Altered cerebral physiology, pathology, and Increase ICP can be detected by cerebral oximetry in numerous pediatric ED studies.  In intubated pediatric ED traumatic brain injury  (TBI)patients detecting & response to treatment for the  alter cerebral physiology and ICP is solely by cardiovascular monitoring  and GCS which has major flaws.  In pediatric TBI  head trauma patients with increased ICP, 3%HTS therapy is a standard therapy for increased ICP but assessing its effect on intubated pediatric TBI patient's cerebral physiology by cerebral oximetry has never been reported.

Objective: In isolated pediatric TBI PED patients who received 3% HTS (5 ml/kg), analyze their cerebral oximetry changes in correlation to their 10 minutes before  and 10, 20 minutes post 3% HTS infusion.

Methods

ED observational convenience study of intubated pediatric isolated TBI patients with positive cerebral pathology by CT-scan( epidural, subdural, TBI) , 3% HTS infusion and cerebral oximetry monitoring. Patient's left and right cerebral oximetry readings 10 minutes before 3%HTS infusion and 10 & 20 minutes after 3%HTS infusion. Patients were further sub-group by their  rSO2 initial readings left, right or both rSO2 initial readings:  abnormal cerebral physiology rSO2 80 & normal cerebral physiology rSO2 60-80

Results

207 patients enrolled, age 2.9(1.14,6.9), epidural 28.5%, subdural 84.5%, TBI only 7%, GCS 7(6,8), time to first 15% rSO2 change was 1.1 minute (0.5,1.8). Figure 1

Conclusions

3%HTS infusion produced  significant cerebral oximetry changes in isolated pediatric intubated TBI patients with abnormal cerebral physiology, increased ICP and pathology.  Changes in Cerebral Oximetry readings from the 3%HTS was rapid 1.1 minutes (0.5,1.8). In intubated isolated pediatric TBI  ED patients with increased ICP from brain injury, cerebral oximetry can detect the effects of 3%HTS on these patient's  increase ICP and abnormal hemispheric cerebral physiology. Further investigation is warranted.

Background: The wound healing process is complex and still poorly understood. Sericin is a silk protein synthesized by silk worms (Bombyx mori). The objective of this study was to evaluate in vivo wound healing effects of sericin containing gel formulation in an incision wound model in rats. 

Material&Methods: Twenty-eight Wistar-Albino rats were divided into 4 groups (n=7). No intervention or treatment was applied to the Intact control group. For other groups, a dorsal skin flap (9x3 cm) was drawn and pulled up with sharp dissection. The Sham operated group received no treatment. Also the placebo group received placebo gel without sericin and the sericin group received 1% gel. Both gels applied to the incision area once a day, from day 0 to day 9. Hematoxylin and eosin stain was applied for histological analysis and Mallory-Azan staining was applied. For histoimmunochemical analysis of antibodies and iNOS (inducible nitric oxide synthase) and desmin was applied to paraffin sections of skin wound specimens. Parameters of oxidative stress were measured in the wound area.

Results: Epidermal thickness and vascularization were increased, and hair root degeneration, edema, cellular infiltration, collagen discoloration and necrosis were decreased in Sericin group in comparision to the Placebo group and the Sham operated group. Malonydialdehyde (MDA) is an important oxidative stress marker which appears after lipid peroxidation, MDA levels were decreased, but activites of important antioxidative defense enzymes such as superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) were found to be as increased in the Sericin group.

Conclusions: We found that Sericin had significant positive effects on wound healing and antioxidant activity. Sericin-based formulations can improve healing of incision wounds.      

e Purpose:Topical agents are commonly used for burn treatment.There is not any agent or a method in the treatment that adopted as an effective and common method.St. John’s wort and galangal has been used for the treatment of numerous disorders for many years. It was aimed to determine whether H.Perforatum and A.officinarum which have been regarded to be effective on burn and wound healing are effective on experimental contact type burns in terms of wound healing,or not and compare their effects with each other.METHOD:35 healthy albino Wistar rats were subjected. Rats were separated into 5 groups. Burns were formed by contacting the 1x1 cm copper end, which was kept at 100°C constant temperature, of the device designed with the aim of forming burn model to the shaved areas for 10 seconds without applying extra pressure..Any procedure or treatment was not applied to Group 1. In Group 2, burns were only irrigated with 100cc SF for 2 minutes and covered with drug-free dressing after burn application and any other treatment was not applied. In Group 3, the gel prepared from galangal plant was applied for one time after burn application. In Group 4, the gel prepared from St John's wort was applied for one time after burn application.In Group 5, plain gel was applied for one time after burn application.FINDINGS:Hour 0 (before burn) and hour 24 (after burn) weights were measured and assessed.Edema amount was seen to be reduce in all groups with time.In this study, the procedures of vein, hair root and degenerated hair root count were performed on all preparates obtained from each animal of each group.Degenerated hair root number increased step by step in burn control group. When galangal and St John's wort were compared in terms of the effect on the degenerated hair root number, any statistically different value could not be obtained. St John's wort had a statistically meaningful difference (p<0.05) in terms of degenerated hair root number. 10 randomized histological sections was taken from each biopsy materials obtained from all animals of each group and tissues of each animal, and in each preparate, epidermis thicknesses of 20 randomized different areas were taken, arithmetic mean results were written and they were assessed statistically. RESULT:it was observed that the topical H.perforatum treatment that was applied for one time in acute contact type experimental burns reduced edema and damages of hair root and glandula sebacea, and was effective both for the protection of hair root number, vein number and epidermis thickness, and lowering the degenerated hair root number.It was understood that A.officinarum treatment had also effects reducing the edema, glandula sebacea damage and was effective for the protection of epidermis thickness and lowering the degenerated hair root number. However when the treatment applications were compared, the effects of H.Perforatum treatment was more prominent than topical A.officinarum treatment for wound healing regarding the contact type burns. It can be said that H.Perforatum topical treatment is going to givmore positive results for acute period burns when compared to A.officinarum treatment.

