Sunday 02 October
08:00

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PC9
08:00 - 12:30

Pre-Course 9 - Acute Pain Management (Half day)

Pre-Course Director: Fabio DE IACO (Chief) (Pre-Course Director, Imperia, Italy)
Two main objectives:
- To lead the clinician toward choices that must be mindful, appropriate and effective,
- To create a patient-centred environment also in the Emergency setting

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PC11
08:00 - 12:00

Pre-Course 11 - Airway Workshop (Half day)

Pre-Course Director: Sabine MERZ (senior consultant) (Pre-Course Director, Villingen-Schwenningen, Germany)
Airway Management is a major topic in the Emergency Department. Anesthesiologists are not always available; therefore each member of the ED needs to be able to perform Airway Management. To secure the airway of a patient, it is necessary to know the different devices and techniques and also to consider, that the algorithm is different to the familiar pre-hospital and OR airway algorithm.

In this course, participants will learn about basic and difficult Airway Management. Furthermore, the technique of anaesthetization will be taught.

All participants will be able to train the different techniques and devices on intubation trainers.

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PC12
08:00 - 13:30

Pre-Course 12 - ECGEM (Half day)
The European Course on Geriatric Emergency Medicine

Animators: Jay BANERJEE (Animator, Leicester, United Kingdom), Pr Christian NICKEL (Vice Chair ED Basel) (Animator, Basel, Switzerland), Fredrik SJOSTRAND (MD PhD) (Animator, Gustavsberg, Sweden)
Pre-Course Director: Pr Abdelouahab BELLOU (Director of Institute) (Pre-Course Director, Guangzhou, China)
Overall objectives:
1- To be familiar with the concept of Geriatric Emergency Medicine (GEM).
2- To be familiar with the management of common and atypical clinical presentations of older patients in the ED.
3- To learn how to use comprehensive geriatric assessment in the ED.
4- To be familiar with ethical issues in older patients managed in the ED.

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PG6
08:00 - 12:00

Pre-course PG6 - DGINA (Half day)
DGINA Führungsakademie: Führung- und Prozesskompetenz in der Notaufnahme

Invited speaker: Michael WUNNING (Invited speaker, Hamburg, Germany)
Pre-Course Director: Sebastian BENKHOFER (Pre-Course Director, Germany)
Workshop für leitende Mitarbeiter (Ärztinnen und Ärzte & Pflegeleitungen) in der klinischen Notfallmedizin.
08:30

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PC10
08:30 - 12:30

Pre-Course 10 - The 12-Lead ECG (Half day)
and Acute Myocardial Infarction: Improving Your Interpretation Skills

Pre-Course Director: Jerry W. JONES (Pre-Course Director, USA)
The objectives of the pre-course are:

1. To be able to recognize subtle changes in the 12-lead ECG that are highly suggestive of acute ischemic episodes or actual myocardial infarction (ST deviation in aVR, inverted U waves, axis shifts)

2. To understand the difference between “reciprocal changes” and “ischemia at a distance”

3. To improve the recognition of “STEMI-equivalents”

4. To learn why some acute MIs are not always visible on the 12-lead ECG: cancellation of forces, electrically silent areas

5. To increase familiarity with new revelations regarding the true location of infarcting areas and the complexities of the vascular supply to the various areas of the heart

6. To increase knowledge of certain conduction disturbances that are classically associated with particular infarctions

7. Becoming more familiar with acute MI confounders: left ventricular hypertrophy, early repolarization, Takotsubo cardiomyopathy
11:00

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EPOSTERS
11:00 - 18:00

EPOSTERS

11:00 - 18:00 #7088 - "e;Yound patient with right sided blindness: a case report"e;.
"e;Yound patient with right sided blindness: a case report"e;.

“Young patient with right sided blindness: a case report"

 Authors: [1] Dr. Srikrishna Vempaty, [1] Dr. Mahdi Alosert, Dr. Dan Ghiurluc,

 Sources: Hospital records.

Keywords: Periorbital swelling, Orbital compartment syndrome, Orbital USS.

Method: electronic engine research using Pubmed, Embase and Medline databases.

 Introduction:

Orbital Ultrasound [USS] provides quick and non-invasive evaluation of the orbit. It allows the clinician to assess structures that may not be visible with routine ophthalmic examination of the swollen eye when swelling makes direct visualisation difficult.1

 

The use of ultrasound is well established in localisation and characterisation of orbital lesions, it provides a detailed cross sectional anatomy of the entire globe with excellent topographic visualisation and real time display of the moving organ.2

 Although this is a routine procedure, missed ocular pathology could be detrimental to a patient’s vision. Gross swelling of the Peri-Orbital tissues can make examination of the eye difficult.

 

Case:

28-year-old male, has no significant past medical history. Attended our emergency department [ED] for right orbital swelling, redness and pain. Symptoms developed 48-hours post right maxillary sinus elective polypectomy. 

 

After a thorough physical examination by the ED and ENT teams, a management plan has been established to treat it as post-operative peri-orbital/ orbital cellulitis for inpatient IV antibiotics. ED bedside orbital USS showed “Pre-septal and orbital collections with sonographic hyperaemia suggestive of orbital cellulitis”

 He remained clinically stable, waiting having orbital CT-scan and joint-assessment by ophthalmology team. 3 hours after the 1st ED bedside-orbital-USS, he developed right-sided blindness that required a 2nd ED bedside-orbital-USS [by the same operator] which revealed “a significant retrobulbar collection in comparison with the previous orbital USS”  

He was moved to the resuscitation-area where an emergency lateral-Canthatomy under local anaesthesia has been done then he was transferred to theatre for further surgical management as orbital compartment syndrome.

 Discussion:

Ten patients presenting to ED with peri-orbital swelling were assessed using bedside-USS. They included patients with trauma, retrobulbar haemorrhage and Peri-Orbital cellulitis. Two patients were diagnosed with retrobulbar pathology, one with retrobulbar haemorrhage and another with a retrobulbar collection. Post-treatment and follow up scans were used to monitor progress. The remaining patients had preseptal cellulitis and orbital floor fractures. These motion scans were recorded and analysed.

 Conclusion:

Assessment and diagnosis of orbital pathology is both clinical and radiological. Acute retrobulbar pathology may not allow the luxury of time to organise computed tomography. This non-invasive procedure could be performed by ED doctors and frontline maxillofacial doctors following adequate training. Bedside-Orbital-USS is helpful in detecting and addressing ocular pathology. Use of ultrasound as an immediate investigation in the ED will help delineate and rationalise the treatment planning.

 

 

References:

 

1        Kendall CJ, Prager TC, Cheng H, Gombos D, Tang RA, Schiffman JS. Diagnostic Ophthalmic Ultrasound for Radiologists. Neuroimaging Clin N Am. 2015 Aug;25(3):327-65

2         Nagaraju RM, Gurushankar G, Bhimarao, Kadakola B. Efficacy of High Frequency Ultrasound in Localization and Characterization of Orbital Lesions. Journal of Clinical and Diagnostic Research : JCDR. 2015; 9(9):TC01-TC06.


Mahdi ALOSERT, Srikrishna VEMPATY, Dan Lucian GHIURLUC (London, United Kingdom)
11:00 - 18:00 #7092 - 10-point plan to increase patient safety in A&E departments.
10-point plan to increase patient safety in A&E departments.

10-point plan to increase patient safety in A&E departments, particularly for geriatric patients - directly integrated SOPs and other procedures for each patient.

Agatharied Hospital, in Germany, has significantly improved A&E patient safety by successfully implementing the 10-point plan. The hospital’s primary care unit deals with 27,000 patients per year, with the largest age group being 70 to 79 year olds. The review and optimisation of processes and the implementation of supporting software using the 10 point plan, have resulted in improved patient safety, including areas such as the timely detection of a heart attacks to early identification of geriatric patients.
The measures taken related to both structural and technical and changes. The measures were developed in collaboration with the company ClinPath, and the SOPs and other procedures were integrated with the new software ERPath (ClinPath’s A&E Patient-management Software). The 10 points were directly integrated and implemented in the software’s pathway solution, based on patient-oriented diagnosis of symptoms and treatment pathways. The system is now deeply integrated into the A&E department’s workflow processes and the hospital’s IT infrastructure, including API’s to relevant systems.
The following 10 points were implemented:
1.) Issue: Undetected levels of treatment urgency
2.) Issue: Insufficient patient documentation
3.) Issue: Forgotten treatment steps or unknown side diagnosis
4.) Issue: Lost or forgotten patients in case of overload
5.) Issue: Uncertainty in the on-boarding of new employees
6.) Issue: Needs of elderly patients are missed under stress
7.) Issue: Medication errors due to misinterpretation of handwritten documentation
8.) Issue: Lack of use of SOPs/guidelines and uncertainty about the up-to-dateness of these
9.) Issue: Mortality and morbidity planning and management - lack of case discussion
10.) Issue: Resource scarcity during unpredictable peak loads


Bernhard FLASCH (München, Germany)
11:00 - 18:00 #7420 - 1000 consecutive ultrasound examinations in the emergency department: Indications, performer and documentation quality.
1000 consecutive ultrasound examinations in the emergency department: Indications, performer and documentation quality.

Background: 

Ultrasound is an important tool in the emergency department (ED), which is already highly integrated in the routine work in the ED. Similar to other emergency departments, the implementation of new ultrasound techniques for different clinical questions is increasing constantly. Continuous medical education for advanced ultrasound techniques seem to be very high among emergency physicians. Data about the exact number of different examinations are lacking as well as indications, quality of documentation and level of experience of the performer.

Methods: 

We collected the data of 1000 Patients retrospectively, who received one or more Ultrasound-Exams during their stay in our ED. We analyzed the documents with regard to the number of certain exam techniques, the quality of documentation and performance.

 

Results: 

In 1000 Patients who received ultrasound in the ED we could identify 1169 different exams. Especially, critical ill Patients receive up to 5 different exams like echocardiography, abdominal sonography, Doppler sonography, etc..

Abdominal Ultrasound contributed to 59,4%, lung ultrasound, venous duplexsonography as well as the focused Echocardiography to 8,5-11,4%. EFAST and ultrasound of fractures (including the ribs) with 3,6 and 4.8%, respectively, are also common procedures. The remaining exams consist of Ultrasound of Soft tissue, Arteries, Cerebral vessels, eyes and a singular area of Interest like assessing urinary stasis. 

Conclusion: Ultrasound Exams in the ED consist of a wide field of target areas. We showed that nearly every field of interest reachable by ultrasound is covered in our department, and sometimes even the bodyparts considered impenetrable by ultrasound like the lungs or bones. Improving quantity of ultrasounds in the ED via standardized and simplified documentation seems prudent and because of the wide range of possible implication, ultrasound should be more promoted and standardized in emergency medicine education, since our data show a very inhomogenous use of this tool.


Felix LORANG (Erfurt, Germany)
11:00 - 18:00 #8134 - 3-year review of unexpected deaths in a tertiary care emergency department: opportunities for improvement.
3-year review of unexpected deaths in a tertiary care emergency department: opportunities for improvement.

Introduction. The emergency department (ED) is a bustling, chaotic environment creating a milieu that poses a serious risk to patient safety. While clinical deterioration needs to be recognized early, supported by a timely response to optimize clinical outcomes, ED boarding places patients in a vulnerable position where the emergency physician (EP) may not be familiar nor the most responsible physician, thereby creating an error-producing perfect storm when called to the bedside of critically ill, deteriorating patients. We sought to describe ED deaths of patients who were stable upon ED presentation as part of a larger quality improvement and patient safety “code resuscitation” initiative.

Methods. A 3-year (March 2013-March 2016) retrospective review of deaths in the ED was conducted at a single, tertiary care centre. Patients were identified through the Emergency Department Information System. Inclusion criteria were: >18years, Canadian Triage Assessment Score (CTAS) 2-5 at presentation, non- and boarded admitted patients in the ED with a departure location of morgue. CTAS 1 was excluded as these represent the most unstable population requiring immediate resuscitative efforts. Clinical, demographic and administrative data were extracted with 10% of charts independently reviewed by a staff Emergency Physician for inter-rater reliability. Outcomes were time-based from triage.

Results. 38 cases met criteria, 35 were assessed by an emergency physician and 3 were direct to service. Mean age 80.8 years (53-99), 22 (58%) males, 34 (89%) arrived by EMS. 37 (97%) were CTAS 2 with 34 (89%) triaged to “major” clinical treatment area. From triage, mean time to RN Assessment was 0:24hr (0:00-2:53hr) and EP Initial Assessment was 0:56 hr (00:00-5:22hr). Code status was documented in 36 (95%) charts: full code (6, 16%), DNR (30, 79%). 25 cases (66%) had a consult, with 14 (56%) having one consult, 9 (36%) two consults, and 1 (4%) had 3 consults. GIM (n=11, 44%) was most common initial consult service; 5 (20%) had ICU as their first consult, and 3 (12%) as second consult. 27 (71%) were admitted to a service at time of death in the ED, in which EPs documented being called to bedside for peri- or arrest care. Average time-to-death (ED LOS) was 6:05hr (0:45-22:00hr).

Discussion. Early recognition, timely response and optimal management of acutely, deteriorating patients is paramount in determining outcome. Despite a significant amount of work developing rapid response systems to improve morbidity and mortality in a variety of settings and support early identification for those at risk of clinical deterioration, none have been shown to be effective in the ED. While developing interdepartmental processes to support patient flow is fundamental to address ED boarding, implementing a protocol-driven system for goal-directed intervention through a "resuscitation huddle" in the ED has the potential to mobilize multidisciplinary resources and care earlier in the clinical course thereby potentially impacting mortality.


Melissa MCGOWAN (Toronto, Canada), Conor LAVELLE, Alina TOMA
11:00 - 18:00 #7278 - A 16-year old girl with impaired vision and instable gait.
A 16-year old girl with impaired vision and instable gait.

Introduction

Dietary supplements may cause adverse events but are usually not listed on the patient’s medication list.  The current case report emphasizes the importance of asking about  these products.

Case report

A 16-year old girl presented to the emergency department with impaired vision, impairment of perception of depth and instable gait. She also complained of nausea, vomiting and abdominal and thoracic pain. 

She was currently treated for a (classical) Hodgkin lymphoma  with chemotherapy (ifosfamide, carboplatin and etoposide). Her current medication consisted of fluconazol, alizapride, lormetazepam and pantoprazol.

Clinical examination revealed a nervous girl who was giggling a lot. She was tachycardic (123 bpm) with a  normal blood pressure (140/74 mmHg). Her body temperature was normal (36.3°C) and oxygen saturation was 99%. On auscultation we found normal bilateral breath sounds. She  presented with a dry skin and conjunctival injection. Her walking pattern was unstable and she had difficulty maintaining her balance without signs of lateralisation. There were no coordination problems, but an ataxic gait was present.

A routine blood exam, an electrocardiogram  and urine toxicology screening were obtained. 

A history taken from the parents revealed that her last chemotherapy session was four days earlier after which she had complained of muscle ache (as usual). To relieve the pain, the patient’s mother had given her some drops of a herbal medicine she had ordered on the internet. A friend had advised her to buy this claiming that it would be highly effective in substituting minerals in patients undergoing chemotherapy. We were able to trace the  drops back to a Spanish company “Terapeutico Dandelions”. They consisted of an oily solution of  TCH (tetrahydrocannabinol) and CBC (cannabichromene), both derivates of cannabis. The company profiles itself as a 'naturalist shop' and promotes several drugs containing cannabis.

The results of the  technical examinations revealed no infection and no liver or kidney impairment. The electrocardiogram  was normal. Urine toxicology screening confirmed the diagnosis of acute cannabis intoxication.

Literature key points

A recent study estimated that in the United States 23000 emergency department visits per  year may be attributed to adverse events related to dietary supplements. Another study showed that nearly one in five young adults reported using dietary supplements.   Furthermore,  physicians do not ask after dietary supplements when performing a patient’s history. 

Conclusion

We report an accidental cannabis intoxication in a young girl caused by a dietary supplement. In a world where everything can be bought online without patients realizing what they are buying, emergency physicians need to remain  vigilant and ask their patients actively about any substitutes or food supplements taken. It is important to thoroughly  check the composition of  these supplements.


Evi VAN DEN KERCKHOVE (Edegem, Belgium), Sabine LEMOYNE, Koen MONSIEURS
11:00 - 18:00 #8159 - A bite which went a bit too deep! ; A case report.
A bite which went a bit too deep! ; A case report.

Introduction:

Animal bites are common presentations to the Emergency Department. Commonly anticipated complications of animal bites are infections; here we present patient with severe necrotising fascitis caused by a rat bite 

Case Report:

A 25 year old man presented to Emergency department with pain, swelling and two distinct rashes on his forearm. He was previously healthy with no significant medical history. He gave history of being bitten by a rat couple of days prior to the presentation. He also complained of severe lethargy.  

On examination he had an abrasion surrounded by erythema over lower end of his fore arm. There were two distinct vesicular rashes over the ante cubital fossa and over the right nipple. The whole arm was grossly swollen limiting movements at elbow and wrist joints. The patient was septic from the infection.

Labs showed acute neutrophilia. Ultrasound with doppler studies of the arm were performed . It showed two haematomas in relation to the Brachio-radialis muscle causing compression of the radial vein. An MRI of the fore arm proved necrotising fasciits deep to the interosseous membrane with muscle necrosis and ischaemia. The patient was treated with Intravenous antibiotics and surigical debridement. He later had a skin graft and recovered satisfactorily.

Necrotoisng fascitis is a uncommon but severe complication of bites. Clinical suspicion and early agressive management is the key to get good results.

 


Ashid KODUMAYIL, Benseena KUNHIMON, Lupe Del Rocio CORONEL CHUMBI (MURCIA, Spain)
11:00 - 18:00 #8021 - A case of cerebral vein thrombosis.
A case of cerebral vein thrombosis.

Background: Cerebral vein and dural sinus thrombosis is less common than most other types of stroke, but can be more challenging to diagnose. Of all cerebral sinus thromboses, 5 to 20 % occur in connection with pregnancy or childbirth, or during the puerperium. The risk is highest during the first month following delivery.

Case presentation: A 23-year-old female patient with no history of illness was admitted to our hospital by ambulance after experiencing near syncope. Her blood pressure was 130/70mmHg, her pulse 76/minute, her oxygen saturation 99% and her fever 36.3 degrees Celsius. She had a Glasgow coma scale score of 15. One day before she had experienced loss of motor function on her right side. There was no evidence of pathology in her physical examination. She was only complaining about headache and weakness. One week before she had had a Caesarian section and she was now breastfeeding. Her blood panel and biochemical parameters were normal. There wasn’t any pathology in her cranial computed tomography. As a generalized tonic clonic seizure occured during her hospital monitoring, diffusion weighted magnetic resonance imaging was applied, and a diffusion limitation was detected on the left precentral gyrus. Because of the atypical localization, sinus venous thrombosis was considered as a prediagnosis. The Neurology Department was consulted and the patient was interned. The MR venography conducted in the Neurology Department showed no flow in the left vein of Trolard or in the superior sagittal vein.

Conclusion: In a postpartum patient with seizures, CVT should be considered as a differential diagnosis. Due to the widespread use of diffusion weighted magnetic resonance imaging in the Emergency Department, it is possible to detect and diagnose CVT early, which can be lifesaving for the patient.

 

 


Incifer KANBUR, Behlul BAS (istanbul, Turkey), Sila SADILLIOGLU, Hakan TOPACOGLU
11:00 - 18:00 #7267 - A case of dysarthria caused by Ricinus Communis tea.
A case of dysarthria caused by Ricinus Communis tea.

The castor oil plant, Ricinus communis, is a perennial scrub of the spurge family Euphorbiaceae. R.communis probably originates from Africa. Nowadays the plant grows wild in tropical and subtropical regions. Castor seeds are a rich source of oil which can be used as an inexpensive fuel for oil lamps and industrial raw material for lubricants, paints, coats and cosmetic products. Ricinus communis is considered to be less toxic in humans. The majority of intoxications were due to direct ingestion of seeds and the most common complaints were vomiting, diarrhea, abdominal pain, and dyspnea in general. But poisoning by water extracts of R. communis with neurologic symptoms have not been reported in the literature so far. Here we report a case of dysarthria caused by drinking tea brewed with R.communis in a 82-year old woman with manifestations of dysarthria. Water extracts of R.communis can cause toxicity and may cause neurological symptoms.


Pr Han Sung CHOI (Seoul, Korea), Seo Kyong LEE, Junsoo SEOK, Kyounghwan KIM, Hyeonsong KIM, Sungkyoo KIM, Young Gwan KO, Seok Hoon KO, Hoon Pyo HONG
11:00 - 18:00 #7493 - A case of minitracheostomy for post of tracheostomy patient.
A case of minitracheostomy for post of tracheostomy patient.

Back ground . From the point of view for stenotic  change of trachea, cricothroyd puncture,such as minitracheostomy  is forbidden for posttracheostomy patient. However, we could  safely performed minitracheostomy under observation of bronchoscopy . Case 37-year old male.  He complained dyspnea,so he transferred to our emegency department. he underwent tracheostomy ,when he was 16 year-old due to cervical spinal cord injury.His ADL(activity of daily life)demonstrated ASIA(American Spinal cord Injury Association) impairment scale A (cervical 5 level).In daily,he moved by wheel chair.This time,he admitted due to bacterial pneumoniae. He underwent intubation due to worsening of poor excetion of sputum and hypoxia. Accidentally,the patient removed tracheal tube himself  after  5 day later, and he could not enoughly breath spontaneously without suctioning. But the patient will not allow us conventional tracheostomy or re-intubation,because he want to speak anytime.in contrast of his willness,on the day 7th ,due to severe hypoxia, we had to intubate him.There is no standard guidelines concerning the indications, index of the intubation and extubation of this case.From the view of his willness,  Cricothroyd puncture as minitracheostomy has not recommended after tracheal  surgical procedure.But, this time ,we performed minitracheostomy safely under observation of bronchoscopy.On the day 13th,he could transferred to general ward,on the day 60th,he discharged.Discussion .There was no  complication of minitracheotomy. We may consider minitracheotomy for airway management after anterior cervical surgical within 2 weeks.Summary .From point of the view of airway management and vocal communication, we consider it may be useful that minitracheotomy for airway management afte r tracheostomy. Further study is needed.


Maeda YUJI, Kurihara MAKI (Kobe, Japan)
11:00 - 18:00 #7935 - A case of Myocarditis presenting with Hyperventilation.
A case of Myocarditis presenting with Hyperventilation.

Introduction:

Hyperventilation syndrome is a relatively common emergency department (ED) presentation in which minute ventilation exceeds metabolic demands. It is associated with a wide range of symptoms without a clear organic precipitant. Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentations, from subtle to devastating. It is caused by a wide variety of infectious organisms, autoimmune disorders, and exogenous agents,

Case report:

A 37 year old Egyptian lady who was 12 weeks pregnant presented to the ED with sudden onset of hyperventilation and chest discomfort. She also complained of numbness in the limbs but denied any other complaints. Clinically, she appeared well and her vitals were stable. Examination of heart and lungs was normal. ECG show normal sinus rhythm and ABG showed signs of hyperventilation (PH 7.54, PCO2 23mmHg, HCO3 20mmol/L and SaO2 99%). Chest x-ray was normal and bedside Echo did not show evidence of myocardial dysfunction, valvular abnormalities or massive pulmonary embolism. Troponin T was 426ng/L (normal < 30ng/L).

Discussion:

Diagnosing myocarditis is challenging in view of its varied presentations. There is no definite clinical feature that is diagnostic of myocarditis. It is typically seen in patients around age of 20-50 years and the variability in presentation reflects the variability in histological disease severity, etiology, and disease stage at presentation. Many cases go undetected because they are subclinical or present with nonspecific signs. Patients of myocarditis usually present with mild symptoms of chest pain, fever, sweats, chills, and dyspnea secondary to heart failure. This is a rare case where patient presented with shortness of breath which was not secondary to heart failure but only showed signs of hyperventilation of clinical examination and ABG.

Conclusion :

Emergency physicians treat young patients who present with shortness of breath secondary to hyperventilation/psychogenic dyspnoea. A high degree of suspicion is needed to diagnose myocarditis which can occasionally present with atypical symptom like hyperventilation.


Dr Amar SATYAM (Singapore, Singapore), Sohil POTHIAWALA
11:00 - 18:00 #7329 - A Case of Rheumatoid Arthritis and Multiple Myeloma.
A Case of Rheumatoid Arthritis and Multiple Myeloma.

Clinical case report

 

A 77-year-old female with sero-positive erosive rheumatoid arthritis (RA) presented with a one month history of fatigue, night sweats, nocturnal pruritis and spontaneous bruising with bleeding gums.  She denied weight loss, fever, epistaxis, haemoptysis, haematuria or recent infection. She was diagnosed with RA in 1985, on treatment with Methotrexate and Etanercept and her RA was in remission with no swollen and no tender joints.

On examination, she had a non-blanching, petechial, non-palpable, pruritic rash affecting her face and neck.  There was no hepatosplenomegaly or lymphadenopathy.  Vital signs and general examination were unremarkable.

Her routine bloods showed a normocytic anaemia (Hb 92g/l) and a new acute kidney injury (creatinine 249 µmol/L). White cell count, platelets and calcium were normal. Her CRP was normal but ESR had risen to 55mm/hour. She had significant proteinurea of 3g/l with no microscopic haematuria. Further blood tests revealed normal haematinics, fibrinogen and complement levels. An ultrasound of the abdomen was normal.

History and investigation suggested a paraprotenemia as the differential diagnosis. A myeloma screen identified an IGA lambda paraproteinemia with immunoparesis and raised B2 microglobulin. A skeletal survey was normal. She had a bone marrow trephine biopsy which demonstrated lambda restricted neoplastic cells consistent with a diagnosis of multiple myeloma. She was diagnosed with multiple myeloma and a myeloma kidney and started on dexamethasone, allopurinol and bortezomib. She responded well and her renal function recovered fully.

 

Discussion

It is well recognised that patients with RA are at increased risk of developing lymphoma. So does RA increase the risk of developing multiple myeloma? A meta-analysis of 18 studies has shown that RA does not increase the risk of developing Multiple Myeloma.  Furthermore, is the RA treatment including biologic therapy a risk for multiple myeloma? A meta-analysis of 63 randomised controlled trials showed that the use of biologics does not increase the risk of malignancy.

 

 Conclusion and learning points

 

This case demonstrates that we should be cautious of ascribing symptoms to the chronic inflammatory disease as it is easy to attribute symptoms of lethargy and anaemia to a flare of the RA. Listening to the patient is of paramount importance and this lady was adamant that her symptoms were not due to a flare of the arthritis but a new condition. Pattern recognition is important as the new acute kidney injury and the lack of RA disease activity suggested a new disease process was occuring and prompted further investigation.

This case illustrates that diagnosis of myeloma is not straightforward especially on a background of chronic inflammatory disease. The new acute kidney injury suggested a new pathological process and a diagnosis of multiple myeloma was made with the patient making a good recovery.

References

1) Shen K, Risk of multiple myeloma in rheumatoid arthritis: a meta-analysis of case-control and cohort studies. Plos one, 2014, 9(3)

2) Dommasch BA, Is there truly a risk of lymphoma from biologic therapies? Dermatologic therapy, 2009, volume 9, p418-430

 

 

 

 

 

 


Rushabh SHAH, Raajul SHAH (London, United Kingdom)
11:00 - 18:00 #7413 - A CASE REPORT: KOUNIS SYNDROME, HEART ATTACK CAUSE.
A CASE REPORT: KOUNIS SYNDROME, HEART ATTACK CAUSE.

47-year-old male with sudden onset severe abdominal pain after the ingestion of food. Profuse sweating, strong weakness, distal coldness and feeling of dysthermia. No nausea or vomiting. He denies chest pain.

Does not have medicine allergy or cardiovascular risk factors except smoking.

 

Physical examination:

 

Vital signs: BP: 60/40 mmHg, 99 bpm, Temperature: 36.7ºC

Conscious and oriented. Eupneic. Paleness with sweaty skin. Erythema in thorax with wheal skyn lesions.

Cardiopulmonary auscultation without pathological data.

The abdomen is soft, depressible, pain to hypogastrium palpation without peritoneal irritation signs. No hernias.

 

Complementary tests:

 

-       ECG: Sinus tachycardia of 103 bpm without data of interest.

-       Chest x-ray: whitout significant radiological findings.

-       Blood test: slight leukocytosis (16100) with predominance of neutrophils (81.8%), the rest of the hemogram is normal. Biochemistry: hyperglycemia (221) and slightly increase of Troponin I up to 0.23 (normal: <0.06).

 

 

 

Differential diagnosis:

 

In a clinical diagnosis compatible with shock we value different causes: hypovolemic, cardiogenic, obstructive or distributive.

The anaphylactic shock (distributive) is produced by the mast cells release, of sudden appearance, is characterized by low blood pressure, skin rash, urticaria, bronchospasm and digestive symptoms such as pain, vomiting and diarrhea.

 

Evolution and Discussion:

 

Initially treated with serum-therapy and administering of 0.5 mg of adrenalin improving clinically with BP 130/80 mmHg and rash disappearance.

 

Second Troponin of 0.46 (↑) again, reason for which suspected Non-ST-Elevation Miocardial Infraction (NonSTEMI) in the context of anaphylactic shock initiating treatment with dual antiplatelet therapy, and was admitted to hospital to complete the study: Normal Echocardiogram and coronary angioplasty without injuries in the coronary arteries. Obtained values of positive Tryptase and lgE specific for Anisakis. The final diagnosis was Kounis syndrome type I.

 

The Kounis syndrome is the simultaneous appearance of acute coronary events and anaphylactic allergy reactions. Through histamine and leukotrienes on smooth muscle can cause the onset of vasospastic angina.

 

Two subtypes I and II are distinguished: without coronary disease and with atheromatous coronary artery disease, respectively. A Type III postulates for patients with stents thrombosis produced by mast cells and eosinophils.

 

The diagnosis is clinical by the presence of signs suggesting an allergic reaction and a coronary event simultaneously. There are no pathognomonic tests and in case of suspicion of it, we must carry out: EKG to assess ST alterations in relation to vasospasm, blood test with Troponin and tryptase levels. Echocardiogram and cardiac catheterization allow to complete the study.

 

It should be noted that many of the drugs used separately in anaphylaxis or in ACS can present contraindications when both episodes appears simultaneously. The adrenalin that can aggravate ischemia of ACS and induce vasospasm. The drugs used in ACS can aggravate anaphylaxis: acetylsalicylic acid cause drug allergic reactions, nitrates are contraindicated in hypotension and tachycardia, and morphine can give rise to mast cell degranulation.

 

Kounis syndrome is infrequent and probably under-diagnosed. Unawareness can cause undesirable effects for the prognosis and evolution of patients that suffer it in case of present interactions between different drugs used in their treatment.


Sergio AZNAR (GUADALAJARA, Spain), Vanessa HERAS, Ezra Honan ROIZ, Gema ESTEBAN, Cesar BRIEGA, María Isabel CARRASCO, María José JIMENEZ
11:00 - 18:00 #7302 - A child's adventure in A and E.
A child's adventure in A and E.

A  guidebook to the children’s emergency department written for children by children

          

I am an emergency medicine consultant based in an inner city hospital which sees approximately 16 000 children/yr.

 

Most children’s experience of hospital is either of or involves the Emergency Department.

 

We have a general assumption that children may find these visits stressful. However I felt that it would be interesting to explore what they really thought and felt about the department and to explore what their hopes, fears and expectations were.

 

Also , due to its nature, visiting an emergency department is unplanned and unpredictable. We decided to create a guide to prepare both children and their parents for what they might expect or encounter.

 

I worked with children from Grafton primary school, their writer in residence Diane Samuels and artist in residence Tessa Garland.

 

Diane and I had sessions with the children during which they asked me anything they wanted to know and they also visited the department. They each selected an accident which they acted out in their drama class. Following this they attended and we role played the management they would receive including waiting.

 

Throughout they were encouraged to write about everything. From this large body of ‘raw work’ they selected what they wanted to tell other children. They wanted a booklet which had a magazine/comic feel to it.

 

They worked with artist Tessa Garland on the illustrations and also selected the layout design, font type etc with graphic designer Alex Anthony.

 

The result , A Child’s Adventure in A + E , is a guide book written for children by children.

 

During their time with us they became experts in the department having experienced it in a very real way. They noticed a variety of things which had previously escaped myself and other staff members or saw things from a whole different perspective. All of which has been captured in a ‘ Child’s Adventure in A + E ‘

 

I feel that this project gave us a very interesting insight into the experience of the department from a child’s perspective. Similarly in producing the booklet the children have captured this information in a fun format which will appeal to other children and hopefully improve their experience of the hospital.

Also most children’s experience of hospital is via the emergency department which, by its nature, is unplanned ; very little information/literature exists to prepare children for this experience.

 

The poster shows highlights from this guidebook all of which are the children’s own words and drawings.

 

       

          

 

 

 


Dr Heidi EDMUNDSON, Louise BROWN (London, United Kingdom)
11:00 - 18:00 #8156 - A crucial case of surgical emergency in Aragon-Spain : idiopathic spontaneous hemoperitoneum.
A crucial case of surgical emergency in Aragon-Spain : idiopathic spontaneous hemoperitoneum.

Intraperitoneal bleeding is common in patients with abdominal trauma or in those with benign gynecologic diseases, but it is very rare to occur spontaneously. The purpose of this communication is to report a female patient with idiopathic spontaneous hemoperitoneum (ISH). Case presentation: A 28-year-old patient was admitted with 12-hour acute abdominal pain. Laboratory tests upon admission showed: Hb 9.0 g/dL, WBC 8.9 x 109/dL and negative immunologic pregnancy test. The ultrasound showed free intraperitoneal fl uid. She underwent exploratory laparoscopy with fi ndings of massive hemoperitoneum, which was resolved and, after a thorough exploration of the abdominal cavity, no evidence of the bleeding site was found. She was closely followed-up for 2 years without any recurrence or complications related to the ISH. An extensive review of the literature was performed. We conclude that ISH is a rare entity that usually presents as a surgical emergency and whose diagnosis is made in the absence of predispo-sing factors and excluding lesions in the abdominal blood vessels and organs. It warrants immediate intervention, which is crucial for patient survival.


Felicidad YAÑEZ RODRIGUEZ (CALATAYUD, Spain), Ana PEREZ ZAPATA, Rebeca ALONSO, Elena ABRIL
11:00 - 18:00 #7979 - A diagnostic dilemma- Unknown case of oesophageal pericardial fistula.
A diagnostic dilemma- Unknown case of oesophageal pericardial fistula.

Oesophageal cancer is statistically the eight most common cancer worldwide with increased incidence in men than women. The prognosis is quite poor as most patients present late with advanced disease. Researchers are looking at genes, role of aspirin and photodynamic therapy apart from regular chemotherapy and surgery. 

We present a case of a 56years old male patient who attended our emergency department at east surrey hospital with acute episode of chest pain and mild shortness of breath which was relieved with analgesia in the deparment. His pain was retrosternal and did not radiate anywhere but was associated with nausea. Patient had a background history of  terminal oesophageal cancer which was stented previously. He also suffered from pancreatic and prostate cancer. His initial observations showed mild tachycardia  and low blood pressure which improved with fluids intravenously. He had no signs of respiratory compromise and was afebrile. His systemic examination was baseline with tenderness along the costochondral joints.His arteial blood gas and laboratory results were normal.His chest xry  did not show any new abnormality. He was observed in the department and as his pain improved he was discharged with a diagnosis of musculoskeletal pain. 

This patient was prioritised later that night into resus as a priority cardiac arrest. He was resuscitated with full life support protoccol despite his known medical condition but he did not survive. Autopsy later on revealed an Oesophageal Pericardial fistula as the primary cause of death despite his terminal cancer. 

Oesophageal Pericardial fistula is a rare clinical entity with a very dismal prognosis and is often a diagnostic dilemma. According to litreature review less than fifty( 50) cases have been doccumented so far. The clinical triad of symptoms include retrosternal chest pain, shortrness of breath and pyrexia. The commonest predisposing causes are oesophagitis, ulcer, foreign body, tuberculosis,iatrogenic, ingested caustic substances,oesophageal diverticula and oesophageal cancer. It can also occur in patients who have had radiofrequency ablation in atrial fibrillation. The common radiological findings are cardiomegaly, pneumomediastinum,pneumopericardium, hemopneumopericardium and pleural effusion. However it is a life threatening complication and diagnosis is often by radiology, surgery or at autopsy. 


Akhtar MUNAZAH (Redhill, United Kingdom), Babak DANESHMAND, Julian WEBB
11:00 - 18:00 #7624 - A different view to appendicitis with artificial intelligence.
A different view to appendicitis with artificial intelligence.

Introduction: Acute appendicitis, a etiology of acute abdomen, is a clinical concern for emergency physicians and general surgeons. With clinical scores risk calculations helps physicians to decide consultation and operation. Most of the patient have negative laparotomy though having a high risk scores. Lymphoid hyperplasia is very common in appendicitis etiology as well as obstruction by other causes. Mostly viral infection results lymphoid hyperplasia and may lead to recurrent or chronic right lower quadrant pain. Most of the emergency services have face diagnosing problems with insufficient stuff and equipment. Thus studies with diagnosing methods via machine learning techniques are recently popular and helpful.

Materials and Methods: One hundred thirty three patients with high risk scores and diagnosed as appendicitis are studied. Laboratory and pathological findings are reported, trained and tested.

Results: Success of machine learning techniques as K nearest neighbour, classification tree, Naive Bayes are all found higher in identifying appendicitis as lymphoid hyperplasia or other causes. Knn method is the successful among machine learning techniques with a accuracy of over 80%.

Conclusions: Patients with right lower quadrant pain and high risk of appendicitis can be classified as urgent or recurrent with the help of artificial intelligence methods. Thus may lower the waiting time to operation of the high risk patients.

References: 1.Xu, Yingding, et al. "Lymphoid Hyperplasia of the Appendix: A Potential Pitfall in the Sonographic Diagnosis of Appendicitis." American Journal of Roentgenology 206.1 (2016): 189-194.

2.Swischuk, Leonard E., et al. "Non-fecalith-induced appendicitis: etiology, imaging, and pathology." Emergency radiology 22.6 (2015): 643-649.

Acknowledgments: There is no conflict of interest in this study.




Goksu BOZDERELI BERIKOL (Istanbul, Turkey), Gurkan BERIKOL, Oktay YILDIZ, Mehmet Serkan YURDAKUL, Attila BESTEMIR
11:00 - 18:00 #7366 - A Fatal Case of Unintentional Colchicine Intoxication.
A Fatal Case of Unintentional Colchicine Intoxication.

Colchicine is widely used in the treatment of gout, Behçet’s syndrome and other disease. Colchicine intoxication, although rare, can cause symptoms ranging from mild gastrointestinal complaints to severe toxic conditions resulting in death. we reported a 32-year-old woman who had Behçet’s syndrome and presented to the emergency department after ingesting 30 tablets(18mg) of colchicine in attempt to alleviate her abdominal pain. Initially, she just complained of abdominal pain and nausea. Gastric lavage was performed and activated charcoal was administered immediately. On admission, The patient hematologic and biochemistry laboratory test result was normal. But she exhibited many progressing features of colchicine intoxication, such as gastrointestinal symptoms, colitis in CT scan, leukopenia, rebound leukocytosis, elevated liver enzymes, multiple organ failure and so on. Fifty hours after ingesting the colchicine, she complained of chest discomfort and dyspnea, and developed cardiac arrest immediately thereafter. Despite cardiopulmonary resuscitation, she was expired unfortunately. This case showed that overdose of colchicine is associated with rapid progression and sudden cardiac arrest. It is important that we have to know benefits and potential dangers of this drug. Careful prescription and explanation maybe needed.


Seo YOUNGWOO, Tae Chang JANG (Daegu, Korea, Democratic People's Republic of )
11:00 - 18:00 #8046 - A headache revealing hemophagocytic syndrome.
A headache revealing hemophagocytic syndrome.

Introduction :

Macrophage activation syndrome also called Hemophagocytic lymphohistiocytosis (HLH) is rare but potentially fatal. It is based on a number of clinical signs and laboratory findings. Five out of the following nine diagnostic criteria for HLH: fever, splenomegaly, cytopenias  (affecting two or more of three lineages in the peripheral blood), hypertriglyceridemia, hypofibrinogenemia, elevated ferritin, hemophagocytosis in bone marrow/spleen/lymph nodes.The causative agent, whether bacterial, viral, fungal or parasitic should be treated urgently.

Case report:

A 19-year-old man presented at our emergency departement with headaches and vomiting lasting for 5 days in a fever context. On admission, examination revealed that he was conscious, afebrile with a respiratory rate of 20 breaths/min, an oxygen saturation of 98% on air, and blood pressure of 100/60 mmhg. He was a jaundiced patient. Abdominal examination and elecrocardiogram were unremarkable. Biology showed acute renal failure (clearance : 14ml/min), cholestasis combined dominance 8N, cytolysis 2N, lipasemia 5N, hypertriglyceridemia, severe thrombocytopenia, hypochromic microcytic anemia 8.9. Cardiac ultrasound trans chest was unremarkable. Injected abdominal CT showed bilateral renal nephritis outbreaks. Hepatomegaly, intra abdominal effusion low abundance.

