INTRODUCTION: Abdominal trauma represent 15 to 20% of lesions observed in trauma and are associated with a mortality of 10-30 %. They are mainly represented by closed lesions due to a contusion of solid organs (spleen, liver, kidneys, pancreas) , or perforation of hollow organs (duodenum , small intestine, colon ). Search intra abdominal injury post traumatic pass through the abdominal CT scan but another exam, urinaysis is frequently used in emergency services during abdominal trauma to search hematuria. The diagnostic and especially prognostic interest of microscopic hematuria remains controversial in abdominal trauma. The aim of our study was to investigate whether the microscopic hematuria of urinalysis in patients with a blunt 
trauma mechanism is in correlation with abdominal lesion.

METHODS : We realized a retrospective, multicentric and observational study between January 2012 and August 2014. Patient with an age ≥18 years old, admitted to the emeregncy unit, had an abdominal CTscan and a urinalysis were included. Demographic, clinical and therapeutic variables were examined from hospital files. Main outcome measure was the correlation between microscopic hematuria on urinalysis and the existence abdominal injuries found thanks to the injected scanner.

RESULTS : 100 patients were included. 56 patients had microscopic hematuria, 17  gross hematuria and 44 no hematuria. The sensitivity and specificity of microscopic hematuria in patients with abdominal injury were respectively 72.2% [54.8-85.8] and 53.1% [40.2-65.7]. The PPV was 46.4% [33-60.3]. The NPV was 77.3% [62.2-88.5]. In univariate analysis, we did not find any significant difference to find an abdominal injury in patients aged over 50 years old (p = 0.96), in men (p = 0.20), patients with anticoagulants (p = 0.3), with medical history (p = 0.88) or with abdominal pain (p = 0.06). The risk was significally increased in case of hypovolemic shock (p <0.001), hematoma on abdominal wall (p = 0.001), acute abdomen (p = 0.001) and anemia (p = 0.014). In multivariate analysis adjusted for age and gender,  risk factors for abdominal injury were hypovolemic shock with OR 9 (p = 0.002) and abdominal pain OR 3.5 (p = 0.039). Microscopic hematuria is not predictive of an abdominal injury and its absence does not exclude the diagnosis of abdominal injury.

CONCLUSION : We don’t recommand the realisation of urinalysis in people with blunt abdominal trauma in the aim of finding microscopic hematuria. We encourage the realization of the abdominal CT scan in case of hypovolemic shock or abdominal pain in patient with abdominal trauma.

Introduction

In this study we aimed to evaluate injury patterns of patients admitted to the emergency department with gunshot wounds, results of imaging studies, treatment modalities, outcomes, mortality ratios, and complications.

Material and Methods

This is a retrospective descriptive study including a total number of 142 patients admitted to Hacettepe University Emergency Department with gunshot injuries between January 1, 1999 and December 31, 2013. The Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Trauma and Injury Severity Score (TRISS) probability of survival for penetrating trauma were calculated for all patients.

Results

Among the 142 patients in the study, 128 (90.1%) were male. The mean age was 36 years. On admission the average GCS score was 13, the mean RTS was 6.64, median ISS was 5 and the median TRISS probability for survival was 99.4% for penetrating trauma. Fluid was detected in 3 (13%) patients in FAST whereas intra-abdominal solid organ injury and bowel injury were detected in 11 (58%) patients in abdominal CT. The pneumothorax, hemothorax and lung injuries were detected in 10 (43.5%) patients, whereas hemothorax was detected only in one patient with thoracic injury by chest X-ray. Twenty four (16.9%) patients died; 18 patients (75%) had isolated severe intracranial injuries, two (8.9%) had thoracic injuries with head and neck injuries, and four (16.7%) patients had intra-abdominal organ injuries (one with concomitant head injury). Ten patients were brought to the ED in cardiopulmonary arrest. In dead patients, GCS, RTS and TRISS were significantly lower and ISS were significantly higher than in surviving patients. The twenty three 23 (95.8%) patients were in critical injury level (ISS 25-75, actually ISS>50) in the exitus group.

Conclusion

Mortality rates in gunshot wound patients with cranial injuries are very high. Spontaneous return is not seen in patients brought to the ED in arrest state. The bullets can cause internal organ injuries which can be greater than expected. In thoracoabdominal gunshot wound injuries, conventional X-ray and bedside FAST can be ineffective in detecting the whole extent of intrathoracic and intra-abdominal injuries. Thus thoracic and abdominal CT should be planned early for hemodynamically stable patients in order to eliminate causes of fatality and make a timely and correct diagnosis. ISS, RTS and GCS are useful in predicting prognosis and mortality. Especially in patients with ISS scores >50 the mortality rate can be as high as 96%.

Objectives: Femur fractures are very common traumatic injuries seen in the emergency department (ED). Adequate pain control is often challenging despite the wide availability of pharmacological agents. Femoral nerve blocks (FNB) for pain control have been used for many years showing safety and effectiveness when performed correctly. Ultrasound (US) guidance has dramatically improved its success and safety. In our department, we train residents to perform peripheral nerve blocks for pain control and procedural analgesia. In order to maximize the success of US guided FNB, echogenic needles (micro laser etched near the tip of transducer to increase visibility) are now available. This study aims to determine if a difference in success rate exists between using standard needles vs echogenic needles in US guided FNB.

Methods: We performed a prospective, double-blinded, randomized trial involving adult patients presenting to the ED with an isolated femur fracture. Patients at least 18 years old, able to verbalize pain level using a visual analog scale (VAS) 1-10, and mentally competent were included. We excluded pregnant and prisoner patients, also those with significant concomitant injuries, cognitive impairment, unable to verbalize pain, allergic to local anesthetics, severe liver disease, existing peripheral neuropathies in the affected limb, local signs of infection in the inguinal area, and those with coagulopathies or anticoagulated. Allocation concealment was performed by a third party. Needles were included in tamper-proof envelops.  Patients and physicians were blinded to needle selection. Using 0.25% Bupivacaine with epinephrine we performed a lateral, medial and posterior perineural injection (5 mL each). Pain score using VAS was recorded prior to and after the FNB (at 15, 30, 45, and 60 minutes).  The primary outcome (dependent variable) was the success of the NB measured by pain control. The needle type was considered the independent variable. 

Results: We have included a preliminary data set of 10 patients ages 21-81, five males. All received a variety of analgesics prior to the FNB without adequate pain control. Prior to the NB all patients had pain 5-10 VAS despite receiving intravenous analgesics. To assess pain scores between the treatment groups over time, a repeated measures ANOVA was conducted.  Based on this analysis, there was no statistically significant difference in pain scores between the groups (P=0.298). Similarly, when assessing the pain difference between baseline (enrollment) and 60 minutes after the FNB: the pain scores dropped by a median of 6 points for patients in the regular needle group while those on the echogenic needle group had a median drop in pain score of 9.5. To formally assess that difference of pain scores, an ordinal logistic regression model was fit.  There was no statistically significant difference between groups (P=0.138). No adverse events have been reported with the included population.

Conclusions: FNB with US guidance offers a safe and efficient alternative for pain control in patients with isolated femur fractures in the ED. With US guidance, echogenic needles do not offer a technical advantage over standard needles.

INTRODUCTION:

Polytrauma is the main mortality cause in under 40 population. The initial management in the ATLS connects fast and priority treatment of lesions with imaging tests. Traditionally imaging tests matched X-ray with fast ultrasound and CT dedicated body regions. In recent years, the whole-body scan is increasingly used in the assessment of these patients.

Objectives:

To describe the usefulness of Whole-body scan in the assessment of polytrauma patient and its ability to detect lesions not diagnosed through primary and secondary review.

To assess the criteria for activation trauma code (Physiological, anatomical, injury mechanism) as determinants factors to the indication of Whole-body scan. In our region trauma code is activated by pre-hospital emergency services, to permit the triage and derivation to trauma-especialized center.

METHODS:

Between  January 2014 and December 2014 whole body scan performed in trauma patients with severe trauma code activated were retrospectively revised.  The data collected were: demographic data, level of trauma code criteria activation (depending of four categories of parameters: physiological variables, anatomical injuries, trauma mechanism or predisposition), clinical signs of injury by anatomical region (skull, cervical spine, chest, abdomen-pelvis, thoracic-lumbar spine). Those were compared with injuries diagnosed by Whole body scan

 Using classification and regression trees (CARTSs) we pretended to identify potential predictors to look for injuries not suspected on the clinical examination.  A prediction model using the pre-admission clinical evaluation of trauma patients variables was developed: physiological variables, anatomical injuries, trauma mechanism or predisposition.

RESULTS:

A total of 117 trauma patients whole body scan performed were collected.  A 81% were male with 48 years old average age. The most common activation trauma code criteria were: trauma mechanism (60%) and physiological variables (23%).  Injuries were diagnosed in 84,4% of whole body scan. By anatomical regions most common injuries were: 38% skull, 55% thorax, 27,4% abdomen-pelvis.  A total of 17 patients don’t have clinical signs of injury on the clinical examination.  In 6 of this patients (35,3%) injuries were diagnosed by whole body scan.