Background:

Acute subdural hematoma (ASDH) is a common traumatic brain injury with a relatively high mortality rate. However, few studies have examined the factors on admission predicting the outcome of traumatic ASDH. This clinical study analyzed the prognostic factors on admission in patients treated surgically for traumatic ASDH.

Participants and methods:

A total of 74 surgical patients for traumatic ASDH between January 2008 and October 2014 were retrospectively reviewed. If surgical evacuation of an ASDH in patient is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty. Glasgow outcome score (GOS) was used for prognostic evaluations and favorable prognosis was defined as 4-5 points. We used univariate and multivariate logistic regression analysis to evaluate the influence of clinical variables on prognosis.

Results:

The majority were male (66.2%) and the mean age was 59 years. The percentage of patients with favorable prognosis was 25.7% and the mortality 36.5%. Age (OR = 0.874), Glasgow Coma Score on admission (OR = 1.851), D-dimer (OR = 0.756) and Rotterdam CT score (OR = 0.137) were independent predictors, while no independent association was observed between prognosis and platelet count, thickness of hematoma, although these variables were correlated with prognosis in univariate analyses. Sex, pupil abnormalities, light reflex, PT-INR, fibrinogen, glucose, electrolytes, arterial blood gas data were no correlated with prognosis in univariate analysis.

Discussion/Conclusion:

This study identified the risk factors for poor prognosis in patients who underwent surgical treatment for traumatic ASDH. Poor outcome in traumatic acute subdural hematoma is higher in elderly patients even after surgical intervention. There is a high incidence of coagulopathy following TBI. The presence of elevated D-dime as well as of severity of TBI are strong predictors of prognosis in these patients. The Rotterdam classification including compressed basal cistern, midline shift >5mm, absent of epidural hematoma mass, present of intraventricular blood or subarachnoid hemorrhage seems to be appropriate for describing the evolution of the injuries on the CT scans and contributes in predicting of outcome in surgical ASDH patients. In conclusion, older patients, lower Glasgow Coma Score on admission, elevated D-dimer, higher Rotterdam CT score tend to have poor prognosis. The findings might help clinicians determine management criteria and improve survival.

Acknowledgement: On behalf of all authors, the first author states that there is no financial other conflict of interests

Introduction:

Inhaled corticosteroids, known to be effective as a maintenance medication in chronic asthma, have also been suggested as a therapy for acute asthma when given at high doses in children. The role of inhaled corticosteroids in the treatment of acute asthma exacerbations in adults is controversial.

Aim of study: to study the efficacy of high dose nebulized budesonide (BUD) in the treatment of severe acute asthma in adults.

Methods:

A double-blind, randomized, placebo-controlled trial conducted over six months. Inclusion: Age ˃18 and ˂45 years with a peak expiratory flow (PEF) <50% of predicted value. Patients were assigned to receive 0.5 mg Budesonide (BUD) nebulized or placebo isotonic saline serum (ISS), in addition to Terbutaline 5mg and 0.5mg Ipratropuim bromide every 20 minutes the first hour. All patients received single oral dose of prednisolone 1 mg/kg given at the beginning of therapy. The primary outcome was the delta PEF in the first hour (H1).The secondary outcome was hospital admission rate within 4 h and length of stay in the emergency department (ED).

Results:

A total of 108 visits by adults with severe acute asthma were evaluated.Mean age = 36 ± 9 years. Sex ratio = 0.43. On admission, the two BUD groups (n = 49) and placebo (n = 55) were similar. The delta PEF in H1 was 25% in the BUD group versus 20% in the placebo group (p = 0.01, OR = 3.4) . The hospitalization rate was 47% in the BUD group against 53% in the placebo group (p = 0.97). The average length of stay was 7 ± 5 hours in the BUD group versus 11 ± 9 hours in the ISS group (p = 0.04, OR = 1.9). No major complications were observed in both groups.Conclusion :The addition of high repetitive budesonide nebulization improve the lung function and decrease the admission rate of adults with severe acute asthma.