Conclusion:

Infectious etiologies of HLH are many, predominated by viral infections. The severity of HLH prognosis requires an approach aggressive diagnosis and a multidisciplinary therapeutic management to determine the best options based on etiology found and the seriousness of the table.


Salwa AMRI, Salwa AMRI (villeneuve saint germain), Sarra JOUINI, Rym HAMED, Zied GUERMAZI, Asma ALOUI, Syrine JAOUANI, Bechir BOUHAJJA, Faten AMIRA
11:00 - 18:00 #6223 - A history to make history?
A history to make history?

Background:

National audits of the Paediatric Emergency Department have highlighted recurrent pitfalls in some areas during initial clerking. These include recognition and management of children in pain, response to abnormal vital signs and consideration of non-accidental injury.

In the local Emergency Department of Wexham Park Hospital it was identified that College of Emergency Medicine standards were not being met when it came to managing moderate pain in a timely fashion and re-evaluating pain. An initial audit examining management of children in pain looked at 50 children presenting to the Emergency Department, Wexham Park Hospital, with moderate to severe pain scores. It demonstrated pain management was below agreed standards from the College of Emergency Medicine. A pain pathway was designed to guide clinicians through appropriate pain assessment and prescribing of analgesia. After creation of the pain pathway a further 50 cases were identified and their management reviewed. This demonstrated an improvement in management of severe pain, but re-evaluation of pain and management of moderate pain remained poor. The repeat audit had failed to demonstrate significant improvement in practice, and highlighted that the pathway was not being utilised.

Non-accidental injury consideration is well documented electronically in Wexham Park Hospital Emergency Department because of a coded link which prevents discharging the patient from the system without completion. Written documentation in patient notes however is not often recorded.

 

Method:

A reconsideration of the clerking documents was commenced in order to improve the quality of the service provided. It was decided that the clerking document should be significantly changed from two blank sheets of headed paper. The new document would aim to encourage clinicians to use appropriate pathways and trigger appropriate responses to areas of previous poor performance. To reform the clerking documents it was decided to use signposting tools, check-points and diagrammatic aids to improve the quality of clerkings and management of patients.

 

Discussion:

At the top of the clerking document a signposting tool reminds clinicians to use the relevant pathway if one is available for the presenting complaint. Having to check a box of confirmation next to the signpost aims to encourage clinicians clerking the patients to take responsibility for this.

Check-points have been compiled for targets considered most important to patient safety and optimum care, based on audits highly recommended by the Department of Health. These include response to abnormal vital signs and management of children in moderate or severe pain.

Artwork was created specifically for the clerking documents by a doctor working in Ear, Nose and Throat surgical speciality. Diagrammatic representations of the mouth and tympanic membrane were included to encourage documentation of tonsillar and aural pathologies. The diagrams are designed to be anatomical aide memoirs and selected to serve as reminders to examine common sources of infection in the paediatric population.

The designed Paediatric Emergency Department clerking document introduced has been specifically designed to encourage optimum and safe care for patients. It is authorised by clinical governance and has been well received by clinicians.


Emily HIGNELL (Bristol, ), Jonathan LEWIN
11:00 - 18:00 #7541 - A New Immunomodulatory Drug, A New Adverse Effect; Adrenal crisis.
A New Immunomodulatory Drug, A New Adverse Effect; Adrenal crisis.

Background: Owing to the advancements in medicine, almost everyday, new information is obtained regarding cancer, and new antineoplastic agents are developed. Frequent use of these new pharmacological agents because of their promising properties propels emergency physicians to be vigilant about their side effects. We present a case of adrenal crisis in a patient with non-small cell lung cancer (NSCLC), caused by nivolumab, which is an immunomodulatory drug.

While adverse events are related to other immunomodulatory drugs have been reported in literature, our case is the first nivolumab-related adrenal failure to be reported.

Case: A patient with lung cancer presented to the emergency room(ER) with nausea and vomiting. The patient also had a seizure in the ED. Hyponatremia, hyperkalemia, persistent hypoglycemia led to the diagnosis of adrenal crisis. The patient was admitted into the ICU and externated after successful treatment.

Discussion: Immunomodulatory drugs are lately popular among new anticancer treatment agents. Having direct effect on the immune system, these drugs were claimed to be highly reliable and were chosen as the drug of the year in 2013. However, there is no reliable data on the side effect profile of these agents. In order to ensure early diagnosis and treatment of these cases, it should be kept in mind that life-threatening auto-immune reactions may occur, even though most side effects are mild.


Funda KARBEK AKARCA (Izmir, Turkey), Ozge CAN, Sercan YALCINLI, Yusuf Ali ALTUNCI
11:00 - 18:00 #7795 - A new point-of-care ultrasound workflow removing the middle man.
A new point-of-care ultrasound workflow removing the middle man.

Objectives

Developing a seamless point-of-care (POC) ultrasound workflow has challenged frontline providers for years. Ideally, it would contain the fewest number of steps, allow for rapid examination performance and interpretation and perhaps most importantly become integrated into the electronic medical record (EMR).

Previously reports of workflow solutions have typically involved third-party “middle-ware.” These products add cost to the process and institution.

We developed a solution utilizing the EPIC EMR existing infrastructure to allow seamless order entry, worklist population and demographic entry, PACS integration, EMR results reporting and medical record billing. Prior to this implementation emergency department ultrasound images were not permanently stored as part of the medical record.

Methods

Physicians enter an application-specific order in EPIC as they would for any other diagnostic test. EPIC routes the order to an ultrasound modality worklist. On the modality the examination is selected and demographic information populates from the order. On study completion, the clinician ends the examination, sending images to PACS from the modality. In the radiology read worklist in EPIC, the physician associates the patient account number and enters a report using customized application-specific templates. The results, including a link to the PACS images, are immediately available to all providers with EMR access.

Results

The process allows for documentation and permanent EMR storage of POC ultrasound studies. The EPIC EMR allows consultants or providers throughout the health system to access a link within the report to review the PACS images. The advantage of using solely EPIC, rather than multiple interfaces, is that clinicians across specialties are able to view important clinical results;providers are also easily able to integrate this process into their workflow as they are accustomed to placing orders and navigating EPIC for all clinical functions. Continuity of care is improved as our patient portal allows the patient to access results and share with providers outside the health system. Additionally, by having the report in the standard results section of the EMR, providers do not have to search the chart for a separate clinical procedure note or flowsheet.

By placing the order for the ultrasound, completing the study (including sending the images to PACS), linking the registration account number in EPIC to the study, and the attending physician entering a report complete with the patient information, indications, findings and impression, the steps required to allow a professional and technical fee bill are complete. This also allows us to easily separate out billed official studies from educational studies, as the later are not ordered in the EPIC EMR. Also, the billers and coders do not need to dissect through notes or access additional systems, as all the elements for billing are stored within EPIC.

Conclusion

This novel workflow solution allows for a streamlined workflow with minimal interfaces with which the clinical sonologist and down-stream providers have to interact. This improves patient care and safety by allowing ultrasound to be used readily at the bedside and have that information available for the provider and as a permanent part of the medical record.


Christopher RAIO, Gerardo CHIRICOLO (Holmdel, USA)
11:00 - 18:00 #7950 - A parody- Anterior shoulder dislocation.
A parody- Anterior shoulder dislocation.

Acute shoulder dislocations are a common clinical correndrum/ presentations in our emergency departments worldwide. Statistics show that shoulder joint dislocations are 90% common with acute anterior shoulder diclocations accounting for 50% of cases. In our busy emergency departments it is important that we use a simple,reliable, less traumatic and time modulated procedure. Over decades we have seen various methods of anterior shoulder reduction procedures being implemented, which have been modified later as pain and time managemnt have always been an issue.

We have found a relaible and modified method of anterior shoulder reduction. Our first author implemented this technique initially with our support. it involves traction parallel to body ( either sitting or lying down position) with one hand and manipulation in affected axilla of humeral head into the glenoid cavity with other hand which leads to successfull repositioning of shoulder if adequate analgesia and muscle relaxtion have been achieved. The process is completed by internal rotation and placing a broad arm sling on the reduced shoulder.

Twenty (20)patients with acute anterior shoulder dislocations were evaluated between Januaury2014 till March 2016 at East Surrey hospital in United Kingdom . The patients were evaluated for the effectiveness of the procedure in achieving reduction, duration of reduction attempt and post procedural complications. The method was not compared with any other method.  However the exclusion criteria were polytrauma and fracture dislocations.

Our results wre quite encouraging as eighteen (18) out of twenty(20) patients achieved successfull redcution through this procedure in five minutes of attempt. However in two patients it was not successfull. There were no reported complications.

This method is in its initial stages and needs more research and time . it is a small  non-comparative study ,however  we feel it has paved a new way ahead. 


Asif MUSHTAQ, Julian WEBB, Akhtar MUNAZAH (Redhill, United Kingdom)
11:00 - 18:00 #8240 - A perforation history: still radiography.
A perforation history: still radiography.

Perforation of the gastrointestinal tract occurs for reasons such as peptic ulcer, trauma, iatrogenic, foreign bodies, appendicitis, inflammation and requires early diagnosis and timely surgical intervention. The main treatment is surgery. Today endoscopic and laparoscopic techniques instead of conventional laparotomy are used increasingly in the treatment stage. We report to case of perforation diagnosed after previous abdominal hernia operation.
A 47-year-old female admitted to the ED complaints of abdominal pain, nausea and vomiting and diarrhea. In physical examination defense there was defense and rebound. X-Ray showed free air under the diaphragm.Laboratory findings revealed Hb:6,9, Hct:21, WBC:9400, CRP:24,2. She was interned to general surgery clinic.
Despite advanced  scanning methods , conventional radiography is still important for diagnose of perforation due to cheap and easy method.


Mehmet UNALDI (ISTANBUL, Turkey), Didem AY, Cihan BUYUKSUTCU, Ersen GUNDUZ, Umit OLMEZ, Onur INCEALTIN, Hatice ERYIGIT
11:00 - 18:00 #6784 - A prospective comparison of bedside ultrasound and CT- scan of the chest for the diagnosis of traumatic pneumothorax.
A prospective comparison of bedside ultrasound and CT- scan of the chest for the diagnosis of traumatic pneumothorax.

INTRODUCTION

In the United States, it is estimated that trauma is responsible for approximately 100,000 deaths annually.

Accidents (unintentional injuries) are the fifth most common cause of death.

Approximately 25% of deaths from blunt trauma arise from chest injuries.

Traditional imaging for a potential traumatic pneumothorax initially begins with chest radiography. However, due to the limitations of spinal immobilization in trauma patients, this examination often consists of anteroposterior (AP) supine films, in which radiographic features of pneumo thorax may be quite subtle. Computed tomography (CT) is much more sensitive for pneumothorax, but requires the patient to be removed from the emergency department (ED) environment and its resuscitative capability.

Bedside ultrasound become a very sensitive tool for the diagnosis of traumatic pneumothorax not only in detection of its presence but also in quantification of its size without the transportation risk and radiation exposure and with a lower cost.

AIM OFTHE WORK

The aim of this study is to evaluate the sensitivity and specificity of chest ultrasound in the detection of traumatic pneumothorax and quantification of its size in comparison to the CT-Chest as a gold standard diagnostic tool. PATIENTS

Exclusion criteria:

Life threatening pneumothorax.

Patients who do not undergo CT-Chest either for not being stable for transportation or do not met American college of radiology appropriateness criteria (ACR APPROPRIATENESS CRITERIA).

METHODS

Patients with chest trauma presenting to our emergency department (ED) at Alexandria Main University Hospital will be examined according to the primary survey described by the ETC course and resuscitated as needed and the attending EM physician will perform the Extended Focused Assessment with Sonography for Trauma (EFAST PROTOCOL). The chest will be scanned (using the superficial probe 7.5 MHz type L7M-A of our CHISON device model ECO 2) at three lines and two views for each hemithorax as the following (1)anterior second through sixth intercostal spaces at the parasternal line, (2) anterior second through sixth intercostal spaces at the mid-clavicular line, (3) fourth through sixth intercostal spaces at the anterior axillary line,(4) fourth intercostal space at the mid-axillary line, (5) fourth intercostal space at the posterior axillary line, to assess for the presence of a sliding lung. Presence or absence of this sign will classify the patient either being negative or positive for pneumothorax. If positive for pneumothorax absent lung sliding in the 3 lines denotes small pneumothorax , absence of this sign up to view 4 denotes moderate pneumothorax and absence of lung sliding at the five views denotes massive pneumothorax (in spontaneously breathing patients or intubated patients after exclusion of right main bronchus intubation). Then the patient will be admitted to the surgical emergency unit where resuscitation is continued as required and the patient will be investigated including CT-Chest scanning if needed according to the ACR APPROPRIATENESS CRITERIA.

Then the result from both will be compared.

REFERENCES

1.Sherry L, Murphy SL, Xu J, Kochanek KD, Jiaquan Xu, Kenneth D. Deaths: Preliminary Data for 2010. National vital statistics reports; Hyattsville, MD: National Center for Health Statistics. 2010; 60(4):4-5.


Dr Muhammad ABDULHALEEM HAMADA (Egypt, United Kingdom)
11:00 - 18:00 #7627 - A Prospective Evaluation of Meritas Point-Of-Care Troponin I Assay.
A Prospective Evaluation of Meritas Point-Of-Care Troponin I Assay.

Background:  Troponin (cTnl) is of great interest to emergency and cardiology departments for rapid rule out of acute myocardial infarct (AMI) in chest pain patients.  Since turn-around-time is of paramount importance in ruling out AMI, point-of-care platforms makes it possible to provide the results rapidly to the clinical team.  The cTnI assay on the Meritas POC analyzer (Trinity Biotech) is an example of a point of care device offering the latest advancement in troponin testing.  Here we present our in-house data for the precision and feasibility of using this system in emergency department (ED) to rule out AMI in chest pain patients. 

Methods:  The precision of the test was assessed by analyses of 3 levels of quality control material (QC) by one operator on a single analyzer 5 times over 5 days.  In addition, two operators analyzed 6 AMI patient’s blood and plasma samples on two different analyzers 9 times each.  To assess whether the test was able to rule out AMIs, 149 subjects presenting to the ED were consented.  Their blood samples were collected in EDTA tubes for analysis of cTnI in both whole blood and in plasma.  Sequential samples were collected 2-4, 6-9 and 12-24 hours after presentation.  All test devices were made available by the manufacturer for this evaluation.  

Results: Out of the 149 chest pain patients consented in this study, 7 had confirmed AMI according to local diagnosis and 144 were ruled out.  The mean cTnI concentration at baseline and the second blood draw for whole blood in the ruled out AMI patients was 15.0 ng/L (SD=15.6) and 15.6 ng/L (SD=14.4), respectively.  The mean cTnI in the AMI subjects was 32.5 ng/L (SD=25.5) for the baseline and 110.5 ng/L (SD=130) for the second draw sample. 

As described above, we assessed the precision in two ways.  Analysis of the low QC by a single operator 5 times over 5 days resulted in %CV of 10.0, a mean of 63.7 ng/L (SD=6.4). The mid QC had a %CV of 7.1%, a mean of 174.2 ng/L (SD=12.4). The high QC had a %CV of 8.9%, a mean of 893.3 ng/L (SD=79.4).  The precision using the six AMI patients by two operators resulted in total CVs ranging from 5.3% to 13.5%.  

Conclusions:  The cTnI measured using a point of care format exhibited acceptable precision and performance for ruling out chest pain patients without AMI who presented to the ED.  The rise of cTnl from the baseline to the second blood draw 2 to 4 hours later in the clinical course is important for ruling in chest pain patients with myocardial infarction.

 


Keivan HOSSEINNEJAD, Shahab GHAFGHAZI, Stanislava PRATHER, Saeed A. JORTANI (Louisville, USA)
11:00 - 18:00 #7794 - A prospective feasibility trial of accucath™ 2.25” blood control intravascular catheter system with retractable coiled tip guidewire placed in difficult access patients in the emergency department.
A prospective feasibility trial of accucath™ 2.25” blood control intravascular catheter system with retractable coiled tip guidewire placed in difficult access patients in the emergency department.

Objective:

The primary study objective is to evaluate insertion success rates.  Secondary objectives include user preference, patient satisfaction, complications, completion of therapy and dwell time of the novel AccuCath™ 2.25” BC Catheter System (FDA approved) placed in difficult access patients.

 

Methods:                 

This is a single-arm feasibility trial evaluating the novel AccuCath™ 2.25” BC Catheter System in a convenience sample of difficult intravenous access patients defined as at least 2 failed initial attempts or a history of difficult access plus the inability to directly visualize or palpate a target vein.  The retractable coiled tip guidewire device is placed under dynamic ultrasound guidance after identification in the ED using a modified Seldinger technique.  All catheters are placed by EM physicians after a 30-minute training session which includes simulated procedures on ultrasound phantoms.  Patients are followed daily until catheter removal. Subject’s demographic (age, race, gender); admitting diagnosis, past medical history, baseline information (height, weight, systolic/diastolic blood pressure); and primary indication for intravenous line will be documented.

The following information is recorded for each subject enrolled:

  • AccuCath™ 2.25” BC catheter device gauge
  • Date, Time and Location of First IV Placement Attempt
  • Time and Location of Each Subsequent IV Placement Attempt
  • Use of USG With Each Catheter Attempt
  • Observation of Flashback With Each Catheter Attempt
  • Total Number of Venipuncture Attempts (each catheter insertion attempt)
  • IV Rating Scale with Factors Contributing to Insertion Difficulty for Each Catheter Attempt
  • Date, Time of Successful Catheter Placement
  • Patient Satisfaction at initial placement and upon removal using a 5 Point Likert Scale
  • Clinician Satisfaction at completion of study using a 5 Point Likert Scale
  • Safety outcomes anticipated to be similar to conventional catheters (Number and Severity of AEs)

 

Device Description

  • The AccuCath BC Intravascular Catheter System is designed to reduce blood exposure once at insertion. The catheter system consists of a radiopaque catheter with a valve mechanism delivered over a guidewire with atraumatic tip design; a notched needle to enhance flashback visualization, and a safety container that prevents sharp injuries.

 

 

 

Results:

120 patients enrolled and completed the study.  These patients had an average of 3.7 (95% CI 3.0-4.0) and median of 3 prior attempts at vascular access prior to Accucath placement by the ED registered nursing team.  Successful access was gained in 100% of the patients, 77% on 1st attempt and all within 3 attempts.  84% of patients completed therapy with no moderate or major complications in the other subjects.  The average patient satisfaction score upon removal on a 5-point Likert scale was highly positive at 4.6.

 

Conclusion:

The AccuCath™ 2.25” BC Catheter System has excellent success rates in gaining vascular access in an extremely difficult patient population.  The device thus far has not led to any significant complications. Patients are also very satisfied with the procedure.

 


Christopher RAIO, Gerardo CHIRICOLO (Holmdel, USA)
11:00 - 18:00 #7974 - A PURPOSE OF A CASE: TOXOPLASMOSIS.
A PURPOSE OF A CASE: TOXOPLASMOSIS.

 

33 year old patient with a history of diagnosed HIV 10 years ago and has abandoned its retroviral treatment 4 years ago by intolerance. Currently do not follow controls by the infectious service.

Is brought to the emergency room by his family for presenting from a week ago picture of high fever accompanied by symptoms of respiratory infection, cough and dyspnea; with fluctuating disorientation, weakness of limbs, asthenia, anorexia and headaches.

Now concerns have suffered traumatic ciliary right without loss of consciousness or other added symptomatology.

The exploration tendency to sleep and low reactivity without clear foci. Analytically only highlights a discrete anemia with hematocrit of 32% and hemoglobin of 10.6 g/dl.

He is Rx thorax that is no evidence image of condensation.

Apply brain CT reporting as hypodense lesions associated with extensive vasogenic parietooccipital location perilesional edema

left, front left, right and left basal ganglia, frontobasal after administration of

contrast show enhancement in ring, as first possibility of toxoplasmosis given the

clinical context of the patient.

The occipital left along with extensive perilesional edema cause compression and displacement of the

occipital Horn ipsilateral and the left hemisphere associated edema also cause mass effect with

contralateral deviation from the centerline of 6 mm.

Intra or extraaxiales acute hemorrhagic lesions are not seen.

With this diagnosis starts m broad-spectrum antibiotic treatment (Sulfadizina, Pirimetadina and folinic acid).

The patient was admitted to the infectious being given high to his home unit.

 

 

Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Elisa RUIZ OLIVARES, Pilar SARASA CLAVER, Ana Belén MARÍN FLORÍA, Sonia Sofía BALLESTIN SOROLLA, Elisa ALDEA MOLINA
11:00 - 18:00 #4546 - A rare case of a paratracheal mass requiring emergency interventions: An infected tracheal diverticulum.
A rare case of a paratracheal mass requiring emergency interventions: An infected tracheal diverticulum.

Recently, progression of radiological imaging has revealed various asymptomatic abnormalities than ever. Tracheal diverticula are relatively rare entities and found incidentally on radiological imaging such as CT scan. We present the case of an infectious tracheal diverticulum presenting as a paratracheal mass requiring emergency interventions.

A 65-year-old male nonsmoker presented with a fever, lower neck pain and aggravation of dyspnea for a week. His enhanced CT scan demonstrated that trachea was displaced by a paratracheal mass with a well-defined thin wall. His respiratory status was so urgent that emergency intubation was performed and surgical drainage of the abscess was carried out as well. His CT scan performed 4days after admission demonstrated the shrinking abscess and he was extubated and discharged 7days after admission without any complication.

We found out two important clinical issues. First, an infectious tracheal diverticulum can present as a paratracheal abscess impairing airway. Second, CT scans is helpful for the diagnosis of this condition. Most patients of a tracheal diverticulum itself have no symptoms. When symptoms occur (sometimes with infection), neck pain, chronic cough, dysphagia, odynophagia, hoarseness or hemoptysis are common. This is the first report describing an infectious tracheal diverticulum presented as a paratracheal mass impairing airway and required emergency interventions such as intubation or surgical drainage. The CT features of an abscess are low-attenuation masses with a well-defined thin wall that usually enhances after intravascular administration of contrast materials. His CT scan performed 4 years before obtained the proof that the mass was originated from a tracheal diverticulum. This is the first report describing a tracheal diverticulum can progress to an abscess on CT scan as well.

Though there are several differential diagnoses detected as a paratracheal mass, this case is clinically important that can require emergency interventions. Also, recent progression of CT scan has revealed various asymptomatic abnormalities including tracheal diverticula. This case also suggests follow-up of such abnormalities can be a clue to obtain the diagnosis.


Shota AKABANE (Kamakura, Japan), Jun KAWACHI, Ryuta FUKAI, Rai SHIMOYAMA, Hiroyuki KASHIWAGI, Hidemitsu OGINO, Kazunao WATANABE
11:00 - 18:00 #7905 - A rare case of Ramsay Hunt syndrome.
A rare case of Ramsay Hunt syndrome.

A 56-year-old man, with history of tonsillectomy, was admitted in the emergency department because of fever and skin lesions.

The patient had been well until 7 days before admission, when he began with fever, malaise, and sore throat, starting treatment with amoxicillin clavulanic. Five days later, fever persisted, and the patient developed skin lesions in form of papules and vesicles, affecting first face, scalp and oral mucosa, and then extremities and trunk. Dizziness, headache and loss of balance accompanied the skin lesions, so the patient went to our hospital.

On arrival at the Emergency Department, the patient appeared ill. On examination, the temperature was 37 ºC, and the blood pressure, pulse and oxygen saturation were normal. Vesicles and pustules in different stage of development involved all the skin, affecting also scalp and mucosae. In neurological examination, the patient was conscious and alert, with normal speech; rightbeat nystagmus was present, as well as mild dysmetria with left extremities and wide base gait. The remainder of the examination was normal.

Blood test revealed mild elevation of transaminases (GPT 66U, GOT 40U, GGT 118U) and PCR 2,8. Other results were normal.  Cranial computed tomography was normal. A lumbar puncture was performed; the opening pressure was 10cm of water, and the results of the cerebrospinal fluid showed 95 white cells (95% lymphocytes), glucose 69mg/dl and proteins 0.61g/l.

A diagnosis of suspected chickenpox with associated rhombencephalitis was made, and treatment with intravenous Acyclovir was initiated. Despite of the treatment, in the next hours the patient developed progressive left peripheral facial palsy, without affecting other cranial nerves, except of persistent nystagmus and tinnitus.

Suspected diagnosis: Ramsay Hunt syndrome due to Varicella-zoster virus (VZV) primoinfection.

Discussion: Ramsay Hunt syndrome typically includes facial palsy, ear pain and vesicles in the auditory canal due to VZV reactivation. Taste perception and hearing (tinnitus, hyperacusia) are usually affected, and vestibular disturbances (vertigo) are frequently reported, so this syndrome is usually considered a polycranial neuropathy. Nevertheless, peripheral facial palsy due to VZV primoinfection is a rare condition.  The pathogenesis of this peripheral neuropathy is not completely understood; it could be explained by a direct nerve lesion due to VZV, or to meningeal inflammation in the course of varicella meningitis. Treatment of this complication is also unclear, and should be individualized.

Our patient was transferred to Neurology department, and treatment with Acyclovir and Methylpredonisolone was administered. Magnetic resonance imaging of the brain showed enhancement of the left VII and VIII cranial nerves, with the remainder of the brain structures without lesions. Serologic test confirmed VZV primoinfection (positive IgM). The patient improved and was finally discharged, with completely recuperation of facial palsy. 


María CUADRADO FERNÁNDEZ (Madrid, Spain), Isabel FERNÁNDEZ MARÍN, Ana Belen CARLAVILLA MARTÍNEZ, Luz Tamara VÁZQUEZ RODRIGUEZ, Alicia Paloma GARCÍA MARÍN, Eva MURO FERNÁNDEZ DE PINEDO, Lorena CASTRO ARIAS
11:00 - 18:00 #8090 - A RARE CAUSE MIMICKING ACUTE APPENDICITIS: INTERNAL HERNIA WITH COLONIC MALROTATION.
A RARE CAUSE MIMICKING ACUTE APPENDICITIS: INTERNAL HERNIA WITH COLONIC MALROTATION.

Introduction: Intestinal malrotation is a developmental anomaly of the midgut. It can be asymptomatic and generally diagnosed incidentally or during checking for atypical syptoms in adults. Intestinal malrotation can mimic other diagnoses as acute appendicitis.  

Case: We present a 23 year old man with having clinical syptoms indicating acute appendicitis in Adıyaman State Hospital. He had right lower quadrant pain and nause. He didn't discribe any alimentary tract symptoms in his history and there was no significant medical or surgical history. The patient operated with diagnosis of acute appendicitis and we saw a midgut malrotation with internal hernia behind the non fixed transverse colon. After hepatic flexure, colon was heading inferior and passing lateral site of assending colon with having omentum. Under the cecum, colonic segment was crossing over to the left side of abdomen. This crossing segment was mobile that not adhered to retroperitoneum. Appendectomy and fixation of colonic segment were applied and operation finished successfully. He was discharged postoperative 6th day with good recovery.

Discussion: Midgut malrotation presents usually in the first month of life. But some asymptomatic cases present in adulthood due to obstruction or other diseases redounded laparotomy. We can face with this diagnose rarely in adulthoods except for childhood or infants. This type of midgut malrotation with internal hernia, mimicking acute appendicitis, hasn’t been seen untill we operated this case.

Conclusion: We can be faced with midgut malrotation during examination or laparotomy. We have to be carefull and consider midgut malrotation in emergency services and surgery clinics.


Mesut YUR, Bünyami OZOGUL, Esra DISCI, Mehmet Ilhan YILDIRGAN ( ERZURUM, Turkey)
11:00 - 18:00 #7511 - A RARE CAUSE OF HEMORRHAGİC OTORRHEA.
A RARE CAUSE OF HEMORRHAGİC OTORRHEA.

A RARE CAUSE OF HEMORRHAGİC OTORRHEA

( UNUSUAL COMPLİCATİON OF TOOTH EXTRACTION )

Serdar KAVAK, Aksaz Military Hospital, Marmaris, TURKEY

Introduction:Hemorrhagic otorrhea is known as blood coming  from de external auditory canal. The most commen causes of hemorrhage is trauma to the external auditory channel, trauma to middle ear, basilar skull fractures and barotrauma

 

Case Report

A 27-years-old female patient visited our emergency medicine department ( EMD ) with complaint of hemorrhage from the right ear.She has no other complaints of pain, hear loss or fever. The hemorrahage had began two hours before she visited the emergency medicine . She has no history of physcial and baro trauma and bleeding disorders.   She had an operation of tooth extraction( right lower impacted third molar tooth ) six hours before the visit. Her vital signs were in normal ranges.  The physical examination findings was blood in right the auditory channel and perforated tympanic membrane.After the detailed history the paitent told us that she had a ear pain six days ago. The pain reliefed one day later and purulant otorrhea occured for one day The source of bleeding was wound on the right mandibular region and while swalloving the salive, she swalloved  some amount of blood. By the retrograde action the blood came to midear and then cam outside to auditory channel. After the physical examination we advise her to follow up with ear throat nose spacialist about the perforated tympanic membrane. After one month follow up the tympanic membrane closed spontanously and her hearin tests were in normal ranges.

 Discussion : The most commen causes of hemorrhage is trauma to the external auditory channel, trauma to middle ear, basilar skull fractures and barotrauma. A detailed history must be taken from all the unusual situations. 


Serdar KAVAK (Marmaris, Turkey)
11:00 - 18:00 #7235 - A rare cause of pulmonar hemorrhage.
A rare cause of pulmonar hemorrhage.

Case Description: 77-year-old male with medical history of hypertension, sigmoid diverticulosis and chronic kidney disease (CKD) (diagnosed by Nephrologist as secondary to nephrosclerosis, without histologic diagnosis), was admitted at the Emergency Department because of hemoptysis and dyspnea with oliguria. He did not have hemoptysis before.

Exploration and additional tests: On physical examination the patient was afebrile with 88% oxygen saturation and blood pressure 100/60 mmHg. The pulmonary auscultation showed decreased breath sounds and crackles in both lungs. The blood tests showed: hemoglobin 8,8gr/dl, hematocrit 27%, creatinine 15,6mg/dl, urea 3,08 g/dl, pO2  in arterial blood gases 65mmHg. Torax X-ray: cardiomegaly, alveolar-interstitial involvement.

After hemodynamic stabilization, the patient was admitted in Nephrology Department to continue the study. To reach the final diagnosis, several complementary tests were requested:

-          Renal biopsy: rapidly progressive glomerulonephritis, with 100% of epithelial crescents

-          cANCA 1,04u/ml

-          pANCA 20,75u/ml

-          Anti-glomerular basement membrane antibodies: positive 3 times

Differential diagnosis: pulmonary-renal syndromes, such as Wegener´s granulomatosis, Goodpasture syndrome, Churg Strauss syndrome, polyarteritis nodosa and microscopic polyangiitis, systemic lupus erythematosus, Goodpasture syndrome, essential mixed cryoglobulinemia. We also should keep in mind as differential diagnosis infectious disease.

Diagnosis: Alveolar hemorrhage with rapidly progressive glomerulonephritis and anti-glomerular basement membrane antibodies is diagnostic of Goodpasture syndrome.

Conclusion: During admission in nephrology, the patient was treated with plasmapheresis and prednisone, with favorable evolution. Goodpasture syndrome is an autoimmune disease with glomerular basement membrane antibodies that mainly affects the kidneys and alveoli. It is a rare disease and a lower incidence is estimated at one case per million population. This case shows the difficulty of early diagnosis of reno-pulmonary syndrome in cases where there is only kidney clinical manifestations, as was our case before the debut with hemoptysis. Therefore it is very important a thorough medical history along with a detailed physical examination and appropriate complementary tests to make a correct differential diagnosis.


Cristina Ana BAQUER SAHUN, Marta JORDAN DOMINGO, Daniel SAENZ ABAD (ZARAGOZA, Spain), Carmen LAHOZA PEREZ, Maria MARTINEZ DIEZ, Raquel MONTOYA SAENZ, Ines MURILLO DIAZ DE CERIO, Miguel RIVAS JIMENEZ
11:00 - 18:00 #8039 - A Rare Condition: Portal Vein Trombosis - A Case Report.
A Rare Condition: Portal Vein Trombosis - A Case Report.

Introduction: Abdominal pain has been shown in the general population to make up between 4.4% and 7.5% of primary care and emergency department visits.(1) In portal vein trombosis patients can present emergently with sudden onset of right upper quadrant pain, nausea, and/or fever. Portal vein trombosis usually associated with cirrhosis, liver transplantation, malignancies, inflammatory disorders, or hypercoagulable states.(2)                          

Case: A 74 years old female admited to ER with right upper abdomen pain. In patient’s medical history, she had a carsinoma of the ampulla vater. On physical examination, the patient was noted to be afebrile with a normal blood pressure and a heart rate of 71 per minute. Spesific examination findings were rebound tenderness over right upper and lower abdominal region. The abdominal pain was associated with meals, consisting of a significant increase in pain approximately 10 to 15 minutes after eating and intermittent post-prandial nausea and occasional vomiting. At laboratuary findings were white blood cell 10.48 10^9/l , hemoglobin level 7.6 g/dl, platelets 115 10^9/l, INR 1.5, AST 20 U/l, ALT 14 U/l, lactat 3.55 mg/dl. In hepatobilier ultrasound result’s  shows that at portalosplenic area 33*14 mm size, allowing blood stream trombus image. Dinamic abdomen CT showed no symptom of mesenteric ischemia. Enoxaparin started to the patient 1 mg/kg SC twice daily. The patient hospitalizated for further  examination and treathment.

Discussion: Portal vein trombosis is rare but should be considered diagnosis,  patients presented to ER with abdominal pain and malignancy history. Neoplasms,  hepatocellular carcinoma and pancreatic carcinoma causing most of these cases,  are second major cause, accounting for 21-24% of cases of portal vein obstruction. (3)


Yusuf Cankat BOZKURT, Burcu GULSEN, Onur TOKOCIN (istanbul, Turkey), Hakan TOPACOGLU
11:00 - 18:00 #7710 - A rare reason of sciatalgia: piriformis syndrome.
A rare reason of sciatalgia: piriformis syndrome.

Introduction:Piriformis muscle (PM) originates from the anterior part of the sacral 2-4. Vertebrae, runs through the greater sciatic foramen and ends on the trochanter major of the femur. PM crosses through the foramen ischiadicum majus with the neurovascular structures in the pelvic region. Piriformis syndrome (PS) is a rare clinical picture with sciatic pain caused by compression of the sciatic nerve in the foramen ischiadicum majus. Pyomyositis is the primary pyogenic infection in the skeletal muscle usually progressing to abscess. It is difficult to diagnose, because pyomyositis is deeply located in the pelvis with a non-specific clinical picture and rarely seen in the temperate climate. Pyomyositis is considered to develop secondary to injuries occurring in muscle during an asymptomatic and undiagnosed transient bacteremia. PM pyomyositis creates edema in muscles, causing irritation and compression in sciatic nerve. Classical sign of PS is pain, tingling or numbness beginning from the hips, extending down the length of the sciatic nerve. Because there is no definitive test for piriformis syndrome, the diagnosis is primarily established on clinic. Treatment of PS is directed to etiology. Methods used in treatment of PS include medical, physiotheraphy, acupuncture, therapeutic perisciatic blocks, botulinum toxin injections or surgical intervention.

Case report:A 18-year-old female patient presented to emergency department with severe pain and numbness  in the right hip, thigh and leg for 5 days and pain induced inability to walk. Vital signs of the patient at presentation were normal except fever (38.8°C). In physical examination, there was tenderness on palpation in right gluteal area, but no other signs of inflammation. Patient was easily bringing her right thigh to flexion and extension, but feeling severe pain during external and particularly internal rotation. Laboratory outcomes were WBC: 17000 and CK:500, while other values were normal. In pelvic tomography ordered for increased tenderness in the gluteal area of patient, there was heterogeneity in the right piriformis, gluteus maximus and minimus muscles, compatible with abscess. MRI was ordered to find source of abscess formation. In MRI; a lesion was observed in right gluteus maximus, minumus and pirifiormis muscles which was hypointense on T1-weighed images (AG) and showed marked signal increase on (WI) fat-suppressed T2-weighted images. The appearance was evaluated as piriformis intramuscular abscess. Piriformis symdrome was considered in the patient from piriformis intramuscular abscess. The patient was consulted to orthopedics clinic, a part of abscess could be drained with the guide of tomography and antibiotherapy was initiated. Staphylococcus aureus was isolated in abscess culture. The patient with complaints resolved at follow-up was taken to operation, abscess was cleaned and closed after insertion of drainage. Upon complaints of the patient were resolved, she was discharged at the 20th day of hospitalization.

Conclusion:Because piriformis syndrome is rarely encountered by physicians, diagnosis may be delayed, causing morbidity and unnecessary invasive examinations. We presented a piriformis abscess case which is a rare cause of piriformis syndrome and emphasized that piriformis syndrome should be kept in mind in differential diagnosis in patient presented with sciataalgia clinical picture. 


Mustafa UZKESER (Erzurum, Turkey), Ilker AKBAS, Orhan KARSAN, Alpaslan UNLU, Abdullah Osman KOCAK, Ihsan YUCE
11:00 - 18:00 #7748 - A rare type of fracture in a traffic accident: A case of isolated fracture of the hyoid bone.
A rare type of fracture in a traffic accident: A case of isolated fracture of the hyoid bone.

Background:  Excluding hyoid bone fracture during strangulation and hanging injuries, this type of fracture caused by blunt trauma is rare. In light of this, it may go unseen during physical examination, causing life-threatening airway obstruction. Thus, appropriate measures should be taken to carefully examine patients with blunt trauma. To date, few cases of hyoid bone fractures caused by trauma have been reported. In this study, we report the case of a young male with an isolated fracture of the hyoid bone as a result of blunt trauma. 

Case Report:  A 21-year-old male was admitted to our emergency department by an emergency ambulance crew following a traffic accident. At the time of the accident, he was sitting in the back seat of an automobile with his seat belt unfastened. As a result, he hit his neck on the edge of the front seat. On physical examination, his vital signs were stable and neck movements were unrestricted and painless. However, his right cricoid bone was tender during palpation.No pathology was detected from the anteroposterior or lateral cervical film.  A cervical computed tomography (CT) scan revealed a fracture within the right arch of the hyoid bone. Consequently, the patient was referred to the otorhinolaryngology department. Indirect transoral laryngoscopy was performed, but failed to detect any airway edema or laceration. The patient’s oral intake was stopped, and he was monitored for airway obstruction in the emergency department. In addition, he was treated with head elevation and a cold compress applied to his neck. His vital signs remained stable and he was discharged after 24 h, returning to the otorhinolaryngology department for a follow-up exam. 

Conclusions: A hyoid bone fracture should be suspected upon the detection of neck tenderness and pain following blunt trauma to the neck region. A delay in diagnosis may result in life-threatening airway narrowing. For diagnosis, CT examination of the neck is the modality of choice due to its high diagnostic accuracy. It is of great importance to closely monitor patients with an isolated closed fracture of the hyoid bone for a prolonged period to prevent airway obstruction. Patients who have no airway obstruction and a normal hyoid bone following indirect laryngoscopy can be conservatively managed.


Mustafa OZTURK (istanbul, Turkey), Ozgur SOGUT, Tuba EVRAN, Demet TAS
11:00 - 18:00 #8109 - A review of cycling injuries presenting to a suburban university teaching hospital in Dublin.
A review of cycling injuries presenting to a suburban university teaching hospital in Dublin.

Objective: The Central Statistics Office Ireland (CSO) reported following the 2011 census that there was a 9.6% increase in the number of people cycling to work compared with 2006. This ultimately leads to a higher prevalence of injuries and hospital attendances. The Road Safety Authority of Ireland (RSA) estimates from their provisional report that there were 12 pedal cyclist fatalities on Irish roads in 2014. There is little published data on cycling injuries in Ireland and the present study aims to describe the cycling related injuries presenting to the emergency department (ED) of a tertiary urban university hospital.

Methods: This is a retrospective review of patients with a cycling-related injury presenting to the ED of St.  Vincent’s University Hospital (SVUH) from 1st of January to 31st of December 2014. We used the ED Maxims © database to retrospectively review all cycling presentations to the ED in 2014. We searched for bike, cycling, bicycle in triage notes to identify patients that presented to the department following a bike-related incident. We also made use of Syngo © radiology database to access radiology reports for the same cohort of patients.

Results: There were 534 cycling related injuries presenting to the ED during the study period. 71.2% of the patients were male. 14.8% of patients presented following a collision with a motor vehicle. There were 2 mortalities during the study period with 5 patients sustaining an injury severity score greater than 15. 40 patients required admission to hospital following their injury with 6 of these patients spending time in the intensive care unit. 10 patients required transfer to other facilities for specialist care.

Conclusion: The Road Safety Authority in Ireland collates data regarding cycling injuries using police reports alone and does not use hospital data. Our study revealed that there was a significant number of cycling injuries presenting to this ED and that the majority of these injuries didn’t involve motor vehicles and therefore may not be reported by the police. Cycling injuries have a significant impact on EDs with significant use made of radiology, ED review and outpatient clinics and admission facilities. Cycling is now a very popular means of transport and exercise activity in Ireland and using hospital based data, it is possible that EDs may provide a vector for guiding injury prevention strategies in the future.


