Introduction. Atrial fibrillation (AF) is the most frequently found sustained arrhythmia in the emergency department. The presence of AF complicates the management of patients presenting as medical emergencies. The treatment is focused on the control of the frequency and cardiac rhythm. AF is associated with an important morbimortality in the form of stroke, thromboembolism and heart failure.

Objective. The aim of the present study is to evaluate the drugs used in treatment of atrial fibrillation in patients with and without prior atrial fibrillation in the emergency department.

Methods. A descriptive observational, and retrospective study in a Hospital Comarcal Del Noroeste Murcia (a rural Centre of Spain) is described. In this study were included all patients aged 18 years with atrial fibrillation as diagnosis in emergency room from the 1st January to the 31th December 2017. We analyzed the pharmacological treatment.

Results. The sample under study is constituted by 209 patients: 116 with previous diagnosis of AF and 93 no. The patients with previous diagnosis of AF had average heart rate 103.27 bpm and the patients without previous AF had average heart rate 101.31 bpm. The treatment used in the emergency department in the patients with previous diagnosis of AF was: electrical cardioversion in 4.3% (5 patients), bisoprolol in 19.83% (23 patients), amiodarone in 20.69% (24 patients), digoxin in 16.38% (19 patients), flecainide in 8.62% (10 patients), diltiazem in 3.44% (4 patients), and other antiarrhythmics in 8.62% (10 patients). The treatment used in the emergency department in the patients without previous diagnosis of AF was: electrical cardioversion in 8.61% (8 patients), bisoprolol in 13.98% (13 patients), amiodarone in 11.84% (11 patients), digoxin in 16.13% (15 patients), flecainide in 4.3% (4 patients), diltiazem in 7.53% (7 patients), and other antiarrhythmics in 12.9% (12 patients). About the patients with previously AF, 54.68% had a sinus rhythm at discharge, and 45.32% remained in AF. Regarding patients without previous diagnosis of AF, 66% had a sinus rhythm at discharge, and 34% remained in AF. The mean time of staying at the emergency room was 508.14 minutes in patients with previously AF and 510.63 minutes in patients without previously AF.

Conclusion. We detected differences in the treatment between patients with de novo AF and previously diagnosis AF but the mean time staying in emergency room was similar in both groups. There is a greater tendency to perform electrical cardioversion in patients without previous AF. About the drugs, greater use was of Bisoprolol, Amiodarone and Digoxin in both groups. Bisoprolol is used in a lesser proportion in patients with previously AF, with greater use of Amiodarone. Sinus rhythm control was obtained in greater proportion in patients without previous diagnosis of AF. The mean time of staying at the emergency room was similar in both groups.

Background

There had recently been a surge in published studies documenting the effectiveness of mechanical intra-arterial thrombectomy (IA) as a treatment for patients with acute ischemia strokes(AIS).This study aim to identify whether there is benefit to direct transport patients with AIS to hospital that be able to provide IA

Methods

We retrospectively recruited all patients receiving IA as the treatment for AIS from January 2016 to December 2018. Neurologist was consulted for all AIS patients . IA criteria including 1. within 8 hours of the time last known to be well for anterior circulation stroke; within 24 hours of the time last known to be well for posterior circulation stroke,2. Computed tomography angiography demonstrated proximal large vessel occlusion,3. National Institutes of Health Stroke Scale (NIHSS) ≧8 or ≦30.Patients were divided into two groups: direct transport to our hospital or transfer from another hospital.The primary outcome of this study was the time since symptoms onset until the time of receiving IA. Our secondary outcomes were NIHSS 24 hours posttreatment , on discharge and Modified Rankin Scale (mRS) on discharge, 1 month follow up, 3 month follow up.

Results

In total, 254 patients were enrolled into this study after excluded those who met the aforementioned exclusion criteria. The majority was males (59.84%) and the transfer group had 148 (0.58) cases. There was no statistically significant in time between symptoms onset to IA between two groups. In the T- test analysis , there was statistically significant difference in NIHSS 24 posttreatment between these two groups(p＝0.002).However, there were no significant difference in NIHSS on discharge in t- test analysis ,or mRS on discharge or further follow-up in chi-square test analysis .

Conclusions

In this retrospective study comprising 254 AIS patients receiving IA, we found there is no difference in NIHSS or mRS between those transferred from another hospital and those who visited our hospital directly.

Case Vignette:

During one of the busy shifts in ED in a DGH, I received a pre alert regarding a 56 years old female who was having continuous seizures for past 30 minutes (SE) and had already received 10mg of P/R diazepam by the paramedics. On arrival she was still having generalized convulsive seizures and I quickly administered I /V LOR 4mg. She continued to seize despite of that and the decision was to give I/V PHT as per the guidelines. Her vital signs showed a SBP of 80mmhg and she had a background of AF.Despite knowing the fact that the most common side effects of PHT are hypotension and arrhythmias, we went ahead and gave the PHT to control the seizures, as per the guidelines. Patient became more hypotensive after that and needed inotropic support. The seizure activity stopped but patient needed RSI and was admitted to ICU.

This raised a question that whether there was an alternative to PHT, which can be used as effectively but more safely. On researching more, I came across LVT, which showed promising results in controlling the seizures and hence prompted me to review the evidence in its use in SE.

Three part Question:

In {adult patients with Status Epilepticus}, is {Levetiracetam a safe and effective second line anti-convulsant compared to Phenytoin}, in {terminating seizures}?

Literature Search:

Using the Athens interface (www.library.nhs.uk), I did a comprehensive literature search of MEDLINE (1946 to date), EMBASE (1980 to present), and CINAHL (1981 to present) databases, searching titles and abstracts, as well as index linking.The abstracts of the 247 unique papers were reviewed to ascertain if they answered the question, using the inclusion and exclusion criteria,this found 8 unique papers.There were 3 retrospective, 2 prospective, one systematic review,one meta analysis and one critical review.

These 8 papers have been critically appraised and reviewed. Levels of evidence have been graded as per the ‘Strengthening the Reporting of Observational studies in Epidemiology’ (STROBE) checklist (scored out of 22, Appendix 1), as well as the Scottish Intercollegiate Guidelines Network¹² (SIGN - Appendix 2). 

Outcome and Conclusion:

All the studies had a clear objective, sound methodology and they showed promising results in terms of the outcome. The efficacy of LVT is comparable to PHT with less serious side effects, although the results were not statistically significant, p value >0.001.All the retrospective case series reported an efficacy between 61.8% to 94% for the use of LVT in SE,especially when used in elderly population with comorbidities,as supported by Z Yasiry⁹ et al, in their meta-analysis.

There is strong evidence to suggest that LVT is a safe and effective drug for its use in SE.The I/V formulation is still not licensed for use in SE, but the accumulating evidence in the literature suggests that the efficacy of LVT is comparable or even better than PHT.The use should be individualised as per the clinical need.

ESSTT³⁰ and ECLIPSE²⁹, are two promising RCT going on at present to compare the safety and efficacy of LVT.

Background: Cerebral edema in traumatic brain injury can lead to cerebral herniation and result in disability or death. Decompressive craniectomy (DC) has been performed for the purpose of relieving elevated intracranial pressure with outcome improvement in severe TBI patients. However, there was little evidence whether DC was effective for outcome of TBI patients. We assessed the relationship between decompressive craniectomy for patients with severe traumatic brain injury and the prognosis using nation-wide hospital-based trauma registry in Japan.

Methods: Using Japanese Trauma Data Bank, we included severe traumatic brain injury patients whose head AIS scores were 3 and over and registered from 2004 to 2017 in this study. Multivariable logistic regression analysis and conditional logistic regression analysis were used to assess the association between decompressive craniectomy and the prognosis of traumatic brain injury patients after one-to-one propensity score matching for DC versus non-DC. The primary outcome was dead at hospital discharge.

Results: Among 69411 eligible patients with severe traumatic brain injury, 1523 patients (2.2%) received DC and 67888 patients (97.8%) did not receive DC. In the univariate analysis, the proportion of dead at discharge was higher in the DC group than the non-DC group (36.5% [556/1523] vs. 14.5% [9828/67888]). In the multivariate analysis, the DC group showed a more favorable survival outcome than the non-DC group (adjusted OR 0.294, 95% CI; 0.265-0.327). However, in the propensity-matched cohort, the DC group did not show a more favorable survival outcome than the non-DC group (68.7% [1045/1522] vs. 63.5% [967/1522], adjusted OR 0.787, 95% CI; 0.675-0.919).

Conclusion: Decompressive craniectomy may not be effective for patients with severe traumatic brain injury.

Background:

Hong Kong has established an inclusive trauma system since the early 2000, and local trauma registries have been using TRISS methodology for audit and benchmarking purposes since its establishment. TraumaRegister DGU in Germany devised its own probability of survival model using data from its 900 trauma centres. RISC II was demonstrated to be superior to TRISS in Germany, and includes pre-trauma ASA, pupil size and reactivity, pre-hospital CPR and laboratory results including INR, base deficit and haemoglobin on top of those parameters used in TRISS. The aim is to compare the predictive ability of the probability of survival calculated using TRISS and RISC II for major trauma patients in Hong Kong.

Methods:

This was a retrospective cohort study using data from all five trauma centres in Hong Kong. Adult major trauma patients (ISS>15) from January 2013 to December 2015 were extracted from the five respective trauma registries. Parameters for TRISS was collected prospectively, and those extra data points in the RISC II scores were retrieved retrospectively. The primary outcome was the area under the ROC curve for TRISS and RISC II using the expected and observed 30-day mortality. Probabilities of survival (Ps) were derived by TRISS with MTOS coefficients and RISC II methodology. The Hosmer-Lemeshow goodness of fit test was used to test for the calibration of the model. Subgroups analyses investigated the performance of TRISS and RISC II for the mechanism of injury and age>80. Ethics approval has been obtained from the local review board.

