriefing techniques, patterns in the use of debriefing, indications for debriefing, attitudes towards debriefing and barriers to debriefing.



Critical incidents involving children carry increased risk of adverse outcome for health care staff.  Emergency department staff in particular are known to be at increased risk of developing adverse psychological sequelae.  Despite a lack of evidence to support its use it is clear that health care staff support debriefing and find it beneficial.  Not only does it support health care staff but it also helps to enhance patient care.  Ideally debriefing should occur within several days following a critical incident, should be led a senior member of staff with appropriate training in debriefing and should address medical, emotional and psychological issues.  Further research is required to address the lack of evidence regarding the use of debriefing interventions in paediatric practice. 

Craig SWINBURNE (Glasgow, United Kingdom)
10:50 - 10:55 #8116 - Evaluation of patients with ventriculoperitoneal shunt in the Division of Pediatric Emergency Medicine.
Evaluation of patients with ventriculoperitoneal shunt in the Division of Pediatric Emergency Medicine.

Background and Aims:

Hydrocephalus is a common chronic disorder that could be a result of various etiologies. Ventriculoperitoneal (V-P) shunting is an established long-term treatment option for hydrocephalus and is one of the most common neurosurgical procedures. Rapid and accurate evaluation of the V-P shunt system in the emergency room setting is necessary as shunt malfunction may be associated with increased morbidity and mortality. Patients with V-P shunt dysfunction frequently present with clinical signs and symptoms of increased intracranial pressure including nausea, vomiting, headache, altered level of consciousness and swelling at the shunt site. However, the prediction of complications of V-P shunt is still remains unclear. The objective of this study is to evaluate the diagnostic utility of head computed tomography (CT) and to evaluate signs, symptoms and laboratory results in patients with suspected V-P shunt dysfunction and infection.


We retrospectively reviewed medical records including signs, symptoms, laboratory and head CT / MRI results in patients with suspected V-P shunt dysfunction between January 2005 and June 2014. One hundred and thirteen patients and 252 visits were reviewed. Each neuroimaging study was classified as “normal” (unchanged or decreased ventricle size) or “abnormal” (increased ventricle size). We classified a patient as having a ventricular shunt dysfunction if operative revision for relief of mechanical causes of altered shunt flow was needed within 72 hours of initial ED evaluation.  Shunt dysfunction within 30 days of the PED visit was also evaluted.


The most common complaints were fever, vomiting and altered consciousness. There is no relation between complaints and the infection or malfunction of shunt (p>0,05). Seizure is inversely related to shunt malfunction (p<0,05). The thrombocytosis (>500000mm3) is significantly predictive of shunt infections(p<0,05). The abnormal results of head CT was not significantly associated with surgical shunt revision within 72 hours and 30 days of initial ED admission (p>0,05).


There is no significant sign and symptom to decide about shunt malfunction and infection. Although the computed tomography utilization for suspected ventriculoperitoneal malfunction commonly uses, it is not clear effect of CT results on decison of shunt surgery.

10:55 - 11:00 #8263 - Cinical and Laboratory Predictors of Injury Severity in Pediatric Trauma Patients.
Cinical and Laboratory Predictors of Injury Severity in Pediatric Trauma Patients.

Aim: to determine significant correlation between clinical and basic laboratory findings and injury severity in pediatric trauma patients.

Methods:In this prospective study, children with high energy blunt trauma presenting to Pediatric Emergency Department of Tepecik Teaching and Research Hospital, Izmir, Turkey were included. The clinical findings, basic laboratorry tests and radiological results were analyzed. Pediatric Trauma Score (PTS), Revised Trauma Score (RTS), BIG score and Injury Severity Score (ISS) were calculated. The patients divided into two group: the patients discharged from emergency department (group 1) and the patients hospitalized more than 24 h or died in the emergency department (Group 2). After the the univariate analysis, logistic regression test were done. The Pearson correlation analysis were used between ISS and the significant parameters.

Results: A total of 213 children with high-energy blunt trauma (mean age: 6.1 ± 3 years, minimum: 1 month, maximum: 15 year, male / female: 143 / 70) were included the study. The most common trauma etiology was trafic accident in 114 patient (53.5%). 108 patients were discharged from emergency department. 103 of 213 patients  were hospitalized more than 24 h. 2 patients died in the emergency department.  The number of patients who died in all patients was 4. In logistic regression analysis, respiratory rate, Glaskow Coma Scale (GCS), WBC, glucose, activated prothorombin time, BIG score, PTS and RTS were significantly different in Group 2. The best correlations were determined between ISS and GCS (p<0.001; r: - 0.604) and between ISS and PTS (p < 0.001, r: - 706).

Conclusion: PTS and GCS were the best basic predictors of trauma severity in emergency department for children with high-energy blunt trauma. 

Murat ANIL (ISTANBUL, Turkey), Serdar SARITAS, Alkan BAL, Yuksel BICILIOGLU, Gamze GOKALP, Ayse Berna ANIL, Fulya KAMIT CAN
11:00 - 11:05 #8274 - Implementation of the Step-by-Step approach in the management of the infant under 90 days old with fever without source.
Implementation of the Step-by-Step approach in the management of the infant under 90 days old with fever without source.

OBJECTIVE: To identify the impact of the implementation of a sequential approach (Step-by-Step approach) in the management of the infant ≤90 days old with Fever Without Source (FWS).

METHODS: Descriptive study including two cohorts of patients (pre- and post-implementation of the new protocol, in December 2013) attended at the Pediatric Emergency Department (PED) of a Tertiary Teaching Hospital. Data were obtained from a prospective registry in which all the infants ≤90 days attended with FWS are included. We excluded those patients in whom any of the complementary tests included in the Step-by-Step approach was not obtained and those in whom a blood culture was not obtained.

During each period, those patients meeting all the following criteria were classified as low-risk patients and so were considered suitable for outpatient management without performing a lumbar puncture and without receiving antibiotic treatment:

- Pre-implementation period (September 2008 – August 2013):

                - Well-appearing

                - >28 days old

                - No leukocyturia or nitrituria in the urine dipstick

                - Procalcitonin (PCT) <0.5 ng/mL

                - C-Reactive Protein (CRP) ≤40 mg/L

                - Leukocyte count 5,000-15,000/mcL

                - Absolute Neutrophil Count (ANC) ≤10,000/mcL

- Post-implementation (February 2014 – August 2015):

                - Well-appearing

                - >21 days old

                - No leukocyturia in the urine dipstick

                - PCT <0.5 ng/mL

                - CRP ≤20 mg/L

                - ANC ≤10,000/mcL

We analysed demographic data, complementary tests performed, diagnostics received, antibiotic received and discharge rate. We defined Invasive Bacterial Infection (IBI) as the isolation of a bacterial pathogen in blood, cerebrospinal fluid or any other sterile fluid.

RESULTS: we included 1,015 out of the 1,236 infants attended in the pre-implementation period (82.1%) and 387 out of 421 (91.9%) in the post-implementation (p<0.01), being classified as low-risk patients 38.6% and 55.8% of them, respectively (p<0.01).

Comparing the two periods, a lumbar puncture was performed in 25.9% vs 15.7% of the infants (p<0.01); 31.2% vs 26.6% received antibiotic treatment (p=0.09) and 46.1% vs 37.9% were admitted to ward (p<0.01). The decrease in the admission rate in ward was associated with a increase in the admission rate in the Observation Unit (for

Among those patients managed as out patients, 8.9% and 6.7% respectively returned to the PED (p=0.35), none of them due to a clinical worsening and without differences in the admission rate in the return visit. Two IBIs were diagnosed among low-risk infants during the first period (0.5%) vs none in the second period. One of the IBIs would have been identified using the Step-by-Step approach (CRP: 33 mg/L).

CONCLUSIONS: the implementation of the Step-by-Step approach has increased the percentage of young febrile infants classified as low-risk patients, suitable for an outpatient management, without increasing the number of patients with IBI misclassified. The admission rate and the lumbar puncture rate have decreased without associating an increase in the return visit rate.

Borja GOMEZ (Barakaldo, Spain), Lidia MARTINEZ, Oihane MORIENTES, Javier BENITO, Iker GANGOITI, Santiago MINTEGI

Tuesday 04 October

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10:45 - 11:05

Poster Highlight Session 4 - Screen 4

10:45 - 10:50 #7594 - Acute cardiogenic pulmonary edema: the efficacy of prehospital treatment.
Acute cardiogenic pulmonary edema: the efficacy of prehospital treatment.


SMURD (Mobile Emergency Service for Resuscitation and Extrication) Sibiu MICU was sent in the last 4 years to a significant number of emergency cases (reported as shortness of  breath, chest pain and unconsciousness) diagnosed as acute cardiogenic pulmonary edema.

Although shortness of breath, chest pain and unconsciousness can be associated with several acute or chronic illnesses, one life threatening condition is acute pulmonary edema. Without proper and prompt medical care, mortality rate is increased, therefore preventing the cardiovascular collapse and the acute respiratory failure is vital.

The aim of this study is to asses the proper path of treatment by relying on internationally guidelines for acute pulmonary edema in different clinical presentations and blood pressure groups. We analysed the effect of age on response to treatment, correlating the systolic blood pressure (SBP), oxygen saturation (SpO2) on admission with the dosages of nitrates, diuretics and opiates.



Data was obtained from SMURD Sibiu medical database, for a period of 4 years, between 01.01.2012 and 31.12.2015. From the total number of alerts dispatched to MICU were selected 138 cases of acute pulmonary edema.



From a total number of 138 patients with acute pulmonary edema, 7 patients had aged below 40 years (Group A),  76 with ages between 40-75 years old (Group B) and 55 patients with ages over 75 years old(Group C).

While following the results of the administrated treatment:

1. From Group A:

  • 2 patient with SBP<140 mmHg and SpO2<85%, 1 had an improved  medical condition when nitrates, diuretics and opiates were used, and 1 deceased on the way to hospital , although CPR was performed.
  • 2 patients with SBP>140 mmHg and SpO2<85%  have improved their condition when using higher doses of nitrates and diuretics.

2.From Group B :

  • 7 pacients with SBP<140 mmHg and SpO2<85%, 3 of them improved their condition when associating opiates with nitrates and diuretics,4 had persisting symptoms when using lower doses of only nitrates and diuretics.
  • from the total number of patients with SBP>140 mmHg and SpO2<85%, 26 patients improved their medical condition when using higher doses of nitrates, diuretics and opiates, 4 of them had persisted symptoms, after the usage of lower doses, 2 of them deceased on the way to hospital

3.From Group C:

  • 10 patients  with SBP<140 mmHg and SpO2<85%, 7 improved their condition, 2 had persisting symptoms and 1 had his condition aggravated after using lower doses of nitrates and diuretics.
  • 22 patients with SBP>140 mmHg and  SpO2<85%,  15 improved their condition and 7 had persisting symptoms on higher doses of  nitrates, diuretics and opiates.



Higher doses of nitrates and diuretics were associated with better improvement to patient condition, than the use of  lower doses to patients from Groups B and C. Also our data suggested that opiates administration enhances even more the chances of recovery.

Response to treatment was significant for patients from Group A comparing to other groups, when using only nitrates and diuretics  comparing to other groups.

Paul SLAVU, Ciprian JURAVLE (Sibiu, Romania), Claudia CIORA, Corina SINTEA, Ioana RADU, Sorina PODARIU, Diana HARAMBAS, Iris MURESAN
10:50 - 10:55 #7646 - Can we improve recognition of acute coronary syndrome in criteria based medical dispatch.
Can we improve recognition of acute coronary syndrome in criteria based medical dispatch.

Introduction: Croatian Index of Urgent Call Admission is  criteria based tool of Medical Dispatch Unit (MDU) in Split, city with 178000 inhabitants. MDU receives   calls according to symptoms and consequently  alerts adequate medical response - red , yellow  and green . EMS in Croatia has two-tier system - it consists of team 1 ( physician, medical technician, driver) and Team2 ( two medical technicians). 12 channel  ECG  is  a standard for evaluating cardiac rhythm and myocardial ischemia in the field.  Adequate assessment and response enable the patient with acute myocardial infarction to arrive in time to PCI procedure.  We tried to assess the correlation of  Index and confirmation of acute coronary syndrom made by EMS physician in field.

Methods: quantitative retrospective analysis of data collected in one-year period  in eRinels database. We compared calls admitted  by Index as criteria A09 ( chest pain/ heart disease) to final physician 's medical records concluded with  International Classification of Disease (ICD) R07 and  I20 - I25 with particular emphesize  to I21  ( acute myocardial infarction confirmed by  12 channel  ECG)  . We also wanted to see what other diagnosis were found  behind the calls admitted as A09. After  that, we made a survey in opposite direction - we searched  medical records for all R07 and I20-I21  trying to see what other criteria have been used besides A09 to dispatch the call which finally resulted  with diagnosis mentioned above. Only primary missions were included ( patients who have been examined by GP,  cases  where T1 from Split was used as transport from harbor or helidrom to hospital, and patients who came by themselves to EMS room were excluded from the survey).

Results: There were  3753 red responses for T1.  There were 496 calls admitted as A09 – red criteria chest pain/heart disease. There were 198 (39,91%) confirmed diagnosis  considering heart problems ( R07, I20-I25).  There were 34 cases I21 (6,85%) – acute myocardial infarction confirmed by 12 channel ECG and assessed as A09 by MDU,  24 cases  I20 – I25 without I21 ( 4,84%), 140 cases R 07(28,22%) pain in throat and chest).  A09 has sensitivity  43,03% and specificity of 87,58% in detecting I21.Other diagnosis after being dispatched as A09 were I group ( other than I20 - I25) 71 (14,31%), R group ( other than R07) 47 (9,47%)… Total number of AMI in 2015 in Split was 79. There were 34 ( 43,03%) calls assessed by MDU as A09; 17  (21,51%)were assessed as A05 – unclear problem. There were 14 (17,72%) calls  dispatched  as yellow response.

Conclusion: Majority  of  I21 ( 82,28%) were dispatched as red response so the patients could benefit of prompt care, although less than half was admitted as A09. More training in MDU through re-listening of incoming calls and reassessment of criteria  is needed in intention to improve acute coronary syndrom  recognition and to diminish undertriage.  Final outcome of such patients could be assessed  with ED records about the time  of the reperfusion.

Radmila MAJHEN UJEVIC (Split, Croatia), Leo LUETIC
10:55 - 11:00 #7658 - Accuracy in emergency medical dispatch - A comparison between two dispatch protocols.
Accuracy in emergency medical dispatch - A comparison between two dispatch protocols.

The Emergency Medical Communication Center (EMCC) is the first contact for patients needing acute care and thus the first part of the chain of emergency care. In Sweden the emergency medical system is based on the single emergency number 112.Today the EMCC uses a computerized, criteria-based protocol called Medical Index to ensure the best possible prioritization in ambulance dispatching. A new dispatch protocol was developed, based on Rapid Emergency Triage and Treatment System (RETTS), the triage scale currently used by the majority of Swedish EDs as well as emergency medical services. The prototype, RETTS-A, has been modified to fit the complex situation of the EMCC. The aim of the current study was to compare the accuracy in priority level between the two dispatching protocols.

Participants and methods
A randomized controlled non-blinded simulation study was performed at the EMCC in Stockholm, Sweden, between 2015-10-27 and 2016-03-17. Fifty call-takers from Swedish EMCC’s were recruited to participate in the study. Callers were recruited from a pool of experienced standard patients. Manuscripts for 26 patient scenarios, based on real-life emergency-medical-calls to the Swedish EMCC, representing the six most common chief complaints (breathing difficulties, chest pain, minor trauma/wounds, stroke, abdominal pain and non-specific complaints) were written by the research group. Priority level and medical condition for each scenario was predetermined by expert consensus. A cross-over model with 13+13 calls was used. A power calculation anticipating a difference in accuracy of eight percentage point between the two protocols showed a need for n= 2x650= 1300 unique calls (two-sided alpha 0.05, beta 0.80). Frequency tables and cross tables were created using SPSS software (SPSS, Version 23, IBM Company, Chicago, IL, USA, statistical software). Differences between groups were calculated with Fisher's Exact Test. P-values <0.05 were considered statistically significant.

A total of 1,300 calls were performed, 650 calls with Medical Index and 650 calls with RETTS-A. According to the predetermined priority level for each of the 26 cases, 45.9% (n=301) were correct with Medical Index and 34.5% (n=226) with RETTS-A (p< 0.0001).

The current simulation study compared two protocols for dispatching. The new dispatch protocol RETTS-A, had a lower accuracy for priority level than the protocol in current use, Medical Index. The results may in part be explained by the call takers being more familiar with the Medical Index having worked with this system. Another factor to consider is that the Medical Index has a three tiered priority, while the RETTS-A is four tiered, which may be a disadvantage for RETTS-A. However, future studies considering other factors e.g. time to dispatching should be considered before deciding which protocol is to prefer.

KB and KO has consult missions at the EMCC organization SOS Alarm Sverige AB. No other conflicts of interest.

Klara TORLÉN (Nacka, Sweden), Lisa KURLAND, Maaret CASTRÉN, Knut OLANDERS, Katarina BOHM

Background: In developing countries including Ethiopia pre hospital care is not well developed asin other developed countries. In Addis Ababa, there are few governmental and private institutions which provide pre hospital care.

Objective:  To assess the knowledge, and perception of residents about pre hospital care in Addis Ababa city

Methods: A house to house cross-sectional survey was conducted between April and March, 2014 in Addis Ababa city. A multi stage sampling technique was applied to select 422 households for the survey..  Data were collected by administrating interviews with a randomly selected individuals using a structured questionnaire. Data was entered, analyzed, and interpreted by using SPSS Software version20.

Results:    A considerable proportion of respondents (86.3%) heard about the existence of pre-hospital care in Addis Ababa, however more than half of the respondents had no information on what to do, who to contact and which phone to call during emergency. About 248(58.8%) and 275(65.2%), respondents reported that they have no phone numbers of Red Cross and Fire and Emergency centers, respectively. About 245(58.1%) of the respondents had some form of emergency in their work place or at home with highest frequency of falling accident (51.4%) followed by road traffic accident (41.6%). When asked about involvement of service providers in pre-hospital care, 254 (60.2%) respondents said that Red Cross Ambulances as primary provider, while only 37 (8.8 %) reported that ambulances of Hospitals and Health centers are involved in the pre-hospital care. Almost all (411(97.4%)) respondents believed that pre hospital care should be strengthened by increasing number of ambulances (23.7%), by training health professionals (18.7%), by teaching the community about pre hospital care (26.1%) and a combination of the above methods(31.5%).

Conclusion: Although the knowledge of the community on pre-hospital care is high, there is lack of information on what actions to take within the community. Therefore, concerned bodies such as the city administration, Red Cross, fire and emergency dispatch centers, hospitals and other concerned bodies need to undertake coordinated works in order to create awareness among the community for proper care of emergency situations at home or work places.+

Asmamaw ABEBE, Aklilu AZAZH (Addis Ababa, Ethiopia)

Tuesday 04 October

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10:45 - 11:05

Poster Highlight Session 4 - Screen 5

10:45 - 10:50 #8077 - Clinical features of severe intoxications associated with analytically confirmed use of NBOMe.
Clinical features of severe intoxications associated with analytically confirmed use of NBOMe.

Background: A novel class of synthetic hallucinogens called NBOMe has emerged as new psychoactive substances (NPS) since 2009. NBOMe are N-2-methoxybenzyl analogues of the respective 2C-X substituted phenethylamines, and they were first synthesized for use as tools to activate 5-HT2A (serotonin) receptors at the Free University of Berlin in 2003 (1).

Participants and methods: A study was conducted through the Italian Emergency Departments network referring to the Pavia Poison Control Centre (PPCC) in order to evaluate the clinical features and the prevalence of analytically confirmed intoxications by NBOMe over the last two years (2014-2015). Cases were assessed for age, history, acute clinical manifestations, outcome, treatment and toxicological-analytical investigations.