Objectives: Venous thromboembolism (VTE) prophylaxis is less frequent in emergency medicine (EM) than in internal medicine (IM) department. The aim of the present study is a critically revue of thromboembolism criteria and score in the medical patient, in EM and IM department. Particularly we hope find a score more suitable for acute patient but with high sensibility and specificity.
Methods: Double case-control observational study, with enrollment, for each case of VTE, of two consecutive patients without VTE, of equal sex and age group (18–50, 50–55, 55–60, 60–65, 65–70, 70–75, 75–80, >80 years).The study involved EM and IM department of 23 hospital/university of Lazio and Umbria, in Italy.

Results: We analyzed data pertaining to 1215 patients, 409 with VTE (50% – deep venous thrombosis (DVT), 9.9% – pulmonary embolism (PE), 40.1% – PE+DVT) and 806 case-control. 222 patients (30%) were in charge to EM department while 520 patients (70%) to IM department. The TEV risk factors at more statistical significance (p<0.01) were: previous VTE, active cancer, known thrombophilic condition, immobilization, chronic venous insufficiency, hyperhomocysteinemia, central venous catheter, recent hospitalization. Obesity, recent surgery, family history of VTE, hormone therapy and treatment with drugs that stimulate hematopoiesis were resulted at intermediate statistical significance (p<0.05 but >0.01). Multiple logistic regression was used with robust standard errors and forward selection of candidate variables using the Bayesian information criterion to develop a new score: the " TEvere Score" This score shows the highest specificity and sensitivity, (respectively 43.3and 87.5 with accuracy 72.1) compared with Padua, Kuscer and Chopard scores. Tevere score had predictive validity for risk of thromboembolism(AUROC 0.7266; 95% CI, 0.71 to 0.73) than was greater than Kuscer score(AUROC 0.6891; 95% CI, 0.67 to 0.70)(p =0.0093).

Conclusions: The TEVERE score  has shown to have a higher accuracy than the other scores most commonly used in clinical practice to stratify the risk of thromboembolism.In particular, in our study, we were taken into exams also patients from the Department of Emergency, which appear to have, for a variety of factors, different characteristics than patients hospitalized in medical wards.This makes the TEVERE a good score to use, fast, also in the Emergency Departments.

OBJECTIVES: To determine the in-hospital outcome and the factors associated with a prolonged treatment (<48 hours) in a group of patients with acute respiratory failure (ARF), treated with noninvasive ventilation (NIV).

METHODS: This was a retrospective study including all patients with ARF requiring NIV over a eleven-month period, admitted in an Emergency Department High-Dependency Observation Unit (ED-HDU). Clinical data were collected at baseline, 1 hour, and 24 hours; Sequential Organ Failure Assessment (SOFA score) was calculated with the worst clinical parameters during the first 24 hours. The patients were classified into 2 groups: acute hypoxic respiratory failure (ARF1) and acute hypercapnic respiratory failure (ARF2). The primary outcome was in-hospital mortality.

RESULTS: During the study period (April, 2015-March, 2016), 150 patients underwent NIV; in 59 patients NIV was maintained beyond 48 hours and in-hospital mortality was 22% (including 7% ED-HDU mortality); only 1 patient was intubated during ED-HDU staying. Persistence of hypoxia (PaO₂/FiO₂<200) 1 hour (59 vs 38%, p=0.029)and 24 hours (65 vs 35%, p=0.012) after NIV beginning, tachypnea (RR>29 per minute) at 1 hour evaluation (30 vs 10%, p=0.017) and a depressed level of consciousness (Glasgow Coma Scale, GCS<15) at all evaluation points(before NIV 46 vs 25%; 1 hour: 48 vs 22%; 24 hours: 41 vs 20%, all p<0.05) were more frequent in non-survivors compared with survivors. Persistence of acidosis (pH<7.30) and tachypnea at 24-hour evaluation were more frequent in patients who underwent NIV beyond 48 hours (respectively 10 vs 1% and 20 vs 5%, all p <0.05).

ARF1 group included 101 patients (67%) and ARF2 49 (33%). Mean age was similar in the two groups (77±13 vs 79±9 years, p=NS), while ARF1 patients showed a higher SOFA score than ARF2 (4.6±2.4 vs 3.3±1.8, p=0.036). NIV was considered the ceiling treatment in 26 (26%) ARF1 and in 11 (22%) ARF2 patients (p=NS). In-hospital mortality was 28% among ARF1 and 9% among ARF2 patients (p=0.005); all but one ARF2 non-survivors and 17/28 ARF1 non-survivors underwent NIV as ceiling treatment. Among ARF1 patients, non survivors showed more frequently than survivors persistence of tachypnea at 1-hour and 24-hour interval (respectively 33 vs 9% and 36 vs 7%, all p<0.05); a 1-hour reduced GCS (46 vs 24%, p=0.05) and hypoxemia at 24-hour interval (71 vs 45%, p=0.063) only tended to be more frequent. No parameter significantly predicted NIV prolonged duration. Among ARF2 patients, only an altered level of consciousness at 1-hour and 24-hour interval was significantly more frequent among non-survivors than survivors (respectively 67 vs 18% and 67 vs 15%, p<0.05); a reduced GCS before NIV beginning and at 24-hour interval was more frequent among patients undergoing NIV beyond 48 hours (37 vs 9% and 33 vs 5%, all p<0.05).