Results:

1864 patients were recruited during the study period. 67.2% was male and the median age was 60 years old. The median ISS was 24, with 40% of patients with ISS over 25. Low fall was the most common mechanism of injury, with head and neck being the most commonly injured body region. The 30-day mortality was 22.4%. The expected mortality was 20.0% using TRISS and 19.7% from RISC II. The AUC was 84.8% (CI 82.7 to 86.9) and HL test 63.2 (p<0.001) for TRISS. RISC II yielded a superior AUC of 89.6% (CI 88.1 to 91.2) and HL test of 78.9 (p<0.001).

Subgroup analyses showed that both score performed worse for ISS 25 or above (AUC: TRISS 80.4%, RISC II 87.7%), age 80 or above (AUC: TRISS 80.6%, RISC II 82.9%), low falls (<2m) (AUC: TRISS 81.7%, RISC II 85.5%), and significant head or neck injury (AIS 3 or above) (AUC: TRISS 83.1%, RISC II 87.7%). RISC II had performed significantly better than TRISS for all subgroups, except in age 80 or above and low falls.

Conclusion:

RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult trauma patients with ISS >15. RISC II also significantly better than TRISS in all subgroups, except in age 80 or above and low falls. These points should be taken note when performing future audit or benchmarking exercises.

Background

NICE Major Trauma Guidelines, introduced in February 2016, support the administration of 1g bolus of tranexamic acid (TXA) within 3-hours in patients with major trauma and active or suspected bleeding, followed by a further 1g over 8-hours. This recommendation, based on evidence from the CRASH-2 trial, illustrated a significant time-dependent mortality benefit. The Queen Elizabeth University Hospital (QEUH), Glasgow, receives the majority of the West of Scotland’s major trauma and was identified as a site where appropriate administration of TXA could yield most benefit.

Aims

To assess those patients admitted to the QEUH, who were administered 1g TXA and whether this was within 3 hours of injury as per NICE guidelines. The second aim was to identify how many of these patients go on to have a second dose of TXA administered as an infusion over 8-hours when clinically indicated.

Methods

After review of supporting literature, a retrospective cohort study was designed. Study population included all trauma patients who were admitted to the QEUH and received TXA between 01/11/2017-28/08/2018.  Data concerning demographics and TXA administration were collected electronically from the trauma registry (eSTAG) and verified using electronic clinical records. Twenty-five secondary transfers were excluded as well as ten patients with insufficient data. Data is presented as a mean (standard deviation) or as a median (interquartile range) as appropriate.

Results

One hundred and fourteen patients were identified by eSTAG as having received TXA and were admitted to the QEUH. Of these, 79 patients were analysed and 35 were excluded. Seventy-three (92.4%) patients received their initial dose of TXA within 3 hours and 6 (7.6%) did not. Median time to first dose was 70 minutes (44-110 minutes). Only 1 (0.79%) patient received an incorrect dose of 200mg, all others received 1g.

Of the 79 patients, 9 received a second dose of TXA, 3 as an infusion. All second doses were given within 24 hours of the initial TXA dose, median time 115 minutes (65-162.5). One patient received a second dose of 800mg, the rest received 1g.

Discussion and Recommendations

In spite of current trial data demonstrating a significant reduction in mortality following use of TXA in major trauma with suspected bleeding, this study indicates that this has not yet been incorporated into clinical practice. This is especially true regarding administration of a second dose with only 9 patients receiving this dose and with none of these following the protocol outlined in the literature. One reason secondary dosing might be so low is that it may not be indicated if patients were found not to be actively bleeding. Not being able to verify those that had a clinical indication and those that did not is a limitation of the study.

With current evidence supporting administration of a secondary TXA dose further efforts should be made to encourage this through education of both pre-hospital and hospital practitioners. It should also be highlighted that first dosing of TXA after 3 hours has been associated with higher rates of mortality and should therefore be avoided.

Epidemiology and outcomes of trauma patients at The Indus Hospital, Karachi. Challenges and opportunities. Authors: Saima Salman, Syed Ghazanfar Saleem, Qurat ul Ain Sheikh3, Kaniz Farwa Haider4, Megan Rybarczyk5, Zayed Yasin6, Lubna Samad7, Anna Q Yaffee8. CONFLICT OF INTEREST: No conflict of interest FUNDING: No external funding was sought for this research work ABSTRACT: Introduction: Structured trauma care has been proven in literature to improve patient outcome. Many organized systems are established across the globe to familiarize and train Emergency Physicians with basic and advance trauma care. The need is more pronounced in low and middle income countries (LMICs) where limited resources and poorly structured health care systems add to the challenges of trauma care with increase in morbidity and mortality. Characterization of epidemiology of trauma helps in identification of risk factors, injury severity and outcomes and establishes the baseline upon which interventions can be structured. Objective: To characterize the epidemiology of trauma patients presenting to the emergency department (ED) at The Indus Hospital (TIH) in Karachi, Pakistan including demographics, presenting Injury Severity Score (ISS), interventions and disposition. Methodology: One year Retrospective chart review of all poly-trauma patients older than 14 years from July 2017 to June 2018 presenting to TIH ED was conducted. Results: Out of 972 trauma patients presenting to TIH ED, 663 (68.2%) were males and 309 (31.7%) were females. Road traffic accidents were the most common mode of presentation with 766 patients (78.8%) followed by 121 falls (12.7%). Injury Severity score (ISS) was calculated upon arrival and 528 (54.3%) were found to be critically injured. All 365 discharged patients (100%) were moderately injured with scores of 9-15 and there was 100% mortality of the maximally injured nine patients with scores of 75. However, only 3.4% of these patients received a Focused Assessment Sonography in Trauma (FAST) ultrasound and none received further helical imaging of chest or abdomen. 90% received intravenous fluids but only 3.4% received a blood transfusion. Industrial trauma (p value 0.01) and falls (p value 0.007) were more common in men whereas burn victims were mostly women (p value 0.0001).  CONCLUSION: Given the unique position of TIH in terms of public-private partnership and philanthropy, the characterization of trauma patients presenting to TIH has strengthened our belief that patient outcomes can be improved through structured approach to trauma patients within the golden hour of trauma management through better inter specialty collaboration and lean utilization of resources. By identifying the gaps within patient management it is our hope that through interventions for capacity building, we will have a positive impact on patient outcome, specifically survival to discharge and stabilization/ diagnostic procedures received. KEY WORDS: Pakistan, Injury, Trauma, Injury Severity Score (ISS), Low and middle income countries (LMIC)

Objectives We sought to estimate the prevalence of patients with cancer presenting to the emergency department (ED) who are undergoing treatment with immune checkpoint blockade (ICB) therapy; report their chief complaints; describe and estimate the prevalence of immune-related adverse events (IRAEs).

Methods Four abstractors reviewed the medical records of patients with cancer treated with ICB who presented to an ED in Paris, France between January 2012 and June 2017. Chief complaints, underlying malignancy and ICB characteristics, and the final diagnoses according to the emergency physician were recorded. Abstractors noted if an emergency physician identified that a patient was receiving an ICB and if the emergency physician considered the possibility of an IRAE. The gold standard as to whether an IRAE was the cause was the patients’ referring oncologist’s opinion that the ED symptoms were attributed to ICB and IRAE according to post-ED medical records. Descriptive statistics were reported.

Results Among the 409 patients treated with ICB at our institution, 139 presented to the ED. Chief complaints were fatigue (25.2%), fever (23%), vomiting (13.7%), diarrhoea (13.7%), dyspnoea (12.2%), abdominal pain (11.5%), confusion (8.6%) and headache (7.9%). Symptoms were due to IRAEs in 20 (14.4%) cases. The most frequent IRAEs were colitis (40%), endocrine toxicity (30%), hepatitis (25%) and pulmonary toxicity (5%). Patients with IRAEs compared with those without them more frequently had melanoma; had received more distinct courses of ICB treatment, an increased number of ICB medications and ICB cycles; and had a shorter time course since the last infusion of ICB. Emergency physicians considered the possibility of an IRAE in 24 (17.3%) of cases and diagnosed IRAE in 10 (50%) of those with later confirmed IRAE. IRAE was more likely to be missed when the referring oncologist was not contacted or when the patient had respiratory symptoms, fatigue or fever.

Conclusions ICB exposes patients to potentially severe IRAEs. Emergency physicians must identify patients treated with ICB and consider their toxicity when patients present to the ED with symptoms compatible with IRAEs.

Background–High –fidelity resuscitation training is near to become the gold standard for training physicians on cardiopulmonary resuscitation techniques. Nevertheless, its effectiveness remains unknown.

Objective–The objective of this study is to identify and synthesise the best available evidence for the effectiveness of high versus low fidelity simulation in physicians’ resuscitation training.

Data source-A systematic search of Pubmed and Embase was conducted considering the period from 1^stJanuary 2008 to 31^stDecember 2017.

Study selection-The research manuscripts evaluating High-fidelity simulation compared with low-fidelity in the training of physicians for CPR were considered for analysis.

Data extraction-Outcomes including written tests results, megacode scoring and other cardiopulmonary resuscitation (CPR) performance assessments were evaluated. The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the overall quality of evidence for each outcome. A fixed effect model was used, assuming standard mean as the effect measure.

Results-545 papers were eligible from the literature search and 17 were included in the analysis (16 RCT’s and one paired cohort study). Meta-analysis of skills performance evaluationusing megacode scoring evidenced a moderate benefit for High-fidelity simulation training when compared with low fidelity programs [SMD 0.54; 95% CI −0.36 to 0.73]. Similarly, written test results were better for High-fidelity simulation learners than for low fidelity simulation trainees [SMD 0.47; 95% CI 0.21 to 0.73]. Time to first compression favored adding some experimental intervention to High-fidelity simulation instead of High-fidelity alone [SMD 0.53; 95% CI 0.39 to 0.68]. 

Conclusion-The training of physicians on CPR with the use of High-fidelity simulation programs results in best technical and non-technical skills performances and increases theoretical knowledge.

Background:

The rate of occurrence of anaphylaxis is increasing in the Emergency Department (ED).

Understanding potential triggers and patient-specific risk factors for severity and fatality is the key to performing appropriate risk assessment in those who have previously experienced an acute anaphylactic episode.

Objective:  

To describe the epidemiology, clinical features, management and outcome of patients with anaphylaxis in ED.

