Wednesday 16 October
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Wednesday 16 October

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A40
08:00 - 08:30

KEYNOTE LECTURE 3

Moderator: Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
08:00 - 08:30 Baby Steps Toward High Level Global Emergency Medicine: Fast and Furious Fails. Pr Jim DUCHARME (Immediate Past President) (Mississauga, Canada)
CONGRESS HALL
08:40

Wednesday 16 October

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A41
08:40 - 10:10

Neurologic emergencies
When time is brain and your brain shoots from the hip
HOT TOPIC SPEAKER!, Neurology

Moderators: Tobias BECKER (Speaker) (Jena, Germany), Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
08:40 - 10:10 Improving door to needle time for stroke patients in the ED. Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
08:40 - 10:10 Acute headache in pregnancy - a special situation? Tobias BECKER (Speaker) (Jena, Germany)
08:40 - 10:10 HOT TOPIC SPEAK! Stroke and TIA update 2019. Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, Canada)
CONGRESS HALL

Wednesday 16 October

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B41
08:40 - 10:10

Black box belly
Science, experience and excellence when dealing with abdominal pain
Gastro intestinal

Moderators: Dorothea HEMPEL (Atteding Physician) (Magdeburg, Germany), Beatrice HOFFMANN (Boston, Germany)
08:40 - 10:10 Symptomatology of the Abdomen. Pr Jim DUCHARME (Immediate Past President) (Mississauga, Canada)
08:40 - 10:10 A pain in the A..bdomen... Assessment of the elderly with abdominal pain. Dr Don MELADY (Associate Professor/Staff Physician) (Toronto, Canada)
08:40 - 10:10 Reading the black box... How to improve your work up of undifferentiated abdominal pain with ultrasound. Beatrice HOFFMANN (Boston, Germany)
FORUM HALL

Wednesday 16 October

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D41
08:40 - 10:10

YEMD - Eye Opener Quiz (interactive)
Learn new things, enjoy and contribute what YOU know!
Diagnosis, INTERACTIVE SESSION, Young Emergency Medecine

Moderators: Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Basak YILMAZ (Faculty) (BURDUR, Turkey)

08:40 - 10:10 Big Interactive Quiz Session. Basak YILMAZ (Faculty) (BURDUR, Turkey), Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Dr Nicolas LIM (Intensive Care Fellow) (Dublin, Ireland)
SOUTH HALL 3C

Wednesday 16 October

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F41
08:40 - 10:10

ABSTRACTS SESSION

Moderators: Marc SABBE (Medical staff member) (Leuven, Belgium), Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic)
08:40 - 08:50 #18282 - OP100 The development of Thailand’s hospital assessment instruction and evaluation for mass casualty incident and disaster preparedness.
OP100 The development of Thailand’s hospital assessment instruction and evaluation for mass casualty incident and disaster preparedness.

Title: The development of Thailand’s hospital assessment instruction and evaluation for mass casualty incident and disaster preparedness

Introduction: Community preparedness is the key component to mitigate the effects from mass casualty incident (MCI) and disaster. The hospital awareness and preparedness is one component of MCI and disaster preparedness in the community as it plays a critical role in taking care of injured patients. To improve hospital preparedness for MCI or disaster management, the first requirement is to assess the current system capacity, readiness, awareness and preparedness. Nevertheless, there is no assessment tool that is appropriate for Thai hospitals and the Thailand context.

Objective: To develop a hospital MCI and disaster preparedness assessment tool for hospitals in Thailand

Material and methods: A systematic search was done of available literature in English and Thai languages published up to 31 December 2014 in various databases: Pubmed, Medline (Ovid), Cochrane library (Wiley), Cinahl (Ebscohost), Embase (Elsevier), World Health Organization (WHO) guidelines and other organizations. The search used the key words ”assessment,” “evaluation,” protocol,” “hospital preparedness,” “thesis,” and “full report.” These terms were combined with disaster or mass casualty-related keywords. The enrolled articles were assessed, and information was extracted independently by three reviewers. The assessment tool was developed by using a modified Delphi method and the WHO health systems (six building blocks plus) framework, expert inputs, public hearing, stakeholders’ inputs, and a pilot feasibility test.

Results: There were 5,869 total articles identified; 5,593 articles irrelevant to medicine or public health and 183 articles not related to hospitals were excluded. The remaining 76 full articles (8/76 (10%) with an assessment tool) were enrolled for analysis and  data and information were extraacted. A new assessment tool was developed independently by three reviewers and finalized in a joint reviewer meeting. The tool is composed of 4 parts; general information, 127 assessment items, suggestions, and hospital actual and surge capacity. All inputs obtained from experts, public hearing, stakeholders meeting, and pilot feasibility test were used to revise the tool.

Conclusion: The hospital assessment tool was developed to evaluate level of preparedness of Thai hospitals for MCI and disaster.



Faculty of Medicine, Prince of Songkla University
Prasit WUTHISUTHIMETHAWEE (Songkhla, Thailand), Rapeeporn ROJSEANGREUNG
08:50 - 09:00 #17970 - OP101 Association between hospital bed occupancy and outcomes in emergency care: a cohort study in Stockholm County, Sweden, 2012–2016.
OP101 Association between hospital bed occupancy and outcomes in emergency care: a cohort study in Stockholm County, Sweden, 2012–2016.

Background:

Previous studies have found an association between high hospital bed occupancy and increased mortality among patients admitted to hospital. We aimed to evaluate the importance of bed occupancy for adverse outcomes among all patients visiting the emergency department (ED).

Methods:

Adults visiting six EDs in Stockholm County, Sweden, from 2012 to 2016 were categorized into groups by bed occupancy: < 85%, 85%–89% (reference group), 90%–94%, 95%–99%, 100%–104%, and > 104%. Cox regression was used to estimate adjusted hazard ratios (HR) with 95% confidence intervals (CI) for 30-day mortality, in-hospital mortality, readmission for inpatient care within 30 days of hospital discharge, and revisits to the ED within 7 days.

Findings:

A total of 816,832 patients with 2,084,554 visits were included in the analysis. Mean bed occupancy was 93·3%. In total, 28,112 patients died within 30 days (1·3% of visits), and 17,966 patients died in hospital (3·9% of admissions). Bed occupancy was not associated with 30-day mortality or with in-hospital mortality, although increased adjusted point estimates indicated associations of bed occupancy > 104% with 30-day mortality (HR = 1·10, 95% CI: 0·96–1·27) and with in-hospital mortality (HR = 1·09, 95% CI: 0·92–1·30). High bed occupancy led to an increased length of stay in the ED and a reduced admission rate for inpatient care.

Interpretation:

Our findings indicate that health care staff are able to prioritize correctly without compromising patient safety at high bed occupancy, despite increased lengths of stay in the ED and a decline in admissions for inpatient care. However, we believe that practitioners should aim for a bed occupancy < 105%, given our observation of a trend towards higher mortality at ≥ 105% bed occupancy. Preparedness to reallocate resources to the ED is needed when bed occupancy increases because the workload is likely to rise even when bed occupancy is at 85%.



This study was funded by a grant from Sjukhusläkarna.
Björn AF UGGLAS (Stockholm, Sweden), Therese DJÄRV, Martin HOLZMANN
09:00 - 09:10 #19150 - OP103 Under-reporting the violence in the Emergency Department: still an unconscionable matter.
OP103 Under-reporting the violence in the Emergency Department: still an unconscionable matter.

Background: Violence against healthcare workers (HCWs) is increasing and Emergency Departments (EDs) frequently face with daily violence occurrence, with staff reporting several episodes each week. Literature shows that HCWs are considered most at risk of aggressive actions, but in Italy there are no consolidated statistics on the spread of the phenomenon, despite the fact that in recent times it is constantly being placed at attention through the media. Recently it has been deemed necessary to detect the episodes of aggression in the Azienda Ospedaliera Universitaria Integrata (AOUI) di Verona (I).

Methods: Starting from the Violent Incident Form (VIF) of Arnetz, a HCWs dedicated self reporting form is accessible 24/24 in our intranet.

Results: data refer to the episodes of aggression reported by HCWs of the AOUI - Verona in 2016-2018 years with reports increasing from 3 to 27 and 66 respectively. Most of the aggressions were by patients (2016: 33%; 2017: 77%; 2018: 73%) or relatives (2016: 67%; 2017: 15%; 2018: 20%) but also colleagues (2017: 8%; 2018: 5%) involving men as aggressors (2016: 60%; 2017: 67%; 2018: 73%) and women as victims (2016: 67%; 2017: 58%; 2018: 73%), mostly paramedics (2016: 100% nurses; 2017: 81% nurses, 11% physicians and 11% health worker; 2018: 82% nurses, 12% physicians and 6% health worker). In most of the cases the aggressor was in age group 18-30 (2017: 30%; 2018: 17%), 31-50 (2016: 67%; 2017: 41%; 2018: 48%) or 51-65 (2016: 33%; 2017: 19%; 2018: 20%) years. The preponderant percentage of the personnel attacked was in 50-59 years age group (40%) in 2018, slightly different from 2016 and 2017 prevalence of 40-49 years  (2016:100%; 2017: 37%). Aggressions were mostly during routine activities or normal conversation (2017: 27%; 2018:38%) and following clarification requests (2017: 33%; 2018: 14%). Took place in wards spaces (2016: 33%; 2017: 48%; 2018: 23%) or in patient's room (2016: 33%; 2017: 26%; 2018: 23%), in the morning (6.00-9.00; 2017: 19%; 2018: 12%), between 12.00 and 18.00 (2016: 66%; 2017: 41%; 2018: 44%) and in the evening (21.00-24.00; 2018: 15%). The workers felt the situation degenerate into violence (2017: 67%; 2018: 64%) and help was needed to stop the aggression (2016: 77%; 2017: 70%; 2018: 51%). The aggressors described as "mentally unstable" (2016: 67%; 2017: 64%; 2018: 24%) used verbal and physical violence. Reports from EDs workers are present only from 2018 (35% of cases).

Discussion and Conclusions: Despite an increasingly number of reports received, data do not reflect the real extent of the phenomenon in our agency. Moreover few reports were received from structures that the literature identifies as having a high risk of aggression, such as the EDs are. This could be explained by poor information about the aggression reporting form accessible in the intranet. Aggressive behaviours are perpetrated by particularly fragile and vulnerable subjects, leading to a widespread tendency to justify aggressive actions. Increasing awareness and reporting of the phenomenon and strategies to recognize and manage aggressions is the next great challenge.



This research received no external funding. The authors declare no conflict of interest.
Massimo ZANNONI (VERONA, Italy), Cinzia BIONDANI, Alberto RIGATELLI, Chiara GIULIARI, Giorgio RICCI, Maurizio LORENZI, Roberto CASTELLO, Chiara BOVO
09:10 - 09:20 #18803 - OP104 The Comparison between high-sensitive troponin T, high-sensitive troponin I and conventional troponin I in diagnosis acute myocardial infarction in the emergency department, observational retrospective cohort.
OP104 The Comparison between high-sensitive troponin T, high-sensitive troponin I and conventional troponin I in diagnosis acute myocardial infarction in the emergency department, observational retrospective cohort.

Background: In the primary care setting such as the emergency department, highly accurate biomarkers are important in diagnosing acute illnesses such as acute myocardial infarction (AMI). In order to quickly and more accurately achieve the diagnosis and disposition, high-sensitive troponin assays have emerged for this decade. We aimed to compare the performance of conventional and different novel high-sensitive troponins. 

Methods: We conducted this observational retrospective cohort study using the existed record as well as waste specimen testing in a tertiary teaching hospital in Taiwan. Utilizing text-mining method to retrieve all patient-visits with symptoms suggestive of an acute coronary syndrome (ACS) with troponin test in the electronic medical record (EMR), we operationally defined AMI using free-text of discharge diagnosis and the ICD-9 and 10 codes. We further utilized the waste specimen to test platforms from Roche, Abbot, and Beckman for the performance of HsTnT and HsTnI. We use the algorithm recommended by the Taiwan society of emergency medicine to categorized patients into subgroups including rule-out, rule-in, and observation. Specific cut-offs for the elderly (> 70 years), different genders and impaired renal function (eGFR<60) were obtained from the manufacture and the literature. The performance of different tests was evaluated by AUROC, sensitivity, specificity, NPV, and PPV.

Results: We included 97,183 patients presenting to ER with symptoms suggestive of ACS and test of troponin from 2006 to 2018. Around 9.5% admission with acute myocardial infarction(n=9,194) were identified through this process. HsTnT outperformed the conventional TnI in our cohorts (overall AUROC: 0.81 vs. 0.71, Sensitivity: 76.83% vs. 30.97%, Specificity: 61.04% vs. 82.54%, PPV: 21.95% vs. 13.43%, and NPV: 94.87% vs. 93.19%, respectively). However, level of HsTnT was more likely to be influenced by age and renal function. We further tested 319 waste specimens out of 143 patients to compare different HsTn plateforms. Accordingly, HsTnT seemed to outperform HsTnI (AUROC 0.833 vs. 0.743, p=0.02, Sensitivity: 76.83% vs. 100%, Specificity: 61.04% vs. 48.21%, PPV: 21.95% vs. 19.44%, and NPV for rule-out: 94.87% vs. 100%, NPV for observation: 92.17% vs.81.58%, respectively. Using different HsTn cutoffs for the elderly, we observed increased PPV for Roche (from 21.95% to 25%) but decreased for Abbott and Beckman (from 20% to 15.79% and from 19.44% to 8.3%). Using different HsTn cutoffs for genders, increased PPV of male (Roche: from 18.75% to 23.81%, Abbott: from 20% to 29.17%, Beckman:f rom 19.44% to 27.27%) and much decreased PPV of female in all tests (Roche: from 18.75% to 5.56%, Abbott: from 20% to 5.26%, Beckman: from 19.44% to 7.69%) were observed. In terms of different cutoffs for impaired renal function, increased PPV of Roche (from 21.95% to 26.09%), Abbott(from 20% to 28.57%) and Beckman (from 19.44% to 19.5%) were observed.