Case series: Among the consecutive cases referred to the PPCC for suspected/confirmed poisoning by NPS between 2014 and 2015, 11 cases of NBOMe intoxication were evaluated (age ranging from 16 to 27 years-old; 82% males). Specific laboratory investigations (liquid chromatography-mass spectrometry) were performed in all the cases on urine and/or blood specimens; 7 patients were positive for 25I-NBOMe, 2 for 25B-NBOMe, 1 for 25C-NBOMe and 1 for 25I- and 25H-NBOMe; patients urine samples were also positive for 2C-I (7 cases), THC (7), amphetamines (3), MDMA (2) and ketamine (1 case). The patients referred assumption of LSD or another hallucinogenic substance (n= 6), mescaline (n=1), other or unknown substances of abuse (n=3), or no assumption. Three patients (27%) took part to a rave party. The most common clinical manifestations were severe psychomotor agitation (91%), tachycardia (64%), seizures and rhabdomyolysis (45%), confusion (36%), hyperthermia (27%), coma, mydriasis, hallucinations and violent behavior (18% each); no lethal case was registered. The treatment consisted in sedation with benzodiazepines (6 cases), intubation, and respiratory support (5 cases). Hospital stay ranged from 10 hours to 11 days for the patients that needed intensive care treatment.

Conclusion: This case series confirms the presence of at least 4 types of NBOMe molecules (25I-, 25B-, 25C- and 25H-NBOMe) in the Italian territory. Seven patients were positive for 25I-NBOMe and 2C-I: this may be due to the metabolism of NBOMe to 2C analogue, or to the simultaneous intake of 25I-NBOMe and 2C-I. Clinicians should be aware of the presence of this new psychoactive substance and its potential for toxicity, and they should suspect possible NBOMe assumption in patients reporting the recent use of LSD or other hallucinogens. All the cases have been reported to the National Early Warning System.

Acknowledgements: Study carried out with the support of DPA - Presidency of the Council of Ministers.

Reference: 1. Kyriakou C, Marinelli E, Frati P, Santurro A, Afxentiou M, Zaami S, Busardo FP. NBOMe: new potent hallucinogens--pharmacology, analytical methods, toxicities, fatalities: a review. Eur Rev Med Pharmacol Sci. 2015 Sep;19(17):3270-81.

Eleonora BUSCAGLIA, Davide LONATI, Valeria Margherita PETROLINI, Sarah VECCHIO, Mara GARBI, Marta CREVANI, Azzurra SCHICCHI, Giulia SCARAVAGGI, Pietro PAPA, Antonella VALLI, Loretta ROCCHI, Laura ROLANDI, Elisa RODA, Teresa COCCINI, Marcello DI TUCCIO, Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy)
10:50 - 10:55 #8137 - Drug anaphylaxis in an emergency department: epidemiology, clinical features and management.
Drug anaphylaxis in an emergency department: epidemiology, clinical features and management.


Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. There are few data on the incidence, clinical features and management of patients with acute anaphylaxis presenting to emergency department (ED).  Studies report that anaphylaxis was under-diagnosed in ED and emergency management was often in disagreement with international recommendations.

Objective: Describe the epidemiology, clinical features, management and outcome of patients with drug anaphylaxis.


Prospective, monocentric study over four years. Inclusion criteria: patients aged over 14 years presenting consecutively to ED with the diagnosis of drug anaphylaxis. Collection of epidemiological, clinical and therapeutic parameters.


Inclusion of 147 patients. Mean age = 40±14 years. Sex-ratio=0, 8. A history of anaphylaxis was reported in 56% of cases. The median time to consult the ED was 90 minutes, with extremes ranging from 5 minutes to 26 hours. Antibiotics were the most represented drug class among drug allergens (n = 93; 63%), the most incriminated were the penicillins (n=77; 83%). Cutaneous features were present in 95% of patients. Cardiovascular, respiratory, gastrointestinal and neurologic features were found respectively in 64, 45, 21 and 2,7%.  An anaphylactic shock was recorded in 56 patients (38%). Anaphylaxis was moderate grade in 136 patients (92%).

Adrenaline was used in 86%of patients, intravenously in 38%.  The total median dose of adrenaline was 40 micrograms with extreme dose ranging from 10 to 1400 micrograms. Fluid resuscitation was given to half of the patients. Seventy two patients (52%) received histamine H1 antagonist, 98% corticosteroids. Nighty-nine percent of patients were discharged directly from ED after a mean period of observation as 6 hours. Biphasic reactions were reported in two patients. There was no death cases registered. Patients were all referred to the allergy clinic.


Identifying the characteristics of drug anaphylaxis presentation to ED and its risk factors helps to improve the diagnosis of this medical emergency and suggest the necessity of a standardized guideline for anaphylaxis management in ED.

Mouna GAMMOUDI, Hanen GHAZALI (Ben Arous, Tunisia), Wided BOUSSELMI, Anware YAHMADI, Syrine KESKES, Mohamed MGUIDICH, Ahlem AZOUZI, Sami SOUISSI
10:55 - 11:00 #8187 - Binge drinking and New Psychoactive Substances (NPS): a potentially dangerous health risk.
Binge drinking and New Psychoactive Substances (NPS): a potentially dangerous health risk.

Objective: Binge drinking is an increasing dangerous practice involving mainly children or adolescents and, in some circumstances (e.g. rave party, college drinking), is possibly associated with the co-assumption of substances of abuse [1]. We analyzed all cases of suspected assumption of New Psychoactive Substances (NPS) in binge drinkers referred to the Pavia Poison Control Centre.

Methods: Cases of binge drinking (<25 years) with Blood Alcohol Concentration (BAC)>0.5 g/L were retrospectively reviewed (January2010-July2015) and assessed for: age, history, substances of abuse declared, circumstances of assumption, clinical manifestations, outcome, BAC, NPS-identified, association with “old-substance of abuse” (cocaine, opiates, cannabis, amphetamine/methamphetamine), correspondence between history and the analytically identified-NPS. Cases with incomplete data were excluded.

Results: 105 patients met the inclusion criteria. The lowest age recorded was 13 years old (65% <18 years); 69% of cases were registered during week-end. Substances of abuse co-assumed were: ketamine (10 cases), MDMA (5), THC (4), amphetamine (5), cocaine (3), energy drink (2), LSD (2), GBL (1) and heroin (1). Co-assumption of more than one substance of abuse was registered in 38% of cases. Main clinical manifestations were: agitation (55%), tachycardia (38%), coma (34%), delirium/hallucinations (31%), drowsiness (28%), mental confusion (17%), seizures (10%); no fatal cases were registered. In 65% of patients BAC was higher than 1.5 g/L (highest BAC 3.26 g/L). Seventy-six cases resulted negative for NPS, while 36% of these resulted positive for “old drugs”. In twenty-nine patients (28%) at least one NPS was analytically confirmed. NPS-analytically detected in biological samples (urine/blood): MDMA (14), ketamine (7), methoxetamine (6), GHB/GBL (2), 2C-series (2), synthetic-cathinones, 4-MEC (1), synthetic-cannabinoids, JWH-073 (1), atropine (1), benzofurans, APB (1). Correspondence between substance declared and lab results was registered in 10% of cases and complete discrepancy in 45% of cases.

Conclusion: Nowadays binge drinking is a relevant and increasing social problem related to acute and late toxic effects (e.g. brain development) especially during adolescence. Association between binge drinking and NPS may be particularly insidious also for appropriate clinical management. In our experience 3 out of 10 binge drinker assumed at least one NPS. A specialist advanced lab support is essential to make correct diagnosis and to guide the treatment.

Reference: 1. Siqueira L, Smith VC. Binge Drinking. Pediatrics. 2015:31;2015-2337.

Acknowledgements: Study carried out with the support of Department for Antidrug Policies-Presidency of the Council of Ministers.

Eleonora BUSCAGLIA, Valeria Margherita PETROLINI, Marta CREVANI, Azzurra SCHICCHI, Emanuela CORTINI, Francesca CHIARA, Mara GARBI, Pietro PAPA, Elisa RODA, Davide LONATI, Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy)
11:00 - 11:05 #8189 - Lethal poisonings: a five-year case series of the Pavia Poison Centre - National Toxicology Information Centre.
Lethal poisonings: a five-year case series of the Pavia Poison Centre - National Toxicology Information Centre.

Objective: According to the WHO, 346,000 deaths due to accidental poisoning occurred worldwide in 2004. Moreover, almost a million people die every year as a result of suicide and, among these, the deliberate ingestion of pesticides causes about 370,000 deaths/year [1]. To describe the fatal intoxications in the case series of the Pavia Poison Centre (PPC).

Methods A retrospective review of fatal poisonings managed by the PCC form 2010 to 2014 were performed. The included cases were assessed for age, sex, modality and route of intoxication, PSS (Poisoning Severity Score) at the first consultation with the PPC and agents involved. Cases for which the cause-effect relationship between exposure and death was considered absent or unlikely by the specialist toxicologist were excluded.

Results In the study period, 239 fatal cases were included (50% males, 60±20 years), distributed all over Italy, with an average of 47 deaths/year. Five patients (5/239; 2%) were younger than 14 years, and fifty patients (50/239, 21%) were older than 78 years. The exposure was considered accidental in 46 cases (19%), voluntary in 103 cases (42%) with 34 cases of suicide, and related to an adverse drugs reaction in 59 cases (25%). In 31 cases (14%) this data is unknown. Among the cases of suicide, 41.5% of patients were aged between 36 and 56 years. Ingestion was the route of exposure in 80% of cases (191/239). Seventy-five percent of patients (179/239) presented a serious clinical picture at the first PPC consultation (PSS 3). Concerning the agents involved, drugs resulted the cause of death in 110 cases (46%). Among these, the death was related to the ingestion of only one molecule in 65 cases (59%), and metformin was involved in more than half of these (35/65). In 18% of cases (42/110) more than one molecule were ingested at the same time.

Other agents involved in more than 15 cases were caustics (7.5%), pesticides (7.5%), drugs of abuse (7%), gas/smoke fire inhalation (7%) and mushrooms (5%).

Conclusion Fatal poisoning are not related only to suicide, but also to adverse drug reactions and accidental ingestions. The role of Poison Centers is also crucial in identifying the main causes and modality of lethal intoxications, and in reporting alerts to the authorities in order to identify possible preventive interventions.

References [1] The global burden of disease: 2004 update. World Health Organization.

Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy), Valeria Margherita PETROLINI, Davide LONATI, Azzurra SCHICCHI, Marta CREVANI, Mara GARBI, Eleonora BUSCAGLIA, Giulia SCARAVAGGI, Francesca CHIARA, Emanuela CORTINI, Sarah VECCHIO

Tuesday 04 October

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11:10 - 12:40

Philosophy & Controversies
General EM

Moderators: Murat ERSEL (Turkey), Pr Lisa KURLAND (speaker) (Örebro, Sweden)
11:10 - 11:40 Biomarkers: help or hindrance? Katrin HRUSKA (Emergency Physician) (Stockholm, Sweden)
11:40 - 12:10 Pain and suffering in the ED. Iain BEARDSELL (United Kingdom)
12:10 - 12:40 Non-specific symptoms in the ED. Pr Lisa KURLAND (speaker) (Örebro, Sweden)

Tuesday 04 October

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11:10 - 12:40

Austria, Germany, Switzerland Invites
Nicht-Invasive Beatmung - Spezial

Moderators: Ulrich BÜRGI (Switzerland), Harald DORMANN (Germany)
11:10 - 11:40 Präklinisch. Stefan PÖTZ (Austria)
11:40 - 12:10 Bei Herzinsuffizienz. Harald HERKNER (Austria)
12:10 - 12:40 Angst vor dem NIV Versagen - Präventivstrategien. Harald DORMANN (Germany)

Tuesday 04 October

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Philosophy & Controversies
P&C Cardiovascular 2

Moderators: Pr Rick BODY (Professor of Emergency Medicine) (Manchester), Said LARIBI (PU-PH, chef de pôle) (Tours, France)
11:10 - 11:40 Should we give oxygen to patients with acute myocardial infarction? Ardavan KHOSHNOOD (Lund, Sweden)
11:40 - 12:10 How do we disentangle COPD and heart failure? Said LARIBI (PU-PH, chef de pôle) (Tours, France)
12:10 - 12:40 How do we make rapid rule out strategies for acute coronary syndromes work? Barbra BACKUS (Emergency Physician) (Rotterdam, The Netherlands)

Tuesday 04 October

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Administration management
ED Design: Innovations

Moderators: Wilhelm BEHRINGER (Director) (Jena, Germany), Youri YORDANOV (Médecin) (Paris, France)
11:10 - 11:40 Lean Process Management in the Emergency Department: The Five Forces of Success. Wilfried VON EIFF (Muenster, Germany)
11:40 - 12:10 Efforts to reduce hospital admission rates from the ED. Youri YORDANOV (Médecin) (Paris, France)
12:10 - 12:40 Chief emergency officer: Between strategic healthcare management and operational caregiving. Christoph RASCHE (Germany)

Tuesday 04 October

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Disaster & Biohazards

Moderators: Kurt ANSEEUW (Medical doctor) (Antwerp, Belgium), Cyril NOEL (Londres, United Kingdom)
11:10 - 11:40 Triage in Multiple site Mass Shooting: is it necessary? Benoît VIVIEN (Adjoint du Chef de Service du SAMU de Paris, Responsable du SAMU Pédiatrique Régional IDF) (Paris, France)
11:40 - 12:10 Triage in Mass Shooting : Any Role for the SWAT doctor ? Matthieu LANGLOIS (medecin) (Paris, France)
12:10 - 12:40 Toward a European guidance for Mass Casualties? Kurt ANSEEUW (Medical doctor) (Antwerp, Belgium)

Tuesday 04 October

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Frontiers of emergency medicine: Podium discussion

Moderators: Riccardo LETO (Chief of ED) (Overpelt, Belgium), Basak YILMAZ (Faculty) (BURDUR, Turkey)
Speakers: Roland BINGISSER (Basel, Switzerland), Eric DRYVER (Consultant) (Lund, Sweden), Oktay ERAY (Speaker) (Antalya, Turkey), Thomas PLAPPERT (Fulda, Germany)

Tuesday 04 October

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EuSEM Nursing Track
Trauma Nursing

Moderators: Hester DIDERICH-LOLKES DE BEER (policy officer family maltreatment) (THE HAGUE, The Netherlands), Ole-Petter VINJEVOLL (Trondheim, Norway)
11:10 - 11:40 Taking care of the severe injured patient: human factors. Bruce ARMSTRONG (United Kingdom)
11:40 - 12:10  Multisite Terroristic attacks in Brussels (B): a challenge? Yves MAULE (MANAGER DE SOINS) (LIEGE, Belgium)
12:10 - 12:40  Training staff in major trauma education. Bruce ARMSTRONG (United Kingdom)

Tuesday 04 October

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Oral Papers 32

Moderators: Al BEHCET (faculty speaker) (Gaziantep, Turkey), Cornelia HÄRTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, Sweden)
11:10 - 12:40 #4588 - OP074 The Effect of Ketamine on Cerebral Physiology as detected by Cerebral Oximetry during rapid sequence intubation (RSI) of critically ill Pediatric patients.
The Effect of Ketamine on Cerebral Physiology as detected by Cerebral Oximetry during rapid sequence intubation (RSI) of critically ill Pediatric patients.

Ketamine is avoided in rapid sequence intubation (RSI) of trauma patients because of an assumption it causes increase intracranial pressure (ICP). However two recent studies showed  that there was no increase in intraocular pressure (IOP), and it was therefore assumed there was no increase in ICP either. An IOP change has never been shown to change cerebral physiology.  Cerebral oximetry studies have established it can correlate with acute alter cerebral physiology and ICP changes. The effect of ketamine on cerebral physiology in pediatric patients who have had respiratory failure or sepsis has not been studied.  Cerebral oximetry studies have shown normal hemispheric cerebral physiology rSO2  is 60-80% with a 10% mean variance. Abnormal cerebral physiology has been  demonstrated to be as  rSO2  < 60 or > 80 and/or side differences > 10.



To analyze ketamine’s effect on cerebral physiology during RSI of patients with sepsis or respiratory failure by utilizing cerebral oximetry in the Pediatric ED (PED).



An observational convenience study of patients intubated in the PED with sepsis or respiratory failure who had: bilateral cerebral oximetry (q 5 sec) placed and ketamine was used as an induction agent.  We analyzed rSO2 10 min before & then 10 and 20 min after ketamine along with cerebral blood volume index (CBVI) and compared to < 10% & 20% variance.  rSO2 side differences  > 10 and patients with rSO2 80 were analyzed as this is considered abnormal cerebral physiology. 



The maximum change on the left was 8.9%(SD+11.6%) and right was 8.7%(SD+9.7%).  Overall, the Left, Right rSO2, CBVI and heart rate changesat all points during data collection were less than 10% (p=0.99). Figure 1 




Patients with sepsis or respiratory failure who underwent RSI with ketamine showed no alteration in their cerebral physiology based on cerebral oximetry.  The normal and abnormal cerebral oximetry (rSO2 & CBVI) for 10 and 20-minute changes were significantly < 10% variance. Since ketamine is used in adult trauma investigating ketamine’s effect on pediatric trauma cerebral physiology by cerebral oximetry is warranted. 

Dr Thomas ABRAMO MD (Apex, USA), Samuel SELBY MD, Gregory ALBERT MD, Todd MAXSON, Jon ORSBORN MD, Nicholas PORTER MD, Elizabeth STORM MD, Zhuopei HU MS
11:10 - 12:40 #7063 - OP075 Reducing the pain of paediatric emergency department intravenous cannulation – comparison of a new local cooling device with topical anaesthetic cream.
Reducing the pain of paediatric emergency department intravenous cannulation – comparison of a new local cooling device with topical anaesthetic cream.


Topical local anaesthetic creams are proven to reduce the pain and distress associated with intravenous cannulation in children. A major disadvantage of their use is the relatively long application time. A minimum of 30 minutes is required for LMX4TM (4% Lidocaine w/w cream) [Ferndale Pharmaceuticals Ltd], the most rapidly acting agent. CoolsenseTM [Coolsense Medical Ltd] is a relatively new, reusable device designed to produce immediate, transient local analgesia through rapid cooling of the skin surface. No study has yet assessed the effectiveness of CoolsenseTM use in the paediatric emergency department (PED).



To determine any difference in age-appropriate paediatric pain score, at the time of intravenous cannulation, following use of the CoolsenseTM device or LMX4TM cream. To describe the effect of each intervention on additional outcomes, such as time from decision to cannulate to performing the procedure, which may influence the decision to select a particular method for use in the PED.



Prospective, quasi-randomised study in a tertiary PED over 6 weeks (February – March 2016).



175 patients were included (mean age 7.4 years). 80 were allocated to receive CoolsenseTM and 95 LMX4TM, on a week-by-week basis. When analysed by allocated intervention, the mean pain score at time of cannulation was significantly lower with CoolsenseTM than LMX4TM (2.5 vs. 3.8; p=0.006). Mean time from decision to cannulate to performing the procedure was significantly shorter with CoolsenseTM than LMX4TM (25.6 mins vs. 48.4 mins; p<0.0001). There was no significant difference in the number of successful first cannulation attempts (67% vs. 73%; p=0.23), or intervention-associated adverse effects (1.2% vs. 3.2%; p=0.39), between the two groups. Redness, vasoconstriction and increased anxiety were associated with LMX4TM application in a minority of cases.



The CoolsenseTM device performed better than LMX4TM cream at reducing the pain associated with intravenous cannulation in children. The immediate nature of its local analgesic effect means it significantly reduces the waiting time to cannulation. Both interventions produce similar first cannulation success rates and frequency of reported adverse effects. CoolsenseTM should be considered a viable alternative to topical anaesthetic cream for providing local analgesia in children requiring intravenous cannulation in the PED.

Vanessa MERRICK (Bedworth, United Kingdom), Jessica FARLOW, Anya WILSON, Rose SACCA, Elizabeth BARNES, Mary MCCASKILL
11:10 - 12:40 #7221 - OP076 Web-based tools for educating caregivers about childhood fever: a randomized controlled trial.
Web-based tools for educating caregivers about childhood fever: a randomized controlled trial.

Title: Web-based tools for educating caregivers about childhood fever: a randomized controlled trial. 