CONCLUSIONS: In this experience reported from a real clinical scenario, mortality rate was comparable with previous reports despite the presence of a significant proportion of patients undergoing NIV as ceiling treatment. Among ARF1 patients, who showed the highest mortality, persistence of tachypnea despite NIV implementation was the most significant predictor of a bad outcome. 

Backgrounds: Prognostic parameters to differentiate injuries that may cause fatality gain extra importance to save this group of patients on time.

Aim: To determine the predictive significance of haematological markers (neutrophil, lymphocyte and platelet counts, NLR and platelet lymphocyte ratio [PLR]) for mortality in patients with multitrauma.

Methods: Data of all consecutive trauma patients according to ICD-10 that admitted to our ED were taken from database of our hospital retrospectively. The following ICD codes were scanned for this aim: S00 to T88, V00 to Y99, R58, Z04. Of 46,497 records in 6 years, 6,917 patients with available completed records and initial complete blood count (CBC) studied in ED within 30 minutes were included: 5,984 patients who were discharged from the hospital were evaluated as the control group and 933 patients who died at the hospital were evaluated as the study group.

Results: Of the patients, 68%(n=4685) were men and mean age was 42.6± 20.4. The ROC curves to discriminate mortal cases among all trauma patients for PLR, PLT, NLR, and RDW were 0.803 [95% confidence interval (CI). 0.784–0.823], 0.763 (95%CI: 0.741–0.784), 0.412 (95%CI: 0.390–0.435), and 0.380 (95%CI: 0.360–0.399), respectively. When the diagnostic value of the cut-off value of the PLR was taken as 74.18, sensitivity, specificity, +LR and- LR of in patients with mortal trauma were 85.4, 66.7, 2.6 and 0.2, respectively.

Conclusion: We found that PLR is a statistically significant independent predictor of mortality with high sensitivity and specificity in patients with trauma.

Background: Despite compelling evidence for better outcome with a shorter pre-hospital time in trauma, there continues to be debate surrounding different approaches used on the scene. North America advocates the “scoop and run” principle comprising basic life support, minimal intervention and rapid transfer to definitive care. However Europe continues to employ a “stay and play” practice with advanced life support and multiple complex procedures being commonplace.

Objective: The purpose of this study was to assess the impact of on scene time on morbidity and mortality for major trauma patients.

Methods: A retrospective analysis of ambulance sheets and trauma proformas for patients presenting to Queen Elizabeth Hospital Birmingham (major trauma centre) was performed from June 2014 to June 2015 from a prospectively maintained database. A complete set of pre-hospital times was defined as call-time, time-on-scene, time-left-scene and time-at-destination. Basic demographics, injury severity score (ISS), length of stay (LoS) and mortality were recorded. Rapid sequence induction (RSI) and advanced life support (ALS) procedures were also documented.

Outcomes were assessed using SPSS software. Multiple linear regression was used to assess how on scene time impacts LoS in hospital with log LoS as the dependent variable. Multivariable binary logistic regression was performed to calculate the effect of on scene time on mortality. Both of these were corrected for age, ISS and remaining pre-hospital time defined as the sum of call-time to time-on-scene and time-left-scene to time-at-destination.

Results: A total of 494 patients presented to the Emergency Department. 363 patients (median age 52 [range 13-101] M275:F88) had a complete set of pre-hospital times. Median on scene time was 39 minutes (range 6 minutes-2 hours 13 minutes) and the median for remaining pre-hospital time was 28 minutes (range 2 minutes-2 hours 14 minutes).Median ISS was 16 (range 1-75) and there was a 14-day median LoS (range 2-128 days). 42 patients (12%) died. RSI was performed on 53 counts (15%) and 14 patients (4%) underwent pre-hospital ALS.

Multiple linear regression revealed that for every additional hour spent on the scene there was a 70% increase in LoS (95% confidence interval 31-123%) with a strong statistical significance after correcting for age, ISS and remaining pre-hospital time (p < 0.001).

Multivariable binary logistic regression similarly showed an odds ratio of 3.19 for mortality (95% confidence interval 1.17-8.68) with every additional hour spent on the scene. This was again statistically significant after correcting for age, ISS and remaining pre-hospital time (p = 0.023).

Conclusion: Trauma networks are established to provide rapid transfer to a tertiary centre for definitive treatment. Pre-hospital medics must be mindful that a longer on scene time negatively effects morbidity and mortality for polytrauma patients. The authors of this study therefore advocate the “scoop and run” approach.

Major trauma presenting to a tertiary centre in Ireland.

Background

Traditionally major trauma has been viewed as a disease of young men involved in high energy transfer mechanisms. With the aging population in Europe the face of major trauma is changing.