After ussing CARTs  analysis  the predictors for unsuspected injuries not detected by first evaluation  were:  fall more than 6 meters,  vehicle smash  with ejection from vehicle or other passenger died or vehicle deformation or more than 60 km/h speed and pedestrian/cyclist smash with vehicle. By anatomical region involved: skull fracture, fail chest, smashed pelvis, more than two long proximal bones crashed or paralysis of limbs  were predictors for unsuspected injuries.

DISCUSSION

The use of whole body scan in trauma patients makes possible to find injuries not suspected on the clinical examination.  It is very important to know the circumstances around the trauma event  registered by pre-hospital emergency medical services.  At the presence of a single criteria of trauma severity, patients have a high risk of injury. The whole body scan should be performed in those patients. Furthermore, if no injuries are detected, we can discharge the patient from emergency department in a short time.

Background:

Mild Traumatic Brain Injury (MTBI) is one of the most common reasons for emergency departments care; it account for over three-quarters of the Traumatic Brain Injury [1]. The management of mild head injury is still controversial [2]. A better understanding of demographic, clinical and prognosis of these patients have an important clinical and organizational implications.

Purpose:

The aim of this study is to identify demographic characteristics, clinical findings and outcomes data of MTBI patients admitted in emergency department.

Participants and methods:

A prospective observational study that was conducted over three months [December 2014 – February 2015]. We included a consecutive adults who were at least 18 years, presented with a MTBI defined according to the criteria of the Head Injury Severity Scale ( HISS).

Results:

One hundred thirty- five patients were enrolled. Mean age = 42± 20 years, 73% were male. Mechanisms of injury were (%): traffic accident (52,5), falls (19,3), assault (18,5) and work accident (9,7). The way of the patient’s arrival at the emergency department was provided by (%): own means (47), pre-hospital care system (53). Patient history (%): hypertension (15), diabetes (7), atrial fibrillation (3), anticoagulants therapy or antiplatelet agents (10) and Alcohol intoxication (14). Clinical findings showed were : GCS =15 (81%), loss of consciousness suspected or confirmed (40%), Repeated vomiting (≥ 2 episodes) (7,5%), clinical signs of depressed or basal skull fracture (10,5%) and physical evidence of trauma above the clavicles (36,3%). Eighty – two percent of our population had a brain computed tomography (CT) wich demonstrated intracranial hemorrhage in 35% cases. Death at 1 month was 1% and thirty -seven patients called had post – concussion syndrome.

Conclusion:

Mild traumatic brain injury is more common in males and in young adults. Traffic accident was the main cause. The observed mortality remains low despite a high incidence of intracranial hemorrhage.Identifying clinical risk factors regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging.

1. Cassidy JD et al. JRehabil Med 2004, 43:28-60
2. Undén et al. BMC Medicine 2013, 11 :50.

Introduction :

Trauma is a time sensitive condition. Initial assessment for severity is essential for care and clinical making decision. Multiple scoring systems have been developed englobing anatomic scores, physiologic scores and combined scores. The aim of this study was to compare the prognostic performance of the scoring system tools in trauma patients admitted to the emergency department (ED) in terms of mortality at day seven.

Methods:

This was a single prospective cohort study. Trauma patients admitted to the emergency ward were enrolled and different scores were calculated: Injury Severity Score(ISS), Trauma Injury Severity Score(TRISS), Revised Trauma Score (RTS), Mechanism, Glasgow Coma Scale, Age and Arterial Blood pressure  score(MGAP), and the new Glasgow Coma Scale, Age and Systolic Blood pressure score (GAP) . The primary outcome was the mortality at day seven.  For each score, the Area under receiver operating characteristics curve (AUC) was assessed and we determined the predictive positive value( PPV) and the predictive negative value (PNV). A P-value <0,05 was considered significant.

Results:

A total of 287 trauma patients were enrolled. Main characteristics were:  Mean age +/- SD = 40+/-17 years ; Sex-ratio= 4,6 ; Traffic accidents were responsible in 74% of cases, ejection was noted in 40%. ISS = 21+/-11 and 212 patients (74%) have an ISS >= 16. Evolution n(%): intubation : 101(35); Surgery 160 (56); Mortality at day seven : 63 (23). The average levels of ISS, TRISS, RTS, MGAP and GAP were significantly different in non survivors than in survivor group with a p-value <0,001. Main characteristics of scores by analyzing the ROC for mortality at day 7: ( Score: AUC; p; PPV; PNV) were respectively : [ TRISS: 0,909; p<0,001; 66%; 95%]; [ ISS: 0,855; p<0,001; 38%; 95%]; [RTS: 0,834; p<0,001; 54%; 93%] ; [GAP: 0,871; p<0,001; 52%; 93%] ; [ MGAP: 0,865; p<0,001; 59%; 92%].

Conclusion:

All the tested scores have shown good prediction for mortality at day seven after Trauma. Whereas the TRISS defined better the mortality. Moreover, GAP and MGAP scores wich can be rapidly assessed on physiological parameters have shown as good predictive performance as anatomical and combined scores and could be proposed for early assessment in emergency ward.

Background: The relationship between intra-cranial injury (ICI) and health-related quality of life (HRQOL) after a traumatic brain injury (TBI) has been examined in limited populations, especially after a mild trauma. The aim of this study was to test if neurological deterioration or presence of ICI affected the experience of HRQOL of these patients six month after index event.

Methods: Over the 5.5-year study period (June 2008- December 2013), we retrospectively  analyzed medical records of 551 patients who were admitted in our Emergency Department High Dependency Unit for trauma. At admission we registered the mechanism of injury, Injury Severity Scoring (ISS), Head Abbreviated Injury Score (AIS); Glasgow Coma Scale (GCS) and clinical parameters were estimated in the Emergency Room (ER) and in HDU at admission (T0), at 12 hours (T1) and after 24 hours (T2). Six months after the ED-HDU discharge, a telephone interview using the Physical (PCS) and Mental (MCS) Health Composite Score (SF12) was conducted; patients reported their QOL both at present and before trauma. We could contact 243 patients, who completed the study.

Results: The study population included 171 male patients, mean age 55±21 years; mean ISS and mean Head AIS were 11±8 and 0.8±1.1. During the acute phase 15 patients showed a neurological deterioration (GCS-), while 228 always showed a normal GCS (GCS+); 80 (33%) patients showed intra-cranial injury. Before the event the most part of our study population had a normal (greater than 39) PCS and MCS score (respectively 97 and 96%). After the event the proportion of patients with normal score values significantly decreased (PCS 63%, p<0.0001; MCS 69%, p=0.006). In the whole study population we observed a significant reduction in both MCS (before: 55±7, after: 46±13; p<0.0001) and PCS (before: 53±5, after: 43±11; p<0.0001) scores after the injury compared with the previous period. PCS score after the event was comparable in presence of GCS deterioration (43±10 in GCS+ vs 38±11 in GCS-) or ICI (43±10 in patients without ICI vs 41±11 in patients with ICI, all p=NS); MCS score was significantly worse in patients who developed a neurological deterioration (36±13 in GCS- vs 46±31 in GCS+, p=0.004) compared with patients who did not; ICI presence did not demonstrate any influence on mental HRQOL 6 months after the event (MCS 45±12 in patients with ICI vs 46±14 in patients without ICI, p=NS; PCS 41±11 in patients with ICI vs 43±10 in patients without ICI, p=NS).

Conclusion: HRQOL deteriorated significantly in this population of mild trauma patients, but this worsening was not associated with the presence of ICI; an early neurological deterioration was otherwise associated with a significantly worsening of the mental component compared with patients with normal or improving GCS. The limited number and the heterogeneity of GCS- patients in this study population requires to be very cautious in interpreting this relationship.



In Paediatric Emergency Departments across Europe, head injury is a common presentation. The vast majority (80%-90%) are mild in severity and do not require specialist intervention. From the TARN (Trauma and Research Network) 2012 data of severely injured children, 75% have a head injury, carrying a 7.5% mortality. There is a bimodal peak in the prevalence of head injuries, with infants and those age 6-16 most at risk, and two thirds being male.

In our District General Hospital serving an estimated paediatric population of 77000, we see up to 12 children a day with a head injury.

It is therefore vital to assess those children at risk of a significant head injury, investigate and treat appropriately. The NICE 2007 guidelines were based on CHALICE clinical decision rules, that have not been formally prospectively validated.

In 2014 NICE, incorporating data from the PECARN and CATCH studies, identified clinical features of children at very low risk of clinically significant brain injury after trauma, and have adapted their guidelines accordingly:

In our study, we retrospectively identified 536 children presenting to our Emergency Department over a 6 month period. Of these, 525 met the inclusion criteria for out study. Of the 525, 111 children would have met the CT imaging criteria in the NICE 2007 guideline, but only 21 met the 2014 guideline, a reduction of 81%. The number of CT Brain scans performed was 18 (3.4% of presentations). Only one CT showed a clinically significant subdural haemorrhage, and was referred to neurosurgery. The remaining CT scans were reported as normal, aside from one non-traumatic incidental finding.