James FOLEY (Bristol, ), John CRONIN, John RYAN
11:00 - 18:00 #7737 - A self pacemaker.
A self pacemaker.

The existence of myocardial infarction  with “normal” coronary arteries (MINCA), was recognized more than 30 years ago, however the etiology is not clear. It is supposed that exists for a multiple pathogenetic mechanisms like coronary vasospasm, thrombosis, embolization and inflammation, alone or combined, in presence of infarction, for example, endothelial dysfunction and myocarditis superimposed to non angiographically evident atherosclerosis, may be an underlying common feature predisposing to the acute event. MINCA typically occurs in the under-50s and it is usually no history of angina or previous myocardial infarction, Symptoms and electrocardiographic (ECG) findings are similar MI with angiographic coronary disease.

Here is the case of a 50 years old woman, with unknown drug allergies, smoking to 7 cigars per day,  from 16 years old, and drinking on weekends. Hipertension without phmacological treatment. She denied other drugs consume or medical or surgical dates. The patient consults in A&E (Emergency department) for servere crushing central chest pain radiating to the neck and jaw, associated  to nausea, vomiting and diaphoresis of 3 hours of evolution that didn´t stop with first step´s painkillers. She didn´t present dyspnea or syncope.The physical examination (PE) revealed normal blood pressure, heart rate and oxygen saturation. On heart auscultation was rhytmic, heart murmurs were no listened to. The rest of PE was normal. In additional tests, no radiological findings on chest X-Ray.At first, ECG complete AV block. ST 4 mm elevation in II, III and aVF leads. ST depression in V1 and V2.  Cardiac ultrasound: mediobasal posterior hypokinesia . Absence of valvular pathology. Given these dates, dual antiplatelet, GTN and analgesia therapy are started, getting pain free. Then, a new ECG was performed, it showing sinus rhythm with no repolarization abnormalities, and in  blood test was alterated with T us-troponine from 139ng/dl initial to 1197 at 12 hours later. Also GOT from 29 to 68, CK from 223 to 655. At Coronary angiography: no significant lesions in epicardial coronary. Images of thrombus laminar non-occlusive in right middle coronary suggestive of spontaneous recanalization of the thrombus. The patient continued improving, and she was discharged home a few days later.

MINCA is usually diagnosed in patients under 50 years old and the prevalence of this condition is 1–12%. It is difficult to find a cause because of the multifactorial mechanism present in that. So is important to the physician recognice that the espontaneous revascularization is possible in STEMI, and also, we have to know that the presence of complete AV block with an inferior STEMI associated is still a relatively common complication, which usually appears early and frequently develop the dilemma of implementing or not a temporary pacemaker, which may involve a delay in the administration of fibrinolytic.


Fernando Constantino BRIONES MONTEAGUDO (ALMANSA, Spain), Francisco Javier LUCAS GALÁN, Rafael SÁNCHEZ INIESTA, Nuria SÁNCHEZ GARRIDO-LESTACHE, Mónica LÓPEZ GARCÍA, Maribel PRADO COSTE
11:00 - 18:00 #8164 - A serial of kidney injury playing football in Calatayud- Spain.
A serial of kidney injury playing football in Calatayud- Spain.

Introduction: Genitourinary trauma amount to an 8-10% of abdominal trauma with the kidney being the most affected organ in 50% of cases, especially the left one. The choice of treatment will depend on the kind of lesion found in the affected renal unit and on the patients clinical conditions.
Objective: The aim of this report is to determine the applicability of conservative treatment in major renal trauma and to assess the evaluation and emergence of possible complications.
Material and methods: We have analysed 3 cases of renal trauma detected in our emergency department, analyzing such variables as the etiology of the trauma, associated lesions in other organs, the therapeutic approach adopted as well as the presence of complications, both in the long and short run.
Results:the three cases were blunt renal trauma in Young men playing football in 2015. We have given a conservative approach in first case and the second was managed with partial nephrectomie,48-72 hours after the trauma.Third was carried out in the Emergency Room because of haemodynamic instability, being the total nephrectomy the definitive treatment.
Conclusions: According to our experience and in the light of the results obtained, we consider the conservative approach adequate for major renal trauma as long as the patient is haemodynamically stable.


Felicidad YAÑEZ RODRIGUEZ (CALATAYUD, Spain), Jose Manuel ARANDA LASSA, Miguel SUAREZ BROTO, Roberto MARTINEZ DELGADO, Abid REYES
11:00 - 18:00 #8270 - A silent bomb in the head; A Case Report.
A silent bomb in the head; A Case Report.

A 59-year-old male patient was brought to the emergency department with complaints  of sudden onset of weakness on his right foot and dizziness. The general appearence was medium and his consciousness was tend to sleep; GCS 14, BP: 138/78 mmHg, pulse:72/min, RR: 24/min with no fever respectively. It was learned that he had suffered balance problems and had a fall history four days ago but no cranial imaging had not been planned by admitted health institution. His medical history only revealed that his simple analgesic use due to recurrent unilateral headache since last year. On neurological examination, pupils were isochoric, spontaneous vertical nystagmus in both eyes and 4/5 right upper extremity strength while the left was 5/5 were detected. A ruptured dermoid cyst extending to silyvi fissure and middle cranial fossa in the right frontal lobe, causing 11 mm midline shift with calcification and fat density was seen on brain CT.  The images also showed widespread distribution of fat density throughout the other parts of cranial fossa and subarachnoid space due to rupture. The patient was consulted with neurosurgery department for hospitalization and operation. After the surgery, he was followed up in ICU post-operatively and discharged from the hospital at 7. day.

Dermoid cysts (DC) are originated from ectodermal cells at embryonic period. They are ectodermal inclusion cysts which are benign, slowly growing and sometimes show malignant transformation. Intracranially localized DC consist %0.2-%1.8 of primary intracranial tumors. Intracranial DC can reach very large sizes due to their slow growth rate without any symptom or sign. Clinical symptoms depend on the localization of the lesion and created adjacent parenchyma compression. However they may be acutely symptomatic in case of a rupture or an infection. Intracranial DC may rupture spontaneously or during a surgery and cyst contents may spread throughout subarachnoid space. When they ruptured, they may present with headache, nausea, vomiting, visual disturbances, dizziness, epilepsy, chemical aseptic meningitis, hemiparesis and changes in mental status. Both for Computed Tomography and Magnetic Resonance Imaging, images of fat particles in subarachnoid space as a result of a rupture or determination of fat content are typical.

The accessibility of brain CT and MR imaging may be vital in the diagnosis of patients with sudden onset of headache, dizziness or neurological diagnosis. 


Oğuz EROĞLU, Ertan CÖMERTPAY (Kırıkkale, Turkey), Mustafa KÖKSAL, Mehmet Faik ÖZVEREN, Figen COŞKUN
11:00 - 18:00 #7800 - A Survey of the Importance of Emergency Ultrasound in Prospective Practice Settings Amongst Emergency Medicine Residents.
A Survey of the Importance of Emergency Ultrasound in Prospective Practice Settings Amongst Emergency Medicine Residents.

Background

 

Point of Care Ultrasound (POCUS) has been integrated into many community and academic emergency departments and is now a mandated skill for all emergency medicine (EM) residents according to the ACGME.  Current EM resident education includes US as a critical part of both life saving procedures and the bedside evaluation of critically ill. It is well accepted that approximately 80% of EM residents will practice in a community setting after completing their training.  Access to US in the community setting is variable and many sites have not secured credentialing to perform these examinations. We question whether current EM residents would be comfortable working in a clinical environment that does not include or has limited access to bedside US.

 

Objectives

 

The goal of this study was to survey EM residents about their experience with POCUS and the importance of the accessibility of US in their future practice settings. This information is important to help set a foundation for the need of US infrastructure in the community setting.

 

Methods

 

FREIDA, an online residency resource, was referenced to obtain contact information for all current ACGME accredited EM residency programs. Each program was asked to distribute a 14-question survey to all residents currently in training at their site. The survey was accessed through surveymonkey.com.

 

Results

 

There were 381 responses from various residency programs around the United States. When asked how often they were using US, 80% said they were performing at least one scan per shift.

The residents were asked on a scale of 1-5, 1 being “absolutely will not” and 5 being “very likely”, How likely are you to take a job that:

Does not have POCUS available?
Has a machine solely for procedural guidance?

The weighted average of responses was 1.84 and 2.18 respectively.

When asked if they felt they could be able to perform quality EM without POCUS, 65% said no, 14% were unsure and 22% said yes.

 

65% of the respondents came from programs that have EM US fellowships.

 

Conclusion

 

Residents felt that procedural guidance, echo, early obstetric, FAST and AAA were considered to have the most utility in their future practice. The majority of residents felt that they were very unlikely to take a job at a site that did not have POCUS available.  It is clear that residents believe that in order to have quality EM performed at your institution POCUS needs to be available.


Chiricolo GERARDO (Holmdel, USA), Christopher MENDOZA, Christopher RAIO
11:00 - 18:00 #7064 - A two-pronged approach to improving efficiency of patient transfer from the emergency department to the ICU in an urban hospital setting.
A two-pronged approach to improving efficiency of patient transfer from the emergency department to the ICU in an urban hospital setting.

BACKGROUND: Emergency Department (ED) volumes have been rapidly increasing, with a 40% increase in annual patient visits in the US from 1995 to 2009. Crowding is a serious problem that can impact patient care, safety, and hospital efficiency. Delays in patient transfer from the ED to the ICU have been associated with higher patient mortality rates. This quality improvement project sought to improve ICU patient transfer from the ED by implementing strategies to decrease patient length of stay (LOS) in the ED.

DESIGN AND METHODS: This project was conducted in a 232-bed urban hospital in Bronx, NY. A two-pronged intervention was implemented to reduce patient LOS in the ED by: (1) removing the SMR’s (Senior Medical Resident’s) involvement from the throughput process and (2) implementing a pull-process of sending the patient directly up to the ICU for the face-to-face nursing handoff. Trained research assistants monitored each patient’s length of stay in the ED from documented patient arrival to exit according to the hospital’s electronic recording system. Average ED LOS was monitored over time to determine if the implementation of this ED-based intervention was associated with a decrease in average patient LOS in the ED. Sepsis data was monitored over time as a marker of healthcare outcomes.  

RESULTS: Average ICU patient LOS in the ED was collected over a 15-month time period (including six months post-intervention). Since the beginning of the two-pronged intervention, average ICU patient LOS decreased from 6 hours to approximately 3 hours and 48 minutes, an overall decrease of 2 hours and 12 minutes. The implementation of the intervention was associated with a clear decreasing trend of patient LOS in the ED. In addition, sepsis data showed a marked improvement on timely administration of several treatment measures. Percent adherence of timely administration of broad spectrum antibiotics increased from 27.8% to 81.8%, timely lactate level increased from 50.0% to 90.9%, and timely administration of vasopressor increased from 60.0% to 100%. 

CONCLUSION: A two-pronged approach to reducing ED patient LOS using multi-staff buy in can improve timeliness of ICU patient transfer. This result has positive implications for both hospital efficiency and patient safety. By utilizing the power of ED-based interventions to improve patient flow, ED management can create a safer, more efficient hospital experience for critically ill patients.


Yvette CALDERON, Uttara GADDE (Bronx, USA), Susan GULLO, Magdalena CHERRY, Daisy NANTA, Frederick NAGEL
11:00 - 18:00 #7306 - A young woman with severe heart failure.
A young woman with severe heart failure.

Introduction: Peripartum cardiomyopathy (PPCM) is one of the most severe cardiac diseases and is a leading cause of maternal death. PPCM is a non-familial form of peripartum heart failure, and is characterised as an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction in the absence of another cause of heart failure, close to the end of pregnancy or in the first months after the birth (1).

We present a case report of a young woman who suffered from dyspnoea, haemoptysis, and palpitations who was diagnosed with acute heart failure resulting from PPCM in the emergency department (ED).

Case Report: A 25 year-old female gave birth by elective Caesarean section at 40 weeks to her first child. She presented to the ED three days later with dyspnoea, haemoptysis, and palpitations. The patient’s initial vital signs were: blood pressure 125/83 mmHg, heart rate 140 beats/min, respiratory rate 20 breaths/min, temperature 36.1, and oxygen saturation 95% on 3-4L/min by oxygen mask. A plain chest film showed pulmonary oedema, and ECG on admission showed sinus tachycardia. Cardiac enzymes were within normal limits. An echocardiogram revealed mitral regurgitation, dilatation of left ventricle, and general hypokinesia with severe left ventricular dysfunction (i.e., ejection fraction of 30%), but no pericardial effusion or cardiac tamponade. The patient was diagnosed as having peripartum cardiomyopathy in pregnancy, based on the echocardiogram and clinical symptoms of congestive heart failure.

Discussion and Conclusion: The diagnosis of PPCM in the current patient was based on the following criteria previously described by Demakis et al and Hibbard et al. (2,3): development of heart failure in the last month of pregnancy or within five months postpartum, no history of pre-existing heart disease, unknown etiology for heart failure, and echocardiography findings that included a left ventricular ejection fraction of less than 45% and/or 30% M-mode fractional shortening, and an end-diastolic dimension of 2.7cm/m2.

PPCM should be considered in dyspnoeic female patients of childbearing age, and should be diagnosed early to prevent fatal consequences. In addition, PPCM should be excluded from other diseases associated with the reduced ejection fraction. PPCM is a rare disease, but due the risk of acute heart failure it should be considered in patients with suspect symptoms. Physicians should be appropriately educated with echocardiography on PPCM symptoms so that it can be diagnosed and treated early.  

References

1. Sliwa K, Hilfiker-Kleiner D, Petrie MC, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: a position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12(8):767-78.

2. Demakis JG, Rahimtoola SH. Peripartum cardiomyopathy. Circulation 1971;44(5):964-8.

3. Hibbard JU, Lindheimer M, Lang RM. A modified definition for peripartum cardiomyopathy and prognosis based on echocardiography. Obstet Gynecol 1999;94(2):311-6.


Adnan YAMANOGLU, Dr Sumeyye CAKMAK (İSTANBUL, Turkey), Ozgur SOGUT
11:00 - 18:00 #8246 - Abdominal pain: time for a second chance?
Abdominal pain: time for a second chance?

Objective Abdominal pain evaluation in the emergency department (ED) is difficult and sometimes we can´t find a precise diagnosis. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible process breakdowns.


Design We conducted a retrospective chart review of ED patients >18 years at an tertiary academic hospital. We reviewed patients admitted in ED in November and Dicember 2015. A computerised ‘trigger’ algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and(2) had a return ED visit within 10 days that led to a hospitalisation.

Results During the months of November and December 2015 19702 visits were recorded to the emergency room, within which, abdominal pain was the main complaint in 1653 visits (8.39%).820 visits (753 patients) with abdominal pain as presenting complaint were recorded in one month (analyzed period between 15 November and 15 December 2015). The average age of patients analyzed is 52.48 years (standard deviation: 21.7,minimum age 15 years,maximum age 104 years). During the period analyzed 82 patients (10.89%) were attended by abdominal pain in the first visit to the emergency room and later returned in a period ≤ 10 days Of this total, after the next visit, the final diagnosis was significantly changed in 40 patients (49%). Of the 82 patients who were evaluated in the ED in ≤10 days, 10 patients (12%) required emergency surgery after diagnosis on the second visit. Pathologies requiring surgery were: cholecystitis (4), Abscesses (3), Appendicitis (2), intestinal obstruction (1).Conclusions Abdominal pain continues to pose diagnostic challenges for emergency clinicians. In many cases, the differential diagnosis is wide, ranging from benign to life-threatening conditions.. Associated symptoms often lack specificity and atypical presentations of common diseases are frequent, further complicating matters.

 


Hector ALONSO-VALLE (, ), Andrea CERVERO, Francisco MATEOS, Enrique PERAITA, Luis PRIETO, Maria GONZALEZ
11:00 - 18:00 #7298 - Ability of emergency residents to identify and localize regional wall motion abnormalities in acute myocardial infarction.
Ability of emergency residents to identify and localize regional wall motion abnormalities in acute myocardial infarction.

Background: The ability of resident emergency physicians to identify regional wall motion abnormalities is unknown. We hypothesized that EM residents would show proficiency with limited training in identifying the presence as well as the location of regional wall motion abnormalities (RWMA) in AMI.

Methods: After reviewing a brief instructional module on RWMA, 9 EM residents analyzed 45 consecutive comprehensive echocardiograms on patients that were taken emergently to the cardiac catheterization suite for ST-elevation MI.  For each study, they responded to questions: 1) is there a RWMA present? (Yes, Maybe, or No) and 2) where is the RWMA located? (Anterior, Inferior, Lateral, Septal, or N/A).  They received 1 point for a correct “Yes” or “No” answer, and 0 points for an incorrect answer, for a total possible score of 90 points. An answer of “Maybe” was only considered valid if the resident localized the RWMA correctly.

Results:  Assuming a competency cut off of 70%, 7/9 ED residents posted a score demonstrating proficiency (Range 57-81%).  All 9 ED residents demonstrated proficiency in identifying the presence of a RWMA (Range 73-89%). 

Conclusion: EM residents with limited training are able to identify both the presence as well as the location of RWMA in patients that have sustained an AMI.  Their ability to identify the presence of a RWMA alone is even more favorable. Phase II of this trial is currently underway and aims to prospectively validate this educational intervention.

References

  1. A. E. Jones, V. S. Tayal, and J. A. Kline, “Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study,” Academic Emergency Medicine, vol. 10, no. 10, pp. 1054–1058, 2003.
  2. P. Sabia, A. Afrookteh, D. A. Touchstone, M. W. Keller, L. Esquivel, and S. Kaul, “Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction. A prospective study using two-dimensional echocardiography,” Circulation, vol. 84, no. 3, pp. I85–I92, 1991.

Acknowledgements: No conflicts of interest.


Peter CROFT (Portland, Maine, USA), David MACKENZIE, Strout TANIA, Samip VASAIWALA
11:00 - 18:00 #7875 - Aborted sudden cardiac death due to ventricular fibrillation in a patient addicted to supplements.
Aborted sudden cardiac death due to ventricular fibrillation in a patient addicted to supplements.

BACKGROUND: Sudden cardiac death (SCD) represents about one-fifth of all mortality in industrialized countries and still remains a major public health issue. Most of SCDs are caused by ventricular fibrillation (VF) and asystole. We experienced the case of ventricular fibrillation of walk-in visit patient while performing ECG examination. We introduce the case of VF due to hypokalemia induced by supplements abuse.

OBJECTIVE: This is a case of aborted sudden cardiac death due to ventricular fibrillation in emergency room. The purpose of this report is to heighten suspicion against not only prescribed drugs or illicit drugs but also on-the-counter supplements as a cause of ventricular fibrillation for all emergency physicians.

CASE REPORT: 56-year-old woman was presented to our hospital because of her continuous chest pain. She began to feel her chest tightened 3 years ago. She was diagnosed as vasospastic angina and followed up without medication. While her examination of ECG, a seizure was developed and ECG showed ventricular fibrillation. Cardiopulmonary resuscitation was started and successfully returned her spontaneous circulation after once of electrical cardioversion. Emergent coronary angiography was performed, found no significant coarctation. Blood examination showed hypokalemia of 2.8mEq/L, the cause of this hypokalemia was abuse of several supplements that claim a great effectiveness on constipation. Intracoronary acetylcholine spasm provocation test revealed the spasm of left anterior descending branch and the high lateral branch. There were no endocrine abnormalities, and serum potassium value was normalized by discontinuation of the supplements. She was discharged without any delayed effect, and she has not experienced the subsequent angina or fatal arrhythmia after discharge.

DISCUSSION and CONCLUSION: This was a case of aborted sudden cardiac death caused by ventricular arrhythmia due to addiction to supplements. In clinical practice, hypokalemia is a common electrolyte abnormality and known as one of the causes of lethal arrhythmia. The use of digitalis or coronary ischemia increases the risk of fatal arrhythmia in hypokalemic patient. In this patient, vasospastic angina was merged with hypokalemia associated with the addiction of supplements, resulting in triggering ventricular fibrillation. Hypokalemia can be critical in patients with heart disease, we should listen to the history, not only medications or illicit substances but also on-the-counter supplements as the cause of the hypokalemia and lethal arrhythmia.


Daisuke NISHIOKA (Nagareyama, Chiba, Japan), Keitaro GOTO
11:00 - 18:00 #7532 - Accidental Ingestion of Digitalis Tea.
Accidental Ingestion of Digitalis Tea.

It is not surprising that there are frequent cases of mistaken identity when amateurs decide to pick their own wild flora herbal remedies. It is also not common for these mistakes to be life-threatening. We present here a case of life-threatening accidental toxic ingestion in an urban environment.

Wild Comfrey (Symphytum officinale) grows in the UK and throughout Europe and temperate Asia. It is frequently used in herbal remedies brewed into a tea and has throughout history been thought to treat many ailments. It was actually named after its supposed ability to assist in bone healing (Greek symphis – the growing together of bones). Unfortunately, during Spring in particular, the thick leaves are very difficult to distinguish between Comfrey and the foxglove (Digitalis purpurea) the plant from which the cardiac glycoside, digoxin is extracted. Reviewing the literature this appears to be a more common problem in China where herbal medicine is more common. It is illustrative to examine the pictures of both plants.

Case report

MM a 53 yr old female presented to the Emergency Department complaining of 12 hours of severe lethargy and feeling presyncopal on standing. The patient had no prior comorbidities but had been suffering from insomnia and was advised by a friend to try a herbal tea made from Comfrey at night. MM duly picked the leaves as instructed and ingested the brewed tea in the evening.

MM was bradycardic at a rate of 40 to 70 and without heamodynamic compromise. Her ECG (shown here with patient consent) showed Mobitz type 2, second degree heart block with t-wave changes consistent with digoxin effect. Her serum digoxin level was 5.3 μmol/L (therapeutic range for digoxin is 1.2-2 μmol/L) and normal potassium.

Not all hospitals stock supplies of the Digoxin antidote, digoxin binding antibodies, and so there were significant delays acquiring the therapy. During this period the patient remained stable while supine without deterioration or improvement in her brady-arrhythmia. Following treatment with ‘Digi-fab’ the patient was in sinus rhythm by the next morning.

Discussion

It is frequently easy to forget that in our urban environment that the wildlife can still be dangerous. This case report serves to highlight a few useful lessons: -

-          It would have been easy to miss or dismiss the herbal remedy part of the history, believing the patient had another cause of new onset arrhythmia.

-          Homemade ‘herbal remedies’ are not as benign as many believe. Especially when the identification and preparation is so easy to get wrong. It is also impossible to know what dose the patient has had.

-          Procuring digoxin binding antidote frequently takes prolonged period in the UK as it is not always stocked locally.


Matt EDWARDS (London, United Kingdom), Mathew VITHAYATHIL
11:00 - 18:00 #7909 - ACCORDING TO CARDIAC DYSFUNCTION, WHAT GROUP HAS INCREASED MORTALITY DURING HOSPITAL STAY?.
ACCORDING TO CARDIAC DYSFUNCTION, WHAT GROUP HAS INCREASED MORTALITY DURING HOSPITAL STAY?.

Introduction
Acute heart failure (AHF) is a common reason for consultation in the emergency services and the leading cause of hospitalization in the elderly. This leads to increased mortality, use of emergency services and health spending.

objective
Knowing hospital mortality according to the type of heart failure in our emergency department.

Material and methods
It is a prospective, observational, descriptive study without intervention in patients who come to our emergency department in the period 2012-2014 choosing two randomized months per year, with a diagnosis of heart failure according to Framingham criteria. Within the inclusion criteria included patients older than 18 years with acute heart failure and give their signed consent. The study variables were: sex, type of heart failure echocardiography as previously described in your medical record (systolic, diastolic, mixed or unknown) and hospital mortality.

Results
During 2012-2014 consulted selected from 119 patients with acute heart failure, of which 57 were women (47.9%) and 62 men (52.1%).
Depending on the type of cardiac dysfunction: 31 patients (26%) had systolic failure, 10 patients (8.5%) diastolic failure, 52 patients (43%) mixed failure and 26 patients (21.84%) of unknown origin.
The hospital mortality was 10.93% (13 patients: 6 men and 7 women), within this group, 2 patients had systolic dysfunction (15.38%), 2 diastolic (15.38%), 4 mixed (30, 77%) and 5 unknown (38.67%).
The hospital mortality compared to the total of all patients diagnosed with heart failure in our emergency department, it was observed that 20% had diastolic heart failure, systolic dysfunction 6.45% and 7.69% mixed dysfunction.

Conclusions:
- Do not objectify a big difference in sex.
- Diastolic heart failure may be a risk factor for hospital mortality.
- Almost half of the patients with previous ultrasound, have a mixed heart failure.
- ICA-hospital mortality is 10.93%, still very low compared to total mortality.
- No differences in hospital mortality observed for systolic HF and mixed.


Patricia SUAREZ-BEKE, Paula LAZARO-ARAGUES, Jose Andres SANCHEZ-NICOLAS, Irene PAGAN-GOMEZ, Jose Luis OTERO URIBE, Rafael QUITANILLA-LOPEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7461 - Accuracy of Alert times in major trauma patients could save substantial amount of money!
Accuracy of Alert times in major trauma patients could save substantial amount of money!

Background:

In the management of major trauma time to the treatment is of utmost importance. This time starts from the time of injury to the time patients receive specialist care. Traditionally all these suspected major trauma patients are received by a trauma team consisting of multiple specialities. The idea of having trauma team is that patient receives best possible care and in timely fashion to improve the outcome.

 

Objective:

 

Primary:

To analyze the data of expected time of arrival (ETA) and actual time trauma arrives in Resuscitation room.   

Secondary:

To estimate the delay in ETAs, which in turn results in human resources unavailable, for clinical work.

 

 

 

Method:

 

We did a retrospective analysis of the notes from 1st July 2015 to 31st August 2015 at UHB.  All adult major trauma patients were included in the study.

 

 

Results:

 

We had a total of 198 patients presenting during this time but only 82 were included due to insufficient record on trauma alert sheet. We had 39 females (20%) and 159 male (80%) with mean age of 50years. The most common single body region involved was the head 23% followed by chest injuries 10% rest had multiple regions involved.

We had only 7% patients arrived within the expected time with 5 minutes margin. Rest of the 93% patients were delayed to a varying length ranging from 6 minutes to 65 minutes with the mean delay of about 36 minutes.

 

Conclusion:

 

In the management of major trauma patients every minute counts. Based on the pre hospital information there might be a theater on standby or surgical team to delay their list, which has its own impact. In general the trauma team in our ED consists ED consultant, Trauma registrar, ITU registrar, Trauma SHO and Trauma HO and 3 nurses. Now a mean delay of 36 minutes in 81 trauma patients will add up to 121 man hours for each clinician and nurse. This in total will add up to 607 man-hours for clinicians and 363 hours for nurses while dealing with 81 major trauma patients, which have been unproductive. We see about 1000 major trauma patients per year and this will lead to 1000s of hours and thus thousands of pounds wasted which potentially can be saved. The above data is for 2 months only but if done over the whole year the results could look even more concerning. We believe in view of above figures the pre hospital team should endeavor to improve the accuracy of the alert times.


M Azam MAJEED (Birmingham, United Kingdom), Mohammed TUHIN, Asif NAVEED, Qasim ALI
11:00 - 18:00 #7344 - Accuracy of emergency physician renal ultrasound in the diagnosis of hydronephrosis : prospective study in comparison with radiologist ultrasound.
Accuracy of emergency physician renal ultrasound in the diagnosis of hydronephrosis : prospective study in comparison with radiologist ultrasound.

Introduction

A renal ultrasound (RUS) is mandatory in renal colic (RC), acute pyelonephritis (AP) and acute renal failure (ARF) in search of a hydronephrosis because management would be different. Studies have explored performances of emergency physician (EP) renal ultrasound (EPUS) compared to computed tomography (CT) but not compared to radiologist ultrasound (RUS). The goal of this study was to evaluate performance of EPUS compared to RUS in the diagnosis of hydronephrosis. EP had different formations and experiences.

Patients and methods

Inclusion criteria

suspected RC, AP or documented ARF

Exclusion criteria

US almost done

absence of RUS

end of life

Methods

It was a non interventionist study which was approved by the Ethics committee. After inclusion and informed consent, an EPUS was performed. A RUS was then performed, the radiologist being blind to EPUS result. Only the RUS result was used for the management of the patients

The primary objective was sensitivity and negative predictive value (NPV). Secondary objectives were specificity, positive predictive value (PPV) and quantification of the hydronephrosis. The required number of subjects for sensitivity 0.9 with alpha risk 0.05 and beta 0.10 was 38.

Statistical methods

Values stored in Microsoft Excel were analyzed with Graphpad. Numerical data expressed as mean + SD were compared by a Student t test. Categorical data by a Khi2 test. P< 0.05 was considered significant.

Results

55 patients were included, 5 excluded because of lack of RUS. Age was 47 + 22 years, sex ratio 1. There was 31 RC, 9 AP and 10 ARF. Sensitivity and NPV were 100% (CI95% [79.1-100%]) and 100% (CI95% [81.5-100%]) respectively. Specificity and PPV were 67.9% (IC95% [47.6-83.4%]) and 71% (IC95% [52.8-81.5%]), respectively. For 19 patients with hydronephrosis, measurement was done in 16, there was no difference (p=0.71)

Discussion

In our department, sensitivity and NPV allow to not confirm the normal result by a RUS. However, in case of hydronephrosis found at the EPUS, a confirmation by a RUS or a non injected CT is warranted because of the lack of specificity. The absence of difference between hydronephrosis measurements could be due to a lack of power. Although non evaluate in this study, the time saving would be important in case of EPUS alone. Formation of the EP has to be improved to enhance the specificity.


Philippe LE CONTE (Nantes), François MOUNIER, Idriss ARNAUDET, François JAVAUDIN
11:00 - 18:00 #7473 - ACID-BASE EQUILIBRIUM ANALYSIS IN PATIENTS WITH ACUTE BURNS INJURIES: CASE SERIES.
ACID-BASE EQUILIBRIUM ANALYSIS IN PATIENTS WITH ACUTE BURNS INJURIES: CASE SERIES.

Introduction: Patients with acute thermal injuries have physiological disorders that make difficult characterizing their acid-base status and identifying factors of poor prognosis.  Studies with non-conclusive results have being done on base deficit (BD) and a serum lactate.  Due to the complexity of the pathophysiological characteristics that define burn patients; the physic-chemical analysis of the acid-base status may hypothetically provide a higher accuracy in detecting metabolic and perfusion disturbances as well as in predicting bad outcomes than the other methods.

 

Methodology: We performed the acid-base analysis of 15 patients older than 15 years-old, with a burned body surface area greater than 20% that were admitted to a burn intensive care unit within 48 hours after the injury. The analysis was performed by using three methods: 1) Conventional method based on Henderson-Hasselbalch’s theory, 2) Anion-Gap (AG),and albumin-corrected AG, and 3) Physic-chemical approach of Stewart’s acid-base state theory.

 

Results: After using the Henderson-Haselbach’s method: 8 patients had metabolic acidosis, 4 patients had a low BD, 5 patients had medium BD, and 5 patients had severe BD elevations. When AG analysis was performed, only 5 patients showed an abnormal AG. In contrast, implementing the albumin-corrected AG it increased the number of patients with abnormal AG to 13 patients. Strong-ion difference was abnormally elevated in all the patients.

 

Conclusions:A higher agreement between abnormal acid-base statuses was observed when using the albumin-corrected AG method and Physic-chemical approach of Stewart’s acid-base state theory. 


Luis Arcadio CORTES-PUENTES (BOGOTA, Colombia), Gerardo LINARES-MENDOZA, Norberto NAVARRETE, Maria Victoria NIETO
11:00 - 18:00 #8243 - Activities of Croatian Nurses Society of Emergency Medicine.
Activities of Croatian Nurses Society of Emergency Medicine.

Croatian Nurses Society of Emergency Medicine (CNSEM) was established in 2014 on the initiative of nurses and medical technicians who work in emergency medicine service and emergency departments. The main objective of activities of CNSEM is focused on professional training of nurses and technicians in emergency medicine. Over the past two years CNSEM has organized numerous training in emergency medicine for EMS teams, education of triage in the department of emergency medicine in accordance with the standards of education prescribed by Croatian Institute of Emergency Medicine. Educational programs are designed to provide specific knowledge and skills needed for a work at emergency medicine system. In addition, there were two courses called school of emergency medicine on the topic cardiorespiratory diseases, and care of trauma patient. There are plans for another 4 modules of school. This year was organized the congress of emergency medicine with international participation, in cooperation with Croatian Medical Association Croatian Society for Emergency Medicine, which brought together 320 participants. CNSEM has almost 300 members who actively participate in society activities. The Society cooperates with Croatian Institute of Emergency Medicine, and with other professional associations from Croatia and Slovenia. Also CNSEM joined the European Society of Emergency Nursing, and it is open for collaboration with another Society from another countries. Activities that are done provide better care for emergency patients.


Damir VAZANIC (ZAGREB, Croatia), Furdek DAVORKA
11:00 - 18:00 #8043 - Acute aortic dissection.
Acute aortic dissection.

Introduction :

Acute aortic dissection (AAD) is a medical emergency with a high mortality rate. It usually presents with severe, unrelenting chest pain of sudden onset.There are several different formats of classification for thoracic aortic dissection; the most commonly used is the Stanford Classification which divides the dissections into 2 types: A - dissection originating in the ascending aorta; B - dissection originating in the aorta distal to left subclavian artery.

Case report:

A 60 year-old man, presented to the emergency department of our hospital with complaints of sudden severe chest pain. His past medical history revealed uncontrolled essential hypertension and diabetes associated with noncompliance with medication and appointments. The pain was described as a retrosternal cramp without irradiation.

On physical examination, the patient was conscious, temperature and blood oxygen saturation were normal. Pulse and respiratory rates were 69/minute and 18/minute, respectively. Blood pressure was 100/50 mmHg in left arm and 150/90 mmHg on the right side. There was no jugular venous distension.His extremities were warm to the touch, with no pallor, finger clubbing or cyanosis. Pulses were symmetrical and there was no peripheral oedema. There was no femoral sound. The abdomen was soft without defence. The rest of the exam was unremarkable. Initial EKG showed a sinusal rhythm with signs of right ventricular infarct. An acute coronary syndrome was mentioned, but an aortic dissection couldn’t be eliminated. Therefore, the patient received the Nicardipine to control a systolic tension (less than 110 mmHg), a titration of Chlorydrate of Morphine and EKG monitoring. The patient’s clinical condition was unchanged, except for a pulse deficit on the left side of his body, a finger cyanosis in the left hand and the patient described a lump parasthesis. The EKG was dynamic with rhythmic alternation, axis changes and Nonspecific T wave modification. The diagnosis of acute aortic dissection was probable.

The Patient was subsequently planned for Computed Tomographic angiography, which showed normal coronary arteries but aortic dissection Stanford type A starting from the aortic valve to the iliac bifurcation and extending to the supra aortic trunks, coeliac trunk and to the superior mesenteric artery. The patient was planned for aortic root replacement with aortic valve conduit and reimplantation of coronary arteries, electively. The patient was urgently transferred to cardiovascular unit. There were no changes in his clinical condition during transport, but while being placed on the operating table, he went into cardiac arrest with unsuccessful reanimation.

Conclusion:

Although aortic dissection is an uncommon entity, its outcome is frequently fatal and many patients with aortic dissection die before diagnosis. When left untreated, about 33% of patients die within the first 24 hours, and 50% die within 48 hours.


Zied GUERMAZI (Trévenans), Sarra JOUINI, Hana HEDHLI, Imene MEKKI, Houda NASRI, Rim HAMMAMI, Bechir BOUHAJJA, Rym HAMED
11:00 - 18:00 #8202 - Acute aortic dissection: unusual presentation in the emergency department.
Acute aortic dissection: unusual presentation in the emergency department.

Introduction:

Acute aortic dissection (AAD) is a critical disease state requiring immediate diagnosis and optimal treatment.  We describe a case of acute type A Stanford aortic dissection with an unusual presentation.

 

Case report:

A 70-year-old man with no medical history presented to the emergency department with agitation that occurred one hour before admission. There were no history of chest pain or dyspnea, no recent trauma and no toxic use. On physical examination, the patient was afebrile, his blood pressure was 100/60 mmHg in the left arm, and not detectable in the right arm without signs of acute ischemia. The pulse was 47 beats per min. Respiratory rate 20 times per min with an oxygen saturation of 98% on air room.  He was agitated, but there was no neurological impairment. His pupils were round, equal, and reactive to light and accommodation. Moreover,  a swinging right cervical mass was found. There were no signs of acute heart failure. The abdomen was soft, non-distended, and mildly tender without rebound or guarding. Electrocardiogram, chest x-ray and blood gas analysis were normals.

An ultrasound of the supra aortic arteries was performed and showed a dissection of right brachio-cephalic arterial trunck with floating membrane image and an obstruction of right sub-claviar artery.

Computed tomography (CT) scan confirmed a Stanford type A dissection with anevrysmal ascending  aorta. The patient underwent urgent surgery and experienced a successful outcome. He was discharged from the intensive care unit a week after his surgery.

 

Conclusion:

Emergency physicians are especially challenged by diseases that require urgent treatment like aortic dissection. Misdiagnosis leads to delay of diagnosis, and exposure to inappropriate treatment. Emergency physicians should consider this diagnosis even in the absence of a typical presentation.

 

 


Aymen ZOUBLI, Hanen GHAZALI, Rania JEBRI (Lyon), Farah RIAHI, Ahmed SOUYAH, Anware YAHMADI, Wided BOUSSELMI, Moez MOUGAIDA, Sami SOUISSI
11:00 - 18:00 #7253 - Acute confusion: A case report.
Acute confusion: A case report.

Acute confusion is a clinical syndrome which is difficult to define exactly, but involves an enormity of thought, perception and levels of awareness.

It is typically of acute onset and intermittent. Both hyperactive and hypoactive delirium is rarely recognised and often patients exhibit features of both. Episodes of confusion with memory loss and temporary amnesia are frequent symptoms of brain disease and varied etiology.

Among the more common causes are: head trauma, senility and dementia, defused vascular disease of the brain, metabolic disturbances which effect the brain such as; hyperglycaemia, intoxication – such as acute alcoholics, alcoholism, psychomotor epilepsy and postictal state of seizures caused by brain tumour and other diseases.

We present a case of a 50 year old gentleman who presented to the emergency department with acute confusion. His friend found him at home; confused, disorientated and aggressive. He wasn’t communicating verbally, although he was his normal self the day before. He had past medical history of kidney stones, depression and anxiety. He was on Lamotrigine and Quetiapine.

On examination his airway was clear, his chest examination did not show any abnormality, respiratory rate was 15 per minute with oxygen saturation of 97% on air. Abdominal examination showed no abnormality. Pulse rate was 60bpm with BP 129/54. GCS of 12/15. Initial presentation was acute confusion state. A CT head and MRI head was performed which was found to be normal. His chest x ray was normal. His bloods were normal; urea 9.3, creatinine of 90 and Creatinine Kinase 1217.

He was diagnosed to be suffering from drug induced rhabdomyolysis, his medication was stopped. The patient improved and was discharged home.

Conclusion:

Acute confusion may be caused by many reasons, but it is uncommon to find somebody developing rhabdomyolysis on Lamotrigine and Quetiapine. 


Inayat REHMAN, Mohammad ANSARI (Birmingham, United Kingdom), Ahmad ISMAIL
11:00 - 18:00 #7233 - Acute coronary syndrome presented with an only presentation of exertional headache.
Acute coronary syndrome presented with an only presentation of exertional headache.

Introduction:
Pain above the nose or below the navel is rarely cardiac in origin. Cardiac cephalalgia means that a case of headache is presented where the underlying cause was cardiac ischemia. This is a very rare syndrome and the mechanism is still unknown now. This time, we presented a case of acute coronary syndrome (ACS) with an only presentation of exertional headache of sudden onset.

Case report:
A 64-year-old female with past medical history of diabetes mellitus and end-stage renal disease under regular hemodialysis presented with severe headache of sudden onset while exercise for one hour prior to admission. Diaphoresis was noted at triage. She denied chest pain or tightness. She denied similar history before. Initial vital signs were T 36.5℃, pulse rate 90/min, respiratory rate 18/min, BP 103/59 mmHg. Physical examination showed no remarkable findings. Due to the suspicion of brain lesion, such as subarachnoid hemorrhage, emergent brain computed tomography (CT) was arranged. Emergent brain CT revealed no obvious intracranial lesion. Patient still complained of severe headache one hour after morphine 5 mg IM . Under the consideration of electrolytes imbalances or cardiac ischemia, ECG and blood exam were arranged. ECG revealed ST elevation of lead aVR and multiple ST depressions of lead I, II, III, aVF, and V2~V6. Previous ECG 2 months ago revealed normal sinus rhythm without ST-T changes. Laboratory data showed troponin I 1.05 ng/mL (Nromal: < 0.11). Coronary angiography was performed by cardiologist. The result showed 80% stenosis of right coronary artery (RCA) and 99% stenosis of left circumflex artery (LCX). Both percutaneous transluminal coronary angioplasty and bare-metal stent were applied for RCA and LCX. Her headache was relieved well after stenting. Then the final diagnosis was confirmed as severe headache of sudden onset due to ACS. She was under regular follow up at cardiovascular outpatient department without complications.