Aim

The aim of this study was to describe the demographics of major trauma presenting to a tertiary urban university hospital in Ireland over a 48-month period.

Methods

St. Vincent’s University Hospital (SVUH) was the first institution in Ireland to contribute to the Trauma Audit & Research Network (TARN) database and has been doing so since September 2013Demographics, mechanism of injury, Injury Severity Score (ISS), length of stay (LOS) and time to CT are presented in this study.

Results

A total of 862 patients were included from September 1^st 2013 to August 31^st 2015. Of this population 52.3% were male. The mean age at presentation was 62.6 years (SD 22.4). 449 patients (52.0%) were >65 years, with a strong female preponderance (160 males (35.6%) and 289 females (64.3%) over 65 years). The most common mechanism of injury was “fall less than 2 metres” (n=511, 59.3%), followed by vehicle collision (n=145, 16.8%). In the over-65 population, 81.7% (n=367) suffered a fall less than 2 metres. 65.5% had an ISS of 1-14 and 34.4% a score of greater than >15. The median ISS was 9 (range 1-57). The mean length of stay was 21.0 days (SD 33.8). 51 patients (5.9%) died, of whom 39 were over the age of 65 (i.e. 8.7% of this group).

Conclusion

Our trauma database included more patients over the age of 65 than under, and the predominant mechanism of injury was one of low energy, i.e. fall from less than 2 metres. Our data is in keeping with other recent studies from large trauma databases.(1) It highlights the need to tailor our major trauma services to specific needs of the elderly.

References

1. The changing face of major trauma in the UK. Kehoe A, et al. Emerg Med J 2015; 32:911–915.

Background:Organophosphorus pesticides are widely used in Taiwan. These insecticides include more than one hundred varieties and have large impact on human and animals. According to the statistical information of World Health Organization, there are about 30 million people with pesticide posioning every year, in which the majority of these patients have organophosphate poisoning. Regardless of the exposure pathways in organophosphate poisoning, it is likely to cause serious outcomes or irreversible harm, even death. Therefore, the purpose of this study was to identify determinants of prognosis in patients with organophosphate poisoning. 

Methods: This retrospective study was conducted at a medical center. Consecutive patients having organophosphate poisoning who visited the Emergency Room between January 2008 and December 2012 were retrospectively enrolled. Data which were collected from the medical record of every patient included demographic information, details of medical history, clinical information, the treatment modalities and outcomes. Logistic regression was performed to determine independent corelates of mortality in patients with organophosphate poisoning.

Results:Of the 46 patients with organophosphate poisoning recruited, their mean age was 57 +/- 18.7 years, in which 80.4% were male and 63.0% were admitted to the intensive care unit. The most common comorbidities in these patients were psychiatric disorder(32.6%), followed by cardiovascular disorders(19.6%) During the study period, 5 of the 46 patients died, giving an overall case fatality rate of 10.9%. In multivariate analysis, an increased Acute Physiology and Chronic Health Evaluation(APACHE) II score (p=0.031) was associated with ICU mortality.

Conclusion:The APACHE II score on ICU admission is a significant prognostic indicator in patients with organophsphate poisoning. A further prospective study to strengthen this point is required.

Key Words:Organophosphate poisoning, risk factor, mortality, APACHEII.

Objective: Time from accident to hospital admission in trauma patients is expected to be longer in mountain as compared to urban areas. The aim of this study was to investigate pre-hospital times and clinical characteristics of multi-system trauma patients in mountainous areas and compare them with urban centres.

Methods: Pre-hospital and in-hospital data of trauma victims included in the prospective International Alpine Trauma Register (IATR) hosted in Bolzano, Italy, were compared with published data of trauma victims from rural and suburban areas included in the TraumaRegister DGU® (TR-DGU) of the German Trauma Society. Only patients aged 16 to 80 years with ISS≥16 were included.

Results: A total of 94 patients from IATR and 11020 patients from TR-DGU met the inclusion criteria. Although helicopter rescue was more frequent in mountain compared to urban areas (92% vs. 40%, Fisher’s exact test p<0.001), the mean prehospital time was significantly longer in mountain areas (117.4±143.9 vs. 68.7±28.6min, Welch’s t-test p=0.002) with 38% of patients having a pre-hospital time of >90min. Mean ISS was higher in ITAR patients as compared to DGU® TraumaRegister patients (38.5±15.8 vs. 28.6±12.2, p<0.001). Moreover, patients presenting with a low systolic blood pressure (≤90mmHg) at scene were more frequent in ITAR (41% vs. 19%, Fisher’s exact test p<0.001), yet less patients from IATR as compared to TR-DGU® received pre-hospital volume therapy (82% versus 92%, p=0.001). The rate of unconscious patients with GCS≤8 (34% vs. 33%, p=0.917) as well as pre-hospital intubation rate (44% vs. 54%, p=0.077) were similar in mountain and urban areas. At hospital arrival mean haemoglobin was comparable (12.0 vs. 12.1g/dl, p=0.774), whereas mean base excess was lower in mountain than urban areas (-5.4±4.1 vs. -3.3±5.1, p<0.001). Furthermore, patients with a low systolic blood pressure (≤90mmHg) at hospital arrival were more frequent in IATR as compared to DR-DGU® (27% vs. 15%, p=0.003). No significant difference in hospital mortality was observed between patients from the two registries (11.1% vs. 17%, p=0.163).