We kept 21% of patients in the Emergency department for observation, and had no reattendances after discharge, and no mortalities. This study illustrates that the update in the NICE 2014 guidelines has reduced the criteria for CT imaging on children with a head injury by approximately 80%, without increasing mortality.

Background: Blunt abdominal trauma (BAT) is a major cause of death in children. Focused Abdominal Sonography in Trauma (FAST) is a rapid, bed side and cost saving screening tool for trauma patient. Decision for surgery or conservative treatment is based on clinical, laboratory, and imaging criteria.

This study aims to:(1) Assess feasibility and accuracy of FAST and Computerized Tomography (CT) in the emergency department (ED) as screening for the detection of intra-abdominal injuries in pediatric patients with BAT; and (2) Correlate the different findings to patient fate.

Design:  Prospective cross-sectional study.

Setting: Level 3 trauma center of Alexandria main University hospital, Alexandria, Egypt.

Participants and Methods: We included all patients aged ≤ 18 years presenting with BAT, admitted between May 2013 and April 2014. After clinical assessment, and laboratory investigations, FAST was done to all patients by radiologists plus CT for selected populations. One week follow up was done for all cases.

Results:  Included were 150 patients (72.6% males) with a median age of 9 years (range 3 days -17 years). Fifty four percent had road traffic accident, while 39.3% reported fall from height. Seventy three (48.7%) children did not show hemoperitoneum upon FAST, and 77 patients (51.3%) with intra-abdominal collection. Of them, 68 (45.3%) cases were discharged home immediately after full survey.  Positive cases with FAST had hemoperitoneum that was minimal in 53 (68.8%), mild in 19 (24.7%), and moderate in 5 (6.5%) cases.  Fifty patients were managed conservatevly. Fifteen patients were operated and 6 cases died. FAST findings were significantly related to the grade of shock (95% confidence interval [CI], P<.001). FAST showed 97.6% sensitivity, 95.12% specificity, 100% positive predictive, and 0% negative predictive values (95% CI). Thirty eight patients underwent contrast CT. Significant relations were found between FAST and CT as regards the mean examination time (11.29 versus 54.72 minutes) (95% CI, P<.001), detection of  fluid collection (95% CI, P=.004). The Spleen was the most common injured organ in both investigation tools where in FAST 15 (19.5%) cases versus 16 (39%) cases with CT (95% CI, P=.002), followed by the liver;  13 cases detected by both FAST and CT . We tested the impact of different parameters against patient outcome using Univariate and Multivariate binary logistic regression. We found significant relations with the grade of shock (P=.01), Odds ratio (OR= 2.95), abdominal examination in both analyses (P=.02, OR=2.42), presence, and grade of fluid collection detected by FAST only in univariate model (95% CI, P<.001).

Conclusions: Our data favors wider use of FAST as screening and follow up tool for free fluid in children with BAT with high sensetivity and specificity. CT scan should be used in selected cases to guides non operative decisions  as the duration of hospitalization, intensity of care, and length of activity restriction. It requires more facilities and time in the crowded ED. Clinical examination remains a significant parameter in decision making.

Background: Improving timely access to life saving reperfusion therapy is well recognized as being a major goal of ST-segment elevation myocardial infarction (STEMI) care. Primary percutaneous coronary intervention (pPCI) is the recommended reperfusion therapy if performed by an experienced team within 120 minutes after first medical care (FMC).

Aim: to assess the impact of delay on in-hospital mortality of STEMI patients transported for pPCI to the catheterization laboratory (cath-lab).

Methods: Data was collected from 2003 to 2013 throughout an ongoing prospective registry that included all STEMI managed within less than 12 hours by mobile intensive care units (MICU) squads in a metropolitan area. The medical dispatch center (SAMU - centre 15) allowed a direct transfer to pPCI-capable hospital bypassing the emergency department. Comparison of in hospital mortality among two groups; with a delay from FMC to cath-lab less than 120 minutes for group 1 more than 120 minutes for group 2. Data were compared using Chi 2 test (significant if p < 0.05).

Results: 10.210 patients were included in the registry during the period. 2.454 patients (24%) received prehospital fibrinolysis and 7.756 patients (76%) were directly admitted to the cath-lab for pPCI. In-hospital mortality was significantly lower (p < 0.0001) in group 1: 122 patients (1.8%) among 6.645 patients, than in group 2: 46 patients (4.1%) among 1.111 patients.

Discussion: Increase of in-hospital mortality for unselected STEMI patients transferred from scene to cath-lab is strongly correlated to time to pPCI beyond 120 minutes, beyond recommended delay. A system delay of less than 120 minutes remains a major goal to achieve for prehospital teams.  Thrombolysis remains an alternative.

Background. The diagnosis of acute aortic syndromes (AAS) requires complex integration of clinical data, blood tests and imaging exams. Lactate dehydrogenase (LDH) is a widely expressed intracellular enzyme which reduces pyruvate to lactate during hypoxia, and plasma LDH is a biomarker of tissue ischemia. Measurement of plasma LDH is rapidly and almost universally available to Emergency Departments (ED), and increased levels of LDH are typically found in hemolysis and in myocardial or skeletal muscle ischemia. Furthermore, increased LDH has been associated with mortality in acute conditions such as pulmonary embolism, pneumonia and acute intestinal ischemia. Indeed, increased plasma LDH has been reported in patients affected by AAS, indicating potential use for diagnosis and/or for prognostic stratification. However, focused experimental data is lacking.

Methods. This was a retrospective diagnostic accuracy and prognostic study of plasma LDH, conducted on consecutive patients evaluated in two Emergency Departments for suspected AAS, from 2008 to 2014. In the study period, consecutive patients were enrolled in a registry if the following inclusion criteria were satisfied: (1) presence of chest pain, back pain, abdominal pain, syncope or signs/symptoms of perfusion deficit; (2) unclear diagnosis after initial medical evaluation; (3) order of an urgent aortic imaging exam by the attending physician to identify/exclude AAS. Trauma patients were excluded. All patients underwent computed tomography angiography for conclusive diagnosis. LDH was assayed at presentation to the ED, as part of the initial diagnostic workup. Diagnostic accuracy of LDH was evaluated by ROC analysis and by calculating sensitivity, specificity, predictive values and likelihood ratios. In-hospital mortality was analyzed by Kaplan-Meier plots and log-rank test.

Results. 999 of 1,578 patients with suspected AAS had plasma LDH assayed at presentation in the ED. The final diagnosis was AAS in 201 (20.1%) patients, while alternative diagnoses (AltD) were made in 798 (79.9%) patients. Median LDH at presentation was 424 (interquartile range [IQR] 366-558) UI/l in patients with AAS, and 383 (IQR 331-461) UI/l in patients with AltD (P<0.001). Using the higher normality cutoff of 450 UI/l, the sensitivity of LDH for AAS was 44% (95% CI 37-51%) and the specificity was 73% (95% CI 69-76%). All-cause in-hospital mortality in patients with AAS was 23.8%. Survival curve analysis showed 32.6% in-hospital mortality in AAS patients with LDH ≥450 UI/l and 16.8% in AAS patients with LDH P=0.017). The hazard ratio for in-hospital mortality associated with LDH ≥450 UI/l was 2.34 (95% CI 1.28-4.28). In logistic regression analysis, LDH ≥450 UI/l was found as an independent predictor of adverse outcome, together with age>65 years and hypotension.

Conclusions. The present results question the utility of LDH in the ED as a diagnostic assay in patients with suspected AAS. Instead, they define plasma LDH as a biomarker potentially allowing prognostic stratification of patients with AAS. Patients with AAS and high levels of LDH in the ED deserve special attention.

Myocarditis is a potentially life-threatening inflammatory disorder of the myocardium. In paediatrics, despite the well-established morbidity and mortality associated with it, myocarditis remains an enigmatic diagnosis and is too frequently missed on first presentation.  The long-term prognosis of patients with myocarditis is more favourable if it is recognised quickly and managed aggressively however, diagnosis is challenging as initial presentation can be anywhere on a spectrum from insidious inflammation of the myocardium to fulminant disease with acute, severe cardiogenic shock.    Consensus recommendations regarding the diagnostic methods in children within the emergency setting are lacking as currently no single clinical or imaging finding confirms or refutes the diagnosis with absolute certainty. Current practice therefore varies and Emergency clinicians need to be aware of when to suspect the disease in children and be aware of the diagnostic utility of the investigations available in order to manage patients accordingly.

The overall aim of this study was to review the literature and determine whether:

1.                  Is there a specific constellation of clinical symptoms or signs that are pathognomic of paediatric myocarditis?

2.                  Is there is a sensitive and specific investigation that could confirm or deny the diagnosis?

This evidence was then compared to current opinions in a tertiary paediatric emergency department regarding the clinical presentation and appropriate investigation of paediatric myocarditis and see if current clinician practice mirrors the literature evidence. 

Opinion was sought from 36 paediatric emergency clinicians from a tertiary hospital encompassing senior trainees (paediatric and emergency medicine) and consultants. This body of professionals all found the diagnosis to be difficult and the majority felt a guideline would be useful to aid the management of these patients. 