Discussion:
When the headache occurs as the only manifestation of an acute coronary event, the clues for suspicion are: (1) older age at onset, (2) no past medical history of headache, (3) presence of risk factors for vascular disorders, (4) onset of headache under stress.


Jiun-Jia CHEN (Taichung City, Taiwan)
11:00 - 18:00 #7390 - Acute epiglottitis in adults: Who needs airway intervention?
Acute epiglottitis in adults: Who needs airway intervention?

Objective:

Acute epiglottitis is a potentially life-threatening condition as an airway emergency, therefore early diagnosis and airway management are essential.

Although laryngoscopy is the gold standard for the diagnosis of acute epiglottitis, this invasive procedure can be dangerous and sometimes hard to perform for emergency department (ED) physicians. In this context, we investigated how the clinical manifestations and X-ray findings can contribute to the diagnosis and proper airway management in patients with acute epiglottitis.

 

Methods:

We conducted a retrospective chart review of patients with acute epiglottitis aged 18 years or above at the presentation who visited our ED between 2005 and 2014.

We evaluated the number of days between the onset and the ED visit, signs and symptoms (sore throat, dysphagia, salivation, dyspnea, muffled voice, and stridor), and examination findings (the width of the epiglottis (EW) on lateral neck X-ray and the degree of swelling of the epiglottis on laryngoscopy).

 

Results:

Out of the 47 patients identified in this study, 10 required airway intervention such as tracheal intubation, tracheotomy, or cricothyroidotomy. More than half of the patients visited the ED within one day of onset. Dyspnea was seen with higher frequency in the patients with airway intervention (90% in the airway intervention group vs 24% in the non-airway intervention group, p<0.01).All of those diagnosed with severe swelling of the epiglottis on laryngoscopy required airway intervention. Lateral neck X-ray was taken in 29 patients, 4 of whom required airway intervention. EW was 7mm or greater in 28 of them. The median value of the airway intervention group (4 patients) and the non-airway intervention group (24 patients) were 25.5mm (interquartile range (IQR), 22.3-30.25) and 11.2mm(IQR, 9.3-18) respectively, significantly greater in the airway intervention group (p<0.01).EW was 20mm or greater in all four patients with airway intervention who underwent lateral neck X-ray.

 

Conclusions:

Patients without dyspnea on arrival are more likely to be treated without airway intervention. Lateral neck X-ray can be helpful both in the diagnosis of acute epiglottitis and in the prediction of those who require airway intervention.


Ryuhei IGETA (Fukui, Japan), Makoto SERA, Taizo NAKANISHI, Hideya NAGAI, Hideyuki MATANO, Shinsuke TANIZAKI, Shigenobu MAEDA, Hiroshi ISHIDA
11:00 - 18:00 #8260 - Acute ischemia of left lower limb and massive pulmonary embolism.
Acute ischemia of left lower limb and massive pulmonary embolism.

Man of 47 years old is brought by ambulance with paraesthesia at the shank and left foot, sudden feels dizziness. He has no previous medical history. As risk factors we have: smoking, caffeine user, stress, sedentary (truck driver).

At at primary evaluation in emergency department patient is conscious, responsive, AV = 98b / min, TA = 160 / 112mmHg, SaO2 = 98% TC = 36.6C, slightly anxious. Secondary evaluation highlights at the examination of the left lower limb following items: local paleness, cold, lack of pulse in pedia artery, posterior tibial artery, popliteal artery, femoral left artery and paresthesia. A few minutes after arrival clinical condition suddenly worsens, patient is showing : dyspnea, tachycardia (AV = 126b / min), paleness, TA = 120/104 mmHg, SaO2 = 86% D-Dimer> 5ug / ml and EKG BRD with SI QIII, TIII. Patient receives 5000 IU intravenous heparin bolus and CT angiography with contrast agent is performed (thorax and abdomen with pelvis) that highlights the pulmonary artery trunk of 31mm caliber, APD and APS 26mm caliber. Endoluminal thrombus in the pulmonary arteries, extended at the level of superior lobar arteries that are completely obstructed, extended also to the bilateral lower lobar and right middle artery with their branch segments almost completely obstructed. Aorta and collateral branches permeable of normal size. Common iliac artery, internal and external permeable with calcified atheroma and segmental stenosis in the internal iliac. Right common femoral artery permeable in the incipient segment with parietal thrombus occluding in a proportion of about 30%. Left common femoral artery shows an intraluminal clot wich completely obstructs. Retractile fibrous lesion in the right posterior sinus phrenic rib. Several nodules in the bilateral pulmonary area. Trachea and main bronchi free. Without fluid in the pleural cavity.

Conclusion: massive pulmonary embolism and acute ischemia of the left lower limb

Is administered intravenously thrombolytic (Actylise) with restore circulation in left lower limb and local,general and pulmonary symptom relief (warm skin; disappearance of paleness, paralysis, pain and mild paresthesia; SaO2 99-100%; without dyspnea and tachycardia). Patient is  hospitalized in coronary intensive care for therapeutic and clinical monitoring.


Florica POP (Arad, Romania), Monica PUTICIU, Johanna Elizabeth KATAI
11:00 - 18:00 #7750 - Acute liver failure, a diagnosis from Emergency Department.
Acute liver failure, a diagnosis from Emergency Department.

Male 25 years old attended the Emergency Department because of 10 days with fatigue, debility, abdominal swelling, fever and jaundice.

No epidemiological, food contact, history risk, travel abroad or consumption of toxic substances or drugs.

In the blood analyse we saw acute liver failure. The ultrasound of his abdomen not found any pathology. Hospitalisation on Digestive service is advised and general supportive measures should be employed.

During his stay in the service of Emergency he suffers repeated episodes of hypoglycemia with clinical deterioration and signs of hepatic encephalopathy.

 

Exploration: Normotensive, jaundice skin and mucous membranes. Eupneic. Bleeding active in areas venipuncture. Abdomen painful with hepatomegaly.

 

We decide to call to the ICU, “zero code transplant” was activated and a successful liver transplant performed at 5 days after admission.

 

Additional tests to filial the origin of failure were all negative (positive serology, toxic, Wilson disease, autoimmunity, liver biopsy, negative bone marrow puncture).

At 20 days after discharge came to the emergency by fever without any focus of it. On blood analyse we could see pancytopenia. And we look for the liver biopsy results, it was non-Hodgkin's B-cell lymphoma, Immediately we contact with hematologist who comes to treat starting QMT.After several cycles of QMT now he is free of disease.

 

CONCLUSION:

NHL as a cause of fulminant liver failure is a rare presentation. Clinically the suspects of it is difficult because of the rapid and aggressive course. Also in this case show an atypical presentation, without lymphadenopathy or B symptoms except fever. Would he have been transplanted if he had NHL diagnosed before?


Veronica PARENT MATHIAS (MALAGA, Spain), Maria Isabel CORREA ROSALES, Maria Del Mar BECERRA MAYOR, Lorea DE UNAMUNO LUMBRERAS
11:00 - 18:00 #4505 - Acute myocardial infarction in a young male with prothrombin gene mutation.
Acute myocardial infarction in a young male with prothrombin gene mutation.

G20210a mutation of prothrombin gene results in difficulty in degradation of prothrombin and favours a procoagulation state that increases the risk of thrombosis. Although it is a relatively frequent cause of venous thromboembolic disease, we present here a case report of myocardial infarction caused by coronary occlusion from a thrombotic clot in a patient with this mutation.

We received in the A&E department a 36-year-old male with previous history of knee injury followed by a pulmonary embolism. He was on acenocumarol and had the INR within normal limits. He complained of atypical chest pain of three-hour long. He had no changes in initial ECG, and blood samples and chest X-ray were performed following the initial examination. After a sudden worsening of his pain he suffered two episodes of cardiac arrest with ventricular fibrillation that were defibrillated with 200J discharge to defibrillate them, with ST elevation in the new ECG performed. The patient was trasferred to the Intensive Care Unit, where an episode of ventricular tachycardia was treated with IV amiodarone and magnessium sulfate. Cardiac catheterization was performed, finding an occlusion of the circumflex artery that was treated with a stent after previous administration of clopidogrel. He was discharged home 1 week later.


Luis Ángel MATEOS VEGA (Valencia, Spain)
11:00 - 18:00 #7098 - Acute myocardial infarction related Duchenne disease. How usseful are STEMI guideline?
Acute myocardial infarction related Duchenne disease. How usseful are STEMI guideline?

Background. Cardiac impairment and events are common to muscular dystrophy (Duchenne) patient, left ventricular remodeling and dilatation, heart failure, arrhythmias, but vascular disease in cardiac damage determinism is not a leading cause.

The aim of the paper are, firstly, to present an exceptional rare event in DMD – acute myocardial infarction, with atypical presentation in context and related diagnostic and therapeutic strategies implemented.

The second intention are to analyze how useful are STEMI guideline for pediatric patient with particular disease causing this event

Finally, we targeted obtaining the best explanation of the phenomenon determinism, how to differentiate aspects of myocardial damages and interpret clinical and paraclinical findigs.

Case presentation. We are presenting a 11 years old boy case with confirmed muscular dystrophy Duchenne, no history of cardiac events, moderate mental retardation, with beta – blockers and corticosteroids treatment, addressed in ED University County Hospital Craiova for upper abdominal pain and vomiting from 8h.

ECG -typical STEMI changes - postero inferior MI, minor RBB.

Troponin T initial level – 2000ng/ml, increasing to 17000 – 30000 ng/ml, decreasing later

NT – pro BNP – 1585pg/ml

Echocardiography –basal septum, posterior and inferior wall hypokinesis, reconnected after 3 days

Emergency coronarography - coronary artery with normal flow, no obstruction, no AMI confirmed

LVEF – under 35%

RMI - multiple cicatricial zones, specific DMD aspect cardiomyopathy

As therapeutic decision – with no guideline recommendation about trombolytic therapy regarding pediatric patient, primary PCI performed after immediate air evacuation to a reference pediatric cardiac center, under heparine subcutaneous administration.

ACE inhibitors (lisinopril) added to treatment

A double dosage of corticosteroids decided for medium period of time

Taking into account acute heart failure – beta blockers withdrawal

Conclusions

Some hypothesis where taken under consideration:

Accelerated apoptosis associate to maldistribution due to cardiomyopathy and decreased LVEF– the most possible hypothesis, well sustained by DMD stage of evolution, age of patient, RMI aspects

Arrhythmia event inducing hipodyastolic insufficiency – not documented

Long term corticosteroids therapy, collateral effects on vessels – not excluded as associate factor

Vasculitis - no founding inflammatory elements or coronarography evidences

Lerning points

Very rarely an acute myocardial infarction cited as a cardiac event related DMD. Evan when ACS confirmed, highly probability it that is not a coronary artery disease involved but, apoptosis events are commonly unpainfull

Cardiomyopathy, ubiquitary in DMD and associate with myocardial fibrosis, are not usually related to CAD

In that circumstances primary PCI strongly indicated

Special investigation (CT angiography, cardiac RMI, eventually Myocardial Late Gadolinium Enhancement MRI), inflammatory tests needed

No any arrhythmic events in this context.

References:

1.Wagner KR, Lechtzin N, Judge DP. Current treatment of adult Duchenne muscular dystrophy. Biochim Biophys Acta 2007; 1772 (2): 229–37

2.Bushby K, Muntoni F, Bourke JP. 107th ENMC international workshop: the management of cardiac involvement in muscular dystrophy and myotonic dystrophy. Neuromuscul Disord 2003; 13 (2): 166–72

3.Daniel P. Judge; David A. Kass; W. Reid Thompson; Kathryn R. Wagner. Pathophysiology and Therapy of Cardiac Dysfunction in Duchenne Muscular Dystrophy. Am J Cardiovasc Drugs. 2011;11(5):287-294


Luciana ROTARU, Cristian BOERIU (Targu Mures, Romania), Letitia BOJIN, Virginia ARMEGA
11:00 - 18:00 #8031 - Acute Neuropsychiatric Syndrome Managed Like Status Epilepticus; Methylphenidate Intoxication.
Acute Neuropsychiatric Syndrome Managed Like Status Epilepticus; Methylphenidate Intoxication.

The authors describe a 2 years old boy presented to the emergency department (ED) about 2 h after accidentally ingestion of 3 Methylphenidate (SR) 18-mg tablets (54 mg Concerta(®)).  At admission he had neuropsychiatric signs and symptoms such as; severe agitation, hyperactivity, irritability and delusion. Physical examination revealed that his body temperature of 36.9C, pulse 200/min and blood pressure 140/100 mmHg. The patient also had hyperreflexia and his ECG showed sinus tachycardia. Beside neuropsychiatric signs cardiovascular effects include hypertension and tachycardia occured. Elevated cardiac troponin T has been detected on laboratory assesment with a value of 0.022 ng/mL (normal value < 0,013ng/ml). Since the present case evaluated as moderate to severe toxicity,  ingestion is recent, the patient is not vomiting, and is able to maintain airway activated charcoal was administered.  The goals of management this toxicity are to control agitation and prevent or limit end organ toxicity. To control CNS and cardiovascular stimulation, he received

received midazolam (0,1 mg/kg) without improvement in his symptoms. Multiple doses of intravenous

midazolam,administered  for a total of 1 mg/kg which provided some transient resolution of his symptoms. The child’s symptoms recurred within 6 hours after ingestion. Continuous midazolam  infusion (0,05mg/kg/h) was initiated  following loading dose with a 0.2 mg/kg.  The infusion was weaned by 0,01 mg/kg every hour to off.    He did not have any recurrence of symptoms with a normal cardiac troponin T level and was discharged after 36 h of observation.  

The authors describe a 2-y-old boy of methylphenidate intoxication in which continuous midazolam infusion was used successfully to abate both CNS and cardiovascular symptoms without respiratory compromise.


Ali YURTSEVEN, Mehmet Arda KILINÇ, Eylem Ulaş SAZ (Izmir, Turkey)
11:00 - 18:00 #7978 - Acute pancreatitis induced by cisplatin and etoposide.
Acute pancreatitis induced by cisplatin and etoposide.

Acute pancreatitis is an acute inflammatory process of the pancreas that may involve surrounding tissue and remote organ systems. The disease can range from mild inflammation to severe extensive pancreatic necrosis and multi-organ failure with mortality rates of 20% to 30% or higher. Most cases are mild with a mortality rate<1% and resolve spontaneously with supportive care.

Many drugs are reported to be associated with acute pancreatitis, but they account for only 1.4% to 2.0% of all cases.  This report describes a man who developed acute pancreatitis while being treated for lung cancer with the cisplatin and etoposide regimen.

Case Report: A 54-year-old patient presented to the ED with nausea, vomiting,  abdominal pain and swelling. In history he had been performed chemotherapy including cisplatin(100 mg) and etoposide (150 mg) before a week. On physical examination, the abdomen was distended and diffuse tenderness which was maximal in the epigastrium and no rebound tenderness was present. Laboratory data on admission showed increased serum levels of amylase (605 U/L; reference value <125 U/L), lipase (1143 U/L; reference value<78 U/L). Serum values of urea, creatinine, AST, ALT, alkaline phosphatase, triglycerides, cholesterol, calcium and bilirubin were normal. Abdominal ultrasound revealed that the head of pancreas was edematous and hypoechoic. The biliary tree was not dilated and no gallstones were seen. He was diagnosed with acute pancreatitis and  interned to gastroenterology clinic.

In conclusion we described drug-induced pancreatitis. Despite the low incidence of it, all patients of  acute pancreatitis  of unknown etiology should be carefully questioned about drugs possibly responsible for the induction of the disease.


Mehmet UNALDI (ISTANBUL, Turkey), Cihan BUYUKSUTCU, Ersen GUNDUZ, Pelin ATA, Tuce DUZKEL, Onur INCEALTIN, Soner ISIK, Hatice ERYIGIT
11:00 - 18:00 #7251 - Acute Physicians in the Emergency Department reduce admissions in Hospital.
Acute Physicians in the Emergency Department reduce admissions in Hospital.

Introduction

The National Health Service in the UK is under severe pressure for vacant beds in the hospital as the number of patients attending Emergency Departments keep increasing every year and the number of admissions increase on a daily basis. We are always looking for ways to decrease the number of hospital admissions. We decided to appoint Acute Physicians in our Emergency Department to see whether it had any impact in reducing admissions to hospital. Acute physicians were to stay in the Emergency Department between 8AM to 8 PM daily. They were to take care of the management of Emergency Medical patients on arrival to our Emergency Department.

Objective

This study was carried out at George Eliot Hospital, Nuneaton to see if appointing acute physicians in our hospital reduced hospital admissions.

Methods

We looked at the total number of patients attending our Emergency Department between the years 2013, 2014, 2015 and 2016. In the March to April of the year before and after the appointment of acute physicians and number of admissions during this period.

Results

64163 patients were seen in Emergency Department in 2013 to 2014 and 14807 were admitted in the Hospital. 66536 were seen in 2014 to 2015 and 14915 were admitted. 700065 were seen in 2015 to 2016 and 14574 were admitted. There was a reduction of 8.88% in the month of December 2015. A reduction of 11.95% in admissions in the month of January 2016. A reduction of 11.21% in the month of Feb 2016 and a reduction of 6.8% in the month of March. There was a total overall reduction of 1.08% in admissions to the hospital for the whole year 2015 to 2016.

Discussion

Emergency department waiting times are continuing to increase with figures of the third quarter of this year (October to December) showing that the number of people waiting longer than four hours has reached its highest level in over a decade The causes of this problem and the solution to address this problem are complex and multifactorial Many patients are waiting for long periods of time in the Emergency Department for a bed. The number of people admitted in hospital has increased overtime and the availability of beds depends on early discharge and less admissions from the Emergency Department.

Conclusions

Our results show that appointing Acute Physicians in the Emergency Department can significantly reduce admissions in the hospital.


Mohammad ANSARI (Birmingham, United Kingdom), Ahmad ISMAIL, Inayat REHMAN, Qazi ZAMAN, David FAROOGI
11:00 - 18:00 #6992 - Acute shoulder dislocation in the ED: Retrospective evaluation of pain management and a proposal for a standard operating procedure.
Acute shoulder dislocation in the ED: Retrospective evaluation of pain management and a proposal for a standard operating procedure.

Introduction:

Shoulder dislocation is a very common condition in the emergency department (ED). It’s one of the most painful medical emergency (VAS score, mean visual analog scale at the admission: 7.3) for which there is no specific recommendation supported. The main objective of this study was to analyze the management of pain in the ED. The secondary objective was to investigate the influence of seven clinical parameters on the choice of analgesic drugs.

Methods:

We conducted a monocentric and observational study, on 238 patients who consulted for an acute shoulder’s dislocation from 1 January 2012 to 30 April 2015 in our ED admitted in the "lying-area” or in the "ambulatory-area”. We excluded all other patients who had already been reduced, who had shoulder prosthesis (dislocation or asymptomatic chronic dislocations with fortuitous discovery). Fifty-seven parameters reflecting the overall management were analyzed.

Results:

Descriptive analysis confirmed that acute dislocation shoulder, were reduced mostly in the ED (221/238: 93% of all dislocations). The main analgesics used were equimolar mixture of oxygen and nitrous oxide (nitrous oxide) (119/238: 50%), midazolam (11%), morphine (6%), nefopam (15%), tramadol (11%) and acetaminophen (25%). Ketamine and propofol were used in less than 1% cases. There was no trace of analgesic prescription in 22% of complicated fracture dislocation files. Admission’s VAS mean score was: 7.5/10 (95% CI: [7-8.1]) for all patients. The univaried analyzes show a significant relationship between the prescription of morphine and other two parameters: the place in the ED of patient care, for “the lying area” (p=0.035) and the presence of an associated fracture (p=0.05). Whatever, the level of analgesic considered, there was no statistical relation with admission’s VAS score (p> 0.05).

Conclusion:

This study showed a very few use of strong analgesics and hypnotics despite high admission VAS score, even if there was an associated fracture. These findings highlight the importance of informations traceability in medical files. Our pain management standard operating procedure try to improve patients analgesics care especially during reduction maneuvers in the ED.


Oriane GUILLOT, Jean-Philippe STEINMETZ, Philippe KAUFFMANN, Pierrick LE BORGNE (Strasbourg), Charles-Eric LAVOIGNET, Claire KAM, Philippe ADAM, Pascal BILBAULT
11:00 - 18:00 #6436 - Adherence to guidelines for the diagnosis and management of acute prostatitis in the ED.
Adherence to guidelines for the diagnosis and management of acute prostatitis in the ED.

Introduction: Urinary tract infections (UTI) are common in the Emergency Department (ED) (male UTI prevalence: 2-9%). There is often a wide variation in the initial clinical presentation. The French guidelines (SPILF, 2014) have specified the management of this disease with an underestimated morbi-mortality risk. The main objective of this study was to assess the management of acute prostatitis in an urban ED. We also wanted to evaluate in our ED whether the existing guidelines were followed

Methods: We present hereby a retrospective and monocentric study, collecting all the patients who attended with a simple acute prostatitis in 2014 in our ED (University Hospital). Patients presenting with complicated urinary infection were excluded from the study. 38 parameters (clinical, biochemical, treatments, outcome…) have been analyzed. 72 patients have been included for statistical analysis.

Results: The median was 68 years (IQ: [50-77]). The initial clinical signs were mixed, 68% of the patients presented with functional urinary signs and only 30% with fever. Biochemistry and hematology revealed an inflammatory profile (mean leukocytosis: 12790/mm3 and mean CRP: 79mg/l). Urine was tested with dipstick in 86% of the patients and 92% had their urine sent for culture. PR examination was performed in only 50% of these patients; it was tender in half of the cases.  Escherichia coli remains the predominant uropathogen (63%). The bacterial environment also found was: 8% S. Epidermidis, 8% C.Koseri, 6% K. Pneumoniae and 15% of other uro-pahtogens. Fluoroquinolons were mostly prescribed (54%) and 33% of the patients were treated with 3rd generation cephalosporin. The median duration of treatment was 21 days (IQ: [15-23]). 20% of these patients were managed directly by the Urology Consultant in the ED. There was no significant difference in term of treatment duration (p=0.10), neither in term of antibiotics used (p=0.49) between physicians. 45% of the patients were sent for imaging (mostly ultrasound). Finally, 42% of the patients were admitted (95% CI: [27-58%]) (average hospitalisation duration: 6.3 days). For the ambulatory patients, a urology consultation was only offered for 61% of them. The mortality at Day28 was 3% (95% CI: [1-7%]).

Conclusion:Our study in the ED highlights the poor adherence to current guidelines. The management of male UTIs in the ED remains heterogeneous. The French guidelines suggest an interesting algorithm, which insists on the urine dipstick, UTIs with few symptoms, admission criteria and the appropriate use of imaging. As well as curbing the additional cost of non-guideline prescription, adherence to guidelines is essential in order to suppress growing resistances to antibiotic treatment.


Pierrick LE BORGNE (Strasbourg), Sébastien KIRSCH, Mihaela MIHALCEA-DANCIU, Hakim SLIMANI, Claude GERONIMUS, Claire KAM, Philippe KAUFFMANN, Pascal BILBAULT
11:00 - 18:00 #7265 - Adverse drug events in adult patients visiting emergency department in korea.
Adverse drug events in adult patients visiting emergency department in korea.

Adverse drug events (ADEs) didn’t unfrequently happen in both inpatient and outpatient. These events are a significant cause of morbidity and mortality, and results in increasing Institutional care, including and physician visits, and diagnostic tests, medication use, increased emergency department (ED) and hospital admissions. ADEs have been estimated that 5–25% of admissions are drug-related and have been studied mostly among hospital patients. However, ADEs occurring in treated in EDs receive less attention, though nearly 3-fold more patients are treated in EDs for ADEs compared to those admitted. In such a reason, we investigate to determine the prevalence, severity, and preventability of ADEs in patients presenting at EDs in Dongguk University Medical Center Ilsan Hospital for 2 years.

A retrospective registry study which was performed by using the spontaneous adverse drug effects reported data on an electronic medical record for adverse drug effects was conducted on a stratified random sample (n = 204) of adults (≥18 y) who presented to EDs from January 1, 2013 to December 31, 2014.The average age of patients with adverse drug effects in ED 42.6 ± 14.5 years, and Male gender were 35.3%. Drug combination was average 0.9 ± 1.2. Severity of symptoms were severe in 2.9% and non- severe in 97.1%. The reporter was nurses in 58.8%, doctors in 41.2%. The most common symptom was urticaria in 32.5% and the most common drug class was analgesics in 59.0%.   Using the spontaneous adverse drug effects reported data on an electronic medical record is worth noting. The future participation of more institutions needs additional study


Jeong Hun LEE, Han Seong LEE (Goyang, Korea)
11:00 - 18:00 #7368 - After acupuncture: Acupuncture-associated pneumothorax.
After acupuncture: Acupuncture-associated pneumothorax.

Introduction

Acupuncture is proven to be relatively effective in chronic pain treatment.[i] [ii] With its increasing popularity, Emergency Physicians (EPs) should be aware of its complications. We report 2 cases of acupuncture-induced pneumothorax presenting to our hospital emergency department in Singapore over a 2 week period.

Case 1

A 72 year-old lady presented with dyspnoea 20 minutes following acupuncture to the chest. She was a non-smoker with no pulmonary-related co-morbidities. On arrival to the Emergency Department (ED), the patient was tachypneic and had SpO2 of 98% on 2Litre oxygen. Other vital signs were normal.  X-ray showed a large right simple pneumothorax. A chest drain was inserted in the ED with symptom resolution and re-inflation of the lung on repeat x-rays. She was discharged the next day following removal of chest tube.

Case 2

An 81 year-old gentleman with no history of smoking or respiratory disease presented with chest tightness and dyspnea 1 hour after acupuncture to the back. He went to the acupuncturist for treatment of back pain from lumbar radiculopathy. He was hemodynamically stable. X-ray revealed a large right simple pneumothorax. Chest drain insertion was performed in ED. He, too had his chest tube removed after resolution of his symptoms and was discharged well the following day.

Discussion

Common[iii] complications of acupuncture such as pneumothorax, penetrating injuries to other organs like the heart, haemorrhage, and infection can be life threatening. Since these patients often present to ED, knowledge and awareness of potential complications of alternative therapies like acupuncture is crucial. Furthermore, with increasing practice of complementary medicine worldwide[iv] [v], such knowledge also allows EPs to better manage, counsel, and educate patients.

Of the severe complications that arise from acupuncture, pneumothorax seems to be commonest[vi]. While the cases we reported were simple pneumothoraces with good recovery and outcome, extreme cases of bilateral tension pneumothoraces have been published[vii][viii]. In the medial scapular or midclavicular line regions, the lung surface is only 10 to 20 mm beneath the skin[ix]. This explains how improper needling of acupoints in this region could possibly lead to lung puncture. A review published by the World Health Organization reveals that most traumatic complications in China occurred after the sessions were performed in village clinics and rural hospitals, where acupuncturists rarely receive formal education in medical colleges[x]. This suggests that training may play a role in improving the safety profile of acupuncture.

More proper training programs are now available[xi] [xii] [xiii]  and this seems to be associated with increased safety[xiv] [xv]. In Singapore, the Traditional Chinese Medicine Practitioners Act passed in 2000 requires registration of practitioners with the government. This is an example of a step forward for better regulation and safety standards in the practice of complementary medicine. In future, with proper regulations and legislation, we hope that the practice of alternative medicine will become safer.


Wei Lin Tallie CHUA (Singapore, Singapore), Corinne LAU
11:00 - 18:00 #7080 - After cardiac arrest - dilemmas in a case of acute coronary syndrome by lupus vasculitis disease.
After cardiac arrest - dilemmas in a case of acute coronary syndrome by lupus vasculitis disease.

Background. CAD as an important cause of cardio respiratory arrest and sudden death, has however, specially to young peoples, so much particular faces to confirm for early and adequate management, some of these difficult to explore or implement during cardiac arrest.

Purpose of the study was to highlight the specific practical issues related to a special coronary artery occlusion etiology, outcome impact and subsequent prevention, for a cardiac arrest case occurring at a very young age women, caused by non usual coronary artery disease in systemic vascular inflammatory disease context

Case presentation – a 29 years women with sudden, in hospital, cardio respiratory arrest (refractory VF). No significant personal or family pathological history or prodrome.

Prompt resuscitation in scene by hospital resuscitation team. Early after ROSC, echocardiography suggests akinesis zone and mitral valve vegetation suggestive for endocarditis. ECG – anteroseptal acute STEMI. Low level of LDL, NT – proBNP – 421pg/ml, creatinine level – 0,9 mg%.

The coronarography identifies a myocardial necrosis area and vascular changes suggestive for autoimmune vasculitis, no elements for coronary artery atherosclerotic plaques or spasm. Completion of  imagistic (CT angiography and cardiac RMI) and laboratory tests reveal elements of confirmation of systemic lupus erythematosus disease with diffuse coronary artery vasculitis and  subclinical renal determinations. Anticardiolipin antibodies founded.

In terms of prompt and vigorous resuscitation, general anesthesia maintaining and immediately air evacuation to a interventional level I cardiology center, myocardial necrosis was restricted to a small apical territory. Evolution without cerebral sequelae, acute heart failure phenomena or signs of heart failure at 4 months.

Conclusions

1.      Focusing on differentiation causes of CAD to a young women without any risk elements for coronary artery atherosclerosis was from the begining a target

2.      Observing anterior mitral valve changes suggesting endocarditis has been the main reason for targeting primary interventional cardiology

3.      The main therapeutic dilemma was to refrain from the initial thrombolysis during resuscitation (INR 2.2 spontaneously) even with approximately 70' delay anticipation to primary PCI

4.      Lupus vasculitis disease existence generated a debate about type, therms, risks and benefits of antiplatelet agents use.

5.      Immunosuppressive - corticoide therapy combination brings into question the subsequent coronary risk augmentation through the side effects of this therapy, even in conditions of vasculitis disease impact control, which, in turn, requires customizing imaging resources algorithm

6.      The recurrence risk of malignant arryhythmias remains high, leading to evaluate defibrillator implantation benefits

Lerning points

Young, healthy peoples developing an ACS  are strongly suspected to have special etiology of CAD, other than thrombotic

In that circumstances primary PCI strongly, early indicated

Special investigation (CT angiography, cardiac RMI),  endomyocardial biopsy, nuclear study,  inflammatory / immunologic tests, risk score assessment remains mandatory to direct therapy

There in unclear how antithrombotic therapy influences the late prognosis, or if thrombolysis during resuscitation (CAD with unknown etiology)  influences ROSC, or survival chance

References:

Ali Karrar, Winston Sequeira, Joel A. Block Coronary artery disease in systemic lupus erythematosus: A review of the literature. Seminars in Arthritis and Rheumatism. June 2001, Vol.30(6):436–443, doi:10.1053/sarh.2001.23498


Luciana ROTARU, Cristian BOERIU (Targu Mures, Romania), Letitia BOJIN, Virginia ARMEGA
11:00 - 18:00 #7257 - After the bike he can’t take a hike.
After the bike he can’t take a hike.

Title

After the bike he can’t take a hike

Authors

N S-Vainberg, F Mustafa, A Gleeson, P Gilligan

Introduction

Bicycle and skate boarding injuries in young patients are a common presentation to the Emergency Department (ED). Not all injuries are obvious on initial assessment of the patient. Therefore, a thorough secondary survey of trauma patients is absolutely crucial to ensure adequate and appropriate management. We present a case of a teenager that had sustained trauma performing a stunt on his bike.

Case Report

A 17 year male patient was brought to the ED by ambulance in spinal precautions after landing on his head whilst undertaking a front-flip on his BMX bike. He had been wearing a helmet and shoulder pads and had fallen from a height of 2 meters on to his head and left shoulder while performing the stunt. He sustained a loss of consciousness of approximately one minute duration and was complaining of severe shoulder pain. He did not complain of any sensory deficit or weakness.

His primary survey was unremarkable.

He received analgesia and had x rays of his left shoulder, cervical, thoracic and lumbar spine. All x-rays were normal.

On further examination, the patient was noted not to have spinal tenderness but, when he was mobilised, he was noted to be Rhomberg’s positive and walked with a broad based gait. Further neurological evaluation revealed reduced co-ordination in his lower limbs, but no sensory or motor deficit. However, he had grade 3/5 weakness of C7 and C8, as well as grade 4/5 weakness for C4-6.

He was referred for an MRI of his cervical spine, which revealed a spinal contusion at C3-4.

He was admitted under the neurosurgical team for conservative management, physiotherapy and occupational therapy and is recovering well.

Conclusion

Spinal cord injury without radiographic abnormality (SCIWORA) refers to spinal injuries, with no identifiable bony or ligamentous injury on complete, technically adequate, plain radiographs or computed tomography. SCIWORA should be suspected in patients subjected to blunt trauma who report early (immediate) or transient symptoms of neurologic deficit or who have findings upon initial assessment. Treatment and prognosis are based upon neurologic presentation and MRI findings. 

It is important to remember that patients with blunt trauma who have a history of transient neurologic symptoms that have resolved by the time of initial evaluation may have a significant injury to the spinal cord and/or spinal column despite a normal physical examination and normal spine radiographs and/or CT.

References:

http://www.uptodate.com/contents/spinal-cord-injury-without-radiographic-abnormality-sciwora-in-children


Nikita SVIRKOV-VAINBERG, Farah MUSTAFA (Drogheda, Ireland), Aidan GLEESON, Peadar GILLIGAN
11:00 - 18:00 #7131 - Agreement of Point-of Care Test and Laboratory Lactate.
Agreement of Point-of Care Test and Laboratory Lactate.

Lactate is a useful prognostic marker in both sepsis and trauma. Point of Care Testing(POCT)for lactate is now readily available in many emergency departments. This study aimed to examine the agreement of the results of 23 blood specimens for POC lactate with the laboratory values in the Singapore General Hospital. Agreement between the 2 assays were analysed and showed good agreemnt of POCT vs lab lactate. 

Hence we conclude that POCT for lactate can be considered for further use in the emergency department to help in instituting early agressive reasuscitation of critically ill patients . 


Jean LEE (Singapore, Singapore), Siti Fatimah ISMAIL, Hm KANG
11:00 - 18:00 #7898 - Alcohol Withdrawal That Contains Severe Mental And Nervous System Changes: A Case Report.
Alcohol Withdrawal That Contains Severe Mental And Nervous System Changes: A Case Report.

AIM: Acute alcohol withdrawal syndrome leads to fluctuating changes in mental status and it is no uncommon to be reason of cardiovascular collapse and death. We report a patient who dies due to delirium tremens.
CASE: A 43 year old male patient with a history of reduction alcohol after prolonged intake was brought to our emergency service. The patient had no current medical history of epilepsy and had no any medication. He had a history of approximately twenty-year alcohol-use. He was admitted to our emergency service because of intractable seizures. The patient was monitored and airway was ensured. Despite positive inotropic agents, hypotension remained as it has already existed in emergency unit. After all these problems, cardiovascular collapse occurred and the patient didn’t respond to CPR administered for 45 minutes. Finally, he died despite all clinical interventions.
CONCLUSION: As a result, serious cardiovascular instability is no uncommon for DTs and to be aware of vital problems of DTs is essential for physicians.


Musa KAYA, Arif DURAN, Mansur Kürşad ERKURAN (Bolu, Turkey), Tarık OCAK
11:00 - 18:00 #7899 - Amlodipine Intoxication: A Poisoning Case Requiring Intensive Follow-Up.
Amlodipine Intoxication: A Poisoning Case Requiring Intensive Follow-Up.

AIM: Calcium channel blockers are drugs used in hypertension, arrhythmia and coronary heart diseases by blocking L type calcium channels. At high concentrations, calcium channels are blocked and calcium entry from L type channels is totally prevented.. In our study, we aimed to present the changes and the treatment approaches for the hospitalization period of a patient who applied to the emergency unit following the intake of high dose of calcium channel blocker, until the discharge
CASE: 18 year old female patient has taken 30 pieces of Amlodipin (5mg) at 18:30. After the patient was brought to public hospital at 20:00, gastric lavage and activated charcoal has been performed. The patient applied to our emergency unit at nearly 23:00 and she was conscious, cooperative and oriented. Vital signs were normal. Infusion of Dopamine, Dobutamine and Adrenaline was stopped in the fourth day in ICU because the blood pressure began to be normal. The patient was extubated and then discharged with recovery.
CONCLUSION: Mortal complications are inevitable unless intoxication is realized in early stages. Therefore, close hemodynamic follow up is essential for these patients in ICU.


Mansur Kürşad ERKURAN, Erhan DÜZENLI (Bolu, Turkey), Tarık OCAK, Arif DURAN, Hakan BAYIR
11:00 - 18:00 #8119 - An alternative method for increasing medical interns’ chest tube insertion skills: A display mannequin.
An alternative method for increasing medical interns’ chest tube insertion skills: A display mannequin.

Introduction

Medical education naturally requires non-patient practical training sessions as much as theoretical training. Simulation-based training therefore plays an important role in this context. Chest tube insertion is a vitally important procedure in the emergency department. This study assessed the effect on intern physicians’ chest tube insertion skills of a low-cost chest tube simulation model developed by ourselves.

Methods

A dummy was prepared for training simulation using a display mannequin. Medical interns then received instruction concerning pneumothorax and the chest tube procedure. Each intern’s procedural skill was assessed using the “Chest Tube Application Skill Check List” prepared by the authors. Each item on the list was scored separately. A mean was then calculated for the total scores obtained.

Results

All 63 interns taking part in the study reported that the simulation model we developed closely resembled reality. Interns’ mean procedural skill score was 40.9±1.3 out of a possible 42. The maximum score of 42 was achieved by 39.7% of the interns, while another 33.3% achieved a score of 41. Eighty-five percent of the participants succeeded in inserting the tube with an appropriate technique by achieving a score of 40 or more. 

Discussion

The low-cost model prepared by us using a display mannequin was successful in terms of developing intern physicians’ chest tube insertion skills. This model can be used to improve the chest tube insertion skills of medical interns during medical training.


Ozgur TATLI, Suha TURKMEN, Melih IMAMOGLU (Trabzon, Turkey), Yunus KARACA, Mustafa CICEK, Metin YADIGAROGLU, Selen BAYRAK TAMER, Olgun ASIK, Murat TOPBAS, Suleyman TUREDI
11:00 - 18:00 #8008 - An Audit of Foot and Ankle Problems in Diabetic Patients presenting to the Emergency Department.
An Audit of Foot and Ankle Problems in Diabetic Patients presenting to the Emergency Department.

Title: An Audit of Foot and Ankle Problems in Diabetic Patients presenting to the Emergency Department

Introduction: Diabetic patients are at higher risk of foot and ankle problems especially if co-existant neuropathy is present. Even relatively minor injures could be the precipitating factor for serious problems such as a Charcot joint. It is recommended that diabetic patients have early access to appropriate foot clinics and podiatry services. We carried out a short audit to determine whether access to the foot clinic could be improved by undertaking a simple audit where we asked staff about the outcome of their patients including whether they were referred to the Diabetic Foot service.

Methods: A retrospective review of foot and ankle problems presenting to the ED combined with a prospective audit carried out after agreeing a protocol with the Diabetic Team to increase referrals to the Foot Clinic. In the retrospective audit patients were identified from the ED information system over a two week period. Non-diabetic foot & ankle problems were excluded. In the prospective audit over 2 weeks staff were asked to record the ID number of any diabetic foot or ankle problem seen in ED. Notes were subsequently reviewed to determine diagnosis & outcome

Results: In the retrospective audit  6 patients were identified, the diagnosis of a Soft Tissue Injury was made in 4 cases. All patients were discharged with no follow up. In the prospective audit 7 patients were identified . In this group 1 fracture was referred to orthopaedics and 6 others were noted to have soft tissue injuries however of these 3 were referred to the Diabetic Foot clinic.

Discussion: Patients with diabetes often present to the Emergency Department with relatively minor injuries or other foot and ankle problems. Inexperienced staff may be unaware of potential longer term problems e.g. ulceration, vascular insufficiency or Charcots joints. Following discussions with the Diabetic Team we have agreed that all patients who are known diabetics with foot and ankle problems should be able to access the Diabetic Foot service. The main limitation of the audit is that it was conducted by medical students on a short clinical atachment and as a result the numbers of patients studied were small. However if extrapolated over a year this would represent significant numbers of diabetic patients with foot and ankle problems presenting to the ED.  The improved referral rates reflect a classic Hawthorne effect of auditing clinical practice and making clinicians consider other discharge outcomes. We are now working on a patient information leaflet and hope to use smart media such as QR codes to facilitate greater numbers of podiatry referrals in the near future.


Katherine KELLY, Gordon MCNAUGHTON (Glasgow, ), Alice UNSWORTH, Andrew CONNELLY
11:00 - 18:00 #7400 - An audit of procedural sedation in adults in the emergency department.
An audit of procedural sedation in adults in the emergency department.