Introduction: Fever is a common reason for an emergency department (ED) visits and misconceptions abound. To date, educational strategies targeting caregivers have made little impact. Multimedia approaches to educate caregivers have proven effective in many childhood conditions. However, the utility of web-based interventions in caregivers has not been explored for childhood fever. In this study, we assessed the effectiveness of an interactive web-based module (WBM), read-only website (ROW), and written and verbal information (SOC) to educate caregivers about fever in their children.

Methods: This was a parallel group, randomized, superiority trial at a pediatric ED in London, Ontario, Canada from December 2013 to January 2015. The caregivers of children 0-17 years presenting to the ED with either a chief complaint of fever or had a temperature greater than 38 C were included. Caregivers were randomized to a WBM, ROW, or SOC. Primary outcome was the gain score on a novel questionnaire testing the caregiver’s knowledge on the measurement and management of fever. Secondary outcome was the caregiver satisfaction with the interventions. Primary outcome was analyzed using ANOVA and contrast analysis using the Student’s t-test was performed if overall differences were found. Caregiver satisfaction scores were compared using the Student’s t-test.

Results: There were 77, 79, and 77 participants in the WBM, ROW, and SOC groups, respectively. Web-based interventions were associated with a significant mean (SD) pre-test to immediate post-test gain score of 3.5 (4.2) [95% CI: 2.5, 4.4] for WBM (p < 0.001) and 3.5 (4.1) [95% CI: 2.6, 4.4] for ROW (p < 0.001) in contrast to a non-significant gain score of 0.1 (2.7) [95% CI: -0.5, 0.7] for SOC. Mean (SD) caregiver satisfaction scores (out of 33) for the WBM, ROW, and SOC groups were 22.6 (3.2), 20.7 (4.3), and 17 (6.2). All groups were significantly different from one another in the following rank: WBM > ROW > SOC (95% CI WBM: 21.9, 23.4; ROW: 19.8, 21.7; SOC: 15.5, 18.5, p < 0.001).

Conclusions: In contrast to verbal and written information, web-based interventions are associated with significant improvements in caregiver knowledge about fever. A web-based module is associated with the greatest caregiver satisfaction and should be routinely used in the ED.


Wallenstein MB, Schroeder AR, Hole MK, Ryan C, Fijalkowski N, Alvarez E, Carmichael SL. Fever literacy and fever phobia. Clinical Pediatrics. 2012; 52(3): 254-259.

Walsh A, Edwards H. Management of childhood fever by parents: Literature review. Journal of Advanced Nursing. 2006; 54(2): 217-227

Kobak KA, Stone WL, Wallace E, Warren Z, Swanson A, Robson K. A web- based tutorial for parents of young children with autism: Results from a pilot study. Telemedicine Journal & E-Health. 2011; 17(10): 804-808

Acknowledgements: The authors have no conflicts of interest relevant to this article

Natasha LEPORE (Cork, Ireland), Lara HART, Naveen POONAI
11:10 - 12:40 #7285 - OP077 Paediatric distal radius and forearm fracture closed reduction - emergency department procedural sedation versus operating theatre manipulation under general anaesthesia.
Paediatric distal radius and forearm fracture closed reduction - emergency department procedural sedation versus operating theatre manipulation under general anaesthesia.

A prospective cohort study of manipulation and closed reduction of paediatric distal radius and forearm fractures - emergency department (ED) procedural sedation versus general anaesthesia in emergency theatre. Single centre study based at the Royal Hospital for Sick Children (RHSC), Edinburgh UK.


Distal radius and forearm fractures are common injuries in the paediatric population.  In the subset of these injuries that demonstrate an unacceptable degree of angulation or displacement, closed reduction is the standard practice of care where instrumentation is not indicated. This may be performed under procedural sedation within the ED or under general anaesthesia (GA) in theatre. It is postulated that procedural sedation within the ED may reduce cost and time to treatment when compared to reduction under GA. However concerns currently exist that reduction under procedural sedation within the ED may be associated with increased anxiety and pain, poorer treatment outcomes and complications arising from sedation when compared with inpatient GA. This study aims to compare the outcomes for the closed reduction of forearm and distal radius paediatric fractures under procedural sedation in the ED to those reduced under GA in emergency theatre.



All patients presenting to RHSC ED from August 2015 with distal radius or forearm fractures appropriate for closed reduction were included. Tertiary referrals and any fractures requiring instrumentation were excluded. Allocation to ED procedural sedation was based on anticipated safety and was assessed by the supervising ED consultant using a departmental standard operating procedure. Sedation agents used varied according to sedationist preference but most commonly were a combination of propofol and opioid. Our measurable outcomes were time to reduction, complications secondary to general anaesthesia or procedural sedation, need for treatment revision, incidence of re-fracture or mal-union/non-union postoperatively.



Over the initial 6-month period, 56 patients aged between 2 and 14 years were included; 43 forearm and 13 distal radius fractures. 34 fractures (61%) were reduced under procedural sedation in the ED, 22 (39%) under GA in theatre. There was a significant difference in mean time to procedure of 15 hours (procedural sedation mean time 3 hours, GA 18 hours; p<0.05). There was no difference in complication rate between ED sedation and inpatient GA (n=0) and ED reduction was not associated with an increased rate of reoperation (n=0). Re-fracture rates were comparable in both groups (n=1) and all fractures were united in an acceptable position at follow-up. We will increase the power of this study through a further 6 months of data collection. We are also assessing service user satisfaction and quantifying the financial savings associated with the procedural sedation treatment limb.



Our preliminary data indicates that ED procedural sedation is as effective as inpatient GA for the closed reduction of paediatric distal radius and forearm fractures in those deemed safe for sedation. It appears to provide a more rapid, efficient and cost-effective alternative to inpatient GA reduction. It has shown to significantly decrease time to reduction and avoids hospital admission and the use of emergency theatre slots.  

Fiona GILLIES (Edinburgh, United Kingdom), Gregor CAMPBELL-HEWSON, Nick BEATTIE
11:10 - 12:40 #7324 - OP078 Influences of clinical spectrum and cultural background on antibiotic prescription in febrile children. A European observational study in emergency care.
Influences of clinical spectrum and cultural background on antibiotic prescription in febrile children. A European observational study in emergency care.

On behalf of the SHIVER group (Studies in cHIldren with feVER) from Research in European Pediatric Emergency Medicine (REPEM) network.


Fever is the most frequent reason for a child to attend pediatric emergency care (ED). We have a high antibiotic prescription rate in febrile children; often broad-spectrum.
The majority of febrile children, however, suffer from self-limiting illness; bacterial infections comprise pneumonia and urinary tract infections mostly. Aim: evaluating antibiotic prescription in febrile children at EDs focusing on variability among countries and clinical symptoms.


Design: Prospective observational multicenter study between October 2014-February 2016.
Population: Febrile children aged 1 month-16 years visiting the pediatric ED.
Outcomes: antibiotic prescription rate (primary); antibiotic type, geographical background, clinical symptoms (secondary). Data collection: each center registered clinical data and treatment (one randomly selected day per month, during 12 consecutive months).


Preliminary results are based on 4544 children from 28 hospitals, 11 European countries. Median age was 2.4 years (25th–75th percentile 1.1–4.9); 2488 (55%) male. Working diagnosis was definite bacterial in 204 children (5%) and probable bacterial in 1181 (26%). Infections were located in upper airway most frequently (n=2777, 61%); followed by lower aiway (n=561, 12%) and enteric (n=506, 11%). The majority was managed ambulatory (n=3979, 88%). Antibiotics were prescribed in 1440 (32%), with (amino)penicillin (36%) and amoxicillin-clavulanic acid (39%) most frequent; cephalosporins in 15%. Two countries could be classified into low MRSA prevalence of <5% (223 ED visits), 7 countries into MRSA prevalence 5-25% (3267 ED visits), and 2 countries into high MRSA prevalence of >25%  (1054 ED visits). Antibiotic use was 23% and 25% for low and intermediate MRSA prevalence countries, and 58% in countries with high MRSA prevalence rates. Small spectrum antibiotics were applied in 45% and 49% in low and intermediate MRSA prevalence countries respectively, but in only 17% for high MRSA prevalence countries. Antibiotic use was also related to younger age, the presence of abnormal vital signs and ill appearance, but not related to the presence of meningeal signs or petechiae. Diagnostic tests (serum-CRP, blood leukocyte count, urine dipstick and chestradiographs) were more frequently performed in those who had antibiotics prescribed. Results of chestradiographs or urine tests were not related to antibiotic prescription. A combination of clinical variables explained 4% of antibiotic prescription variation.

Conclusions In a multicenter study among European EDs, a minority of febrile children is at risk for bacterial infections. Antibiotics were prescribed in 32%, with (amino)penicillin and amoxicillin-clavulanic acid most frequently. Antibiotic use in febrile children is most related to MRSA prevalence rates, but also to the clinical presentation. The performance of diagnostic tests, but not the result of chestradiographs or urinetests are related to higher antibiotic prescription rates. International best practices need to be identified for management of acute febrile children.

Elles VAN DER VOORT, Santi MINTEGI, Henriette MOLL, Alain GERVAIX, Rianne OOSTENBRINK (Rotterdam, The Netherlands)
11:10 - 12:40 #7523 - OP079 Nurses’ gut feeling about serious illness in children visiting the emergency department.
Nurses’ gut feeling about serious illness in children visiting the emergency department.


The recognition of children with time-sensitive conditions amidst the large group of children with benign or self-limiting illnesses remains a challenge at the emergency department (ED). Because children present to the ED with a wide spectrum of problems, it is unlikely that a single clinical feature, vital sign or diagnostic test can accurately rule in or rule out a serious condition in a child. “Gut feeling”, the intuition that something is wrong despite a reassuring clinical assessment, may be a promising tool to identify children with serious illness. A previous study reported that primary care physicians’ gut feeling increased the risk of serious infection in children. Little is known, however about the gut feeling of ED nurses. The aim of this study was to define determinants of nurses’ gut feeling at the ED and to assess its diagnostic value for the recognition of children with a serious illness.


The study is based on a prospective observational cohort of all children aged


During the study period, we included 6390 children who attended the ED with a medical problem and had information about gut feeling documented. A gut feeling was present in 20.0% of these visits. Gut feeling was associated with triage urgency (OR 10.2, 95%CI 8.0-12.9 for urgency category 1 and 2 and OR 4.2, 95%CI 3.4-5.3 for urgency category 3), fever (OR 2.7, 95%CI 2.3-3.1) and the presence of abnormal vital signs (OR 1.6, 95%CI 1.4-1.9 for 1 abnormal vital sign and OR 3.6, 95%CI 2.9-4.3 for 2 or more abnormal vital signs). Moreover, a gut feeling occurred less frequent in self-referred patients (OR 0.6, 95%CI 0.5-0.7) and patients presenting outside office hours (OR 0.8, 95%CI 0.7-0.9). When adjusted for age, gender, triage urgency and fever or abnormal vital signs, presence of a gut feeling was significantly associated with ICU (OR 4.4, 95%CI 3.0-6.3), and hospital admission (4.1, 95%CI 3.5-4.8). Sensitivity of nurses’ gut feeling for the recognition of patients requiring ICU admission was 0.71 (0.63-0.79), and specificity 0.81 (0.80-0.82). Sensitivity for hospital admission was 0.48 (95%CI 0.45-0.52), and specificity 0.85 (95%CI 0.84-0.86).


Nurses’ gut feeling at the emergency department is associated with clinical and non-clinical factors. The presence of a gut feeling increases the risk of ICU or hospital admission, but is in itself not an accurate predictor. It is important to combine gut feeling with other clinical parameters to determine the severity of illness of a child.

Joany ZACHARIASSE (Rotterdam, The Netherlands), Dominique VAN DER LEE, Nienke SEIGER, Rianne OOSTENBRINK, Henriëtte MOLL
11:10 - 12:40 #7835 - OP080 Validation of a Predictive Model for Identifying Febrile Young Infants With Altered Urinalysis at Low Risk of Invasive Bacterial Infection.
Validation of a Predictive Model for Identifying Febrile Young Infants With Altered Urinalysis at Low Risk of Invasive Bacterial Infection.

Urinary tract infections (UTI) are the most common serious bacterial infection in infants less than 90 days of age. Guidelines recommend inpatient treatment under 60-90 days old, due to risk of complications. In 2010, a predictive model was published by Schnadower et al. trying to find a subgroup of patients with low risk of adverse outcomes. That model shown high accuracy, but for predicting risk of bacteremia secondary to UTI. In 2014, a new approach was published by Velasco et al. This new model did not focus not in patients with a positive urine culture, but in patients with an altered urine dipstick, trying to select a group of low risk of having a invasive bacterial infection (IBI). Sensitivity and negative predictive value of this model were 100%.

Aim of this study was to test the performance of the predictive model in a new sample of febrile infants with altered urine dipstick. 

Study design

Retrospective multicenter study including 9 Spanish hospitals. Febrile infants ≤90 days old with altered urinalysis (presence of leukocyturia and/or nitrituria) were included. According to our predictive model, an infant is classified as low-risk for IBI when meeting all the following: being well appearing at arrival to the emergency department, being >21 days old, having a procalcitonin value <0.5 ng/mL and a C-reactive protein value <20 mg/L. Patients were excluded if any of the data evaluated by the predictive model was missed, a blood culture was not performed or if informed consent was not given by the parents. Invasive bacterial infection (IBI) was defined as the isolation of a single pathogen in a blood or cerebrospinal fluid (CSF) culture. IBI was considered as secondary to UTI if the same pathogen was isolated in the urine culture and in the blood or CSF culture


Four hundred twenty-five febrile infants attended in the participant hospitals had an altered urine dipstick. After applying exclusion criteria, 391 (92%) patients were analysed. Mean age was 50.5 days old (SD 23.0), and 297 (69.9%) were male. Median hours of fever when attended in the PED was 4 (P25-P75: 2-12). Urine culture was positive in 346 (88.5%) patients, being Escherichia coli the most frequently isolated bacteria, in 302 (87.5) infants. Thirty (7.7%) patients were diagnosed as IBI. Among them, 28 had bacteremia, being 25 (89.3%) secondary to UTI. Two patients had meningitis, one due to E. coli and the other one growth Klebsiella oxytoca in both urine, blood and CSF culture.

According to the predictive model, 104 (26.6%) infants would have been classified as low-risk patients. Two low-risk patients (1.9%) presented an IBI vs 9.8% (p<0.05) of the infants classified as not low-risk patients, although 1 of them growth Moraxella catarrhalis, suspected of being a contaminant, even it was not defined as one in the study's protocol.


Outpatient management might be suitable for 1 of each 4 patients diagnosed as possible UTI, although limitations of the study make mandatory prospective validation prior its incorporation to clinical practice.

Dr Roberto VELASCO (Laguna de Duero, Spain), Borja GOMEZ, Susanna HERNANDEZ-BOU, Andres GONZALEZ, Izaskun OLACIREGUI, Mercedes DE LA TORRE, Aris RIVAS, Alba RUBIO, Isabel DURAN
11:10 - 12:40 #8253 - OP081 Practice Variation In The Management Of Minor Head Trauma In Children In Europe. A REPEM Study.
Practice Variation In The Management Of Minor Head Trauma In Children In Europe. A REPEM Study.

BACKGROUND: Head injury is an important cause of mortality and morbidity in children. Earlier studies have described significant practice variation in the use of imaging after pediatric head trauma, with  evidence to suggest that pediatric emergency departments (EDs) have lower rates of imaging than general EDs. Computed tomography (CT) is the imaging modality more commonly used in the ED evaluation of children with head trauma. The use of CT, however, is not uniform across all EDs, and variation between clinicians and pediatric EDs  exists.and appears unrelated to the frequency of clinically important Traumatic Brain Injuries (ciTBIs).

OBJECTIVE: To describe the variation in use of imaging, observation and admission rate for children with minor head trauma (MHT) in Europe.

DESIGN: A 3 years retrospective chart review involving 17 pediatric EDs of 9 European countries was conducted. A structured data collection method was used. Inclusion criteria included children 18 years or less, history of trivial or MHT in the previous 24 hours from the evaluation in the ED. Data collected included demographic information, type of injury, mechanism of injury, type of imaging  used and rate of admission to the observation unit or ward.

RESULTS: We report the preliminary results of  9 centers. Of 6535 charts reviewed, 6493 (99.4%) were analyzed. The mean age was 55.5 months (SD 49.4). 60.2% of the patients were male, without significant differences between hospitals. CT and observation rates varied across hospitals respectively from 0.8% to 19.6% and 12.3%  to 41%. Main data about the management are shown in Table 1.


                                             1          2           3          4           5            6            7           8                9

n                                      517      895        430       141       438       459       1190        515         1950

Minor HT                       91.5%   86.1%   70.2%   32.6%    82.0%   84.8%   82.6%    85.4%      63.6%

Craneal X-Ray                8.1%     1.9%    11.4%   18.3%    21.7%   18.6%     3.6%      0.4%       4.8%

Head CT                        2.2%     5.5%     2.1%     0.8%      4.6%   14.7%     3.0%    19.6%       2.9%

Observation Unit          24.1%    41.0%   17.9%   14.3%    30.1%   39.8%   23.5%    23.1%      12.3% 

Admitted (Ward/PICU)    0.5%     1.8%     1.2%     0.8%     0.2%     1.2%     2.9%     18.3%      7.5%

CiTBI                               0%     1.5%      0.7%     0.7%       0%      0.2%    0.4%          0%      0.5%


CONCLUSIONS: Preliminary results demonstrate a significant variation in the   management of MHT in Pediatric ED across Europe when considering the rate of imaging, observation and ward admission. The reason for this variability may be based on differing criteria used by clinicians to order imaging, differences in the patient populations presenting to the various departments or training of physicians staffing EDs in the different hospitals.