Key findings from the literature were that unexplained symptoms in a previously healthy child such as vomiting, tachycardia, dysarrhthymia or progressive respiratory distress should trigger investigation for a cardiac cause and in particular myocarditis. This should include ECG, Chest radiograph with consideration of Echocardiogram and cardiac biomarkers.  In general this was echoed in professional opinion of when to suspect paediatric cardiac disease.  In terms of investigations however, despite the literature evidence finding in favour of ECG and Chest radiograph, professional opinion felt that bedside echocardiogram would be the most useful discriminatory test in the Emergency department. The utility of cardiac biomarkers remain an area of uncertainty, an opinion that mirrored the literature, however myocardial biopsy was overestimated in terms of its sensitivity.  (Statistical analysis will be provided)

A provisional algorithm for diagnosis is offered with a red-flag system of signs of symptoms that trigger the next level of investigation. This is however with the caveat that this generic approach may not clinically possible without causing over-investigation of well children. Probably the most important aspect in improving diagnosis of myocarditis in children is to improve awareness of the diagnosis, lowering the index of suspicion of this important diagnosis.  

Introduction: Chest pain is a common reason to seek medical care at the emergency department (ED), and more than half of chest pain patients are discharged with the diagnosis unspecified chest pain. After discharge a small amount will nevertheless experience a major adverse cardiac event (MACE). Chest pain patients are often evaluated with the help of risk scores that are based on risk factors for cardiovascular disease (CVD). However, the predictive value of risk factors such as hypertension, diabetes, treated hyperlipidaemia or previous CVD have not been sufficiently studied in this setting.

Aims: To investigate the predictive value of CVD risk factor for MACE after discharge from the ED in patients with unspecified chest pain, with a special focus on hypertension.

Material and Methods: This register-based retrospective cohort study included all patients over 18 years discharged with the diagnosis “unspecified chest pain” from a Swedish hospital ED between 2006 and 2013. Information about medical history and drug prescriptions were collected from national registers and related to the occurrence of MACE (myocardial infarction, unplanned revascularisation or death) within 30 days of discharge. Odds ratio for the different variables were calculated with logistic regression analysis and the additive discriminatory value of treated hypertension to a risk factor model were calculated with category-free net reclassification improvement (cNRI).

Results: A total of 83 673 patients were included. Among patients that were discharged directly from the ED (n=74329) 0.8% experienced a MACE within 30 days whereas the incidence was 4.0% among patients discharged after an initial short term ward admission (n=9344). Among patients that were discharged directly from the ED a history of treated hypertension (OR 4.0, CI 3.3-4.8 p<0.001), diabetes mellitus (OR 3.9, CI 3.0-4.9, p<0.001), hyperlipidaemia (2.0, CI 1.4-2.8 p<0.001), and CVD (OR 6.1, CI 5.0-7.3, p<0.001) were associated to MACE. The addition of treated hypertension to a risk factor model based on all others significant risk factors improved net reclassification (cNRI 48%, CI 15-59%). The odds ratio for MACE increased with the number of anti-hypertensive drugs up to three different drug classes among patients discharged directly from the ED. Among patients discharged after an initial admission no linear correlation between number of drugs and the OR for MACE were found.

Conclusions: A history of treatment or hospitalisation for CVD or CVD risk factors were all associated to incident MACE within 30 days after discharge from the ED with unspecified chest pain, both in patients that were discharged directly from the ED and in those that were discharged after an initial short term ward admission. Awareness about risk factors, and specifically hypertension, for adverse outcome after discharge among chest pain patients can lead to improved evaluations at the ED and fewer cases of misdiagnosis. Our findings support the use of patient history in risk scores, such as HEART score, which has not been properly evaluated previously. 

INTRODUCTION :

Episodes of faintness, even cardiac arrests upon the arrival of long haul flights are frequent. The diagnosis of pulmonary embolism is regularly confirmed. The population exposed to this risk is considerable. Circumstances it occurs are badly known, in particular, moment of arisen the symptoms.

MATERIAL AND METHODS :

Systematic review of suspect patient of pulmonary embolism, after a long haul flight, taken care in the Roissy Charles de Gaulle Airport, by the Emergency Medical Departement 93, from 1993 till 2013. 

Inclusion : Age upper to 16 years. Pulmonary embolism confirmed by lung angioscanner  or lung scintigraphy of ventilation-drip.

Assessement criterion : 

  - Moment of arisen the symptoms : during the flight, on the footbridge(of the rise at the exit of the plane up to the airport), in the airport.

  - Risk reported in the time of exposure : known duration of flight, time spent on the footbridge estimated at one hour and in the airport at two hours.

RESULTS :

156 patients where included in this study.

Symptoms arisen 21 time (13%) during flight, 132 time (85%) on the footbridge, one (1%) time in the airport and two time in unknown circumstances.

Duration accumulated by flight : 1.866 hours.

The number of event per hour were : 0.01 during flight, 132 on the footbridge and 0.5 in the airport.

CONCLUSION :

Pulmonary embolism after a long haul flight occurs essentially on the footbridge. The migration of the thrombus would occur in the rise or during the first steps.

The name of "the footbridge syndrome" should be preferred to the usual name of "syndrome of the economic class".

OBJECTIVE: To evaluate the adaptation of new antiplatelet therapy in acute coronary syndrome (ACS) in the emergency Department.

MATERIALS AND METHODS: This is a descriptive study of patients that have been seen in the emergency department with ACS from November 15, 2013 to February 15, 2014. We analyzed clinical and laboratory variables obtained from the Information System of our Hospital (Lozano Blesa Universitary Hospital, Zaragoza, Spain).

RESULTS: 105 patients were treated for ACS with an average age of 70.71 years (SD 13.82). 72 were men (68.6%) and 33 women (31.4%). 82 (78.1%) were ACS without ST elevation (NSTEMI) and 23 (21.9%) elevation (STEMI). Acetylsalicylic acid (ASA) was provided to 81 patients (77.1%), Clopidogrel to 54 (51,4%), Ticagrelor to 18 (17,1%) and Prasugrel to 3 (2.9%). Non invasive therapy was provided to 89 patients (84.8%) and coronary angiography to 16 (15.2%). 18 patients (17.1%) had high risk of bleeding (CRUSADE> 40) and ASA was administered to 13 of them, Clopidogrel to 11, Prasugrel to 1 and Ticagrelor to 1. 87 patients (82.9%) had low risk of bleeding (CRUSADE <40), and AAS was administered to 68 of them, Clopidogrel to 43, Ticagrelor to 17 and Prasugrel to 2. Thrombotic risk (TIMI) in NSTEMI was high in 9 patients (8.6%), intermediate in 32 (30.5%) and low in 41 (39%), prescribing ASA to 7 high-risk patients, 22 of medium risk and 34 of low risk; Clopidogrel was provided to 5, 14 and 34 respectively, Ticagrelor to 2, 6 and 6 respectively and Prasugrel wasn´t provided to any NSTEMI.

CONCLUSIONS: Non invasive therapy is the treatment most often used in ACS and ASA is the antiplatelet most used. Clopidogrel is the association with ASA most frequent, followed by Ticagrelor (that it is the only alternative to Clopidogrel in patients with NSTEMI with medical treatment). Most of the ACS admitted in our Emergency Department are NSTEMI. The use of Ticagrelor is used less than Guidelines recommendations in patients with intermediate or high risk of thrombosis, and its use in patients with low risk is still higher, against current recommendations. It would be recommendable to apply strictly the scales of risk to the correct choice of antiplatelet therapy in ACS. Patients with high risk of bleeding are a minority, and the use of Ticagrelor or Pasugrel in these patients is exceptional, in agreement with the current Guidelines.

Does Coronary CTA Increase the Downstream Testing and Cost of Acute Chest Pain Workup? A Single Center Randomized Prospective Study.

Ahmad Nama, Ronen Durst, Ayelet Shauer, Aluma Weiss, Dorith Shaham, Yelena Milovanov, Israel Gotsman, Yaakov Asaf, Darawshe Aziz

Heart Institute, Radiology Department and Emergency Medicine Department

Hadassah University Hospital

Jerusalem, Israel

Background:

Coronary CTA has high negative predictive value in ruling out ACS and shortens the duration of hospital admission in patients with acute chest pain. However, it is thought to increase the downstream testing and cost of chest pain workup. To evaluate this we compared the number of catheterizations, duration of hospitalization and the cost of downstream evaluation between patients who performed CTA as the first test and patients who underwent stress tests (GXT) in our chest pain unit.

Methods and results:

82 patients admitted with acute chest pain and low- intermediate probability for ACS were randomized to coronary CTA versus GXT. Patients were treated according to the results of the test. Follow up was continued up to six months. The primary endpoint was the number and cost of downstream diagnostic tests at three and six months after discharge. Secondary endpoints were number of coronary interventions and duration of hospitalization. Costs of exams were calculated according to the official ministry of health tariff.