Introduction

Sedation is commonly administered in the Emergency Department (ED) to promote relaxation or sleep during painful or distressing procedures. Given correctly sedation can improve a patient’s experience of an unpleasant procedure. However sedative drugs can be unpredictable and if used incorrectly can cause unexpected complications and even death. The Royal College of Emergency Medicine (RCEM) designed the following audit to reflect the need to address safety before, during and after the administration of sedation for a procedure in the ED.

Aims

  1. To benchmark current performance in emergency departments against RCEM/RCOA (Royal College of Anaesthetists) and AoMRC (Academy of Medical Royal Colleges) clinical guidelines
  2. To allow comparison nationally
  3. To identify areas in need of improvement
  4. To provide a baseline for future comparison
  5. To develop a local document which outlines the fundamental concepts for delivering safe sedation which can also be used to document procedural sedation in patient notes.

Standards

  1. There should be documented evidence of the patient’s informed consent unless lack of mental capacity has been recorded.
  2. Patients undergoing procedural sedation in the ED should have documented evidence of pre-procedural assessment 
  3. Procedural sedation should be undertaken in a resuscitation room or one with dedicated resuscitation facilities 
  4. Sedation requires the presence of all of the below:
    1. A doctor as seditionist
    2. A second doctor or emergency nurse practitioner (ENP) as procedurist
    3. A nurse
  5. Monitoring during procedural sedation must be documented to have included all of the below 
    1. Non-invasive blood pressure
    2. Pulse oximetry 
    3. Capnography
    4. ECG
  6. Oxygen should be given from the start of sedative administration until the patient is ready for discharge from the recovery area 
  7. Following procedural sedation, patients should only be discharged after documented formal assessment of suitability.

Methods

This was a retrospective case note audit from January 2015 to January 2016. The inclusion criteria, as defined by the RCEM, consisted of adult patients aged over 16 years, undergoing procedural sedation. Patients receiving Entonox (50% nitrous oxide/oxygen) only, opiates only or Entonox and opiates in combination were excluded. Our sample size was 50 patients.

Results

Pre-procedure assessment of ASA grade was documented in 10% of cases, potential airway difficulty was assessed in 2% of cases and fasting status in 8% of cases. Most patients were sedated with a benzodiazepine but in 20% of cases the agent used was not recorded in the notes. Only 32% of patients had blood pressure monitored, 30% ECG monitoring, 20% capnography and 34% pulse oximetry. Only 28% of patients had oxygen during the procedure. Post sedation assessment was virtually completely unrecorded.

Conclusion

The results of this audit indicate that currently our department is not meeting the standards set by RCEM before, during or after the sedation. Whether this is because  the standards were physically met at the time of sedation but just not documented in the notes we cannot be sure. We plan to design and implement a document to be used for procedural sedation cases to improve patient safety and our documentation of clinical practice.


Eve FOLEY (Newcastle Upon Tyne, United Kingdom), Mark HARRISON
11:00 - 18:00 #7127 - An Evaluation of Patients with Carbon Monoxide Poisoning Using the TEMPS-A Temperament Scale.
An Evaluation of Patients with Carbon Monoxide Poisoning Using the TEMPS-A Temperament Scale.

Aim:  The purpose of this study was to determine whether patients diagnosed with carbon monoxide poisoning (COP) would differ in terms of temperament in the early and late periods using the “TEMPS-A temperament questionnaire.”

Materials and methods:Patients presenting to our emergency department with carboxyhemoglobin (COHb) levels of 10% or above and diagnosed with COP by our clinic, with no neuropsychiatric disease and aged over 18 were included in the study. Subjects presenting to the emergency department with nonspecific symptoms, with no neuropsychiatric disease and aged over 18 were enrolled as the control group. All patients’TEMPS-A temperament scale results were recorded.

Results:When the results of the TEMPS-A temperament scores of patients diagnosed with COP at first presentation to the emergency department were compared with the scores of the healthy volunteers, DT type scores were 7.5±3.96 and 5.69±3.39, respectively,(p=0.016), ST type scores7.01±4.29 and 6.71±4.19 (p=0.72), HT type scores 11.75±3.81 and 11.26±3.03 (p=0.484), IT type scores 5.16±4.07 and 3.73±3.36 (p=0.06), andAM type scores 6.52±5.72 and 3.88±4.09 (p=0.01). On the basis of these data, comparison of TEMP-A temperament scale scores performed when patients diagnosed with COP first presented to the emergency department with the results from the healthy volunteers revealed statistically significant differences between the two in terms of DT and AT types.

Conclusion: Illumination of the mechanisms behind the relationship between COP and temperamental characteristics, which are affected by the factors of low socioeconomic level and female gender, will be important in terms of preventive measures aimed at reducing the risk of encountering COP.


Oğuz EROĞLU (Kırıkkale, Turkey), Orhan Murat KOÇAK, Şadiye Visal BUTURAK, Figen COŞKUN, Turgut DENIZ
11:00 - 18:00 #6611 - An hour to save your life? Does intra-arrest extracorporeal membrane oxygenation application save life?
An hour to save your life? Does intra-arrest extracorporeal membrane oxygenation application save life?

Introduction 

Extracorporeal membrane oxygenation [ECMO] integrated Cardiopulmonary resuscitation [CPR] [E-CPR] has become one of the most promising advancement in the field of resuscitation medicine. Our aim is to conduct an independent meta-analysis combining all available high quality observational studies, in order to evaluate whether E-CPR can result in neurological intact mortality benefit as compared with conventional CPR.

Method

A comprehensive search was performed in the following databases; Medline [1946 to present], EMBASE[1974 to present], CINAHL [1981 to present], BNI [1992 to present], AMED [1985 to present] andHealth Business Elite [1922 to present]. The literature search was supplemented with additional search of the following databases; Reference search and personal discussion with ECMO expert regarding grey literature.

Results

5 high quality comparison observational studies were identified. E-CPR application to IHCA and OOHCA has an impressive association with short term neurological intact survival benefit. [OR 0.24 (0.14-0.44) p<0.0001] Surprisingly, the analysis indicates that OOHCA E-CPR [OR 0.196 (0.085-0.455) p<0.0001] has a better survival benefit as compared with IHCA. [OR 0.3 (0.13-0.66) p=0.003]. 

Conclusion 

E-CPR is associated with neurologically intact survival benefit. The main limitation of this meta-analysis is that the combined data are all observational dates, hence causation of benefit is yet to be proven.


Jonathan LEUNG (Kent, United Kingdom)
11:00 - 18:00 #7545 - An interesting case of chicken pox in the elderly with Intestinal perforation and Prevertebral abscess.
An interesting case of chicken pox in the elderly with Intestinal perforation and Prevertebral abscess.

INTRODUCTION

Chicken pox also known as Varicella is a highly contagious disease caused by Varicella Zoster Virus(VZV).
It is an uncommon inefction presenting in the elderly population which has more morbidity and mortality.
This case report is to present one such interesting clinical presentation of an elderly man with chicken pox and a set ofunusal clinical findings.

CASE PRESENTATION
A 64 yr old chinese male was brought in by the family to the fever zone of the hospital with c/o vesicular rashes
and lowerlimb weakness for the past 3 days.
Pt was appropriately triaged and was isolated in the fever area of the emergency department.
Patient had no past medical issues.His weakness had started simulataneously in thelower limbs overpast week
and progressively worsened to the extent  he needed assistance to walk.

Physical examination revealed widespread vesicles over the limbs.
Neurological examination was significant for power 0/5  both lower limbs and 4/5  both upper
limbs.Pt was insensate below T2 sensory level and lax anal tone along with mild
tenderness in the RUQ.
x rays  revealed opacity in  rightlung apex and  free air under the right hemidiaphragm.
Pt was hypotensive on arrival from radiology and was uptriaged to resuscitation room and found tobe in ?spinal shock.
Urgent CT-Abdomen and pelvis  showed Pneumoperitoneum - site of perforation was likely greater curvature/fundus
of the stomach.He  had bilateral psoas abscess  with presence of gas within the fluid collection.
MRI cervical spine was done which showed C5-6 discitis with a large prevertebral abscess extending from C2 to T3.

Resulting mass effect contributed to central canal stenosis with possible cord compression at c5-6 and c6-7

CLINICAL COURSE IN HOSPITAL

Pt underwent exploratory laparotomy and omental patch repair  noted to have perforated D1 anterior duodenal ulcer of abouut 4cm diameter.
Pt developed refractory hypotension post operatively and required triple inotropes and 
activation of massive transfusion protocol.
Repeat CT showed ?subcapsular bleeding form liver and haemoperitoneum.Pt underwent another exploratory laporotomy and splenectomy.
Patient underwent ACDF-anterior cervical discectomy and fusion for prevertebral abscess extending from C3 to T1.
pt also underwent percutaneous drainage of psoas abscess .
His hospital stay was further complicated by disseminated MSSA bacteremia and  tracheostomy .

DISCUSSION

Chicken pox a common childhood disease is more severe in adults. This is because a key immune response – cell-mediated immunity
weakens with age.
This can lead to complications which are potentially fatal, especially among the elderly.
Presentation of multiple significant clinical findings in a previously healthy person should alert the physician about the likelihood of
immunocompromised states.

CONCLUSION
Chicken pox in elderly is a rare pesentation in A&E. So it is pertinent for a  doctor in A&E to be extra vigilant while handling such patients
It can lead to complications like Pneumonia and Encephalitis.
A high level of suscpicion and thorough investigations in patients of this group may benefit from early interventions and hence better outcomes.


Vetrivel RAMAR (Bournemouth, ), Irfan ABDULRAHMAN SHETH, Faizur Rahman MOHAMED MADEENA, Evelyn WONG
11:00 - 18:00 #7166 - An Italian version of the Ottawa crisis resource management rating scale: A reliable and valid tool for assessment of simulation performance.
An Italian version of the Ottawa crisis resource management rating scale: A reliable and valid tool for assessment of simulation performance.

INTRODUCTION:  Objective measurement of simulation performance requires a validated and reliable tool.  However, no published Italian language assessment tool is available.  Translation of a published English language tool: The Ottawa Crisis Resource Management Global Rating Scale (GRS) may lead to a validated and reliable tool.

 METHODS:  After developing an Italian language translation of the English language tool, the study measured the reliability of the new tool by comparison to the English language tool used independently in the same simulation scenarios.  In addition, validity of the Italian language tool was measured by comparison to a skills score also applied independently.

RESULTS: The correlation coefficient between the Italian language overall GRS and the English language overall GRS was 0.82 (Adjusted 95% confidence interval: 0.62 to 0.92).  The correlation coefficient between the Italian language overall GRS and the skill score was 0.85 (Adjusted 95% confidence interval: 0.68 to 0.94).

DISCUSSION:  This study demonstrated that the Italian language GRS has acceptable reliability when compared to the English language tool, suggesting that it can be used reliably to evaluate performance during simulated emergencies.  The study also suggests that the tool has acceptable validity for assessing simulation performance.

CONCLUSION:  The study suggests that the Italian language GRS translation has reasonable reliability when compared to the English language GRS, and reasonable validity when compared to the assessment of the skills scores.  Data suggest that the instrument is adequately reliable for informal and formative type examinations, but may require further confirmation before used for high stakes examinations such as licensing.

744
757

Dr Jeffrey FRANC (Edmonton, Italy), Manuela VERDE, Alba Ripoll GALLARDO, Luca CARENZO, Pier Luigi INGRASSIA
11:00 - 18:00 #7452 - An unusual case of central venous thrombosis after central venous catheterisation in a young patient with undiagnosed Behcet’s disease.
An unusual case of central venous thrombosis after central venous catheterisation in a young patient with undiagnosed Behcet’s disease.

Introduction: Behcet’s disease (BD) is a systemic small vessel vasculitis. Aneurysm formation and venous thrombosis are rare but life-threatening complications. We present the unusual case of central venous thrombosis in a young man under investigation for BD.

Case report: A 20-year-old-gentleman of Afro-Caribbean descent presents to the Emergency Department with severe right-sided neck pain unresponsive to intra-venous (IV) morphine plus sore throat and difficulty swallowing for 10 days.

He was under investigation for BD following infra-renal aortic aneurysm repair 5 weeks ago. Recovery on ITU had been uncomplicated aside from an incidental small non-occlusive thrombus in the right internal jugular vein (IJV) secondary to central venous catheterisation. He was discharged with a PICC line in-situ for IV antibiotics. On examination, the anterior border of right sternocleidomastoid was significantly tender and there was follicular tonsillitis with normal neck movements.

Vascular and ENT opinions were sought and the patient was treated for acute bacterial tonsillitis with meropenem and vancomycin since blood tests were consistent with infection (white cell count 14.7 and CRP 273).  After a few days, he developed marked head and neck swelling which triggered ITU admission for impending airway compromise. This responded well to a course of dexamethasone however antibiotics had been ineffective. CT imaging was therefore performed and revealed an occlusive thrombus in the right IJV extending cranially to the level of C2. This was significantly worse than before and there was new thrombosis in the right subclavian vein with extension into the origin of the left subclavian vein. Other findings were retropharyngeal oedema, bilateral prominent cervical lymphadenopathy and enlarged right axillary lymph nodes.  He received 5 days of anticoagulation before removing the PICC line to minimise the risk of dislodging the thrombus. Treatment was continued with warfarin. A lack of positive microbiological tests made it difficult to identify a source of infection however blood tests were later seen to improve on antibiotics. They were therefore stopped 24 hours after PICC line removal during which time he developed another thrombus at the site of a peripheral venous cannula in the left antecubital fossa. Unfortunately the patient subsequently underwent endovascular repair for a leaking pseudoaneurysm. Treatment for BD was commenced soon after discharge from hospital.

Discussion and conclusion: There are a handful of case reports for central venous thrombosis in BD.  They all present with swollen face, neck and upper limbs in the very first instance. This was different in that severe neck pain was the only presenting complaint and also complicated by signs and symptoms of tonsillitis. A referral to the vascular team was made because the level of pain was inconsistent with a diagnosis of tonsillitis. Both atypical head and neck presentations and risk factors should alert the emergency physician to suspect central venous thrombosis. Systemic vasculitis is another important consideration especially with central venous catheterisation.


Vittorio DECARO (Northampton, United Kingdom), Azam MAJEED
11:00 - 18:00 #8100 - An unusual presentation of aortic saddle embolism.
An unusual presentation of aortic saddle embolism.

TITLE OF PAPER:

An unusual presentation of aortic saddle embolism

 

Abstract type (please select only one):

 

1. ORIGINAL RESEARCH      2. CASE REPORT/CASE SERIES      3. OTHER (e.g. clinical governance, clinical audit, and quality improvement initiative) CASE REPORT

Author(s) Title (Dr., Mr., Ms., Prof. etc), Professional Grade, Department and Hospital (please underline name of presenter):

Dr G.  Nfila, SpR EM, BH

Dr O. Oginni, Reg EM, BH

Dr P. Gilligan, Consultant EM, BH

 

Contact e-mail address: galanfila@gmail.com

 

Contact telephone number: 0872483373

 

My preferred format for the presentation of this abstract is (please select only one):  Poster

 

POSTER

 

Name of PRINCIPAL AUTHOR: 

 

Dr Galamoyo Nfila

Date: 16/05/2016

TITLE OF PAPER

 

An unusual presentation of saddle aortic embolism

 

INTRODUCTION

A saddle embolism of the aorta causes an acute ischemia of the lower extremities. In a third of patients, various degrees of sensory and motor deficits occur, but sudden paraplegia is seen rarely and its cause is unclear.

 

METHODS

 

We report a case of an unusual presentation of saddle aortic embolism just above the bifurcation of the aorta

 

RESULTS

An 82 yr old woman with background history of CVA presented with sudden onset of lower back pain radiating to both legs and progressed to paralysis of both legs. ECG showed new onset AFIB, ABG revealed metabolic acidosis and lactate of 5.5

Her lower limbs were mottled, pale, cold with absence of pulses. She was paraplegic with reduce anal tone. CT angio reveal a large saddle embolism just above the bifurcation of the abdominal aorta,

She was given oxygen, intravenous fluids (saline), she was anticoagulated and transferred to vascular as appropriate.

  

CONCLUSION

 

Doctors must remember that the cause of lower back pain, paraplegia and loss of sensation doesn’t always represent caudal equine syndrome. In this patient, the cause of her paralysis and loss of sensation could be as a result of ischemia of the spinal cord from occlusion of arteries via branches from abdominal aorta or from ischemia of peripheral nerves

 


Olayinka OGINNI, Peadar GILLIGAN, Galamoyo NFILA (Dublin, Ireland)
11:00 - 18:00 #7849 - An unusual presentation of Intracranial Abscess.
An unusual presentation of Intracranial Abscess.

A fifty five year old patient was referred to the Emergency Department wit a diagnosis of hyponatremia.On assessment in the Emergency Department he was found to have a three day history of fever,headache,body aches and nexk pain.Although he was fully  conscious during initial he was found to have intermittent periods of delirium.An initial working diagnosis of meningitis was made and patient was started on IV antibiotics.LP was turbid and was consistent with bacterial infection .A CT scan and later an MRI scan showed multiple foci of abcesses in his cerebellar and thalamic region.

On further review of his medical file it was found that he was admitted a few months prior with lung empyema and required a thoracostomy at that point.This was an unusual case and it is presumed that the patient had thrown off several septic emboli to the brain.

We will intend to discuss ED presentations of intracranial infections and elaborate on investigation and treatment protocols as pertaining to managing such patients in the Emergency Department.


Omar GHAZANFAR (Abu Dhabi, United Arab Emirates), Saleh FARES
11:00 - 18:00 #7254 - An unusual presentation of Pulmonary Embolism.
An unusual presentation of Pulmonary Embolism.

We present a case of bilateral pulmonary embolism which presented to the accident and emergency department of George Eliot Hospital, Nuneaton following an injury to the patient’s chest.

Case report:

A 79 year old lady presented to the accident and emergency department after being unwell and found collapsed. She had a fall two days previously while she was visiting London. She injured the right side of her chest. She was seen in the local hospital and discharged with analgesia.

Two days later she collapsed. She felt light headed and dizzy and being very pale. An ambulance was called and when the paramedics arrived her pulse rate was 119bpm and her BP 85/48. Her past medical history included hypertension. She was on Lisinopril. She was fit and well, independent and self-caring.

On examination she was alert and orientated. The airway was clear. She was breathing spontaneously. Respiratory rate of 21.  We were unable to get her oxygen saturations on 15 litres. She had decreased air entry on the right base, and she as tender over the right chest wall. Abdominal examination showed tenderness over the right upper quadrant. By this time her pulse rate had risen to 127bpm with a BP 104/59. Clinical diagnosis of abdominal injury was made and she was referred to the surgical team. Her chest x ray was unremarkable.

Later on a CT scan of her chest and abdomen was performed, which showed bilateral pulmonary embolism (PE) and generalised fatty liver. She was treated with dabigatran for a period of six months for bilateral PE.

She was discharged home with a follow up appointment in an outpatient clinic. 


Inayat REHMAN, Ahmad ISMAIL, Mohammad ANSARI (Birmingham, United Kingdom)
11:00 - 18:00 #7651 - An Unusual Source For Nosocomial Infections Due To Multi Drug Resistant Acinetobacter Baumannii Complex: Emergency Department.
An Unusual Source For Nosocomial Infections Due To Multi Drug Resistant Acinetobacter Baumannii Complex: Emergency Department.

Introduction: The treatment and control of nosocomial infections due to multidrug-resistant Acinetobacter boumannii is a challenge. Many multi-problem patients were treated in critical care area of the ED for a long period of time. Therefore we aimed to investigate with this retrospective study the prevalence of multidrug resistant A. baumannii and ED related risk factors.

Methods: Patients who admitted between 1 July 2012 - 1 April 2016 to the ED and has a positive culture for A. baumanii were included to the study. Risk factors and patient history were recorded from the patient charts.

Results: Our new emergency department was builded three years ego. Fourty eight patients’ (29% female) who were hospitalized in our emergency deparment during the last three years, cultures were positive for Acinetobacter baumannii complex. Mean age was calculated as 70.04 +/- 13.43 years. A.baumanii complex were isolated from the cultures of peripheral blood, urine, sputum, deep tracheal aspiration, pleural fluid, tissue and wound swab with the numbers of eight, twenty four, four, three, one, two, one and five, respectively. Eleven culture positivities were not accepted as an infection and one of the culture couldn’t been evaluated. Emergency department was thought to be the source of infection for the total number of eight patients whose hospitalized for a long time or only had admission to the emergency department. The main complaints of the patients were fever, nausea-vomitting and confusion. Half of the patients (24/48) were confined to bed. Fourty two patients had a history of hospital or nursing home stay. Fourty one patients had comorbidities as a complicatory factor. Success rate of empirical treatment which was started according to initial complaints was only 50 percent (23/48). Avarage stay in the emergency department was 1.8 day. Twenty one patients were hospitalized and eighteen patients were discharged with oral treatments. Seven patients were transported to another hospital intensive care unit and two patients were accepted as exitus in our emergency department. Twenty one of the isolated Acinetobacters which were thought to be cause of infection were quite susceptible bacterias. Whereas, twenty seven of them were susceptible to colistin, amikacin and tigecycline but resistant to beta-lactams including widely used carbapenems, quinolones and trimethoprim-sulfamethoxazole. In one of the patients, there was also Pseudomonas positivity (colistin resistant) with Acinetobacter complex. In addition to this, vancomycin resistant enteroccus (VRE) was spotted in one patient and carbapenem resistant enterobactericae (CRE) was spotted in another one.

Conclusion: Nosocomial infections due to resistant gram-negative microorganisms are the important causes of mortality. The treatment choices are limited in Acinetobacter baumannii infections, especially if they are panresistant. The data presented in this study demonstrates that patients who have complicated factors and hospitalized before, should be considered carefully. Empirical treatments should be directed according to previous antibiotic history in these population. Maximum isolation measures should be taken even in the ED, because of spreading the isolates such as acinetobacter, pseudomonas, CRE, VRE from these patients to other ones and full compliance of these measures must be done. 


Pr Murat ERSEL (IZMIR, Turkey), Husnu PULLUKCU, Meltem TASBAKAN, Sohret AYDEMIR
11:00 - 18:00 #7116 - Anal abscess in a patient after multiple Emergency Room assists.
Anal abscess in a patient after multiple Emergency Room assists.

Case Report:

MAle Patient 80 years old with personal antecedents of atrial fibrillation, hypertension, benign prostatic hyperplasia and chronic obstructive pulmonary disease is treated with digoxin, Sintrom, doxazosin and inhalers.

He Comes to the emergency room for intense rectal pain one year of evolution that has intensified since one month that prevents the seated accompanied by fear of defecation and emission of liquid stools per day ago.

He Goes to the emergency room several times where he was diagnosed with hemorrhoids syndrome  continuously with no evidence of hemorrhoids thrombosed and not relieved after multiple treatments prescribed.

Exploration

Affected by pain.

DRE with hypertonic sphincter. Ischiorectal red zone at 3 in the lithotomy position. No cracks or fistulas. Palpation endo-rectal mass, well defined, warm, fluctuating in the left posterior perianal area.

Complementary tests

Blood tests: highlights leukocytes: 14700 with neutrophilia and lymphopenia, thromboplastin time: 22%. INR: 3.2. Creatinine: 1,29. Remaining unchanged.

X-Ray: unchanged.

Pelvic CT: abscess with accumulation of purulent content of 4.7 x 1.5 cm and increasing your wall, located in the left and posterior perianal region affecting Ischiorectal left fossa and partially the ipsilateral levator ani muscle.

Diagnosis: anal abscess

Evolution:

It is discussed in General Surgery for evaluation and transfer is done at the university Regional Referral Hospital, for performing abdomino-pelvic CT scan which shows an anal abscess and testing for elective surgery is decided. We proceed to general ward with antibiotics and analgesia until the date decided.

During surgery, extraction is performed and emptying anal abscess without incident.


María Del Pino SALINAS MARTÍN, María Eugenia REYES GARCÍA (Málaga, Spain), Iván VILLAR MENA
11:00 - 18:00 #7824 - Analgesic treatment of ST-segment elevation myocardial infarction (STEMI). Characterization and outcomes of affected patients.
Analgesic treatment of ST-segment elevation myocardial infarction (STEMI). Characterization and outcomes of affected patients.

Introduction : analgesic treatment in coronary patients is recommended. Almost half the time, Morphine is used in almost half of the cases. Some recent interactions (ATLANTIC study) lead to raising questions about this practice.

Objectives : compare STEMI patients receiving  analgesic treatment to those who don’t.

Methods : Inclusion : data analyse of a regional registry including  all STEMI patients from 2004 to 2015. Secondary transfers were excluded from the analysis. Inclusion criteria: characterization, delay) for treatment, treatment and outcomes. Adjusted Odds Ratio (95% confidence interval, significant if p<0.05).

Results : 14892 patients have been analyzed. Factors associated with analgesic treatment administration were: male versus female gender, (0.81 [0.73-0.90] ; p < 0.0001), delay between chest pain and first medical care less or equal to 60 minutes (1.61 [1.46-1.78] ; p < 0.0001), high blood pressure (1.11 [1.01;1.22] ; p=0.037), dyslipidaemia  (1.13 [1.02-1.24] ; p = 0.0159).

Conclusion : patient receiving  analgesic showed different outcomes from the others. This should be taken into account in the interactions morphine / platelets aggregation inhibitor management.


Gilles LENOIR, Clément DERKENNE, Alexandre ALLONNEAU (Paris), Thévy BOCHE, Aurélie LOYEAU, François-Xavier LABORNE, François DUPAS, Mireille MAPOUATA, Yann-Laurent VIOLIN, Sophie BATAILLE, Frédéric LAPOSTOLLE
11:00 - 18:00 #5845 - Analysis correlation between different scales of severity assessment in acute pancreatitis: study in emergency department.
Analysis correlation between different scales of severity assessment in acute pancreatitis: study in emergency department.

Introduction: Acute pancreatitis is a disease characterized by severe form in 20% of cases, presenting a high mortality which is vital to predict its severity. At present there are different clinical and biochemical severity scales as Ranson, Apache II, Marshall and Bisap, which carry discrepancies when being compared to tomographic scales like Balthazar.

Objetive: Description of degree severity in acute pancreatitis according to Ranson, Apache II, Marshall and Bisap scales applied in patients at the moment of admission and correlate these outcomes with the results by Balthazar scale.

Methodology:Descriptive, observational and retrospective study. Population study were all patients admitted to the emergency department with acute pancreatitis between July to December 2014. The diagnosis of acute pancreatitis was established with the following criteria: severe abdominal pain and elevated amylase and/ or lipase more than three times the upper limit of normal. Patients who were not performed abdominal CT scan within 72 hours of onset of symptoms were excluded. A correlation between clinical scales (Ranson, Apache II, Marshall and Bisap) and Balthazar scale was performed based on the Pearson Correlation coefficient. Sensitivity, specificity, positive and negative predictive value of each clinical scales were calculated with respect Balthazar scale. The predictive capacity of every scale was measured by the area under the receiver-operating curve (AUC). Data were analyzed by SPSS v.10.

Results:The study included 90 patients with a mean age of 62,5 years (SD 17.5 years). 46,7% were women. The alcohol induced pancreatitis ocurred in 95 % of men and a only case in women. Most patients were hospitalized an average of 11 days (SD 6,029). The Ranson scale classified as severe 37,7% of patients compared to the Apache II scale that rises to 72,2%. Marshall and Bisap  scales classified to the patients similarly as mild approximately 80% and 20% severe. Balthazar classified as severe acute pancreatitis almost 70% of cases.  BISAP is the scale with the best Area Under the Curve (AUC) (0,609). BISAP presented the best Pearson´s corrrelation with respect Balthazar: 0,244 (p=0,010).

Conclusions: Acute pancreatitis is distributed equally in both sexes; alcoholic etiology is clearly more common in men. Ranson scale applied only one time to the admission of patients is not valid as predicted scale. Acute pancreatitis may have pancreatic and extrapancreatic complications so the scale of Balthazar CT should not be used as a benchmark, but as a complementary tool in risk stratification and prognosis of acute pancreatitis. Bisap is postulated as the most appropriate scale in our study showing high specificity and good Pearson´s correlation with Balthazar scale.


Maria GIL LOPEZ (OSUNA, Spain), Elena PRADO MEL, Florentina MORENO CALATRAVA, Antonio Bernabé ROJAS RAMIREZ
11:00 - 18:00 #7914 - Analysis of destination of patients presenting with acute heart failure in our emergency department after being cared.
Analysis of destination of patients presenting with acute heart failure in our emergency department after being cared.

INTRODUCTION
Acute heart failure is a common reason for consultation in the emergency department (ED), and the leading cause of hospitalization in the elderly. With high mortality and reconsultations involving a large increase in health spending.

Objective: To assess the need for hospital admission depending on the type of heart failure assessed by echocardiography and destination at discharge from the emergency department.


Material and methods:
Prospective observational study without intervention in patients who come to our ED for acute heart failure (AHF) according to Framingham criteria in the period 2012-2014 choosing two randomized months per year. Inclusion criteria: age 18 years with ICA and give their written consent. The study variables were: Destination income (Cardiology, Internal Medicine, Short Stay Unit, other services and high direct from the Emergency Department Observation), type of heart failure (systolic, diastolic, mixed and unknown)

results:
During the 2012-2014 selected 119 patients consulted by ICA of whom 57 were women (47.9%) and 62 men (52.1%). 31 patients (26%) had systolic heart failure, 10 patients (8.4%) diastolic, 53 patients (43%) mixed and not the kind of dysfunction was known in 26 patients (21.84%)
24 patients were discharged directly from the emergency department (20.19%) and 94 patients admitted to our hospital (79%) of which 24 had systolic HF (25.53%), 10 diastolic (8.5% ), 37 mixed (39.36%) and 23 unknown (24.45%).
77% of systolic dysfunction (24 patients) were admitted, 100% of the diastolic, 71% of mixed (37 patients) and 88.4% of type unknown origin (23 patients).
By Services: 17 patients were admitted to cardiology (14.2%), in Internal Medicine 61 patients (51.2%) in Short Stay Unit 13 patients (10,92) and other services 4 patients (3.36 %)

conclusions:

- 100% of diastolic heart failure were admitted to hospital
- More than 55% were admitted to Internal Medicine while only 14.2% were admitted in Cardiology
- Up to 20% of patients who come to our Service are discharged directly, without requiring hospital admission.


Paula LAZARO-ARAGUES, Patricia SUAREZ-BEKE, Jose Andres SANCHEZ-NICOLAS, Irene PAGAN-GOMEZ, Elena SANTAMARIA-HERNANDEZ, Cesar CINESI GOMEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #6279 - Analysis of Patient with Burn.
Analysis of Patient with Burn.

Burn  has  been  an  important cause  of  trauma  trough human history.  Most  of  the

burn causes can be prevented by informing people and simple precautions but there is no

decline in the number of burn cases with tecnological advancements. Treatment  of burn

trauma is a long and costly process.  All around the world there are many researchs done

about burn treatment but there are limited researches about the cost of burn treatment. The

decrease in life quality after burn trauma effects patients’psychological health and financial

status. It has been shown because of these reasons, not only major burn trauma patients but

also simple burn patients should receive high quality healthcare service and this service

should be given by experienced helthcare providers. Because of this reason all the patients

that has come to emergency department with burn should be treated efficiently and with

low costs.

All admitted we aimed to analyze  age, gender, admittance   time, type  of  burn,

clinical prognosis, mortality, and percentage of burnsite, and total cost of treatment of the

patients presented with burn injury to the emergency department.

According to this purpose we have acquired the data of 264 patients who have been

admitted to Baskent University Emergency Department with burn injury between 2012 to

2014. We analysed age, gender,  time, months and year of admitance, causes of burn,

whether it is work related or not, self induced or not, if the treatment consists surgery or

admittance for follow up, burnsite, thickness of burn and the total cost of treatment. The

data has been collected from hospital patient registiration system.

In conclusion, it is shown that patients’condition, gender, admittance year, surgery,

burn cause, age does not effect cost of the treatment. On the other hand the main factors

that changes the cost are degree of burn and burn site.


Tolga ESER, Cemil KAVALCI (Ankara, Turkey), Afsin KAYIPMAZ
11:00 - 18:00 #8256 - Analysis of patients admitted to our hospital with pet bite wounds.
Analysis of patients admitted to our hospital with pet bite wounds.

Objectives

Pet bite wounds, specially dogs, it isan important pathology in medical emergencies and sometimes can be very serious. The aim of this study is a quantitative and qualitative analysis in our hospital to assess the quality of care of these processes.

Methodology

This paper presents a descriptive retrospective study of severe bite wounds by pets admitted in the Virgen del Rocío University Hospital during the years 2012-2015. The variables analized were: type of pet, age, sex, diagnosis, instituted treatment of patiens analyzed, hospitalization time, and final destination of the patients. Statistical programs inferences using chi-squared

Results

Patients with animal bite wounds: 71; among them were men: 56 (/)%) and women 15 (21%) with minmun age of 0y and a maximun of 82y

In 2015 there were 33 patients admitted with dog bite wounds; among them there were women 5 (15%)

In 2014 were 15 and they were 4 women (27%)

In 2013 there were 9 patients, among them 4 women (44%

In 2012 there were 13 patients and 2 of then were women (15%). The diagnostics obtaines were cranial an facial fracture: 7 (10%), fractures in extremities 8 (11%), head injuries 6 (8%), wounds on limbs an trunk 34 (48%), eyebal injuries 1 (1,4%), finger amputation 1 (1,4%, liver trauma: 3 (4%), pulmonary trauma 2 (3%), septic shock 3 (4%) an exitus 0 (0%). The hospitalization time had a minimun of 1 day an a maximun of 60 days; with an average of 6 days. Surgical treatment was performed in the 100% of cases. In 2013 ungent interventions were 11 (85%) an scheduled 2 (15%). In 2013 urgent interventions in 7 (78%) an scheduled 2 (2%. Urgent interventios in 2014: 13 (87%) an scheduled 2 (13%). In 2015 urgen interventions: 22 (67%) and scheduled: 11 (33%). complications during admission: 7 (10%)

Conclussions

1)More than half of patients admitted to the Hospital with dog bite injuries were male (56%)

2)All patients admitted to the hospital required surgical treatment.

3)A high percentege of pa

4) 21% of bite wounds were associated with fracture.

5) 7% of the patients had serious injuries that couls jeopardize their life.


Pilar CONDE (SEVILLA, Spain), Jesus MORENO, Pilar MORENO, Alberto MORENO, Raul NEVADO
11:00 - 18:00 #7595 - Analysis of Prehospital Emergency Medical Service missions in Croatia for 2015.
Analysis of Prehospital Emergency Medical Service missions in Croatia for 2015.

At the end of 2012 new organisation model for Prehospital Emergency Medical care(PEMC) in Croatia has been finished. Instead of four models which existed by then, one unique model has been established for whole country. Today, PEMC is being provided by County Institutes of Emergency Medicine (21 in total) whish consists of two types of medical field providers (medical doctor units and medical technician units). Likewise, the Institutes employ medical dispatch units staffed with medical techniciansor, in case of four largest counties, medical technicians and physicians. Location of field teams and their distribution is defined by Emergency Medicine Network, as well as location of medical dispatch centers in each county (Official Gazette 71/2012). According to Emergency Medicine Network, currently there are 595 physicians teams on 99 locations and 229 medical technicians teams on 49 locations. On 44 locations PEMC is being provided by general practitioner on duty and on 22 locations by general practitioners on call.

In 2015 Prehospital Emergency Medical Service took care for 1.363.970 patients. Out of total number of interventions, 853.212 (40.14%) were field missions and 510.758 (59.86%) were walk in patients which have been examined in resuscitation rooms on team locations. Out of total inmterventions, 97.225 (11.40%) patients were prioritized as priority A (most urgent), 299.557 (35.11%) as priority H (urgent) and 456.430 (53.50%) as priority V (no need for PEMC). Out of total of 456.430 interventions dealing with priority V, 78.522 (17.20%) were field missions and 377.908 (82.80%) were walk in patients.

Since Emergency Medicine Network is designed to cover field missions and there are no teams designated to provide stationary medical care in County Institutes of Emergency Medicine for walk in patients, large number of non-urgent patients that utilize EMS can in future jeopardize EMS team response time and delay help for emergency medical patients.


Branka TOMLJANOVIC (ZAGREB, Croatia), Maja GRBA-BUJEVIC, Ingrid BOSAN - KILIBARDA
11:00 - 18:00 #7182 - Analysis of Spontaneous Volunteer Response to 2013 Sudan Floods: Changing the Paradigm.
Analysis of Spontaneous Volunteer Response to 2013 Sudan Floods: Changing the Paradigm.

Study Objectives:
The role of spontaneous volunteers during the initial response to disasters remains controversial. In an attempt to resolve some of the debate, investigators examined the activities of a spontaneous volunteer group called Nafeer after the Sudan floods around the city of Khartoum in August of 2013.
Methods:
This retrospective descriptive case-study involved: 1) interviews with Nafeer members that participated in the disaster response to the Khartoum floods; 2) examination of documents generated during the event; and 3) subsequent benchmarking of their efforts with the Sphere Handbook. Interviews were held with volunteers who held top administrative positions within Nafeer as well as individual members. Members who agreed to participate were requested to provide all documents in their possession relating to Nafeer. The response by Nafeer was then benchmarked to the Sphere Handbook’s six core standards, as well as the eleven minimum standards in essential health services.
Results:
A total of 11 individuals were interviewed (6 from leadership, and 5 from active members). Nafeer's activities included: food provision; delivery of basic healthcare; environmental sanitation campaigns; efforts to raise awareness; and construction and strengthening of flood barricades (Table). Its use of electronic platforms and social media to collect data and coordinate the organization’s response proved highly effective. Members of Nafeer came from diverse backgrounds, including employees of corporations and NGOs, medical practitioners, nurses, pharmacists, and university students. Nafeer adopted a flat-management structure, dividing itself into 14 committees. A coordination committee was in charge of liaising between all committees. The Health and Sanitation committee supervised 2 health days which included mobile medical and dentistry clinics supported by a mobile laboratory and pharmacy. A total of 613 patients were seen. The engineering committee managed to construct and maintain flood barricades. Nafeer used crowd-sourcing to fund its activities, receiving donations locally and internationally using supporters outside Sudan. It also received in-kind donations. Nafeer's total budget was $328,097 US; of which 12% was spent on administration. Nafeer completely or partially fulfilled all 6 core Sphere standards but none of the essential health services standards. Nafeer did not set specific objectives for itself based on which data elements would be identified and subsequently measured. Even though the Sphere Handbook was chosen as the best available gold standard to benchmark Nafeer’s efforts, it showed significant limitations in effectively measuring such groups. A specific template does not currently exist to evaluate community-led initiatives in disasters.
Conclusion:
It appears that independent spontaneous volunteer initiatives like Nafeer potentially can play a significant role in the humanitarian response. Such organizations should be the subject of increased research activity. Relevant bodies should consider issuing separate guidelines supporting spontaneous volunteer organizations.

Acknowledgment: Dr. Albahari’s only financial conflict of interest is his donation of $100 to the Nafeer organization. Dr. Schultz reports no conflict of interest.


Amin ALBAHARI (Galway, Ireland), Carl SCHULTZ
11:00 - 18:00 #7719 - Analysis of the 12-Year Search and Rescue and Medical Evacuation Activities of Turkey Main Search and Rescue Coordination Centre.
Analysis of the 12-Year Search and Rescue and Medical Evacuation Activities of Turkey Main Search and Rescue Coordination Centre.

Introduction and Purpose

Turkey is a peninsula surrounded on three sides by the seas and that has Dardanelle and Bosporus, which have a strategic importance on the world. In this respect, Turkey is in the transit country position in marine transportation and marine trade. Therefore, she is a risky country for marine accidents. In order to efficiently, fast and actively intervene in marine accidents, national and international coordination are vital. This complementary study was made for determining the features of marine accident/incident and medical evacuations that were coordinated by Main Search and Rescue Coordination Centre between the years 2001 and 2012.

Material and Method

 This research is a descriptive epidemiological study. The population of study includes Main Search and Rescue Coordination Centre’s all accident/incident and medical evacuation reports between the dates 01.01.2001 and 31.12.2012. In this research, 1796 forms have been examined. The data in the registration forms have been input into a data base that was created in SPSS 15.0 programme and these data are evaluated statistically. In statistical evaluation, Frequency Distribution, Univariate and Bivariate Poisson Regression and non-metric Multidimensional Scaling Analysis are used. In frequency analysis, variables such as accident year, accident month, accident types, accident causes, accident area; the numbers of patients, people who were injured, dead, missing and evacuated, presence of environmental pollution and the units that joined the rescue operation have been examined. The research was performed between October 2012 and March 2014.

Results

In inspected reports as part of the research, 2010 has the highest percentage of cases on year basis with an incidence ratio of 12.7% (228 accident/incident/medical evacuation), autumn is the first in distribution among the seasons with 22.7% (497 accident/incident/medical evacuation), between the hours 12:00 and 17:59 has the highest percentage according to occurrence hours with 30.0% (538 accident/incident/medical evacuation), Istanbul region is the region where the most accident happens with a ratio of 44,3% (795 accident/incident/medical evacuation). 58.7% of the cases (1054 accident/incident/medical evacuation) were responded by Coast Guard Command. Inspected reports as part of research between the years 2001 and 2012, total number of people  injured is 150, the number of people saved is 6042, total loss of life is 311, missing persons is 202 and the number of patients is 73. It has been stated in the reports inspected as part of research that the number of the people affected in marine accident/incident and medical evacuations in 12 years is 6778. 70,6% (n=48 hospital) of the patients and  the injured were taken to public hospitals. The number of accident/incident that caused injuries is significantly more in the international area in comparison with Istanbul (8.5 times more, 95% confidence limits 4.5-15.8).