Dr Roberto VELASCO (Laguna de Duero, Spain), Niccolo PARRI, Carmel MOORE, Federica D'ELIA, Liviana DA DALT, Zsolt BOGNAR, Ricardo FERNANDES, Patrick VAN DE VOORDE, Özlem TEKSAM, Merel BROERS, Santiago FERNANDEZ, Maider ALCALDE, Sergi PIÑOL, Anaida OBIETA, Javier GONZALEZ

Tuesday 04 October

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State of the Art
Infectious Disease & Sepsis

Moderators: Dr Philip D ANDERSON (Professor) (Boston, MA USA, USA), Edin ZELIHIC (Schweinfurt, Germany)
14:10 - 14:40 How to avoid end organ failure in septic shock. Christoph DODT (Head of the Department) (München, Germany)
14:40 - 15:10 Causes of sepsis in migrants from North Africa and Middle East. Murat ERSEL (Turkey)
15:10 - 15:40 The new definition of Sepsis and Septic shock. Tobias SCHILLING (ÄD) (Stuttgart, Germany)

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Austria, Germany, Switzerland Invites
Rekrutierung, Motivation

Moderators: Wilhelm BEHRINGER (Director) (Jena, Germany), Alexandra-Maria WARENITS (Vienna, France)
14:10 - 14:40 wie finde ich Personal ? Roland BINGISSER (Basel, Switzerland)
14:40 - 15:10 wie binde ich Personal ? Wilhelm BEHRINGER (Director) (Jena, Germany)
15:10 - 15:40 wie bilde ich Personal ? Philip EISENBURGER (Head) (Vienna, Austria)

Tuesday 04 October

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Philosophy & Controversies
P&C Neurological

Moderators: Greg HENRY (USA), Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
14:10 - 14:40 Do we ever need a neurologist in Vertigo? Greg HENRY (USA)
14:40 - 15:10 The Big 3: A concise and Practical Approach to Vertigo. Peter JOHNS (Speaker) (Ottawa, Canada)
15:10 - 15:40 Stroke mimic - how much should we fool around with the painless aortic dissection? Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, Canada)

Tuesday 04 October

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Philosophy & Controversies
Disaster & Biohazards - European Preparedness

Moderators: Pr Francesco DELLA CORTE (Speaker) (Novara, Italy), Matthieu LANGLOIS (medecin) (Paris, France)
14:10 - 14:40 New Terrorism: Anything to learn from the military? Charles STEWART (Tulsa, OK, USA)
14:40 - 15:10 Mass shooting: is it a matter of scoop and run? Kurt ANSEEUW (Medical doctor) (Antwerp, Belgium)
15:10 - 15:40 Terrorist attacks: the same model throughout the years? Pr Ives HUBLOUE (Chair) (Brussels, Belgium)

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Moderators: Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, United Kingdom), Pr Lisa KURLAND (speaker) (Örebro, Sweden)
14:10 - 14:40 Risk stratifying patients with chest pain: what's best? Pr Edd CARLTON (Emergency Medicine Consultant) (Bristol, United Kingdom)
14:40 - 15:10 War on troponinitis: How to beat the plague. Pr Rick BODY (Professor of Emergency Medicine) (Manchester)
15:10 - 15:40 Evidence-based management of heart failure: an update for 2016. Said LARIBI (PU-PH, chef de pôle) (Tours, France)

Tuesday 04 October

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How to teach decision making in the ER

Moderators: Roberta PETRINO (Head of department) (Italie, Italy), Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
14:10 - 14:40 10 commandments in emergency medicine. Pr André GRIES (Medical Director) (Leipzig, Germany)
14:40 - 15:10 Decision-making as an essential non-technical skill for emergency physicians. Anna SPITERI (Consultant) (Malta, Malta)
15:10 - 15:40 Making decisions in the Ed: strategies to cope with pressure, cognitive errors and human conditions. Roberta PETRINO (Head of department) (Italie, Italy)

Tuesday 04 October

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EuSEM Nursing Track
Emergency Nursing Education

Moderators: Jochen BERGS (Hasselt, Belgium), Petra VALK-ZWICKL (Clinical nurse specialist and eduactaor) (Switzerland, Switzerland)
14:10 - 14:40 Emergency Nursing education in Australia. Mark TYLER (Australia)
14:40 - 15:10 Educating the future emergency nurse: professional competence and development. Dr Thordis K. THORSTEINSDOTTIR (Professor) (Reykjavik, Iceland)
15:10 - 15:40 Development of an e-learning program to increase knowledge and awareness for the recognition of elderly abuse in the ED. Sivera BERBEN (research coordinator) (Nijmegen, The Netherlands)

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Oral Papers 33

Moderators: Luca CARENZO (SIMULATION COMPETITION ONLY) (NOVARA, Italy), Dr Kim GEYBELS (Emergency and prehospital physician) (Zottegem, Belgium)
14:10 - 14:20 #7104 - OP082 Evaluation of a management tool for fever of unknown origin in infants younger than 3 months in the Emergency Department.
Evaluation of a management tool for fever of unknown origin in infants younger than 3 months in the Emergency Department.


Management of infants younger than three months old presenting to the Emergency Department (ED) with fever of unknown origin remains a difficult challenge for clinicians. Prenatal Group B Streptococcus screening and recently developed vaccinations changed the occurrence and epidemiology of serious bacterial infections (SBI) in this population. An evidence-based guideline was developed for use in the Paediatric ED of a tertiary university hospital in Brussels.

The purpose of this study is to examine the accuracy of this guideline to detect SBI, to search for the infectious agents in this population, and to analyse physicians' compliance to the guideline.


All infants younger than three months old who presented to the ED with fever without clinical source, between January 1, 2012 and November 15, 2013 were eligible to include. All anamnestic and clinical data, laboratory test and culture results, chest X-ray findings, treatments and clinical outcomes were obtained from digital medical records, and retrospectively analysed.


From 31713 paediatric patients who presented to the Paediatric ED over 23 months' time, 1592 (5%) were under three months old, of whom 287 (18%) had fever of unknown origin. Median age was 42 days (range 6–90 days), 159 were boys (55%), and 16 (5.5%) had a history of prematurity.

Diagnostic screening categorised 143 infants (49.8%) as high-risk for SBI, of whom 26 (18%) had confirmed SBI. In 144 infants (50.2%) categorised as low-risk, no SBI was detected.

In 122/287 infants (42%), a microbiological source was found: 96/287 (33%) had a viral infection, 16/287 (5.5%) had a urinary tract infection (UTI), and 10/287 (3.5%) had a bacterial pneumonia. In the majority of infants (n=165/287; 58%), no pathogen was detected. The most frequently detected pathogens were Escherichia coli (mostly in urine) and Enterovirus (mostly in cerebrospinal fluid).

Most infants (n=279/287; 97%) were admitted to the hospital, of 8 patients (3%) parents refused admittance. In 62% (n=178/287), empiric antibiotherapy was initiated. In the high-risk group, all infants were treated; in the low-risk group 35/144 (24%) infants received intravenous antibiotics. In 11 cases (3.8%) acyclovir was added.

One infant died following septic shock after peritonitis due to bowel perforation.

Many non-adherences to the guideline were detected: in 14 infants (5%) no blood culture was obtained, only 35/287 urine samples (12%) were obtained in a sterile collection, 19% (n=56) did not undergo lumbar punction, and 3% (n=8) did not have a chest X-ray. Most infants (n=185/287 or 64%) were not screened for Bordetella pertussis. In the low-risk group, 20% (n=35/178) received antibiotics although the guideline recommended differently.


This study indicates that in 9% of infants presenting to the ED with fever without source an SBI was detected. Most common infections were of viral origin, most common SBI were UTI. Adding standard screening for Bordetella pertussis to the guideline is recommended. Given these results, the compliance of physicians to the evidence-based guideline should be improved, and attention is needed regarding sterile urine collection and antibiotic policy in the low-risk group.

Andy DE LEEUW (Lennik, Belgium), Gerlant VAN BERLAER, Dominique BULCKAERT, Ives HUBLOUE
14:20 - 14:30 #7234 - OP083 Diagnosing teenage pregnancy in ED: When to test.
Diagnosing teenage pregnancy in ED: When to test.

Background: Adolescent girls presenting to emergency departments (ED) with abdominal pain are a common presentation. Pregnancy is one differential diagnosis amongst many but if missed can have serious consequences. The UK is one of the European countries with the highest rate of teenage pregnancies with large regional variations.  4.5% of all deliveries are to mothers aged 18 or younger (31,000 p.a.). There is limited guidance on when to screen for pregnancy in this age group. In our study we audited practice in a cohort of adolescent girls presenting to a tertiary teaching hospital ED with abdominal pain following a review of the literature.

Methods: Resource websites of RCPCH (UK), RCEM (UK), AAP (US), NHS Improving Quality (UK) and Pubmed were searched for protocols and guidelines. All female attendances aged between their 12th and 18th birthday with a presenting problem of abdominal pain between October 2015 and January 2016 were identified and the electronic records reviewed. Data was collected on whether a menstrual history was taken, sexual activity, pregnancy testing and final diagnosis and disposal.

Results: A total of 124 ED attendances by 98 patients were identified. One 16 year old girl was found to be pregnant on testing with suspected ectopic pregnancy. 27% of attendances did not have a pregnancy test, when excluding pre-menarchal patients this rate dropped to 25%. 14 and 15 year olds had a pregnancy test result documented in only 60% of cases. Of those patients not tested, 12% went to theatre and 14.7% were exposed to ionising radiation including CT scans. Sexual activity was asked about in only 25% of cases but did not impact on the rate of testing. Menstrual history was documented in 66% of attendances. 12% of attendances who were not tested had no definitive diagnosis on discharge from the ED.

Conclusion: Detection of teenage pregnancy is important. There are recommendations for testing in risk groups but this is not universally implemented. A number of factors account for substandard practice as highlighted in our cohort and we present current latest recommendations and propose a management algorithm.

Marcus Y. L. SIM (Cambridge, United Kingdom), Peter HEINZ
14:30 - 14:40 #7237 - OP084 What is the coagulopathies' impact on arrival at the hospital in severe trauma patients initially cared for by prehospital medical teams? A retrospective observational study.
What is the coagulopathies' impact on arrival at the hospital in severe trauma patients initially cared for by prehospital medical teams? A retrospective observational study.

Introduction: Pre-hospital severe trauma patients' (STP) clotting disorders are early and worsen their prognosis. The aim of this study was to describe the incidence of coagulopathy and to explore the existence of statistical associations between the presence of coagulopathy and other characteristics gathered from STPs cared for by prehospital medical teams in urban areas.

Material and method: This was a retrospective observational study.  The inclusion criterias were patients cared for hemorrhages by prehospital medical teams, transported to a hospital recovery room, and for whom the initial hospital hemostasis record sheet was available. The pre-hospital variables recorded were 1. Epidemiological (age, gender, circumstances) 2. Paraclinical and biological (shock-index, Glasgow scale score, blood lactate values) 3. Therapeutic (intubation, tranexamic acid and/or catecholamines administration) 4. Time from "prehospital medical team engagement to recovery room arrival. The hospital variables were the early biological results (prothrombin time (PT)). The analysis of results was gathered and then multivariated using STATA 14.0 ®.

Results: Over 11 months, including 1570 medical transports, 156 (10%) were STPs.   For 72 of these 156 STPs, initial hospital hemostasis record could be found. For these 72 (100%) included, the median age was 33 years, IQR [26-44], with 63 (88%) men. The trauma was linked to either a public highway accident (n=42 or 58%) or penetrative weapon wound (n=19) or defenestration (n=11). The initial shock-index was >1 in 9 (12.5%) cases. The patients were intubated in 10 (14%) cases, received catecholamine in 2 (3%) cases and received pre-hospital tranexamic in 22 (31%) cases. The median "prehospital medical team engagement-recovery arrival" time was 64 min (IQR [52-78]). On hospital arrival, 15 (21%) STPs had a PT<70%. .

In univariate analysis, the hospital PT tended to be correlated with pre-hospital lactate values (p=0.06). In multivariate analysis, we found an association between hospital PT <70% and respectively: pre-hospital shock index >1 (p=0.02), the elderly (p=0.02), and pelvis injury (p=0.04).


Discussion: Clotting disorders were found in one in five despite currently proper care.  The study continues on a larger cohort taking into account survival. It also constitutes the reference group of a pre-post study. The "after" period will be to administer lyophilized plasma at the pre-hospital phase. 

14:40 - 14:50 #7242 - OP085 Simulation-based trial of crisis checklists in the emergency department: a pilot study.
Simulation-based trial of crisis checklists in the emergency department: a pilot study.

Background: Checklists improve the management of crises in simulated operating rooms and intensive care units. Crisis checklists have not been evaluated in the emergency department (ED) setting. Checklists may not necessarily have the same value when used in the actual working environment as opposed to a simulation center.

Aim: The aim of this pilot study was to evaluate crisis checklists using in-situ simulations in an actual ED.

Methods: Checklists of key emergency treatments were developed for eight crises:anaphylaxis, hemorrhagic chock, ST-segment elevation myocardial infarction, beta-blocker and/or calcium antagonist poisoning, poisoning with a membrane stabilizing agent, status epilepticus, severe sepsis, increased intracranial pressure.The content of the checklists was based on international guidelines and other authoritative sources.Emergency care teams working in the ED of Lund, Sweden, were randomized to manage simulated crises with or without access to these checklists, for a total of 16 simulations lasting 10-12 minutes. Time from scenario start to key treatment delivery was independently measured by two observers. Each crisis featured between 7 and 11 key treatments.Checklist user-friendliness was evaluated using a questionnaire.

Results: The median percentage of treatments carried out was 83% (range 38-100%) with checklist access versus 44% (range 15-86%) without (p = 0.03). One simulation needed to be prematurely terminated due to clinical care requirements and subsequently repeated. Of the 36 participants who had checklist access, 26 (72%) felt that the checklist helped them manage the case. Almost all participants, 67 of 71 (94%), would want the checklists used if they were the patient.

Interpretation: Studying crisis checklists in an actual ED is feasible. The pilot study results suggest that checklists may improve the care of critically ill patients in the ED.

Eric DRYVER (Lund, Sweden), Charlotte ODEVALL, Anders BERGENFELZ, Ulf EKELUND
14:50 - 15:00 #7546 - OP086 Hygiene in the emergency medical services – A systematic review.
Hygiene in the emergency medical services – A systematic review.

Introduction Infections caused by microbial contamination in healthcare settings result in increased morbidity, mortality and economic burden. Hygiene in the emergency medical service is challenged due to the non-static environment with limited access to cleaning equipment etc.  The personnel are working in varying environments e.g. retirement homes, industrial farms or at roadsides after a car incident, often with little time to prepare the acute care and treatment. In addition, continually patient courses lead to limited time to clean and prepare the ambulance in-between patient courses, thus posing a risk of transferring infection. Knowledge of bacterial contamination in environment, on medical equipment and the personnel and related challenges is therefore substantial, thus future hygiene interventions can be organized and effectuated according to evidence (1, 2). The aim of this review is to create a systematic summary of the current evidence concerning hygiene in the emergency medical service focusing on 1) environmental contamination, 2) cleaning interventions and 3) personnel compliance. Methods A scoping review including English or Scandinavian literature, were performed in PubMed Central (PMC) from March to April 2016. At least two of the investigators decided the relevance of each report, and all inclusions/exclusions were unanimous, and the articles not blinded.  Results We found documentation of environmental contamination by several different pathogenic bacteria, on a wide variety of equipment and materials within the ambulance environment and limited effect of conventional cleaning, and risk of cross contamination. Furthermore, hygiene compliance appears challenged on a number of aspects e.g. hand- and uniform hygiene, cleaning and disinfection procedures etc. Conclusion Hygiene in the emergency medical service appear challenged on several aspects. This review reveal risk of infection due to environmental contamination by pathogens and lack of personnel compliance, thus underpinning a necessity of focus on prehospital hygiene and future research in order to secure evidence-based practice. 

Heidi Storm VIKKE (Kolding, Denmark), Matthias GIEBNER, Hans Jørn KOLMOS
15:00 - 15:10 #7580 - OP087 Are parent-uploaded You-tube videos of unwell children a useful source of information for other parents?
Are parent-uploaded You-tube videos of unwell children a useful source of information for other parents?

BACKGROUND – YouTube, the third most popular website in the world, is a vast repository of user-uploaded video content and a potential source of freely accessible medical information. To our knowledge no study has identified or focused on parent uploaded videos which describe illness in their children.  

OBJECTIVE – to be able to describe the quantity, quality and use of videos featuring unwell children posted on YouTube by their parents, and the implications for and use of these videos in educating parents.

METHODS – Croup and dehydration were the two medical conditions used for comparison.  YouTube was searched for videos using the search terms ‘croup’ and ‘dehydration’ from servers based in the United Kingdom (UK) and the Netherlands on October 6, 2015. The first 400 videos were searched and videos which clearly had been uploaded by parents or caregivers selected for evaluation. Videos created by doctors or by educational institutions were excluded. 
The included videos were analysed independently by two research students and two paediatricians for different characteristics (duration, likes/dislikes, number of views) and technical quality (using the validated VRS system with a total maximum score of 5 to rate light, sound, angle, resolution and duration). 
Independently of this, each video was assessed for whether it represented a good clinical example of the condition or not.

RESULTS – for the condition croup there were 40 videos which met the criteria for inclusion after 400 videos had been screened. The 40 corresponding videos had a wide range number of views (142 – 121928). Out of 40 videos, 14 (35%) were judged to be a good clinical example. Only 7 of these 14 videos were also found to be of high technical quality, meaning that 7 of the videos judged by the study team to be a ‘good clinical example’ were of poor technical quality.

For the condition dehydration a total of 28 videos met the criteria for inclusion. 2 of 28 (7%) parent uploaded videos were judged to be a good clinical example. Both these videos had good technical quality (score 4-5). 

In most videos of both conditions, the reason for upload was unclear. 

CONCLUSION – Useful and high quality videos do exist for the condition croup (a clearly defined condition), but this was not the case for dehydration (a vaguer symptom). Some of the videos for croup could be used as educational material. However, these videos will not always be obvious to those searching and it can be hard to find these informative videos in the large amount of information available. 
Conversely, parents could be confused by apparently high technical quality videos (which have good light, sound and picture quality), which are not in fact good clinical examples. 
Further research into reason for uploading should be undertaken to understand why videos are uploaded which could be beneficial for understanding parents’ health seeking needs. YouTube could be a useful information source for parents if clearly guided.

Knight KATIE, Dorothy M VAN LEEUWEN (Rotterdam, The Netherlands), Oostenbrink RIANNE, Dr Damian ROLAND, Moll HENERIETTE
15:10 - 15:20 #7845 - OP088 EMS systems´comparison across the cases.
EMS systems´comparison across the cases.


The study compares pathways for the same patient conditions of different Emergency Medical Services from 17 European Nations. These cases were designed as urgent but not life threatening emergencies: A simple laceration, an adult experiencing an asthma attack, a patient with lower back pain, a caller having cough and chest pain, an elderly after a fall, a patient with fever and a senior in need to have a urinary catheter change.


Participants and methods

Services in Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Hungary, Italy, Luxembourg, Norway, Slovakia, Slovenia, Spain, Sweden, Switzerland and United Kingdom participated in the study. The seven case scenarios have been answered via questionnaire or personal interview during participation in field ambulance work.


There is a high degree of variation in steering the patient into different medical pathways via phone evaluation or on scene assessments between the different services that have been researched. Overall, in the observed institutions there is a tendency to treat and release patients if ambulance providers also have a nursing or community/advanced paramedic background, combined with standardized assessment protocols or if there are general practitioners systematically involved. Some services have a strict ‘transport to the hospital strategy’ whereas others have a ‘hear and refer or treat’ or ‘see, treat and release’ response.


Ambulance services fulfill primary care tasks in all nations. If there is no common strategy developed with traditional primary care providers such as general 

Christoph REDELSTEINER (Wien, Austria)
15:20 - 15:30 #8101 - OP089 Appropriateness of utilization of a physician-staffed rescue helicopter in Austria.
Appropriateness of utilization of a physician-staffed rescue helicopter in Austria.

Background: Physician-staffed rescue helicopters are a high-end and very expensive resource of limited availability, therefore a deliberate dispatch system is of paramount importance. This retrospective observational study aims to evaluate how often the use of a helicopter was justified at a single rescue helicopter base in southern Austria.

Methods: Austria operates a dense network of ground-based physician-staffed prehospital response units and an additional coverage with rescue helicopters during daylight conditions. The protocol sheets and electronic records of the rescue helicopter base in Graz, Austria of a one-year time period were screened and entered into a database. The respective helicopter serves a population of about 900,000 people and 9,000 square kilometers covering both heavily populated urban areas, rural areas and poorly accessible mountain regions and can thus be viewed as representative for a large part of Austria´s territory. Three aspects of helicopter deployment were considered: rapid transport priority to a maximum care hospital according to the emergency physician´s diagnosis, use of the helicopter for extrication purposes and in inaccessible areas and the provision of invasive prehospital medical treatment provided by the specialized aeromedical crew. A scoring system incorporating these three aspects was generated to evaluate whether the utilization of the helicopter was justified or whether the call could have been attended to by a ground-based crew. Interhospital transfer missions and missions which were cancelled en-route were excluded from the analysis.

Results: From July 1st, 2014 until June 30th, 2015 1043 primary missions were the helicopter landed and attended to a call were registered. In 43,8% of those cases, there was no evidence of any benefit of the deployment of the helicopter versus a ground-based physician response unit (e.g. non-life threatening medical condition in close proximity to a ground-based crew). In the other 56,2%, we found at least some indication of an advantage of helicopter utilization. In 31,7% of all cases, there was a clearly comprehensible advantage of the helicopter as a rescue vehicle (e.g. severe multiple trauma in a poorly accessible mountainous area).

Conclusion: Despite the limitations of retrospective reviews, this study suggests that a large fraction of calls attended to by aeromedical crews could have been resolved employing ground-based emergency crews. Since rescue helicopters are a scarce and expensive resource, further studies to investigate the reasons for our findings are warranted and an audit system of feedback and quality control seems advisable.

Richard REZAR (Graz, Austria), Gilbert SANDNER, Barbara HALLMANN, Stefan HESCHL, Geza GEMES
15:30 - 15:40 #8173 - OP090 Effect of vertical location on survival outcomes for out-of-hospital cardiac arrest in Singapore.
Effect of vertical location on survival outcomes for out-of-hospital cardiac arrest in Singapore.