Conclusion: In this observational study, we found the HsTnT provided almost two-fold higher PPV than TnI in diagnosing AMI in the ED. HsTnT seemed to outperform HsTnI. However, the differences between different HsTnI platforms were not significant. Nonetheless, this study is limited to the retrospective nature so the incorporation bias could not be avoided.



The study was supported by the Ministry of Science and Technology (Taiwan) and Chang Gung Memorial Hospital (107-2314-B-182-052-MY2, 106-2314-B-182-028, CMRPG2H0311, CMRPG2H0321). The funder has no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.
Jyun-Long CHEN (Taoyuan, Taiwan, China), Chia-Yu CHAO, Kuan-Fu CHEN
09:20 - 09:30 #18331 - OP105 Prognostic performance comparison between clinicians and endothelial biomarkers to predict the deterioration of septic patients in Emergency Department.
OP105 Prognostic performance comparison between clinicians and endothelial biomarkers to predict the deterioration of septic patients in Emergency Department.

Background: Accurate prognostic assessment of septic patients is challenging in the emergency department (ED). Identification of patients at high risk of organ failure or shock could help to prevent deterioration and reduce mortality. Clinician’s assessment is based on initial severity, scoring, social context, hospital bed capacity, and on personal experience. The performance of emergency physicians in predicting septic patient’s outcome has been scarcely described, and the additional value of a prognostic biomarker has not often been evaluated in the ED. Therefore, we calculated the prognostic performance of emergency physicians to predict clinical deterioration of septic patients during their initial management in the ED and evaluated whether adding biomarkers information could improve this clinical prediction.

Methods: This is an ancillary study of the TRIAGE study (ClinicalTrials.gov: NCT02739152) designed to evaluate a panel of prognostic endothelial biomarkers (sVEGFR2 and sUPAR) in a cohort of adult septic patients admitted to the ED. The analysis was performed on non-severe patients (SOFA<2) of two teaching hospitals. The risk of clinical deterioration was assessed by an adjudication committee composed of three independent emergency physicians (blinded from deterioration outcome) according to the emergency medical records and the first conventional biological and imaging results. This first judgement allowed calculating the clinical emergency physician’s performance. Then, adjudicators were unblinded from the results of biomarkers (which helped classifying patients into two groups: “high risk” or “low risk”) and were asked to keep or revise their first judgement. This second judgement allowed assessing the additional value of biomarkers. Finally, the performance of biomarkers alone was calculated.

Results: Analyses were performed on 145 patients (age = 50±20 yr; Charlson score: 1.7 [0-3]; SOFA score: 0.5 [0-1]; lactates: 2.03 [1.17-2.41]; site of infection: pulmonary 12.4%, urinary 32.4%, abdominopelvic 34.5% and 30 patients deteriorated (21%). The clinical performance of emergency physicians to predict deterioration was: Sensitivity=80; Specificity=21; Negative Predictive Value=80; Positive Predictive Value=21. Adding the biomarkers improved the clinical prognostic performance of emergency physicians (Sensitivity=90; Specificity=19; Negative Predictive Value =88; Positive Predictive Value =23). Biomarker alone was the best predictor of deterioration (Sensitivity =93; Specificity =50; Negative Predictive Value =97; Positive Predictive Value =33).

Conclusion: This study confirms that predicting the clinical deterioration of septic patients in the ED remains challenging. Adding prognostic biomarkers (sVEGFR2 and sUPAR) to clinical evaluation could be helpful in early assessing the risk of deterioration of septic patients, and safely ruling out patients after ED admission due to its high negative predictive value.



ClinicalTrials.gov: NCT02739152
Thomas LAFON (Limoges), Marie-Angélique CAZALIS, Arthur BAISSE, Christine VALLEJO, Karim TAZAROURTE, Pierre-François LATERRE, Valérie GISSOT, Bruno FRANÇOIS
09:30 - 09:40 #18549 - OP106 Identifying septic patients in the Emergency Department using the novel biomarker Intensive Care Infection Score – a non-interventional prospective study.
OP106 Identifying septic patients in the Emergency Department using the novel biomarker Intensive Care Infection Score – a non-interventional prospective study.

Background

Acute infections are one of the major reasons patients present to the Emergency Department (ED). An acute infection may lead to sepsis, a life-threatening condition. Identifying the infected or septic patient is a crucial task because accurate diagnosis and rapid treatment both have a massive effect on the prognosis. The Intensive Care Infection Score (ICIS) is a novel biomarker, already established for ICU patients, which displays the activity of the innate immune response. The ICIS is based on automated blood cell count, which makes it fast, easily accessible and low cost. Here we evaluated the ability of ICIS to identify the infected and/or septic patient presenting to the ED.

 

Method

In a non-interventional prospective study, we enrolled potential septic patients with ≥2/4 criteria for systemic inflammatory response syndrome (SIRS) or/and ≥2/3 quick sequential organ failure assessment score criteria(qSOFA) presenting to the ED. 222 patients were enrolled and received a microbiological screening for a pathogen causing the altered SIRS or qSOFA criteria.  ICIS and C-reactive protein (CRP) were compared in predicting a microbiological proof of infection and the decision for antibiotic treatment.

 

Results

The area under the receiver operating characteristic curve (AUROC) for the prediction of infection (positive culture or indirect proof of a bacterial infection) for ICIS was 0.76 (95% CI: 0.70–0.82), compared to CRP 0,75 (CI: 0.69–0.82). The AUROC for predicting the decision for an antibiotic treatment: ICIS 0.74 (95% CI: 0.68–0.81), CRP 0,78 (CI: 0.71–0.84).

 

Conclusion

The data show that compared to CRP, ICIS provides a similar ability to identify infections and to guide antibiotics. However, being less expensive and quicker in determination, ICIS may play a considerable role in the ED in the future.

 

 

 

 

 

 

 

 



This study did not receive any specific funding and was approved by the local Charité – Universitätsmedizin Berlin ethics committee, Ethics application no.: EA4/011/17.
Dr Wolfgang BAUER (Berlin, Germany), Hans GEßNER, Kai KAPPERT, Rudolf TAUBER, Rajan SOMASUNDARAM
09:40 - 09:50 #18126 - OP107 Soluble triggering receptor expressed on myeloid cells-1 as an inflammatory biomarker of myocardial ischemia/infarction in patients with acute coronary syndrome (ACS): A case-control study.
OP107 Soluble triggering receptor expressed on myeloid cells-1 as an inflammatory biomarker of myocardial ischemia/infarction in patients with acute coronary syndrome (ACS): A case-control study.

Background: Coronary artery disease (CAD) is caused by vascular atherosclerosis together with persistent low-grade innate immune inflammation that plays a role in the initiation, progression, and destabilization of the atherosclerotic plaque. Triggering receptor expressed on myeloid cells (TREM)-1 is a novel member-bound receptor expressed on myeloid cells. Soluble TREM-1 (sTREM-1) reflects innate immune cell activation and its levels are significantly elevated in patients with well- established CAD as well as in acute coronary ischemic events. 

Aim: We seek to determine the plasma levels of sTREM-1 in acute coronary syndrome (ACS) and the association with the severity and 30-day outcome in patients who present with chest pain (CP) to the emergency department (ED).

Methods: We conducted a prospective, case-control study of 121 consecutive patients who presented to the ED with new-onset CP  (≤ 24 hours) suspected suffering of ACS, defined as CP with either ECG changes compatible with ST elevation MI (STEMI), non ST elevation MI (NSTEMI), unstable angina, or advanced angina pectoris. Patients with known inflammatory, infectious or neoplastic diseases were excluded. Patients were divided to 59 (48.7%) patients with ACS (59; 48.7%) and 62 (51.3%) patients with non-coronary CP (NCCP) groups according to the clinical, laboratory and ECG data. Final diagnosis and 30-days outcome were obtained.  Seventy-three age- and sex-matched healthy individuals served as a control group.  Blood samples were collected at the time of arrival to the ED and plasma samples were kept in -80°c until assayed for the level of sTREM-1 using a commercial ELISA kit. 

Results: Within the group of patients with CP, plasma sTREM-1 level was significantly higher in the ACS group compared to NCCP  (   432 + 23 vs. 292 + 56 pg/ml, p=0.03). In a multivariate analysis using Linear regression model, we found that plasma sTREM-1 level correlates  with ACS ( p= 0.001, 95% CI 92.2-360.2)  and smoking (p= 0.06, 95% CI 1.9-137.6) and with  elevated  creatinine ( p= 0.03, 95% CI 27.0-502.3). ROC analysis of plasma sTREM-1 level among ACS vs. NCCP  was AUC 0.703, 95% C.I 0.610-0.796 P<0.001, and in the group of STEMI/NSTEMI (n=30) vs. control  was AUC 0.842, 95% C.I 0.760-0.924 P<0.001.

Conclusions: Our data of elevated plasma sTREM1- level in ACS is in accordance to previous studies that suggest a role for innate immune activation, and more specifically TREM-1, in the evolution of ACS including MI. We suggest that plasma sTREM-1 might serve as a biomarker for the differentiation of ACS from NCCP in the ED.    



Shachaf Shiber 1, 2, 6 , Vitaly Klemiski 4, 6 , Katia Orvin 3, 6 , Iftach Sagy 1, 5 , Mordechai Vaturi 3, 6 , Yair Molad 1, 4, 6 1Rheumatology Unit, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 2Emergency Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 3Cardiology Department, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel 4Laboratory of Inflammation Research, Felsenstein Medical Research ,Petach Tikva, Israel 5Clinical Research Center, Soroka University Medical Center, Beer Sheva, Israel, 6Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Shachaf SHIBER (Tel aviv, Israel), Drescher MICHAEL, Yair MOLAD
09:50 - 10:00 #19280 - OP108 Stratification of the risk of pulmonary embolism in an emergency service according to the wells scale ¿we request for D-dimer properly?
OP108 Stratification of the risk of pulmonary embolism in an emergency service according to the wells scale ¿we request for D-dimer properly?

Introduction:Venous thromboembolic disease (VTE),which includes deep vein thrombosis (DVT) and pulmonary thromboembolism (PE), is the third most frequent cause of cardiovascular death, with an incidence of 1-2people/every1000, every year in the USA. The incidence of PE increases exponentially with age. Its diagnosis tends to pose a challenge for the emergency physicians because of the non-specific and heterogenic signs and symptoms. 

Most patients with PE usually have the following clinical significances:dyspnea,sudden onset,tachypnea,chest pain (usually substernal with pleuritic features). A differential diagnosis of pulmonary disorders has to be set out:pneumonia,exacerbation of chronic lung disease,cardiac disorders,musculoskeletal disorders or PE. In view of this characteristics,objective tests are needed to identify patients who are likely to have PE. For that,clinical prediction scales such as Wells' are necessary,taking into account the existence of previous VTE,recent surgeries or immobilization,cancer,hemoptysis,heart rate up to 100beats/minute,clinical signs of DVT or if there is an alternative diagnosis less likely than PE. It can stratify at low,moderate or high risk. According to the result,we will decide if it is necessary an imaging test,according to the calculated risk and the indication to measure the D-Dimer in blood.

Objective:Review the indications for requesting D-Dimer in patients who attend an emergency service and thus review the correct use of the clinical scales that predict the risk of suffering a PE, such as the Wells scale.

Method:Retrospective descriptive study of the patients who D-Dimer was requested, who attended the emergency department of a university hospital of third level, in a period between 1/1/2017 and 30/6/2017. A data collection sheet was made with the clinical and sociodemographic variables previously defined. Subsequently, the data was analyzed with the statistical package SPSS.

Results: During the period described, a total of 251DDimer were requested. 52% were men with a median age of 70years. Regarding the pathological background, 83.7% had history related to a possible increase in thromboembolic risk and 29.8% of patients had specific risk factors. The scale value of Wells was collected only in 1.3% of the medical reports. D-dimer request was indicated in 57.8% of the cases. Regarding risk stratification, 79.6% had low risk and 19.6% moderate risk to suffer VTE. The median score on the Wells scale was 1point. The D-dimer was positive in 60.8%, however when D-dimer was adjusted at age, it was positive in 46.8%.