Conclusion

In this research, it has been found that overturning, fire and explosion are the most seen types of accidents, comparing to others. Fire and explosion risks, in the tankers that carry petrol, gas and chemicals should be considered both for the people in the ship and the people near the ship must be considered.


Hüseyin KOÇAK (Çanakkale, Turkey), Kerim Hakan ALTINTAŞ
11:00 - 18:00 #8184 - Analysis of the pain assessment practice by the medical team of Jeanne de Navarre Hospital Center.
Analysis of the pain assessment practice by the medical team of Jeanne de Navarre Hospital Center.

Title: Analysis of the pain assessment practice by the medical team of Jeanne de Navarre Hospital Center

Authors: Boukhalfa.I, Ouedraogo.L, Kodzin.MJ, Fiani.N

Hospital Center Jeanne de Navarre, Château-Thierry, France

Background

The proper management of patients' pain requires an efficient assessment. Mastering this practice by the medical team, based on protocols using validated and adapted rating scales, is the only guarantee.

Participants and Methods

To analyze the practice of pain assessment by the medical staff at the Jeanne De Navarre Hospital Center of Chateau-Thierry, we conducted a prospective and a cross-sectional study using a self-administered questionnaire to all of the staff members during the month of March 2016. The results were analyzed using Microsoft Excel software.

Results

We collected 149 questionnaires: 47% nurses, 26% care-assistants, 20% doctors and 5% obstetric nurses. 60% were aged between 30 and 50 years and 42% were under 10 years of experience. 80% took courses on the pain management and only half was entitled to ongoing training. 87% said they know about the different analgesic medicines for pain and 40% ranked them according to OMS levels and yet 15% have confused the auto and straight assessment scales. Despite the presence of a protocol in each service, 82% were aware and only 70% applied it. The VAS (visual analog scale for pain) was the most used scale in adults and children and ALGOPLUS for the elderly. 54% assessed the pain in less than one minute and 30% couldn’t do anything for against pain without prescription. 65% of physicians do early prescription for the pain treatment. 38% of staff recognized the difficulty of pain assessment especially in demented and non-communicative patients. In total 67% consider the pain assessment  as good.

Conclusion

Although the majority of the staff in our hospital adheres to the pain management protocols, some of them remain not aware of this practice. It is essential to ensure continuous training and organizing awareness days to improve the current situation.

 


Imene BOUKHALFA (Bizerte, Tunisia), Louis OUEDRAOGO
11:00 - 18:00 #7371 - Analysis on the regulating activity of psychiatric files. Do they last so long?
Analysis on the regulating activity of psychiatric files. Do they last so long?

Introduction

At the EMS call centre, management of phone calls for psychological or psychiatric distress seems often complex and tend to monopolise a lot of the resources of the regulating team regulation team. We present here the results of our analysis of this activity.

Material and method

Retrospective analysis of the files entered in the call centre from 2011 to 2014. Selection of files related to psychiatric cases such as psychoses, neurosis, addiction, intoxication... comparative analysis to other cases. taking into account their evolution during this time period using as criteria: number of files, their regulating duration (i.e. period of time between the start and the end of a call), identification of the physician regulator and decision Comparison via Chi-2 tests for the qualitative variables and with mean of Wicoxon[CDa1] 's tests for the regulating duration.

Results.

On 671.421 files (167.855 files per year), 4,8% were identified as a psychiatric distress. Their annual number has increased by 50% between 2011 and 2014, while the global activity did increase by only 7%. The median duration of the regulation was 50 min for psychiatric files against 34 min for the other files (p<0,0001). This median duration [CDa2] of regulation had constantly decreased while it had been relatively stable for the non-psychiatric files (respectively between 55 and 35 min in 2011, 47 and 34 min in 2014). In 2011, 0,3% of the psychiatric files did not have any identified regulator physician against 10% in 2014 (p<0,0001). In 2014, while 26% of the studied cases (25% for the non-psychiatric) ended in a simple advice to the callers, 63% of them were taken to hospital (52% for the non psychiatric p<0,0001).

Discussion and conclusion

Calls to the EMS call centre for psychiatric distress had clearly increased during the the past few years, requesting a new distribution of this workload among the different actors of regulation. Those call cases generated a meaningful time of regulation, even if the trend was decreasing. Some improvements could come through actions such as organising the call flow, training the teams, establishing networks, writing procedures, switching to others operators (psychologist, nurse...), which all may reduce the impact of this activity on the EMS call centre.


Roger KADJI (Melun), Stephanie POLINI, Jean-Pierre ROSSI, Anne Sophie FURET-PIGNON, David SAPIR, Jean Christophe ROBART, Aurelia ROCHEDREUX, Francois-Xavier LABORNE
11:00 - 18:00 #7391 - Anemia expression of upper gastrointestinal hemorrhage.
Anemia expression of upper gastrointestinal hemorrhage.

Anemia expression of upper gastrointestinal hemorrhage

 

Virgiliu Cezar Bologa (1) ; Denisa Elena Vintila(1) ; Ramona Ganea(1); Francesca Iulia Paius(1);

1. Emergency Department, UPU-SMURD Sibiu, Sibiu, Romania

                                                     

Keywords:  anemia, gastrointestinal bleeding, ulcer, esophageal varices  

Speaker : Denisa Elena Vintila

 

BACKGROUND

The upper gastrointestinal bleeding is 5 times more frequent compared to the lower one.  UGIB has a prevalence of approximately 170 cases per 100.000 inhabitants per year!!!

The present study aims to evaluate the incidence and etiology of the upper gastrointestinal bleeding at the patients who arrived at the Emergency Department of Sibiu County Clinical Emergency Hospital as well as their hospitalization according to the hospital’s departments.

 

MATERIALS AND METHODS

The study was performed through a retrospective observational method on a number of 190268 cases emerged in the Emergency Department of Sibiu County Clinical Emergency Hospital between 01.01.2013 – 31.12.2015, out of which 848 were diagnosed with UGIB.

 

RESULTS

Out of the total number of cases registered at the Emergency Department of SMURD Sibiu between 01.01.2013 – 31.12.2015, 848 were UGIB, which represents 0.4 %.

The distribution of the 848 cases of UGIB emerged at the Emergency Department of SMURD Sibiu for the studied period was as follows: 316 (37.26%) in 2013, 276 (32.54%) in 2014, 256 (30.18%) in 2015.

Out of the total number of UGIB cases, 141 (16.62%) were cases where patients have associated severe anemia, and 707 (83.37%) were cases where patients have shown mild and moderate anemia.

According to the etiology of UGIB, the following values were registered: 28 (3.30%) cases of esophageal varices, 67 (7.9%) cases of gastric and esophageal neoplasms, 753 (88.79%) cases of gastric and duodenal ulcer.

The distribution of hospitalizations of patients with UGIB according to the hospital’s departments was the following: Gastroenterology - 80.42%; Surgery - 2.12%; Medical - 7.42%; Oncology - 0.4%; refused hospitalization - 9.43%.

 

CONCLUSIONS

Between 2013 – 2015 the percent of patients diagnosed with UGIB, hospitalized at the Emergency Department, decreased: 2013 -37.26%, 2014 –32.54%, 2015 –30.18%.

Out of the total number of UGIB cases, 141 (16.62%) were cases where patients have associated severe anemia, and 707 (83.37%) were cases where patients have shown mild and moderate anemia.

The majority of UGIB cases were caused by ulcer: 753 (88.79%) registered cases, the rest being represented by gastric and esophageal neoplasms (7.9%) and bleeding esophageal varices (3.30%).

Out of a total number of 848 patients diagnosed with UGIB, the hospitalization according to the hospital’s departments was as follows:  Gastroenterology - 80.42%; Surgery - 2.12%; Medical - 7.42%; Oncology - 0.4%; Discharged - 9.43%.

 


Ramona GANEA, Virgiliu Cezar BOLOGA, Denisa Elena VINTILA (Sibiu, Romania), Dr Francesca Iulia PAIUS
11:00 - 18:00 #7513 - ANGIOEDEMA SECONDARY TO TREATMENT WITH ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACEI): A CASES REPORTS.
ANGIOEDEMA SECONDARY TO TREATMENT WITH ANGIOTENSIN CONVERTING ENZYME INHIBITOR (ACEI): A CASES REPORTS.

INTRODUCTION

Angioedema (AE) is a vasodilatation phenomenon associated to edema in deep dermis and subcutaneous tissue, without well defined contours, painless and elastically, that can be observed  in any area of the body.

CLINICAL CASE

We presented a  case of an 75-year-old men with no history of allergies, arterial hypertension and paraplegic due to a spinal cord injury in a traffic accident and secondary neuropathic pain. Usual treatment is omeprazol 40mg/24 hours, lactulosa 5ml/8 hours, acetyl salicylic acid 100mg/24 hours, pregabalin 150 mg/12 hours, enalapril 10 mg/24 hours and metamizol 575mg/8 hours.

She consulted in the emergency department for facial erythema and edema of the tongue from her awakening without dysfagia, difficulty in breathing, rash or pruritus. On physical examination she showed erythema and edema of the tongue without injuries in neither her thorax, nor her limbs. Her blood analyses findings were impaired serum creatinine (2 mg/dL).

We suspected AG secondary to enalapril, which was suspended, and methylprednisolone plus dexchlorpheniramine therapy was initiated. Clinical improvement was clear after 6 hours. Subsequently Icatibant was administered with clinical improvement by  4 a.m.

DISCCUSION

Angiotensing Converting Enzyme Inhibitor (ACEI) is the treatment of choice for arterial hypertension, heart failure and diabetic nephropathy with proteinuria. Dizziness, cough, migraine, hypotension and renal failure are the most frequent side effects. Angioedema Secondary to ACEI appears in 0,2 % of the treated individuals. A progressive incidence is estimated because of new therapeutic indications. AE should not be related with neither the administration nor the dose.

C O N C L U S I O N S

AG may vary from facial and tongue edema as well as in the supralotic area, worse conditions than other presentations, such as hands, feet and visceral edema.

Bradikinine is the nonapeptid and proinflamatory vasodilator in the physiopathologycal mechanism. Nevertheless, in AG secondary  to ACEI an allergic reaction should not be considered and in some cases it can be refractory to the treatment with antihistaminics and steroids, being necessary the introduction of new therapies in the emergency department.


Ana Maria MARTINEZ VIRTO (MADRID, Spain)
11:00 - 18:00 #8080 - Angioedema. Nasal vestibulitis.
Angioedema. Nasal vestibulitis.

History:

Male 69 years referred pain in the right nasal vestibule 24hours evolution with declines during the last hours, spread to appreciate holofacial eyelids edema and fever up 39'5ºC and shivering.

From the previous days it presents box progressive facial swelling. The family reports that in the previous days food material by nostrils, with further manipulation by the patient, presenting from the last 24 hours swelling, redness, and blisters fluctuation around the facial bones, with pain on palapción

AP: severe COPD. Iª chronic renal. Permanent AF anticoagulated with rivaroxaban. Lung carcinoma with liver metastases in trataminto with palliative chemotherapy.

Physical exploration:

Purulent nasal area in both halls, columella and upper lip philtrum.

Facial swelling from chin to glabela associated with redness, heat and intense tenderness. Lobby with purulent nasal discharge erythematosus. Great bilateral palpebral edema preventing eye opening.

 

 Investigations:

Blood tests: Blood count: Leukocyte 35100, neutrophilia 92%. Hb 7'9, Platelets 293000. Coagulation: PT activity 78.6%. Venous blood gases: pH 7.11. Biochemistry: glucose 379, urea 52, creatinine 1.74, normal ions, PCR 245, Procalcitonin 6.71.

TAC skull and sinuses: mucosal thickening of both maxillary sinuses with partial occupation of the left and anterior ethmoid cells for soft tissue density material, as well as thickening of the mucosal lining of the left maxillary sinus. Significant increase in thickness and density of soft tissue to diffuse facial level, which could be related to inflammatory-infectious process. focal bone defect with cortical thinning and front right supraorbital level.

Final diagnosis:

Facial cellulitis in immunocompromised patient

Evolution:

Admission is decided in observation area given the severe sepsis box of origin in skin and soft tissue facial and cervical region, starting treatment with ceftriaxone, cloxacillin and methylprednisolone.

Given the proper evolution during the first 24 hours admission is decided in charge of Internal Medicine discarded surgical approach given the palliative stage of his previous illness.

After almost a month of hospitalization, and after adding to valaciclovir intravenous treatment is decided discharged home after progressive improvement of the infection with facial and cervical recovery.

 

 

Conclusions:

However minimal possible entry must take special precautions in cancer patients being immunocompromised and complications that might entail.


Juan Antonio RIVERO, Enrique CARO (MALAGA, Spain), Daniel FERNANDEZ VARGAS, Eduardo ROSELL, Pedro ARRIBAS, Francisco TEMBOURY
11:00 - 18:00 #7270 - Anisakis, an unusual cause of anaphylaxis.
Anisakis, an unusual cause of anaphylaxis.

CASE REPORT: A 48-years-old man with any antecedent of interest, presented to the Emergency Department (ED) complaining an episode of 12 hours of evolution of a periumbilical and epigastric pain of moderate intensity without irradiation and associated with malaise. He did not refer fever. In the last hours, he presented as well skin lesions as an urticaria in armpit and abdomen. When the patient arrived to the ED, it highlights hypotension (85/40 mmHg), tachycardia (110 beats per minute), low oxygen saturation (90% baseline) and erythematous lesions in abdomen and armpits, not scaly and confluent. On abdominal examination, it highlights epigastrium pain, without sings of peristonism. With the initial suspicion of anaphylaxis, treatment was initiated with intramuscular adrenaline, antihistamine and corticosteroid and intensive intravenous fluid therapy. Clinical situation was stabilized disappearing itching and skin lesions but not abdominal pain. Analytical results were normal, except for the presence of mild eosinophilia. Due to the persistence of abdominal pain, ultrasound was performed demonstrating the presence of free liquid perisplenic and perihepatic fluid and no evidence of biliopancreatic or anyother alterations. The study was extended by abdominal Computed Tomography (CT), with evidenced thickening of gastrics folds suggesting gastric inflammatory process (Figure 1).

DIFFERENTIAL DIAGNOSIS: complicated hydatid cyst, episode of histaminergic intestinal angioedema, food-induced anaphylaxis, parasitic gastritis, eosinophilic gastritis.

EVOLUTION: Following the findings in abdominal CT, new oriented anamnesis was performed, and the patient recognized intake unfrozen fish (anchovies in vinegar) prior to the start of abdominal pain. Anisakiasis was suspected, and urgent gastroscopy was requested, watching live parasites in the gastric mucosa, predominantly in the body and fundus (Figure 2). Endoscopic removal of all parasites displayed was performed and the patient showed progressive improvement with final disappearance of pain.

FINAL DIAGNOSIS: Anisakis anaphylaxis

DISCUSSION: The Anisakis simplex, the main species causing human anisakiasis complex, has an extensive distribution. It is transmitted to humans by eating raw or undercooked fish. In Spain, the main responsible fish are fresh anchovies, but they have also involved other species: hake, sardines, cod ... Anisakiasis is an underdiagnosis disease in our area, so its actual prevalence is probably higher than documented in the literature. It is produced by the local action of the parasite on the stomach, after a latency period of 24-48 hours from the ingestion of parasitized fish. The most common forms of presentation are gastric, intestinal and gastro-allergic. In the stomach, the parasite attaches to the mucosa, producing local irritation that cause intense epigastric pain, nausea, vomiting and fever within a few hours after that ingestion. It may be accompanied by skin rash. The diagnosis of this parasitosis can be difficult, especially if the history of intake of raw or undercooked fish is not taken into account. The analytical and radiological findings are very unspecific. Endoscopy is diagnostic and therapeutic because it allows the extraction of the parasite and the consequent improvement of symptoms.


Marta JORDÁN DOMINGO, Daniel SÁENZ ABAD, Cristina BAQUER SAHÚN, Susana MONZON BALLARIN, Miguel RIVAS JIMÉNEZ (Zaragoza, Spain)
11:00 - 18:00 #7170 - Another causes of acute coronary syndrome: Kounis Syndrome.
Another causes of acute coronary syndrome: Kounis Syndrome.

Clinic history:

 63 years old woman with hypertension and osteoporosis that after eating a chocolate begins with erythema and itching in upper extremities and oppresive chest pain accompanied by sweating. On physical examination, the patient has blood pressure 174/98, heart rate 85 and temperature 36º; erythema and wheals on trunk and upper extremities, lip edema. The blood count and biochemestry have no notable changes. In the initial electrocardiograma ST is decreased in V4, V6 and II. After treatment with nitroglycerine and antihistamines drugs, improves the pain and the ECG changes. At 12 hours the patient begins again with chest pain and LBBB in ECG then activating the myocardial code. Catheterism is performed without coronary lesions objectified. The pain improves again after administrataion NTG, metilprednisolone and antihistamines drugs. At no time myocardial enzymes rise.

Conclusion:

The association between coronary events and allergic reactions  are recognized for years. The first case was described in 1950 after allergic reaction to penicillin. In 1991 Kounis and Zayras describe Kounis syndrome establishing two types: Type I , patients with cardiovascular risk factors and coronary spasm with normal coronary arteries . Type II, with atherosclerotic plaques in the coronary arteries that are broken during the allergic reaction.

In coclusion an allergic reaction can lead to cardiovascular events ACS on arteries with or without angiographic lesions being the pathogenic mechanism vasospasm produced by mediators delivered in anaphylaxis as histamine and leukotrienes that act as a potent vasoconstrictor. Facilating factors are the presence of cardiovascular risk factors and the existence of atherosclerostic plaques. 


Alicia RODRÍGUEZ (MADRID, Spain), Virginia LOZANO, Fátima FERNADEZ SALGADO, Guillén IRENE, Rico RAQUEL
11:00 - 18:00 #7946 - Another Life Saved. Integrated use of Ultrasound In pulse pause of Adult life support.
Another Life Saved. Integrated use of Ultrasound In pulse pause of Adult life support.

Diagnosing and treating a cause of cardiac arrest has been challenging for Emergency physicians for years since clinical signs of most reversible causes (4H and 4T) are either absent or difficult to interpret in noisy Resus and often due to continuous chest compressions . Use of integrated Ultrasound has helped Emergency Physicians to solve this clinical dilemma.

We are reporting an unusual case of cardiac tamponade and pleural effusion in a 77years old female who was diagnosed and drained during PEA cardiac arrest in our resusitation /emergency department. Integrated Ultrasonographic approach was used to get  satisfactory images and to insert drains during pulse pause of Adult life support.Successful drainage of 200mls of pericardial fluid and 1500mls of pleural fluid lead to return of spontaneous circulation(ROSC). Patient was sucessfully resusitated and stabilised and transferred to intensive care unit for furthur management. She was consecutively discharged after 18days of hospital admission. However on furthur imaging it was revelaed that she had Adenocarcinoma of the lung which was the primary cause of her disease process.

Our case report highlights the importance of training and skills required by Emergency Physicians to perform Integrated Ultrasound during Life support scenarios which aid us in diagnostic management of patients. We demonstrate that acquiring such skills are life saving.


Asif MUSHTAQ, Akhtar MUNAZAH (Redhill, United Kingdom), Julian WEBB
11:00 - 18:00 #7072 - Antibioprophylaxis in nonsurgical facial trauma in the ED.
Antibioprophylaxis in nonsurgical facial trauma in the ED.

Introduction:

Facial fractures are a frequent cause of emergency department (ED) visit. The indication for surgery is rare. Antibiotic prophylaxis is frequently introduced in not requiring urgent surgery patients. Infectious complications of theses fractures are unusual. The indications and modalities of this antibioprophylaxis are not well codified in the literature and are based mostly on empirical habits. Any antibiotic provides bacterial resistance. We aim to determine what proportion of patients are treated with antibiotics in non-surgical trauma of the face. We also wanted to discuss the modalities of such an antibioprophylxis in our ED.

Methods:

We conductes a single-center and retrospective study for 3 months (from June to August 2015) in the ED of an urban teaching hospital. All patients with 1 or 2 facial fractures without urgent surgical indication were included. The existence of antibiotic therapy and its modalities (molecule, dosage, duration) were sought. Patients with a fracture requiring urgent surgery, or with multiple fractures were not included.

 

Results:

105 patients were enrolled in this study for statistical analysis. Antibiotic treatment was introduced in 44 patients (41.9%, [CI: 32.6-51.4%]). The amoxicillin-clavulanic acid association was used in 43 cases (97.7%) with an average of 6.14 days of treatment (SD: 1.87 days).

Conclusion:

Antibiotics are prescribed in nearly 40% of injuries in the non-surgical facial trauma whereas real indications are rare.  In the current climate of increasing bacterial resistance and concern, interest of antibiotic prophylaxis in nonsurgical trauma of the face should be discussed taking into account the risk of selecting resistant bacteria, or encourage late infection with resistant organisms. When antibiotic treatment indication was laid in prophylaxis, especially in fragile patients and in situations with increased risk of infectious complications, the use of amoxicillin-clavulanic acid combination is a possibility. However, the environmental consequences of its widespread use should be considered. Pristinamycin and clindamycin may constitute interesting alternatives in this non-surgical trauma situation. The duration of treatment should not exceed 48 to 72 hours.


Charles-Eric LAVOIGNET, Pierrick LE BORGNE (Strasbourg), Carmen HAMMANN, Céline RENFER, Sarah UGÉ, Philippe KAUFFMANN, Hakim SLIMANI, Pascal BILBAULT
11:00 - 18:00 #7920 - ANTIBIOTIC TREATMENT DISCHARGE TO EMERGENCY SERVICE IN PATIENTS OVER 75 YEARS OF INFECTIOUS CAUSES COPD EXACERBATIONS.
ANTIBIOTIC TREATMENT DISCHARGE TO EMERGENCY SERVICE IN PATIENTS OVER 75 YEARS OF INFECTIOUS CAUSES COPD EXACERBATIONS.

INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is a lung disorder It characterized by the existence of an obstruction of the airways usually progressive and irreversible. The exacerbation of COPD (COPD exacerbations) is defined as a sustained worsening of respiratory symptoms, beyond its daily variation, and its most frequent infectious cause. The frail elderly or high risk is one that has a high probability of suffering an adverse process and therefore have higher morbidity and mortality. In them, strict control of COPD exacerbations is, if anything, more important.
OBJECTIVES
Evaluate the use made of antibiotics in acute exacerbation of COPD exacerbations of infectious origin in patients over 75 years discharged from the emergency department.
MATERIAL AND METHODS
descriptive, observational and retrospective study General Hospital Universitario Reina Sofia. 1172 patients diagnosed with COPD by spirometry who came to the emergency department of HGURS from January 2012 to June 2015 were included.
RESULTS
1172 patients of which 643 (57.67%) were older than 75 years were analyzed. 592 (92%) were discharged home with a diagnosis of respiratory infection. Of these, 151 (28.9%) were prescribed antibiotic from the Emergency Department.
529 (42.33%) patients were younger than 75 years, of which 495 (93.58%) were discharged from the emergency department with a diagnosis of respiratory infection. Of these, 157 (31%) were Standard antibiotic from the Emergency Department.
CONCLUSIONS
Patients over 75 are considered high risk when severe complications from infectious diseases, so that, if necessary, appropriate infection control is essential to prevent further complications. For prescribing antibiotics should stick to the criteria ruled by experts. In our case, we can see that the differences in prescribing in older or under 75 years are not significant so the fragility based on this almost age does not seem to be a criterion to be taken into account by EPs when antibiotic treatment prescribed at discharge from the Emergency Department.


Blanca DE LA VILLA ZAMORA, Maria CORCOLES VERGARA, Nuria RODRIGUEZ GARCIA, Fernandez-Camacho DANAE, Maria Consuelo QUESADA MARTINEZ, Cesar CINESI GOMEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7921 - ANTIBIOTIC TREATMENT IN DISCHARGE OF EMERGENCY DEPARMENT IN PATIENTS WITH COPD EXACERBATIONS AS GOLD SEVERITY RATING.
ANTIBIOTIC TREATMENT IN DISCHARGE OF EMERGENCY DEPARMENT IN PATIENTS WITH COPD EXACERBATIONS AS GOLD SEVERITY RATING.

Introduction
Chronic obstructive pulmonary disease (COPD) is an irreversible, progressive disease characterized by chronic airflow obstruction. The use of antibiotics in exacerbations of COPD (COPD exacerbations) has precise indications reflected in the latest Clinical Practice Guidelines, although there is controversy.

objective
Analyze the antibiotic treatment at discharge from the Emergency Department patients with COPD exacerbations and the relationship between antibiotic prescribing and the severity level.

Material and methods
observational, retrospective study conducted at the University General Hospital Reina Sofía. patients diagnosed with COPD were included by spirometry for COPD exacerbations attended between January 2012 and July-2015. antibiotic treatment prescribed at discharge and its relation to gravity Stadium was analyzed according GOLD (FEV> 80% mild, moderate 50-80%, 30-50% severe and <30% very severe).

results
1029 patients with COPD exacerbations value. They received antibiotic treatment 35% of patients with FEV> 80% (20 patients), 33.8% with FEV 50-80% (290 patients), 31.2% with FEV 30-50% (446 patients) and 23.4% with FEV <30% (273 patients). 9.6% was discharged with amoxicillin clavulanate, Moxifloxacin 6.7%, 13.7% Levofloxacin, Ciprofloxacin 1.5%, 0.9% Cefditoren, Ceftriaxone 0.2%, 0.9% versus active Cephalosporin Pseudomonas and 3% with other antibiotics and the rest were discharged without antibiotic or were admitted.

conclusions
The Levofloxacin was the most used antibiotic, amoxicillin clavulanate followed, corresponding largely as described in the Clinical Practice Guidelines.
In response to gravity, we note that in the case of patients with severe very severe stage (FEV <30%) and (FEV 30-50%) only treatment prescribed at discharge in 23.4% and 31.2% of cases respectively. This could be explained by the fact that most patients with advanced stage disease are admitted, being discharged only those with a stable clinical condition and, in principle, no criteria antibiotic therapy. It would be interesting to extend the study to assess these results.


Danae FERNANDEZ-CAMACHO, Blanca DE LA VILLA ZAMORA, Maria CORCOLES VERGARA, Nuria RODRIGUEZ GARCIA, Maria Consuelo QUESADA MARTINEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7929 - ANTIBIOTIC TREATMENT IN THE EMERGENCY DEPARTMENT IN PATIENTS WITH EXACERBATION OF COPD ACCORDING TO THE CRITERIA OF ANTHONISEN.
ANTIBIOTIC TREATMENT IN THE EMERGENCY DEPARTMENT IN PATIENTS WITH EXACERBATION OF COPD ACCORDING TO THE CRITERIA OF ANTHONISEN.

Introduction
Exacerbations of COPD (COPD exacerbations) represent today the main reason for consultation in the emergency of these patients. The use of antibiotics have precise indications but no longer in dispute.

Objetive:
Evaluate the use made of antibiotics in patients with COPD exacerbations of infectious origin according to the criteria Anthonisen.

Material and methods
Observational, retrospective study in a General Hospital with an area of 200,000 inhabitants and 275 urg / day. The medical records of patients with a previous diagnosis of COPD exacerbation had consulted January 2012 to July 2015 were reviewed.

Results:
A total of 1027 were included with COPD exacerbations. Of the 1027 patients studied 283 (27.6%) did not meet the criteria Anthonisen and 744 (72.4%) did the meet. Of those who did not present criteria Anthonisen 83 (29.3%) went with antibiotic therapy at discharge and 200 (70.3%) left without antibiotic therapy at discharge. Of the patients who were Anthonisen criteria were with antibiotic therapy at discharge 224 (30.1%) and 520 (69.9%) left without antibiotic therapy at discharge.

Conclusions:
Over 70% of patients with COPD exacerbations presented criteria for the use of antibiotics. Our results reveal that the use of antibiotics in the Emergency Department is independent of the criteria Anthonisen because we use exceeds 30% of cases where it would be justified if their use.
It seems that if we better leave without antibiotic treatment to those who have no criteria where only prescribe antibiotics to 29% of patients.
These results should make us reflect on this aspect that is really improved in accordance with the recommendations.


Nuria RODRIGUEZ GARCIA, Danae FERNANDEZ-CAMACHO, Blanca DE LA VILLA ZAMORA, Maria Consuelo QUESADA MARTINEZ, Maria CORCOLES VERGARA, Pascual PIÑERA SALMERÓN (montepinar, Spain), Maria Encarnacion SANCHEZ-CANOVAS, Cesar CINESI GOMEZ
11:00 - 18:00 #7466 - Anticoagulant-Induced Intramural Intestinal Hematoma: Report of two Cases.
Anticoagulant-Induced Intramural Intestinal Hematoma: Report of two Cases.

Introduction: Spontaneous intestinal hematoma is a rare and severe complication of anticoagulant therapy.

Cases: we reported two cases of intramural and submucosal small bowel hematoma resulting from warfarin administration. The first patient presented with abdominal pain, had intramural hematoma at jejunum, the most common site of intramural small bowel hematoma. Another patient who had submucosal duodenal hematoma presented with epigastric tenderness . Typical findings on abdominal computerized tomography yielded the diagnosis. All patients rapidly improved after conservative treatment.

Conclusion: The history of anticoagulant use with prolonged INR value in patients presented with abdominal pain should alert physicians to search for this entity. It is extremely important to recognize this syndrome in order to avoid an unnecessary operation since the outcome is usually excellent after conservative treatment


Mohamed Ali CHERIF, Asma BEN ALI, Farah RIAHI (Belfort), Mohamed MEZGHENI, Rim BEN KADDOUR, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7361 - Aortic dissection in the Emergency Department.
Aortic dissection in the Emergency Department.

Dissection of the aorta is a condition that usually occurs suddenly, and in most cases, arise from an incidental finding, during a secondary abdominal pain or acute chest assessment. This condition is not as common as other causes of chest pain, but it is essential to maintain a high index of suspicion based on adequate knowledge of this entity.

 The objective of this study is to describe the prevalence of this disease in our population and thus identify risk factors and demographic characteristics thereof with special interest in the timely diagnosis. Based on this we propose an algorithm of action in the ED. Methodology: Transversal, retrospective descriptive study on the epidemiological, clinical, with special attention to the presentation, diagnosis in the emergency department at our center.

 The importance of this study is to propose an early diagnosis for better patient outcomes. Within our sample, 77.77% of patients were male. The most common symptom that led to emergency room patients was chest pain by 100%. The initial clinical suspicion, after making history and examination was 11.1% for dissection prior to any diagnostic, in other cases another diagnosis was assumed, so the patients were admitted to hospital, diagnosed with "chest pain in study" in a 9.09%.

The 66.6% of patients were operated. The hospital mortality was 22.2%.

 The sudden onset of severe, retrosternal or interscapular chest pain, sometimes referred to as tear and subsequent progression downward or toward the back region would typically wait picture. 100% of the cases had chest pain related to the range described in the literature (14-55%).

The use of complementary diagnostic tests, differs markedly from a serious to others, explained by the availability depending on the center and experience in use, varying from one center to another and even from staff is on call in the emergency services .

 So an algorithm care is proposed to these patients from the perspective of the emergency department, integrating the most important data of clinical and suggesting the most simple and effective guidelines for care before chest pain suggestive of aortic dissection applicable to all emergency  services..


Cruz SALEME (Mexico, Mexico), Karla HERNANDEZ, Hector MONTIEL
11:00 - 18:00 #7889 - APHER: Analyzing Acute Pyelonephitis Handling in Emergency Hospitalary Room: observacional study.
APHER: Analyzing Acute Pyelonephitis Handling in Emergency Hospitalary Room: observacional study.

Acute pyelonephritis (APN) is a frecuent infection that mainly affects to sexually active healthy women. APN represents a 3% of the urological patients attended in the Emergency Hospitalry Room (EHR) wich prevalence is around 12% in women and decreases to 2-3 % in men. APN encompasses both renal parenchyma and collecting system and it presents with 3 key symptoms: fever, lowerback pain and voiding syndrome. However, a high amount of the APN are uncomplicated. It´s of a vital importance to know the patient epidemiological characteristics, reason for consultation and therapeutic management in order to achieve a quick and safe handling in HER.

Observacional descriptive study enrolled patients with APN diagnosis made in EHR during a 5 moths period. Medical histories, current complaints, labortory test results and prescribed hospitalary and ambulatory treatment were recorded to all patients, as well as final destination and analyzed with SPSSv17 stadistical programme.

43 patients were included with an average age of 38.4 ± 15.9 years, being 93 % women. The total incidence for APN was 1.7 ‰. No risk factors for developing APN were detected in most of the patients. The 86 % of the patients showed fever as the most prelavent symptom in association or not with renal fossa pain and sickness. More than the 90 % had urinary sediment altered, with a 74.4 % presenting leukocytosis and neutrophilia. A 53.3 % of the abdominal ultrasounds made were pathological. Urine culture, recorded in 35 patients, were positive in 30.2%, with Escherichia Coli as leader pathogenic agent and antibiogram sensivity test positive for nitrofurantoin and fosfomicyne. Empirical intraveous antibiotic therapy was performed with ceftriaxone in association with tobramicyne(67.1%) and discharged home with oral cefuroxime and cefditoren treatment. More than a half of the patients required hospital stay in Urology or Intensive Care Unit.

Discharge home from the EHR is therefore justified after an observation period less than 24h in which a first pal antibiotic dose is administered(ceftriaxone+tobramicyne) and an appropriate oral antibiotic is chosen. The patient should be warned about possibility of the persistence of some symptoms and referred for appropriate outpatient follow-up.

Virtually all the patients were women with no risk factors. E. Coli was the most common patohenic agent, with high rate of resistance, particularly to trimethoprim-sulfamethoxazole and ampicillin. Therefore we can afirm that our results are similar to other studies consulted


Álvaro MARTÍN PÉREZ (Badajoz, Spain), Ana SANTOS LUCIO, Concepcion DE VERA GUILLÉN, Juan María FERNANDEZ NUÑEZ
11:00 - 18:00 #7442 - Aplasia of the posterior arches of the atlas: a rare cause of acute neck pain in emergency departement.
Aplasia of the posterior arches of the atlas: a rare cause of acute neck pain in emergency departement.

Introduction: Cervical pains are a common reason for visit in emergency department. About 20% of the population had at least one episode of neck pain in her life [1-2]. The cause can be traumatic, postural, inflammatory, infectious, tumor or secondary to bone deformities. Agenesis of the posterior arch of the Atlas is a rare cause.

Observation: We have reported the case of a young woman, aged 25, basketball player who has consulted in the emergency for isolated neck pain, lasting for two days. On physical examination, the patient was  non-febrile , mobility was preserved and painful and there was no sensory-motor deficit. The rest of the examination was without abnormalities. Radiography of cervical spine showed agenesis of the posterior arch of C1. The patient benefited from a symptomatic treatment based on anti-inflammatory and analgesic drugs and she was sent to the orthopedic consultation to complete the exploration by an MRI of the cervical spine.

Conclusion: malformations of the cervical spine are a rare cause of neck pain. Their clinical expression may remain asymptomatic for a long time and their discovery is often fortuitous.


Dorsaf BELLASFAR, Mouna TITEY (tunis, Tunisia), Jihene AOUEM, Saloua HOUIMLI, Abdelmajid BEN ROMDHANE
11:00 - 18:00 #8179 - Apparent insect bite that ends in finger amputation.
Apparent insect bite that ends in finger amputation.

Introduction: A patient presented with a suspected insect bite ends up having his finger amputated. This case report include a brief review of the literature about necrotising soft tissue infections. Case report: A 47 years-old male, presented to the Emergency department with mild itching and pain on his left index finger.He initially denied any trauma but observed a erythematous patch on the dorsal aspect of the finger. Two hours after the ED consultation re represented hours after patient consulted by increasing of pain and required opiates to relieve the pain Upon arrival she showed mild erythema and Oedema only in the finger. Labs showed leucocytes at 22 000. He was treated as a cellulitis by possible insect bite and empirical antibiotic therapy was initiated. Few hours later he presented with lymphangitis in the arm and signs of necrosis in the finger. A venous Doppler ultrasound of left upper limb done and was normal. He underwent surgical debridement but developed necrosis and later ended up having amputation of the finger. Blood culture showed Streptoccocus pyogenes. Two weeks later patient report he remembers injury the finger with a rose thorn the day before initial presentation. Necrotising cellulitis presents with pain and swelling, the onset is gradual, but the process may spread rapidly with systemic toxicity. Early surgical exploration and debridement are required to prevent spread of infection in the different planes of tissues References: 1. Demain JG. Papular urticaria and things that bite in the night. Curr Allergy Asthma Rep 2003; 3:291. 2. Siljander T, Karppelin M, Vähäkuopus S, et al. Acute bacterial, nonnecrotizing cellulitis in Finland: microbiological findings. Clin Infect Dis 2008; 46:855. 3. Leppard BJ, Seal DV, Colman G, Hallas G. The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. Br J Dermatol 1985; 112:559. 4. Woo PC, Lum PN, Wong SS, et al. Cellulitis complicating lymphoedema. Eur J Clin Microbiol Infect Dis 2000; 19:294.


Lupe Del Rocio CORONEL CHUMBI (MURCIA, Spain), Juan Antonio HIDALGO RAMOS, Ashid KODUMAYIL, Monica Asuncion ALEIXOS ZURIAGA, Meulry CAPELINI, Margarita Gertrudis FERRANDEZ ABELLAN, Kissy Marlene RUIZ RIVERO, Elisa MENDAZA GOMEZ
11:00 - 18:00 #7422 - Application of qSOFA score compared with Modified early warning signs for predicting 24-hours-in-hospital cardiac arrest : A retrospective review.
Application of qSOFA score compared with Modified early warning signs for predicting 24-hours-in-hospital cardiac arrest : A retrospective review.

Purpose

Quick SOFA (qSOFA) is a newly purposed simple screening tool to predict in hospital mortality from sepsis and it should also be used to predict mortality from other causes too. But the role of this score for predicting overall in hospital cardiac arrest in 24 hours is not known. Modified early warning signs (MEWS) was a widely used score for predicting in hospital mortality from any causes now but recent studies showed that low MEWS score still cannot ruled out in hospital mortality. So the aim of our study was to determine the role of qSOFA and comparison to MEWS score in predicting 24-hours-in hospital cardiac arrest.

Methods

This is a single-centre retrospective study. The study included adult in-hospital-cardiac-arrest (IHCA) patients who were monitored and resuscitated by a medical emergency team in the emergency department, on the general ward or ICU. They were enrolled in this study between January to December 2015. qSOFA and High risk MEWS score (MEWS: ≥5) were calculated for the highest score tracing back to 24 hours before cardiac arrest. Timing before IHCA, ROSC rate and survival-to-discharge rate were collected.

Results

Preliminary results were reported from 50 patients. Out of 50 patients, 40.6% had a return of spontaneous circulation. And 18.8% of the patients had survival until discharge. After tracing back until 24 hours before they had IHCA event, there were 53.1% and 59% IHCA Patients who have qSOFA ≥2 and High risk MEWS respectively. The mean time that qSOFA ≥2 was presented was 3.2 hours before cardiac arrest. While for high risk MEWS was 2.9 hours. There was no statistical difference reported in any elements.

Conclusions

As our preliminary results showed, there were no differences in using qSOFA for predicting 24 hours-IHCA compared with high risk MEWS. We supposed that this result will also be presented in the final result of this study and qSOFA should be able to use as an early predictor for IHCA of any causes.


Wisarut BUNCHIT (Bangkok, Thailand), Veerapong VATTANAVANIT
11:00 - 18:00 #8124 - Application of telemedicine between primary care and emergency department of the Hospital of Barbastro.
Application of telemedicine between primary care and emergency department of the Hospital of Barbastro.

INTRODUCTION:

The application of new communication technologies for the realization of medical consultation between the different services of emergency primary care and reference hospital, allows the advice from doctors hospital emergency of the patient without the need to scroll to hospital and can offer different options for the correct diagnosis of pathological conditions and provide early therapeutic response, optimizing time and quality of care.1,2,3

TARGET

Describe the process of medical care for patients with urgent health problems using new technologies of medical consultation between primary care and hospital emergency doctors.

MATERIALS AND METHOD

Prospective study of medical interconsultations made through videoconferencing and / or calls between the emergency department of the Hospital of Barbastro and its different primary care centers over a period of 12 months (01/01/2016 - 31 / 12/2016).

At the present time obtained a sample of 35 interconsultations, it will proceed to the final analysis of statistical data through SPSS

RESULTS

Pending final results at the time of shipment. At the current time of sending present work it has obtained a sample of 35 interconsultations, all of which have been phone calls. Only 10 patients were sent for evaluation and hospital admission. The rest was followed by his primary care doctor. The most frequent reason for consultation with 42% was questions of interpretation of diagnostic tests, followed with 28%  dyspnea in patients with chronic obstructive pulmonary disease.