Background: A large proportion of out-of-hospital cardiac arrests in Singapore (OHCA) occur in high-rise residential buildings.[1] This study aims to investigate the effect of the vertical location (floor level of apartment building) at which patients collapse from cardiac arrest, on survival outcomes and response times.

Participants and methods: A retrospective study was done based on data obtained from the Singapore cohort of the Pan Asia Resuscitation Outcome Study (PAROS). OHCA data from January 2012 to December 2014 were used. All OHCA patients conveyed by Emergency Medical Services (EMS) and confirmed by the absence of pulse, unresponsiveness and apnea were included. All OHCA cases occurred in Singapore. OHCA cases with incomplete data on vertical location were excluded. Primary outcome was survival to hospital discharge or to 30 days post cardiac arrest. Statistical analysis was performed using SAS V9.3 (SAS Inc., Cary NC, USA) and expressed in terms of counts and percentages, odd ratio (OR) and the corresponding 95% confidence interval, mean and the standard deviation (SD) as well as p-value.

Results: A total of 5114 OHCA cases met the inclusion criteria for this study. 76 cases (1.5%) had missing vertical location data and were excluded. Out of the 5038 OHCA cases analyzed, 1482 (29.4%) cases occurred at ground level, 41 (0.8%) cases occurred at basement levels and 3515 (69.8%) cases occurred at ≥ 2nd floor level. 3653 out of 5038 cases (72.5%) occurred in home residences. The response time (in minutes) from time of ambulance arrival on scene to patient contact by EMS for cases that occurred at basement levels (mean 3.32 [SD 4.24]) and cases that occurred at ≥ 2nd floor level (mean 2.53 [SD 1.66]) are both significantly higher (p<0.001) than those that occurred at ground level (mean 1.67 [SD 1.99]). Survival outcomes for OHCA patients were poorer as the vertical location increases away from ground. For every 1 floor increase in vertical distance from ground, OHCA was 4% less likely to result in survival (OR 0.96 [0.92 – 0.99]). OHCA was also 3% less likely to be witnessed (OR 0.97 [0.96 – 0.98]), 1% less likely to have bystander CPR performed (OR 0.99 [0.98 – 1.00]), and 16% less likely to have bystander AED applied (OR 0.84 [0.79 – 0.89]) for every level increment in vertical distance from ground. First arrest rhythm was also 7% less likely to be shockable at every floor increment (OR 0.93 [0.92 – 0.95]. Return of spontaneous circulation (ROSC) on scene or enroute was 3% less likely to happen (OR 0.97 [0.94 – 0.99] and 3.5% less likely to be maintained at the ED [OR 0.97 [0.94 – 1.00] for every increase in vertical floor distance from ground.

Conclusion: There is significant effect of vertical location on survival outcomes for OHCA in Singapore. Interventions aimed at improving access to OHCA patients in high vertical floors need to be investigated.

[1] Goh, E.S., Liang, B., Fook-Chong, S. et al. Effect of location of out-of-hospital cardiac arrest on survival outcomes. Ann Acad Med Singapore. 2013;42:437–444.

Tracy LIAN (Singapore, Singapore), John ALLEN, Swee Han LIM, Nur SHAHIDAH, Yih Yng NG, Nausheen DOCTOR, Benjamin LEONG, Han Nee GAN, Desmond MAO, Michael CHIA, Si Oon CHEAH, Lai Peng THAM, Marcus ONG

Tuesday 04 October

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15:45 - 16:05

Poster Highlight Session 5 - Screen 1

15:45 - 15:50 #8082 - Systemic Inflammatory Response Syndrome or Q SOFA: that’s the question!
Systemic Inflammatory Response Syndrome or Q SOFA: that’s the question!


Sepsis is the first cause of infection related death. Its diagnosis must be early to start treatment and improve prognosis. Sepsis diagnosis is classically based on the association of two or more Systemic Inflammatory Response Syndrome (SIRS) criteria with suspected infection. The new definition recommends the Q SOFA as quick sequential organ failure witch can be more helpful for the management of septic patients. We hypothesized that both SIRS and Q SOFA can be used in all the ED users in the prediction of a poor prognosis.

The aim of this study was to evaluate the prognostic value of Q SOFA in emergency population and to compare SIRS to Q SOFA in prediction of in hospital mortality in septic patients.


We conducted a prospective observational and descriptive study in the emergency department of la Rabta teaching hospital during two months. Inclusion criteria were: adult patients presenting to the emergency department and required hospitalization in observational unit.  Exclusion criteria were: patients under the age of 18, injured patients, patients in cardiorespiratory arrest. We evaluated in-hospital mortality, organ failure and need of hospitalization in intensive care unit.


342 patients were included. The mean age was 59 years with a sex ratio of 1.47 in the past medical history, we found diabetes (36%), hypertension (25.4%) and cardiac pathology (9.9%). Final diagnoses were sepsis (54.1%), heart failure (21.1%) and decompensated diabetes 15.8%. 49.5% of patients with SIRS had organ failure vs 14.5% without SIRS (p<0.001). SIRS was correlated with in hospital mortality: 16.8% in patients with SIRS vs 4.3% in patients without SIRS (p=0.008). The in-hospital mortality was about 14.3% with a statistically significant association with Q SOFA: 27.3 % of patients with a Q SOFA ≥2 vs 8.2% of patients with a Q SOFA < 2 (p<0.001). A Q SOFA ≥ 2 was significantly correlated with developing organ dysfunction: 65.5% vs 31.5% of patients with a Q SOFA < 2 (p<0.001). 54.1% of patients had a sepsis or a severe sepsis: SIRS wasn’t correlated with in hospital mortality: 20.1% in SIRS group vs 18.8% in group without SIRS criteria. Q SOFA was correlated with in hospital mortality in septic cases: mortality was 28.2% in patients with a  Q SOFA ≥2 vs 14 % in patients with a Q SOFA <2 (p=0.01).

69 patients didn’t met the SIRS criteria: 9.1% died and had a Q SOFA≥2 vs 3.4% died with Q SOFA<2. There was no correlation between Q SOFA and in hospital mortality (p=0.41). Ten of them developed organ failure: 4 had a qSOFA < 2 vs6 with a Q SOFA≥2 (p<0.001).


Both SIRS and Q SOFA can be used to determine critically ill emergency patients with a superiority of q SOFA especially for septic patients.

15:50 - 15:55 #8231 - Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department?
Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department?

Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department?



Scoring systems are used to show risk stratification in intensive care units (ICU), but they are not routinely used in emergency departments. The aim of this study is to determine accuracy for predicting mortality in emergency medicine with scoring systems: Sequential Organ Failure Assessment (SOFA), Mortality in ED Sepsis (MEDS), and Simplified Acute Physiology Score (SAPSII).


This is a prospective observational study. Patients presenting with evidence of sepsis are included, while SAPSII, MEDS, and SOFA scores are also calculated. Analysis compares areas under the receiver operator characteristic (ROC) curves for 28-day mortality.


Two hundred patients are included in the study: thirty-one (14.3%) with septic shock, 138 (69%) with severe sepsis without shock, and 31 (15.5%) with infection without organ dysfunction. Fifty-three (26.5%) patients died within 28 days of presentation.

Areas under the ROC curve for mortality involve 0.76 for MEDS (95% CI = 0.69 to 0.82), 0.70 for SAPSII (95% CI = 0.62 to 0.78), and 0.68 for SOFA (95% CI = 0.60 to 0.76) scores. Pairwise comparison of AUC between MEDS, SAPSII, SOFA, and Lactate are not significant. (p > 0, 05).


According to our results, SOFA, SAPSII, and MEDS are not sufficient to predict mortality. MEDS also has better results than other scoring systems.

Merve GUNES (Istanbul, Turkey)
15:55 - 16:00 #8235 - Increasing unusual microorganisms in community-acquired pneumonia.
Increasing unusual microorganisms in community-acquired pneumonia.

Introduction To determine the etiologic agent of community-acquired pneumonia (CAP) is not always possible at the initial moment. Knowing the most common organisms in our environment can help us in making empirical treatment decisions.

Objective To evaluate the microbiological etiology of CAP diagnosed in the emergency department for a year.

Patients and methods

descriptive prospective observational study. subjects of 14 or more years with clinical and radiographic diagnosis of CAP were included during a period of 383 consecutive days.

Sociodemographic variables, personal history, prognostic scales of gravity, evolution and pathogens were collected. In order to obtain an etiologic diagnosis detection of bacteria was made in  blood by fluorescence, detection of urinary antigens was obtained for Streptococcus pneumoniae and Legionella pneumophila by immunochromatography, sputum culture was  seeded in agar plate, influenza viruses were determined by immunochromatography analysis and PCR and detection of Streptococcus pyogenes was obtained by immunochromatographic test. Categorical variables as absolute value and percentage and continuous variables by their means and standard deviations were described.


338 patients were studied. They were included in the study 287 patients (42% women; mean age 66 ± 22 years). They died 10.45% 70% entering. etiologic diagnosis was achieved in 43 patients (14.98%), determined 16 microorganisms in 59 positive samples. The most frequently isolated pathogens was Streptococcus pneumoniae (24/59, 41%) followed by gram negative enteric bacilli, Klebsiella pneumoniae, Escherichia coli, Serratia marcescens and Enterobacter cloacae isolated in 20% of the samples (12/59), virus influenza (5/59, 9%), Staphylococcus aureus methicillin-resistant all (3/59, 5%), Pseudomonas aeruginosa (2/59, 3%), Moraxella catarrhalis (2/59, 3%), Legionella pneumophila ( 2/59, 3%), Haemophilus influenzae (2/59, 3%), beta-hemolytic Streptococcus group A (2/59, 3%), Clostridium perfringens (2/59, 3%), Corynebacterium pseudodiphtheriticum (1 / 59, 2%), Gemella spp (1/59, 2%) and Stenotrophomona maltophilia (1/59, 2%). Polymicrobial infections accounted for 14% (8/59).


In our sample we found a high percentage of unusual microorganisms in NAC. We think that in the coming years we will face a scenario in which the aging population and the growing need for health care acrecentarán the unusual microorganisms that generate the NAC.

16:00 - 16:05 #8249 - HIV screening by rapid tests: acceptance and feasibility in an emergency department.
HIV screening by rapid tests: acceptance and feasibility in an emergency department.

Introduction. Since 2010, in France, the HIV screening strategy including the use of rapid tests has been strengthened and extended to the entire population aged 15 to 70 years old. This study aims at assessing the acceptance and feasibility of a systematic proposition of HIV testing using rapid tests, for adults consulting in the emergency department (ED) in an academic hospital.

Material and methods. We conducted a monocentric prospective study in a Parisian ED from February 29 to March 4 2016. Following national guidelines, we suggested to carry out HIV rapid test to any patient consulting in the ED. All these patients completed a questionnaire about their HIV risk factors. The primary study endpoint was the HIV rapid test acceptance rate. The secondary endpoints were (i) the feasibility of HIV screening by rapid tests in an ED, and (ii) the link between HIV risk factors and rapid test acceptance.

Results. Among 471 patients consulting in the ED, 200 were offered HIV testing, the screening rate was 42.6%. Among them, 153/200 (76.5%) accepted HIV testing. 80 patients (40%) had at least one risk factor for HIV, such as sexual partner native from an “at risk” country, multiple partners, use of intravenous drug or homosexual relationships. Risk factors for HIV are not significant factors to accept rapid test (43.1% vs 29.7%, p=0.1). After adjusting on confounding, age, nationality, factor risks for HIV and recently tested for HIV by blood test are not significantly associated to rapid test acceptance. Only knowledge concerning HIV auto tests seems to be a significant factor for accepting rapid test (OR=2.78; 95% IC [1.21-6.39]).

Conclusion. HIV rapid tests are accepted and feasible in an ED. Having HIV risk factors does not appear to affect the HIV rapid test acceptance. The autotest option tends to be an alternative for patients reluctant to rapid testing in ED. 

Anaïs GUINCESTRE (Paris), Isabelle VASSOR, Anne-Laure FERAL-PIERSSENS, Pauline MOREAU-AELION, Richard CHOCRON, Philippe JUVIN

Tuesday 04 October

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15:45 - 16:05

Poster Highlight Session 5 - Screen 2

15:45 - 15:50 #6623 - Oxygen concentration during patient transportation in the ambulance car.
Oxygen concentration during patient transportation in the ambulance car.


European Resuscitation Council Guidelines for Resuscitation 2015 and Advanced Life Support Provider Course teach that the oxygen supply must be removed from the patient during defibrillation to the distance of minimum of 1 meter. Scientific articles describe few incidents of fire during defibrillation in oxygen – enriched atmospheres.


We performed a series of measurement of the oxygen concentration in the ambulance vehicle of 10 cubic meters. The measurements were made in parked vehicle. Patient was seated on the stretchers and oxygen was applied with oxygen mask on high flow (15 l per minute).

We measured the oxygen concentration on different places in the ambulance car – the patient‘s face, on the chest, on the wall in front of the car, on the wall in the rear and on the celling. We measured temperature, atmospheric pressure and humidity together with oxygen concentration.

We used Dräger X-am 5600 device with XXS sensor for the CH4, O2 a CO. For the oxygen concentration was used DrägerSensor XXS O2 with range of 0 – 25 % with measurable variation of 0,1 %. We also used another device GasAlert MicroClip XL with sensor for the H2S, O2 a CO with the range of 0 – 30 % with measurable variation of 0,1 %.


The result of our study showed that the oxygen concentration has risen from 21 % to more than 25 % at all locations of the ambulance. In certain locations the concentration has increased over 30 %.


We have prepared recommendations for defibrillation during oxygen administration according to the literature and our study:

I. Remove the oxygen supply to the distance of minimum of 1 meter from the patient before defibrillation is performed (if the oxygen is given via open circuit).

II. Do not remove the oxygen before defibrillation is performed if the circuit is closed without any leak because of the risk of dislodging the endotracheal airway.

III. During the defibrillation of a patient receiving oxygen, apply the defibrillator paddles firmly (i.e. with at least 25 lb of pressure).

IV. Do not defibrillate if the chest is coated with enough gel or saline solution to form a conductive bridge between the paddles.

V. Ensure that the patient’s ECG leads are not draped near an area of the body where delivering oxygen is likely to pocked or go undetected or where the paddles are placed.

VI. Open the window or turn on the fan during administration of the oxygen in an ambulance car.


  1. EUROPEAN RESUSCITATION COUNCIL. Advanced Life Suport. Belgium: ERC, 2011. ISBN 9789079157280.
  2. Defibrillation in oxygen-enriched environments [hazard]. Health Devices. 1987; 16:113
  3. McANULTY GR, Robertshaw H. Risk of fire outweighed by need for oxygen and defibrillation. J Accid Emer Med. 1999;16:77

Jiri KODET, David PERAN (Prague, Czech Republic)
15:50 - 15:55 #7202 - Medical emergency data - potential impacts and benefits.
Medical emergency data - potential impacts and benefits.

1. Introduction

A considerable number of problems in emergency care are caused by a lack of provider access to pre-existing patient information at the point of care [1, 2].

In order to improve access to vital patient data in case of emergency the German Electronic Health Card (EHC) is supposed to hold emergency data. On request of the insured, the emergency data is supposed to be saved on the card by authorized health professionals (e.g. primary care physicians), so that it can be securely accessed in case of emergency by providers of emergency care.

As a basis, the German Medical Association developed a medical emergency dataset (MED), which provides the possibility to store information on contact persons, prior diagnosis, medications, allergies, implants and other emergency-relevant information.

The aim of the study group is to investigate what impact the developed MED will have on the treatment process and which benefits can be expected in a specific emergency situation.

 2. Participants and methods

From 2013 to 2014 a first exploratory study was conducted to test the usability and the potential benefits of the MED. Within this study 13 primary care physicians completed a total of 64 emergency data sets. Afterwards the usability and potential benefit of the completed data sets were assessed by emergency care providers (14 clinicians with experience in emergency care, 14 emergency physicians and 9 paramedics) based on a semi-standardized questionnaire. Since the necessary telematic infrastructure is not yet established, the evaluation process was performed paper-based.

Based on the first study, a two-armed simulation study is currently prepared to test the MED under lifelike conditions and to compare the treatment process with and without MED.

Both mentioned studies are funded by the European Union and the Federal Ministry of Health, Emancipation, Care and Aging of North-Rhine Westphalia.

3. Results

Within the exploratory study clinicians, emergency physicians as well as paramedics rated the emergency data set in more than 70% of the reviewed cases as very useful or useful. The greatest benefit was attributed to the information on diagnoses and medication.

The simulation study will start in fall 2016, so the results are pending at this time. 

4. Discussion

First results indicate high potential benefits of the emergency data set in real patient care situations. Further research will show whether these benefits can be confirmed under realistic conditions.


  1. J.S. Shapiro et al., Emergency Physicians’ Perceptions of Health Information Exchange, Journal of the American Medical Informatics Association 14 (2007), 700-705.

  2. A. Stiell et al., Prevalence of information gaps in the emergency department and the effect on patient outcomes, Canadian Medical Association Journal 10 (2003), 1023-1028.



Judith BORN, Jürgen ALBERT, Andreas BOHN, Norbert BUTZ, Karlheinz FUCHS, Johannes SCHENKEL, Christian JUHRA (Muenster, Germany)
15:55 - 16:00 #7888 - Correlation Between the Translated Italian Global Rating Scale and Technical Abilities in Critical Care Simulation.
Correlation Between the Translated Italian Global Rating Scale and Technical Abilities in Critical Care Simulation.

INTRODUCTION: As simulation is playing an ever increasing role in medical education, methods to objectively evaluate simulation performance are becoming more important. At present, no single method for simulation performance has become universally recommended. This study aimed to establish the correlation between simulation performance ratings of the Translated Italian Global Rating (TIGR) scale, and ratings of technical abilities (AT). The null hypothesis of no correlation between any of the seven fields of the TIGR and AT was tested against the two sided alternative hypothesis of significant correlation.

METHODS: Medical residents partaking in the 2015 and 2016 Italian national SIMCUP performed at SimNova in Novara, Italy were rated independently by two trained observers using the TIGR and an AT rating scale. The TIGR score used the previously validated Italian version of the Ottawa Global Rating Scale (Franc J et al, unpublished data). The TIGR scores global performance on a 1 to 7 scale in 6 domains: 'overall', 'leadership', 'problem solving', 'situational awareness', 'resource utilization', and 'communication'. The AT scoring was specific for each simulation scenario, and included technical skills expected to be performed to manage the cases appropriately. The AT scores included a variable number of fields which were rated on a scale of 0 to 2, with 2 signifying correct performance, 1 signifying incomplete performance, and 0 signifying lack of performance. Correlation between each of the 7 fields of the TIGR scale to the AT score was assessed using linear regression. P-values for the regression coefficients were corrected using the Holm method.

RESULTS: Fourteen teams completed 75 simulations. The mean AT score was 66%. Mean score for the TIGR fields was: 'overall': 4.1/7; 'leadership': 4.3/7; 'problem solving': 4.2/7; 'situational awareness': 3.9/7; 'resource utilization': 4.3/7; and 'communication': 4.3/7. Of the six fields of the TIGR tool, only the field of 'utilization' was found to be statistically significantly correlated to the AT (p=0.0027). Correlation coefficient between 'utilization' and AT was 0.78 (95% confidence interval 0.68 to 0.86). Post-hoc analysis of plots of TIGR vs AT suggest a stronger correlation when the TIGR is either very low or very high, and poor correlation between TIGR and AT at the mid level scores.

CONCLUSIONS: The results support that the TIGR and AT have poor correlation. This suggests that simulation performance may require assessment of both global rating and technical abilities. The apparent stronger correlation at very low or very high scores may deserve further study. This finding suggests that teams who are very strong in global rating, also appear to be be very strong in technical abilities; the same may be true for very weak teams. Conversely, teams with global ratings in the mid scale have much more variable technical abilities.


