Introduction: Early identification of septic patients is one of the key elements in appropriate management to recude mortality. Diagnosis of sepsis requires high clinical suspicion as signs of infection and organ dysfunction may be subtle. The systemic inflammatory response syndrome (SIRS) criteria are inaccurate for the early detection of sepsis. Shock index (SI), defined as heart rate/systolic blood pressure, has previously been shown to identify high risk septic patients. Our objective was to compare the ability of SI, individual vital signs, and SIRS criteria to predict hyperlactatemia (serum lactate ≥4.0 mmol/L)(primary outcome), as a surrogate for disease severity and marker for cryptic septic shock, and 28-day mortality (secondary outcome). Methods: We performed a retrospective analysis of a cohort of adult patients presenting to an Urban Hospital Emergency Department (ED) (with 380000 annual visits), from January 1st, 2013 to December 31st, 2013. Adult patients presenting to the ED with a suspected infection were screened for severe sepsis using triage vital signs, basic laboratory tests and an initial serum lactate level. Test characteristics were calculated for two outcomes: hyperlactatemia (marker for morbidity and cryptic septic shock) and 28-day mortality. We considered the following covariates in our analysis: fever (body temperature ≥38° C); systolic arterial pressure <90 mmHg; ≥2 SIRS criteria; and SI >0.7. We report sensitivity, specificity, and positive and negative predictive values for the primary and secondary outcome. Results: 113 patients (82.4%) had complete records and were included in the analysis. 16 (14.1%) patients presented with hyperlactatemia and 20 (17.7%) patients died within 28 days. Subjects with an abnormal SI >0.7 (87.5%) were more likely to present with hyperlactatemia than those with a normal SI (58.2%). The negative predictive value (NPV) of a SI ≥0.7 was 95.3%, close to the NPV of SIRS (96%). Moreover, 28-day mortality is much greater in subjects with SI >0.7 (50%) than those with a normal SI (12.2%). Conclusion: In this cohort, SI >0.7 performed as well as SIRS in NPV and was the most sensitive screening test for hyperlactatemia and 28-day mortality. SI >0.7 is a no-cost bedside triage tool that predict hyperlactatemia and cryptic septic shock, with implications for efficiency and cost effectiveness in ED protocols and for management and prognosis of patients with severe sepsis and septic shock.

Objective: To analyze the sensitivity of procalcitonin (PCT), C-Reactive protein (CRP), white blood cell (WBC) count and absolute neutrophil count (ANC) for occult bacteremia (OB) and sepsis among previously healthy patients attended at the Pediatric Emergency Department depending on their etiology.

Methods: prospective, multicenter registry developed by the Infectious Disease Working Group of the Spanish Pediatric Emergencies Society (SEUP). Patients with a positive blood culture collected in any of the 22 participating Hospitals are included. Patients recruited between 2011/01/01 and 2013/12/31 with a final diagnosis of severe sepsis or occult bacteremia are analyzed. We defined severe sepsis as the presence of signs of organ dysfunction and OB as the presence of a normal Pediatric Assessment Triangle with no associated focal infection and no associated signs of organ dysfunction. Bacteria with at least 10 cases of one of these pathologies were studied. The following values were considered elevated: PCT≥0.5 ng/mL; CRP>20 mg/L; WBC>15,000/mm³; ANC>10,000/mm³.

Results: there were 931 positive blood cultures, being 711 (76.3%) of them collected in previously healthy patients. Finally, 133 met criteria of OB (most frequently isolated bacteria: S.pneumoniae [50], S. agalactiae [20], S. aureus [17] and E. coli [10]) and 109 met criteria of severe sepsis (most frequently isolated bacteria: S. agalactiae [36], N. meningitidis [26], E. coli [15] and S. pneumoniae [12]. Patients with infections by E. coli and S.agalactiae were younger and were attended with shorter evolution of fever.

Overall, the most frequently elevated test among patients diagnosed with a severe sepsis was PCT (97.2%), followed by CRP (69.2%). Among patients with an OB the four blood tests were elevated in a similar percentage: PCT 53.1%; CRP 43.7%; WBC count 47.4%; ANC 42.9%. In both cases, there were significant differences in relation of these results depending on the etiology.

Among patients with pneumococcal OBs, 82% of them presented leukocytosis and neutrophilia (vs 54.5% and 57.4% of patients in whom PCT and CRP were respectively elevated). The only blood test that was elevated in a significant percentage among patients with OB by S. agalactiae was PCT (62.5%, vs <30% for the other studied tests). OB by S. aureus and E. coli did not significantly elevate any of the studied tests.

Among patients with severe bacterial sepsis, PCT was elevated in at least 85% of them regardless the etiology. CRP was also elevated in a similar proportion except in patients with sepsis by S. agalactiae (31.4%). WBC count and ANC count were only elevated significantly in patients with pneumococcal sepsis (66.7%). 

Conclusions: among patients with occult bacteremias and severe bacterial sepsis, sensitivity of PCT, CRP, WBC count and ANC vary significantly depending on the causing bacterium. The WBC count and the ANC can still be useful to rule out a pneumococcal occult bacteremia. Overall the most sensitive test among septic patients is the PCT.

Background: Health care workers are exposed to blood or fluid exposure (BFE). They are therefore at risk for occupational infections. Emergency medicine (EM) physicians and residents are at potential high risk of occupational infections as they routinely care for large amounts of patients with a paucity of information on their past medical history. The aim of this study was to investigate the epidemiological characteristics of BFE and occupational infection risk among EM residents and young physicians (

Methods: We conducted a cross-sectional, anonymous, online survey among EM residents and young physicians in France, from January to April 2015. The survey was designed by consensus among the authors. The link to the online survey was distributed by email via the AJMU network (Association of young emergency medicine practitioners). AJMU aggregates the majority of young EM physicians trained since 2004. Demographic data, history of occupational BFE, details of the last BFE and vaccination status were collected.