CONCLUSION

With the data obtained is too early to draw reliable conclusions but it can be noted that the time has facilitated communication between professions Primary care and emergency departments, reducing uncertainty professional must make a medical decision in a short period of time optimizing of this form the medical care of the patients.

BIBLIOGRAPHY:

  1. “Telemedicina”, http://es.wikipedia.org/wiki/Telemedicina, última visita 8 de diciembre de 2015
  2. “Las TIC En la sanidad del futuro”, http://www.telefonica.es/sociedaddelainformacion/pdf/informes/espana_2006/sociedadinformacion2006.pdf, Última visita 4 De diciembre de 2015.
  3. “La telemedicina: ¿ciencia o ficción?”, http://recyt.fecyt.es/index.php/ASSN/article/view/2703/2072, última visita 8 de diciembre de 2015.

Juan José EITO CUELLO, Ana Graciela MORENO MEJIA (Huesca, Spain), María Dolores LONCAN MARGALEJO, Clara LORIENTE MARTINEZ, Beatriz BENITO RUIZ, Manuel GRIABAL GARCIA, Pilar CANELLAS SANCHEZ, Ana Maria ARILLA ALBAS
11:00 - 18:00 #7216 - Application of the Canadian C-Spine Rule and Nexus low criteria and results of cervical spine radiography in emergency condition.
Application of the Canadian C-Spine Rule and Nexus low criteria and results of cervical spine radiography in emergency condition.

Background: The Canadian C Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (Nexus) low criteria are well accepted as guide to help physician in case of cervical blunt trauma. We aimed to evaluate the application of these recommendations in our emergency department. Secondly we analyzed the quality of cervical spine radiography (CSR) in an emergency setting.

Results: 281 patients with cervical blunt trauma were analyzed retrospectively. The CCR and the NEXUS rules were respected in 91.2% and 96.8% of cases respectively. No lesions were found in 96.4% of patient. A lesion was present in 1.1% of patient and suspected in 2.5% of patient. The quality of CSR was adequate in only 37.7% of patient. The poor quality of CSR was due either to the lack of C7 vertebrae visualization in 64.6% or other lower vertebrae in 28%. Other causes included the absence of open mouth view (8%), the absence C1 vertebrae visualization (3.4%), artifact in 2.3% and the absence of lateral view in 0.6% of patient.

Conclusions: CCR and NEXUS are widely used in our emergency department. The high rate of inadequate CSR reinforces the debate about it’s utility in emergency condition.


William NGATCHOU, Jeanne BEIRNAERT, Daniel LEMOGOUM, Cyril BOULAND, Pierre YOUATOU, Ahmed Sabry Elsaeid RAMADAN (BRUXELLES, Belgium), Regis SONTOU, Maimouna BOL ALIMA, Alain PLUMAKER, Virginie GUIMFACQ, Claude BIKA, Pierre MOLS
11:00 - 18:00 #7091 - Appropriate use of CT Pulmonary Angiography at a Brisbane Hospital - An analysis of ordering D-Dimers in the Emergency Department and the potential for improvement.
Appropriate use of CT Pulmonary Angiography at a Brisbane Hospital - An analysis of ordering D-Dimers in the Emergency Department and the potential for improvement.

Purpose:

 

The symptoms and signs of a pulmonary embolism (PE) are extremely varied and thus a clinical diagnosis of PE can be unreliable. A robust way to stratify a patient’s risk of PE is to use one of the validated clinical decision tools such as the Wells score. 1 Using these tools, a patient can be stratified into a low, moderate or high pretest probability of PE. The addition of a d-dimer test provides a pathway to determine if a patient requires imaging to exclude a PE. 2

 

The d-dimer is a breakdown product of crosslinked fibrin and occurs coincident with activation of the coagulation cascade. The d-dimer level may be elevated in the presence of a clot that embolises to the lungs causing a pulmonary embolism (PE). The d-dimer level should be used in patients with a low to moderate pretest probability for PE. 3

 

Methods and Materials:

 

A retrospective audit was performed of patients who underwent CT Pulmonary Angiography (CTPA) for suspected PE from the emergency department in January 2016. IMPAX search parameters:

 

Study Dates = 01/01/2016-01/03/2016.

Study Description = “CT Pulm”

Request = ED Clinician and/or location ED.

 

Using these studies a more detailed review of the available documentation including d-dimer result, a recent chest x-ray, vital signs and clinical history were used to produce a retrospective Wells PE probability score.

 

Results:

 

The first 100 CTPAs performed were analyzed. 13% of the patients had a positive CTPA for PE. 98% of patients were of low to moderate pretest probability for PE. 15% of these patients had a d-dimer requested prior. 12 (92%) of the patients who had a confirmed PE were of low or moderate pretest probability. It was noted, one patient with low pretest probability of PE, who had a negative d-dimer, still continued to have a CTPA which was also negative.

 

Conclusion:

 

The positive CTPA rate for PE was 13% - less than the rate recommended by the Royal College of Radiologists of 15.4-37.4%. 4 Only 15% of the low and moderate pretest probability patients had a d-dimer requested. If the d-dimer test was utilized appropriately, it could have conceivably avoided up to 71% of the CTPAs. . Education sessions and emphasis on the diagnostic imaging pathway would save cost, reduce exposure of patients to ionizing radiation, the risk of contrast complications and would improve patient turn over in the emergency department.

 

References:

 

  1. Lucassen W, Geersing GJ, Erkens PM, et al. Clinical decision rules for excluding pulmonary embolism: a meta-analysis. Ann Intern Med 2011;155:448–60.
  2. Department of Health, Government of Western Australia. Diagnostic imaging pathways – respiratory. Available at: www.imagingpathways.health.wa.gov.au/index.php/imaging-pathways/respiratory [Accessed 28 March 2016].
  3. Torbicki A, Perrier A, Konstantinides S, et al. Guidelines on the diagnosis and management of acute pulmonary embolism. The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008;29:2276–315.
  4. Duncan K, Howlett D. Appropriateness of usage of computed tomography pulmonary angiography investigation of suspected pulmonary embolism. 2010. Available from: https://www.rcr.ac.uk/audittemplate.aspx?PageID=1020&AuditTemplateID=166

Amit CHACKO (Brisbane, Australia), Carl DUX
11:00 - 18:00 #8127 - Are patients with asthma that arrive in emergency department treated following the recommendations?
Are patients with asthma that arrive in emergency department treated following the recommendations?

Introduction: Asthma is a highly prevalent disease that presents commonly to the emergency department (ED) in acute exacerbation. Recent Spanish Ashtma Management Guide(GEMA) has set the management for both regular therapy, with 6 therapeutic steps, and exacerbation therapy.
Objetive: To determine whether patients with asthma treated in the emergency department for exacerbations had a previous treatment, had been treated in the emergency room, and have been discharged with treatments that followed the
recomendations of the Spanish Ashtma Management Guide(GEMA)
Method: Prospective study of patients treated in emergency for exacerbation of asthma, checking pretreatment, during emergency admission and discharge fitted the guidelines.
Results: We studied 117 clinical reports of patients treated for asthma exacerbations in the ED of our Hospital during 2015. 6 patients were in the first therapeutic step, 11 in the second, 45 in the third, 37 in the fourth, 11 in the fifth, and 7 in the sixth. Only 35% of the patients were recieving treatment according to the GEMA guidelines, 23% were overtreated, and 42 were not recieving enogh treatment. In emergency admission 85% of the patients (99) were treated according to the guidelines, and 15% (18) were overtreated, with 0 patients not recieving enough treatment. 27 patients were admitted to the hospital ward. Of the 90 patients discharged, 66% were prescrieved treatment according to the guidelines, 12% were not recieving enough treatment and 22% were overtreated.

Conclusion: low compliance is found in the application of clinical guidelines in patients with asthma so it is necessary to find tools to improve the correct application of the recommendations of clinical pathways.


Luis ESCOBAR Y ALVARO (Lorca, Spain), María TRENZA PEÑAS, Joaquín JIMENEZ GONZALEZ, María Ángeles MAYOL VILLESCAS, Ricardo BARRAGÁN ALARCÓN, Clara SANCHEZ PARRA
11:00 - 18:00 #7122 - Arrhythmogenic dysplasia evidenced after food poisoning.
Arrhythmogenic dysplasia evidenced after food poisoning.

Case Report

Patient presenting with symptoms of vomiting and diarrhea after dinner last night. He goes on his own picture described referring to hospital and decay.
No known drug allergies. Hypertension, chronic renal insufficiency. Treatment: Olmesartan 20 mg.

Physical Exploration:

Conscious. Oriented. Feeling disease, mucocutaneous pallor, mild dehydration of mucous. Ausculatacion cardiorespiratory: rhythmic tones, 120 beats per minute, no murmurs or extratonos. Preserved vesicular murmur without superadded noise. Abdomen soft and palpable, no palpable masses or organ enlargement, no signs of peritoneal irritation. Increased peristalsis. Preserved distal pulses, no signs of deep vein thrombosis.

Additional tests

Rx thorax and abdomen without interest.
Analytical requested with gases and proceeds to channeling to start intravenous fluid and enters observation for stabilization.

Evolution

On admission observation was continually monitored displayed on TV monitor sustained monomorphic, with hypotension when it comes to electrical cardioversion with 200 J shock after which happens to sinus rhythm.
He turns to interrogate the patient acknowledges occasional episodes of palpitations with exercise dominance for which he had never consulted.
In analytical results highlights decompensation previous renal function (creatinine 3.5 no other findings).
After entering picture stabilization plan of Cardiology. Finally, during admission was diagnosed with arrhythmogenic right ventricular and proceeds to implantation of implantable cardioverter defibrillator (ICD).

CONCLUSION: Sometimes considered banal pathology can afford the casual diagnosis of serious latent disease.


David NÚÑEZ CASTILLO, María Eugenia REYES GARCÍA (Málaga, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7537 - ASCITES IS NOT ALWAYS FROM A CAUSE DIGESTIVE.
ASCITES IS NOT ALWAYS FROM A CAUSE DIGESTIVE.

Medical history:
Male 72 years old witha history of atrialfibrillation, severeaorticinsufficiency and hypertension treatedwith anticoagulantsandACE inhibitors, which came due to have increasedtheirabdominal perimeterandoliguriainthe previous two weeks. Blood presure 105/85,157bpmheart rate,tachypneic. Flapping++.IY+AC:panfocalrhythmicsystolic murmurgradeII-III.AP:hypophonesiswidespread. Abdomen:globular,significant increase inabdominal circumference,signwave+.peneoescrotaledema.EEII:edemawithfovea+tothigh.Analytical:2.3ureacreatinine119regularrest.AcxFAECG157. Bilateralpleural effusiononchest X-ray. Due to an importantpenoscrotaledemaand presentinginability tobladdercatheterization, bladder size was carried out despite beinganticoagulated, because of this punctureascitic fluid was discarded. Treatment was initiatedwithSegurilat maximumdoseand Digoxin, and as oliguria and elevated heart rates persisted was necessary to add Amiodarone to the treatment. InEchocardiographywas observed dilated cardiomyopathywith severe systolicdysfunctionand ejection fractionof 45%. Moderate mitral regurgitation. Moderatepulmonary hypertension. Having suspicions of dilated cardiomyopathy andAnasarca, he hospitalized in Cardiology,wherecontrolEchocardiographywas performedat 24 hoursobjectifyingserious deteriorationwithejection fraction20%and significantpericardial effusion. Severe pulmonary hypertension. Severe mitral-aorticinsufficiency. Because ofthe poor performanceand poor generalcondition of the patient,  the family agreed alimitationof the therapeutic effort, passing awaya few hours after.
Conclusion:
Dilated cardiomyopathy isa disease of theheart muscle thatcauses theheart becomes enlarged and cannot pump blood efficiently. The causesare uncertainand varied:viral, autoimmune, alcohol abuse,coronary artery disease, hypertensionand valvulardisease, which may triggerheart failure and, inthe worst case, may becongestive causing edema, pleuraleffusion, ascitesandanasarcainfinal stages. The most reliable diagnostic test is  the echocardiogram and the treatmentis based onthecontrol of heartrate and blood pressureanddiuresisreinforcement. In very advanced cases orwhen there are severe arrhythmias, themost appropriateoption is usuallycardiactransplantor placement ofICDs. The probabilityof deathin the final stagesis high.

María Teresa FERNANDO GROS (ZARAGOZA, Spain), Patricia BONED BLAS, María Pilar POVEDA SERRANO, Rocío ESCRICHE ROS, Alicia BAGUENA GARCÍA
11:00 - 18:00 #7481 - Assessing accuracy and inter-rater reliability of the emergency severity index in triage in the al-rahba emergency department: A cross-sectional observational study.
Assessing accuracy and inter-rater reliability of the emergency severity index in triage in the al-rahba emergency department: A cross-sectional observational study.

Background: The Emergency Severity Index (ESI) is a five-level triage scale used by the vast majority of emergency departments (ED) in the United States (US) and a growing number of EDs globally. The scale was developed and validated within the US, and there is little data to support its use in other settings where clinical training, resource availability, and cultural norms vary. ESI relies heavily on operator experience and intuition, and accurate triage designation is dependent on rapid assessment of illness severity and accurate prediction of clinician treatment decisions. Reports of ESI performance in countries where emergency medicine (EM) is a relatively young specialty suggest sub-optimal performance of ESI in these settings.

The purpose of this study was to assess triage accuracy, variability, and self-perception among formally trained nurses performing ESI triage at Al-Rahba Hospital (ARH) in Abu Dhabi, United Arab Emirates. We hypothesized that ESI user performance would be lower than has been previously reported in the US, and there would be greater variability in triage decisions.  

Methods: We utilized twenty-five standardized triage cases from the ESI Handbook to evaluate accuracy and inter-rater reliability in ESI score assignment in a cross sectional cohort of ESI-trained ED nurses at Al-Rahba Hospital in Abu Dhabi. The gold standard of accuracy was the ESI handbook answer key.

The survey data was analyzed with Krippendorff’s alpha to assess for inter-rater reliability. Accuracy was calculated for each question and broken down based on ESI triage level and scenario type (medical, trauma, or pediatric case). We also determined percent “under-triage” and “over-triage” overall and for each case, and assessed self-perception of triage level assignment accuracy among nurses.

 Results: Thirty-five ED nurses from ARH participated in the study. Overall accuracy in triage scale assignment was 58.7%, with 28.8% of cases under-triaged and 12.3% over-triaged.  Range of accuracy by individual scenario was 2.9% to 100%. The lowest accuracy was observed for pediatric cases, with 48.9% of all scenarios scored correctly (range by individual scenario: 2.9% to 94.3%). Accuracy was slightly higher for adult trauma (56.2% overall accuracy, range 40% to 85.7%) and adult medical cases (overall accuracy 66.2%, range 28.6% to 100%). Overall inter-rater reliability was moderate (Krippendorff’s alpha = 0.78), and self-perceived accuracy among nurses was either “moderately confident” (40%) or “very confident” (60%).

Discussion: We observed low accuracy in ESI score assignment and significant case-to-case variability for these standardized cases, yet nursing self-perception of performance was high. Nurses scoring these cases had 5 or more years of experience, were formally trained in ESI, and undergo regular triage performance assessments. While more work is required to determine causality, we believe that practice environment has a significant impact on ESI user performance, and that this triage scale, which relies heavily on provider experience, intuition and predictive capacity for treatment decisions, may not be suited to all practice environments.  Future directions include semi-structured interviews with nurses to assess for barriers to using ESI in real-time and repeating this study at other sites globally. 


Binoy MISTRY (Silver Spring, MD, USA), Jeremiah HINSON, Kamna BALHARA, Sarah STEWART DE RAMIREZ, Xavier ANTON, Scott LEVIN, James SCHEULEN, Maysoon ABDEL LATIF E'NOUZ, Iman YASSIN OTHMAN
11:00 - 18:00 #7552 - Assessment of antibiotic prescription in the Emergency Department.Prospective study (about 100 patients).
Assessment of antibiotic prescription in the Emergency Department.Prospective study (about 100 patients).

Introduction: sepsis is associated with high mortality worldwide. It is now accepted that the precocity of the treatment is related to a significant prognostic improvement. Antibiotic therapy which is the specific treatment is usually started in emergencies. Furthermore, there is a consumer increasing use of antibiotics in emergency services generating some reservations for its justification. In this work, we tried to evaluate antibiotic prescription in terms of justification, relevance and compliance.

Materials and Methods: This is a prospective study over 5 months that enrolled 100 patients admitted to the unit of hospitalization of the emergency department for sepsis. We used our local registry of sepsis. We collected Clinical, biological, microbiological, the final diagnosis and characteristics of antibiotic therapy for each patient. An evaluation of antibiotic prescription was conducted by two experts blindly regarding 3 items: justification, relevance and the compliance (of doses and the route of administration) of the antibiotics.

Results: hundred patients were enrolled. The average age was 62 years. The sex ratio was 1.04. The most common sites of infection were urinary and pulmonary in 43% and 28% of cases. Among our patients there were 46 cases of sepsis, 49 cases of severe sepsis and 4 cases of septic shock. 99 patients received antibiotics. The most used drug was cephalosporin in 83.83% of cases (in association in 71.08% of cases) followed by Quinolone in 52.52% of cases. The antibiotic therapy was considered justified in more than 95% by the two experts. A mismatch was noted between the two experts regarding the relevance and compliance (Kappa=0,34). However our choice of antibiotic was deemed appropriate in 53% of cases (expert 1: 53.7%, expert 2: 80.8%), the largest rate relevance concerned the pulmonary pathology for both experts. The administration route was deemed compliant in more than 76% of cases (expert1: 76.8%, expert 2: 100%). There was an agreement between the two experts regarding the unit dose and the spacing of doses (the compliance rate has exceeded 80%).

Conclusion: The assessment of prescription of antibiotics is important. Some disparities were noted in our practice. An available guide for antibiotic prescriptions in emergency case is essential to ensure the quality of prescriptions.


Ibtissem CHAIEB, Asma ZORGATI (Sousse, Tunisia), Naouefel CHEBILI, Houda BEN SALAH, Khaoula BELHADJ ALI, Riadh BOUKEF
11:00 - 18:00 #8144 - Assessment of community acquired pneumonia with fine’s score and a radiological score.
Assessment of community acquired pneumonia with fine’s score and a radiological score.

Introduction: Community acquired pneumonia (CAP) is a frequent leading cause of hospital admission worldwide. Through this study we investigate the accurancy of Murray radiological  score (RS) associated to Fine score (FS) as a triage tool for CAP in the emergency department.  

Methods: a prospective observational study including patients admitted in an emergency department of a general teaching hospital for a CAP. FS and RS were calculated on admission and we analysed the rate of hospitalization and outcome at 30 days and analysed  the correlation between the two scores. Statistical analysis were based on Chi 2 test with significant statistical difference (SSD) if p < 0,05.

Results: 174 CAP, 104 men and 70 women, mean age = 57,5 ± 17,7 years. RS was 3 ± 0 in FS class I (n = 6), 3.6 ± 1.4 in class II (n = 46), 3.54 ± 1.5 in class III (n = 40), 4.1 ± 2 in class IV (n = 67) and 4.33 ± 2 in class V (n = 15).  Among patients who were hospitalized in medical ward, 60% of them belongs to class I, 83.3% to class II, 53.4% to class III, 15.1% to class IV and 16.6% to class V. 17.5% of patient hospitalized in ICU had a fine score class III , 52.8% had a class IV and 41.1% had a class V. Checking out  was possible for 40% of patients in class I, 13.9% in class II, 22.6% in class III and 11.3% in class IV. Mortality ranged from 2.8% in class II to 41.7% in class V.

We found an association  between FS and RS (r=0.16, p=0.034). The RS in survivors versus  not survivors in the FS categories was respectively 3.46± 1.3 vs 5±1 in class II, 3.25 ± 1 vs 5 ± 2.4 in class III, 3.7 ± 1.7 vs 4.8 ±2.3 in class IV and 4 ±1.3 vs 5 ±2.5 in class V. There was a SSD only in category II (p = 0.01).

 

Conclusion: Radiological score may improve Fine score. Further studies with larger cohort are necessary to show better results.

 


Majed KAMEL, Mohamed Amine KALLEL (tunis, Tunisia), Zaouche KHEDIJA, Baccouche RAMLA, Khelil MOHAMED HASSENE, Maghraoui HAMIDA, Modhafer MOHAMED, Hammouda CHOKRI, Borsali NEBIHA
11:00 - 18:00 #7886 - Assessment of passive leg raise by thoracic electrical bioimpedance in spontaneously breathing volunteers, a pilot study.
Assessment of passive leg raise by thoracic electrical bioimpedance in spontaneously breathing volunteers, a pilot study.

Background: While Intravenous fluid resuscitation is common in emergency departments (ED), existing standard monitoring techniques are relatively poor indicators of fluid responsiveness (FR). Passive Leg Raise (PLR) creates a reversible haemodynamic response similar to fluid challenge. Thoracic Electrical Bioimpedance (TEB) is a non-invasive cardiac output (CO) monitoring technology which can be used to quantify the cardio-haemodynamic response to PLR.[1, 2]

Objectives: To study the haemodynamic response to PLR measured by TEB (Niccomo, Medis, Germany), assess the feasibility of the test and the reproducibility of the findings.

Methods: A prospective observational study was conducted on healthy volunteers (≥18 years old). Blood pressure was recorded and TEB device was used to record continuous data of heart rate (HR), CO and stroke volume (SV). Subjects were placed in head-up position for 3 minutes followed by 3 minutes lying flat with legs elevated (PLR1). Subjects were returned to semirecumbent position for 5 minutes, then the procedure was repeated (PLR2). FR was defined as a rise in CO by more than 10% during the test.

Results: Fifteen volunteers were enrolled. Median age was 35 (interquartile range [IQR] = 28 – 47) and 8 were males. Median mean arterial pressure was 100 (IQR = 90 – 107). FR was observed in 11 subjects during PLR1 and 14 subjects during PLR2. Median change of CO during PLR1 was 13.9% (IQR = 11.2 -18%) and 15.2% (IQR = 13.4 - 18.2) during PLR2. Repeated FR testing showed fair agreement (Kappa = 0.328; 95% confidence interval [CI] = -0.175 to 0.832). In the 30 PLR tests CO and SV responses showed weak correlation (rs = 0.45, CI = -0.08 to 0.78).

Conclusion: These initial data suggest that PLR-TEB test is a promising tool to predict FR in ED. The test showed fair repeatability, however this should also be established in a patient group. The weak correlation between CO and SV responses suggests that the response to increased preload is more complex than the current literature recognises. Additional patient data will allow us to determine the CO response to PLR-TEB test with more confidence and to establish the limits of agreement of repeated PLR-TEB. The next step will be evaluating the accuracy of this test to predict FR to a fluid bolus.

References:

1. Cherpanath TG, Hirsch A, Geerts BF, Lagrand WK, Leeflang MM, Schultz MJ, et al. Predicting Fluid Responsiveness by Passive Leg Raising: A Systematic Review and Meta-Analysis of 23 Clinical Trials. Crit Care Med 2016; 44(5):981-91.

2. Summers RL, Shoemaker WC, Peacock WF, Ander DS, Coleman TG. Bench to bedside: electrophysiologic and clinical principles of noninvasive hemodynamic monitoring using impedance cardiography. Acad Emerg Med 2003; 10(6):669-80.

Acknowledgements: We would like to thank the Ministry of Higher Education – Missions Sector, Egypt and the British Council for their support through Newton-Mosharafa Fund.


Dr Mohammed ELWAN (Leicester, United Kingdom), Ashraf ROSHDY, Assem KHAMIS, Eman ELSHARKAWY, Salah ELTAHAN, Timothy COATS
11:00 - 18:00 #7297 - Assessment of the epidemiology and the management of the patients with acute heart failure diagnosis in Emergency department.
Assessment of the epidemiology and the management of the patients with acute heart failure diagnosis in Emergency department.

Background: Majority of acute patients are admitted to the hospital through the emergency department (ED). Acute heart failure (AHF) is a frequent cause of presentation to the ED and increase with age. Emergency physician suggests a potential case to the cardiologist who decides to accept it or not.

Objective: To describe epidemiology and outcome of patients with acute heart failure diagnosis in ED.

Methods: A prospective, observational, monocentric, study was carried out over a 6 weeks period. All patients with AHF diagnosis were included.

Results: From 14/10 to 25/11/2014, there were 4873 emergency department admissions and 55 patients (1%) had AHF diagnosis: 32 (58%) women, 23 men. The average age and median age was respectively 83.7 and 87 year old (58 – 101). Sixty-four percent of patients had conserved autonomy and no cognitive decline. 71% were older than 80 years. The mean and median time elapsed from arrival and medical consultation was respectively 31 and 18 minutes. 41 patients (75%) had AHF only, 14 patients (27.3%) had combined with sepsis pathology.  The cardiologist would be called for 36 patients (65%) with mean age 80 year old, among them 5 had combined pathology, 30 had no functional impairment and no dementia. 20 patients (36%) were older then 90, cardiologist would be called for 6 of them. All the patients were hospitalized:  49% in a cardiology unit, 18% in geriatric unit and 33% in medicine department. All the patients with AHF diagnosis at ED had the same diagnosis at discharge. The mortality was 10% (5 patients).

Discussion: Emergency physician’s assessment selected patients to propose to the cardiologist.  Age, dementia and functional impairment are limited factors to cardiology department hospitalization.  

Conclusion: A high proportion of patient with AHF are aged more than 80 years. The diagnosis is commonly associated with sepsis. Cardiologist call and hospitalization in a cardiologic unit are motivated by absence of comorbidity, functional impairment or cognitive decline.


Dr Christelle HERMAND (Paris), Jennifer SOBOTKA, Ines LEUNG, Clement TOURNON, Dominique PATERON
11:00 - 18:00 #8118 - Association between acute phase course of systolic blood pressure and early neurological improvement in stroke patients treated with rtPA.
Association between acute phase course of systolic blood pressure and early neurological improvement in stroke patients treated with rtPA.

Background

The relation between systolic blood pressure (SBP) and neurological outcome in acute ischemic stroke is not well understood in spite of research for more than a decade. Conflicting results of the previous studies may be attributed to the difference in methodological design and passing over the potential effect of blood pressure course on stroke outcome. This study aimed to evaluate the relation between SBP tendency during acute phase of ischemic stroke and early neurological outcome in patients treated with intravenous thrombolysis.

Methods

A total of 155 ischemic stroke patients who received intravenous recombinant tissue plasminogen activator (rtPA) were retrospectively examined. Blood pressures were measured every 15 minutes for the first 6 hours from the administration of rtPA (0–6 h), then every 30 minutes for the next 6 hours (6–12 h). Time course was divided into 4 phases by every 3 hours. The average, standard deviation, coefficient of variation (standard deviation / average x 100) of SBPs during the periods of 0–3 h, 3–6 h, 6–9 h, and 9–12 h were calculated. Data on baseline demographics, vascular risk factors (hypertension, diabetes mellitus, atrial fibrillation, dyslipidemia, and obesity), pre-stroke disability (using the modified Rankin Scale score), stroke severity (using the National Institutes of Health Stroke Scale score), time of rtPA administration, and laboratory parameters were collected. Early neurological outcomes were assessed at 24 hours after thrombolytic therapy. To determine independent predictors for early neurological improvement (National Institutes of Health Stroke Scale score of 0–1, or of decrease ≥8-point), a multiple logistic regression analysis fitted with backward stepwise selection procedure was performed. Two-way repeated-measures analysis of variance was used to compare the 12-hour SBP course between the patients with and without early neurological improvement.

Results

Patients with early neurological improvement (n=43) showed higher frequency of dyslipidemia, higher triglyceride level, lower HDL-cholesterol level, and lower SBPs during the periods of 3–6 h, 6–9 h, and 9–12 h, in univariate analysis. On a multiple logistic regression model, atrial fibrillation and mean SBP during 6–9 hours were independently associated with early neurological improvement after adjustment of covariates. Comparing the time course of SBPs, mean SBP values in patients with good outcome constantly reduced until 9 hours after thrombolysis, whereas those without neurological improvement showed plateau pattern in their SBP course.

Conclusion

The tendency of average SBP level during 3–12 hour after rtPA therapy was predictive of early neurological outcome at 24 hours in ischemic stroke patients.


Junsoo SEOK (Seoul, Korea), Kyounghwan KIM, Sungkyoo KIM, Hyeonsong KIM, Ki Young JEONG, Jong-Seok LEE, Young Gwan KO
11:00 - 18:00 #7132 - Asthma is not the only cause of dyspnea in young patients.
Asthma is not the only cause of dyspnea in young patients.

Objective: The description of this case is due to the rarity of this clinical entity and its semiotic diversity that implies a high level of suspicion for a correct and quick diagnosis.

The case describes a 17-year-old male who presented to the A&E department complaining of odynophagia and cervical pain from 2 days ago. He also complained of haemoptysis in the last 24 hours. He started with shortness of breath, mild in severity, and several bouts of intense cough 5 days ago after touching a rabbit His GP doctor prescribed him antihistaminic and dry powder inhalers, which didn’t improve his respiratory symptoms. No fever, no shivering. He denied any similar symptom in the past.

Past medical, social, surgical and family history

He also denied any use of illicit drugs or any history of trauma. He had a history of asthma but he was on no prescription medications and participated in sports without any difficulty. He did not smoke or drink alcohol.

Physical examination

Blood pressure was 133/79 mmHg, HR 95 bpm, temp. 36.4ºC and RR was 24/min, SpO2 97% on room air.

He was well developed but in mild respiratory distress.

HEENT: crepitance felt in the right supraclavicular area. Otherwise unremarkable. Trachea was in the middle.

Chest: clear to auscultation bilaterally. No stridor

Heart: No murmurs, rubs or gallops. Regular rate and rhythm.

Abdomen: no remarkable

No pedal edema was appreciated.

No focal findings of neurological deficits.

Next step in the management of this patient

A PA chest X-ray (posteroanterior and lateral view) was done, which showed a slight layer of air surrounding the cardiac silhouette, right chest wall and extensive subcutaneous emphysema in supraclavicular area.

Diagnosis

Spontaneous pneumomediastinum

Development

He was admitted to the hospital, followed up of a chest X-ray within 12-24 hours to detect any progression or complications. Treatment included analgesia, rest, and initial oxygen therapy. He was discharged on the 5th day of hospitalization and there were no signs of recurrences.

Summary

The diagnosis of spontaneous pneumomediastinum in an acute hospital setting can present as a challenge. Pneumomediastinum should not be confused with other pathological conditions such as interstitial emphysema, pneumothorax and pneumopericardium, which mostly require specific types of management. Spontaneous pneumonedistiinum is rare in adults, with young male being the most frequently affected, with a male/female ratio of 8/1. Based on previous studies, the prevalence of spontaneous pneumomediastinum ranging from 1 per 800 to 1 per 42,000 patients presenting to a hospital emergency department. Of these cases, approximately 1% has a history of asthma. The natural course is for the pneumomediastinum to spontaneously resolve.

 

 

 


Patricia BAZAN (Madrid, Spain), Elena AZNAR, Marta MERLO, Raquel CASERO, Virginia ALVAREZ
11:00 - 18:00 #7194 - Asymptomatic ruptured of abdominal aortic aneurysm in a patient with COPD presented in Emergency Department.
Asymptomatic ruptured of abdominal aortic aneurysm in a patient with COPD presented in Emergency Department.

Ruptured abdominal aortic aneurysm (AAA) is one of the most fatal surgical emergencies, with an overall mortality rate of  90%.The classic triad consists of abdominal or flank pain, hypotension and a pulsatile abdominal mass, but only manifests in 50% of cases at best. AAAs can be symptomatic without acute rupture as well. We present the case of a 67 years-old-man with COPD, active smoker, hypertensive, brought by ambulance in the Emergency Department with mild dyspnea, cough and hemoptysis. Physical examination revealed a pulsating abdominal mass. Laboratory investigations showed mild anemia. Abdominal ultrasound revealed an infrarenal aortic aneurysm. Un urgent angioCT was performed, which showed un infrarenal aortic aneurysm with minimal extravasation of contrast. Rupture of an abdominal aneurysm is a catastrophic complication with a high mortality rate. In this case, the aneurysm rupture was asymptomatic and only a thorough clinical examination identified a pulsatile mass which raised the suspicion of aortic aneurysm.


Vasile GAVRILA, Gabriela FILIP (TIMIS, Romania), Alexandru Nicolae CARSTEA, Rodica Daniela GAVRILA
11:00 - 18:00 #7715 - Atmed eTriage System, new model of EMS triage in the structure of the Smart City.
Atmed eTriage System, new model of EMS triage in the structure of the Smart City.

Study/ objective

Worldwide, Information and Communication Technologies (ICT) and telemedicine have been used more often in prehospital emergency care and emergency and disaster medicine. In Poland, the use of ICT in routine emergency practice does not raise any concerns, but its application in mass casualty incidents and disasters is still  being discussed. The development of intelligent management systems in particular “SMART CITY” project requires an adequately intelligent medical emergency management system for EMS. Atmed eTriage System (AeTS) is a new concept of triage for routine emergency care and disasters.

Methods

The study was conducted based on the analyses of the Kraków EMS database and field simulations of mass casualty incidents (MCI). The study measured the following aspects: the kind of management and decision-making model, the effectiveness of EMS (the response time and the appropriate management medical staff), the effectiveness of triage, the information flow to/from the command and control center, the criteria deciding on a patient transport mode and the adequate allocation of patients in hospitals. The observation concerned the period 2009-2016.

Results

Within the scope of research, ICT monitoring emergency medical care proved greater effectiveness of the ICT model rather than the traditional one. Moreover, ICT lets take decisions that could not be taken within the traditional model due to lack of current feedback from the incident analysis and hospital database. ICT provides new management possibilities.

Conclusion

The use of etriage based on ICT in EMS contributes to more effective management. The initial research results allow to define new directions for development of  intelligent EMS management systems.  

 


Arkadiusz TRZOS (Krakow, Poland), Katarzyna DŁUGOSZ
11:00 - 18:00 #7247 - Atraumatic limp in children presenting to a tertiary paediatric emergency department (PED): time for change?
Atraumatic limp in children presenting to a tertiary paediatric emergency department (PED): time for change?

AIMS: To retrospectively review the investigations and outcomes of all children with atraumatic limp presenting to a tertiary paediatric emergency department in 2014 to assess whether the current management protocol, advocating blood tests and ultrasound for all, was necessary.

METHODS: All patients who had a hip or knee ultrasound scan ordered from the PED were identified and their electronic patient records accessed with relevant consent to retrieve the following data: age, duration and nature of symptoms, examination findings including ability to weight bear, blood results (white cell count, absolute neutrophil count, C-reactive protein, erythrocyte sedimentation rate), pyrexia preceding or documented during PED attendance, duration of symptoms, examination findings, clinical diagnoses and outcomes. 

RESULTS: 535 patients had hip and/or knee ultrasound scans in 2014, of which 492 were performed for atraumatic limp and were therefore included in the analysis. Age range was 10 months-15 years (median 4.5 years). Three hundred and twenty seven patients (66%) had a diagnosis of transient synovitis, three patients had septic arthritis and osteomyelitis respectively (0.6%), four patients had Perthes disease (0.8%) and one had slipped capital femoral epiphyses (SCFE), 0.2%.  Twenty three percent had no formal diagnosis recorded (but no significant later diagnoses emerged in any) and there were small numbers of overuse, soft tissue and fracture injuries aswell as single patients with rheumatological or neurological causes.  All the patients with septic arthritis were young (18 months or younger) and a febrile history and raised inflammatory markers. All the patients with osteomyelitis were diagnosed on MRI scan. Two had mildly raised blood inflammatory markers, none were pyrexial. The positive predictive value and sensitivity of WCC, neutrophils, CRP and ESR were universally poor in identifying septic arthritis and ostemyelitis though negative predictive values, as expected, were very high (>0.99).   Slipped capital femoral epiphyses was identified in a 10 year old who had a pelvic xray (as per the existing protocol) as were the Perthes disease patients, who had more protracted histories ranging from 5 days – 4 months.  The laboratory cost of performing FBC, CRP and ESR in this cohort was £3,956 and Consultant Radiologist time to perform the hip/knee USS was in excess of 40 hours (estimated at 5 minutes per scan).               

CONCLUSIONS:  The majority of children who are well and afebrile presenting with atraumatic limp can be safely managed at first presentation without blood and radiological investigations given the extremely low incidence of infective pathologies in this population. Bony abnormalities such as SCFE and Perthes must be considered in older children or those with atypically lengthy histories and a plain xray is the investigation of choice. Our protocol has been redesigned to reflect this with attention to rigorous safety netting in the form of written caregiver information leaflets and PED Consultant review in 3-5 days at which time further investigations including blood tests and imaging might be considered in the patient who has not improved.      

 


Jennifer Kate SMITH (Edinburgh, ), James CARR, Gordon WHITE
11:00 - 18:00 #7446 - Atrial fibrillation in the Wolff-Parkinson-White syndrome: a challenging arrhythmia.
Atrial fibrillation in the Wolff-Parkinson-White syndrome: a challenging arrhythmia.

Background: Wolff-Parkinson-White syndrome often represents a diagnostic and therapeutic dilemma for emergency physicians especially if it’s associated with atrial fibrillation. It is life-threatening because of the fast ventricular response and the possibility of degeneration to ventricular fibrillation.

Case report: We report the case of a 25 years-old man, with a medical history of hypertension, presented to the emergency room for loss of consciousness with palpitation and dizziness. Clinical examination found a clammy patient with a Coma Glasgow Scale of 15, a blood pressure about 100/60 mmHg and a pulse about 200 bpm. Admission electrocardiogram showed irregular wide QRS complex tachycardia. Intravenous amiodarone was administrated at a dose of 300 mg. With the persistence of the same arrhythmia an electrical cardioversion was performed with success. A sinus rhythm and a delta wave were shown in the post cardioversion electrogram. Then, the patient was transferred in the department of cardiology for radiofrequency ablation of the accessory pathway.

Conclusion: Clinical clues to the diagnosis of atrial fibrillation occurring in the setting of the Wolff-Parkinson-White syndrome include essentially medical history and electrocardiogram signs. An irregular wide QRS complex in a young patient with palpitations, dizziness or syncope has to lead to this diagnosis. treatment depends on the initial hemodynamic status.


Dorsaf BELLASFAR (Rennes), Karim OUNALLI, Saloua HOUIMLI, Mouna TITEY, Ghania Fetiha AOUADI, Amel AMAMOU, Jihen AOUEM, Fatma BEN SALEM, Ben Romdhane ABDELMAJID
11:00 - 18:00 #7891 - Atypical presentation of abdominal aortic aneurysm complicated with shock.
Atypical presentation of abdominal aortic aneurysm complicated with shock.

Introduction

    Abdominal aortic aneurysms (AAAs) contribute significantly to disease burden in developed countries. Ruptured abdominal aortic aneurysm (rAAA) is characterized by the presence of blood outside the adventitia of the dilated aortic wall. Free rupture, with egress of blood into the peritoneal cavity, is distinct from covered rupture, in which there is less blood loss because the periaortic hematoma is enclosed by retroperitoneal tissue.

 

Case Report

    A 77-year-old male patient was brought to our emergency department by emergency medical services (EMS) a history of short of breath, ECG showed sinus tachycardia. Laboratory studies with Artery Blood Gas analysis revealed metabolic acidosis (PH:7.165, HCO3:10.9mmol/L),WBC:12500/uL,Lactate:12.2mmol/L, a normal Hemoglobin and normal troponin level . His BP initially was 50/41mmHg and dyspnea.

    In the absence of abdominal pain, a chest CT scan with contrast scan was arranged to confirm the diagnosis of pulmonary Embolism. The CT scan revealed rupture of abdominal aortic aneurysm with massive hematoma in the para-aortic and left retroperitoneal space. He was transferred directly to operation room.

    During operation, we found abdominal aortic aneurysm 8 cm in diameter rupture with shock and bilateral iliac artery stenosis post PTA (percutaneous transluminal angioplasty) procedure. The patient made a recovery and he was admitted to SICU of following respiratory insufficiency.

 

Discussion

     For someone with unknown reason of shock, rAAA should be kept it in mind. 


Ching-Fang CHAO (Changhua, Taiwan)
11:00 - 18:00 #8010 - Audit of the management of buckle fractures of the wrist in the paediatric emergency department.
Audit of the management of buckle fractures of the wrist in the paediatric emergency department.

Buckle (torus) fractures of the wrist account for one third of all wrist fractures in children. These fractures are stable and heal well. Traditionally they have been treated in a Plaster of Paris with orthopaedic review.

Critical appraisal of the evidence revealed splints to be as effective as Plaster of Paris in pain control and healing as well as resulting in improved physical function, patient satisfaction and significant cost savings. Based on this we developed a new policy for the management of buckle fractures in children.

The aims of the policy were to improve management of buckle fractures, improve functional outcome, improve patient and parent satisfaction, reduce fracture clinic appointments and reduce the cost of treatment.

An audit of the changes made revealed that 35% (227) of all wrist injuries seen in the Emergency Department were buckle fractures. Of these 126 were treated in removable splints and 119 did not attend fracture clinic. Of those who were treated in a splint the re-attendance rate was 7% compared to 21% for those in a Plaster of Paris.