Methods:

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

Results:

A total of 687 patients were included. The mean age was 40 ±15years. Sex ratio=0,74.A history of anaphylaxis was reported in 40 % of cases. Cutaneous features were present in 96% of patients. Respiratory, cardiovascular, gastrointestinal and neurologic features were found respectively in 27, 22, 16 and 2%. Causative agent was known in 84% of cases. Most common category of causes n (%): drugs 363 (52,8%), food 170(24,7%) and insects 37(5,4%). No causes were apparent in 16,2% of cases. An anaphylactic shock was recorded in 336 patients (49%). Five factors were identified to be predictive for anaphylactic shock occurrence: history of anaphylaxis, anaphylaxis induced by antibiotics, parenteral administration, neurologic features and time elapsed between symptoms onset and the first medical contact equal to one hour. Adrenaline was used in 42%of patients, intravenously in 16,2%,via a breathing mask in 177 patients (25,8%).Fluid resuscitation was given to 610patients(89%).409 patients (59,5%) received histamine H1 antagonist, 658 patients (95,8%) received corticosteroids. 86%  of patients were discharged directly from ED after a mean period of observation of 5 hours. Biphasic reactions were reported in 13 patients. There was no death cases registered. Patients with drugs anaphylaxis were all referred to the allergy clinic.

Conclusion :

Anaphylaxis requires prompt recognition and management to improve patient outcomes.

Background: In the last decades, substance abuse has been mostly steady, with the exception of a significant increase in cannabinoids and cocaine circulation. From a clinical point of view, emergency department (ED) clinicians may evaluate substance abusers for a wide variety of symptoms. While adults and adolescents usually come to the ED with well-known clinical manifestations, no studies have thoroughly investigated how passive cocaine exposure might reveal itself in younger children.

Objectives: The aim of the study was to investigate the prevalence and describe presenting complaints and clinical manifestations of unsuspected exposure to cocaine in children attending to the pediatric ED.

Methods: We performed a retrospective study of children below 16 years of age evaluated in the ED of a tertiary care Pediatric Hospital of Padua, Italy, in 2018. Children were included if they received urine or blood toxicology screenings, in absence of a clear history of cocaine exposure.

Results: 102 children under 16 years underwent toxicology screening after evaluation in our Pediatric ED, 13 children showed positivity of urine or blood screening. Of these, 12 had confirmation of cocaine exposure by second-level analyses. Three were evaluated for signs and symptoms compatible with a first episode of absence epilepsy [Odds Ratio (OR) of cocaine exposure in these patients = 14.7, 95% confidence interval (CI) 2.16-99.7, p<0.05]. Other signs such as first convulsive episodes [OR = 1.44, 95% CI 0.35-5.87], tachycardia [OR = 2.52, 95% CI 0.58-10.94] or irritability [OR = 2.04, 95% CI 0.61-6.9] showed no correlation with confirmed cocaine exposure. All 13 patients were hospitalized, nine (69%) resulted positive for other substances, the most frequent being cannabinoids. Ten patients had dysfunctional family dynamics that would mostly surface during hospitalization, and were not investigated in the ED history-taking.

Conclusion: With the increase in cocaine abuse among adults, the risk of transfer to children is also increasing. Unfortunately, no single sign and symptom can be used to accurately identify children who have been exposed to cocaine. Toxicology screens may be useful for children presenting to the ED with suspicion of absence epilepsy. Clinicians should consider cocaine exposure in infants and children presenting with non-specific signs and symptoms, seizures or movement disorders. Larger studies will be needed to develop a prediction model of cocaine exposure in childhood.

BACKGROUND: In hospitalized medical patients, the venous thromboembolism (VTE) risk is notable. Nevertheless, the available assessment model (TPF) is generally underused. In this work, we propose an ex novo risk assessment model based on the elaboration of the clinical data exhibited by the VET patients. Differently from previous studies, the proposed approach does not exploit pre-established models, resulting in a more valid and easy-to-use score.
METHODS: We performed a double case-control observational study. For each case of VTE, we enrolled two consecutive patients without VTE of equal sex and age group.
RESULTS: We analyzed the data of 1215 patients, 409 with VTE and 806 case-control. 365 patients (30%) were in charge to the EM department, while 850 patients (70%) to the IM one. The VTE risk factors with more statistical significance (P<0.01) are: 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 are resulted at intermediate statistical significance (P<0.05 but >0.01). A multiple logistic regression was used with robust standard errors and forward selection of the candidate variables using the Bayesian information criterion. A new score is developed, the “TEVere Score”, which shows a higher specificity and sensitivity (respectively 43.3 and 87.5, with accuracy 72.1) compared with the Padua, the Kuscer and the Chopard Score. TEVere Score also exhibits a greater predictive validity for thromboembolism risk (AUROC 0.7266; 95% CI: 0.71 to 0.73) than the Kuscer Score (AUROC 0.6891; 95% CI: 0.67 to 0.70) (P=0.0093).
CONCLUSIONS: The TEVere Score has proven to exhibit a higher accuracy than the other scores commonly used in clinical practice to stratify the thromboembolism risk.

Background: Acute heart failure (AHF) patients with high levels of troponin have a worse prognosis. High-sensitive troponin T (hs-TnT) has been used as a tool to stratify prognosis in many scales but always as a qualitative variable, not as a quantitative one.

Objectives: The main objective of this study is to determine a cut-off for hs-TnT with an elevated  negative predictive value (NPV) for 30-day all-cause mortality.

Methods: We analyzed the EAHFE registry, a prospective follow-up cohort of patients with AHF. A propensity score analysis of the optimal hs-TnT cut-off point was performed, previously determined by a receiver operating characteristic (ROC) curve analysis.

Results: Of the 13791 patients in the EAHFE cohort, we analyzed 3190 patients in whom hs-TnT determination was available. The area under the ROC curve for 30-day all-cause mortality was 0.70 (95%CI 0.68 to 0.71; p < 0.001) and established an optimal cut-off of hs-TnT of 35 ng/L. The sensitivity and specificity for this cut-off were 76.2 and 55.5%, respectively, with a NPV of 95.3%. Thirty-four variables showed differences based on the cut-off of 35 ng/L for hs-TnT and a propensity score was made with them. A greater mortality at 30 days was shown in patients with hs-TnT > 35 ng/L in the analysis of the population obtained with the propensity score, with a HR of 2.95 (CI95% 1.83 – 4.75; p < 0.001).

Conclusions: A hs-TnT value of 35 ng/L is an adequate cut-off point to evaluate 30-day all-cause mortality with a NPV of  95.3%

Introduction:

Digoxin was the cornerstone of heart failure therapy for decades due to its positive inotropic and neuro-hormonal modulation properties until the change of paradigm in heart failure pathophysiology. Our study evaluates outcomes stratified by heart function status in patients with heart failure treated with digoxin.

Materials and methods:

This is a prospective randomized ,  double blind ,placebo controlled parallel group multicenter clinical trial  . We randomly assigned  patients with  heart failure to treatment with digoxin or placebo(median dose of digoxin  is 0.25 mg per day). The effects of each one on hemodynamic parameters : systolic time interval , cardiac output , left ventricular ejection fraction and BNP level were compared during a period of 48 hours , double –blind trial  ,performed at the emergency unit of Fattouma Bourguiba hospital in Monastir over a period of four  years( 2016-2017-2018-2019).We also aimed to compare the risk of mortality and  hospital stay time with digoxin use versus no digoxin in patients with heart failure. The diagnosis of heart failure was based on current or previous symptoms such as dyspnea, radiologic or echo graphic evidence of pulmonary congestion ,BNP level > 350 pg / ml or  NT proBNP > 1400 pg/ml.  Participants were excluded if they already received digoxin as a background treatment. Those who had a pacemaker or suffered from severe renal impairment (creatinine clearance of less than 30 ml/min) were also excluded.

Results :

We have been collecting during 2016,2017,2018 and 2019 ,  cases of patients with heart failure and only 438 of them have met eligibility criteria  : 104 of them have received digoxin while 229 of them did not.

In our study ,  both groups had comparable demographic characteristics .There was no significant difference between the two groups ,in terms of age , sex or NYHA functional classification .

The increase of cardiac output within two days : 11.35 % in the group treated with digoxin ,7.75 % in the other group (without significant difference).
The increase of the systolic ejection fraction : 7.39 % in the group treated with digoxin ,2 % in the other group. The difference between both results appear to be significant

Systolic time intervals: pre-ejection period  decreased by 12.67 % in the group treated with digoxin ,1.01 % in the other group (the difference was highly significant)

( p= 0.02). Left ventricle ejection time  increased by  0.82 % in the digoxin group , 0.2 % in the other group . The difference was estimated to amount to 0.037.

  ED length of stay in the digoxin group : 6.67 days , 10 days  in the placebo group . The difference between the two was significantly high (p = 0.019). Death rate in the hospital : 1 % in the digoxin group and 0 % in the other group . The difference was not significant (p=0.78 ).

 Conclusion : In patients with acute heart failure  , short course digoxin is  associated with an improvement of  heart function parameters  and decrease of hospital length of stay.

Background: The electrocardiogram (ECG) remains central in the risk stratification of non ST-segment elevation acute coronary syndrome (NSTEMI). The ST segment depression appears to be the most predictive marker of mortality at day 30 and at one year. Recently, many studies had demonstrated that the sum of ST-segment depression provides much more information than the simple qualitative assessment of ST-segment depression>0.5 mm.

Objective: To find out the association between the sum of magnitude of ST segment depression and angiographic severity in NSTEMI patients.

Methods: A prospective observational study was conducted over six years. Patients with the diagnosis of NSTEMI and an ST segment depression > 0.5 millimeters (mm) in at least one lead were included. ST segment depression was measured and the cumulative sum of the ST-segment depression, in mm was calculated. The location, the number of leads with ST segment depression was also measured in all ECG leads. The prognosis was based on the evaluation of major adverse cardiac event (MACE) at six months.

Angiographic severity was assessed by a validated vessel score. The sum of the magnitude of ST segment depression was correlated with angiographic severity of coronary artery disease.