Conclusion: Multi-system trauma in mountain areas has some distinctive characteristics and is associated with a significantly increased pre-hospital time despite helicopter rescue in over 90% of cases.

INTRODUCTION:
The predictive value of a single elevated blood lactate or blood lactate clearance on mortality in trauma patients has been demonstrated in a number of studies. The aim of this study was to evaluate the lactate level on the arrival to the hospital after our prehospital interventions in polytrauma patients and subsequent hospital mortality.
METHODOLOGY:
We have retrospectively evaluated 51 polytrauma patients who were evacuated by the helicopter emergency service and admitted to the clinics of anaesthesiology and intensive care of 2 trauma centres in a period from 2010 to 2014. These patients were divided into 3 groups according to the lactate level, which had to be taken immediately on the arrival to the hospital. Into the first group the patients with lactate ≤2.5 mmol/l (L1), were enrolled, into the second group the patients with the lactate level of 2.6-4.0mmol/l (L2), and the third group was formed by the patients with the lactate level ≥ 4.1 mmol/l, (L3). These groups were compared taking into account the age, duration of HEMS mission from the first alert to the admission to the hospital, the prehospital amount of intravenous fluids, the intake haemoglobin, and mortality. For statistical analysis ANOVA, Tukey Kramer test and Kruskal –Wallis with Dunn test were used. The differences in numbers of individual categories were tested using the 3x2 contingency table. P value <0.05 was significant for all statistical tests.
RESULTS:
The average age of all patients was 38.3 years, without significant difference among the groups (L1:36.0, L2:40.8, L3:40.3, ANOVA, p=0.63). The average time from the first alert to admission was 69.7 minutes without significant difference among the groups (L1:69.54, L2:64.3, L3:73.31). We prehospitaly administered in average 1260 ml of intravenous fluids. The amount of fluids was increasing with elevating lactate. (L1:1110ml, L2:1230ml, L3:1510ml, with statistical significance between the groups L1 and L3. The intake haemoglobin was significantly lower in the third group (L1:119g/l, L2:121 g/l, L3:89g/l). The hospital mortality rose with increased lactate (L1:16%, L2:20%). In the third group the mortality reached 43.75%. In this last group 75% of patients had at least in one prehospital measurement the systolic blood pressure less than 90mmHg and 62.5% were continuously administered Norepinephrine during the mission.
CONCLUSION:
We have confirmed the growing hospital mortality with increasing lactate, but this study has been limited by the small number of patients. We have observed quite high hospital mortality in the group with lactate ≥ 4.1 mmol/l, despite the higher prehospital amount of intravenous fluids, early intubation and artificial lung ventilation if there was an indication. What could help to decrease mortality in these patients is the further shortening of prehospital phase even though our transport
times are comparable with another helicopter emergency system (London´s Air Ambulance: 66 min). The next thing could be administration of blood products on board of a helicopter.

Introduction

Trauma care systems aim to reduce death and to improve quality of life and functional outcome in trauma patients. It is well documented that trauma systems result in improved survival after injury, yet there is little data on post-trauma functional outcome. Such evaluation of functional recovery is important as this will allow comparison with other settings, will help evaluate the impact and effectiveness of trauma systems as a whole, and may provide prognostic information for healthcare workers and patients. The aim of this study was to evaluate baseline, discharge, six month and 1, 2, 3 and 4 year post-trauma functional outcome and predictors of optimal functional outcome in Hong Kong.

Participants and methods

From 1^st January to 30^th September 2010 patients were recruited to a prospective multi-centre cohort study of trauma patients and then followed up for four years to 30^th September 2015.  The study was conducted in three trauma centres in Hong Kong. Adult patients aged ≥18 years with ISS≥9, entered into the trauma registry, and who survived the first 48 hours of injury were included. The main outcome measures included theextended Glasgow Outcome Scale (GOSE) and SF36.

Results

During the study, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited. There were no statistically significant differences in baseline characteristics between responders (N=143) and surviving non-responders (N=179). Only 81/400 (20.3%) cases reported a GOSE≥7.  If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 20.3% to 45.6%. Univariate analysis showed that poor functional outcome at 48 months was significantly associated with admission to ICU (OR 2.267), ISS 26-40 (OR 3.231), baseline PCS on SF36 testing (OR 0.940), one-month PCS (OR 0.933), 6-month PCS (OR 0.904) and 6-month MCS on SF36 testing (OR 0.96).

Conclusions

At 48 months after injury, 45% of patients sustaining moderate or major trauma in Hong Kong had an excellent recovery. Admission to ICU, ISS 26-40, baseline PCS, one-month PCS, 6-month PCS and 6-month MCS predict 4-year functional outcome.