Dr Jeffrey FRANC (Edmonton, Canada), Luca CARENZO, Federico BARRA, Pier Luigi INGRASSIA
16:00 - 16:05 #7910 - Evaluation of the heterogeneity of sublingual microcirculation in acute cardiac patients.
Evaluation of the heterogeneity of sublingual microcirculation in acute cardiac patients.

Introduction: Microvascular alterations can play an important role in the development of organ failure in critically ill patients. Microcirculatory changes are observed in septic shock as well as in acute cardiac conditions such as myocardial infarction (MI), unstable angina (UA) and other. Patients with acute cardiac pathology are at risk for developing cardiogenic shock. We aimed to assess the heterogeneity of microcirculation in this cohort of patients and evaluated whether early changes in sublingual microcirculation might serve as a predictor of worsening clinical condition or developing hemodynamic deterioration.

Methods: We have carried out a prospective, non-randomized study of 23 patients admitted to the intensive cardiac care unit of a university hospital. The inclusion criteria were: acute myocardial infarction (last 24 hours), unstable angina pectoris, cardiogenic shock (CS), myocarditis or severe arrhythmia. Patient groups were defined based on the admission diagnosis: MI group, CS group and other acute cardiac pathology (OACP) group. Real time patients’ microcirculation was assessed with The MicroScan Video Microscope system, data was processed with Automated Vascular Analysis 4.0 research software. Data was analyzed using SPSS v23 statistical package. Independent samples T-tests and analysis of variance (ANOVA) was used to compare the results amongst individual groups.

Results: 16 (69,5%) patients were male and 7 (30,5%) female. MI group consisted of 15 (65,2%) patients, CS group of 5 (21,7%) and OACP group of 3 (13,1%) patients. Mean total vessel perfusion was 89,83 ± 15,25% in the CS group, 91,96 ± 9,34% in the MI group and 99,54 ± 0,76% in the OACP group (p>0,05). Both small and medium vessel perfusion was most altered in the CS group (93,04 ± 10,05% and 83,31 ± 32,97% respectively). De Backer vessel density showed no significant difference between three groups (10,35 ± 2,03 in CS group vs. 10,91 ± 1,67 in MI group vs. 11,14 ± 1,05 in OACP group). Total vessel density was 8,06 ± 3,08 in the CS group vs. 6,67 ± 1,51 in the MI group and 4,99 ± 1,84 in the OACP group. Perfused vessel density was 7,42 ± 3,63 in the CS group vs. 6,12 ± 1,53 and 4,97 ± 1,85 in the MI and OACP groups respectively.

Conclusions: Altered sublingual microcirculation can serve as a valuable predictor of worsening condition and developing cardiogenic shock after acute MI, however the method still needs further investigation with a larger cohort of patients. Certain inconsistencies of microcirculation are visible between patient groups with different acute cardiac pathologies, nonetheless current cohort is yet not sufficient to analyze the significance of these alterations. Further research is needed to establish the role of microcirculation in the development of CS.

Gabrielius JAKUTIS (Vilnius, Lithuania), Vitalija POLEVODA, Rokas SERPYTIS, Pranas SERPYTIS

Tuesday 04 October

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15:45 - 16:05

Poster Highlight Session 5 - Screen 3

15:45 - 15:50 #7185 - PULSE's support for an enhanced European health system.
PULSE's support for an enhanced European health system.

Nowadays, our society faces an increasingly number of tragedies due to deadly threats such as pandemic disease and major accidents, terror attacks or natural hazards leading to the necessity of an European platform for medical support during major emergencies. In such situations, it is critical for the European emergency medical services to be in an excellent state of preparedness supported by first-class planning and decision support tools. Moreover, in the response phase, European emergency medical services need consistent, coordinated and standardized advanced support methods and tools providing support in critical tasks like e.g. early threat detection, common operational picture, creation of surge capacity etc.

This paper presents the developments and the achievements of the PULSE (Platform for European Medical Support during major emergencies) project - a Collaborative Research Project under the European 7th Framework Programme – Theme SEC - 2013.4.1-4:”Development of decision support tools for improving preparedness and response of Health Services involved in emergency situations”.

PULSE Platform is made up of three high level components: software mathematical models, software tools and SOPs (Standard Operational Procedures). It is expected that End-users will take benefit from the PULSE platform using the software Tools while operating according to the processes optimized by the PULSE project with SOP based on European best practices. Software Tools will use Models, which may be considered as “software routine” based on mathematical models/algorithms. PULSE Platform will mainly support the End-users making the best decision on the two related issues of Resource allocation and also Patient dispatch with respect to the expected future flow/status of patients with the constraint of available resources and medical doctrines.  PULSE substantially improves the preparedness and response capabilities of the health services involved in major emergency situations, mitigating the loss of life and raising the survival rates among mass casualties. 

The PULSE project provides validated procedures which will be adequate to improve the operation and success of the healthcare system in challenging disaster situations where combined operations are required at local, regional, cross border and international levels.

PULSE project supports an enhanced European health system by the improvement of the health services in both preparedness and response stages of a major medical incident leading to a more efficient emergency management, operational procedures harmonization, improved cross border cooperation of the medical services, improved understanding of the public acceptance, and legal, ethical and social issues in major emergency management.

Viorel PETCU (Bucharest, Romania), Adelina GEORGESCU
15:50 - 15:55 #7230 - Evaluation of the inflamatory profile (kinins and cytokines) and eletrocardiographic in patients with Arboviroses (Dengue and Zika Virus) attended in Ribeirao Preto- Brazil.
Evaluation of the inflamatory profile (kinins and cytokines) and eletrocardiographic in patients with Arboviroses (Dengue and Zika Virus) attended in Ribeirao Preto- Brazil.


The Arbovirus are viruses transmitted by arthropods (Arthropod- borne viruses), and part of its replicative cycle occurs in insects. It is transmitted to humans and other animals by the bite of blood-sucking arthropods. The arboviruses that cause diseases in humans are of families: Bunyaviridae, Togaviridae, Flaviviridae, Reoviridae and Rhabdoviridae.

The Flaviviridae family has single-stranded RNA virus and encapsulated. They are mainly found in ticks and mosquitoes (Aedes albopictus and Aedes aegypit) and can infect humans. The Flavivirus have significant morbidity and mortality and are worldwide. Among the viruses transmitted by mosquitoes belonging to this family are: Yellow Fever, Dengue (DENV), Encephalitis and Zika virus (ZIKV).

In May 2015, the Pan American Health Organization reported the risk of transmission of ZIKV in some cities in northeastern Brazil. Were laboratory confirmed indigenous cases, warning of the potential for global spread of the virus, similar to the DENV and CHIKV. From oct / 15 there was an increase in cases of microcephaly in the northeast.

By the above, as already announced, in 2016 began with an epidemic of DENV and an avalanche of suspected cases of ZIKV. Due to the rapid progress of cases and appearance in other countries, the World Health Organization in feb/16, announced that ZIKV is an international public health emergency.

Objectives: General- investigate the pathophysiology of infection ZIKV. Specific- electrocardiographic evaluation and plasma inflammatory response profile (kinins and cytokines) in patients with different types of arboviruses (DENV, ZIKV)

Because it is new virus in our environment, we have little knowledge about ZIKV. Thus, with these reviews we hope to identify a pattern of variation in the inflammatory profile between arboviruses and electrocardiographic changes, particularly in patients with ZIKV. Will be assessed.:

1 Levels of high Kininogens and low molecular weight (CAPM and CBPM); amidolytic activity plasma prekallikrein, kallikrein and kininase II (ECA).

2- Profile Determination of cytokines associated with Th1 pattern (INF-gamma, IL-12), Th2 (IL-4, IL-10, IL-13, IL-5) and TH17 (IL-17, IL-22 and IL-23)

3- Quantification of cytokines with anti-activity and serum pro inflammatory: IL-1beta, TNF-alpha, IL-6, IL-12 and TGF-beta 1/2.

In electrocardiograms the following changes will be evaluated: tachycardia sinus bradycardia sinus, atrial fibrillation, atrial flutter, right bundle branch block, left bundle branch block, ST-T changes, QTc interval, QT dispersion

Methodology: Patients treated at 10/03/16 to 30/05/16 period, the Emergency Unit Attendance- Ribeirao Preto with clinical arbovirus (DENV and ZIKV) will undergo blood collection for laboratory tests and performed an electrocardiogram.

Data analysis: nonparametric Mann-Whitney, Kruskal-Wallis or Wilcocox

Results: The exanthem in cases of ZIKV appear in the first days of symptoms accompanied by pruritus. Arthralgia is more intense in the case of DENV well as fever. In blood count thrombocytopenia is more severe in cases of DENV, however ZIKV presents an important leukopenia. We are still in the data collection and analysis phase. At present we have 300 samples for analysis.


Rosemary DANIEL (ribeirão preto, Brazil), Santos LUIS, Deborah FERREIRA, Leandro PERES, Matheus FERREIRA, Walther CAMPOS, Cesar MENDES, Gabriel LOPES, Felipe LEÃO, Edson TEXEIRA, Renata JOVILIANO, Reinaldo BESTETTI
15:55 - 16:00 #7528 - Can lactate guide the indication for thrombolysis in ischemic stroke of uncertain onset?Preliminary study in Emergengy Department.
Can lactate guide the indication for thrombolysis in ischemic stroke of uncertain onset?Preliminary study in Emergengy Department.

Background: Ischemic stroke is worldwide the second single cause of death and disability among adult population. Intravenous thrombolysis with recombinant tissue plasminogen activator ( rtPA ) is currently the only approved therapy ; however current guidelines restrict its use to a 4.5 hours maximum interval time from onset of symptoms to treatment (Onset -to - Needle Time , OTN). Consequently patients without known time of onset of symptoms, which represent up to 30% of cases of ischemic stroke , are today excluded from thrombolytic treatment. Various prognostic scores have been proposed to assess the stroke patient risk/benefit ratio of thrombolysis but there are no randomized clinical trials to demonstrate sufficient confidence for their clinical use. None of the proposed scores consider the role of lactate in the ischaemic process. In fact, lactates represent a marker of hypoperfusion and metabolic stress and nowadays they are rapidly available in emergency room.

Aims: evaluate lactate concentration, before thrombolytic treatment, as a prognostic marker for treatment choices in patients affected by ischemic stroke, especially those whose symptoms onset time is not available. According to the current guidelines those patients would be excluded from the potential benefits of a thrombolytic treatment. Lactate prognostic activity had been compared with the shock index, a a reliable and easy to use tool for the early identification of hypoperfusion.Methods: we retrospectively analyzed 190 patients admitted and treated with systemic thrombolysis for ischemic stroke in the Emergency Department of the University Hospital of Verona (Verona - Italy) from June 2014 to July 2015. Accordingly to onset, patients were divided in two groups: patients with clear stroke onset time (133) and patients with uncertain stroke onset time (57).  Each patient had OTN time, lactate plasma concentration and shock index before systemic thrombolysis. Outcome, expressed as difference in the National Institutes of Health stroke scale score, was evaluated at admission and a week after the treatment.

Results: patients with uncertain stroke onset time and worse outcome had a significant higher lactate concentration (1.80 mmol/L; 1.30-2.36) compared to the same patients with unchanged or improved outcome (1.08 mmol/L; 0.97-1.59; p=0.018). We also observed, in the this group of patients, that high pre-thrombolysis lactate concentration significantly correlate with clinical deterioration a week after the treatment (p=0.018; AUC 0,718, IC 95%: 0,556 – 0,879). We found no difference in the patient group with clear stroke onset time. Instead index shock and poor outcome had a significant correlation (p = 0.023) in this patient group.

Conclusions: the present study point out the role of lactate as a useful prognostic marker in patients with ischemic stroke of uncertain onset. Lactates concentration, quickly obtained by arterial blood gasses analysis at patient arrival in ED point of care, could be useful in choosing thrombolytic treatment or not. Although the limitation of retrospective analysis and limited sampling of patients, the preliminary data of the present study point out hypoperfusion and its markers, lactate in example, a possible prognostic tool for outcome of systemic thrombolysis in ischemic stroke patients.

Massimo ZANNONI (VERONA, Italy), Luca FOLLADOR, Gianni TURCATO, Dr Antonio BONORA, Giorgio RICCI, Valentina SERAFINI, Gabriele TAIOLI, Domenico VERALDI, Mariano BELLONI, Francesco BUONOCORE
16:00 - 16:05 #7694 - Congenital coagulopathy patients attending at general emergency department.
Congenital coagulopathy patients attending at general emergency department.

INTRODUCTION: The purpose of the emergency care of patients with congenital coagulopathies is the adequate replacement of deficient clotting factors in order to restore haemostasis and control the acute bleeding episode. However, the clinical and epidemiological profile of patients with congenital coagulopathies attended at de ED is not yet defined.  OBJECTIVE: We developed the following retrospective study in order to meet the clinical profile, the leading causes of consultation and complications of congenital coagulopathies patients treated at the General ED. MATERIALS AND METHODS: All patients attended at  the ED of La Paz University Hospital in the period from April 1, 2011 and November 30, 2011 with congenital coagulopathy (hemophilia A [HA], B[HB] and von Willebrand disease[vW]). We analyzed demographic variables, cause of consultation, type and severity of coagulopathy, use of blood products or specific clotting factors, destination at discharge of Emergency Department (ICU admission, conventional care admission, death or discharge at home) and definitive diagnosis were recorded. Analytical variables were also recorded. The decision of studies and treatment was defined by emergency physician. RESULTS: 68 patients with congenital coagulopathy were treated in the ED. Of these, 80.9% (55) were men. The average age was 36.3 ± 13.3 years. A total of 32 patients with HA (47.1%), 29 patients with VWD (42.6%) and 7 patients with HB (10.3%) were attended. There was no difference in age (35.0±13.0 years in HA, 36.3±12.7 in VWD and 42.4±16.7 in HB; p = 0.41). The most frequent ED presentations were: bleeding manifestations 25% (Minor bleeding: 13,2% [subcutaneous hematomas 4,4%, gingival bleeding 4,4%, Epistaxis 2,9%]; Major bleeding 13,2%[lower gastrointestinal bleeding 5,9%, Upper gastrointestinal bleeding 1,5%, pharyngeal hematoma 1,5%, hemoptysis 1,5%, retroperitoneal hematoma 1,5%, intramuscular hematoma 1,5%]), abdominal symptoms 16,2%, fever 11,8%. Minor bleeding was observed only in patients with mild haemophilia and type 3 of VWD. Major bleeding episodes occurred in 77.8% of haemophilia patients and 22.2% of VWD patients (p=0.20). All patients with minor bleeding were discharged and 66% of patients with major bleeding were admitted to a hospital unit (p<0,001). Only 29.4%, required specific clotting factor therapy in the ED. There was no statistically significant difference between the type of coagulopathy and the requirement of in-hospital specific clotting factor therapy (34% HA, 42.9% HB and 20.7% VWD; p=0.35). Equally, there was no difference in the requirements of specific clotting factor treatment and severity of bleeding. CONCLUSION: We observed no difference in the rate of major and minor bleeding according to diseases severity. Therefore, life-threatening bleeding complications are independent of the severity of congenital coagulopathy and the assessment of all patients with congenital coagulopathy who consult the ED for a bleeding complication should be independent of the severity of the coagulopathy. All patients are at high risk of life-threatening conditions.


Tuesday 04 October

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15:45 - 16:05

Poster Highlight Session 5 - Screen 4

15:45 - 15:50 #7332 - The evaluation of pain reduction and nerve block efficacy in extremities with injury among patients in a teaching hospital emergency department.
The evaluation of pain reduction and nerve block efficacy in extremities with injury among patients in a teaching hospital emergency department.


Pain is one of the most common complaints in the emergency room (ER) but it is poorly controlled. In addition to patients enter in pain , many procedures that take place in the ER need local anesthesia, sedation and tranquilizers to achieve patient’s pacification and cooperation.

Considering the importance of pain for patients and the high prevalence of pain in the ER makes it necessary to work more on this issue. The purpose of this study is to investigate patient’s as well as physician’s satisfaction from nerve blocks as a pain management technique in the ER.


Study conducted at the biggest teaching hospital around the country which contains more than 800 beds with emergency department annual entrance of 45000. Forty-six patients who referred to the emergency room with injury in upper or lower extremities were enrolled in the study. Patients received either femoral, axillary or sciatic nerve block based on the site of their injury. Ultrasound-guided nerve block performed by emergency physicians with 1.5 mg per kg of Bupivacaine plus distilled water. Patients were asked about their level of pain before (NRS1) and after (NRS2) receiving the nerve block based on numerical rating scale. The difference between NRS2 and NRS1 was calculated (NRS3). Patients as well as the physicians were asked about their satisfaction from the nerve block in 5-level Likert scale. All patients were monitored for 2 hours afterwards for any complications. Patients’ blood pressures and pulse rates were measured before and after the nerve block for possible changes.


High levels of satisfaction were seen in both patients and physicians. There was a significant decrease in NRS after the nerve block. Mean NRS1 was decreased from 8.066 to 2.044 in NRS2 after the nerve block.  87% of the patients and 83.3% of the physicians were satisfied and highly satisfied from the procedure and its effects. There was a significant relationship between NRS3 and patients’ satisfaction as well as physician’s satisfaction.  There was a significant statistical reduction in both blood pressure and pulse rate after the nerve block, however it wasn`t clinically important.


Considering the fact that both patients and physicians were appropriately satisfied with the results and also the fair reduction in patients’ pain after the nerve block, it can be concluded that Ultra sound-guided nerve block has proved to be an effective and safe method for analgesia in the ER.

Amir NEJATI (Tehran, Islamic Republic of Iran), Leili BEHROOZ, Seyed Hossein HOSSEINI DAVARANI
15:50 - 15:55 #7829 - Acute coronary syndromes in peak hours and off-peak hours. Is there a lost opportunity?
Acute coronary syndromes in peak hours and off-peak hours. Is there a lost opportunity?

Introduction: The time-period before prehospital patient management of an acute coronary syndrome (ACS) is influenced by many factors. The time when patient care begins is a factor altering these time periods significantly.

Method: Data was retrieved from a regional prospective register that lists all acute coronary syndromes with ST segment elevation (STEMI) managed by 8 prehospital Emergency Medical Services (EMS) and 39 MICUs. Patients with a STEMI within 24 hours from 2003 to 2014 were included, excluding secondary transport. Two periods were defined: ON from 7.00 a.m. to 7.00 p.m. from Monday to Friday, excluding public holidays; otherwise OFF. Average time periods studied: the beginning of chest pain - calling EMS dispatching center (112) (DT-112), calling centre 112 and starting patient medical care by the MICU (112-med). Wilcoxon test is significant if p <0.05.

Results: 19,965 patients were included during the period. The CP-112 time periods decreased unlike 112-med time periods which remained stable. The increment between ON and OFF periods has decreased; it is almost non-existent since 2011.

Discussion: Since 2003, the time taken for prehospital care for STEMI in our region has been constantly improving, nowadays without loss of opportunity during ON periods. Calling centre 112 at the onset of any chest pain is vital and is well understood by patients; this can be further improved as it seems difficult to act on the 112-med time periods.

Alexandre ALLONNEAU (Paris), Isabelle KLEIN, Aurélie LOYEAU, Gaelle LE BAIL, Mireille MAPOUATA, François-Xavier LABORNE, Jean-Michel JULIARD, Lionel LAMHAUT, Frédéric LAPOSTOLLE, Sophie BATAILLE, Yves LAMBERT, Hugues LEFORT
15:55 - 16:00 #7923 - Which autonomous portable infusion warmer should we use on the field?
Which autonomous portable infusion warmer should we use on the field?

Background: In the wilderness or on the battlefield, when a hemorrhagic shock occurs, fluid therapy may be necessary to sustain life. Hypothermia is one of the determinant of the lethal triad. The infusion of warm fluids is probably a key point in the management of injured patients. Infusion warmers using batteries are heavy to carry and batteries don’t last very long in cold environments.