Conclusions: As shown in the data obtained, a minimum percentage of the reports had collected the value of Wells or Geneva scale in order to stratify the risk. The evaluation of the probability of suffering VTE in a patient through clinical presentation is essential for the subsequent interpretation of complementary studies. Although, as has been demonstrated, VTE is not always suspected due to the variation of the presentation. There are numerous scales in this regard. Depending on the score given by them, the clinical probability of suffering from this disease can be concluded. Since clinical impression is often nonspecific, because many of the symptoms are common among many patients who do not have this disease, clinical prediction scales are necessary.


Cramp Vinaixa MIREIA, Dr Hernandez Medina IRINA (TARRAGONA, Spain), Condon Abanto ANA, Mendoza Mendez MARIA, De La Torre Trillo MARINA, Espin Aguade PABLO, Berned Sabater MARTA
10:00 - 10:10 #18722 - OP109 The course of the illness as an essential factor to consider in predicting sepsis-associated mortality using biomarkers and symptoms for patients visiting the emergency departments: a hospital-based cohort study.
OP109 The course of the illness as an essential factor to consider in predicting sepsis-associated mortality using biomarkers and symptoms for patients visiting the emergency departments: a hospital-based cohort study.

Background: 

Sepsis is a disorder that commonly encountered in the emergency department (ED) with high morbidity and mortality worldwide. Conventional investigations of biomarkers for sepsis were limited to the time patients diagnosed with sepsis. However, sepsis is a dynamic illness that could manifest differently from time to time. Previously, researchers either focused on specific biomarkers for the longitudinal change, or comparison of different biomarkers at a single time point. 

 

Methods: 

We conducted a prospective hospital-based cohort study in two EDs in the tertiary hospitals in Northern Taiwan with patients with documented infectious diseases during the initial24 hours between 2012 and 2018. We evaluated the performance of 15 novel biomarkers along with some conventional biomarkers and the symptoms and signs in prognosticating outcome for patients with suspected sepsis in ED. We applied the multiplex platform of Bio-Plex ProTM Assays to evaluate 15 novel biomarkers: angipoietin-2, pentraxin 3, sTREM-1, ICAM-1, VCAM-1, sCD14 and 163, E- and P-selectin, TNF-alpha, INF-gamma, CD64, IL-6, 8, and 10. Besides, we assessed several conventional markers including albumin, lactate, D-dimer, C-reactive protein, procalcitonin, liver function, renal function, electrolytes, and coagulation profile. Time of symptom onset and other symptoms and signs were collected prospectively by dedicated research coordinators. Sepsis-associated mortality was defined by chart review to include cases developed inpatient mortality developed related to the initial infectious insult. Logistic regression and odds ratios were used to evaluate the association between the standardized level of biomarkers and mortality. Trend-tests were performed to evaluate the temporal trend of these biomarkers. 

 

Results: 

A total of 1478 patients were enrolled, among them 882 were male (59.68%), 675 were older than 65 years of age (45.67%), 1155 had SIRS (78.15%), 912 had severe sepsis (or Sepsis 3.0, 61.71%), and 466 had septic shock (31.53%) with a mortality rate of 9.2%. The median day after symptoms onset was 2 (IQR: 1 – 4). We found the trend that an early elevated level of VCAM-1, INF-gamma and CD64 and the late elevated level of lactate, uric acid, RBC count and AST were associated with mortality. We also found a decreased level of albumin, calcium, C3, and protein C, red blood cell, platelet, and eosinophil count were constantly associated with mortality. Furthermore, symptoms of chills and fever were constantly associated with survivorship. The most important biomarkers identified were day-4-5 p-selectin (OR: 3.25, 95% C.I. 1.04-10.2, p=0.043) and albumin (OR: 0.26, 95% C.I. 0.14-0.49, p=<0.001)

 

Conclusion: 

In this prospective hospital-based cohort study, we found that the course of illness could be an important factor while evaluating the associations between some biomarkers and outcome of patients with suspected sepsis. 



The study was supported by the Ministry of Science and Technology and Chang Gung Memorial Hospital in Taiwan Chang Gung Memorial Hospital (107-2314-B-182-052-MY2, 106-2314-B-182-028, CMRPG2H0311, CMRPG2H0321). The funder has no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Pr Kuan-Fu CHEN (Taipei, Taiwan, China), Chia-Yu CHAO
TERRACE 2B

Wednesday 16 October

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C41
08:40 - 10:10

Open Research Meeting
The digital transformation of Emergency Departments

Moderators: Carlos GARCIA ROSAS (Mexico, Mexico), Nagi SOUAIBY (Chief Editor) (Byblos, Lebanon)
08:40 - 10:10 EUSEM working together with the European Federation of Medical Informatics. Goksu BOZDERELI BERIKOL (Emergency Medicine Specialist) (Istanbul, Turkey)
08:40 - 10:10 Pan European Database project. Dr Kelly JANSSENS (PHYSICIAN) (Dublin, Ireland)
SOUTH HALL 3AB
10:10 COFFEE BREAK AND EXHIBITION - E-POSTER SESSION
10:15

Wednesday 16 October

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EPOSTER 6.1
10:15 - 10:35

ePoster 6.1 - Short Oral Presentation - Screen 1

Moderator: Stefano MALINVERNI (Emergency Consultant) (BRUSSELS, Belgium)
10:15 - 10:20 #18116 - SP101 Assessment of the management of acute cholecystitis diagnosed in an emergency department of a French University Hospital.
SP101 Assessment of the management of acute cholecystitis diagnosed in an emergency department of a French University Hospital.

Introduction

Acute cholecystitis is an incidental biliary disease and a frequent reason for emergency room visits. Its incidence is high with a significant socio-economic impact. The number of cholecystectomy in France is increasing.

The main objective of our study was to evaluate compliance with the recommendations of the High Authority for Health (HAS) 2013 and the Tokyo Guidelines 2013 (TGL13) in the management of patients diagnosed with Acute Cholecystitis in our French University Hospital.

Material and methods

We conducted a monocentric, retrospective and observational study including all adult patients for whom a diagnosis of Acute Cholecystitis was carried in the emergency department of our French University Hospital, between January 1, 2016 and December 31, 2016. The population characteristics have been described and the diagnostic and therapeutic course of these patients has been compared with the French recommendations of HAS 2013 and the Japanese Guidelines (2013).

 

Results

A total of 70 patients were selected including 37 men (53%). The mean age was 70 ± 17 years and 65 patients had a follow-up of more than 1 year. The most common comorbidity was hypertension (40%) and 20% were diabetic. Forty-three percent of patients consulted less than 24 hours after the onset of symptoms and almost two-third in the first 72 hours. Cholecystectomy was performed in 52 patients (74%) of whom 49 (94%) were laparoscopic. Surgery was performed less than 24 hours after admission for 29 patients (56%) and was performed in the first hospitalization for 42 patients (81%) with a median time of 1 day [IQR : 0-2 ].

Thus, 71% of patients received a management in accordance with french recommendations and only 54% according to TGL13. Respectively, 95% and 88% of patients out-of french and TGL13 guidelines were justified and recorded in the medical file. The cumulative duration of the two hospitalizations for patients operated later was twice that of the patients operated in the first time of hospitalization (4 days [3; 9] vs 8 days [6; 14], p = 0.0361).

The duration of hospitalization of patients operated without TGL13 recommendations was significantly greater (11.6 days vs 5.4 days, p = 0.0021), the intraoperative complications significantly more frequent (56% vs 25%, p = 0.029), as well as the recurrence rate (53% vs 7%, p = 0.009). For 14 patients (27%), post-operative complications occurred, with no significant difference in terms of non-compliance with recommendations. Eleven deaths were recorded during the follow-up period, 3 (4.6%) related to the biliary pathology.

 

Conclusion

 

In our center, the recommendations of the HAS and TGL13 are generally respected. If necessary, the justification of the therapeutic approach and almost always drawn in the medical file. Failure to comply with these recommendations is associated with an increase in complications, particularly intraoperative complications, length of hospital stay and recurrence rate.

The update of the Tokyo Guidelines in 2018, taking into account the general condition and co-morbidities of the patient at admission, may be more appropriate for our population, whose average age is high and comorbidity existing series.


Mélissa FLEURY, Farès MOUSTAFA (Clermont-Ferrand), Nicolas DUBLANCHET, Marie THOMAS, Mathilde QUINTY, Sonia AJIMI, Marine MONDET, Jeannot SCHMIDT
10:20 - 10:25 #18127 - SP102 Pregnancy outcome following bacteriuria in pregnancy and the significance of nitrites in urinalysis - A retrospective cohort study.
SP102 Pregnancy outcome following bacteriuria in pregnancy and the significance of nitrites in urinalysis - A retrospective cohort study.

Objective: An association between bacteriuria and adverse pregnancy outcomes has been extensively described. The current practice of screening all pregnant women for bacteriuria has been challenged by recent studies. We aimed to evaluate pregnancy outcomes among women with positive urine culture and to assess the significance of positive urinary nitrites in this setting.

Methods: Retrospective cohort study conducted between 2014-2018 at the emergency department(ED) of Helen Schnider women center, Israel. Included all Gravida women >18 years old within 20st week of pregnancy or above admitted to the ED with diverse complains, who had urinalysis collected and subsequently a positive urine culture. Clinical and obstetrics’ characteristics were stratified by positive vs. negative nitrites in urinalysis. The primary outcome was premature delivery and the secondary outcomes were composite outcome of all recorded pregnancy complication and the significance of urinalysis in predicting UTI.

Results: Overall, 874 pregnant women with positive urine culture were included. Of them 721(79%) patients had negative nitrite in their urine exam(NNU-group) and 153(21%) patients had positive nitrite in their urine exam(PNU-group). E.coli was the most common pathogen, with significantly higher rate of growth in the PNU-group vs. NNU-group (129(84.3%)vs.227(38.4%), p<0.001). premature delivery was recorded with no association to symptomacity or nitrite status. Among symptomatic women with classic symptoms of UTI, PNU was significantly associated with decreased risk for major peripartum complications((OR with 95%CI of 0.22(0.05-0.94)).

Conclusions: Our findings support that PNU among symptomatic pregnant women with UTI-related symptom was associated with lower risk to develop major adverse obstetrical outcome.



none
Shachaf SHIBER (Tel aviv, Israel), Irit AYALON-DANGUR, Naamany EVIATAR, Drescher MICHAEL
10:25 - 10:30 #18538 - SP103 “Early prediction of mortality based on predisposition, qSOFA and renal function in patients admitted to the Emergency Department with a diagnosis of pneumonia: a prospective study”.
SP103 “Early prediction of mortality based on predisposition, qSOFA and renal function in patients admitted to the Emergency Department with a diagnosis of pneumonia: a prospective study”.

Background

Although lower respiratory tract infection is one of the most common cause of death worldwide, at present mortality risk stratification for mortality in patients admitted to the Emergency Department (ED) with pneumonia is not identified adequately using currently available risk scores like CURB65 and PSI: the former has a low sensitivity, the latter a low specificity. 

Aim 

The purpose of this study was to identify the main features associated with mortality within one month in patients admitted to the ED for pneumonia. We focused both on the main predispositions, comorbidities and on clinical and laboratory data.

Methods:

We started from a prospective study in which we evaluated all patients admitted for infection of any origin (a total of 542 patients) between March and June 2017 in San Paolo Hospital and Niguarda Hospital in Milan; then we focused on patients admitted for pneumonia (diagnosis based on clinical and radiological criteria), and at the end we considered the main features related to mortality in this specific subgroup. 

Results:

There were 214 patients admitted for pneumonia (62.1% males): among them, 181 were discharged from the hospital and 31 died (14.4%). The features related to mortality were: age (71.2 vs 82.7 years, p<0.001), being bedridden (18.1% vs 51.6%, p<0.001), use of antibiotics in the previous month (32.4% vs 54.8%, p<0.01), a recent hospitalization (less than a month before) or coming from a nursing home (15.5% vs 32.2%, p<0.05) and serum creatinine levels (1.2 mg/dL vs 2.1 mg/dL, p<0.001). Moreover, a qSOFA ≤2 on arrival in ED had a high specificity (91.1%) predicting a better outcome.

Conclusions:

Patient’s predisposition (age, recent use of antibiotics or hospitalization and coming from a nursing home), qSOFA, renal function and being or not bedridden could be relevant features to achieve a more accurate early risk stratification for mortality in patients admitted to ED and hospitalized for pneumonia. Further studies and a larger sample will be needed to confirm our results.



NCT03601767
Dr Livio COLOMBO, Simone PASINI, Piera PUGLIESE, Silvia COLOMBO, Greta ROSSIGNOLI, Elena CLERICI, Irene RUSCONI, Alfredo MACHEDA (Milano, Italy), Fabia CASTAGNA, Federica BIANCHI, Adele Anita RADICI, Pier Maria BATTEZZATI
10:30 - 10:35 #18747 - SP104 Impact of implementation of a rapid influenza Point of Care Testing (POCT) in the Emergency department (ED).
SP104 Impact of implementation of a rapid influenza Point of Care Testing (POCT) in the Emergency department (ED).

Background:

Seasonal Influenza is a common pathology leading to a surge in patient visits in ED.  The diagnosis is usually clinical with association of fever, headache, asthenia and respiratory tract involvement symptoms. The main complications are pneumonia and can lead to acute respiratory distress syndrome and underlying chronic illness decompensation. Isolation measures and single-room admission are needed to avoid transmission. PCR for respiratory virus analysis is performed in another center and results are available 24 to 72 hours after the sample was made.