Results: 1779 participants were contacted, with a response rate of 36% (n=633). Among the respondents, 459 (72%) reported at least one BFE. Mean age was 30.4 years and 63% were women (n=289). The rate of self reported exposure increased with medical experience: 60% (n=69) for first year residents, 71% (n=86) for second year residents and 77% (n=304) for post graduates (p<0.01). Among participants with at least one BFE, 35% (n=163) never reported the exposure to the relevant medical authorities or support. Only 30% (n=136) always reported their BFEs. Among participants who reported exposure, 78% (n=232) immediately reported it. Among participants who never or not systematically reported their BFE, 62% (n=181/289) did not do it because the procedure was too long, and for 28% (n=82/289) because they estimated the risk as low. The circumstances in which the participants had the most BFE were: suture 57% (n=262), when making precipitated gesture 24% (n=111) or while handling an agitated patient 17% (n=79). Only 19% (n=88) systematically checked the patient’s viral status. One third (n=153) never used condoms with their partner after a BFE and 18% (n=83) never informed their partner of the transmission risk. The latest exposures were most commonly caused by a solid needle 42% (n=191) or hollow-bore needle 27% (n=123). Half of the participants (n=226) reported their last BFE. Only one third (n=166) checked their HIV status with two blood tests even though the BFE was at a transmission risk.

Conclusions: EM residents and young physicians were frequently exposed to BFE, mostly with a solid needle. Post-exposure reporting rates were low. Reporting procedure itself and self-management were the main reasons for BFE underreporting. Simplifying occupational blood exposure procedures might increase BFE reporting rates, and allow appropriate post exposure counseling and/or prophylaxis. Preventing exposure is of major importance among health care workers to avoid occupational infections. EM residents and young physicians should be included in educational programs.

Background : Third-generation cephalosporins and fluoroquinolones are particularly prone to promote bacterial resistance. Their use in Emergency Departments (ED) is poorly known and should be monitored in order to guide antibiotic stewardship programs. 

Objectives: To assess the use of antibacterial agents in French Emergency Departments (ED).  

Methods : Retrospective study of antibiotics delivered to the adult units of 11 EDs of French academic centres between 2009 and 2012.

Results: The total antibiotic use was 66.4 Defined Daily Doses (DDD) /1000 ED visits in 2012, and increased between 2009 and 2012 (yearly estimate, +1.8 ± 0.9 DDD/1000 ED visits, P=0.048). The broad spectrum agents class, that grouped 3rd-generation cephalosporins and fluoroquinolones, accounted for 39.2% of total antibiotic use, and was highly variable among EDs (range, 31.6% to 49.5% of total antibiotic use). The aminopenicillin and beta-lactamase inhibitor / broad spectrum agents ratio varied among  EDs (median [range], 0.91 [0.52 – 1.25]). Between 2009 and 2012, there was a significant decrease for broad spectrum agents (yearly estimate, -0.8%±0.4% of total antibiotic use), antipneumococcal fluoroquinolones (-0.8%± 0.3%) and other fluoroquinolones (-0.9%± 0.3%), and a significant increase for 3rd-generation cephalosporins (+0.7%± 0.3%), aminoglycosides (+0.4%± 0.1%), imidazole derivatives (+0.4%± 0.1%) and lincosamides (+0.1%± 0.0%).

Conclusion: Fluoroquinolones and 3rd generation cephalosporins are widely used in French EDs. Their use is highly variable among EDs. Antibiotics as a whole, and 3rd generation cephalosporins have been increasingly used between 2009 and 2012, while the use of fluoroquinolones has decreased. Reduced ED use of cephalosporins, without increasing fluoroquinolones, should be aimed through antibiotic stewardship programs.   

Background: The empirical therapy of pyelonephritis is based on a fluoroquinolone or a 3^rd generation cephalosporin. However, these agents are particularly prone to promote bacterial resistance to antibiotics, and their use should be restricted. A rapid detection of amoxicillin-susceptible bacteria in the urine would allow to start amoxicillin in the Emergency Department for pyelonephritis without a preliminary broad spectrum empirical treatment.

Objectives: To develop and validate a triple real-time PCR for the diagnosis of Urinary Tract Infection (UTI) due to amoxicillin susceptible Escherichia coli.

Methods: We developed a triple real time PCR for Amoxicillin Susceptible E. coli (ASEC) applied to fresh, uncultured urine. The ASEC PCR detects the E. coli specific gene ycct, and genes of the main beta-lactamases causing amoxicillin resistance in French E. coli isolates (bla_TEM and bla_CTX-M ). The ASEC PCR is considered positive for ASEC when the PCR is positive for the yccT gene and negative for both bla_TEM and bla_CTX-M genes. We assessed prospectively the ASEC PCR on patients with suspected urinary tract infection, who have been hospitalized in 2014 for less than 3 days in a French hospital. Routine identification and susceptibility tests were used as the gold standard.

Results: Among 200 patients, routine tests isolated E. coli (n=117, 58%, including 58 amoxicillin susceptible isolates), another bacterium (n=47), or proved sterile (n=36). The ASEC PCR result was obtained in 3 hours and 10 minutes after urine sampling (CI 95% 3:07-3:14). The ASEC PCR was positive in 42 (21%) patients. The specificity of ASEC PCR was 97,9% (CI 95% 95.9 -99.9), the sensibility was 65.0% (CI 95% 58.4-71.6), the positive predictive value (PPV) was 92.9 % (CI 95% 89.3-96.41) and the negative predictive value was 86.7% (CI 95% 82.0-91.4).

Conclusion: The ASEC real time PCR allows a rapid diagnosis of UTI due to amoxicillin susceptible E. coli , as its result is available 3 hours after urine sampling. Thanks to its high positive predictive value, the ASEC PCR may be used to treat UTIs with amoxicillin in the Emergency Department. Its use would have reduced by up to 21% the prescriptions of fluoroquinolones or 3rd generation cephalosporins for pyelonephritis in the ED. The ASEC PCR is a promising tool to save fluoroquinolones and 3rd generation cephalosporins in the ED.

Introduction: Sepsis is a systemic inflammatory response caused by an infection. It is well recognised that this inflammatory response is associated with complex changes in both the coagulation system and the cells that regulate this system [1].  These changes can lead to a hypercoagulable state that can increase the risk of thrombosis, which is dependent on the severity of the disease [2]. In severe sepsis and septic shock, upregulation of the procoagulant pathways and dysfunction of the natural inhibitory pathways can lead to the development of Disseminated Intravascular Coagulation (DIC) [3]. DIC causes microthrombi to form systemically, causing microvascular obstruction, thromboembolic events and organ dysfunction [4]. It also causes increased consumption of platelets and coagulation proteins leading to a bleeding diathesis [5]. However, the complex changes in coagulation pathways in sepsis are poorly understood. This study aims to assess the relationship between sepsis severity and a new biomarker of clot microstructure, fractal dimension (D_f) [6], in patients across the sepsis spectrum (sepsis, severe sepsis and septic shock).