Acknowledgement

This study was supported by Health and Health Services Research Grant 07080261 and Health and Medical Research Fund Grant 10110251.

Introduction

The aim of this study was to provide preliminary data on RTW status for patients in Hong Kong with moderate and major trauma.

Participants and methods

A multi-centre prospective cohort study of trauma patients was conducted in three trauma centres in Hong Kong: the Prince of Wales Hospital (PWH), Queen Elizabeth Hospital (QEH) and Tuen Mun Hospital (TMH). Patients were included if they were in the trauma registry, aged≥18 years, had moderate or major trauma (ISS≥9), and answered ‘yes’ to question 5c of GOSE which specifically asks about whether the patient was working or seeking work prior to injury. Patients were followed up for 48 months. The primary outcome was 48-month post-injury RTW.

Results

From 1^st January  to 31^st September 2010, 400 patients recruited to the study (mean age 53.3 years; range 18-106; 69.5% male), of which 197 (49.3%) met the inclusion criteria (mean age 42.9 years; range 18-87; 78.7% male).  Of these patients, 31 (21.1%[C1] ) had RTW at 1-month, 39 (37.5%) at 12-months and 46 (52.3%) at 48 months. Return to work within four years was significantly associated with shorter total length of hospital stay, head injury AIS <3, abdominal injury AIS <3, and multiple injury sites, and higher PCS at one month post injury. After multivariate analysis, one-month PCS on SF36 testing (OR 1.068, P=0.039) significantly predicted 48 month RTW.

Conclusion

The 48-month post-trauma RTW rate in patients with ISS≥9 was 52.3%. One month PCS post injury may be used to predict 48 month RTW.

Acknowledgement

This study was supported by Health and Health Services Research Grant 07080261 and Health and Medical Research Fund Grant 10110251.

In altered traumatic brain injury (TBI) patients, the current ED monitoring skills for detecting and assessing increased ICP and therapeutic response is inconsistent due healthcare provider's clinical assessment variability. Cerebral oximetry can detect acute changes in cerebral physiology, pathology, and ICP changes. . Pediatric Cerebral rcSO2 normal ranges 60- 80%. rcSO2 < 60%, or rcSO2 >80%, and interhemispheric side differences > 10% reflect abnormal cerebral physiology & increase ICP. 3% HTS therapy has been used in ED non-intubated TBI showing clinical benefit but no objective cerebral physiology effect change. Assessing HTS effect on intubated TBI cerebral physiology changes is done only invasively in ICU.ref 1 Assessing 3% HTS effects in altered non-intubated ED-TBI patients with cerebral pathology (epidural or subdural) or without by cerebral oximetry has never been investigated.

Objective: Assessing in altered non-intubated isolated TBI patients who received therapeutic doses of 3% HTS (5 ml/kg) with simultaneously cerebral oximetry readings ( rcSO2) and GCS changes compared to their pre & post 3% HTS infusion times.

Methods: PED observational convenience study of altered (GCS < 14) non-intubated TBI patients with CT-scan and clinical decisions for 3% HTS infusion had simultaneous cerebral oximetry monitoring during their 3%HTS infusion. Patient's cerebral oximetry & GCS changes were compared at 10 min before, and 10, 20 min after 3%HTS infusions. Patients were subgroup and analyzed by their rSO2 initial readings:
1. Abnormal Cerebral Pathology: rSO2 < 60 or >80,
2. Normal Cerebral Pathology: rSO2 60-80.

Results: Age 3.96(2.3, 8.4), All TBI groups GCS changes before & after 3%HTS were 10( 9,10) & 13( 13,14) , GCS difference 4(3,4) p < 0.0001. 3%HTS infusion time from start to the first 15% change in Left & Right rSO2 was 1.5 minutes( 1.1, 2.0). Table 1

Conclusions: This preliminary study has demonstrated the ability of Cerebral Oximetry to detect the real-time effects of 3%HTS on the altered non-inutbated TBI patient's cerebral physiology in an ED. In isolated non-intubated altered TBI PED patients with or without abnormal cerebral pathology (epidural and or subdural) the 3%HTS effect on their cerebral physiology as defined by cerebral oximetry changes were highly significant and correlated with GCS changes. Cerebral Oximetry monitoring has shown its capabilities as an objective neuro-assessment and monitoring tool in altered non-intubated TBI patient's cerebral physiology and response to therapy. This study along with our prior studies further substantiate cerebral oximetry’s utilization in euro-emergencies and neuroresuscitation and a standard neuro-monitoring tool in the ED.