The aim of this study was to evaluate the impact of a rapid influenza POCT.

Patients and method:

It’s a prospective, observational, monocentric study from 15/01/2018 to 05/02/2018. We assessed a rapid influenza POCT by immunochromatograhy system.  One hundred kits were available. Two nasal swabs were collected; one for the POCT and the second one for PCR test. The indication was left to the physician decision, however the recommendations were: patients who needed admission to the hospital or when the rapid result could change the patient managment.   

Results:

During the study period, 3784 ED visits were recorded. Among the 100 available tests, 97 were interpreted. The mean and median ages were respectively 69.7 and 75 year old [22-101]. 36 patients (37%) had influenza diagnosis, 13 influenza A and 23 influenza B, confirmed with PCR test. The diagnosis with POCT failed for 21 patients: one false positive and 20 false negatives (52% of influenza cases).The sensibility, specificity, positive predictive value and negative predictive value were respectively 44, 98, 94 and 75%. 6 patients had a respiratory syncytial virus infection. Among patients with influenza confirmed diagnosis, 3 had association of fever, sudden onset, asthenia and respiratory symptoms, 19 had fever and respiratory symptoms, 2 isolated fever. 19.4% had influenza vaccine. Leucocytes were increased (>10 000 /mm3) in 39% of patients, CRP was upper then 50mg/l for 10 of 25 patients who had the test and 5/15 PCT were superior to 0.5 µg/l. Among patient with positive POCT, 37% had an antibiotic prescription versus 75% when the test was wrongly negative and 87.5% versus 0 had oseltemivir prescription. 13 patients with positive rapid test were admitted (81.25%) with a length of stay of 9.92 days and 18 patients (90%) with negative POCT and PCR secondary confirmed influenza diagnosis with a length of stay of 10 days.

Discussion:

Influenza diagnosis is usually an association of symptoms during epidemics. In elderly population, clinical presentation is uncommon with high risk of complications. Rapid diagnosis is useful to plane isolation measures. Antibiotic prescription increases in case of non-contributive test. Regarding the test assessment, due to its low sensibility, we didn’t use it during the 2018-2019 season and decide to use a rapid molecular test (isothermal nucleic acid amplification technology).

Conclusion

Rapid influenza diagnosis for admitted patients has an organizational impact. This affects the antibiotics and oseltamivir prescriptions. A test with good sensibility is required.


Dr Christelle HERMAND (PARIS), Narjis BOUKLI, Aurélie SCHNURIGER, Nicolas CURY, Youri YORDANOV

Wednesday 16 October

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EPOSTER 6.2
10:15 - 10:35

ePoster 6.2 - Short Oral Presentation - Screen 2

Moderator: Robert LEACH (Head of Dept.) (BRUXELLES, Belgium)
10:15 - 10:20 #18114 - SP105 Prognostic impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest.
SP105 Prognostic impact of the conversion to a shockable rhythm from a non-shockable rhythm for patients suffering from out-of-hospital cardiac arrest.

Background

For patients suffering from an out-of-hospital cardiac arrest (OHCA), having an initial shockable rhythm is a marker of good prognosis. As such, it has been suggested as one of the main selection criteria for extracorporeal resuscitation (E-CPR). However, the prognostic implication of converting from a non-shockable to a shockable rhythm, as compared to having an initial shockable rhythm, remains uncertain, especially among patients that can otherwise be considered eligible for E-CPR. The objective of this study was to evaluate the association between the initial rhythm and its subsequent conversion and survival following an OHCA, for the general population and for E-CPR candidates.

Methods

This study used a registry of OHCA in Montreal, Canada. Adult patients suffering from a non-traumatic OHCA for whom the initial rhythm was known were included. Patients were considered E-CPR candidates if they met the following criteria: less than 65 years of age, witnessed collapse and bystander cardiopulmonary resuscitation, no return of spontaneous circulation after 15 minutes of prehospital resuscitation. The primary outcome measure was survival to hospital discharge. The association of interest was assessed using a multivariable logistic regression, if appropriate. If not, it was planned to perform only univariates analyses using a Chi-squared test or a Fisher’s exact test, as appropriate.

Results

A total of 6681 patients (male=64%, mean age=70 years [standard deviation {SD}=17], survival=11%) were included, of whom 1788 (27%) had an initial shockable rhythm, 1749 (26%) had pulseless electrical activity (PEA) and no subsequent shockable rhythm, 295 (4%) had PEA and a subsequent shockable rhythm, 2694 (40%) had asystole and no subsequent shockable rhythm, and 155 (2%) asystole and a subsequent shockable rhythm. As compared to patients having an initial shockable rhythm, patients in all other groups had significantly lower odds of survival (adjusted odds ratio [AOR] between 0.15 [95% confidence interval {CI} 0.12-0.18] and 0.017 [95%CI 0.010-0.030]; p<0.001 for all comparisons). Among patients with a PEA and asystole, there was no association between evolving to a shockable rhythm and survival to hospital discharge (AOR=0.74 [95%CI 0.40-1.35], p=0.32, and AOR=1.37 [95%CI 0.17-10.83], p=0.77, respectively). A total of 556 (male=73%, mean age=53 years [SD=10], survival=18%) patients were considered E-CPR candidates according to their clinical characteristics. Among these patients, 248 (27%) had an initial shockable rhythm, 175 (31%) had PEA and no subsequent shockable rhythm, 26 (5%) had PEA and a subsequent shockable rhythm, 76 (14%) had asystole and no subsequent shockable rhythm, and 5 (1%) asystole and a subsequent shockable rhythm. Given the small number of patients and events in some groups, only univariate analyses were performed. Patients with an initial shockable rhythm had better odds of survival than patients in all other groups (p<0.001 for all comparisons). No other comparisons yielded significant results (p=0.09 to p=0.80).

Conclusions

There is no clinically significant association between the conversion to a shockable rhythm and survival in patients suffering from OHCA. The initial rhythm remains a much better outcome predictor than subsequent rhythms and should be preferred when evaluating the eligibility for advanced resuscitation procedures.



Financial support: This project received funding from the ‘Département de médecine familiale et de médecine d’urgence de l’Université de Montréal’ and the ‘Fonds des Urgentistes de l’Hôpital du Sacré-Cœur de Montréal’.
Dr Alexis COURNOYER (Montréal, Canada), Sylvie COSSETTE, Brian POTTER, Raoul DAOUST, Luc DE MONTIGNY, Luc LONDEI-LEDUC, Yoan LAMARCHE, Dave ROSS, Judy MORRIS, Jean-Marc CHAUNY, Catalina SOKOLOFF, Jean PAQUET, Martin MARQUIS, Martin ALBERT, Francis BERNARD, Massimiliano ISEPPON, Éric NOTEBAERT, Yiorgos Alexandros CAVAYAS, André DENAULT
10:20 - 10:25 #18239 - SP106 High-flow nasal cannula versus low oxygen flow therapy in weaning from non-invasive ventilation in patients with acute respiratory failure due to COPD exacerbation: a subICU experience.
SP106 High-flow nasal cannula versus low oxygen flow therapy in weaning from non-invasive ventilation in patients with acute respiratory failure due to COPD exacerbation: a subICU experience.

Background:

In patients with acute respiratory failure (ARF) due to chronic obstructive pulmonary disease (COPD) exacerbation, non-invasive ventilation (NIV) is strongly recommended as first line treatment able to improve pH, reduce respiratory rate, prevent immediate intubation and improves survival. In stable COPD patient the rationale of use of high-flow nasal cannula (HFNC) is providing warm and humidified air, reducing transcutaneous carbon dioxide (CO2) and decreasing work of breathing.

Nevertheless, weaning protocol after NIV are not so well defined.

In this study we observed the difference between the use of HFNC versus low oxygen flow treatment (LOFT) in patients with COPD exacerbation after a period of NIV. The aim was to determine if HFNC reduces the need to return to NIV compared to LOFT during the weaning period. In addition, we observed how vital signs and blood gases changes along the recovery time.

 

Methods:

This is a prospective randomized study. We enrolled 28 patients with ARF due to COPD exacerbation treated with NIV from January 2018 to May 2018. NIV started in emergency room (ER) and when NIV support ended, patients were randomized 1:1 between HFNC and LOFT, based on the availability of HFNC (AIRVO® 2 Fisher and Paykel) at the time of randomization.

HFNC therapy was applied at a flow of 60 L/min and minimal FiO2 to maintain an oxygen saturation of 91% or more. LOFT was applied through nasal cannula or face mask to reach the same target.

SO2 and pO2 were significantly higher in HFNC than in LOFT group (p=0.030 and p=0.054 respectively). Besides, respiratory rate was significantly lower at 60 m in the HFNC group compared to LOFT group (p=0.0173).

 

 

 

 

Results:

Eight (29%) of all patients returned to NIV, 1(8%) in the HFNC and 7 (47%) in the LOFT group respectively (HR 7.5 – p=0.060). Patients in the LOFT group returned to NIV sooner than those in the HFNC group.

 

 

Conclusions:

As main result, we observed that HFNC reduces the need to return to NIV during the weaning period in patients with ARF due to COPD exacerbation. Regarding the time between the two cycles of NIV, we reported a shorter time in patients treated with LOFT. This is of great value in order to assess standard protocol of weaning from NIV in patient with COPD exacerbation, in which often the length of stay is affected by the need of prolonged ventilation.Ethical approval and informed consent are not needed due to the type of study.


Francesca NORI (Cesena, Italy), Stefano GENIERE NIGRA, Marina BUDA, Giacinto PIZZILLI, Annalisa DE SILVESTRI, Patrizia CUPPINI, Alessandro VALENTINO
10:25 - 10:30 #19010 - SP107 Interaction effect between mechanical chest compression device use and post cardiac arrest care on survival outcomes after out-of-hospital cardiac arrest.
SP107 Interaction effect between mechanical chest compression device use and post cardiac arrest care on survival outcomes after out-of-hospital cardiac arrest.

Backgrounds: The characteristics of OHCA patients are very diverse, and the potential benefits and risks of PCA care may not be the same among subgroups. We hypothesized that there were some interactive effect of PCA care on survival and neurological outcome after OHCA was observed across patients depending on the use of mech-device. This study aimed to investigate whether use of mech-device has any impact on the neurological outcomes of PCA care.

Methods: This study is a cross-sectional study using a nation-wide registry database of OHCA in Korea. The OHCA registry began in 2006 in collaboration with the Korea Centers for Disease Control and Prevention (CDC) and the National Emergency Management Agency (NEMA) of the Republic of Korea government to improve the outcome of cardiovascular disease in Korea.

The data were extracted between January 2016 and December 2017. The inclusion criteria were all OHCA adults who are older than 18 years with presumed cardiac etiology and survived to admission. Patients were excluded who achieved return of spontaneous circulation (ROSC) at the scene, those with cardiac arrest that occurred in the ambulance, and patients with missing information on neurological status at hospital discharge. The primary outcome was favorable neurological recovery at hospital discharge, defined as a cerebral performance category (CPC) of 1 or 2, [14] and the secondary outcome was survival to discharge.

Results:

After adjusting for other covariates in the interaction model, the aOR of TTM and CRT for survival to discharge was no different in patients with use of mech-device (aOR 2.28, 95% CIs 0.81-6.45, aOR 3.76, 95% CIs 1.44-9.80), respectively) and patients without use of mech-device (aOR 1.08, 95% CIs 0.76-1.54), aOR 8.02, 95% CIs 6.09-10.57), respectively). For good neurological recovery, the aOR (95% CIs) of TTM and CRT were 2.41 (1.90-3.06) and 3.40 (2.79-4.14) in patients without use of mech-device whereas the effect was statistically non-significant in patients with use of mech-device with aOR (95% CIs) of 1.89 (0.97-3.68) and 1.54 (0.79-3.01) (Table 5).

Conclusions:

Use of mech-device modified the effect of PCA care on neurological outcomes for OHCA patients. PCA care is significantly associated with good neurological recovery in non-mech-device group, but not in mech-device group in Korea.


Kyuchul CHOI, Eujene JUNG (gwangju, Korea, Republic of)

Wednesday 16 October

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EPOSTER 6.3
10:15 - 10:35

ePoster 6.3 - Short Oral Presentation - Screen 3

Moderator: Mohammad Ashraf BUTT (Consultant in Emergency Medicine) (Cavan, Ireland)
10:15 - 10:35 #18927 - SP109 Emergency department nurses can safely remove cervical collars in low risk adult trauma patients: a systematic review of literature.
SP109 Emergency department nurses can safely remove cervical collars in low risk adult trauma patients: a systematic review of literature.

Introduction

Cervical collars, immobilization devices applied in the pre-hospital setting by ambulance staff following a trauma, are not without risk. Some of these short-term risks include patient discomfort, complicated airway management, and increased exposure to radiation. Clinical decision-making algorithms such as the Canadian C-Spine rule and the National Emergency X-Radiography Utilisation Study (NEXUS) criteria were created and validated to support the safe removal of this devices in alert, orientated and low risk adult trauma patients. The aim of this systematic review is to assess whether appropriately trained nurses working in the emergency department can safely remove cervical collars using cervical spine rules in low risk adult trauma patients.