Results: Inclusion of 287 patients. Mean age was 62±11 years. Sex ratio = 1.7. Comorbidities (%): hypertension (59), diabetes (45), dyslipidemia (33), coronary artery disease (28). Mean sum of ST segment depression was 5 [1,28].

Mean delay of door to balloon = 4 hours [1, 72]. Twenty seven percent of patients developed a MACE.  In multivariate analysis a cumulative sum of ST-segment depression > 7 mm (adjusted OR = 5.34, p <0.001, 95% CI [2.71 to 10.51]) was independently associated with MACE at six months.

Positive correlation was found between the sum of ST segment depression, the number of leads with ST segment depression and the severity of coronary artery disease with (r=0.352; p<0.0,1) and (r= 0.361; p<0.001) respectively. 

Conclusion: This study shows that the sum of ST segment depression in all ECG leads is a powerful predictor of severity of coronary artery disease.

Background:

The ability to perform high quality chest compressions is one of the basic skills that medical staff should have. Current CPR guidelines recommend performing chest compression in infants and newborns using either two fingers (TFT) or two thumbs (TTHT). However, both have their advantages and disadvantages. In the first case, as shown by the studies, there is full chest recoil, however, the chest is pressed too shallow, in the second case the results are the opposite. The aim of the study was to compare these two methods with the authors' own new method of chest compression. 

Methods:

This was prospective, randomized, crossover, observational, simulation trial. The study involved 60 nurses who participated in Basic Life Support trainings. After the correct demonstration of the recommended compression methods (TFT and TTHT) and the innovative chest compression method (nTTT) based on thumbs perpendicular to the chest,  the participants had the opportunity to practice individual methods with the use of an infant simulator. During the study, participants were asked to perform 2-minute neonatal resuscitation based on continuous chest compression. Both the sequence of participants and methods of chest compression were random and ResearchRandomizer was used for this purpose. The study analyzed the depth and rate of chest compression as well as the correctness of chest recoil.

Results:

The study involved 60 nurses whose median age was 43 years (IQR; 32-48), and work experience achieved 17 years (IQR; 5-25). The median depth of chest compression based on particular compression techniques (TFT, TTHT, nTTT) was differentiated and achieved 32 mm (29-35) vs. 41 mm (37-42) vs. 40 mm (37-42; p<0.001) respectively. The rate of compression was the highest for TFT and was 127 (118-130) compressions per minute (CPM), followed by 115 CPM (108-122) and 112 CPM (102-120; p<0.001) for TTHT and nTTT (102-120; p<0.001), respectively. Correctness of chest recoil was 96% (83-100) for TFT, 35% (29-43) for TTHT, and 96% (89-100) for nTTT.

Discussion and Conclusions:

The results of the study show that the nurses participating in the study performed the highest quality chest compressions on the newborn using the new authors method of chest compression nTTT. Further research is needed to verify the results obtained in the study. 

OBJECTIVES: High-quality CPR including early defibrillation, uninterrupted chest compression and optimal airway management are primary components associated with return of spontaneous circulation (ROSC) and preventing neurological impairment. We hypothesized that the multi-tier response will provide higher quality of CPR including airway management, but the type of combination will make different interaction to the airway management for outcomes after OHCA. The aim of this study was to determine the effect of advanced airway management method on outcomes and compare the effect size across the multi-tier response type on outcomes after OHCA.

METHODS: This study was a retrospective and observational cohort study utilizing the Korea OHCA Registry (KOHCAR), which included all adult EMS-assessed OHCA patients with presumed cardiac etiology. The study period was from January 2015 to December 2017. Airway management methods were categorized into the endotracheal intubation (ETI) group and supraglottic airway (SGA) group. Tier system were divided into single-tier response and two types of multi-tier response (MTR) including an ambulance-ambulance multi-tier response (ATR) and an ambulance fire engine multi-tier response (FTR). Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to show the association between airway management/tier type and patients with ROSC rate, survival to discharge rate and neurological outcomes. Multivariable logistic regression analysis performed to assess the interaction effects of airway management method and tier type.

RESULTS: Among 87,551 EMS-assessed OHCAs during the study period, a total of 25,888 patients were analyzed. In comparison of single-tier response and MTR type, ATR was significantly associated with higher ROSC rate, survival to discharge and neurologic outcomes than single-tier response. However, there was no significance difference between FTR and single-tier response. Interaction analysis shows that regardless of tier type, SGA was significantly lower ROSC rate than ETI.

CONCLUSION: In this nationwide observational cohort study, we observed that ATR provide good clinical outcomes than single-tier response or FTR. And regardless of tier system, SGA showed significantly lower ROSC rate than ETI. The indeterminate evidence of optimum airway management and tier type for OHCA has encouraged calls for randomized controlled trials to clarify precise circumstances, patients’ conditions and characteristic of the EMS system and survival outcomes.

BACKGROUND:

Point-of-care ultrasound (POCUS) offers additive value in the diagnosis and treatment of emergency and/or critically ill patients. To help spread this medical practice in Romania within the nonradiologist community, under EUSEM guidance we conducted a POCUS course. The course was done in a single major university medical centre of Romania under the guidance of established POCUS faculty.

OBJECTIVE:

Our aim was to characterize the current practice of emergency physician and the effect of the POCUS course on the practice of junior, registrar and consultant level doctors that had no or not enough previous ultrasound (US) experience.

METHODS:

A 11-question anonymous survey was emailed to 40 graduates over a 4-week period, before the course and 2 months after attending.  All the participants had as their primary speciality Emergency Medicine.

No incentives were provided for completion of the questionnaire. Descriptive statistics are reported.

RESULTS:

A total of 21 participants completed the study for a response rate of 52.5%.

For the vast majority of them, this was the first ultrasonography course they attended, but 28.7% attended an US course previously.

Out of the doctors that completed the questionnaire 66,66 % were registrars, 28,58% consultants and just 4,76% junior doctors. Interesting note is the fact that although without previous formal training 71,42% were already using US in their practice, this percentage increasing to 100% after attending the course. Those that used US in their daily practice used it quite rarely, 47,61% reporting using it less than 2 times per month, justifying this due to lack of time (66,66%) but also lack of legislation to support them (28,57%). 33.33% of the participants also named the lack of trust of other specialities as an important discouragement. The main situations in which US was used in the ED was to check for cardiac activity in PEA (76,19%), detecting free intraabdominal fluid in trauma (57,14%) and facilitating invasive procedures such as central venous access and pleural taps. A majority also used POCUS to guide them in the ALS protocols especially in reversible cases such as hypothermia and cardiac tamponade but also in making decisions to stop resuscitation.

The second questionnaire showed an increase in US usage in the ED but the users did not rely on their findings and requested second opinions in severe cases.

CONCLUSION: The analysis shows that the interest in POCUS, especially in the Emergency Department, is quite high in Romania. This tendency is more common in the younger generation of doctors (juniors and registrars) who prefer to use it in answering quick FAST questions but also aiding in making tough ALS/ATLS protocol decisions and in invasive procedures. Further similar undertakings will probably open ground for more US based protocols making this practice more common in Romania and Easter European countries.

Emergency ultrasound should be introduced into an emergency medical service area as a diagnostic modality that provides benefits to patients. Emergency physicians have to be specifically trained and to participate in continuous education activities.

Background

The year 2013 saw the publication of minimum standards for medical teams working internationally in response to disasters.  This has been a true game-changer and pivot point for emergency medical team (EMT) practice worldwide and has set in motion a process of world health organisation (WHO) verification which seeks to ensure that EMTs are working to a minimum acceptable standard and when called upon to assist a foreign government with a disaster, they are actually able to perform as expected.  Within this process it was recognised that in order for EMTs to develop to this standard, certain guidelines for best practice would be needed.  One area which warranted its own working group was the minimum data set (MDS) for daily reporting.  In 2017 the WHO produced its first MDS for EMT daily reporting during sudden onset disasters (SODs), following expert consensus.  The initial challenge lies in ensuring EMTs adopt this MDS under the direction of in-country ministries of health (MoHs). However the subsequent challenge is understanding the utility of the data to help resource-manage an acute response.  This study looks at the specific coding of injuries to determine how reproducible the coding of severity is between practitioners using the WHO EMT MDS.

Methods

25 clinical case vignettes were developed to reflect potential injuries encountered in a SOD. These were presented in an online format between April and July 2018 to practitioners who have experience of/training in managing patients in SODs.  The pool of participants was derived from three sources: UK-Med’s register members, the Australian Medical Assistance Team (AUSMAT)’s Northern Territory members and the New Zealand Medical Assistance Team (NZMAT) clinical members.  UK-Med hosts and trains National Health Service (NHS) medical staff for the UK Emergency Medical Team (UK EMT) and both AUSMAT and NZMAT have a register of practitioners engaged in and interested in disaster response.  The participant pool was restricted to those who encounter injured patients in their clinical practice.  Practitioners were asked to code each injury according to the WHO EMT MDS case classifications.  Randolph’s kappa statistic for free-marginal multi-rater data was calculated for the whole data-set as well as subgroups to ascertain inter-rater agreement

Results

86 practitioners responded, giving >2000 individual case responses. Overall agreement was moderate at 67.9% with a kappa of 0.59 [CI 0.49,0.69].  Despite subgroups of paramedics (kappa 0.63 [CI 0.53,0.72]), doctors (kappa 0.61 [CI 0.52, 0.69]) and those with disaster experience (kappa 0.62 [CI 0.52, 0.71]) suggesting slightly higher agreement, their CIs (and those of other subgroups) suggest overall similar and moderate levels of practitioner agreement in classifying severity of injury.

Conclusions

An inter-rater agreement of 0.59 is considered moderate, at best, however it gives MoHs some sense of how tightly they may interpret injury data derived from daily reports using the WHO EMT MDS.  Similar studies, with weighting for injury likelihood using sample data from true SODs would further refine the level of interrater agreement to be expected. Consequently MoHs may develop appropriate frameworks of resource allocation during SODs.

INTRODUCTION: 

Patients presenting with acute cholecystitis to the emergency department will often have to wait for a diagnostic radiology performed ultrasound (US). Point of care ultrasonography (POCUS) with targeted images of the gallbladder has the potential to assist in early identification and expedite management. Our objectives are to identify the clinical features and the potential role that POCUS may have for emergency physicians (EPs) and general surgeons (GS) in the diagnosis of acute cholecystitis in the emergency department.