Mean duration of hospitalization was 2.1±1.3 in the CTA arm and 2.2 ±1.7 in the GXT arm (p=0.87). At three months mean number of ambulatory tests per patient was 0.24±0.62 in the CT arm and 0.43±0.71 in the GXT arm (p= 0.21), and at six months it was 0.22±0.42 and 0.57±0.82 (p= 0.05) accordingly. The cost of these exams ( NIS ) was 332±1,044 in the CT arm versus 708±1,532 in the GXT arm (p=0.2) and at six months 239±755 versus 580±1,201 (p=0.2) accordingly. 6 patients in the CTA arm underwent invasive coronary angiography, of which four had coronary interventions, while 4 patients in the GXT group had invasive coronary angiography, and only one of them had a coronary intervention.

Conclusions: Evaluation of acute chest pain with coronary CTA does not prolong the duration of hospitalization, causes less downstream testing at six months after discharge, and was not found to be more expensive than evaluation with GXT.   

Background

Acute dyspnea is a diagnostic challenge for emergency physicians. The discrimination between cardiac and non-cardiac causes is key for improving patients’ management in the Emergency Department (ED). Lung ultrasound (LUS) has emerged as a non-invasive valuable tool in this scenario. We have recently shown in a multicenter study that the implementation of LUS with clinical evaluation (“iLUS” approach) may improve acute dyspnea diagnosis accuracy in the ED (Chest, 2015). Natriuretic peptide (i.e. NT-proBNP/BNP) dosage is still indicated for ruling out decompensated heart failure diagnosis among dyspneic patiens, also with a  large grey zone.

Objective

Aim of this study was to compare costs of management of acute dyspnea in the ED using LUS versus natriuretic peptides  dosage in order to differentiate acute decompensated heart failure from other causes of acute dyspenea.

Patients and Methods

We designed a multicenter prospective observational study in seven Italian EDs, between November 2010 and October 2012. Patients presenting to the ED with acute dyspnea as the main complaint were eligible. LUS was mandatory for all enrolled patients but NT-proBNP/BNP dosage was not. The study protocol was approved by the Ethical Commitees of the involved centers. After clinical evaluation, all patients underwent a LUS scan. Then clinical and iLUS diagnosis were recorded. For this study, we analyzed all natriuretic peptides results available. Costs were calculated based on those  provided at AOU Città della Salute e della Scienza di Torino (coordinator center of the study).

Costs for LUS were i) purchase a three probes portable ultrasound machine, ii) 10 years amortization, iii) maintenance (6% of original prize), iv) training of operators, and v) execution time. NT-proBNP/BNP costs were i) loan of instruments for dosage, and ii) working time of laboratory crew.

Net reclassification improvement (NRI) is a recently proposed (Statist. Med. 2008) statistical tool for evaluating the usefulness of a new diagnostic tool.

Results

Nt-proBNP/BNP dosage was available for a subcohort of 486 patients.

NRI for iLUS was 20.6 (CI 95% 14.3-27.2), for LUS alone 6.5 (CI 95% 0-14.8), and null for natriuretic peptides dosage.

NT-proBNP/BNP dosage was totally valued at about 50 euros/test.

We evaluated LUS training using cost of participation to a Winfocus-Simeu (Italian National Society of Emergency Medicine) course in emergency ultrasound, and we based estimation of execution time for each LUS evaluation on table of charges of Ethical Committee of AOU Città della Salute e della Scienza di Torino (20 minutes of a staff physician’s work value 20 euros). Patients with natriuretic peptide dosage available were enrolled by 14 emergency physicians with a median execution time for LUS of about 5 minutes. Total cost for LUS approach was 31.5 euros/test (reduced to 21.5 euros after implementation of process).

Conclusions

Our study shows LUS approaches, both alone and iLUS, has a higher NRI and lower costs than natriuretic peptides in differentiating acute dyspnea in the ED, with a progressive reduction of costs for LUS approach after starting training programme.

Introduction: Handover is a poorly examined transaction in ED’s especially among physicians and is an area deserving further research.

Aim: to analyze independent factors effecting handover duration in ED. Secondary aim was to identify factors affecting the ED handover rates.

Methods

A prospective, cross-sectional, observational and descriptive study at seven ED’s of urban tertiary referral teaching hospitals.

Results

A total of 267 handover sessions (44.6% conducted in off-hour time period) were included with a mean duration of 22.3 min (range 1-80 min). Handover duration per patient was 3.5±1.7 (3.3-3.7). The numbers of shifts examined were 267 with a median duration of 15 hours (8-24 h). Verbal violence and technical failures occurred in 16.9% and 13.1% of the shifts, respectively.

Multivariate logistic regression analysis showed that rate of biochemical analysis per patient (OR: 1.069, 95%CI:1.013-1.128), rate of imaging studies per patient (OR: 0.880, 95%CI: 0.798-0.970), rate of handover per shifts (OR: 0,387, 95%CI: 0,191-0,781), handover duration/Number of handovered patients(OR: 0.260, 95%CI: 0.099-0.684), rate of consultation per patient(OR: 1.380, 95%CI:1.070-1.780) were independent parameters effecting handover duration.

Multivariate logistic regression analysis showed that Shift duration (OR:1.352, 95%CI:1.178-1.551), Rate of hospitalizations per patient (OR:0.799, 95%CI:0.674-0.946), Rate of Biochemical Analysis per patient(OR:1.059, 95%CI:1.030-1.089), Rate of imaging Studies per patient(OR:0.945, 95%CI:0.912-0.978), Rate of microbiological tests per patient(OR:1.095, 95%CI:1.022-1.173), Mean number of physicians per shift (OR:2.841, 95%CI:1.699-4.750), Handoverduration/numberofhandover (OR:2.004, 95%CI:1.393-2.882) were independent parameters effecting handover duration.

The AUC for the shift duration cut-off value of 8.5 was 0.796 (0.744-0.849). The sensitivity, specificity, +LR, and -LR detected for the shift duration cut-off value of 8.5 were 97.8%, 22.6%, 1.26, and 0.98, respectively.

Conclusion: Handover duration and rate are independently effected by certain shift characteristics. Shortening shift duration may lower handover rates. 

Objective In context of the increasing problem of ED overcrowding, most research on (in)appropriateness of ED use has focused on patient’s perceptions and motivation for choosing the ED for non-urgent medical problems. In contrast to patient-self referral, general practitioners (GPs) have the ability to make appropriate referrals which might be helpful in reducing ED-crowding by patients who could be helped more efficiently elsewhere. There is however only limited research on whether or not these referrals are always justified. This study aims to investigate in a prospective way to which extent ED referrals by GPs are appropriate, based on patient’s initial clinical presentation and GP’s differential diagnosis.

Methods An observational prospective study was performed at the ED of the University Hospitals Leuven.  Referral letters (n=187) were analyzed on major motives of referral and allocated to one or more of 15 categories.  Consecutively, they were independently assessed twice on appropriateness of referral using a newly created operational definition. ED referrals were considered appropriate if GP’s differential diagnosis included one or more of  following conditions requiring immediate diagnosis and treatment:  respiratory distress, shock, acute chest pain, cardiovascular symptoms, severe abdominal pain, altered state of consciousness, acute neurological signs, acute hematologic disorders, sepsis, severe traumatic injuries, acute psychosis or suicidal ideation, and certain endocrine emergencies.  Referrals were also coded as appropriate if the patient received an ESI code 1 or 2 at  triage or if predictable need existed for interventions not available out-of-hospital.

Results  Among 187 referrals, 73.8% was considered appropriate. Excellent inter-observer agreement was observed (kappa 95.8%), demonstrating that the operational definition is an effective tool to reliably assess referrals as appropriate or not. The 24.6% inappropriate referred patients presented more often with social or psychiatric difficulties, infectious or inflammatory problems, or ‘other’ complaints in comparison to the appropriate referred group.

Conclusions To our knowledge, there is no previous study assessing appropriateness of GP referrals in a prospective way, not taking results of technical examinations or discharge diagnosis into account. Results demonstrate that a substantial amount of GP referrals, nearly 1 out of 4, were considered inappropriate according to the predetermined criteria. This suggest that GPs might have different, more contextual than purely medical reasons for ED referral. These potential discrepancies in mutual expectations, attitudes and perceptions on appropriate ED use, might reflect a hiatus in the current health care system. Further research is needed to link inappropriate referrals to underlying motives of referring GPs. These findings could contribute in devising an improved health care organization model, in which each patient is referred to an appropriate place to receive the most suited treatment and care, based on a well understood principle of subsidiarity.

Objective: Categorizing short term readmissions in Emergency Department (ED) and exploring methods to reduce avoidable ED readmissions.

Introduction: Readmissions in the ED are multifaceted. A recent meta-analysis illustrated that less than a quarter of readmissions could be considered avoidable. Research till now, has focused on the predictive risk factors and the most common diagnosis of readmission. Less is known about its systemic causes. A study was undertaken to identify factors associated with this quality care indicator.

Method: Prospective observational data from electronic hospital and patient health records was collected from 1^st September 2013 through 31^st August 2014 at Max Superspecialty Hospital, Saket, New Delhi, India. The number of ED readmissions within 72 hours of index ED registrations were considered. Exclusive and hierarchical categorizations of these ED readmissions were done as: Avoidable readmissions- due to inadequate care or due to poorly managed transitions during discharge; Unavoidable readmissions- due to complications or due to recurrences; Unrelated readmissions (different body systems); Planned readmissions; Readmissions after LAMA (leave against medical advice). Statistical analysis was done using SPSS 16.0 and cross-tabulation technique applied on patient variables.