Methodology: Adult patients (>18yr old) presenting with sepsis were recruited from the Emergency Department (ED) and Intensive Care Unit (ICU) of a large teaching hospital in Wales. Patients with diseases affecting the coagulation profile (liver failure, coagulation disorders) and who were on anticoagulants were excluded. Rheological analysis was performed on whole, unadulterated blood samples to determine D_f. Citrated and EDTA samples were also taken to assess standard markers of coagulation and a full blood count. Healthy volunteers matched for age and gender were also recruited as a control group. This study had ethical approval from the South West Wales research ethics committee.

Results: 95 patients were included in the study: 49 with sepsis, 19 with severe sepsis and 27 with septic shock. 44 healthy volunteers were recruited as a matched control. Mean D_fin the healthy control group was 1.74 ± 0.03. Mean D_fin patients with sepsis and severe sepsis was significantly elevated (1.78 ± 0.07 and 1.80 ± 0.05 respectively (p<0.05, One-way ANOVA Post-hoc Bonferroni correction)). Mean D_f in patients with septic shock was significantly reduced compared to all other groups (1.66 ± 0.10 (p < 0.001, One-way ANOVA Post-hoc Bonferroni correction)).

Conclusion: Our results indicate that patients with sepsis and severe sepsis form tight highly branched fibrin clots (as indicated by high D_f) that are resistant to fibrinolysis. As the disease progresses to septic shock, much weaker clots are formed (as indicated by low D_f) that are more susceptible to fibrinolysis. This may explain the dichotomy of thrombogenicity and bleeding diathesis in patients across the sepsis spectrum. The new functional biomarker, fractal dimension (D_f), therefore can be used to quantify clot microstructure across the sepsis spectrum.

References:

1.          Remick DG (2007) Pathophysiology of sepsis. Am J Pathol 170: 1435–1444.

2.          Donze JD, Ridker PM, Finlayson SRG, Bates DW (2014) Impact of sepsis on risk of postoperative arterial and venous thromboses: large prospective cohort study. Bmj 349: g5334–g5334.

3.          Faust SN, Heyderman RS, Levin M (2000) Disseminated intravascular coagulation and purpura fulminans secondary to infection. Baillieres best Pract Res Clin Haematol 13: 179–197.

4.          Gando S (2010) Microvascular thrombosis and multiple organ dysfunction syndrome. Crit Care Med 38: S35–S42.

5.          Levi M (2007) Disseminated intravascular coagulation. Crit Care Med 35: 2191–2195.

6.          Evans P a, Hawkins K, Morris RHK, Thirumalai N, Munro R, et al. (2010) Gel point and fractal microstructure of incipient blood clots are significant new markers of hemostasis for healthy and anticoagulated blood. Blood 116: 3341–3346.

Introduction

The aim of the study was to evaluate the incremental prognostic value of different scoring systems over clinical data in a population of septic patients.

Methods                                        

Retrospective study on 548 septic patients admitted in the Emergency Department (ED)-High-Dependency Observation Unit of Careggi University-Hospital of Florence between June 2008 and May 2014. We calculated retrospectively Modified Early Warning Score (MEWS), Charlson Comorbidity Index, Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II, Mortality in Emergency Department Sepsis (MEDS), Predisposition, Insult, Response, Organ dysfunction (PIRO). The scores were calculated at the time of ED admission (T0) and after 24 hours (T1) using data obtained from clinical records. A follow-up based on telephone interviews was performed to ascertain 28-days vital status.

Results

Medical records of 548 subjects aged 75±14 years, 52% men, were examined; diagnosis was sepsis in 108 (20%) patients, severe sepsis in 272 (49%) and septic shock in 168 (31%). Overall 28-days mortality rate was 31%; 10% of patients were transferred to an Intensive Care Unit (ICU). The lactate dosage was 4.7±8.5 mmol/L at T0 and 3.4±8.4 mmol/L at T1. The mean T0 SOFA score was 6.1±3.4 at T1 and 5.8±3.2. The different scoring systems showed a modest to moderate discrimination (area under the curve of T0 PIRO: 0.663, T1 PIRO: 0.686, T0 SOFA: 0.718, T1 SOFA: 0.758, T0 MEWS: 0.667, T1 MEWS: 0.694, Charlson: 0.598, APACHE II: 0.775, MEDS: 0.663). Only MEWS at T1 (5.2±2.3 vs 3.7±2.2, p=0.001) and SOFA at both T0 (7.4±3.4 vs 5.9±3.3, p=0.002) and T1 (7.5±3.7 vs 5.7±3.2, p=0.003) were significantly higher in patients who were admitted to ICU. At a multivariate stepwise Cox analysis we firstly entered age (RR 1.037, 95%CI 1.018-1.056, p <0.0001) that was significantly associated with a higher mortality, then Charlson Comorbidity Index (RR 1.090, IC95% 1.037-1.146, p=0.001) that was a significant mortality predictor even when age-adjusted. MEWS score provided incremental prognostic value (RR 1.153, 95%CI 1.062-1.251, p=0.001), making comorbidities to lose their independent prognostic value. T0 lactate value did not show any independent prognostic value. Finally we separately entered two organ dysfunction scores: PIRO and SOFA. SOFA showed an incremental prognostic ability both at T0 (RR 1.206, IC95% 1.136-1.279, p <0.0001) and T1 (RR 1.239, IC95% 1.153-1.331, p<0.0001), while PIRO showed no independent prognostic value at any time. Lactate dosage proved independent prognostic ability only at T1 (RR 2.088, IC95% 1.297-3.360, p=0.002).

Conclusions

SOFA score correlated with both mortality and ICU transfer need and showed incremental prognostic power compared to age, comorbidities, vital signs and lactate dosage.

Introduction: Sepsis is a systemic inflammatory response caused by an infection. It is well recognised that this inflammatory response is associated with complex changes in both the coagulation system and the cells that regulate this system [1].  Respiratory infections especially pneumonia are one of the most common causes of sepsis seen in the Emergency Department. These patients often require respiratory support. Patients with pneumonia can develop severe sepsis and septic shock. This subgroup analysis aims to quantify changes that occur in clot microstructure [2] in patients with pneumonia from a septic cohort of patients recruited across the sepsis spectrum.

Methodology: Adult patients (>18yr old) presenting with sepsis were recruited from the Emergency Department (ED) and Intensive Care Unit (ICU) of a large teaching hospital in Wales. Patients with diseases affecting the coagulation profile (liver failure, coagulation disorders) and who were on anticoagulants were excluded. Rheological analysis was performed on whole, unadulterated blood samples to determine D_f. Citrated and EDTA samples were also taken to assess standard markers of coagulation and a full blood count. Healthy volunteers matched for age and gender were also recruited as a control group. This study had ethical approval from the South West Wales research ethics committee.