Methods: The aim of our study was to evaluate different autonomous portable infusion warmers (Aptonia® and Grabber® air activated disposable hand warmers, Grabber® crystallization-type reusable hand warmer, Badabulle® and Babysun® baby bottle warmers) in comparison to Trekmates® flameless cook box (using a reaction similar to heat packs of Meals Ready to Eat) on 250 and 500 ml 17°C intravenous (IV) bags (7.5% hypertonic or 0.9% normal saline and 6% tetrastarch 130/0.4). Temperatures were measured inside IV bags using a thermocouple. The endpoint was the time to reach 45°C or the temperature reached after 30 min of warming process. The experiment was repeated eight times. Four disposable hand warmers were used for 250 ml IV bags, six for 500 ml bags. Two reusable hand warmers and one baby bottle warmer were used for 250 or 500 ml IV bags.


Results: Trekmates® flameless cook box was the only device able to heat fluids up to 45°C in less than 30 min (250 ml: 5 min 8 s; 500 ml: 8 min 15 s; p = 0.03). Disposable hand warmers heated 250 ml bags up to 23°C (± 1.3) and 24.9°C (± 1.3) and 500 ml bags up to 21.5°C (± 0.4) and 23.4°C (± 0.9). Reusable hand warmers heated 250 ml bags up to 34°C (± 3.1) and 500 ml bags up to 27.4°C (± 1.5). Baby bottle warmers heated 250 ml bags up to 29.9°C (± 2.3) and 33.4°C (± 2.4) and 500 ml bags up to 27.8°C (± 2.3) and 29.9°C (± 2.3). For devices not efficient enough to reach 45°C, the temperature reached in 30 min was 3.1°C greater with 250 ml IV bags than with 500 ml bags (p < 10-3). The composition of IV fluids didn’t make any difference on the heating efficiency.


Discussion, conclusion: Trekmates® flameless cook box is the most efficient infusion warmer. However, while using it, the temperature of the fluid should be checked before the infusion to make sure that the fluid isn’t too hot. Rescuers should also take into account the cooling process along the IV line. Reusable hand warmers or baby bottle warmers are the second best option to heat fluids but the heating process is long and should be anticipated. Heating first 250 ml of hypertonic saline is probably the best option (lighter to carry and faster to heat with the greatest volume expansion capability), than 500 ml of tetrastarch if a long lasting expansion effect is required due to delayed evacuation.

Vincent DES ROBERT, Christophe LEBLEU, Jean-Stéphane DAVID, Karim TAZAROURTE, Romain KEDZIEREWICZ (Brignoles)
16:00 - 16:05 #8106 - Prognosis interest of pulse oxygen saturation at hospital admission in survivors of non-hypoxic cardiac arrest.
Prognosis interest of pulse oxygen saturation at hospital admission in survivors of non-hypoxic cardiac arrest.

Introduction: The hyperoxia in the first 24 hours of return spontaneous circulation (ROSCS) following a cardiac arrest aggravates the neurological outcome and mortality hospital. It is recommended to adjust the oxygen to obtain a pulse oxygen saturation target range between 94 and 98%. From the national data of the french electronic register of cardiac arrest (RÉAC), we compared the values of pulse oxygen saturation post ROSC observed at hospital admission with prognosis neurological and hospital mortality.

Méthod: Prospective, comparative, multicenter studie based on RÉAC between July 2011 and August 2015. The inclusion criteria were the ROSC with pulse oxygen saturation admission ≥94%, vital status and scale CPC (Cerebral Performance Categories scale, gradually pejorative 1 to 5) at 30 days. CPC and survival rates are compared by level of pulse oxygen saturation (98% or less vs more 98%) by Fisher exact test. We then conducted a multivariate logistic model factors related to survival at D30, including the level of pulse oxygen saturation (≤ or> 98%) and the main prognostic factors confounding.

Results: We included 3727 ROSC. Univariate analysis showed no relationship between the values of pulse oxygen saturation and observed mortality or the CPC to D30 has been objectified. In multivariate analysis, there are no link between the level of pulse oxygen saturation at the admission and mortality at day 30 (p = 0.82). The median time between RACS and admission Hospital is 49 minutes.

The recommendations of the target values in post ROSC are not followed to the stage pre-hospital (66% pulse oxygen saturation> 98%).

Variables                      OR  [IC95]                p-value                     OR adjusted [IC95]         p-value

age                                0.98 [0.976-0.984]   <0.001                    0.970 [0.965-0.975]      <0.001

male                             1.618 [1.385-1.896]  <0.001                    1.608 [1.333-1.944]      <0.001

no flow                        0.958 [0.947-0.970]  <0.001                     0.965 [0.951-0.979]      <0.001

low flow                      0.936 [0.928-0.944]  <0.001                     0.927 [0.917-0.937]      <0.001

traumatic cause       0.316 [0.223-0.436]  <0.001                     0.150 [0.095-0.229]      <0.001

Bystander                  1.812 [1.556-2.115]  <0.001                     1.220 [0.988-1.507]      0.065

pulse oxygen saturation at the admission

 94-98%                 1                                                                       1

99-100%                     1.109 [0.956-1.287]  0.17                       1.021 [0.853-1.223]       0.82

Conclusion:  The study suggests that the level of pulse oxygen saturation in the early phase of the ROSC has no link with hospital mortality. This could be explained by a delay or duration of exposure to hyperoxia particularly short  between prehospital ROSC and the hospital admission. If this study did not determine a threshold exposure time, compliance with the recommendations is binding, however, and the use of an alarm set pulse oxygen saturation above 98% and close nursing supervision remains recommended especially during prolonged exposure times.

Steven LAGADEC (Corbeil-Essonnes), Joséphine ESCUTNAIRE, Francois Xavier LABORNE, Marion MENAY, Valentine BAERT, Agnes THIVELLIER, Bruno GARRIGUE, Réac GR-

Tuesday 04 October

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15:45 - 16:05

Poster Highlight Session 5 - Screen 5

15:45 - 15:50 #7134 - JUVEX PEPPER Trial - pilot study (jugular vein expansion by positive end expiratory pressure positioning in emergency department patients).
JUVEX PEPPER Trial - pilot study (jugular vein expansion by positive end expiratory pressure positioning in emergency department patients).


Guidelines recommend central venous access in Trendelenburg position. Critically ill patients in the emergency department (ED) often show contraindication for this positioning. Non-invasive ventilation (NIV) with positive end-expiratory pressure also increase the caliber of the internal jugular vein. We hypothesize that the cross sectional area (CSA) of the right internal jugular vein (RIJV) in Trendelenburg is equal to the CSA in 30° elevation position with PEEP by NIV in critically ill patients in ED.

Materials and Methods

91 critically ill adult patients in ED were examined between 08/2014 and 05/2015. The CSA was measured by ultrasound in 3 different positions: 30° elevation, supine and Trendelenburg position. We repeated measurements with a continuous application of NIV (PEEP of 6.9mBar). Patients without being able to give informed consent or relative/absolute contraindications for NIV were excluded. We defined critical illness by an emergency severity index >4 in combination with the necessity to lie on a stretcher or bed.


The increase of the CSA of the RIJV in Trendelenburg position was the largest (0.99±0.66cm²) compared to the supine (0.57±0.58cm²) and 30° elevation position (0.25±0.41cm²). 30° elevation positioning with PEEP (0.62±0.70cm²) was significant larger than without PEEP. NIV was a well-tolerated procedure (98%).


30° elevation positioning with PEEP via NIV is an alternative procedure for central venous access, especially for critically ill patients in ED unable to remain in Trendelenburg position. Based on the results, a successful cannulation of the RJIV seems viable in patients who need to move to the 30° elevating position for whatever reason. The current guideline about patient positioning during central venous access should consider these findings for critically ill patients in the emergency department.  In the 30° elevation positioning with PEEP in 68.1 % a safe puncture (≥0.4cm²) could be expected. 


Claudia EHRLICH, Christian HOHENSTEIN (Bad Berka, Germany), Johannes WINNING, Hendrik RÜDDEL
15:50 - 15:55 #8149 - Could high sensitivity troponin (0 & 2 hrs.) avoid unnecessary admissions and save money?
Could high sensitivity troponin (0 & 2 hrs.) avoid unnecessary admissions and save money?


Every four minutes someone is admitted to hospital suffering from a heart attack or a chest pain event in the UK, totalling over 150,000 hospitalisations a year. Chest pain is one of the most common presentations in the emergency department and quite a few of them get admitted as low risk ACS patients. With the developments in technology, we have increasingly sensitive troponin assays available. Previous-generation troponin assays have been used as diagnostic and prognostic markers in acute coronary syndrome patients and for risk stratification to guide triage decisions and aid in treatment selection. New, high-sensitivity troponin assays represent an important advance with added sensitivity for cardiac myocyte necrosis. High-sensitivity troponin assays detect concentrations of the same proteins that conventional sensitivity assays are aimed at detecting, just in much lower concentrations.



Can high sensitivity troponin avoid unnecessary admission and save money.



We did the retrospective data analysis for 100 patients presenting in the emergency department of University hospitals Birmingham in the month of March 2016. All adult patients admitted with the diagnosis of ACS were included in the study.



We included 100 patients admitted with the diagnosis of ACS under the medical team in the month of March 2016. 86% patients had a serial troponin done during the admission. Rest of the 14% had a single troponin done. Only 8% patients had a raise in the serial troponin, rest of them were discharged home. The average length of stay was 33 hours.




We have 5-10 patients every day presenting to the emergency department with chest pain. About 50% of them get admitted with the diagnosis of ACS. 86% of our patients could have been potentially discharged home by using high sensitivity troponin at 0 and 2 hours and hence could have avoided 86% admissions. This in turn could have saved quite some money and beds. With the growing pressure in the emergency departments due to ever increasing number of patients all these high sensitivity tests could potentially make some difference.


M Azam MAJEED (Birmingham, United Kingdom), Imran TAHIR
15:55 - 16:00 #8200 - Blood lactate as a predictor for in-hospital mortality in patients admitted in emergency department.
Blood lactate as a predictor for in-hospital mortality in patients admitted in emergency department.


Using blood lactate monitoring for risk assessment in the critically ill patient remains controversial. Some of the discrepancy is due to uncertainty regarding the appropriate reference interval, and whether to perform a single lactate measurement as a screening method at admission to the hospital, or serial lactate measurements.


To examine whether blood lactate levels are predictive for in-hospital mortality in patients admitted to the emergency department.


We carried out a prospective observational cohort study in consecutive patients whose arterial lactate concentration was measured in the ED over six months. The initial arterial lactate level was categorized as low (<2 mmol/L), intermediate (2-3.9 mmol/L), or high (≥4 mmo/L). The main outcome measure was 7-day mortality.


Inclusion of 146 patients. Mean age was 58 +/- 21 years. Sex ratio = 1.75. The overall mortality at 7 days was 17.8%. The median admission lactate (25th, 75th percentile) was 2.8 (1.97, 4.90) mmol/L. Thirty six patients (25%) had low lactate, 66 patients (45%) had intermediate lactate and 44 patients (30%) had high lactate.

Multivariate logistic regression revealed lower lactate levels were associated with 7-day survival: ORs for 7-day death compared with lactate ≥4 were: 0.34 (95% CI 1.01 to 1.33) for lactate <2 and 0.585 (95% CI 1.04 to 1.27) for lactate 2-3.9. Admission lactate >4mmol/L was a significant independent predictor of mortality in adult patients admitted to ED (adjusted OR=3.36, 95%IC 1.52 to 8.8, p= 0.04).

Conclusion: All patients with a lactate at admission above 4 mmol/L should be closely monitored for signs of deterioration, and patients with even lower lactate levels should be considered for serial lactate monitoring.


16:00 - 16:05 #8221 - Is there a level of NT-proBNP from which we can predict the clinical scenario of acute heart failure syndromes?
Is there a level of NT-proBNP from which we can predict the clinical scenario of acute heart failure syndromes?

Introduction :


The acute heart failure is a common pattern to seek care in the emergency department (ED). The objective of our study was to investigate the relationship between the rate of NT pro BNP and the acute heart failure (AHF) syndromes in the emergency department.


Methods :


A descriptive prospective study was conducted over eight months. Were included all patients who presented to the ED with dyspnea and in whom the diagnosis of acute heart failure was made.


 All patients had a NTproBNP laboratory test and underwent echocardiography by the same operator within 24 hours. Were noted the demographics, clinical, biological, echocardiography and evolutionary criteria.


Results :


Inclusion: 107 patients. Mean age 65 ± 12 years. Sex ratio: 2.34.

A clinical scenario CS1 was noted in 28% of cases, CS2 in 36% of cases, CS4 in 16% of cases, CS3 in 12% of cases and CS5 in 8% of cases.


The mean rates of NTproBNP were 7109 ± 6896 pg / ml for CS1, 4422 ± 5816 pg / ml for CS2, 2802 ± 3999 pg / ml for CS3, 4516 ± 6189 pg / ml for CS4 and 2215 ± 824 pg / ml for CS5.


Regarding the results of the echocardiography, 30% of patients had preserved left ventricular ejection fraction (LVEF) with diastolic dysfunction and 70% had a reduced LVEF.

 Elevated LV filling pressures were found in 95% of patients. Disorders of wall motion in 14% of cases and isolated right heart failure in 12% of cases.


The mean NTproBNP was higher when LVEF was preserved: 6607 ± 6801 pg / ml vs 4015 ± 5353 pg / ml (p=0,043).


The NTproBNP could predict the clinical scenario CS1 with a cut-off at 5513 pg / ml but did not predict the other clinical scenarios.



Conclusion :


The mean NTproBNP was higher when LVEF was preserved. The NTproBNP could predict the clinical scenario CS1 from a threshold of 5513 pg / ml but did not predict the other clinical scenarios.

Rania JEBRI (Lyon), Olfa DJEBBI, Mehdi BEN LASSOUED, Mounir HAGGUI, Khaled LAMINE

Tuesday 04 October

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State of the Art

Moderators: Barbra BACKUS (Emergency Physician) (Rotterdam, The Netherlands), Ardavan KHOSHNOOD (Lund, Sweden)
16:10 - 16:40 Advances in the emergency management of heart failure. Pr Martin MOECKEL (Head of Department, Professor) (Berlin, Germany)
16:40 - 17:10 Management of Recent-onset Atrial Fibrillation and Flutter (RAFF): Time for the ED to take Control. Hans DOMANOVITS (Austria)
17:10 - 17:40 Acute coronary syndromes diagnosis, version 2.0. Pr Rick BODY (Professor of Emergency Medicine) (Manchester)

Tuesday 04 October

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Austria, Germany, Switzerland Invites

Moderators: Friedrich PRISCHL (Austria), Dominik ROTH (vienna, Austria)
16:10 - 16:40 Umgang mit Angehörigen bei Reanimation. Markus WEHLER (Germany)
16:40 - 17:10 AND/DNR. Maria KLETEČKA-PULKER (Austria)
17:10 - 17:40 Tips und Tricks für das Überbringen schlechter Nachrichten. David HÖRBURGER (Physician internal medicine) (St. Gallen, Switzerland)

Tuesday 04 October

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Philosophy & Controversies
P&C Infectious Disease & Sepsis

Moderators: Christoph DODT (Head of the Department) (München, Germany), Patrick PLAISANCE (Head of Department) (Paris, France)
16:10 - 16:40 Metabolic Failure in Sepsis – Consequences for the Emergency Treatment? Edin ZELIHIC (Schweinfurt, Germany)
16:40 - 17:10 Biomarkers in ED sepsis care. Stuck in square one? Bas DE GROOT (Amsterdam, The Netherlands)
17:10 - 17:40 Antibiotics in the ED, are we killing patients? Yuri VAN DER DOES (Rotterdam, The Netherlands)

Tuesday 04 October

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Moderators: Gaby GURMAN (Israel), Marc SABBE (Medical staff member) (Leuven, Belgium)
16:10 - 16:40 How to attract a young physician to a young profession. Gaby GURMAN (Israel)
16:40 - 17:10 Emancipation from surgery, how did that work? Clemens KILL (PHYSICIAN) (Marburg, Germany)
17:10 - 17:40 How to attract a young physician to a young profession. Gaby GURMAN (Israel)

Tuesday 04 October

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Moderators: Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany), Carsten KLINGNER (Germany)
16:10 - 16:40 Scientific basis for neuro intervention in stroke. Mauro GALLITELLI (Italy)
16:40 - 17:10 Telestroke - a frontier in the globalization era. Carsten KLINGNER (Germany)
17:10 - 17:40 Limbic Encephalitis - a differential diagnosis in the young psychotic patient. Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, Canada)

Tuesday 04 October

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Dark side of publishing

Moderators: Luis GARCIA-CASTRILLO (ED director) (ORUNA, Spain), Basak YILMAZ (Faculty) (BURDUR, Turkey)
16:10 - 16:40 Detecting pitfalls when reading medical literature. Harald HERKNER (Austria)
16:40 - 17:10 Sham, bogus and predatory journals. Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, Hong Kong)
17:10 - 17:40 Ethical issues in research. Luis GARCIA-CASTRILLO (ED director) (ORUNA, Spain)

Tuesday 04 October

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EuSEM Nursing Track
Emergency Nursing Research

Moderators: Frans DE VOEGHT (The Netherlands), Gudbörg PÁLSDOTTIR (Iceland)
16:10 - 16:40 Emergency Nursing Research: Why? How? Christien VAN DER LINDEN (Clinical Epidemiologist) (The Hague, The Netherlands)
16:40 - 17:10 Applying research into emergency nursing – examples from Iceland. Dr Thordis K. THORSTEINSDOTTIR (Professor) (Reykjavik, Iceland)
17:10 - 17:40 Thinking outside the box: a few things I have learned from other fields of research. Jochen BERGS (Hasselt, Belgium)

Tuesday 04 October

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Oral Papers 34

Moderators: Hayette MOUSSAOUI (Emergency Physician) (London, United Kingdom), Cyril NOEL (Londres, United Kingdom)
16:10 - 16:20 #7054 - OP091 Striving for Balance.
Striving for Balance.

Background: New nurses in the prehospital emergency care service are a precious and valuable resource, however they enter a challenging environment and the risk of clinical errors is increased. The transition from novice to proficient has been described as a process of becoming. An evolutionary journey that, although not always linear or strictly progressive, is ultimately transformative. This transformational journey has been well described in students becoming professionals in intrahospital context. Little is known however about the experience of being new in the prehospital setting, where a novice prehospital care nurse work with the sole medical responsibility of the patients, with no doctor and often without an experienced nurse to ask for support when difficult situations emerge.

Aim: This study aimed to deepening the understanding of newly hired ambulance nurses experiences of the first year of employment in the Emergency Medical Service, EMS.

Method: Data were generated from 13 semi-structured interviews with newly hired prehospital emergency care nurses, PECN’s, from seven districts representing rural, urban and suburban areas in Sweden. Analysis was a latent inductive qualitative content analysis.

Result: The findings show that being new is experienced as Striving for balance in internal expectations and external conditions and can be described with the three generic categories; Reflecting on the own ability, Searching for identity and Strategies for learning.

This study adds to the knowledge about being new in the EMS and illuminates the need for further research in how to support novice PECN’s strive for balance in this context.

Anna HORBERG (Stenhamra, Sweden), Veronica LINDSTROM, Susanne KALÉN, Max SCHEJA, Veronica VICENTE
16:20 - 16:30 #7078 - OP092 Multicentre validation of AMPDS code with ICU admission and 30 day mortality.
Multicentre validation of AMPDS code with ICU admission and 30 day mortality.


Algorithim based dispatch codes are widely used amongst ambulance services to prioritise dispatch of ambulance resources. This prioritisation is based on perceived urgency at the time of dispatch. There is little described in the literature about how this perceived level of urgency at ambulance dispatch relates to long term outcome.


To determine whether the AMPDS dispatch code was a predictor of a composite outcome of mortality within 30 days and/or ICU admission within two days.


All adult patients attended to by ten Scottish Ambulance Service (SAS) paramedics working across 5 centres.over a 13-month period. Data for all patients in the study was obtained from the electronic records via the SAS Data Warehouse. This data was then matched with the receiving Intensive Care Units and hospital information systems to ascertain outcome.


A total of 1900 patients were available for analysis. Complete data on AMPDS code and outcome was available for 1895/1900 (99.7%).