Results: A total of 19,205 ED registrations were recorded through the year. Of these, 473 patients (2.46%) got readmitted in the ED within 72 hours of their index ED registration. Rates of both, short term ED readmission and ED registration showed minimal month to month variability. The mean age of patients was 43 years, with minimal gender disparity. Males (253) outnumbered females (220) marginally. Of 473 short term ED readmissions, 181 (38%) were avoidable followed by 86 (18%) unrelated followed by 82 (18%) unavoidable followed by 76 (16%) readmissions after LAMA followed by 48 (10%) planned readmissions. In the avoidable readmission category, 66 (36%) readmissions were due to inadequate care while 115 (64%) due to poorly managed transitions during discharge from the ED. In the unavoidable readmission category, 44 (52%) readmissions were due to complications while 38 (48%) due to recurrences of signs and symptoms.

Conclusion: A readmission could be due to healthcare factors- hospital or primary care associated; or patient related- patient’s understanding of disease, management, compliance, adequate follow-up, social support; or disease associated- progression, exacerbations, recurrences, complications, co-morbidities; or a combination of all the above. Our analysis suggests that addressing the transit during discharges from ED, by bridging the gap and sustaining the quality of care from hospital to home, may promisingly improve patient outcome. Thus, interventions are targeted at three levels. Firstly, the pre-discharge interventions must include discharge planning, medication reconciliation and setting up a follow-up visit prior to departure from the ED. Secondly, the post-discharge interventions may include home care and ambulance services, assigning case or transition care managers who would educate the patient about the disease, its management, follow-up visits and answer all concerns. Thirdly, the administrative interventions may include ED readmission policy, readmission prevention checklist and automated marker in electronic hospital and health records which may expedite readmission identification, address its origin and help in reducing the avoidable ED readmissions.

Background:

In western europe, the gp plays a significant role in providing after-hours care, with 77% of the GP s in italy, 89% in the UK, and 97% in the Netherlands providing after-hours arrangements. A substantial number of patients visit the emergency department (ED) without a referral by a general practitioner. Many of these self-referrals may lead to inefficient care. We examined ED use and assessed the characteristics of self-referrals and their need for hospital emergency care.

Objective:

To assess the appropriateness and characteristics of self-referrals to the ED of an acadamic hospital. And whether there is a difference compared to a community hospital.

Methods :

Observational study conducted at RadboudUMC Nijmegen an academic hospital and a level 1 traumacenter. Data were collected on all self-referred patients in august 2013 and 2014. The appropriateness of an ED visit was determined on; (1) urgency at entering the ED (triage), (2) diagnostic testing or treatment done and (3) final destination after ED visit.

Results:

A total of 3656 patients visited the ED during the inclusion period; 860 were self-referrals (23,5%) The majority of the self-referred patients were male ( %) and most self-referrals were under the age of 40. Our first results showed that 31,6% of the self-referrals presented themselves during office hours. Most patients (72,2%) were classified as non-urgent (triage >1 hour).

The majority (55,7%) required diagnostic testing such as: x-ray (38%), laboratory investigations (16%), ECG (9,2%), computed tomography (11,6%), sonography (3,1%).

Eventually 28,8% of patients were admitted to the hospital and 71,2% were discharged.

Conclusion:

Preliminary results showed that 27,8%-55.7% of self-referred patients were scored as appropriate ED visits, determined by the urgency and requirement for additional diagnostic testing. These results are comparable previous results from ED visits to a community hospital in the Netherlands.This study is a pilot and more patients are being included and an analyses making use of all determinates follows.

Background

Lack of inpatient beds, or “hospital crowding”, is often discussed in the context of ED overcrowding. However, alternate strategies for care delivery in the ED, that take effect when no inpatient beds are available, have been less frequently studied. The aim of the present study is to investigate effects of hospital crowding on the management of patients who present in the ED with chest pain. Study outcomes are inpatient admission, the 72-hour revisit rate and the ED length of stay (EDLOS) for patients not admitted to a hospital ward (i.e. discharged from the ED). The exposure was hospital occupancy at the time of patient presentation in the ED.

Methods

The study was conducted as a registry study on ED admin data from a 420-bed emergency hospital in southern Sweden, during 2011-2013. The association between the exposure and the outcome was addressed in contingency tables (Fisher’s exact test) and by logistic regression models.

Results

12,223 cases were included in the study. Multivariate models revealed a negative association between hospital occupancy and the probability of inpatient admission (OR 0.87, 95% CI 0.79–0.95) at 105% occupancy compared to at 95%. ED length of stay (EDLOS) was longer in patients discharged from the ED at high hospital occupancy (>105%) than in patients discharged otherwise (<95%), 3.55 vs. 3.03 hours (p=.001, Kruskall-Wallis). Moreover, a lower 72-hour revisit rate was observed in patients discharged at times of high hospital occupancy.

Conclusions

Study results suggest that patients who present to the ED with chest pain are less likely to be admitted to inpatient wards at times of hospital crowding. The observed increase in EDLOS and decreased 72-hour revisit rate may reflect a mechanism by which patients are increasingly evaluated and treated in the ED when no inpatient beds are available. This may decrease resource expenditure in inpatient wards and strengthen the position of the ED within the hospital.

Introduction: Fire smoke inhalation results in relatively rare but sometimes life-threatening poisoning. The aim of this study is to describe prehospital and in-hospital management, early complications and prognostic factors.

Material and methods: We conducted an observational retrospective investigation. All the patients managed by a pre-hospital medical team and presenting signs of fire smoke intoxication with burned body surface area of < 20% and no traumatic injury were included. The following variables were collected: clinical features, comorbidities, arterial blood gases, plasma lactate concentrations, HbCO levels, prehospital resuscitation and treatments, bronchoscopy results if done. Univariate followed by multivariate analyses were performed to identify prognostic factors of survival. Statistic test of Khi2 (Pearson) was significant if p < 0.05.

Results: During a 5-year period, 203 patients were included (mean age: 45 +- 24 years, 110 M/93 F). Time to reach the victims was 30 min and time to provide care was 55 min. Comorbidities were present in 95 patients (46%) including cardiovascular (7.8%), respiratory (6.4%) and psychiatric diseases (2%). No immediate or delayed smoke inhalation-related complications were observed in 155 patients (76%) while 48 patients (24%) presented absolute emergencies: 29 patients (14%) were in cardiac arrest, 15 (7%) with acute respiratory failure and 4 (2%) with severe neurological impairments. Hydroxocobalamin was administered to all patients categorized as absolute emergencies (n=48) allowing in 10 cardiac arrest patients (among 12) in a return of spontaneous circulation after 77 min of advanced cardiac life support. After transportation to hospital, 29 patients were admitted to the intensive care unit (ICU) and 4 to a burn unit. Bronchoscopy showed bronchial edema without necrosis in 24/29 ICU patients. Twenty-seven patients died (mortality rate of 13%) in relation to cardiac arrest (24/29), neurological impairments complicated with acute respiratory distress syndrome (ARDS) and septic shock (2/4) and pneumonia with septic shock (1/15). HbCO was higher in absolute than relative emergencies (p < 0.0001). Blood lactate did not significantly differ between survivors and non-survivors (5.6 ± 3.4 vs. 8.6 ± 5.0 mmol.L-1, p=0.4). Using a multivariate analysis, predictors of death were the delay required to access to victims, prehospital care duration, comorbidities, soot in the airways and HbCO measured in the prehospital setting and Glasgow scale. Only Glasgow scale was associated with mortality (OR, 10.0 [95%-IC, 1.0-100.5]; p=0.05).

Discussion: Fire smoke inhalation mainly result in systemic effects and less in local bronchial complications. All the times in the resuscitation chain have major prognostic impact. Prompt and multidisciplinary management is required to improve final outcome.

Introduction: Voluntary drugs intoxications is a major health problem in France and also a frequently use pattern in the in the prehospital emergency services (SAMU) and emergencies departments (ED). Variety of drugs offered by the pharmaceutical industry generates many clinical situations which can complicate diagnostic or treatment for emergency physicians. The aim of our study was to assess one-year patient’s characteristics hospitalized for deliberate drug poisoning and their management, in the ED of a french hospital. 

Methods: This descriptive and forward-looking study was conducted from January 1^st to December 31th 2013 in an ED of a French county, by a computer request. Cases were eligible if patients were over 18 years old and admitted in ED  if the cause of admission or the final diagnosis code (International Classification Disease v10) was related to poisoning or suicide attempt. Demographic, clinical, toxicological and therapeutic data were collected for any patients. Categorical variables are presented with absolute (n) and relative (%) frequencies. We used univariate analysis to compare different demographic data. We performed Chi2 test for categorical variables analysis and Student t test for numeric variables analysis. Results were considered significant with a p-value below 0.05 with a significant result (p < 0.05). Numerical data are reported as medians with interquartile ranges [Q1;Q2].