 METHODS: 

An electronic survey with questions relating to diagnosis, management and use of biliary POCUS in patients with acute cholecystitis was devised. The survey was pilot tested by two EPs and two GS. Staff EPs and GS at an urban academic hospital were invited to participate in the survey using a modified Dillman method as part of a quality improvement project. Descriptive statistics were used to analyze the data.

 RESULTS:

The response rate for EPs was 76% (59/78) and GS was 68% (17/25). Both EPs and GS used a constellation of clinical signs and symptoms, laboratory and radiological investigations for the diagnosis of acute cholecystitis. Only 22% of EPs and 18% of GS were confident in interpreting US images for acute cholecystitis with most not reviewing or interpreting radiology performed US images in the course of patient care. Although most EPs (95%) utilize POCUS in their daily practice, only 39% of EPs perform biliary POCUS, citing limited exposure and training and non-acceptance by GS as main barriers to use. None of the GS perform biliary POCUS themselves and 70% did not feel comfortable using biliary POCUS to diagnose acute cholecystitis. In three different clinical scenarios involving patients presenting with acute cholecystitis in the emergency department with POCUS findings presented, over 80% of ACS respondents were willing to accept consultation from EPs while awaiting radiology US and 44% were willing to admit in a typical scenario prior to radiology US with only one GS willing to take to the OR without radiology US. GS identified the following that would improve acceptance of POCUS in the diagnosis of acute cholecystitis - improved training and decreased operator variability, access to POCUS images, and clear written interpretation of POCUS images on the medical record, recognizing that POCUS is not a replacement for pre-operative imaging but to improve ED length of stay (LOS) and expedite ED management.

 CONCLUSIONS:

Our survey has identified important clinical and imaging features for the diagnosis of acute cholecystitis in the emergent setting by EPs and GS, especially with regards to expectations and perceptions of the use of biliary POCUS. Both EPs and GS have identified a willingness to incorporate POCUS for patients with acute cholecystitis to potentially improve ED LOS. Quality improvement initiatives that include education, training, and change in work processes can now be directed to incorporate POCUS in the diagnosis of acute cholecystitis for both EPs and GS.

Background

Availability of rapid and high quality test results offered by Point-of-care testing (POCT) speeds up clinical decision making in critical care settings.  POCT sampling and analysis is usually performed by non-laboratory staff with varying levels of experience. Several pre-analytical pitfalls can dramatically reduce the quality of the POCT result, regardless of the analytical quality of the test.

Aim

Present study aimed to identify pre-analytical challenges of POCT within critical care settings.

Methods

Issues influencing the quality of the POCT result - apart from the analytical quality - were collected during focus conversations and in-person consensus meetings with POCT experts from different European countries and different professional backgrounds (clinical laboratory, ICU, nursing).  

Results

Main areas identified in the pre-analytical phase were: patient and user safety, user and analyser related errors, timeliness expressed as turn-around-time (TAT), training and competence testing of the user, connectivity and over-all quality of the test result (apart from the analytical quality).

The specific challenges in these areas were further detailed. 

Patient safety is negatively impacted by human errors such as incorrect identification of the patient or incorrect ethnography assessment, by blood & sharps exposure, and by delayed, incomplete or erroneous data transfer.  User safety is impacted by blood and sharps exposure.

Human and material errors reported by instruments lead to wasted samples and test materials and cause sample recollection and retesting, prolonging the TAT. TAT is also negatively impacted by high complexity testing. A prolonged TAT negatively impacts patient waiting time and time to medical decisions, thereby decreasing the effectiveness of the test and also has a negative impact on staff time and workflow, thereby decreasing efficiency and increasing working costs.

The most important key factor defining pre-analytical quality is training and competence of the user.  Training and (re)certification of POCT users should be provided by the laboratory’s POCT coordination team.  Lab support frees users of practical and logistical issues concerning POCT such as analytical quality issues, follow-up of lot numbers, expiry dates and quality controls.  POCT coordinators are lab experts trained to provide this support.  Higher user-friendliness of the equipment decreases the necessary training.

Connecting POCT instruments to the Lab Information System and the Electronic Health Record of the patient is an essential contributing factor to correct patient and user identification and to full traceability of the POCT result.

Quality of the test result is negatively impacted by incorrect procedures, such as waiting too long to test the sample, incorrect filling of sampling devices, insufficient sample, haemolysis, improper mixing, improper air evacuation.   

Suggested measurable key performance indicators for the pre-analytical phase are instrument down-time and percentages of incorrect patient and user ID’s, no-result samples, instrument error codes, out-of-control QC results, interventions by POCT coordinator and manufacturer.

Conclusion

We conclude that this initiative has identified several pre-analytical key factors determining the over-all quality of POCT.  A future study is planned to measure the above-mentioned key performance indicators for the pre-analytical phase in real-life critical care settings.

Introduction: Prevalence of brain injuries is estimated at about 200 people per 100,000 in developed countries and more than 500 people per 100,000 in the United States. CT scan is in fact a selective method for evaluating patients with skull trauma. More than 98% of hit-head imaging did not have positive finding. This study aimed to evaluate the frequency of CT scan requests without indication in patients with head trauma in Rasoul–e Akram, Firoozgar and Haft-e-Tir university hospitals.

Methods: In this cross-sectional study, patients who were referred to our hospitals with chief complaint of head trauma, during study period, were retrospectively assessed for eligibility. Patients were selected through hospital information system (HIS) and using consensus sampling method. Demographic information of patients as well as signs, symptoms and brain CT scan results were recorded in a predesigned checklist. In the present study, considered brain CT scan indications were resulted from integration of Canadian CT Head Rules, NICE Head Injury Guideline, ACEP Clinical Policy (Rosen) and New Orleans Criteria guidelines.

Results: Eventually 464 (322 male and 142 female) patients were investigated. Mean age of patients was 35.11±18.3 years old and mean GCS score at the time of primary assessment was 14.46 ±2. Fourty-five patients who were referred or attended to our hospitals did not have intended indications but CT scan was requested for them. Finally 86 cases did not have indications for CT scan among which 41 cases were correctly diagnosed by physicians and CT scan was not performed on them.

Conclusion: In conclusion the result of the present study revealed that about 11% of performed CT scans in trauma patients are unnecessary and without related indications.

Introduction: Ceftriaxone is being used, widely, these days, and it is less according to the current guidelines. The aim of this study was to determine the appropriate usage of ceftriaxone. Considering the results may help looking for a way to prevent its inappropriate use in Emergency Department (ED).

Methods: In an observational-analytical study, the patients referred to EDs of two teaching hospitals since September 23, 2017 to March 19, 2018 who have been treated with ceftriaxone, were analyzed. The rational usage of ceftriaxone was determined based on latest evidence based literatures.

Results: Ceftriaxone had been prescribed properly in 156 patients (38.4%; 95% CI, 33.5-42.9%) and its use did not meet logical criteria in the rest of cases consisting of 250 patients (69.6%; 95% CI, 57.1-66.5%). Logical use of ceftriaxone was independently related to treatment-goaled use, level I triage, urinalysis (U/A) compatible with urinary tract infection (UTI), and chest radiographic evidence of pneumonia.

Conclusion: Our study revealed a range of appropriate use of ceftriaxone not acceptable for a teaching medical center; more education seems to be necessary in this field.

PURPOSE: Pulmonary embolism (PE) is associated with high morbidity and mortality and often has a nonspecific clinical presentation. The use of diagnostic testing to reduce the risk of missing a potentially life-threatening diagnosis increases both the cost of care and the use of medical resources. Various score systems exist to evaluate the probability of PE, which can also be used for risk stratification to obtain the most accurate diagnosis. The aim of our study was to review the evidence for existing prognostic models in acute PE and determine their validity and usefulness for predicting patient outcomes. We also determined the accuracy of an age-adjusted D-dimer threshold to detect PE.

METHODS: The study involved the retrospective application of an age-dependent D-dimer cut-off (age/100 in patients aged >50 years) in 659 consecutive patients, both in and outpatients, aged ≥18 years who had undergone CT pulmonary angiogram for suspected PE according to the European Society of Cardiology (ESC) guidelines. We included individuals who presented to an emergency department with a suspicion of PE and who were then referred for objective testing; all participants included were capable of providing informed consent. This study was performed in three emergency departments in Hungary between January 2016 and September 2018. We retrospectively collected information regarding symptoms (dyspnoea, unilateral leg swelling, and haemoptysis), vital signs, and medical and social history (cancer, recent surgery, medication, history of deep vein thrombosis or PE, and chronic obstructive pulmonary disease). We calculated test characteristics, including sensitivity and specificity. We applied three different D-dimer approaches to the low and moderate-probability patients. The primary outcome was exclusion of PE with each D-dimer approach, while the secondary objective was to estimate the negative predictive value for each rule. Data were analysed using SPSS 24.0 statistical software.

RESULTS: In the 659 cases (407 women and 252 men), a total of 105 D-dimer assays, 51 CT angiograms, and 212 chest X-ray examinations were carried out redundantly; if these procedures were not carried out, it could have saved money for the hospitals and reduced radiation exposure for patients. The age-adjusted D-dimer threshold was more specific (70% versus 60%) but less sensitive (95% versus 98%) than risk stratification. The sensitivity of the combined technique (risk stratification and age-adjusted D-dimer test) was 100%.

CONCLUSION: Our study showed that Geneva score (which was calculated from the patients’ complaints, medical history, and physical examination) had the closest correlation with the true diagnosis. An age-adjusted D-dimer limit has the potential to reduce the need for diagnostic imaging and is more accurate than the standard threshold of 500 ng/dL. The combination of risk stratification and age-adjusted D-dimer can be used to safety diagnose PE. Finally, we can conclude that risk evaluation in acute PE is indispensable and the appropriate use of guidelines results in lower healthcare costs. Our data support the use of age-adjustment and perhaps adjustment for other factors also seen in patients evaluated for PE.