The mean age of subjects in the study was 61.6 years (95% CI 60.7 to 62.6) with 50.5% of subjects being male gender.

Regarding outcome, 0.3% of subjects were admitted to an Intensive Care Unit within 48 hours and 4.9% of subjects died within 30 days of the initial ambulance call. The combined outcome of ICU admission within 48 hours or death within 30 days contained 5.0% of all subjects. Some subjects were in both of these groups.

There were a total of 191 different AMPDS codes used to dispatch an ambulance resource to the subjects in our study.

24 of 191 codes had more than 20 subjects dispatched. In this group of 20 codes the combined outcome measure again varied between 0 and 17.9% with a median of 3.5%.

9 of the 24 codes, covering 270 subjects, had a 10% or greater rate of the combined outcome measure of ICU admission within 48 hours or death within 30 days.

10 of the 24 codes, covering 364 subjects, had no subjects associated with a combined outcome measure of ICU admission within 48 hours or death within 30 days.



This data is the first to link initial AMPDS coding to medium term outcomes such as ICU admission or 30 day mortality. Firstly the data from our study shows that this is feasible.


We also show that there is a wide variation in outcomes according to AMPDS code, Some codes, such as cardiac arrest, are associated with a high incidence of adverse outcome,. Some other less specific codes such as sick person/unwell are also associated with a high incidence of adverse outcome.


Conversely, some codes have no adverse outcomes associated with them. Although these are based on low absolute numbers, this may support down grading or regarding of some dispatch codes.


These findings will require replication in a much bigger cohort to confirm its accuracy at an acceptable level, however they open the possibility of basing dispatch codes based on hard outcomes such as ICU admission or 30 day mortality, rather than just immediate outcomes.

Alasdair CORFIELD (Glasgow, United Kingdom), Rooney KEVIN, Kelly PAUL, Stewart ELAINE, Silcock DANNY
16:30 - 16:40 #7162 - OP093 Practice study on the use of Gamma-OH in pre-hospital emergency medicine.
Practice study on the use of Gamma-OH in pre-hospital emergency medicine.

Introduction: Nearly 50 years after its discovery, Gamma-OH (GOH) is used less and less in pre-hospital emergency medicine. Yet it offers good hemodynamic tolerance, is not much of a respiratory depressant and is easy to use in extra-hospital situations. In the absence of recent practice studies, we determined reporting its most frequent indications in the current pre-hospital setting as the main objective. Secondary objectives were to assess compliance with proper use, associated anesthetics and the occurrence of complications.

 Material and methods: Retrospective monocenteric practice study in a pre-hospital emergency medical service with 6 mobile intensive care units (MICU). Inclusion criteria: all patients who received GOH administration in a pre-hospital situation. Data collected from medical observation sheets were epidemiological, clinical, therapeutic (indication and dose of Gamma-OH administered, associated hypnotic and/or analgesic treatments) and safety (adverse events, complications from anesthetics).

 Results and Discussion: From 01/01/2015 to 12/31/2015, 111 patients were included, with a mean age of 51 years [3-91] and 81 (73%) men. Prescription of GOH was related to: in 61 (55%) cases, return of spontaneous circulation (ROSC) after cardiac arrest; in 19 (17%) cases, coma; in 17 (15.3%) cases, severe trauma, including 9 associated with severe head trauma (SHT); in 7 (6.3%) cases, an isolated SHT; in 6 (5.4%) cases, acute respiratory distress with reduced consciousness; and in one case, a burn patient. Note that among the severe trauma patients there were 4 victims of multiple ballistic wounds in the November 13 attacks that received maintenance dose of GOH after tracheal intubation using rapid sequence induction.

After tracheal intubation, maintenance of sedation was performed by GOH alone in 26 (23.4%) cases; by GOH associated with sufentanil in 27 (24%) cases and GOH+midazolam+sufentanil in 54 (48.6%) cases. In adults (n=109), the initial dose was 60 mg/kg in the majority of cases (85%) as recommended, and 30 mg/kg in 10% of cases. This administration was followed by a second half-dose injection in 16 (14%) cases. No anaphylactic complications were reported. Only 2 episodes of hypotension were observed in patients who received it with midazolam. 

Conclusion: Because of its ease of use and a low complication rate, Gamma-OH proves even today to be a relevant product in pre-hospital situations or in disaster medicine. Gamma-OH remains in favour with our MICU physicians, particularly in cases of ROSC after cardiac arrest or severe trauma. These preferences are explained by facilitating the management of anesthesia, especially during long and difficult transportation by stretcher. A prospective study should be started to compare it to other products.


Amandine ABRIAT (Paris), Michael LEMAIRE, Daniel JOST, René BIHANNIC, Michel BIGNAND, Jean-Pierre TOURTIER
16:40 - 16:50 #7195 - OP094 Is there a relationship between the mode of transport to the hospital and the deadline for the first imagery of stroke ?
Is there a relationship between the mode of transport to the hospital and the deadline for the first imagery of stroke ?

Introduction. The referral of cerebrovascular accident patients (CVA) to neurovascular units (NVU) has improved the prognosis of said patients. Imaging (CT or MRI) must be systematically carried out on arrival at the hospital. The aim of this study was to evaluate in urban areas of high population density the time between stroke onset and the completion of the 1st brain imaging, according to the transportation of patients to the hospital. 


Materials and methods: This was a prospective observational study including all patients hospitalized in NVUs of a large metropolis. Data collection involved patient characteristics (age, gender), their means of arrival in the service: personal vehicle (PV), private ambulance (PA), professional rescuers (PR), emergency physician (EP); time of CVA onset and, first arrival in care, 1st brain imaging, at the beginning of early thrombolysis if carried out. The different times were reported by their median [interquartile range]. Comparison of times made use of a median test (STATA® 14.0)


Results.  From the June 1st to 30, 2015, 554 patients (with the average age of 69 + 15 years, 306 men) were admitted in 13 NVUs in the studied geographic area. The average "CVA-1st imaging" times were 550 [128-559] minutes in case of personal transportation (n=141), 236 [144-510] min by private ambulance (n=99), 167 [105-325] min. by professional basic life support (BLS) teams (n=220), 180 [135-154] min by a medical team (n=41), 69 [45-70] minutes in case of intra-hospital transfer (n=23).

Transient Ischemic Attackpatients favored a personal mode of transport; hemorrhagic CVA, BLS teams transport; ischemic CVA, a medical team tied with the rescuers.


Discussion. The time between the 1st symptoms and carrying out the 1st imaging doubled when patients used their personal transportation versus that of institutional care. Awareness campaigns for institutional care in case of onset of CVA signs should continue to be carried out.

16:50 - 17:00 #7815 - OP095 A qualitative approach to evaluating the global barriers of International Emergency Medicine development.
A qualitative approach to evaluating the global barriers of International Emergency Medicine development.

Study Objectives The ACEP International Ambassador Program was developed as a venue for international experts to provide the current status and progress of Emergency Medicine (EM) in their assigned countries. An annual one-day conference was created to convene the ambassadors and allow for collaboration in order to reach the common interest of advancing emergency care. Our objective was to analyze the major perceived barriers for the evolution of the specialty.

Methods Open-ended interviews were conducted during the program’s annual conference and collated from 2013-2015. ACEP International Ambassadors (N=75), who represent over 60 countries, were divided into focus groups through break-out sessions. Interviews were centered on thematic topics, including barriers encountered by stage of EM development; local, regional, and international needs for EM development; and barriers and needs of International Emergency Medicine (IEM) education. Data collection took place in real-time using scribes and subsequently grouped into key themes and findings. An inductive approach to data analysis was used to identify barriers for the evolution of EM abroad.

Results Ambassadors represented 83 countries which accounted for almost 50% of the world’s nations. The definition of EM is very country specific. Identifying local stakeholders in each country that would advocate for EM can be difficult. Even though the motivations of local governments are difficult to recognize at times, the involvement of Ministers of Health, public officials, and local leaders are an essential part in advancing the specialty. Furthermore, international organizations could provide quality control that allows for the development of EM through a process of merit. A heterogeneous curriculum and lack of knowledge of EM as a specialty has been a major challenge for residency programs. Centralizing educational resources can reduce duplication of efforts and would benefit educational processes for EM residency programs and health personnel.

Conclusion International Emergency Medicine remains underdeveloped and there still is not a clear definition of EM as a specialty. The scope of practice of EM abroad is still not widely recognized, which further increases the difficulty of its evolution. The indispensable expansion of EM will be exponential with the support of regional leaders to form a unique identity of the specialty. These leaders play a vital role in standardization and communication, while serving as catalysts in resolving shared concerns. It is important to attempt to professionalize IEM education. With the support from ACEP and IFEM, initial steps to professionalize IEM education would include course maps with milestones and guide for a core curriculum.

Nirma BUSTAMANTE, Andres PATINO (Cambridge, USA), Alex VON ECKARTSBERG, Rebekah COELHO, Sebastian SUAREZ, Christian ARBELAEZ
17:00 - 17:10 #7874 - OP096 Performance of early warning scores calculated in the prehospital setting by ambulance crew to define the level of medical response: the SAPA/EAS study.
Performance of early warning scores calculated in the prehospital setting by ambulance crew to define the level of medical response: the SAPA/EAS study.

Introduction: Currently, in the prehospital setting, the first line ambulance crew don’t have any objective tool for helping to define the usefulness of Mobile Intensive Care Unit (MICU - SMUR) intervention. Early Warning Scores (EWS), based on vital signs, are used to monitor inpatients and to trigger a timely medical response. EWS in the prehospital setting might provide an objective tool leading to a more rational use of Emergency Medical Services (EMS). This study compares the performance of ten EWS among which the new EAS (Emergency Alert Score).

Material and method: 2343 ambulance’s report forms recorded during two months (January and July 2014) were retrospectively reviewed. Patients not transferred into one of the six participating hospitals of the ambulance district, patients aged less than 16 years, patients known to be pregnant and incomplete forms were excluded. Seven criteria for a medical response, independent of vital signs, were taken into account before calculating EWS. The primary outcome was the usefulness of MICU intervention, who was assessed by reviewing hospital medical files (adverse event and/or severity level at admission).

Results: 1120 patients were analysed. Hospitalisation rate was 45 %, among which 8 % in intensive care unit. Areas Under the Curve (AUC’s) of the best EWS (i.e. the EAS) without or with criteria for a medical response, independent of vital signs, were 0.76 (95 % CI: 0.74 – 0.79) and 0.83 (95 % CI: 0.80 – 0.85) respectively. For an EAS > 3, sensitivity was 73 % (95 % CI: 67 – 79), specificity was 80 % (95 % CI: 77 – 83), predictive positive value was 48 % (95 % CI: 43 – 53) and predictive negative value was 92 % (95 % CI: 90 – 94).

Discussion and Conclusion: Criteria for a medical response, independent of vital signs, improve the performances of the EAS score. A negative score (EAS ≤ 3) may help ambulance crew to decide to stop or to not call the MICU, with the advantage of an improvement in EMS management. These results must be confirmed by a prospective study.

References: Fullerton JN. et al. Resuscitation 2012; 83: 557-62. Silcock DJ et al. Resuscitation 2015; 89: 31-35.

Denis RANS (NIVELLES, Belgium), Marc VRANCKX, Bernadette CUVELIER, Benjamin KERZMANN, Thierry SOTTIAUX, Christian MÉLOT, Fabien GUÉRISSE, Didier TAMINIAU
17:10 - 17:20 #7948 - OP097 Comparing Intraosseous And Intravenous Access For Out-of-Hospital Cardiac Arrest In Singapore.
Comparing Intraosseous And Intravenous Access For Out-of-Hospital Cardiac Arrest In Singapore.


Vascular access in out-of-hospital cardiac arrest (OHCA) patients is challenging. Locally, emergency ambulance paramedics have a 50% success rate of obtaining an intravenous (IV) access in order to administer epinephrine. The aim is to evaluate the use of intraosseous (IO) in addition to IV to determine if there is an improvement in return of spontaneous circulation (ROSC).



This is a prospective, parallel group, cluster-randomised, crossover study comparing ‘IV only’ against ‘IV+IO’ in medical and traumatic OHCA cases in Singapore. In the ‘IV+IO’ arm, if 2 IV attempts failed or took more than 90 seconds, paramedics may have 2 attempts of IO. Inclusion criteria for IO were OHCA adult (body weight ≥40kg) and paediatric (body weight between 3 to 39kg) patients. Exclusion criteria were contraindications to IO. The primary outcome was ROSC. Secondary outcomes were insertion success rate, epinephrine administration, time taken for 1st dose of epinephrine and survival outcome.



Based on phase 1 results (prior to crossover) from 1 September to 31 December 2014, there were 251 cases in the ‘IV only’ group and 307 cases in the ‘IV+IO’ group. Baseline characteristics were similar in both groups. There were more successful vascular access and prehospital epinephrine administered in ‘IV+IO’ compared to ‘IV only’ (69.4% vs 53%, p<0.001, 62.5% vs 47.8%, p<0.001 respectively). There were 38 IO attempts in the ‘IV+IO’ group, of which 5 failed as the 1st attempt was unsuccessful but a 2nd attempt was not made. Median time to epinephrine was similar in both ‘IV+IO’ and ‘IV only’ groups (10 min [IQR 7-16 min] vs 11 min [IQR 7-18 min] respectively, p=0.104), also ROSC whether it was prehospital ROSC (8.5% vs 10% respectively, p=0.558) or hospital ROSC (25.7% vs 26.7% respectively, p=0.847), as well as survival to discharge or 30 days (3.9% vs 5.6% respectively, p=0.421) and good neurological outcome of cerebral performance category (CPC) ≤2 (2.6% vs 4.8% respectively, p=0.178).



The use of IO in addition to IV led to higher vascular success rate and prehospital epinephrine administration. However, it was not statistically significant for ROSC, survival to discharge or 30 day survival, or good neurological outcome.



We would like to thank the SCDF paramedics for their participation in this study. We have no conflicts of interest to declare. This study was funded by NMRC New Investigator Grant and AM-ETHOS Duke-NUS MSRF Grant. 

Yun Xin CHIN (Singapore, Singapore), Kenneth Boon Kiat TAN, Zhi Xiong KOH, Yih Yng NG, Nur Ain Zafirah Bte MD SAID, Masnita RAHMAT, Stephanie FOOK, Marcus Eng Hock ONG
16:10 - 17:40 #8135 - OP098 Feasibility of a prospective risk analysis to improve patient safety in the chain of emergency care, a pilot study.
Feasibility of a prospective risk analysis to improve patient safety in the chain of emergency care, a pilot study.


Patient safety is an important issue in emergency medicine. However, patient safety management is mainly focused on the care within  the emergency department (ED), although safety risks are known to take place in the chain of emergency care. For instance problems in the handovers of emergency care occur in safety incident reports of the general practitioner (GP) practice, ambulance emergency medical services (EMS) and other departments in the hospital. However, these reports are retrospectively focused, and insight in underlying causes is usually lacking. In this pilot study we explored the feasibility of a prospective risk analysis (PRI) in the chain of emergency care from the perspective of professionals, managers and board members.  


The pilot was performed in two emergency regions (provinces) in the Netherlands. Professionals of the emergency GP practice, EMS, ED and neurological department were included. We developed a protocol for the PRI process in the chain of emergency care, based on the health failure mode and effect analysis (HFMEA-light) method. The HFMEA-light method provides insight in safety risks of a care process or a chain of care through a systematic  assessment. Furthermore, we developed criteria for the selection of a care process that needs a safety risk assessment. An independent health policy advisor, with ample experience in facilitating PRI within hospitals, guided the PRI process in the (pre)hospital working group. We defined evaluation criteria for professionals, managers and board members of the participating organizations, as patient safety is a responsibility for each of them in a different role.


We performed a PRI focused on changes in the Dutch national guideline for the emergency treatment of patients with a cerebro vasculair accident (CVA), and a PRI focused on handover of medication (errors) in the chain of emergency care. Professionals of the GP, EMS, ED, radiology and neurology  identified 14 patient safety risks in the CVA emergency care chain and 15 risks around medication handover. Risks were related to: inadequate or different education of professionals (knowledge and expertise), lack of ICT facilities and hampering communication between ICT systems, lack of synchronization of protocols in different organizations, miscommunication in oral and written handovers, lack of qualified staff for adequate performance of emergency care. The participants formulated a mutual plan for the improvement of patient safety, as part of the method. Professionals, managers and board members reported that the PRI was a useful and practical method, that contributed to a constructive improvement of patient safety (management) in the chain of emergency care. The PRI method connected well with the professional knowledge and expertise (intrinsic motivation) of the participants and improved the patient safety culture, when preconditions on confidentiality and mutual trust were met .


The PRI method provides prospective insight in safety risks in the chain of emergency care. It is a feasible method to improve patient safety  (culture) in the chain of emergency care, and professionals, managers and board members reported additional value of the method, with regard to others (retrospective) methods in use.

Marie-Jose LITJENS, Sivera BERBEN (Nijmegen, The Netherlands), Gijs HESSELINK, Karin VAN DEN BERG, Miranda DIRX, Lisette SCHOONHOVEN
16:10 - 17:40 #8141 - OP099 Governance of patient safety in emergency care: a mixed-methods study of emergency care services in the Netherlands.
Governance of patient safety in emergency care: a mixed-methods study of emergency care services in the Netherlands.


Executives of emergency healthcare services (EMS), such as Helicopter EMS, ambulance EMS and the emergency department (ED), have a fundamental governance role in overseeing and managing safety risks, because they are accountable for the overall quality and safety of healthcare their services provide. In the last decade, attention for the responsibility of executives towards patient safety has rapidly increased. This attention is stimulated by the crucial role executives have in the implementation of quality and safety improvement programmes, and by multiple patient safety incidents with great societal impact and directly related to poor governance. However, insight into the governance of patient safety within high-risk emergency care settings and the chain of emergency care is scarce. This study explores the factors that hinder executives in overseeing and improving safety risks within their own EMS, and in the chain of pre-hospital emergency care.



A mixed-methods study was performed in two Dutch regional emergency healthcare networks covering a large part of the southeast Netherlands (provinces Gelderland and Limburg). In the Netherlands, pre-hospital emergency care is provided by General Practitioners (GPs), GP Out of Hours Service, EDs, ground-based ambulance and helicopter EMS and Psychiatric EMS. The Dutch EMS system operates on a variation of the Anglo-American model of EMS care. We performed 28 in-depth interviews with executives from different EMS organisations. The interviews lasted between 40 and 70 minutes and followed a semi-structured format using an interview guide. The guide was based on patient safety and governance literature, the input from experts (n=10) in the field of emergency care, public administration and patient safety, and brainstorm sessions with the research team. A pilot interview with the director of a regional emergency healthcare network was conducted to pre-test and refine the interview guide. Interviews were digitally recorded and transcribed verbatim. Transcripts were analysed based on the Grounded Theory approach. Furthermore, we collected and analysed relevant documents, such as annual reports, board minutes, policy statements, protocols and work instructions, to identify governance activities.


Results: Executives are satisfied with the governance of patient safety within their service. However, the professional autonomy often seems to conflict with the need of executives to be accountable for patient safety. Risk oversight and management are hindered by: the provision of care out of the executives’ sight, inadequate tools to measure or assess safety risks and fear amongst staff for the negative consequences of incident reporting. Many services lack a reliable organisation of up-to-date and easy accessible safety protocols. Governance within the chain of emergency care is hindered by conflicting interests and safety norms between services, the absence of an administrative authority and lack of appropriate risk identification tools.


Conclusions: Important safety risks within pre-hospital emergency care may be unnoticed and unmanaged by executives due to: inadequate risk monitoring, absence of a reporting culture and the lack of a shared sense of responsibility among executives for patient safety in the chain. Improvements should focus on these aspects as primary conditions for improving the governance of patient safety within emergency care.

Gijs HESSELINK, Sivera BERBEN (Nijmegen, The Netherlands), Miranda DIRX, Karin VAN DEN BERG, Lisette SCHOONHOVEN

Tuesday 04 October

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17:40 - 18:40

EuSEM Annual General Assembly


Tuesday 04 October

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19:00 - 20:00

EuSEN - General Assembly