Results: 95 patients were included in the initial study, 28 who had pneumonia. Of these 28 patients, 11 had a diagnosis of sepsis, 7 had severe sepsis and 10 septic shock. 10 healthy volunteers were recruited as a matched control. Mean D_fin the healthy control group was 1.74 ± 0.03. Mean D_fin patients with sepsis and severe sepsis was 1.78 ± 0.06 and 1.75 ± 0.10 respectively. Mean D_f in patients with septic shock was significantly reduced compared to all other groups (1.63 ± 0.07 (p < 0.001, One-way ANOVA Post-hoc Bonferroni correction)).

Conclusion: Our results indicate that septic patients with pneumonia undergo similar changes in clot microstructure that we observed in the sepsis group as a whole. Patients with sepsis and severe sepsis form tight highly branched fibrin clots (as indicated by high D_f) that are resistant to fibrinolysis. As the disease progresses to septic shock, much weaker clots are formed (as indicated by low D_f) that are more susceptible to fibrinolysis. This may explain the dichotomy of thrombogenicity and bleeding diathesis in patients across the sepsis spectrum. The new functional biomarker, fractal dimension (D_f), therefore can be used to quantify clot microstructure in patients with pneumonia.

References:

1.          Remick DG (2007) Pathophysiology of sepsis. Am J Pathol 170: 1435–1444.

2.          Evans P a, Hawkins K, Morris RHK, Thirumalai N, Munro R, et al. (2010) Gel point and fractal microstructure of incipient blood clots are significant new markers of hemostasis for healthy and anticoagulated blood. Blood 116: 3341–3346.

Background: In about 40% of septic patients, a new left ventricular (LV) systolic dysfunction develops. LV ejection fraction (EF) does not represent an accurate parameter for cardiac function’s evaluation in sepsis due to its high preload and afterload dependency. Two-dimensional (2D) echocardiography based analysis of strain (GLS) could represent a valid alternative, providing a measure of myocardial contractility, poorly influenced by loading condition. Aim of this study was to evaluate the reversibility of septic myocardial systolic dysfunction by LVEF and GLS.

Methods: Unselected patients affected by severe sepsis and septic shock admitted consecutively to a High Dependency Unit from the Emergency Department between October 2012 and November 2014 were prospectively enrolled. Anamnestic data and main clinical and laboratory parameters were obtained for each patient to evaluate Sequential Organ Failure Assessment (SOFA) score. An echocardiogram was performed within 24 hours from sepsis diagnosis (T1). LVEF was calculated by Simpson’s rule. The longitudinal GLS was evaluated from apical LV views, with a commercially available system (Philips Q-LAB ver. 8.1). In a consecutive group of survivors we repeated an echocardiogram after 3 months from discharge (T2).

Results: We enrolled 100 consecutive patients; 29% of them died at 28 days. Among 71 survivors, in 24 unselected patients (G1) we could repeat an echocardiographic evaluation after three months; remaining patients (G2) refused to come to the hospital to undergo the second echocardiogram, in most cases for persistent immobilization syndrome. G1 included 16 males, mean age 67±12 years; main comorbidities were hypertension in 68% of patients, diabetes in 54%, coronary artery disease in 17%. Pulmonary sepsis was found in 68% of patients; six patients (25%) developed septic shock. Sepsis severity appeared worse in G1 than G2 patients: T1 SOFA score (G1 5.9±2.7 vs G2 7.2±2.6; p=0,04) and lactate dosage (G1 1.29±0.92 vs G2 2.6±2.94 mmol/l p= 0,01) were significantly higher in G1 compared with G2 patients;  nevertheless GLS (GLS% G1: -11.4±3.2 vs G2: -10.9±3.3%; NS) and EF (G1: 52±16 vs G2 50±16%; NS) at the first evaluation were comparable. After three months the echocardiographic evaluation showed a myocardial function’s improvement, demonstrated by both GLS (-11.4±3.2 vs -12.9±2.4%; p=0.03) and EF  (52±16 59±13%, p=0,02) better values. Considering individual patients, GLS appeared better at the follow-up compared with baseline evaluation in 17 patients (71%) and it worsened in remaining 7: patients with reversible dysfunction were significantly older compared with patients with worsening dysfunction; indices of sepsis severity, like T1 SOFA (5.8±2.9 vs 6.3±2.4) and T1 lactate dosage (1.3±0.7 vs 1.2±1.4 mmol/l, p=NS) were comparable between the two groups.

Conclusions: Myocardial dysfunction during sepsis appears to be reversible in a high proportion of patients: the limited population size precluded the identification of parameters significantly associated with reversibility. 

Introduction: Systemic Inflammatory Response Syndrome (SIRS) can match with numerous infectious or non-infectious conditions, frequently observed in the Emergency Department (ED). Inflammation and coagulation are closely linked and SIRS is often characterized by early alterations of clotting and platelets, with major thrombotic and bleeding complications. Thrombelastometry (Rotem®) and Impedance Aggregometry (Multiplate®) are point-of-care (POC) technologies with a potential diagnostic and predictive value in critically ill patients. The former is a viscoelastic method able to quickly assess the whole plasmatic coagulation process according to different activation pathways; the latter evaluates global platelet function in response to different stimuli. Early identification of SIRS is a prime target for optimal treatment and the application of acute coagulopathy POC tests in the ED may help to define a peculiar coagulation profile to distinguish the genesis of SIRS, increase diagnostic effectiveness and speed, evaluate the severity of disease and identify high risk patients.

Methods: In this prospective observational study we enrolled 110 patients presenting to 2 local ED, with clinical diagnosis of infectious SIRS (40 sepsis, 38 severe sepsis/septic shock) and non-infectious SIRS (32 severe trauma with Injury Severity Score> 15). Clinical scores and Laboratory values were recorded at first presentation, together with Rotem® tests (Extem for extrinsic pathway, Intem for intrinsic pathway, Fibtem for evaluating  fibrinogen and Aptem tests to exclude hyper-fibrinolysis) and Multiplate® tests (ASPI, ADP, TRAP, COL and RISTO test). Trauma patients (T) were considered as controls and compared to sepsis (S) and severe sepsis/septic shock (SS) patients; the group with non-infectious SIRS (T) was furthermore compared to the infectious SIRS (S + SS) group. Final diagnosis, in hospital length of stay and survival were obtained from clinical records.