Methods

We conducted a systematic review of the existing literature searching PubMed/MEDLINE for studies that investigated clearance of c-spine immobilization with validated criteria in low-risk trauma patients by emergency nurses. 

Results

We identified 8 research articles. Emergency nurses used the Canadian C-Spine rule to remove the collar in six articles and the NEXUS criteria in the remaining two. Five articles assessed the inter-rater reliability between nurses and physicians on cervical collar removal. Of these, four reported a kappa statistic ranging among studies from 0.60 to 0.78 indicating a substantial agreementand one study reported an agreement of 94.3% indicating a strong agreement. Two articles demonstrated a reduction of the time patients spent in the ED with a cervical collar and one a reduction of length of stay in the ED.  As investigated in five studies, ED nurses were confident in applying a cervical spine clearance protocol. 

Conclusions

Trained ED nurses can safely remove cervical collars in alert, orientated, low risk trauma adult patients by using validated algorithms like the Canadian c-spine rule or NEXUS criteria. Adoption of these algorithms improves the flow of patients and may reduce wait times in the emergency departments. Also, nurse clearance of c-spine reduces radiations and time spent by patients with cervical collars leading to less discomfort and pain. Implementation of a nurse c-spine clearance protocol should be accompanied by appropriate training and continuous supervision over time looking for cases of missed injuries.


Arianna GAZZATO, Tommaso SCQUIZZATO (Milan, Italy)
10:15 - 10:35 #19060 - SP110 Are we providing appropriate advice to patients discharged post head injury?
SP110 Are we providing appropriate advice to patients discharged post head injury?

After a departmental teaching session it was identified that there was a gap in knowledge, among various members of staff across a range of grades, in regards to the appropriate advice to give patients who had presented to the emergency department with a head injury. In particular on the issue of driving after a head injury. A study carried out in 2010 by Headway showed 35% of EDs in the UK failed to give out advice on post concussion syndrome. Given around 1 million people present to ED with a head injury each year in the UK this would result in a significant number not receiving adequate medical advice; this could potentially lead to further accidents and injuries or really in a patient driving while uninsured. While our department has a post head injury leaflet to give to patients this leaflet contains no advice regarding driving. 

Our emergency department is split across two sites at District general hospitals in the West of Scotland caring for both adult and paediatric presentations.

A search of electronic records was carried out for all patients presenting to the ED over the course of one week in December 2018 using the diagnostic codes for head injury, head wound and concussion. The notes were reviewed looking for evidence that the patient had been advised not to drive if they had persistent symptoms of a head injury and whether they received the ED's written advice on head injury. 

This showed that no patient had been advised not to drive while they had ongoing symptoms of a concussion. However almost every patient had received a head injury leaflet. 

The intervention was to update the leaflet with appropriate advice on driving after a head injury and to alter the head injury proforma to include driving advice in the discharge checklist. Members of staff in the department were provided with teaching and informed of the updated leaflet. 

The same search was carried out following the teaching for a one week period in May. This demonstrated that > 80% of patients now received adequate advice.

Ensuring we give our patients the best and most accurate advice for management of post concussion syndrome is vital to empower them to make the best choices for their health and wellbeing. 



N/A
Dr Christopher KELLY (Glasgow, United Kingdom)
10:15 - 10:35 #19162 - SP111 COST ANALYSIS OF TRAFFIC ACCIDENTS IN WINTER SEASON THROUGH ANATOMIC SCORING.
SP111 COST ANALYSIS OF TRAFFIC ACCIDENTS IN WINTER SEASON THROUGH ANATOMIC SCORING.

INTRODUCTION:Traffic accidents have been a bleeding wound due to developing technology and increasing number of vehicles.High costs appearby tests and treatments as well as further health problems and loss of labour power in traffic accidents.The aim of the study was to assess the costs of traffic accidents from first referral to emergency department through anatomic scoring and to search the effect of traffic accident pattern and anatomic scores on the costs.METHOD:The study was conducted through retrospective review of hospital automation system, juridical records and patient files of the patients who referred our hospital between December,1,2018 and February,28,2019. 651 patients whose records were complete were enrolled into the study.Conformity test was performed for all variables to normal distribution;Kolmogorov Smirnov test was run to asses the conformity to parametric test criteria.The data obtained in the study within the scope of clinical research have a non-parametric quality in terms of
statistics.Therefore, Kruskal-Wallis H tests were used for statistical evaluation of associated variables according to dependency status.FINDINGS:The patients enrolled into the study included 457 males and 194 females with an age average of 33.89.The patterns of traffic accidents were intra-vehicle traffic accident by 31.2%,extravehicular traffic accident by 50.5%,motorcycle accident by 18.1%.Injured body site of the patients were lower limb by 45.3%,upper limb by 35.9,head by 30.7% and face by 19%, respectively.GCS, AIS and ISS scores were grouped for statistical calculations.Evaluation of patient outcomes revealed discharge in a healthy state by 88.8%,admission to the clinic by 8.6%, admission to intensive care unit by 2% and exitus by 3%.Mean cost of traffic accidents was found 247,38TL.The effect of traffic accident pattern on the cost was not statistically significant.The effect of clinical outcomes on the cost was found statistically significant.There was a statistically significant effect of GCS,AIS,ISS trauma scores on the cost.A correlation test was performed in the study to detect a significant conformity between traffic accident patterns,clinical outcomes,trauma scores and cost.There was not any significant association between traffic accident patterns and cost.The association between clinical outcomes and cost was weakly significant. A positively weak association was found between the cost and GCS. The association between AIS and ISS and the cost was moderately significant and a positive correlation was found.DISCUSSION:Traffic accidents are one of the basic causes of death among younger population below 50 years of age. Traffic accident patterns were evaluated in terms of AIS and ISS efficiency and correlation.There was not any difference between test and treatment costs and traffic accident patterns when efficiency of traffic accidents was evaluated on costs.Costs increase by increase of AIS and ISS scores.Clinical outcomes are also effective on the cost.CONCLUSION:Traffic accidents usually cause multi-traumas and costs of the tests and treatment services are detected higher.The association and correlation between trauma scores and cost were evaluated; and costs increase by increase in numeric data of the trauma scores.An increase in costs were detected according to the clinical progress of the patients. We believe that trainings should be increased to reduce traffic accidents for health as well as country economy.


Dilek ATIK, Burçe KOÇKAN, Bensu BULUT, Hilmi KAYA, Ramiz YAZICI, Ramazan GÜVEN (ıstanbul, Turkey), Başar CANDER
10:15 - 10:35 #19287 - SP112 Epidemiology and Outcomes of Acute Kidney Injury in an Irish Trauma Population.
SP112 Epidemiology and Outcomes of Acute Kidney Injury in an Irish Trauma Population.

INTRODUCTION

Acute kidney injury (AKI) following trauma has been shown to be associated with significant morbidity & mortality. We carried out a retrospective study in order to examine epidemiology and outcomes of AKI in an Irish population. 

  

METHODS

Major trauma patients attending a tertiary referral university hospital with an annual ED census of approximately 56,000 between 01/09/13 and 31/12/15, who were included in the Trauma Audit and Research Network (TARN) database and for whom more than one laboratory creatinine value was available, were eligible for the study. The primary outcome measure was AKI diagnosed during admission or within 30 days of arrival to hospital. AKI was defined as per the Acute Kidney Injury Network (AKIN) criteria. A logistic regression analysis was performed to identify factors associated with the development of AKI. 

  

RESULTS

967 patients were included, 487 (50.9% were male). 116 patients (12.0%) developed AKI during the study time period. The mean age of the AKI group was 75.97 years (standard deviation (SD) 15.36) compared to 62.19 years (SD 22.18) for the non-AKI group. The AKI group had a higher mortality rate (10% vs 3%) and ICU admission was more common (16% vs 7%). Hospital length of stay was longer for the AKI group (46.2 vs 18.9 days, p<0.0001). There was no significant difference in the incidence of shock or in injury severity scores (ISS) between the two groups. 

  

DISCUSSION

The incidence of AKI in our study group was similar to previously reported studies. AKI was shown to be associated prolonged length of stay, an older cohort of patients and increased mortality. No association was shown with shock or ISS. The findings of this study should alert treating physicians to the increased incidence of AKI in older trauma patients and to its potential effect on hospital stay and mortality. 

 


Dr Filip LIS, Owen KEANE, Dr John CRONIN (Dublin, Ireland)

Wednesday 16 October

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EPOSTER 6.4
10:15 - 10:35

ePoster 6.4 - Short Oral Presentation - Screen 4

Moderator: Katarina VESELA (MD) (Prague, Czech Republic)
10:15 - 10:20 #18132 - SP113 Theatre of the oppressed: empowering emergency staff.
SP113 Theatre of the oppressed: empowering emergency staff.

Background and Objectives

Originally pioneered by Augusto Boal, Forum Theatre (a technique of Theatre of the Oppressed) uses interactive drama to explore challenging encounters in a shared group environment. It promotes wider reflection and allows individuals to explore and rehearse solutions in a ‘safe environment’, empowering participants to address oppressive situations in real life. 

Burnout and job dissatisfaction are well documented amongst staff members working in the Emergency Department (ED). Contributing factors include challenging interpersonal interactions and a lack of administrative and clinical autonomy. Measures of staff wellbeing correlate positively with patient satisfaction and are associated with reduced adverse clinical outcomes. We explored the application of Forum Theatre methods in empowering ED staff to better handle challenging encounters in the workplace.

Methods

A mixed disciplinary group from an ED in London attended a four-day course to learn the methods of forum theatre. Participants used their own experiences to write and perform two scenarios depicting workplace oppression to an audience of hospital staff. Themes, outcomes and the potential for change around the scenario were discussed by the audience and audience members assumed the role of the protagonist in the scenario to put audience suggestions into practice.  

Results

Participants (n= 10, all female, average age 31) all stated that they sometimes felt they had no power or choice at work. All felt that it was important to do fun activities at work and that their wellness was important to the functioning of the department.

Attendees to the performance (doctors, nursing staff, senior management) found it uniformly enjoyable and useful. Most found that it encouraged them to think about how to handle difficult situations at work (94%).

Conclusions

Forum theatre can empower ED staff to feel more prepared and confident in addressing conflict in the workplace. 


Christina Lalani HANDALAGE, Hajela SAPNA, Javadian PARISA, Dr Edmundson HEIDI (London, )
10:25 - 10:30 #18794 - SP115 Novel ethanol point-of-care test device Albio™: first results in world and introduction to coming studies.
SP115 Novel ethanol point-of-care test device Albio™: first results in world and introduction to coming studies.

Novel ethanol point-of-care test device Albio™: first results in world and introduction to coming studies.

 

Introduction

Ethanol is one of the leading causes of death worldwide.  Once intoxicated, the risk for trauma increases as the ethanol percentage rises. After valuating reasons for patient flow to emergency department ethanol related visits cover 12 to 15 % in daytime and the frequency rises in the weekend nights nearly to 70 %. Further, ethanol intake can masquerade the real reason for the visit; after the first triage 23 % of the patients have been triaged with a false intake diagnose.

Generally ethanol levels are measured via breathalyzer or intravenus blood sample.

Both options have their weaknesses and cannot be utilized in every situation. Breathalyzer demand a co-operating patient. Patients with lowered consciousness cannot exhale properly. Further, disoriented patients who cannot grasp the concept of long steady exhale cannot be evaluated reliable with breathalyzer. 

The problem with venous sample is processing time. The process can take up to 30 – 90. Thus, it doesn’t help the clinician in the first evaluation of the patient.

To our best knowledge PAL Finland has developed world`s first point-of-care test for ethanol, Albio™. It is patented in EU, US patent pending. Albio™ can analyze blood ethanol concentration during less than 10 seconds from a small sample of blood. The sample can be taken from capillary blood; thus, it is easy and quick to use. In most countries paramedics control blood sugar levels and capillary sample for ethanol levels can be taken from the same sting. Basic operating principles are based on chemical reaction where ethanol and nicotinamide adenine dinucleotide in the presence of alcohol dehydrogenase (ADH) oxidize forming acetaldehyde and oxidized form of nicotinamide adenine dinucleotide.

Objective

Firstly, the device had to be validated by the company. In the second phase independent research team will test the device in the field. The objective is to study whether, the device is accurate enough also in the real life and is reliable/practical to use. The study will start in late 2019 and it is composed by the main author of this abstract (with research team) without any engage from the company. 

Methods and results

We studied the changes of electric current in the Albio™ device in relation to blood ethanol concentration. For ethanol concentration of 0.0 permille, the device gave a certain number of arbitrary units. When ethanol concentration was risen to 0.25 and 0.50 permilles the mean values were 1.84 and 2.31 times higher than for 0.0 permilles, respectively. Further, the mean values were 2.64 and 2.98 times higher for 1.0 and 1.5 permilles than for 0.0 permilles, respectively. The individual values were clearly separable from those taken in other ethanol concentrations.