Background: Serious Adverse Events in hospitalized patients, such as unanticipated admission to Intensive Care Unit and cardiac arrest, are often preceded by deteriorating vital signs. Early Warning Scores (EWS) are used to allow detection of deterioration. EWS systems is implemented based on the strong association between vital sign abnormalities and poor outcomes shown in several retrospective studies. Only few studies have examined the clinical impact of EWS.

Individual Early Warning Score (I-EWS) is a newly developed track and trigger system where the assessment of vital signs by EWS is combined with a clinical assessment of the patient. This combination has in a previous randomized study improved triage of acutely admitted patients. Prior to comparing I-EWS to the already implemented National Early Warning Score (NEWS) in a prospective cluster-randomized crossover multicenter study, a feasibility study was performed.  The aim was to test the use of I-EWS in a clinical setting and to explore the nursing staff’s experience with I-EWS.

Methods: We performed a feasibility study of the implementation of I-EWS. I-EWS is integrated as a mandatory part of the electronic health care journal. Vital signs are registered, and an aggregated score calculated. Nursing staff is asked to revise the score based on their clinical assessment. The score can be adjusted with a maximum of -4 or +6 points or kept unchanged if the score matches the patient’s clinical presentation. We recorded the number of I-EWS scores and the proportion of up- and down adjustments of the scores. A questionnaire was sent electronically to the staff subsequently to assess the level of information about I-EWS and the applicability of I-EWS. As well as to assess the nursing staff’s perception of I-EWS as a track and trigger system. Data was collected at Herlev and Gentofte Hospital, a 949-bed University Hospital in the Capital Region of Denmark. Eight medical and surgical wards with a total of 250 beds used the I-EWS for a 2-week period in June 2018. Ambassadors from every ward, participated in an introduction course prior to initiation of the study. The Ambassadors introduced their colleagues to I-EWS.  

Results: We recorded 5669 observations during the study period. I-EWS was used in 4585 (80.9 %) of the observations by the end of the second week. Of these scores 876 (19.1 %) were downgraded and 116 (2.6 %) were upgraded. Eighty-one of the 181 questionnaires (45%) were returned and 65.4% were very satisfied/satisfied with the level of information and 16 % answered neither nor. 80.3 % found the registration of I-EWS easy. Less than 6.7 % found no clinical relevance of I-EWS.

Conclusions: The possibility to adjust EWS was feasible and well received among hospital staff. The effect of I-EWS being tested in an ongoing multicenter study that is ongoing.

An observational study of Older adults admitted to the head injury ward

Introduction

Head injuries in the older adult population are an increasing presentation to the emergency department as a result of an aging population. The cause of injuries can be more complex in the frail older adult, require further investigations and multidisciplinary input to facilitate safe discharge home.

Our department at the Royal Alexandra Hospital (RAH) in Paisley, Scotland serves a population of approximately 200,000 people with approximately 750 beds.  The RAH has a dedicated ward for head injuries managed by Emergency Department (ED). consultants. It provides inpatient observation of patients unsuitable to discharge home from the ED who have sustained a head injury. Patients can be admitted who do not require a CT scan, a normal CT result, or who have sustained an intracranial bleed which does not require operative input after discussion with neurosurgical colleagues.

This ward aims to manage symptoms, observe those without social support and discharge patients within 48 hours. Patients with clear other care needs are admitted under the appropriate speciality. Presentations of frail older adults are the most complex to manage and ensuring appropriate care by the right team can improve patient outcomes in this group.

We wanted to determine if the cohort of frail patients are inappropriately admitted under the care of the ED as they do not meet criteria from initial presentation that would allow discharge within 48 hours due to increased care needs.

Methods

This retrospective cohort study reviewed medical notes of all patients aged over 65, admitted to the head injury ward over a 1-year period (Jan 2018-Jan 2019).

Frailty was assessed using the F.R.A.I.L screening tool. A patient is deemed frail if there is evidence of:  functional impairment due to significant co-morbidity, a care-home resident, documented acute confusion, impaired mobility, or require increased support on discharge.

Results

116 patients were admitted and reviewed, the median age was 79.(Minimum 67 and maximum 98 with an average of 79) Average length of stay on the head injury ward was 1.94 days.

 32/166 patients were referred to a different inpatient speciality following admission to the head injury ward.

45/116 of patients were regarded as frail. Their average length of stay was 2.6 days and 15/45 were referred to other specialities compared with 1.52 days and 17/71 respectively in the non-frail group.

Discussion

We found 95/116 patients over 65 admitted to our head injury ward were appropriately admitted and discharged within 48 hours. However, 40% were described as frail when using the frailty scoring tool. Notwithstanding a degree of hindsight bias, the results show that this cohort have a prolonged LOS and require subsequent transfer to another speciality during admission.

Head injuries in older adults can be the result of disequilibrium in a complex, frail patient and the use of frailty screening tools in the ED can help identify those patients requiring specialist input from elderly care teams rather than admission to a short stay ward and subsequent transfer.

Background:

Road Accidents cause the occurrence of a large number of victims in Romania,  trauma cases specifically requiring medical teams starting from Mobile Emergency Service for Resuscitation and Extrication, to complex surgery and the Intensive Care Teams. This aspects led to the need for a study, which emphasises several important elements, of the cases in the last three year. Thus, we used criterions like mainly pathology, the age and the annual distribution of the victims, area where the car crashed, association of alcohol consumption and the state in which the patient was brought to Emergency Room of Sibiu.

Methods:

We conducted a retrospective observational study on a total of 189.397 patients presented at the Emergency Room of Sibiu County Emergency Clinical Hospital, between 01.01.2016 and 31.12.2018.

Results:

From the total of 189.397 patients, in the Emergency Department were reported 1084 victims of road accidents.

We examined how many pacients were brought in the Emergency Trauma Room every year and the results are:

2016 - 401 (36,99%) victims

2017 - 311 (28,69%) victims

2018 - 372 (34,31%) victims

The age distribution during the study was the following:

Age category 18-20 years old:   31 cases (2,85%)

Age category 21-30 years old: 298 cases (27,49%)

Age category 31-40 years old: 210 cases (19,37%)

Age category 41-50 years old: 209 cases (19,28%)

Age category 51-60 years old: 145 cases (13,37%)

We were interested to assess the areas from which patients were brought in the Emergency Room and the results are:

Urban Area: 738 (68,08%)

Rural Area:  346 (31,91%) 

369 (34,04%) Patients had suffered cranio-cerebral trauma of which:

210 (56,91%) associated one or multiple Contusions

108 (29,26%) were Poly-Traumatized 

17,80%, meaning 193 victims, drunk alcohol before driving and had positive results using Breath Test. 

Discussion & Conclusions:

The main category of patients injured in crashes is included in the age range between 21 and 30 years old, mostly because lack of preventive behavior.

Although not statistically representative, it is clinically significant that a fairly large number (about one third) of victims presented cranio-cerebral trauma, so we can conclude the fact that vehicles, even if equipped with modern safety systems, are still not prepared to efficiently protect the cephalic extremity, which is actually the most exposed area of the body in the case of road accidents.

There are still situations when drivers are choosing to drive despite having consumed alcohol before.

The large number of victims brought to the Emergency Room from the Urban Area is primarily due to heavy traffic in the crowded cities.

Background

Currently available analgesic options for severe pain in the emergency setting have limitations such as the challenging safety profile of opioids and limited efficacy of weaker analgesics. Inhaled methoxyflurane is an easy-to-administer, rapid-acting, non-narcotic analgesic that has been used in emergency settings in Australia and New Zealand since the 1970s and is now approved in Europe. InMEDIATE was a pragmatic trial in Spanish emergency units (including one pre-hospital unit) that compared the pain relief achieved with methoxyflurane versus standard analgesic treatment (SAT, administered according to each site’s own analgesic protocol).; we report results of a subgroup analysis in patients with severe pain (NRS ≥7).

Methods

InMEDIATE (EudraCT: 2017-000338-70; NCT03256903) was a Phase IIIb, open-label, randomised controlled trial conducted from July 2017 to April 2018 by the Pain Group of the Spanish Society of Emergency Medicine/Spanish Clinical Research Network. At triage, eligible patients with moderate-to-severe trauma pain (score ≥4 on the Numeric Rating Scale [NRS]) were randomised 1:1 to receive inhaled methoxyflurane (up to 2´3mL) or SAT whilst in the unit. Exclusion criteria included use of analgesic for the acute traumatic pain before randomisation, and contraindications to analgesics to be used in the trial. Primary efficacy endpoint was change in NRS pain intensity, co-primary endpoint was time to onset of pain relief and patient/clinician-reported outcomes were secondary endpoints. The treatments were compared for the severe pain subgroup (NRS ≥7; N=165) in an exploratory manner using 2-tailed t-tests.

Results

The methoxyflurane group included 89 patients, mean age 47.8±19.8 years, 55% male. The SAT group included 76 patients, mean age 45.6±17.9 years, 47% male; 86% received non-opioid analgesia (mostly intravenous NSAIDS) and 13% received opioids. Main injury types were contusion (N=96), fracture (N=43) and swelling (N=27). Mean NRS pain intensity at baseline, 3, 5, 10, 15 and 20min was 8.57±0.82, 6.73±1.70, 5.73±1.91, 4.59±2.19, 4.02±2.32 and 3.32±2.23 for the methoxyflurane group and 8.68±0.78, 8.08±1.38, 7.56±1.70, 6.70±1.91, 5.87±2.30 and 5.20±2.47 for the SAT group. The decrease from baseline was significantly larger for methoxyflurane than SAT at all time points (p<0.001), with the largest treatment difference at 10min (-2.11; 95% CI: -2.75, -1.47; p<0.001). Methoxyflurane-treated patients first reported pain relief at a mean of 6.13min compared with 11.58min for SAT (difference: -5.45min; 95% CI: -8.27, -3.02min; p<0.001). Mean time to first meaningful pain relief was 13.34min for methoxyflurane and 27.38min for SAT (difference: -14.03min; 95% CI: -19.01, -9.06min; p<0.001). Patient satisfaction (scored out of 10) was significantly greater for methoxyflurane than SAT for efficacy (difference: 1.19; 95% CI: 0.59, 1.80; p<0.001) and comfort (difference: 0.77; 95% CI: 0.00, 1.54; p=0.05), and similar for safety. Methoxyflurane exceeded patient/clinician expectations of treatment in 73%/67% of cases compared with 45%/28% for SAT. Adverse events were reported for 31 (35%) methoxyflurane-treated patients (mainly dizziness) and 5 (7%) SAT-treated patients.