Results: Significant differences were observed in the Intem clotting time (CT) mean values  between the trauma, sepsis and the severe sepsis/septic shock populations (p=0.031). Analysis of clot firmness (MCF and A10) displayed significant differences among the trauma population and  populations with sepsis and severe sepsis/septic shock in Extem (p=0.016) and Fibtem (p<0.0001). Rapidity of clot formation (alpha angle) was also significantly increased in the population with infectious SIRS. Multiplate® analysis demonstrated a widespread tendency to hypo-aggregability in the populations with infectious SIRS, via ADP (p=0.005), COL (p=0.001) and TRAP (p=0.002) tests. Diagnostic accuracy of POC tests in discriminating cases of infectious SIRS was good and far superior to classical laboratory variables and clinical scores. Preliminary data furthermore suggest a role for POC tests in patient risk stratification and mortality prediction.

Conclusion: This work represents one of the first examples of joint application of coagulation POC methods in patients with infectious and non-infectious SIRS in the ED. Peculiar alterations of the coagulation system together with a global platelet hypo-aggregability were observed in patients with sepsis, severe sepsis and septic shock since their first presentation. These modifications were able to distinguish with good accuracy the infectious etiology of SIRS, together with stratifying for severity and displaying a potential prognostic role.

Emergency Research (ER) is the experimentation of new diagnostics/therapies for patients coming in emergency departments in critical condition, frequently incapable to consent, and with a not otherwise treatable disease. Today the debate is particularly focused on the issue of the participation of the incapable subjects in ER. Oviedo Convention and the Additional Protocol (2005) set up a safeguards system to ensure the protection of incompetent persons in clinical research. But the application of the Oviedo Convention in Europe has been quite “patchy”: most countries have ratified it, but in some cases the Convention was not ratified or the ratification process has never been completed. This main debate seems to have been solved by the adoption of the new European Regulation (EU) 536/2014, in which the provision for the carrying out of ER in subjects incapable to give IC is included in article 35.

In the USA the exception to informed consent was introduced in 1996 from FDA through the adoption of Regulation 21 GFR 50.24, updated in November 2014. Many studies have been conducted in American emergency departments where patients and legal authorized representative (LARs) had the possibility to exhibit their opinions in case of necessity of an ER.

In particular, after what was established by point d), art. 35 of the EU Regulation "the investigator certifies that he or she is not aware of any objections to participate in the clinical trial previously expressed by the subject" some dilemmas arise about ethical application of ER in incapable subjects. Therefore, we have designed  the EROIS Study, an international multicenter study involving some centers in European countries and in USA.

Patients hospitalized for severe and acute diseases that in the future may be eligible for ER, their LARs, patient associations and healthy control subjects are included to investigate, through questionnaires, their perspectives about emergency research on incapable subjects. In particular four specific anonymous questionnaires, one for type of stakeholders, was designed with the aims to understand patients/LARs’ knowledge, awareness, choices, level of trust in the physicians-researchers/RECs, that will be involved in the application of the ER.

Preliminary application of EROIS Study involved at the “A. Gemelli” University Hospital in Rome was carried out on patients of Stroke Unit, Cardiology and Nephrology and Dialysis department; on LARs of these patients and on healthy persons in particular university students of health care degree courses. The early data of the EROIS in our center at the “A. Gemelli” UniversityHospital showed a poor knowledge about ER meaning and a differences of opinion between patients and LARs. Indeed only 15% know what is ER and regarding the trust on researchers and RECs the 37% of patients believe on them against the 49% of LARs which have trust on researchers and RECs.

EROIS preliminary data highlights the need to improve public knowledge and culture on Emergency Research in order to the correct implementation of the article35, point d) and to ensure the integral management of ER on patients incapable to give IC.

Introduction

Thrombocytopenia, defined as platelet (PLT) count < 150x10⁹/L, is a common finding in critically ill patients. In patients admitted to Intensive Care Units, thrombocytopenia represents a risk factor for acute bleeding, transfusion requirements, and higher mortality rate^[1]. Nowadays, only few data are available about thrombocytopenia in the Emergency Department (ED) setting^[2,3]. Aim of our study was to define the relationship between plt count at the admission in the ED and the in-hospital mortality risk.

Partecipants and methods

We retrospectively enrolled 1218 patients (830 males, 388 females; age 69 ± 17.7 SD) presenting with thrombocytopenia to the ED of "Città della Salute e della Scienza" Hospital of Torino in four non-consecutive months in 2012. No exclusion criteria were adopted. Preliminary data about this population concerning epidemiological details, bleeding frequency, and therapeutic strategies have been previously published^[3].

Results

In our population, 12% of patients had severe thrombocytopenia, defined as PLT count < 50x10⁹/L. In these patients, signs of minor and major bleedings and hypovolemia were more frequently present than in patients with less severe thrombocytopenia; moreover, patients with severe thrombocytopenia required more therapeutics interventions, and haematological consultations.

The in-hospital mortality rate in patients affected by severe thrombocytopenia was higher (19.7%) than in those with mild thrombocytopenia (8.6%). For every drop of 10x10⁹/L in PLT count at the admission in the ED, indeed, the mortality odds increased of 12% (OR 0.988 - p < 0.001), even after adjusting for the major confounding factors, such as age, sex, comorbidities, admission category in the ED, and in-hospital length of stay. Furthermore, a drop in plt count at the admission of 10x10⁹/L, even adjusting for several confounders, such as PT-INR, anticoagulant and antiplatelet medications, age, and sex, was associated with an increased probability of major bleeding of 16% (OR 0.984 - p < 0.001).

Finally, patients presenting to the ED with signs of major bleeding had an increased mortality risk of 87% compared to those without evidence of bleeding (OR 1.876 - p = 0.014).

Conclusions

This is the first study to assess the mortality risk in thrombocytopenic patients presenting to the ED. Thrombocytopenia could represent a helpful and important prognostic tool for the ED physician. Our findings may stimulate further prospective research studies. 

References

1. Williamson DR, Lesur O, Tetrault JP, et al; Thrombocytopenia in the critically ill: prevalence, incidence, risk factors, and clinical outcomes. Can J Anaesth, 2013; 60(7): 641-51.

2. Howell MD, Powers RD; Utility of thrombocytopenia as a marker for heparin allergy in adult ED patients. Am J Emerg Med, 2006; 24(3): 268-70.

3. Turvani F, Pigozzi L, Barutta L, et al; Bleeding prevalence and transfusion requirement in patients with thrombocytopenia in the emergency department. Clin Chem Lab Med, 2014; 52(10): 1485-8.