Conclusion

In the internal validation of the company, the point-of-care blood ethanol device looks very promising. If it holds the results in the coming field test, it will become a useful asset to first responders, paramedics together with doctors and nurses working in emergency departments.


Tuukka TOMMINEN (Hämeenlinna, Finland), Ville HÄLLBERG, Ilkka VARTIAINEN, Topi MATTILA, Shu ALEX, Ari PALOMÄKI
10:30 - 10:35 #19007 - SP116 In pursuit of the most efficient technique of improving feedback skills among emergency medicine residents- a randomized controlled trial.
SP116 In pursuit of the most efficient technique of improving feedback skills among emergency medicine residents- a randomized controlled trial.

Background: A good feedback should have certain attributes, as cited extensively in the literature.   Appropriate and timely feedback is crucial in improving the clinical practice of the residents. In spite of its importance, the residents regularly express their displeasure with the quality of feedback. One of the important barriers to constructive feedback is a lack of appropriate training and skill of giving feedback.  Accreditation Council of Graduate Medical Education has recommended feedback as a core skill for Emergency Medicine Residents (EMR).

 

Aim/Objectives: The primary aim of the study was to find the most efficient technique of teaching the skills of feedback to EMR. The secondary aim was to gauge their preferred educational technique.

 

Method:  This was a prospective mixed method study that included 45 EMR in the current training program.  A computer-generated block randomization with concealed and opaque envelopes.  All residents were randomized to group A, B and C.  Group A received no prior training, Group B read a brief document about the attributes of a good feedback and group C received one to one tutoring from one experienced faculty about the attributes of a good feedback. A brief 4 minute- teaching video on Rapid sequence intubation (RSI) was prepared by the teaching faculty which was assessed by two senior faculty and approved for this trial Each resident was asked to watch the video and provide feedback on the skills of the physician performing RSI.  An assessment form based on good feedback attributes cited in the literature was created and validated. The feedback techniques of EMR were audio recorded and assessed by two senior faculty blinded to the study. The study was approved by institutional research council and exempted from ethics review. The EMR preference for their preferred educational technique was obtained through a semi structured interview from a group of 7 volunteers. 

 

Results: The baseline characteristics of the three groups were similar.  With Group A set as the baseline, as compared to that baseline Group A score Group B subjects’ total score was 1.3 points higher (95% CI 0.3 to 2.3, p = .014) and Group C subjects’ total score was 2.7 points higher (95% CI 1.7 to 3.7, p < .001).  (Overlapping 95% CIs between Group B and Group C suggested there was no statistically significant difference between those two groups’ total scores). The residents favored self-reading and 1:1 tutoring equally.

 

Discussion: Learning a feedback skill is essential during EMR program. This skill can be acquired through either self-reading an appropriately written document or 1-1 teaching by appropriately trained faculty. The study may also have implications on the utilization of faculty time for teaching core skills to EMR.

 

Conclusion: Compared to Group A, Groups B and C scored significantly higher on the overall assessment and statistically similarly to each other. There was no sign of association between either sex or PGY year or total score.  EMR preference for feedback technique was equally distributed between self-reading and 1:1 tutoring.



Funded by MRC of Hamad Medical Corporation
Dr Khalid BASHIR (Doha, Qatar), Amr Mohammed Abdallah ELMOHEEN, Mohamed Ahmed SEIF MOHAMED, Saleem FAROOK, Shahzad ANJUM, Kodumayil ASHID, Kumar THIRMOOTHY SAMY SURESH, Thomas PROF. STEPHEN

Wednesday 16 October

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EPOSTER 6.5
10:15 - 10:35

ePoster 6.5 - Short Oral Presentation - Screen 5

Moderator: Door LAUWAERT (Manager) (BRUSSELS, Belgium)
10:15 - 10:20 #18498 - SP117 Non-invasive Zip wound closure for lacerations in pediatric and adult A&E departments.
SP117 Non-invasive Zip wound closure for lacerations in pediatric and adult A&E departments.

Background: Cutaneous lacerations requiring sutures remain a common reason for seeking medical care in the emergency. Suturing can cause pain, anxiety and necessitates time to ensure a good outcome. This study assesses if non-invasive Zip wound closure could be a way for Accident and Emergency (A&E) departments to save time as well as improve patient experience. Method: 13 adult and 13 pediatric patients presenting with minor lacerations to their respective A&E departments at the Karolinska University Hospital were randomized to nylon suture or non-invasive Zip wound closure. Closure and overall procedure durations and patient pain (using a Visual Analog Scale (VAS)) were measured. Patient satisfaction, pain and adverse events were recorded via phone interview at 10 and 30 days after treatment. An independent panel of physicians assessed digital photographs of the wounds after 10 and 30 days using the 0-6 Wound Evaluation Scale. Results: Average total treatment time in the pediatric and adult cohorts was reduced 59% (p=0.004) and 62% (p=0.010) respectively in the Zip cases vs. traditional sutures. Patients reported 69% less pain during closure (mean VAS 12.8 and 40.9, respectively), 31% less pain during closure removal and 54% less pain when assessing overall scar pain (mean VAS 9.7 and 20.8, respectively) with the Zip device compared to sutures. Patients treated with the Zip device reported 66% less fear or anxiety during wound closure compared to patients treated with sutures (mean VAS 11.8 and 34.6, respectively). Baseline grading on the Wound Evaluation Scale was an average 4.9 and 4.6 in the sutures vs. Zip cohort. After 30 days the wounds were graded 4.8 and 5 respectively. Conclusion: The Zip device demonstrated reduced treatment time, patient pain and anxiety and increased patient satisfaction in both the pediatric and adult emergency department. Using the Zip device, there was no requirement to use infiltration with local anesthetic and a superior cosmetic outcome after 30 days was seen. Additionally the Zip can also eliminate the need for a suture removal visit, which may save time and overall healthcare cost.



Trial Registration:This is a post-market clinical study using a CE-marked product for its intended used, hence no registration was needed. Ethical approval by Regionala Etikprövningsnämnden (Regional Ethics Review Board) i Stockholm: Zip-009, EPN diarie number: 2017/831-31/1 Funded by: ZipLine Medical, Inc. 747 Camden Ave., Suite A Campbell, CA 95008 USA
Filippa LINDÉN BERGMAN (Stockholm, Sweden), Anna DAHL, Christian SCHYLLERT, Ellinor MAGNUSSON, Emmanuele PATTI, Jeremia JILKE, Felicia RYDEBERG KJAERNET, Margaretha LANNGE, Krakowski RADEK, Pia MALMQUIST, Therese DJÄRV
10:20 - 10:25 #18767 - SP118 Is trainee led research the future? Subarachnoid haemorrhage in emergency departments – a service evaluation of the UK trainee emergency research network.
SP118 Is trainee led research the future? Subarachnoid haemorrhage in emergency departments – a service evaluation of the UK trainee emergency research network.

Introduction

The UK Trainee Emergency Research Network (TERN) was established in August 2018. To understand the potential of the network, a pilot study was designed to assess the ability of TERN to collect standardised multi-centre data on subarachnoid haemorrhage (SAH). This topic was chosen after competitive review of submitted research questions by Trainees.  Extensive work by Perry showed almost perfect sensitivity of CT within 6 hours in suspected SAH, the results are yet to be adopted into UK clinical practice. It has therefore been listed in the top 20 RCEM/James-Lind Alliance research priorities and adopted as a TERN study.

Methods

Design

Sites were invited to participate via email to Trainees registered with TERN. Sites that registered interest were assessed for data collection completion and levels of data variability. 

Setting

The study was conducted in twenty-two Emergency Departments (EDs) in the UK, that included a mixture of tertiary referral centres and district general hospitals. Retrospective data was collected for patients presenting with a headache between 26/11/2018 at 0000 until 02/12/2018 at 2359. Data entry was open for two months to allow for entry of final diagnosis.

Outcomes

Primary

  • Assess feasibility of TERN to collect standardised multi-centre data on SAH.

 Secondary

  • Identify number of patients presenting to ED with headaches in a 2-week period.
  • Identify number of patients who underwent CT scan within 6-hours of symptom onset.
  • Identify number of SAH.

Results

29 sites registered interest in data collection. 24 (82%) sought approval from their hospitals, 2 were denied permission, which left 22 (76%) who collected data.

Data on 403 eligible patients were collected. The average number of eligible patients per hospital was 18.3 (min=5, max=53). Median age was 42 years (Q1-Q3 = 30-56 years). Overall, 68% of eligible patients were female, varying from 43 to 100% between sites. 

A CT scan was performed in 161 (40%) eligible patients, with an average of 7.3 (min=2, max=15) CT scanned patients per hospital. CT scan rates varied from 19% to 100% between sites. Abnormalities were found in 20 (13%) scanned patients, with 3 confirmed SAH (1.9%).

Onset to CT duration was calculable in 105 cases, and under 6 hours for 24 of these (23%, ranging from 0 to 100% between sites). Arrival to CT duration was calculable in 154 cases and was under 6 hours in 135 of these (88%, ranging from 0 to 100% between sites). 

Discussion and Conclusion

Though data quality varied between sites, this pilot study has identified possible improvements that minimise these issues including stricter data validation rules, clearer questions, and prospective data collection. Patient case-mix and treatment practices, including SAH prevalence and CT rates, should be cautiously interpreted as this pilot was not powered to accurately estimate these quantities. A future study is being developed to validate the 6-hour CT head rule based on an improved and expanded data collection process. More generally, this pilot has demonstrated that, with careful planning and execution, TERN is able to collect multi-site data of sufficient quantity and quality to conduct large-scale studies.



Funded by the Royal College of Emergency Medicine
Tern TRAINEE EMERGENCY RESEARCH NETWORK, Tom ROBERTS (Bristol, ), William HULME
10:30 - 10:35 #19387 - SP120 A Review of Management Neck of Femur Fracture Pathway in the Emergency Department.
SP120 A Review of Management Neck of Femur Fracture Pathway in the Emergency Department.

Background

Patients who present to the Emergency Department (ED) of Sligo University Hospital (SUH) with a suspected hip fracture are managed with the aid of the ‘Neck of Femur Fracture (NOF) Pathway’, which is a guide designed to facilitate speedy assessment and transfer of patients to the Orthopedic ward for definitive treatment, while delivering optimum care. SUH guidelines set a target of 4 hours from ED presentation to ward arrival time.

We investigated how efficiently patients with NOF are being managed and transferred from the ED to the Orthopedic ward, while aiming to identify specific points of potential time delay.

Methods

We performed an audit of patients who presented to the ED with NOF between December 2018 and February 2019. Specific parameters included time from arrival to receiving Fascia Iliaca Compartment Block (FB), documentation of agents used in FB and door to ward time. Further categories included documentation of mechanism of injury, pre hospital mobility status, and if an Abbreviated Mental Test (AMT) was performed in the ED.

Results

22 charts were available for analysis. These included 16 Female patients (73%) and 6 Males (6%).  95.5% of injuries occurred due a low energy mechanism. Of the 22 patients investigated, 19 had an FB performed in the ED. The average time from door to FB was 2 hours 16mins. Of the 19 patients who received an FB, 10 (52.6%) had documentation of agents used. All 10 of the documented cases used a combination of Bupivocaine and Lidocaine, with a variation in strength and quantities of these agents. All but one case had documented prehospital mobility status. An AMT was performed in 9 cases (41%). The average door to ward admission time was documented in 18 cases, with an average time of 4 hours and 43mins.

Conclusion/Discussion

The majority of patients are being treated in the ED with FB. There seems to be poor documentation of agents used in the procedure, with a large variation of preferences for particular agents among individual doctors. The time from door to FB of 2hrs 16mins may potentially be improved to facilitate a faster admission to ward time. The target door to ward time is being missed by an average of 43 minutes, which may not necessarily reflect ED delay, and is likely a multi-factorial issue (bed shortages etc). However, the possibility to improve ED management time is evident. Documentation of prehospital mobility is adequate. Our quality improvement plan includes the introduction of ‘Regional Anesthesia Trolley’, which will have all equipment required for a FB in one location, thus reducing preparation time. We have consulted national guidelines to create a standard approach guideline for agents used in FB. We presented our initial audit findings at ED teaching, with emphasis on these factors to help improve overall care of patients suffering NOF. Data is currently being collected to assess any new change in practice post these quality improvement measures being introduced.