Conclusions

Methoxyflurane may be considered as an easy-to-use, rapid-acting, first-line alternative to opioid and other analgesic treatments for patients experiencing severe trauma pain.

Background : Severe trauma is a life threatening situation and is widely described in young patients. Therefore, only few studies were interested in evaluating prognosis in senior trauma patients. Moreover, mechanisms of trauma in elderly  are not as so high velocity-related as in younger patients .This situation could expose to an undertriage of trauma. Fewer scoring tools were proposed in literature. The aim of this study was to evaluate the value prognosis of one Senior trauma score: Geriatric Trauma Outcome score ( GTO Score) to predict mortality at day 7 in aged severe trauma  patients

Methods : it was a prospective study with inclusion of trauma patients aged over 65 years. GTO score was evaluated. Prognosis value towards mortality at Day-7 was studied by characteristics of ROC curve.

Results:  A total of 65 patients was included from the cohort of 699 severe trauma patients admitted to the emergency department during the study period.  Characteristics of the population : mean age = 74 ± 6 years; Mean Injury Severity Score = 23 ± 15; Mean GTOS = 133 ± 38; need of vasocative agents n=16 (25%); massive transfusion in the first 24 hours n=2 (3%); Mortality rate was = 32 % ( n= 21) at Day 7. GTOS was statistically higher in non survivors compared to survivors senior patients : 160 ± 45 versus 120 ± 27 with p < 0,001. Characteristics of the ROC curve of GTO score to predict mortality at Day7 were: AUC = 0,790; p <0,001; CI[95%] = [0,667-0,913]; cut-off = 139; sensitivity = 71% ; negative predictive value 84% )

Conclusion : In this study, GTO score was predictive of mortality at day 7 post severe trauma in senior. Further comparisons with other specific scoring tools is whereas necessary to a better evaluation and emergency field application

BACKGROUND

Considering the substantial number of death resulting from meningo cerebral lesions, we aimed to track the causes that led to these lesions and the number of death. These autopsies were performed at Medical Examiner Service( SJML) Sibiu between 2014-2018.

MATERIAL AND METHODE

The current retrospective research is made on a total of 1814 autopsies, performed at SJML Sibiu, between the period of 1 january 2014 – 31 December 2018. From this total, 243 had meningo cerebral lesions.

RESULTS

From a total of 1814 autopsies, performed at SJML Sibiu, the number of meningo cerebral lesions was 243, which represents 13,39 %, being distributed as follows: in 2014- 53 patients (21,82%), in 2015- 45 patients (18,51%), in 2016- 46 patients (18,93%), in 2017- 49 patients (20,16%) and in 2018- 50 patients(20,58%).

From these medical situations 104 (42,80%) came from the urban area and 139 (57,20%), from the rural area, and in terms of their gender distribution: 179 (73,66%) are man and 64 (26,34%) women.

During the study, patients with LMC was divided into aged groups as follows: 8 (3,30%) < 18 years, 72 (29,60%)- 19-39 years-, 101(41,57%)- 40-59 years-, 46 (18,93%)- 60-79 years-, 16 (6,60%) >80 years.

During the study, the causes that led to these lesions were: road accident - 103 (42,40%), railway accident- 18 (7,40%), forest accident – 11 (4,52%), falling out from the same level or height - 82 (33,75%) and aggression- 29 (11,93%).

CONCLUSIONS

Our research based on a 5-years period of study reveals that the number of patients with LMC during the autopsy in significantly higher to men compared to women and the number of rural patients is predominant.

Most patients fall into age groups: 19-39 (29,60%) and 40-59 (41,57%).

Most frecvently causes that led to LMC are road accidents and falling out from the same level or height.

The number of death caused by LMC is from 2015-2018 in continuous growth.

Introduction: There are some critical ill patients who cannot measure oxygen saturation (SpO₂) by pulse oximeter at the pre-hospital settings. For example, among emergency patients who were treated by emergency medical service (EMS)personnel of Osaka Municipal Fire Departmentin 2016,there were 3,571 patients who had urgent conditions judged by on-scene EMS personnel but did not have cardiopulmonary arrest (CPA), but the measurement of SpO₂ at the scene could not be measured for 395 patients. On the other hand, the measurement of cerebral regional oxygen saturation (rSO₂) during resuscitation has been recently paid to attention.

Purpose: To evaluate whether rSO₂ could be measured for these patients.

Materials and methods: We developed portable rSO₂ monitors (weighs 600 g and can be carried easily by hanging it around the neck) and equipped them in nine ambulances (There are 63 ambulances in Osaka City). We measured serial changes in cerebral rSO₂ among emergency patients who had urgent conditions judged by on-scene EMS personnel and could not be measured SpO₂ at the scene from April 1st 2018 through March 31th 2019. “SpO₂ could not be measured at the scene” was defined as patients in whom SpO₂ could not be measured for at least 30 seconds from one finger and after attempting measurement on at least two or more fingers at the scene.

Results: During the study period, there were 14 patients who had evaluated serial changes in cerebral rSO₂ with incapable-measurement SpO₂ who had urgent conditions judged by on-scene EMS personnel but did not have CPAat the prehospital settings. In many cases, rSO₂ values were lower than normal but stable. There are two cases, rSO₂ value rose by the ventilation support of the EMS personnel. 

Discussions: Even when SpO₂ cannot be measured, maintenance of a constant value of rSO₂ suggests that oxygen supply and demand in the brain are stable. Monitoring of cerebral rSO₂ is very useful for EMS personnel under the condition EMS could not evaluate their effort for patient’s by SpO₂.

Conclusions: We could measure serial changes in cerebral rSO₂ among 14 patients without the measurement of SpO₂ at the scene. Our data suggest that pre-hospital monitoring of cerebral rSO₂ might be a new physiological monitoring for urgent patients during transport.

Background: Longer time to neurosurgical admission may increase mortality and morbidity for patients with spontaneous subarachnoid haemorrhage (sSAH).

We aimed to determine the time from first telephone contact to the Emergency Medical Services (EMS) in Copenhagen to admission to a neurosurgical department. Secondly, to determine if the absence of the textbook symptom “thunderclap headache” was a predictor for late admission.

Methods: This retrospective cohort study was performed in March 2019. From the Danish National Patient Register data were extracted on all patients aged 18 years or older, admitted to any hospital in the Capital Region of Denmark between May 1, 2011 and December 31, 2014 with a primary discharge diagnosis of sSAH. Medical record review was performed to verify diagnoses. Time of the emergency telephone call was extracted from the EMS-database. Predictors for late admission to the neurosurgical department were analyzed in a logistic regression model adjusting for age and sex. Time interval was reported as median with inter-quartile range (IQR) and range. Proportions and odds ratios (OR) were reported with 95% confidence intervals (CI). Late admission was defined as being above the median value.

Results: Of 262 patients admitted with sSAH, no information was found on admission pattern in 96 patients, 34 patients had been admitted via general practitioners, and one was excluded due to a non-transparent pattern of admission. Thus, 131 patients had called either the European emergency number 1-1-2 or the non-urgent medical help line in Copenhagen both operated by EMS Copenhagen.

Data on initial hospital arrival were available for 119 patients and information about neurosurgical admission was available for 124 patients. Data on symptoms at the time of contacting the emergency telephone line was available for the period May 1, 2011 thru December 31, 2013 for 98 of the 102 patients admitted through the EMS.

Median time from EMS contact to neurosurgical admission was 207.5 minutes (IQR 147-305, 37-5,634). Eighty-six (72.3%, CI: 63.3-80.1) patients were initially admitted to a hospital without neurosurgical facilities and secondarily transferred. For these patients, the median time from arrival at the referring hospital to neurosurgical admission was 186.5 minutes (IQR 128-328). In comparison, in a hospital with neurosurgical facilities, the corresponding time interval between arrival to the hospital and admission to the neurosurgical department was 85.0 minutes (IQR 73-111). Seventeen (17.4%, CI: 10.4-26.3) patients had presented to the emergency telephone line with thunderclap headache. The crude OR for late admission in the absence of thunderclap headache was 5.1 (CI: 1.3-19.3). Adjusting for age and sex, the OR was 4.66 (CI: 1.2-18.1), p=0.0259.

Discussion: We found a median time from initial EMS contact to neurosurgical admission of 207.5 minutes in patients with spontaneous subarachnoid haemorrhage. The absence of thunderclap headache was a predictor for late admission.

Background: Marijuana is one of the most frequently used illicit drugs in the United States (U.S.) with 7.3% of the population above 12 years of age reporting marijuana use in the past month. Several U.S. states have legalized and regulated the use of marijuana for recreational purposes. The objective of our study was to evaluate the trends in marijuana calls to the U.S. poison centers (PCs) since these regulatory changes were undertaken.

Methods: The National Poison Data System (NPDS) was queried for exposures to marijuana from 01/01/12 through 12/31/18 using the generic code identifiers. We identified and descriptively assessed the relevant demographic and clinical characteristics. Marijuana reports from acute care hospitals (ACHs), emergency departments (EDs), and overall calls including the public were evaluated as a subset. Trends in marijuana frequencies and rates (per 100,000 human exposures) were analyzed using Poisson regression methods. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: During the study, there were 49,268 toxic exposures to marijuana that were reported to the PCs. The frequency of marijuana exposures increased by 209.4% (95% CI: 202.5%, 216.5%; p<0.001), and the rate of exposures increased by 227.1% (95% CI: 193.8%, 265.9%; p<0.001). Of the total marijuana calls, the proportion of calls from ACHs and EDs decreased from 66.1% to 60.9%, with the percentage of calls from the general public increasing. Multi-substance exposures accounted for 59.2% of the overall marijuana calls and 70% of calls from ACHs and EDs. Approximately 15% of the patients reporting marijuana exposures were admitted to the critical care unit (CCU), with 9% of patients being admitted to a psychiatric facility. The residence was the most common site of exposure (83.4%). Cases were predominantly male (58.7%), with the most common age group being 13-19 years (27.1%). The reports for young children under 12 years of age (6.2% to 19%) and older adults above 60 years (3.5% to 7.6%) increased. Intentional abuse (48.1%) was the common reasons for exposure, with the proportions of suspected suicides being higher in cases reported by ACH (20.3% vs 26.9%). During the study period, the proportion of reported marijuana abuse exposures decreased (50.3% to 35.3%), while unintentional exposures increased (11.4% to 22.4%). Major effects were seen in 5.6% cases and there were 223 deaths reported, with 10 fatalities reported for single substance marijuana exposures. The most frequently co-occurring substances associated with the cases were alcohol (16%) and benzodiazepines (15.7%).  Tachycardia (27%) and agitation (17.5%) were commonly observed clinical effects.