Acknowledgments

The study was designed according to the Helsinki Declaration, and approved by the local Ethical Committee. 

The authors disclose any financial competing interests.

Mild traumatic brain injury (mTBI) is a major concern for modern Health Systems because of its high incidence, subtle clinical presentation, and potential long-term disabilities. Our local protocol defines mTBI according to GCS, to clinical presentation and according to some pre-traumatic and post-traumatic risk factors, pointing out specific criteria that patients should meet before taking a head CT. It also proposes clinical stratification into three evolutive risk classes (low, medium and high risk mTBI), according to risk factors and clinical criteria previuosly collected. After patient’s evaluation, physicians should decide if the patients has to undertake Head CT scan or not.

Aims: Thanks to the “duplex nature” of our protocol, that can work both as a decision making tool that as a clinical stratification tool, we could compared its performance to other internationally validated clinical decision rules and to recently pubblished international guidelines. To our knowledge, this is the first paper that aims to do so.

Methods: We conducted a retrospective analysis of charts gathered during a six months period to determine clinical presentation, instrumental findings and outcome in 1246 consecutive ED patients who underwent head CT scan because of a mTBI in AOUI - Verona. 

Results: Patients inappropriately submitted to CT (thus not presenting any risk factor or clinical finding that would mandate taking scans) were 9,2% of  the totality , defining an overall 90,8% adhesion rate to our protocol. Sensibility of our protocol was 97,4% and specificity 10,4 %. First of all, we tested our protocol’s performance compared to the most notorious clinical decision rules: the Canadian CT Head Rule established a sensibility of 86,4% with a specificity of 40,1%, while the New Orleans Criteria proved respectively 98,3% sensibility and 6,4% specificity. These findings are in accordance with the few previous studies that directly compared this two rules outside the settings in which they were developed. Since guidelines provide clinical stratification of patient’s risk, by analysing ROC curves we could compare our protocol both to the NICE Head Injury guideline 2014 and to the Scandinavian Head Injury Management Guideline 2014: our protocol proved AUC = 0,74 while Scandinavian had AUC = 0,69 and NICE demonstrated AUC = 0,68 (p was <0,001 for all three). 

Conclusions: Our protocol proved good performances, both as a decision-making tool (compared to NOC and CCHR) that as a clinical stratification tool (compared to NICE 2014 and Scandinavian guidelines 2014). It only missed a few patients, and none of them had neurosurgical complications. This results are statistically significant, and consistent with a very sensitive tool, unfortunately with low specifity that is mostly due to the high number of CT requested. Additional tools are needed to obtain a more accurate selection of patients, in order to increase the specificity of our protocol without decreasing its sensitivity. Biomarkers could serve this purpose, if integrated into an effective clinical decision and stratification support tool as our protocol is.

Introduction: We compared the ECG exercise test and physical stress-echocardiography (ESE) diagnostic performance, in order to identify patients who were more likely to take advantage from the use of an imaging modality in a group of subjects presenting to the Emergency Department with chest pain.

Methods: Between 2008, June¹⁵ and 2013, December³¹, 612 patients with an episode of spontaneous chest pain or angina equivalent, non diagnostic ECG and negative cardiac necrosis markers were evaluated with ESE. Patients with inducible ischemia were admitted for further diagnostic assessment. Patients with a negative exam were discharged and later contacted by telephone in July 2014, to investigate the occurrence of new cardiac events.

Results: ESE demonstrated inducible ischemia in 104 patients, was negative in 488 and inconclusive in 20. Eighty (77%) patients with a positive test underwent coronary angiography: critical coronary stenoses have been evidenced in 68/80 (85%) patients; a percutaneous revascularization procedure has been performed in 39/80 (49%) patients. Among patients with a negative test, one only patient reported an ACS within one month (cumulative 1-month incidence of new events 1/612, 0.2%). We compared ECG exercise test and ESE results: among patients with a negative test, 38 (8%) demonstrated ECG modification or symptoms, but ESE was considered negative due to the absence of new asynergic areas at peak-exercise echocardiography. We compared the 38 patients with false positive test and the 450 patients with negative exercise ECG: the only significant difference was a more advanced age in the first group (65±13 vs 60±13 years, p=0.044) compared with the other subjects. Gender distribution (male gender, 61 vs 66%), prevalence of arterial hypertension (50 vs 55%), diabetes (13 vs 10%) and history of known CAD (26 vs 20%), baseline LV EF (63±12 vs 62±11%) and FPR score (3.0±1.6 vs 2.7±1.6, all p=NS) were similar in both groups.

We also compared exercise ECG and Str-T results among the 68 patients with a positive Str-t who showed critical coronary stenoses at coronary angiography: up to 32% of these patients did not show any symptom or ECG modification and were identified only for the development of new asynergic areas at peak stress echocardiography. Patients with symptoms and ECG modifications were significantly younger than patients with a negative exercise ECG (68±9 vs 72±6 years, p=0.016); we did not evidence any significant difference between the two groups in terms of gender distribution (male gender, 76 vs 73%), prevalence of arterial hypertension (63 vs 82%), diabetes (9 vs 18%) and history of known CAD (35 vs 55%), baseline LV EF (62±9 vs 59±9%) and FPR score (3.7±1.6 vs 3.4±1.5, all p=NS). Overall ESE prevented unnecessary further diagnostic assessment in 38 (6%) subjects and avoided a missed diagnosis of CAD in 23 (4%) patients.

Conclusions: ESE demonstrated an incremental diagnostic value over ECG exercise test, especially among elderly patients. 

Introduction: ESI triage system has been first applied by Wuerz et al. in USA in 2000. It is different from complaint-dependent classification methods and treatment priority of the patient is determined according to the sources to be consumed and vital signs. These vital signs for adults have 3 parameters including respiratory rate (RR), pulse (p) and oxygen saturation (SaO2).

Objectives: In the present study, we practiced ESI triage system with 7 vital signs including arterial blood pressure (BP), p, RR, SaO2, body temperature (BT), blood glucose (BG) and shock index (SI) instead of 3 vital findings, and we called this method is modified ESI (mESI). Results were compared with determine whether differences in efficacy and safety between the ESI with mESI.

Method: The present study was conducted prospectively and included the patients over 18 years of age with categories 3, 4 and 5 according to ESI triage score who referred Emergency Department Clinic of Konya Training and Research Hospital between 08.00 a.m. and 04.00 p.m. and September, 1st, 2014 and October, 1st, 2014.  Patients with category 1 and 2 according to ESI triage scoring, all trauma patients and brought to the emergency room with ambulance were excluded. All of our patients have evaluated by  the same three triage officer in our triage unit (triage officers consists of nurses, paramedics and emergency medical technicians and all received the education of ESI triage system ) and after looking their 7 vital signs , they all recorded according to ESI and mESI.