Results: Four hundred and seven patients were included in 2013, whose 78% patients with a psychiatric desorder. Two hundred seventy one (67%) were women and median age was 42 years old [31;52]. The deliberates drugs poisonings were often during winter seasonal (p < 0.01). 54% patients were transported to the ED by first responders, 35 (8%) by a mobile intensive care unit, 116 (29%) by private ambulance and 36 (9%) by own means. The most (91%) had called the emergency number. The delay of medical’s support was 21 [11;35] minutes. The ED length of stay was 284 [51;306] minutes. The most intoxicated patients (85%) were slight symptoms without haemodynamic, respiratory and neurological disorder. Concerning toxicological data, toxics used were mainly: anxiolytic 297 (44%), analgesics 127 (19%), antidepressants 91 (14%), neuroleptics 55 (8%) and drug cardiologic 26 (4%). Only twenty six patients (6%) were transferred to an intensive care unit and two hundred eighty nine (71%) were admitted in hospitalization unit of ED. Overall, eighty (20%) of patients benefited from at least one resuscitation technique (i.e. tracheal intubation, vasopressor support or more than 1L of intravenous fluid bolus) and one hundred one (26%) supported  toxicological treatment. The overall mortality was 0.5%.

Conclusion: The most intoxicated patients were not vital sign in our ED. Despite low mortality, the diversity of poisoning requires frequent knowledge updating and clinical assessment rule to improve patient care. Its role is crucial in the detection and management of acute drug overdose.

INTRODUCTION

Agitated patients can be a source of anxiety for staff within the Emergency Department (ED). It is well documented that novel psychoactive drugs, so called “legal highs”, can cause agitation and aggression. Patients presenting to the ED with agitation due to novel psychoactive drugs is increasing. National institute of Clinical Excellence (NICE) guideline CG25 emphasises de-escalation techniques, identifying and treating the provoking factor. Further to this the next step is that of the use of oral, then intramuscular medication. This is in keeping with our local Trust policy, CG25 and guidance set out by the Royal College of Emergency Medicine (RCEM).

AIMS

Our primary objective was to identify patients that presented with agitation due to “legal highs” and determine whether our department was compliant with CG25, our local Trust policy and RCEM guidelines on rapid tranquilisation.

METHODS

Patients were identified using our electronic patient management system (TRAK ED) that presented to the ED between 01/04/2014 – 30/09/2014. Firstly, we used the incident type category and included all patients that presented with a category of intentional self harm, psychiatric condition or unspecified. Secondly, we included all patients that had a free form text written by the receptionist or the triage nurse which included terms such as “overdose”, “poisoning”, “intoxication”, “illicit/recreational drugs”, “legal high”, “unknown substance” and variations of the adjectives “agitated”, “aggressive”, “violent” and “psychotic”. Finally, we included all patients that had a discharge diagnosis of International Classification of Disease (ICD) 10 codes T36-65, F00-F99, R40-46. Patients that presented with an incident type category of accidental poisoning, injury (of any cause) or medical/surgical conditions were excluded.

Once identified, patient’s clinical records were interrogated by two of the authors for further details. The third author re-examined the patient’s record if there was any confusion.

RESULTS

Out of 467 cases, 14 cases were reported at triage as agitated, 20 had intervention for agitation, either physical restraint (2), isolation (2) or chemical restraint (16). 8 patients were given oral medication, 7 were given IV and one received IM. 7 cases of rapid tranquilisation correctly followed the local policy and guidelines. 12 agitated triage patients were successfully de-escalated. The main reason for attendance was drug overdose 178 (38.1%), alcohol and drugs 76 (16.3%), alcohol 66 (14.1%) and legal highs 43 (9.2%). Of the 43 patients that had taken legal highs, 3 of them required some form of chemical treatment. 261 patients were admitted, 4 admitted to ITU and 12 to HDU.

DISCUSSION/CONCLUSION

Drug overdose was the most common cause for agitation. Of the 14 cases that were initially triaged as agitated, only 2 required medications or isolation, indicating that de-escalation techniques were successful and therefore compliant with guidelines. Two thirds of those who required chemical restraint were treated in accordance with the guidelines. In conclusion, lack of full compliance with rapid tranquilisation guidelines. Due to increasing presentations after taking psychoactive drugs, greater awareness of these guidelines is required to manage patients correctly.

Background: Foodborne botulism (FBo) is a neuroparalytic disease caused by the blockade of neural transmission in the cholinergic synapses due to botulinum neurotoxins. The onset of clinical manifestations can be rapid and dramatic. Early diagnosis and prompt specific treatment may represent critical aspects in the management of foodborne botulism in Emergency setting. The aim of the presented study is to evaluate clinical presentation characteristics of FBo poisoned patients admitted in Emergency Departments (EDs) to obtain clinical data useful for emergency physicians to make clinical suspicion, diagnosis and early antidotal treatment. Participants and methods: A retrospective analysis of cases of FBo registered at Pavia Poison Control Centre (PCC) was performed during the study period (2007-2013). Implicated food, clinical presentation, latency between symptoms/ED-admission/treatment, clinical course, response to the antidotal administration and laboratory analysis data were analyzed. Results: 98 cases were studied (mean age 55,14±17,9; 53/98 male) and 17 outbreaks (involving more than 2 people) were registered. History was positive for consumption of vegetables (77%) and fish (16%) in water or oil, or meat conserve in 88.7%. In 81 cases (93,2%) causative food were home-made produced, in 4 cases were industrial and in 2 cases were ingested at restaurant. Most common symptoms reported at ED were dysphagia (55,1%) followed by ocular manifestations [diplopia (40%), accommodation troubles (32%), mydriasis (26%) ptosis (18%)] and xerostomia (35%). In three cases dysphagia was the unique neurological manifestation of the poisoning. Twenty-four patients (24%) required mechanical ventilation. Antitoxin was administered in 59 patients (60,2%), with an average of 63 hours after neurological symptoms onset and 26% were treated within 24 hours. In this group 7 patients (26%) required mechanical-ventilation (mean duration 13,6±5,6 days) (vs 53,8% in treated group after 24 hs; mean duration 21±15,5 days). Five adverse reactions were registered. Laboratory analysis confirmed the poisoning in 66,4% of cases;  toxin type-B was the most common identified (83,6%). Serotype-A was isolated in 6 cases (12,2%): among these 83% required mechanical ventilation (p=0.004). Neurological permanent sequelae was registered in 1 case and 1 lethal case occurred. Conclusion: Botulism is a rare disease in which early correct diagnosis is difficult and may require a toxicological consultation. This intoxication represents also a medical challenge for the emergency physicians. Clinical presentation at EDs could be undefined, diagnostic procedures could be problematic and patients must be monitored because of dramatic respiratory failure. So, the PCC support is essential for the diagnosis and the management of poisoned patients (e.g. specific laboratory tests, antidotic treatment), and in the identification and surveillance of possible outbreaks.

Background: Viper envenomation may be characterized by severe local/systemic symptoms with an estimated mortality up to 1%. Clinical and laboratory disorders and antidote administration are often debated (1). Poisoning severity, laboratory alterations and antidote administration in viper-envenomed patients referred to Pavia-Poison-Centre (PPC) are described in order to evaluate predictable clinical and laboratory factors in viper envenomation management. Participants and methods: All viper bitten patients referred to PPC from 2002-2012 were retrospectively studied among those clinically followed until conclusive outcome. Clinical manifestations and evolution were evaluated according to a Grading-Severity-Score (GSS) (2). Laboratory parameters and antidote treatment were evaluated and related to GSS at acme. Results: During the 11-years study-period, 482 viper bitten patients were evaluated (age 44±23 years; male 65%). At hospital admission 43.2% presented only fang-marks (GSS0), 39% local edema (GSS1), 15.8% regional edema and/or mild systemic manifestations (GSS2), 2% severe local and/or systemic manifestations (GSS3). Among GSS0-admitted patients, 38/208 (18%) developed GSS≥1, and 10/208 (5%) needed antidote because developed GSS≥2. Among GSS1-admitted patients, 73/188 (38.8%) developed GSS≥2, and 59/188 (31.3%) needed antidote. Most GSS2-3 (63-100%) admitted patients received antidote. Among 482 patients, 170 (35%) remained dry bytes and 312 (65%) developed envenomation. Systemic symptoms were mainly gastrointestinal (118/312; 38%), hemodynamic (37/312; 11.8%), neurotoxic (36/312; 11.5%) and local thrombosis (24/312; 8%). Seven patients presented hemodynamic shock and three presented splenic, myocardial, cerebral ischemia respectively. No fatal cases were registered. Mean time-onset of local manifestations from viper byte ranged 11.8-27.5 hours for mild-extensive edema respectively; gastrointestinal and hemodynamic disorders developed within 5-7 hours, neurotoxic effects appeared within 10.7±6.2 hours. Increase of leukocytes, d-dimer, INR and decreased thrombocytes and fibrinogen were statistically related with GSS≥2. Antidote was needed in 44% of symptomatic patients and administered with a mean time of 15.5 hours from viper byte. Most patients (76%) improved after antidote administration. In those (24%) where GSS≥2 was present within few hours from the byte already at hospital admission edema worsened despite antidote administration. Conclusion: Viper bite is a potentially serious event that requires immediate hospital care. GSS0-patients at hospital admission may worsen and require antidote within 12-24 hours after the byte. Leukocytosis and increased d-dimer are related with severe envenomation. Prompt antidote prescription is important and further administration may be evaluated in patients that present severe envenomation already at hospital admission. References: 1. Pozio E. Trop Med Parasitol. 1988 Mar; 39(1):62-6. 2. Audebert F et al. Human and Experimental Toxicology 1994; 13:683-88.