1.Lumba-Brown.: 3%HTS as a therapy for pediatric concussive pain: a randomized controlled trial of symptom treatment in the emergency department Pediatr Emerg Care. 2014 Mar;30(3):139-45

Objective: Since 2005, the Italian State has established an extraordinary endowment of antidotes for terrorists chemical and radio-nuclear events (Scorta Nazionale Antidoti-SNA). Charged by the Ministry of Health, the Pavia Poison Control Centre (PPCC) is the clinical unit responsible for (i) the diagnostic-therapeutic specialist consultation for non-conventional attacks, (ii) the SNA operational management (e.g. upgrade, distribution planning), and (iii) the continuous training of the Italian NHS. SNA is organized on national scale (regional and national stockpiles, located in hospitals and in State’s deposits, respectively), and is an intangible stockpile whose integrity is essential to fulfill its functions. However, when an absolute shortage of an antidote occurs in the NHS hospitals and the antidotal treatment of intoxicated patients is necessary, a quote of the SNA stockpile can be extraordinarily mobilized. Operational procedure need a clinical evaluation by the PPCC first, and then an on-time authorization by the Ministry of Health. Rapid replacement of the mobilized amounts by the requiring hospital is a procedural obligation. To evaluate the SNA’s extraordinary mobilizations (SNA-EM) in a seven-year period. Methods: We investigated all SNA-EM authorized/made in the period 2008-2014. For each mobilization (i) the cause of the extraordinary request (clinical indications, antidotes availability/shortage in neighboring hospital and Poison Centers), (ii) the time required for the antidotes arrival to the requiring hospital and (iii) the SNA stockpile involved were assessed. Results: Exceptional mobilizations from the SNA to the NHS hospitals were performed 25 times (for 28 patients), always linked to single/multiple poisoning from conventional causes/events. The mobilized antidotes were pralidoxime (n=17), DMSA (n=3), DMPS (n=2), hydroxocobalamin (n=1), methylene-blue (n=1) and Prussian-blue (n=1). In 21 cases, SNA-EM occurred to hospitals located in the same region of the SNA deposit and in 4 toward different regions. In some cases, the mobilized antidotes (DMPS, prussian-blue and DMSA) are rarely used and difficult to find in the NHS hospitals. Conclusions: SNA is an essential facility in each country in order to have the necessary antidotes in case of exceptional events. The Italian current organization of SNA, considered highly important in EU, combine clinical toxicological expertise and antidotes supply in order to obtain diagnostic and therapeutic appropriateness. Nevertheless, this organization has proven useful and able to overcome the hospital shortcomings of normal/rare antidotes in cases where toxic agents are unusual or the need for antidotes exceed the normal hospital availability. Acknowledgements: Support of Ministry of Health (4393/2013-CCM).

Objective: EU marketed viper antivenoms differ for pharmaceutical characteristics (e.g. Fab/F(ab’)₂, equine/ovine, viper spp. neutralizing activity), dosage and registered route of administration. A different availability in Italian hospitals offers the opportunity to preliminary evaluate the relative frequency of use and the clinical response to treatment with 4 different antivenom.

Methods: All viper bitten patients treated with antivenom referred to Pavia Poison Control Centre from 2013-Oct2015 were retrospectively assessed for sex, age, site of bite, time elapsed between bite and ED admission/antivenom administration, type of antivenom and number of vials, GSS and clinical response (improvement/worsening during 6 hours), need of adjunctive doses, adverse effects. Clinical manifestations were evaluated according to the Grading-Severity-Score (GSS).

Results: 50 patients (age 44,3±27,2 y-o; male 70%) were included; 13 were paediatric (1-13 y-o). Considering geographical distribution, vipera aspis spp. was mainly involved. Upper and lower limbs were involved in 88% and 12% of cases, respectively. Average time between bite and ED-admission was 4 hours (15min-23hours), and 9 hours (40min-26hours) between bite and antivenom administration, that occurred in patients with GSS 2 or 3 (76% and 24%, respectively). The 4 antivenom were administered intravenously: Viper Venom Antiserum-European® (VVAE) (30/50;60%) [7=1 vial, 23=2 vials], Viper Venom Antitoxin® (VVA) (16/50;32%) [11=1 vial, 5=2 vials], ViperaTab® (3/50;6%) [2 vials] and Viekvin® (1/50;2%) [1 vial]. Clinical improvement was observed after 1 and 2 vials of VVAE administration in 86% and 96% of cases, respectively, and after 1 and 2 vials of VVA in 55% and 80% of cases. ViperaTab treated patients (n=3) improved in 66.6%; 1 patient treated with Viekvin (9 years-old) promptly ameliorated. Adjunctive doses of antivenom were needed in 6 patients (12%) aging (except one, 49 y-o) from 2 to 6 years that received only 1 vial of VVAE (1/6;16%) and VVA (5/6;83%). Acute adverse reactions occurred after VVAE (2 cases; angioedema, pruritus) and VVA administration (1 case; mild hypotension). Serum sickness (3 weeks later) occurred in 1 case (VVA). Statistical evaluation requires a greater number of cases.

Conclusions: A different availability of 4 antivenoms is observed in Italian hospitals, with a prevalence of those that declare neutralizing activity against vipera aspis spp. Intravenous administration is usually safe, even if adverse reactions are observed. An initial dose of 2 vials of all formulation is suitable to reduce the probability of worsening and the need of adjunctive doses, especially in paediatric patients.