Results: Totally 4536 patients were involved into the study. Mean age of the patients was 36.4 (18-81). Number of male patients was detected 2143 (47.2%) whereas female patients was 2393 (52.7%). The most common complaints for referral to emergency department were throat pain (1560 patients-34.4%), headache (503 patients-11.1%) and abdominal pain (412 patients-9.1%).The most common diagnosis was upper respiratory tract infection in 1871 patients (41%). The other common diagnoses included myalgia in 545 812%) patients, acute gastroenteritis in 244 (5.4%) patients, acute bronchitis in 225 (5%) patients. 4271 (94.2%) of our patients were examined and treated as outpatients although 265 (5.8%) patients were hospitalized. In terms of identifying patients who need to be hospitalized between ESI with mESI , the ESI was detected statistically significant and effective according to mESI. ( ROC curve: area under the curve mESI:0.69, %95 confidence interval (Cl):0.66 – 0.71; ESI:0.753, %95 confidence interval (Cl):0.73 – 0.77; p ≤ 0.001 ) There are also statistically significant positive correlation was found between the 2 scoring system. ( cc:0.55, p ≤ 0.001 )

Conclusion: ESI triage system in three vital signs are sufficient and reliable method used to separate the 2 categories of patients only with 3.category. Searching more vital signs or searching vital signs for all patients with 3, 4 and 5 categories is unnecessary and time-consuming method.

CT pulmonary angiography for the exclusion of pulmonary embolism in a general hospital: is it overused?

A. Klijn¹, S. van der Voort²,^,F. Roodheuvel¹, D. Linzel¹, E. Bierdrager³, B. van der Maat⁴, M. ten Wolde²

Departments of Emergency Medicine ¹, Internal Medicine ², Radiology ³en Pulmonary Medicine ⁴, Flevohospital, Almere, the Netherlands

Background. In patients presenting with chest pain, pulmonary embolism is frequently considered in the differential diagnosis. The use of CTPA is guided by algorithms consisting of a decision rule (mainly the Wells rule) and D-dimer blood test. In spite of these algorithms, performance of a computed tomography pulmonary angiography (CTPA) to exclude the diagnosis of a pulmonary embolism (PE) seems the rule rather than the exception. This should be avoided because of long term complications due to radiation harm, irrelevant incidental findings, contrast induced nephropathy and unnecessary high charges. When these algorithms are inadequately used or passed by, CTPA could be overused. Aim. The aim of this study is to compare the percentage pulmonary embolism as final diagnosis after CTPA with the results expected in earlier studies using Wells criteria based algorithms. Subsequently, we investigated whether the algorithms were adequately used, and if not, whether a low percentage of positive CPTA could be due to no or inadequate use of the Wells score. Methods. All CTPA’s performed to exclude pulmonary embolism, between January 1^st and March 1^st 2013, were reviewed. Given a short amount of time these were the only data available. Additionally, clinical data were retrieved by review of medical records, containing the Wells criteria (hemoptysis, immobilization, signs of a deep vein thrombosis, deep vein thrombosis in patient history, heart rate>100, malignancy and PE is most likely diagnosis), way of referral, symptoms of dyspnea and pain related to breathing, D-dimer results. Results. CTPA’s of 90 patients were available. In 13 of these CTPA’s, PE was the final diagnosis (14.4%). In 26 (28.9%) of the cases no D-dimer was determined, which was justified in 8 (30.8%) of this cases because of a high Wells score. In only 4 (15%) PE was the final diagnosis. In 12 (46.1%) of the cases it was unclear whether D-dimer should have been determined or not, because not all Wells criteria were noted. Summary/conclusions. In contrast to earlier studies, in daily clinical practice in a general hospital, in only 14.4% of patients with suspected pulmonary embolism undergoing CTPA, pulmonary embolism was the final diagnosis. This is probably due to inappropriate use of current decision rules and D-dimer testing. In spite of the small database, the results were very surprising. There is a new protocol being used in the ER, containing three criteria and D-dimer to diminish CTPA’s in excluding PE. Results will follow in the near future.

Background For the diagnosis of pulmonary embolism (PE) doctors frequently use a clinical decision rule (CDR) comprising the Wells score for PE with or without D-dimer assessment. Literature suggests this CDR is often used in the wrong way or even not at all. It is unclear if there is a difference in usage between ‘regular patients’ and ‘tertiary patients’, and especially if the CDR is applicable in larger populations with, for example, hemato-oncologic diseases. This could affect outcome and have implications for current practice. Since the UMCG is a tertiary care facility and referral centre for, amongst others, patients with rare hematologic or oncologic diseases and transplanted patients (‘tertiary patients’), population differs from populations described in the literature. This setting allows to assess the use of the CDR for PE in a tertiary care facility and to compare this use in tertiary patients with other patient categories.

Method All patients that presented to the emergency department in 2014 in whom the diagnosis PE was considered were included. Data about Wells score for PE, D-dimer, diagnostic imaging and patient history was extracted from medical records. This data was then analyzed to assess the use of the CDR. To determine if the CDR was used we applied a ‘benefit of the doubt’ method, meaning that we assumed it was used when the Wells score was either documented or could be calculated with information from the medical record. The percentage of patients with the diagnosis PE was calculated for each possible outcome of the CDR (high/low Wells score and normal/elevated D-dimer) and compared with percentages found in the literature. We used the Chi² to determine whether differences were statistically significant.

Results Of the 240 patients in whom the diagnosis PE was considered, 49 were considered to be tertiary patients. The Wells score was documented in 117 patients overall. In 102 patients it was possible to calculate the Wells score with documented Wells items from the medical records. The CDR was used correctly in 189 patients overall, respectively in 156 out of the 191 regular patients (82%) and in 33 out of the 49 tertiary patients (67%) (p=0.029). The most documented reasons for disregarding the CDR were use of the age-adjusted D-dimer, risk of developing contrast nephropathy with CTA and lack of clinical consequence in demonstrating the existence of PE.

Conclusion Preliminary results suggest the correct use of the CDR was significantly less in tertiary patients (67 vs 82%). Analyses on the entire studypopulation will show if and how this affects the outcome of diagnostic imaging.

These are preliminary results. We expect to include a total of 800-1000 patients within the next month. Analyses on the presence of PE for each outcome of the CDR in regular and tertiary patients and subgroup analyses of the correct use of the CDR for different populations will follow in the entire study population.