Conclusions: Our study results demonstrate a significant increase in the reports of marijuana exposures made to the PCs. The timeline of this study coincides with changes in federal and state laws regarding medical or recreational marijuana use in many states. The exposures in the adolescent age group increased which might be attributed to the unsafe storage practices of adults. Continued surveillance and public health prevention efforts are key to track the population effects of marijuana legalization.  

BACKGROUND

Traditionally, superficial venous thrombosis (SVT) has been considered a benign disorder. It is known that it shares risk factors with deep venous thromboembolic disease (VTE) and therefore a risk of serious thromboembolic complications. There is no an homogeneus consensus in the diagnostic and therapeutic management of patients with SVT. Our objective was to describe the characteristics of patients diagnosed with SVT and their management in the emergency departments (ED) of Spain.

METHODS

Multicentric, retrospective, observational study with all patients diagnosed of SVT, during the period between January 2016 and May 2017 in 18 spanish ED.

Inclusion criteria were patients with diagnosis in ED of SVT in lower limbs, excluding those who presented an indication for anticoagulant treatment for any other pathology.

 The collected variables were demographic, characteristics of patients, comorbidity, VTE risk factors and the diagnostic and therapeutic management in the ED. Also, we collected any complication (recurrence or extension of SVT, deep venous thrombosis (DVT) or pulmonary embolism (PE)), haemorrhage or death in the next six months after SVT. In order to identify independent variables related to the decision of perform an ultrasound and prescribe anticoagulation by the physician, a multivariate analysis was carried out.

RESULTS

A total of 1202 patients were recruited, 67.4% of them women. The mean age was 59.55 ± 16.85, 24.5% had previous VTE, 4.6% active cancer, 2.4% a BMI> 30, and 50% had a history of varicose veins in lower limbs. 39.4% had hypertension and 26.5% diabetis. The median number  days of symptoms was 4 days (interquartile range (IR) 2-7), 50.7% had signs of SVT, being painful cord the most frequent (50.4%). 13.6% had symptoms of DVT. Only 0.5% had clinical symptoms of pulmonary embolism (PE). Only 56.7% underwent ultrasound. 927 patients (77.1%) received anticoagulant treatment with a median of 22 days (RI 10-30). Enoxaparin was the most used, 79.3%. 9.1% suffered a complication in the first six months, being SVT recurrent the most frequent (4.6%). The median number of days to complication was 77 days (RI 19-153). 84.3% had received anticoagulant treatment at diagnosis but only 22% were on anticoagulant treatment at the time of complication. The independent variables associated with the anticoagulation decision were previous VTE [OR 1.5 (95% CI (1.082-2.255); p <0.014)], history of varicose veins [OR1.440 (95% CI (1.079-1.920); p <0.013 )], SVT signs [OR1.42 (95% CI (1.059-1.882), p <0.018)], limb pain [OR1.572 (95% CI (1177-2.098), p <0.002)] and the performance of doppler ultrasound [OR2.241 (IC95% (1680-2988), p <0.001)].

CONCLUSIONS

SVT has an important incidence of complications. The diagnostic and therapeutic management is heterogeneous. The present study evidences that 84% of the patients with complication had received anticoagulant treatment, but 22% remained on anticoagulation at the time of the complication. The duration and/or intensity of anticoagulation for SVT patients in real clinical practice might be suboptimal. 

Background: We show further evidence for clinical utility of the modified bougie as a conduit for magnetic intubation.  This technique has been demonstrated in theory, subsequently optimized with industrial grade materials on an airway mannequin.  We presented preliminary work at the 2018 European Society for Emergency Medicine 12^th Congress. The purpose of this study is to advance understanding through application of the same technique and equipment on four cadaver specimens. 

Methods: We obtained the following: SunMed Introducer Adult Bougie 15Fr x 70cm with Coude Tip, Hillman Group Ook 18 Guage Steel Galvanized Wire, DdFeB, Grade N52 DISC Magnet NiCuNi Plating Magnet to a Steel Plate: 377.6 Pound Pull Force, 2 dia x 2 thk (in), MAC blade laryngoscope, standard trauma shears, four cadaveric cephalus and torso specimens.  We used shears to cut the bougie at the 55 mark.  The guide wire was fully inserted.  Anatomy was visualized with the MAC blade.  The magnetic field was applied to the distal bougie in the cadaveric oropharynx and hypopharynx with navigating magnet via a location anterior to the cadaver neck.  We confirmed anatomic location via fluoroscopy and sensation of tracheal rings. 

Results: Magnet assisted anterior navigation of the bougie coude tip was obtained in the hypopharynx facilitating passage through the vocal cords into the trachea of each cadaveric specimen.  We replicated prior experience with this magnetic intubation technique on a mannequin in four cadavers.

Conclusion: The authors’ understanding of this unique magnetic intubation technique with industrial products has expanded beyond prior theory and use in the mannequin.  Inability to control the coude tip of the bougie as an adjunct tool for the difficult airway increases the likelihood of surgical airway.  Application of a magnetic field to control endotracheal instrumentation could be a useful tool in the difficult airway algorithm through expansion of existing device functionality.  Successful application in this limited sample of four cadavers suggests further study is important to better understand the magnetic intubation technique and its potential for future clinical utility.

Objectives

To implement in ED Procedural Sedation RCEM guideline in order to improve patient’s safety. The first audit was  completed over the  period from 19th of November 2018 to 31st of january 2019, results from documentation pre-procedure, procedure and post-procedure being calculated. The necessity of this QIP arose when an 2017 Audit regarding documentation of procedural sedation in our department  revealed non-compliance with RCEM guideline regarding this procedure.As part of this project, A File for"Procedural Sedation" was set up in Resus containing: RCEM guideline for procedural sedation, a new designed Sticker to be applied on the front page of the patient's notes with inscription "Procedural sedation", a table for patients details for auditing, 3xpages booklet to be completed with patient assessment(airway assessment ,fasting status,etc), patient's consent, vital signs of the patient, pre and post-procedure leaflet to be given to the patient. nasal capnography set up in Resus airway trolley. Monthly teaching performed in order to promote this project.

Results                              

From 33 patient who should have had procedural sedation, 16 patients had the procedure.Documentation improved from 0% to 48.48%. From the patient with documented pre-procedure, improvement were found in: ASA documentation(from 0% to 75%), prediction difficult airway(from 0% to 87.5%), documentation fasting status(from 0% to 68.75%), documentation informed consent (from  37% to 100%), pre-procedure leaflet given( from 0% to 100%),; documentation procedure in Resus(from 46% to 75%), documentation staffing performing the procedure(from 0% to 87.5%), documentation capnography ( from 0% to 12.5%), when oxygen was given( from 0% to 25%),  post-procedure leaflet (from 0% to 62.5%), documentation discharge suitability( from 0% to 37.5%).

Discussion

It is room for improvement for documentation oxygen time / quantity administered, capnography monitoring, documentation discharge suitability, which will be recorded on the second audit in progress.

A second audit is in progress at the moment. Because the usage of the nasal capnography is not satisfactory, teaching regarding the capnography usage was attached to the monthly teaching for this project. The final QIP presentation  will use a PDSA( Plan-Do-Study-act) model for improvement, measuring the documentation of the pre-, post and procedural patient's management. A Gunt and Run charts will be calculated at the final writing paper of this project. 

At the moment a Poster is planned to be placed in RESUS with pictures of the File and capnography and a meeting with a second speciality is in place, in this context Anaesthetics, in order to seek for help in managing the airway for Procedural sedation Project.

Background: Several biological markers are used to predict poor outcomes in acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Each of Glycemia and white blood count are known as predictive factors of poor outcomes in AECOPD. The combination of the two could have more sensitivity and specificity value ; The aim of our study was to evaluate the prognosis value of leukoglycemic index( LGI )in patients admitted to the emergency department (ED) with AECOPD.
Methods: Prospective observational study over one year. Inclusion of patients admitted to the ED with AECOPD. The primary endpoints were the need for mechanical ventilation (MV), and 30-day mortality. Test performance was assessed using the area under the receiver operating characteristic curve.

Results: 120 patients were enrolled. Mean age was 63 +/-8 years. Men n (%) was 64 (52, 9). Mean LGI was 12, 10 +/- 7, 14. The LGI area under the receiver operating characteristic ( ROC ) curve (AUC) for the use of (MV) and for the one –month mortality were respectively: 0,74 ;p=0,01;IC 95% [0,58- 0,90] and 0,83;p=0,000; IC 95% [0,69- 0,96]. The best prognostic cut-off value for LGI was 8. In univariate analysis LGI > 8 was associated to 2.1 threshold risk of MV (p=0.001; IC 95% [1.386-3.528] and 4.4 threshold risk of death (p=0.001; IC 95% [1.497-8.839]).
Discussion & Conclusions:
Despite the relatively small number of patients and the fact that the study was conducted only at one hospital, our findings might assist the risk stratification
of AECOPD in the ED, contributing to a better management .At the same time, further medical complications as a result of downgrading the risk of patients with AECOPD in the ED could also be avoided. The LGI is a good prognostic index easy to calculate with a good prognostic value . It can predict poor outcomes during the acute exacerbation.