 

 



This study did not receive any specific funding
Maeve LEONARD, Ahmed AL RASHEED (SLIGO, Ireland)
10:40

Wednesday 16 October

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A42
10:40 - 12:10

Global Emergency Medicine
General EM, Global

Moderators: Simon CARLEY (Consultant in Emergency Medicine) (Manchester), Shweta GIDWANI (United Kingdom)
10:40 - 12:10 Why should we care about global health? Giles CATTERMOLE (Consultant in Emergency Medicine) (London, United Kingdom)
10:40 - 12:10 Opportunities for everyone in global health. Dr Claire CRICHTON (Emergency Medicine Trainee) (Edinburgh, United Kingdom)
10:40 - 12:10 Refugees in your ED. Dr Anisa Jabeen Nasir JAFAR (Emergency Medicine trainee) (Manchester)
CONGRESS HALL

Wednesday 16 October

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B42
10:40 - 12:10

No Risk no Fun
Looking at Risk and Fun from Different Perspectives
Decision making, Human factors, Psychology

Moderators: Wilhelm BEHRINGER (Director) (Jena, Germany), Christian HOHENSTEIN (PHYSICIAN) (Bad Berka, Germany)
10:40 - 12:10 No risk no fun - the day to day risk in (un)concious decision making. Wilhelm BEHRINGER (Director) (Jena, Germany)
10:40 - 12:10 How to play with fire - behaviour to patients that can bring you to court. Dr David CARR (Associate Professor of Emergency Medicine) (Toronto Canada, Canada)
10:40 - 12:10 How to Avoid Errors in Procedural Sedation. Dr Reuben STRAYER (Emergency Physician) (Brooklyn, USA)
FORUM HALL

Wednesday 16 October

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C42
10:40 - 12:10

Open Research Meeting

Moderators: Pr Abdelouahab BELLOU (Research) (Boston, USA), David SCHWARTZ (Researcher) (Israel, Israel)
10:40 - 12:10 Pain Consensus Initiative. Said HACHIMI IDRISSI (head clinic) (Ghent, Belgium)
10:40 - 12:10 Physicians' attitudes towards smartphone-based Emergency Response Communities. Pr Abdelouahab BELLOU (Research) (Boston, USA)
10:40 - 12:10 Research Committee Meets with Researchers. Mehmet Akif KARAMERCAN (Chair of EuSEM Research Committee) (ANKARA, Turkey)
SOUTH HALL 3AB

Wednesday 16 October

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D42
10:40 - 12:10

YEMD - Here they come... Science Busters!
Academia doesn't have to be boring!
Academia, Research, Women in EM, Young Emergency Medecine

Moderators: Dr Andrea DUCA (Emergency physician) (Bergamo, Italy), Dr Lina JANKAUSKAITE (MD, PhD) (Kaunas, Lithuania)
10:40 - 12:10 Academic emergencies. Rok PETROVCIC (Resident) (Maribor, Slovenia)
10:40 - 12:10 First: Learn to read (a paper). Dr Lina JANKAUSKAITE (MD, PhD) (Kaunas, Lithuania)
10:40 - 12:10 Research is not for me!! Patricia VAN DEN BERG (Academic Clinical Fellow Emergency Medicine) (Manchester, United Kingdom)
10:40 - 12:10 Infographics to communicate science for EVERYONE! Tommaso SCQUIZZATO (Milan, Italy)
SOUTH HALL 3C

Wednesday 16 October

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F42
10:40 - 12:10

ABSTRACTS SESSION

Moderator: Lisanne KOSTEK (Physician) (Magdeburg, Germany)
10:40 - 10:50 #18712 - OP109 Improving the management of infants with bronchiolitis: a cluster randomised controlled trial of tailored knowledge translation in paediatric acute care.
OP109 Improving the management of infants with bronchiolitis: a cluster randomised controlled trial of tailored knowledge translation in paediatric acute care.

Background and objectives

Bronchiolitis is the most common reason for infants to be hospitalised following presentation to emergency departments (EDs).  Management is supportive with high-level evidence of no efficacy for salbutamol, glucocorticoids, chest x-rays, antibiotics, or adrenaline. Despite all international guidelines recommending against the use of these therapies, significant practice variation exists, with the use of inappropriate therapy a worldwide problem. Knowledge translation (KT) interventions that are tailored to the factors that influence practice can improve care; however there is little high-level evidence in acute paediatrics. The primary objective was to establish whether tailored, theory informed KT interventions, compared to passive guideline dissemination, reduces the use of salbutamol, glucocorticoids, chest x-rays, antibiotics, and adrenaline, in infants <1 year of age with bronchiolitis.

Methods

Tailored KT interventions were developed, following qualitative interviews using the Theoretical Domains Framework, to target key identified factors influencing bronchiolitis management. We then compared the tailored KT interventions versus passive dissemination in a cluster randomised controlled trial of 26 hospitals in Australia and New Zealand during the 2017 Australasian bronchiolitis season. The primary outcome was compliance with the Australasian Bronchiolitis Guideline during the acute care period (first 24 hours of care) with no use of salbutamol, glucocorticoids, chest x-rays, antibiotics, or adrenaline. Secondary outcomes included compliance in ED, compliance in in-patients, compliance during total hospitalisation, compliance for individual therapies and length of stay. Analysis was by intention-to-treat using Generalised Linear Mixed Models.

 

Results

Baseline data was collected on 8,045 infants from all 26 sites for 3 years prior to the intervention year (2014-16 bronchiolitis seasons). There were no major differences between the intervention and control sites. Data was collected on 3,727 infants for the intervention year (2017). Compliance with the Australasian Bronchiolitis Guideline for the acute care period was 85.1% (95%CI 82.6-89.7%) in the intervention sites and 73.0% (95%CI 65.3-78.8%) in the control sites, risk difference 14.1% (95%CI 6.5-21.7%), p<0.001. Compliance while in ED was 87.2% in the intervention sites and 78.8% in the control sites, risk difference 10.8% (95%CI 4.1-17.4%), p=0.002. Compliance in in-patients was 90.5% in the intervention sites and 83.0% in the control sites, risk difference 8.5% (95%CI 2.7-14.3%), p=0.004. Compliance during total hospitalisation was 82.2% in the intervention sites and 69.9% in the control sites, risk difference 14.4% (95%CI 6.2-22.6%), p<0.001. Median length of stay was 0.5 days in the intervention sites and 0.5 days in the control sites, incident rate ratio 0.9 (95%CI 0.7-1.2), p=0.67.   

 

Conclusions

The use of tailored KT interventions substantially reduces the use of inappropriate therapies in the management of infants with bronchiolitis. As bronchiolitis is the most common reason for infants to be admitted to hospital this study has important implications for future management of bronchiolitis and worldwide for KT for paediatric presentations to EDs. 



The trial is registered in the Australian and New Zealand Clinical Trials Registry (ACTRN12616001567415). Supported by a National Health and Medical Research Council Centre of Research Excellence grant for Paediatric Emergency Medicine (GNT1058560), Australia and the Health Research Council of New Zealand (HRC 13/556).
Libby HASKELL (Auckland, New Zealand), Pr Franz E BABL, Emma TAVENDER, Catherine WILSON, Sharon O'BRIEN, Meredith L BORLAND, Elizabeth COTTERELL, Rachel SCHEMBRI, Nicolette SHERIDAN, David JOHNSON, Ed OAKLEY, Stuart R DALZIEL
10:50 - 11:00 #19333 - OP110 Comparison of time to antibiotics, - IV fluids and mortality of septic patients before and after Implementation of an Electronic Shock Alert.
OP110 Comparison of time to antibiotics, - IV fluids and mortality of septic patients before and after Implementation of an Electronic Shock Alert.

Backgorund:

Sepsis is a leading cause of hospital mortality world wide. We know that time to treatment reduce morbidity and mortality. We don't know if implementation of a shock alert forcing physicians to select the cause of shock and if sepsis, guiding them to resuscitation goals, will lead to improved time to treatment and mortality. The primary objective was to evaluate time to treatment with antibiotic and IV fluids and the outcome of patients presenting with shock and impression of sepsis, before and after implementation of an electronic ShockAlert.

Design and Method: This is a ambispective before and after study of patients presenting with Septic Shock to an academic tertiary Emergency Department before and after implementation of an electronic Shock Alert; May 16, 2013 through November 13, 2014 and January 15, 2015 through January 14, 2017. Patients were defined as having sepsis when they met Shock Alert criteria (a single episode of either hypotension (systolic blood pressure ≤ 90 mmHg) or Lactate ≥ 4 mmol/L) and had a physician impression of sepsis. In the pre-implementation group, subjects were identified by retrospectively applying Shock Alert criteria to all patients ED patients and by chart review identifying patients with sepsis or septic shock as the cause of shock. Subjects in the post group were identified through the Shock Alert tool (AWARE). Time to antibiotic was calculated in both groups and defined as time from ED arrival to the first antibiotic was ordered. Time to IV fluids was calculated similarly.

Continuous features were summarized with means and standard deviations when approximately normally distributed and with medians and interquartile ranges (IQRs) otherwise; categorical features were summarized with frequency counts and percentages. Features were compared between patient visits before and after implementation of the electronic sepsis notification system using two-sample t, Wilcoxon rank sum, chi-square, and Fisher exact tests based on the type and distribution of the feature under study.

Results: A total of 670 patients were eligible for this cohort study, 270 (40%) from the pre-implementation period and 400 (60%) from the post-implementation period. The mean age at ED arrival was 70 years in the pre-cohort and 68 years in the post-cohort (p 0,23), 58% and 57% were men in the pre- and post- implementation cohort respectively. The median time to first antibiotic was 1.7 (0.8-2.6) hours pre-implementation and 1.2 (0.7-2.3) hours post (p<0,001). In the pre-group, 38% received ≥30 ml/kg fluids within 3 hours from trigger time, this was 46% in the post group (p=0.039). The ICU admission rate was 61% pre-implementation and 73% post implementation (p=0.001). We found an in-hospital mortality in the pre and post group respectively of 15% and 8% (p=0.002)

Conclusions: This study shows a significantly reduced time to antibiotic treatment and order of ≥30 ml/kg IV fluids to patients presenting to the Emergency Department with sepsis or septic shock after implementation of an electronic Shock Alert. We found an increased rate of ICU admission and significantly decreased in-hospital mortality after implementation of the electronic Shock Alert.



No funding IRB approved study
Anne Sophie BROGAARD (Aarhus, Denmark), David KOCEMBA, Casey CLEMENTS, Maria JENSEN, Hans KIRKEGAARD, Dr Bo MADSEN
11:00 - 11:10 #17915 - OP111 Significance of macrophage migration inhibitory factor for sepsis in hemorrhagic shock patients.
OP111 Significance of macrophage migration inhibitory factor for sepsis in hemorrhagic shock patients.

Background

Many patients die from sepsis and multiple organ failure, even though proper management in hemorrhagic shock patients. Early diagnosis of sepsis in hemorrhagic shock patients is important and used in various ways, such as CRP and WBC, procalcitonin (PCT), but they have some problems. Recently, macrophage migration inhibitory factor (MIF) have emerged as predictive factors. Our study aims to explore the significance of MIF as a predictor of sepsis in hemorrhagic shock patients.

Methods

This study was conducted on prospective observational study patients who visited an emergency medical center in a university hospital from March 1, 2018 to December 31, 2018 and were intended for hemorrhagic shock patients aged 15 or older. We measured WBC, CRP, PCT, MIF, TNF-α, Interleukin-6 (IL-6), and lactic acid with serum taken from the patient's blood. The definition of sepsis was defined as being part of SIRS criteria with infections within a week.

Results

180 hemorrhagic shock patients were registered in emergency department, 28 of whom had sepsis within a week. The CRP, WBC, TNF-α, IL-6 did not differ in the comparison between sepsis and non-sepsis patients, while the PCT was somewhat high in sepsis patients (0.24±0.1ng/mL > 0.18±0.07ng/mL), but with had no statistical significance. However, MIF was significantly elevated in sepsis (2633±710pg/mL) to non-sepsis group (1460±680pg/mL). There was no correlation between MIF and lactic acid, which is the diagnostic criteria of shock.

Discussion & Conclusions

It is believed that MIF may be used as a measure of sepsis in hemorrhagic shock patients. However, more research on the occurrence of MIF is thought to be necessary.



This study used in hemorrhagic shock patients (#180) This research was supported Basic Science research program through the National Research FOundation (NRF) funding by the Ministry of Education, Science and Technology (R1804431), and was partially supported a Korea University Grant This study protocol and informed consent documents were reviewed and approved of Korea University Guro Hospital (IRB No. 2018GR0155)
Kim KYUNG-HWAN, Sung-Hyuk CHOI (korea, Korea, Republic of), Yoon YOUNG-HOON, Jung-Youn KIM
11:10 - 11:20 #19357 - OP112 Differences in Fluid Resuscitation and Mortality in Patients with Sepsis or Septic Shock and Pre-Existing Heart Failure.
OP112 Differences in Fluid Resuscitation and Mortality in Patients with Sepsis or Septic Shock and Pre-Existing Heart Failure.

Background&objective: The lifetime risk of heart failure is estimated to be 1 in 5 and is one of the leading causes of hospitalization in the United States in patients aged 65 and older. Sepsis is a leading causes of death in hospitals. Concurrent heart failure and sepsis presents a treatment paradox: Heart failure mangement focuses on managing and avoiding fluid overload whereas fluid administration is a key element in the treatment of septic shock. We studied the difference in fluid administration and mortality between septic patients with and without pre-existing heart failure.

Design and Method: This is a retrospective study of a consecutive cohort of 837 patients who presented to the emergency department (ED) of an American suburban academic medical center between May 2013 and January 2017. All patients presented with either hypotension (≤ 90 mmHg), an elevated lactate (≥ 4 mmol/L) or a combination and had a physician impression of sepsis recorded during the ED course. Patients were divided into two groups based on ICD-9/10 diagnosis of heart failure before ED arrival; there were 306 (37%) with pre-existing heart failure and 531 (63%) without. Additionally, the pre-existing heart failure group was subdivided into HFpEF and HFrEF based on the most recent ECHO before admission; there were 142 (46%) with a reduced ejection fraction <50% and 164 (54%) with a preserved ejection fraction ≥50%. Comparisons of total fluids ordered at 3 and 6 hours, ICU admission, ventilatory support and mortality between patient groups after adjusting for chronic kidney disease were evaluated using multivariable linear and logistic regression models.