Final results will guide recommendations for further, prospective research and possibly have direct implications for current practice.

INTRODUCTION: The optimal management of Community-Acquired Pneumonia (CAP) in Emergency Departments (EDs) is pivotal for the right access to hospital resources and to ensure proper management for every patient. Despite a relevant body of significant literature, several unresolved questions remain, namely related to the best definition of clinical severity, the most appropriate criteria for patient allocation, the value and usefulness of immediate microbiological tests and diagnosis, and the criteria for different treatment choices

MATERIALS AND METHODS: Prospective, multicentre cohort study, enrolling, for a period of 24 consecutive months, all CAP cases referred to 9 different EDs in Italian hospitals. For every included patient demographics and clinical data were recorded, and clinical severity was defined using and comparing three different well-known and widely used predictive rules

RESULTS: Of 1214 enrolled patients, 844 were admitted to hospital. Of these, the mean age was 64 years, and only 56.9% were over 65 years old. Nearly 50% of patients admitted had low scores of severity (as resulted by celinical severity system scores), but over 70% had one or more comorbidities. Overall mortality was 8.5%. Streptococcus pneumoniae was the most frequent etiological agent, but, globally, the yield of microbiological work up was scant (16%)

CONCLUSIONS: In a real-life study condition, predictive rules, who are known to be very attractive for prognosis, are not useful for clinicians in deciding on admission of a patient with CAP, mainly when compared with assessment of comorbidities and welfare conditions

Background/introduction: Acute pancreatitis (AP) is a common potentially lethal acute inflammatory process with a highly variable clinical course. AP progresses to a severe form in approximately 10-20 % of patients resulting in systemic inflammatory response syndrome, multiple organ failure and a prolonged hospitalization with significant morbidity and mortality. The aim of this study was to analyze if early changes in the serum concentrations of cytokines in peripheral blood of patients with acute pancreatitis can predict the outcome of this disease, especially in those patients who had lethal outcome.

Participants and method: We have conducted a prospective study which included 52 subjects who were admitted in Clinical Center Kragujevac, Serbia from October 2011 to July 2013. Serum levels of cytokines were measured using sensitive enzyme-linked immunosorbent assay (ELISA) kits. In all analyses level of statistical significance was set at alpha value of 0.05. The statistical analyses were performed using SPSS 13.0 software.

Results: The study enrolled 52 patients who were divided in interstitial form of acute pancreatitis (IAP) (65.38 % of patients) and necrotic acute pancreatitis (NAP) (34.62 % of patients) group. Serum levels of interleukins (IL) 6, 8 and 10, together with tumor necrosis factor (TNF)-alfa were determined on the 1^st and 3^rd day of hospitalization. Significantly higher values of IL-6, IL-8 and IL-10 were found on day 1 and 3 in NAP than in IAP. IL-6 was significantly higher on both days of measurement, while IL-10 on the first day and IL-8 on the third day were significantly higher in the group of patients who did not survive in comparison with patients who had interstitial form of AP.

Discussion/conclusion: Acute pancreatitis is no more considered only as a disease of the pancreas because there is strong evidence for systemic effects of the disease. We showed that early changes in serum cytokine profile could distinguish NAP from IAP and could also indicate lethal outcome. In the clinical setting, early diagnosis and, if possible, assessment of the prognosis of AP is a major interest for the clinician. Indeed, early aggressive treatment in patients who will develop necrotizing form of the disease could potentially change the outcome. In conclusion, the data from this study showed that immune suppression and excessive immune stimulation in the first three days after admission could indicate the development of NAP and potentially lethal outcome.

References:

1. Kylanpaa ML, Repo H, Puolakkainen PA. Inflammation and immunosuppression in severe acute pancreatitis. World J Gastroenterol 2010; 16: 2867-2872
2. Panek J, Kusnierz-Cabala B, Dolecki M, Pietron J. Serum proinflammatory cytokine levels and white blood cell differential count in patients with different degrees of severity of acute alcoholic pancreatitis. Pol Przeglad Chirur 2012; 84: 230-237
3. Li JP, Yang J, Huang JR, et al. Immunosuppression and the infection in patients with early SAP. Frontiers in Bioscience 2013; 18: 892-900

Acknowledgements:This study was partially financed by grant No III41010 given by Serbian Ministry of Education, and by the project No 13/11 of Faculty of Medical Sciences, University of Kragujevac, Serbia.

Background

Heart rate is a central component of many triage systems and early warning scores. It is heavily weighted as an indicator of the severity of the patient’s illness in some systems. The majority of these systems included heart rate as a result of clinical consensus, rather than from a strong evidence base; the value of heart rate alone in triage systems and early warning scores has not been reliably validated.

Objective

To determine whether heart rate alone is a reliable marker for severity of disease in a population presenting to a paediatric emergency department.

Methods

A prospective observational study was conducted in a paediatric emergency department with the heart rates and ages of patients with non-traumatic presentations being recorded at attendance. Abnormal heart rate was investigated as a prognostic indicator for severe disease. An abnormal heart rate was defined using the current Advanced Paediatric Life Support (APLS) reference ranges and those of a recent meta-analysis reviewing normal age-specific paediatric heart rate by Fleming et al. (2011). The need for hospital admission for inpatient treatment was used as a surrogate outcome measure for severe disease.  Data from 540 children were analysed after the application of relevant exclusion criteria. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and the area under the receiver operating characteristic (AUROC) curve were calculated.

Results

Abnormal heart rate as determined by the APLS reference ranges had sensitivity = 0.52, specificity = 0.65, PPV = 0.28 and NPV = 0.83 for predicting admission. The 1%-99% centile ranges of the meta-analysis showed sensitivity = 0.44, specificity = 0.72, PPV = 0.29 and NPV = 0.83. The 10%-90% centile ranges of the meta-analysis showed sensitivity = 0.64, specificity = 0.48, PPV = 0.25 and NPV = 0.83. The 25%-75% centile ranges showed sensitivity = 0.84, specificity = 0.32, PPV = 0.25 and NPV = 0.88. The AUROC curve of data plotted using the meta-analysis cut-off centiles was 0.61 units squared.

Conclusions

The results of this study indicate that the sensitivity and specificity of heart rate alone limits its use as a reliable predictor of disease severity. It is important to emphasise that heart rate does have a valuable role to play within clinical assessment of presenting patients. However, relevant literature and the results of this study do not support the current weighting of heart rate within some early warning scores and triage systems.