Objective: To determine specific features in the clinical course and epidemiology of acute poisonings of different types of novel psychoactive substances (NPS). Methods: Retrospective evaluation of clinical records of patients admitted to our department between 1st December 2013 and 30th November 2014 due to acute intoxication caused by any type of drugs of abuse. The assessment consisted of demographic data, patient’s history, street name of drugs, way of use, coingestant(s), vital signs and parameters , any clinical symptom related to the consumption of drug, treatment. Results: There were a total of 2036 acute poisoning episodes by 1611 patients during one year. 152 patients had more than one episode, 74 patients had more than three episodes. Length of hospital stay was less than 6 hours in 170 patients, 6 to 24 hours in 1262 patients and more than 24 hours in 604 patients. There were a total of 359 acute poisonings caused by classic-type drugs of abuse  and 1677 acute poisonings caused by NPS. Three new designer drugs have become wide-spread (causing 1642 intoxications): “penta crystal” (typically containing pentedrone) in 527 patients , “music” (typically containing alpha-PVP or PV8) in 362 patients and “bio-grass or herbal smoke” (containing various synthetic cannabinoids and often kathonines) in 753 patients. There were 1216 males and 461 females intoxicated by NPS. The mean age was 25.2 years, but in the autumn period about one-third of the patients (132/439) were younger than 18 with regard to the use of herbal smoke.  The use of classical amphetamine-like stimulants resulted in the followings: accelerated psycho-motoric activity (82.3%), increased heart rate (76.6%) and blood pressure (71.2%), dilated pupils (70.8%), headache (30.2%), chest complaint (28.1%). Hyperthermia was not frequent (5.2%) but very problematic. As for kathinones the most characteristic symptoms were: agitation (78.9%), confusion (72.1%), hallucinations (45.4%), paranoid psychosis (42.5%), rage (34.7%), traumatic injuries (27.6%). Hyperthermia on the central origin did not occur. Cannabis typically caused dizziness (86.9%), nausea/vomiting (80.6%), mild hypotension (29.1%), collapse (14.1%). After using herbal smoke the problems related to the central nervous system were massively higher in number: CNS depression (55.3%), confusion (53.25%) and hallucination (24.3%). According to the Poison Severity Score the intoxication caused by the classical stimulants was dominantly mild (40.6%) or moderate (51.1%); however, the new kathinon-typed drugs typically caused moderate (48.1%) and severe (34.9%) poisoning. We did not register any serious poisoning induced by cannabis, but we identified a great number of moderate (55%) or severe (13.8%) intoxication due to the use of bio-grass. There were altogether 3 fatal cases. After using "penta crystal" and "music" 711 patients were treated with clonazepam, 578 patients with IV fluids, 301 patients with midazolam, 277 patients with haloperidol.  Conclusion: The drug market has profoundly changed, including the substances of abuse and their consequences. NPS more often result in serious psychosis, aggressive state and traumatic injuries than classic-type drugs. 

Background: Poisoning is one of the injury mechanisms inducing high mortality. Aims of this study were to describe the epidemiology of poisoning, and to identify age effects on clinical outcomes.

Method: An observational study was conducted using ED injury in-depth surveillance. Eligibility was poisoning patients who visited six urban tertiary hospitals’ ED from 2010 to 2012. We excluded the patients with unknown survival outcomes after ED treatment. Endpoints were mortality in ED and hospital. We tested age trends on survival outcomes.

Result: Total of 5416 poisoning patients, 3031 (56.0 %) were female and 2669 (49.3%) used EMS. Anti-psychotic drug was a leading cause of substance (30.5%), followed by artificial substance (21.2%). Insecticides (8.7%), herbicides (6.2%), painkiller (8.6%), and gas poisoning (12.3%) were identified. Among them, 2772 (51.2 %) used substances with self-injury intention, and 1234 (22.8%) consumed alcohol. Admission rate was 28.5% and mortality rate in ED and ward were 2.2% and 1.6%.

By age group, teenage used painkiller (37.1%), and elderly used herbicides and insecticides (32.2% in 60-69 and 38.7% in ≥70) (p-value <0.01). Teenage (60.8%) and mid-old age (61.9% for 30-39, 61.4% for 40-49) groups had more self-injury intention (p-value <0.01). Mortality in ED and ward were increased by age (6.0% and 5.5% for 60-69 and 7.2% and 9.0% for ≥70, respectively) (both p-for-trend <0.01).

Conclusion: Poisoning induced mortality was increased by age. It may be affected by not only natural age effect but also poisoning substances, which elderly more likely to use fatal substances like herbicides.

Objective: To evaluate trends in oxidative stress markers, SOD, CAT, GPx, MDA, TOS, and TAS, in a mouse α-amanitin poisoning model with three different toxin levels.

Methods: The mice were randomly divided into four groups: Group 1 (control group), Group 2 (low dose poisoning group; 0.2 mg/kg α-amanitin), Group 3 (moderate dose poisoning group; 0.6 mg/kg α-amanitin), and Group 4 (high dose poisoning group; 1.0 mg/kg α-amanitin). At hour 0, the their calculated dose of α-amanitin was injected to the mice in poisoning groups intraperitoneally. At hour 48, all mice were sacrificed and their livers were collected for biochemical and histopathological evaluation.

Results: Median liver tissue SOD activity in moderate and high dose groups was significantly higher than the median SOD activity in control (for both, p = 0.001). Median liver tissue CAT activity in Group 2 was significantly higher than the median CAT activity in Group 1 (p = 0.001). Median liver tissue CAT activity in Groups 3 and 4 was significantly lower than the median CAT activity in Group 1 (for both, p = 0.001). Median liver tissue GPx activity in Groups 2, 3, and 4 was significantly higher than the median GPx activity in Group 1 (for Group 2, p = 0.006; for Group 3 and 4, p = 0.001). The median liver tissue MDA levels of Groups 3 and 4 were significantly higher than the median MDA level of Group 1 (for Group 3, p = 0.015; for Group 4, p = 0.003). There was a significant positive correlation between liver CAT activity and liver TAS level, and a significant negative correlation between liver CAT activity and liver TOS level (r = 0.935 and r = −0.789 respectively; for both, p<0.001).

Conclusions: Our findings support a significant role for increased oxidative stress in α-amanitin induced hepatotoxicity. In particular, identifying the pathophysiological mechanism responsible for the direct relationship between CAT, α-amanitin, and TAS levels may be very helpful for further treatment investigations.

Background: To describe clinical manifestations of cases of high-pressure injection (HPI) injuries referred to the Pavia Poison Centre (PPC), in order to identify toxic effects and treatments. HPI injury of hand represent one of the most serious surgical emergencies of the upper extremities. Participants and methods: A 20-year retrospective analysis (1995-2014) assessed all cases for sex, age, injected fluid’s nature, site of HPI, clinical manifestations, treatment, outcome. These factors influence the seriousness, the extensiveness of subcutaneous damage and the functional outcomes of patients [1]. Results: Forty-two cases were studied (37 M; mean aged 40.9±10.5). Mechanism injury described in 24/42 (57%), 20 injection by pressure guns, 4 blast pipe pressure. It mostly concerns non-dominant hand. More than 36% of injections occurs in the index finger. The second most touched region is the hand palm 19%, and only 17% of the injections occur on thumb. The categories so formed were: oily substances (38%), solvent-based paints (17%), water-based paints (14%), organic solvents (12%), fats (10%), solid materials (5%), gas (2%) and unknown (5%). The most serious injuries occurred in the categories of solvent paints and oils. The clinical course was characterized by: edema (69%), pain (63%), punctiform skin lesions (44%), necrosis (16%), local hyperemia (12,5%), tissue functional impotence (9,5%). Ischemic phalanx (9%) and necrosis (6%) were also involved. Fifty-one per cent of patients was admitted to ED within 6 hours after the incident. Outcomes are available for 10 cases that underwent urgent immediate surgical exploration/decompression: 4 showed a finger amputation: 3 solvent-based, 1 water-based paints; 2 reported permanent sensory deficits: 1 paint solvent, 1 hydraulic oil, 1 fat; 1 presented decrease of functionality of the hand; 3 patients recovered without sequelae. The amputation rate of these injuries is up to 10% without adequate treatment and on average, time between inoculation and presentation in ED was 24 h. Conclusion: The real gravity of HPI injuries, due to the apparent safety of initial injury is often missed by the emergency room physician who ignores the potential morbidity of the injury itself. Each victim of HPI injuries should be considered at risk for amputation and be sent immediately to the attention of the surgeon. References:  1. N. Verhoeven Æ R. Hierne. High-pressure injection injury of the hand: an often underestimated trauma: case report with study of the literature. Strat Traum Limb Recon 2008; 3:27–33