Results: Patients with pre-existing heart failure received less fluid at 3 hours (mean 26.3 vs 30.7 ml/kg; p=0.009) and at 6 hours (mean 38.4 vs 45.0 ml/kg; p=0.003) compared to patients without heart failure after adjusting for chronic kidney disease. The adjusted odds ratio for the association of heart failure with ICU admission was 1.57 (95% CI 1.14-2.18; p=0.006), Patients with heart failure were not more likely to need intubation or vasopressors (p=0.35 and 0.22). Those with heart failure did trend toward an increased likelihood to die in-hospital or within 30 days, but these differences were not statistically significant in a univariable setting or after multivariable adjustment in this sample (p=0.10 and 0.14 respectively). However, the adjusted odds ratio for the association of heart failure with 90-day mortality was 1.46 (95% CI 1.03-2.06; p=0.032). There were no statistically significant differences in the outcomes studied between heart failure patients with reduced and preserved ejection fraction.

Conclusion: Patients with pre-existing heart failure who present to the ED receive significantly less fluid than patients without pre-existing heart failure at 3 and 6 hours after ED arrival and are more likely to require ICU admission during hospitalization. 90-day mortality is increased among patients with pre-existing heart failure. Based on the results of the current study, heart failure type does not appear to significantly affect the course of sepsis and septic shock.



IRB approved No funding Informed consent waived
David KOCEMBA, Maria JENSEN, Casey CLEMENTS, Hans KIRKEGAARD, Dr Bo MADSEN (Rochester, USA, USA)
11:20 - 11:30 #18429 - OP113 Learning hypertensive emergency management: Simulation versus video case.
OP113 Learning hypertensive emergency management: Simulation versus video case.

Introduction: Contextualization and reproducibility are features of high fidelity simulation that have allowed it to take an advanced place in the medical curriculum. Teaching by "video-case" is a teaching tool based on placing the learner at the center of his learning. The objective of the study is to compare these two means of learning in the acquisition of skills concerning the management of hypertensive emergency crises.

Material and methods: Randomized prospective study including emergency family medicine residents randomized into 2 groups: simulation group, video-case group for the same educational objective: management of an hypertensive emergency crises. After randomization, the study starts with a pre-test of 10 multiple-choice questions in 10 minutes on the prerequisite knowledge. After the two teaching sessions, students are asked to repeat the same test in multiple choice questions under the same conditions to compare the progress for each student and between the two groups.As a Judgment Criterion we retained the student progression judged by significant increase in average marks between pre-test and post-test.

Results: A total of 38 residents are included whose average age is 27.6 years with a sex ratio of 0.5. The pre-test average was comparable between the two groups: 9.2 / 20 (+/- 1.9) for the simulation group and 9.4 / 20 (+/- 1.7) for the video-case group (p = 0.268). For the post-test, averages increase significantly within each group. It goes from 9.2 / 20 (+/- 1.9) to 13.44 (+/- 1.28) (P <0.001) in the simulation group and from 9.4 / 20 (+/- 1.7) to 11.91 (+/- 1.5) ( P <0.001) in the video-box group. Relative progression is greater for the simulation group (P <0.03).

Conclusion: The superiority of simulation method over video-case teaching is concluded.

 


Houda BEN SOLTANE, Ikhlass BEN AICHA (TUNISIA, Tunisia), Ahmed GUESMI, Myriam KHROUF, Zied MEZGAR, Mehdi METHAMEM
11:40 - 11:50 #19101 - OP115 Epidemiology of Gabapentin Exposures using the National Poison Data System.
OP115 Epidemiology of Gabapentin Exposures using the National Poison Data System.

Background: Gabapentin prescriptions have by 64% between 2012 and 2016, in part due to the off label use for conditions like chronic pain. It was also one of the most commonly reported drug causing overdose deaths in the United States from 2011 through 2016. It has been noted that almost one-fifth of the patients who abuse opioids, also abuse gabapentin. The objective of the study was to describe the epidemiology of gabapentin exposures using a near real-time national poison center (PC) database.

Methods: The National Poison Data System (NPDS) was queried for all human exposures to gabapentin from 2012 to 2018 using the American Association of Poison Control Center (AAPCC) generic code identifiers. We descriptively assessed the relevant demographic and clinical characteristics. Gabapentin reports from acute care hospitals and emergency departments (EDs) were analyzed as a sub-group. Trends in gabapentin 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: There were 122,810 gabapentin human exposures reported to the PCs from 2012 to 2018, with the number of calls increasing from 11,336 to 22,776 during the study period. Polysubstance exposures accounted for 65.2% of gabapentin exposures. Of the total gabapentin calls, the proportion of calls from acute care hospitals and EDs increased from 55.1% to 64.7% during the study period. Multiple substance exposures accounted for 75.4% of the calls from acute care hospitals and EDs. Approximately 21% of the patients reporting gabapentin exposures were admitted to the critical care unit (CCU), while 21.3% patients were treated and released. Residence was the most common site of exposure (94.5%), and 68.2% cases were enroute to the hospital when the PC was notified. Among the patients, 59.1% were females, with the majority of gabapentin exposures occurring between the ages of 40-59 years (33.5%). Suspected suicides (51.6%) was the most commonly reported reason for exposure. The proportion of such cases was higher in reports from acute care hospitals and EDs (71.5%). During the study period, the proportion of suspected suicides increased (46.8% to 54.4%) among gabapentin exposures. Major effects were seen in 5.5% cases and the case fatality rate was 0.4%. Notably, there was an approximately 2-fold increase in the number of deaths during the study period. The most frequently co-occurring substances associated with the cases were benzodiazepines (16.7%) and antipsychotics (10.7%). Tachycardia (16.1%) and hypertension (8.5%) were commonly observed clinical effects. During the study period, the frequency of gabapentin exposures increased by 200.9% (95% CI: 196.4%, 205.5%; p<0.001), and the rate of gabapentin exposures increased by 217.8% (95% CI: 195.8%, 242.2%; p<0.001).

Conclusions:  Gabapentin exposures increased during the study period. Abuse and diversion of gabapentin may be as a result of its low cost and non-schedule status. Gabapentin has also been increasingly associated with suicidal ideation, the most common reason for exposure in our sample. Increasing prescriber awareness and better screening may be key to reduce such overdoses.



n/a
Saumitra REGE (Charlottesville, VA, USA), Angela HOLIAN, Andre BERKIN, Dr Christopher HOLSTEGE
11:50 - 12:00 #19254 - OP116 Tracking the Serious Adverse Events due to Opioids Using a National Real-time Database.
OP116 Tracking the Serious Adverse Events due to Opioids Using a National Real-time Database.

Objectives: Misuse of prescription opioids continues to be a significant public health crisis globally. The number of patients with opioid dependence worldwide was estimated to be 15.5 million in 2010. According to the Centers for Disease Control and Prevention (CDC), there were more than 72,000 overdose deaths in the United States (U.S.), with 49,068 involving an opioid, with 11.4 million misusing prescription pain medicine. The present study sought to evaluate the recent trends in the severe outcomes to opioid exposures reported to the U.S. poison centers (PCs).

Methods: The NPDS was queried for opioid exposures that were reported from 2012 to 2017. Cases with severe outcomes (SO) were defined as exposures that resulted in either a death or major clinical outcomes We descriptively assessed the demographic and clinical characteristics. Calls from acute care hospitals and emergency departments (ACH) were studied. Poisson regression was used to evaluate the trends in the number and rates (per 100,000 human exposures) of opioid exposures resulting in SO. Percent changes from the first year of the study (2012) were reported with the corresponding 95% confidence intervals (95% CI).

Results: There were 184,645 opioid-related SO cases reported to the PCs during the study period. Among these, 84% were reported by ACH. Cases between 20 and 39 years (39.3%) constituted the most common age group. The proportion of older adults above 60 years of age among SS cases almost doubled during the study period (7.4% to 14.2%). Females accounted for 63.8% of cases. Most exposures occurred in a residence (94.2%). More than one substance was reported for most cases (78.2%). Major clinical effects were demonstrated in 9.4% of exposures and the case fatality rate was 0.8%. Major effects were less common in teenagers (4.3%) and there were 92 deaths among this age group during the study period. Among cases, 33.2% were admitted to a critical care unit (CCU) while 22.6% were admitted to a psychiatric facility. The proportion of cases from ACH increased during the study period (80.4% vs 86.4%). Hydrocodone (36.7%) was the most common opioid reported in SS cases followed by tramadol (20.8%). Benzodiazepines were the most common non-opioid co-occurring substance reported for SS (28.9%). The most frequent clinical effect demonstrated was drowsiness (51.8%), while tachycardia (22.5%) and respiratory depression (10.3%) were commonly seen. Naloxone was used in 28.3% of cases. In approximately one-fourth of the cases, these therapies were used after recommendations from the PCs. SS decreased by 24.4% (95% CI: -25.7, -23.1%, p<0.001) while the SS rate also decreased by 16.5% (95% CI: -23.4%, -9.3%, p<0.001).

Conclusions: The number of SS cases handled by the PCs decreased significantly. Moreover, there was a low fatality rate.  Hydrocodone and tramadol were the most common opioid reported for the sample. Personalized evidence-based strategies, population-level interventions, creation of protective environments, and better screening of patients at risk of suicide are some key measure to limit this trend. PCs should play a significant role in the care of this patient population and become involved earlier in the case. 



n/a
Saumitra REGE (Charlottesville, VA, USA), Dr Christopher HOLSTEGE
12:00 - 12:10 #18587 - OP117 Clinical Prediction Rule Using Multiple Risk Factors for Torsade De Pointes from Drug-Induced QT Prolongation.
OP117 Clinical Prediction Rule Using Multiple Risk Factors for Torsade De Pointes from Drug-Induced QT Prolongation.

Background: Torsade de Pointes (TdP) from drug-induced QT prolongation is rare, but life-threatening.  Corrected QT with a cut-off value has long been widely used to estimate the probability of TdP. However, it is neither sensitive nor specific enough. This study sought to construct a clinical prediction rule using multiple risk factors for drug-induced TdP.

Methods: The study population was drawn from a previous retrospective case-control study. Within the case group, a systematic review from Medline was undertaken from the point of its establishment to 10th December 2015. All subjects were adults exposed to QT-prolonging drugs and had TdP. A total 230 patients were included. The control group consisted of 291 patients from 3 hospitals in Atlanta, Georgia, USA, admitted from 2008 to 2010. They had overdosed on QT-prolonging medications but did not develop TdP later. Univariate and multivariate analyses were done to identify significant risk factors. The coefficient of each significant risk factor was converted to a score. Scores were categorized as low, intermediate, and high probability for TdP. Area under the ROC curve (AUROC) and likelihood ratio were calculated.

Results: Univariate analysis revealed 6 significant factors: age>65 years old, female, underlying heart disease, heart rate <60 beats/minute, QTcB (Bazett’s formula) >490 milliseconds (ms), and exposure to drugs known to cause TdP based on Crediblemeds.org. For the multivariate analysis, only old age, slow heart rate, QTcB >490 ms, and exposure to drugs known to cause TdP were significant. The Hosmer-Lemeshow test was 0.89. A scoring system was invented based on the coefficients of these significant risk factors.  The clinical prediction rule has an AUROC of 0.98 (95%CI: 0.97-0.99). In the low risk group, likelihood ratio for TdP was 0.02 (95%CI: 0.01-0.06), and in the high risk one, the likelihood ratio was 120 (95%CI: 30-479).

Conclusions: This clinical prediction rule using multiple risk factors, including QTcB >490 ms, provided very high performance for predicting TdP in those who were exposed to QT-prolonging drugs. However, this rule still needs to be validated.


Rittirak OTHONG (Bangkok, Thailand), Warisa PRASERTSUP
TERRACE 2B
12:10

Wednesday 16 October

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HOT TOPIC SPEAKER LECTURE
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12:10 - 12:40 The Emergency Bathtub: addressing demand in urgent & emergency care systems. Pr Suzanne MASON (Professor of Emergency Medicine) (Sheffield, United Kingdom)
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Wednesday 16 October

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CLOSING CEREMONY

12:40 - 13:10 EUSEM 2019 figures. Dr Jana SEBLOVA (Emergency Physician) (PRAGUE, Czech Republic), Patrick PLAISANCE (Head of Department) (Paris, France)
12:40 - 13:10 Euro Sim Cup award. Guillem BOUILLEAU (Responsable Urgences - SHCD) (Chinon, France)
12:40 - 13:10 Best research award. Felix LORANG (Consultant) (Jena, Germany)
12:40 - 13:10 Audience award. Senad TABAKOVIC (Medical director emergency department) (Zürich, Switzerland)
12:40 - 13:10 Introduce EUSEM 2020 Copenhagen. Christian SJAERBAEK (Copenhagen, Denmark)
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