A Plaster of Paris costs £6-£7 per patient and requires 15-20 minutes of nursing time to apply, splints cost £2 and can be applied in seconds at the end of the consult. In addition these patient did not require a review appointment in the fracture clinic and demonstrated a marked reduction in re-attendance in the in the emergency department for Plaster of Paris complications. The result was a reduction in work load for the emergency department staff, a reduction in waiting times for affected patients, reduction in hospital attendances and a reduction in fracture clinic appointments. In addition the savings for treating patients with a splint for one year were an estimated £11,500.

A significant cost saving has been demonstrated in the reduction of fracture clinic appointments. Further adjustments to the policy will result in an estimated £20,000/year saving and better patient satisfaction. This policy demonstrates how a well-run journal club with critical appraisal can directly affect service provision and quality of care.


Tudor OMAN (Belfast, United Kingdom)
11:00 - 18:00 #7944 - Aurora Bridge Bus Crash review of a mass casualty event pre-hospital and hospital response, lessons learned.
Aurora Bridge Bus Crash review of a mass casualty event pre-hospital and hospital response, lessons learned.

At 11:11 on September 24, 2015, an amphibious DUKW (a two-ton vehicle, was refurbished in 2005 for tourist use) with 37 people on board lost control due to a catastrophic left front axle mechanical failure.  The vehicle crossed the center line into oncoming traffic and struck a charter bus transporting 50 members of an international college group including students and staff.[i]  This event occurred on an urban bridge with heavy traffic.  A Mass Casualty Incident response was activated at the levels of EMS, the inter-hospital coordinating system: Disaster Medical Control Center (DMCC), the regional inter-hospital coordination group Northwest Healthcare Response Network (NWHRN) and the City of Seattle.

There were 62 reported injuries, however this number might be low due to reported delayed self-directed medical attention care seeking after the event.  The incident had many unique features that affected the incident response including: location on a bridge with limited access points, involvement of an amphibious DUKW vehicle, involvement of two commercial vehicles mandating investigation of the National Traffic Safety Board, and large numbers of foreign nationals.  This mass casualty event demonstrates the challenges to a complex mass casualty response and how many aspects of our disaster response system met those challenges.

There were four victims pronounced dead on the scene and another victim died three days later of his injuries.  A total of 51 victims were triaged and transported via the EMS system to 8 area hospitals.  These included 12 triaged red (emergent), 11 yellow (urgent) and 28 green (delayed).  The four on scene fatalities were triaged stripped (expectant).  A pre-hospital county issued EMS MCI triage tag was used to help patient tracking. 

Many small but not irrelevant elements were in play that made this tragic accident unfold in a manner that maximized healthcare and good outcome for the patients as well as a supportive and informed environment for the victims’ families and the general population of Seattle.  Years of coordination and collaborative agreements and planning, as well as drills came to play as patients were appropriately managed in the field, distributed appropriately to area hospitals who were aware of and prepared for their arrival, their whereabouts were tracked and available to public officials who were able to inform and support family and the public.  Several elements also contributed to the event in a negative manner.  As a commercial tourist vehicle and a commercial transportation vehicle neither vehicle was required to or had seat belts.  The DUKW vehicle, having been involved in prior mass casualty accidents, does not meet current safety standards, and concerns over the vehicles size, shape, blind spots and buoyancy have also been raised.[ii][iii][iv]  Despite the robust response of our community’s EMS, city and hospital based emergency services, it is likely many of these injuries and fatalities may have been averted with improved safety guidelines and implementation.


[i] Preliminary Report National Transportation Safety Board: HWY15MH011, http://www.ntsb.gov/investigations/accidentreports/pages/HWY15MH011_preliminary.aspx

 

[ii]http://www.cnn.com/2010/US/09/17/duck.boat.safety/

 

[iii] http://www.ntsb.gov/_layouts/ntsb.recsearch/Recommendation.aspx?Rec=M-00-005

[iv]http://www.wnwlaw.com/ride-the-ducks-wrongful-death/

 


Stephen MORRIS (seattle, USA), Andrew MCCOY, Joshua JAUREGUI
11:00 - 18:00 #7831 - Autopsic examination of injured bicyclists due to disease.
Autopsic examination of injured bicyclists due to disease.

The objective of this study was to clarify the relationship between injury severity in bicyclists involved disease. Autopsic records were reviewed for all cadavers from 1995 to 2014 in Shiga University of Medical Science and from 2003 to 2014 in Dokkyo Medical University School of Medicine. The mechanism of injury, Abbreviated Injury Scale (AIS) score, and Injury Severity Score (ISS) of the patient were determined. A total of 26 cadaver’s records were reviewed. The mean patient age was 62.2 years. The average ISS was 6.6, with an average maximum AIS (MAIS) score of 1.7. The mean chest AIS scores were as high as 1.3, with head ones were 0.9. This study provides useful information for emergency physicians who suspect disease in bicyclists involved in the traffic accidents.


Satoshi FURUKAWA (Otsu, Japan)
11:00 - 18:00 #7797 - B-Mode Ultrasound Signs in Ovarian Torsion and Normal Doppler Blood Flow: Masses, Cysts, and Follicular Ring Sign - A Potential Diagnostic Algorithm.
B-Mode Ultrasound Signs in Ovarian Torsion and Normal Doppler Blood Flow: Masses, Cysts, and Follicular Ring Sign - A Potential Diagnostic Algorithm.

Background: Ovarian torsion is a surgical emergency for which ultrasonography is the gold standard imaging modality. Absence of blood flow is diagnostic, but blood flow may be visualized in the setting of torsion.  B-Mode signs may be sufficient to establish torsion in the presence of blood flow.   Ultrasound finding of masses or cysts, as well as, “Follicular Ring Sign” (FRS), a prominent hyperechoic ring around the antral follicles of the affected ovary, have been identified in patients with ovarian torsion.

Objective: To determine if the presence of ovarian mass, cyst, or FRS can predict the diagnosis of ovarian torsion, when Doppler blood flow analysis is nondiagnostic.

Methods: A retrospective chart review was done for patients diagnosed operatively with ovarian torsion at a large community, teaching hospital from January 1, 2011 to January 1, 2015. Preoperative pelvic ultrasounds from these cases were examined for the presence or absence of Doppler flow, ovarian mass or cysts, and FRS.

Results: 63 patient charts were reviewed. 43 patients were found to have preoperative ultrasounds and surgically confirmed ovarian torsion. In total 46 scans were reviewed. 34 were radiology scans (RAD), and 12 were point-of-care scans (POCUS) performed in the ED.

Doppler flow was done in 44 of 46 scans. 19/44 (43%) had normal arterial and venous Doppler flow. 25/44 (57%) had abnormal or absent arterial flow. 15/44 (34%) had abnormal or absent venous flow and 15/44 scans (34%) had abnormal or absent arterial and venous flows.

The presence of ovarian mass alone had sensitivity of 28%, specificity of 100%, PPV of 100% and NPV of 77%. Ovarian mass or cyst had sensitivity of 84%, specificity of 79%, PPV of 80% and NPV of 83%.

Of the 46 ultrasounds reviewed, ovarian follicles were seen in 30 scans. The presence of FRS was assessed in these 30 scans (22 RAD and 8 POCUS). Overall FRS had a sensitivity of 60%, specificity of 83%, PPV of 78% and NPV of 68%. For RAD only, FRS had a sensitivity of 50%, specificity of 82%, PPV of 73% and NPV of 62%. For POCUS only, FRS had a sensitivity of 88%, specificity of 88%, PPV of 88% and NPV of 88%.

Conclusion: 43% of the patients with ovarian torsion had normal arterial and venous blood flow.  The presence of ovarian mass was found to be 100% specific for the diagnosis of ovarian torsion.  FRS alone does not appear to be highly sensitive or specific for the diagnosis of ovarian torsion. The sensitivity and specificity of the ED POCUS scan is higher compared to the Radiology Department scans.

An algorithm starting with Doppler flow and, when present, progressing to ovarian assessment for mass, cysts, and FRS may have high predictive value.


Chiricolo GERARDO, Christopher RAIO (Dix Hills, USA), Harinder SINGH
11:00 - 18:00 #8047 - Bacterial meningitis in Syrian refugee pregnant women.
Bacterial meningitis in Syrian refugee pregnant women.

Introduction: Altered mental status is one of most important and complicated issue for an emergency medicine doctor. Enfectious diseases is rare for  that patient groups. Enfectious diseases in 5th place patient with altered mental status causes acording to Kanich et al. Because of the norologic status sometimes sedoanelgesia should be used for diagnosis. Propofol(category B) could be use safetly for sedoanelgesia in pregnancy. In some rare situation  like immigrants (language barrier etc.) differential diagnosis even more harder.

Case: A 18 year old pregnant (38 weeks) Syrian refugee patient was admitted to ER with delirium and altered mental status. Because of the communication problems with patient and her relatives, patient’s medical history was not taken at all. Patient had lack of cooperation and orientation. She was hurting herself and agitated. Glaskow coma score evaluated as 14/15.

 She was examined as low blood pressure (70/40 mmHg), tachycardic (110 bpm), tachypneic (28 bpm). The patient’s fever was 36.7 C and sO2 was %97. Respiratory and cardiac examination was normal.  Pupillas were seen isocoric and with intact light response. Four ekstremity reflexes were normal. Nuchal rigitidy and other neurological examination couldn’t evaluated properly. There weren’t any rush at patient’s body. IV fluids resutation was started. As lab results were; WBC 42.03 10^9/L, HGB 10.7g/dl, NEU 39.17 10^9/L, Lactat 3.4 mg/dl, Blood Glucose 114mg/dl, AST 24U/L, ALT 10U/L. Spot urinary test showed no leukocyturia, no proteinuria. In brain MRI there was no intrcranial mass, other focal brain lesion, bleeding area or infarction.Because of the white blood cell count was elevated, with a shift to right and  confusion, we tought bacterial menengitis as a prediagnosis and ceftriaxone was applied 2 gr twice daily.

The patient was consultated with gynecology and obstetrics clinic for fetal distress and emergent C-section. NST was showed decelerations. After the sedation with propofol (0,1 mg/kg/min) lomber puncture was performed to patient then patient transfered to gynecology and obstetrics clinic for emergent C-section. Cerebro-spinal fluid was cloudy. Gram strain positive, >%80 PMN, pandy test +++, Glucose(CSF) 50mg/dl, protein(CSF) 296.2 mg/dl. Antibiotherapy was set ceftriaxone 2grp twice daily and vancomisin 500 mg four times per day by enfection and microbiology clinic. After C-section patient admitted to ICU. After a week of antibiotherapy; patient’s vital signs, mental status and lab results were seen normal. Patient‘s medical treatment has ended and was discharged.

 

Conclussion: Bacterial meningitis is a rare, life-treatining and important reason of altered mental status. Lumber puncture is the main procedure to establish a final diagnosis of meningitis. Main medical theraphy is ceftriaxone. Sometimes sedoanelgesia is necessary for examination and prosedures. In pregnancy , propofol(category B) is reliable agent for prosedural sedation. Emergency cesareans are sometimes further classified by degree of urgency like an immediate threat to life of the mother or fetus is present. Early antibiotherapy and emergent C-section can provide an improvement of maternal and fetal health status as seen as in our case.


Yusuf Cankat BOZKURT, Aziz VATAN, Burcu GULSEN, Emine GAFFARI, Onur TOKOCIN (istanbul, Turkey), Hakan TOPACOGLU
11:00 - 18:00 #7767 - Bad mood after a long flight.
Bad mood after a long flight.

We present the case of a 27 year-old woman with no relevant medical history

The symptoms began 8 hours before admission to the Emergency Department. After landing from a ten hours flight, she began with malaise,  weakness, nausea, vomiting and strange behavior.

She is taken to the Hospital by her husband, who tells that during the holidays and flight her behaviour was totally normal and that most of the time in the flight back to Spain she was sleeping with her head over his shoulder.

They have stayed in Cuba for a week celebrating their honey moon. Her husband said she did not consume any type of drugs during the holidays or the flight.

At the general examination no fever, normal blood pressure and no tachycardia, but although she had a Glasgow Score of 15, the neurological exploration showed some abnormalities: she was in an unlike mood, with unmotivated laughter, disoriented with inappropiated answers to the doctor's questions. No visual problems, no loss of strength or sensitive afection. Reflex exploration was also normal. She could walk properlly and no signs of meningeal or cerebellum disorders were found at the first examination.

Laboratory tests were taken, including chest and abdominal radiography, pregnancy test and study of different types of toxics , being all of them normal and negative. 

A Computerized Axial Tomography of the brain was taken that showed  an hypodense lession in the frontal right part of the brain, suggesting ischemia in the territory of the right anterior cerebral artery

Just five hours after admission, her clinical condition got worsed, decreasing her level of consciousness, vomiting, and with more abnormalities in the neurological examintaion as dysphasia, paresis of the right central facial nerve and right hemianopia. As time went by also paresia of the right hemisphere with positive Babinski appeared, so treatment with intravenous anticoagulation was prescribed suspecting a progressive ischaemic stroke.

She was admitted to the Stoke Unit. During admission, a Magnetic Resonance Imaging  was performed, reported a stenosis of the cervical segment in the left internal carotid due to a dissection with also affection in both frontal hemispheres.

The final Diagnosis was Bifrontal and Left parietal ischaemia with spontaneous dissection of  left carotid artery.

She continued with anticoagulation treatment, with progressive improvement of the neurological condition and after thirty-two days of admission, she had a nearly complete resolution of symptoms, remaining just some attention problems.

A month later, she could manage to do normal life without any help.

As always in Medicine, the most important thing to do is a good clinical history and physical examination before jump into wrong conclusions.

As in this case, we must ruled out potentially serious illness, before attributing the cause of the wrong behaviour to a toxic or psychiatric origin.


Luz Tamara VÁZQUEZ (Madrid, Spain), María CUADRADO, Luis YUBERO, Isabel FERNÁNDEZ, Luis PÉREZ, Santiago BERMEJO, Francisco JIMÉNEZ, Manuel GIL
11:00 - 18:00 #8048 - Be careful! It may be emphysematous cystitis.
Be careful! It may be emphysematous cystitis.

Introduction:Urinary tract infections are a large share of emergency servise visits. Although most of the them are outpatient, complicated urinary infections are hospitalized. Besides it is an etiology of abdominal pain and sepsis, one of the complication of urinary tract infection is emphysematous cytitis. Emphysema is seen in bladder wall and lumen and also can results with a air embolism in vena cava.

Case report: Our patient is 87 year old woman applied to emergency department with abdominal pain, fever with unstabil condition. She has hypertension, diabetes mellitus, hyperlypidemia, chronic renal disease, coronary artery diseases. In her physical examination the blood pressure was 90/60 with sinus tachicardia of 120/min. Her temperature was 38.5C, arterial oxygen saturation estimated by pulse oxymetery was 95%, respiratory rate was 14/min and blood glucose was 290mg/dl. The lungs were clear oscultation. The heart sounds were normal with no murmur. Lower of abdomen was distanded and tender. There were positive peritoneal irritation signs and bowel sounds were alleviated. Laboratory findings are respectively; WBC:14,400/µl, CRP:40,3mg/dl Creatine:1,3mg/dl, Urea:65,9mg/dl. Urinary catheterisation was applied but no urine output occurred in the first hours of visit. Her abdominal computer tomography was done and air-fluid level in bladder, gas bubble accumulation in bladder wall and lumen, air bubbles in vena cava inferior lumen were seen. While observation, she had cardiac arrest. She was resuscitated for 45 minutes and was not responded to CPR.

Discussion: Emphysematous cystitis with venous air embolism is rarely seen in emergency services. It can be a mortal complication of urinary tract infections in patients with predispositing factors like diabetes mellitus as our case. The pathophysiology is has not identified yet, but the accepted mechanism is accumulation of carbondioxyde and hydrogene by infected microorganisms. Computer tomography demonstrates the gas accumulation not only in bladder wall and lumen but also in vena cava inferior. An accelerated process was occurred in our patient resulted with mortality. The management of emphysematous cystitis is drainage and antibiotherapy sensitive to organism. In conclusion, the emergency physicians should keep this complication with differential diagnosis of abdominal pain in mind.

References: 1.KARASHIMA, E., EJIMA, J. I., NAKAMURA, H., KOIKE, A., KANEKO, T., & OHMURA, I. (2005). Emphysematous cystitis with venous bubbles. Internal Medicine44(6), 590-592.

2.Yokokawa, R., H. Tsuka, and K. Muranaka. "[Emphysematous cystitis with air bubbles in the vena cava]." Nihon Hinyokika Gakkai zasshi. The japanese journal of urology 105.1 (2014): 22-25.

Acknowledgments: There is no conflict of interest in this study.


Attila BESTEMIR, Goksu BERIKOL (Istanbul, Turkey), Mehmet Serkan YURDAKUL
11:00 - 18:00 #7323 - Bedside Percutaneous Cecostomy, a Candidate Treatment Option for 'Acute Tension Megacolon’ at ED: a Case Report.
Bedside Percutaneous Cecostomy, a Candidate Treatment Option for 'Acute Tension Megacolon’ at ED: a Case Report.

Introduction

The treatment of Ogilvie’s syndrome begins with usual conservative treatment of ileus followed by neostigmine administration and/or colonoscopic exsufflation, with surgery as the last choice. We report a case, for which bedside percutaneous cecostomy, a rarely utilized method, was tried at ED.

Case presentation

A 20-year-old, uncommunicable, bed-ridden male patient with cerebral palsy and epilepsy on levetiracetam presented at ED. According to the caregiver, his abdomen began to distend 3 days ago with constipation. The next day, he vomited twice. One day ago, fever developed. Nothing was given via the PEG since then. He had undergone mediastinal tracheostomy and percutaneous endoscopic gastrostomy (PEG) for aspiration tendency.

He looked acutely ill, slightly drowsy, and cachexic (168cm, 36kg). Vital signs were 129/76mmHg-140/min–20/min-39.0°C. Abdomen was distended, tense, and hyper-tympanic on percussion. Metallic sound was heard. PEG drained brown to dark green fluid. There were no pressure ulcers. Chest x-ray was non-specific. Abdomen x-ray revealed megacolon. Routine laboratory findings were normal except leukocytosis (15.31*103/µl) and high CRP (22.2mg/dl).

Suspecting ileus-related sepsis, we initiated full hydration and empirical antibiotics (ceftriaxone and metronidazole). PEG was naturally drained. A rectal tube was inserted. Abdomen CT revealed megacolon (maximum diameter: 11.5cm) without obstructing mass, free air, or meaningful peritoneal fluid. On consultation, with possible laparotomy in mind, the general surgeon inserted a 40mm-long, 22 gauge needle vertically at 3cm above the umbilicus, where the megacolon abutted abdominal wall. He compressed abdomen very gently for 10 minutes for the gas inside the megacolon to come out. The width and height of abdomen, at the umbilicus level, decreased from 26.0cm to 22.0cm and from 22.5cm to 19.0cm, respectively. The patient looked comfortable and was admitted to a general ward with stabilized vital signs: 118/68mmHg-90/min-20/min-37.8°C.

Colonoscopic exsufflation was also performed. However, the patient got unstable and received oxygen and meropenem from the 2nd hospital day (HD). Two days later, he underwent right hemicolectomy. The remarkably dilated ascending colon showed ulcer and perforation at its right lateral aspect with generalized peritonitis and adhesions. (The needle decompression puncture site, far from these lesions, was undetectable.) Despite intraabdominal abscess, which was drained percutaneously for 3 weeks (14th-36th HD), he has improved steadily and will be sent home soon as of the 50th HD.

Discussion

As no obstruction nor colitis caused megacolon, this case could be defined as Ogilvie’s syndrome, acute colonic pseudo-obstruction (ACPO). In case of ACPO, supposedly caused by decreased parasympathetic activity, neostigmine and colonic exsufflation are recommended additionally. For this bed-ridden patient with malnutrition, surgery was to be delayed, if possible, considering high postoperative mortality rate (40%). Bedside needle decompression, which has been reported for treatment of ACPO, was tried initially. Although surgery was performed finally, percutaneous cecostomy seems to have delayed the septic process. It remains to be answered whether a retention catheter placement might have obviated the need for surgery.

References

1. Pereira Pet al. Ogilvie's Syndrome-Acute Colonic Pseudo-Obstruction.J Visc Surg. 2015;152(2):99-105

2. vanSonnenberg E et al. Percutaneous Cecostomy for Ogilvie Syndrome: Laboratory Observations and Clinical Experience. Radiology. 1990;175(3):679-82


Sung-Bin CHON (Ras Al Khaimah, United Arab Emirates), Intaek LEE
11:00 - 18:00 #8185 - Benzylglycinamide abuse: a new psychoactive substance analytically-confirmed case.
Benzylglycinamide abuse: a new psychoactive substance analytically-confirmed case.

Objective: We present a case of analytically-confirmed consumption of benzylglycinamide, a phenyl derivative of glycinamide and an analogue of milacemide (1,2) in a patient with a suspected intoxication by New Psychoactive Substances (NPS).

Case report: A female patient, 21, with a history of addiction was admitted to the psychiatric ward with a suspected NPS intoxication. She showed reduced emotional expression, dysphoria, restlessness and denied any consumption of drugs of abuse. Her mother referred about some episodes of “absence” during the previous month. Standard toxicological screening in urine, neurological examinations, standard and sleep-deprived EEG and MRN tested negative. Urine sample and a powder found by the patient’s mother were sent to our laboratory for NPS screening. The analysis of the powder performed both in gascromatography-mass spectrometry (GC-MS), full scan mode and in 1H-NMR proved it was benzylglycinamide. The benzylglycinamide transitions (precursor ion 165.05; quantifier transition 90.95, qualifier 120) used for the analysis in Liquid Cromatography-Tandem Mass Spectrometry, Multiple Reaction Monitoring mode, were obtained through the tuning of the powder, being a certified standard of benzylglycinamide difficult to purchase from our supplier companies. 1ml urine, additivated with dosulepin as internal standard, was extracted with a mixture of exane:ethylacetate (3:1) at pH14 and analysed by the LC-MS-MS system. The analysis resulted positive for benzylglycinamide (230 ng/ml). Urine was also submitted to the screening for NPS (3) that involves: a generic analysis for basic, non-volatile substances by GC-MS; a screening by LC-MS-MS for NPS belonging to the classes of cathinones, benzofurans, 2C-family drugs, other amphetamine-like substances, dissociative anaesthetic and two immunoassays for synthetic cannabinoids in urine. No positivity emerged. Buprenorphine, LSD, and ecstasy tested negative, too.

Conclusion:Benzylglycinamide was never commercialized and no data about its pharmacokinetic and pharmacodinamic in human is available. The evidence presented here is concerning with a warning of N-benzylglycinamide as a possible NPS whose effects are almost completely unknown.

 

References: 1. Sussan S, Dagan A, Blotnik et al. The structural requirements for the design of antiepileptic-glycine derivatives. Epilepsy Research 1999;34:207-220: 2. O’Brien E M, Dosterrt P, Pevarello P et al. Interactions of some analogues of the anticonvulsant milacemide with monoamine oxidase.1994 Biochem Pharmacol;48:905-914; 3. Papa P,  Rocchi L,  Rolandi L, Valli A et al. Research and identification of new psychoactive substances in cases of suspected intoxication in Italy. 2014 Italian Journal on Addiction;4:50-56


Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy), Antonella VALLI, Eleonora BUSCAGLIA, Pietro PAPA, Loretta ROCCHI, Laura ROLANDI, Marcello DI TUCCIO, Massimo SERRA, Davide LONATI, Valeria Margherita PETROLINI
11:00 - 18:00 #7865 - Beware: unexpected heart reaction.
Beware: unexpected heart reaction.

INTRODUCTION: Brugada syndrome (BS) is classified as an channelopathy, whose consequence is the predisposition to arrhythmias. SB prevalence is around 5 in every 10,000 people, although it is estimated that there is also a large percentage of the population with silent forms of the disease and, therefore, there are people who are undiagnosed. Between 17% and 42% of them present syncope or sudden death due to ventricular arrhythmia during mostly, the third or fourth decade of life. SB patients have an increased risk of suffering atrial arrhythmias, especially atrial fibrillation (AF) risk. The incidence of atrial fibrillation in patients with Brugada syndrome is 10 to 20% and, in turn, the presence of AF was associated with a severe presentation of disease and increased risk of ventricular fibriliación. AF is the arrhythmia most common presentation in the Emergency Departments (ED), so it is crucial to know all the possible etiologies of the AF for proper patient management, minimizing the risk that the patients would suffer adverse events.

OBJECTIVE: Recycling and update training for the management of Brugada syndrome in the context of tachyarrhythmias that are handled in the usual emergency practice.

METHODS AND RESULTS: A case report: Male, 42 years without allergies, smoker ten packs / year, without family or other personal factors of structural heart disease. He arrived to Hospital in an ambulance with well tolerated palpitations, that started 2 hours ago. He refers previous episodes that are self-limiting in recent years, with electrocardiogram (ECG) without pathology when he is seen. Upon arrival, hemodynamically stable, the ECG shows a narrow QRS tachyarrhythmia with left axis and morphology of Incomplete Right Bundle branch block compatible with AF to 130 bpm. The chest X-ray shows no findings. The patient is not with chest pain and there are not signs of heart failure, so we proceed to cardioversion pharmacologically with intravenous flecainide. After 5 minutes, the patient reported being "dizzy", while retaining hemodynamic parameters. We repeat ECG, that confirms us became to sinus rhythm (SR), although with alterations in repolarization of V1 to V3 compatible with BS type I.

The patient has hemodynamic and clinical stability, and being asymptomatic, so he goes to observation area, where he recovered the ECG original morphology of repolarization, and remaining in SR in the following 6 hours. Serial tests of markers of myocardial necrosis are made more than 12 hours of onset of symptoms, and there is not evidence of an ischemic event. The patient is valued by Cardiology, and due to the clinical presentation and evolution (Asymptomatic, BS morphology type I after blocking sodium channels drugs, and without family history of sudden death), the patient is discharged from hospital to continue the study and monitoring by the Arrhythmia Unit. 

CONCLUSIONS: Although the BS has a low prevalence, the high incidence of AF and its management in Emergency Departments, must motivate us to have a proper recycling in the etiology of atrial arrhythmias, to ensure patient safety and proper integrated management in the ED.


Daniel FERNÁNDEZ VARGAS, Enrique CARO VÁZQUEZ (MALAGA, Spain), Carmen Adela YAGO CALDERÓN, Susana MARTÍN CARAVANTE, Ana José DUARTE ROMERO, Juan Antonio RIVERO GUERRERO
11:00 - 18:00 #7900 - Bilateral Perforating Eye Injury during Mole Hunting.
Bilateral Perforating Eye Injury during Mole Hunting.

AIM: Trauma of eye can cause significant morbidity and effects on human life. Perforating eye injuries due to trauma are almost always unilateral. In this case report, bilateral eye perforation is caused by a primitive tool, a mole gun.
CASE: A 63-year-old male patient applied to the emergency service after the mole gun, a pistol used to trap moles, accidentally discharged and caused eye injury. He was conscious, cooperative and his vital signs were stable. On examination, both eyelids were edematous. Several buckshot inlet holes and gunshot residue were present on his face and eyelids. Serious subconjunctival edema (chemosis) and subconjunctival hemorrhage findings were determined. The operations which the patient underwent were correction of the perforation of the right eye, posterior vitrectomy and removal of the intraocular foreign object. The left eye wasn’t operated because, there was no any expectation for vision.
CONCLUSION: Bilateral eye perforation, which has a very low incidence, may lead to serious morbidity. Increasing work safety and refinement of training programmes about consciousness-raising will reduce a considerable part of eye traumas.


Tarık OCAK (Bolu, Turkey), Arif DURAN, Mesut ERDURMUŞ, Ümit Yaşar TEKELIOĞLU
11:00 - 18:00 #7113 - Bilateral pneumoperitoneum in patient with vomiting.
Bilateral pneumoperitoneum in patient with vomiting.

Case Report:

50 year old male, smoker 1.5paquetes / day, benign prostatic hypertrophy

The patient comes to the emergency department with vomiting for two days of evolution, has barely tolerated referred liquids and abdominal discomfort right upper quadrant and right flank,

Exploration / Development

Upon arrival to the emergency department presents a blood pressure 125/63. Heart rate 95 beats per minute (bpm) and temperature 36.5 ° C.

Signs of dehydration in mucosal disease strikes, skin pallor, abdominal examination to tenderness in abdomen RH signed Murphy + and voluntary muscular defense; When thinking about possible disease of the bile duct or kidney disease, blood test request, urine, abdominal radiography and peripherally administering channeled Pantoprazole + Metamizol IV.

After 40 minutes of arrival, Nursing warns us for worsening of the patient, which is rescanned and presents an abdominal palpation with widespread pain, belly "on board" with signs of peritoneal irritation; he moved to radiology and abdominal radiography in which dilated small bowel loops and absence of distal gas and chest radiography in principle is performed in supine for patient comfort in which no pathological images are seen seen is performed, but in the diagnostic impression drilling is performed seated chest, appreciating imgen of "bilateral pneumoperitoneum."

It contacts the service of Digestive Surgery and treatment is initiated with antibiotics (piperacillin / tazobactam 4 mg).

Then they proceed to surgery and they appreciate a sharp stomach ulcer with pyloric perforation 3 cm long axis and chemical peritonitis with involvement of the 4 quadrants 

Investigations:

Chest x-ray: No pictures of pneumonic infiltrates are seen.

Blood test: 13.92 leukocytes with 75% neutrophils, creatinine 0.79, normal liver profile and PCR 56

Evolution:

After surgery, the patient is admitted to plant antibiotics Surgery

Conclusions:

It is important to the successful completion of certain diagnostic tests in suspected acute abdominal pathology


Manuel AGUILAR CASAS, María Victoria ALARCÓN MORALES (BCN, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7808 - Bleeding after change anticoagulation.
Bleeding after change anticoagulation.

History:

Male patient 66 years after change of anticoagulant therapy makes a 20días (taking rivaroxaban and initiated acenocumarol) refers bleeding episodes at several levels: bleeding gums, epistaxis and from the previous day hiposfagma with hematoma infraorbitario left without trauma or eye clinic. Refers dyspnea with moderate effort, without fever or infectious clinic.

AP: Permanent Atrial Fibrillation. IHD. Mellitus diabetes. HTA.

 

Physical exploration:

REG. BHyP. TA 120 / 80mmHg. Sat O2 99%. Afebrile.

ACP: arrhythmic and audible tones. No murmurs. MVC with some isolated roncus.

Left Eye: left infraorbital hematoma, hiposfagma with conjunctival edema.

 

Supplementary tests:

CBC: Hb 12.2. Platelets 330000. Leukocyte 9200.  Coagulation: INR 10'7. Biochemistry:Glucose 33. Urea 82. Creatinine 0'9. Na 136. K 4'6

Rx thorax: alveolar-interstitial infiltrate bilateral.

 

Evolution:

After the analytical results, the patient was admitted to observation area where prothrombin complex is administered, achieving figures of INR in range.

He later joined by pulmonology for development of pulmonary hemorrhage.

conclusions:

Updates pharmacopoeia helps prevent complications of older drugs such as acenocumarol complications and difficult INR control.


Valentina MORELL, Enrique CARO (MALAGA, Spain), María Carmen RODRÍGUEZ CASIMIRO, Juan Antonio RIVERO, Eduardo ROSELL, Antonio Ramón BOSCÁ CRESPO
11:00 - 18:00 #7782 - Bleeding in anticoagulated patient: report of a rare case.
Bleeding in anticoagulated patient: report of a rare case.

79 year old woman patient, diabetic, hypertension, ischemic heart disease with triple bypass and pacemaker carrier, treated with acenocoumarol, atorvastatin, enalapril and metformin. Go to emergency room for nausea, vomiting and abdominal pain 12 hours of evolution, previously serviced by ambulance and treated coin antiemetics and sulpiride, without improvement. Not refer other symptoms.
Physical examination: neurological examination, abdominal and cardiorespiratory auscuktation within normal limits.
Blood tests, urine and abdominal radiographs are requested. Sulpiride is intramuscular regimen, without improvement.
results:
- Analytical discrete neutrophilia, PCR <1, INR 2'3. Rest within normal limits.
- Urine: neutrophilic leukocytosis.
- Radiography abdomen without pathological images.
During the stay in the ER, suffers clinical worsening, with dizziness and convulsion, why is serviced in Box CPR.
Immediately, the patient is monitored, stabilized and ECG and CT scan are requested. While performing cranial CT suffers ventricular fibrillation episode objectified in monitor, so electric shock is applied with 150 J and permeability of the airway is maintained with self-inflating bag and oropharyngeal cannula.

Results cranial CT: acute parenchymal hematoma in left cerebellar hemisphere of 2.5 x 2.5 cm, with perilesional edema without mass effect on the fourth ventricle or other infratentorial parenchyma.
It warns Intensive Care Unit and the neurosurgeon. Vitamin K and prothrombin complex are administered. Analytical requested magnesium levels. Neurosurgery discarded surgical approach. Intensive Care indicates tell if clinical worsening. The patient remains in watching ER. It is reported relatives of the patient.
Analytical stands glucose 288 mg / dL, magnesium 1'1 mg / dL.
After the replacement of magnesium, neurological patient monitoring and maintaining the Glasgow score 15 without objectified hemodynamic deterioration, it is admitted by Neurology.

Conclusion:
Faced with a suggestive picture of vertigo resistant to treatment, we must suspect a central source. In this case, since the patient is anticoagulated, it is important to perform a CT scan to rule out bleeding. We know the management of hemorrhage in the anticoagulated patient, since the reversal of INR help control bleeding and therefore clinical worsening. It is also important to know the classification of bleeding in anticoagulated patients: minor bleeding, severe bleeding and severe bleeding with life-threatening. In our case, this is a hemorrhage of the third kind, since it is symptomatic intracranial hemorrhage (debuting with vomiting, dizziness and seizure). In severe bleeding in anticoagulated patient with acenocumarol we must administer vitamin K and prothrombin complex to reverse the anticoagulant effect of the drug as soon as possible.


Marina BUFORN, Enrique CARO (MALAGA, Spain), Carmen Adela YAGO, Andrés BUFORN
11:00 - 18:00 #7479 - Blood products wastage in major traumas.
Blood products wastage in major traumas.

Introduction

The major haemorrhage protocol (MHP) is frequently activated in major trauma (MT) cases and consequently blood products wastage becomes inevitable.

 

Since Aintree University Hospital became a Major Trauma Centre (MTC) in June 2012 there have been 349 MHP activations for traumas alone.

Code Red (CR) activations were introduced at Aintree University Hospital in October 2014 whereby the MHP could be activated prior to patient arrival in the Emergency Department (ED) in anticipation of massive transfusion requirements.

Not all blood products that are ordered and issued are appropriately used or returned to the laboratory, resulting in avoidable wastage and extra costs. From November 2015 to March 2016, at Aintree University Hospital, there was £2,942 worth of wasted blood products on trauma cases.

 

Objective

To review the wastage of blood products when the MHP is activated in MT cases and to see if this has changed following the introduction of CR activations in October 2014.

 

Method

Data from MHP activations as a result of MT was collected and collated.

A 3-month period was chosen and data prior to the introduction of CR activations (June to August 2013) was compared with data after its introduction (June to August 2015) and analysed.

 

Results

There were a total of 26 MHP activations as a result of MT from June to August 2013 and also 26 activations from June to August 2015.

There were 3 units RBC (O-negative), 18 units FFP and 1 unit of platelets across 6 cases wasted from June to August 2013 compared to 2 units RBC (O-negative), 12 units FFP and 1 unit Cryoprecipitate across 5 cases (3 were CR cases) from June to August 2015.

 

Conclusion

This audit demonstrates that blood products are wasted in MT cases when the MHP is activated. Reasons cover blood products that are collected, not used and then returned out of their controlled temperature (>30 minutes post collection) to the laboratory or blood products that are ordered and issued post MHP activation but then no longer needed nor returned to the laboratory.

Interestingly the wastage of blood products did not significantly change following the introduction of CR activations for this cohort of data.

This wastage of blood products can be potentially avoidable. This audit highlights the need for the introduction and reinforcement of clear protocols within the ED for effective blood product management in MT cases to reduce blood product wastage and associated costs.


Tom BARKER, Abdo SATTOUT (Liverpool, UK, United Kingdom), Michael HICKEY
11:00 - 18:00 #7751 - Both renal infarction and renal colic.
Both renal infarction and renal colic.

INTRODUCTION: Acute renal infarction is a serious medical emergency. The diagnosis is often delayed or missed as it is not common.Hence, the exact incidence of acute renal infarction is not known. Failure to consider renal infarction in the initial differential diagnosis results in a delay in diagnosis and treatment, which in turn leads to permanent loss of renal function. We present a case of acute kidney infarction that was initially treated as renal colic.
CASE: A 45-year-old man presented to the emergency department with left flank pain and right lower quadrant abdominal pain. In his medical history, left side renal stone and suffered cerebrovascular accident were detected. Physical examination revealed right costavertebral angle tenderness. His pain continued despite NSAID and narcotic drugs. The CT scan revealed wedge style cortical and medullar hypodens areas accordance with renal infarct on level of the central and upper pole of the right kidney. Renal angiogram confirmed to infarct. He was interned to interventional radyology.
CONCLUSION: Acute embolic renal infarction is an entity that is often misdiagnosed as a renal calculus because of similar presenting symptoms. This leads to delay in the initiation of treatment and to increased morbidity.


Mehmet UNALDI (ISTANBUL, Turkey), Ersen GUNDUZ, Umit OLMEZ, Cihan BUYUKSUTCU, Onur INCEALTIN, Kurtulus ACIKSARI, Hatice ERYIGIT
11:00 - 18:00 #8063 - Breaking Bad News: the Take five program.
Breaking Bad News: the Take five program.

Introduction

For many years, bad news delivery’s impact on patients or their relatives, as well as physicians’ stress has been a major concern. On the basis of studies emphasizing the potent efficacy of training courses to help physicians delivering such news, many protocols, like SPIKES, BREAKS or SHARE, have been developed worldwide. However, training to such protocol might be time-consuming and not suitable with junior doctors or trainees’ turnover. Indeed, there is currently no teaching program validated to date. We hypothesised that a short simulation program (the TAKE 5 program) could improve bad news delivery performances, reaching a level comparable with longer course programs. We therefore designed the present study to evaluate the potential impact of this standardized 5-hours training program.

Participants and methods

This preliminary study was conducted in the Emergency Department of a tertiary care academic hospital accounting for 90 000 ED census per year, 16 attending emergency physicians, 10 junior residents, and 5 trainees per month. Data were extracted from a 5-months period between November 2015 and April 2016.

The study included three phases over 4 weeks. Video recorded individual role-playing sessions happened the first (T1) and the fourth (T3) weeks. A 3-hour theoretical training group session happened the second week  (T2), introducing the basic principles of therapeutic communication and delivering bad news based on the SPIKES protocol. Each role-playing session lasted approximately 1 hour with 10 minutes briefing and medical case acknowledgement, 10 minutes role-plays and 40 minutes group debriefing. We created an 8 scenarios database (paediatric with severe asthma attack, road accident, intracranial bleeding) for the role-playing sessions.

Bad news delivery performance evaluation was based on a 14 points retrospective assessment tool (1). We collected data about the status and impact of a stressful event at 3-days using the french version of the IES-R scale (2). We applied Student t-tests for statistical analysis.

Results

A total of 14 volunteers (10 trainees and 4 junior emergency physicians) were included in the study. On average, bad-news delivery process took 9’45’’ at T1 and 10’20’’ at T3. Form T1 to T3, bad-news delivery performance increased significantly for both the junior emergency physicians and trainees (p=0.0003 and p=0.0006, respectively). Further analysis revealed that most relevant increases concerned the “situation” (p<0.001), “presentation” (p=0.009), “knowledge” (p=0.037), “emotions” (p=0.01) and “summary” (p=0.001) steps. Interestingly, we also found a significant decrease of the impact of bad-news delivery on trainee physicians’ stress (p=0.006).

Conclusion

These preliminary results indicate some potential for this new standardized course of breaking bad news delivery.  Apart from allowing physicians increase their communications skills, we believe that this simple 5-hour simulation-training program could alleviate physicians’ stress when they happen to break bad news.

References

1. Brunet, A. et al. (2003). Validation of a French version of the Impact of Event Scale-Revised. Can J Psychiatry, 48(1), 56-61.

2. Park, I. et al. (2010). Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol. J Emerg Trauma Shock, 3(4), 385-388.


Aline GILLET, Isabelle VAN CAUWENBERGE (Mechelen, Belgium), Rebecca TUBES, Alexandre GHUYSEN
11:00 - 18:00 #7620 - Broken or not? nuchal ligament ossification: case report.
Broken or not? nuchal ligament ossification: case report.

Introduction: The nuchal ligament extends from the external occipital protuberance on the skull and median nuchal line to the spinous process of the seventh cervical vertebra in the lower part of the neck. It is responsible for providing the stabilizing of the head and maintaining the lordotic alignment of the cervical spine during the movement of the neck. The pathogenesis of this condition is not clear, as a result of mechanical factors and repetitive trauma, calcifications occurs at the nuchal ligament. This calcification often round or ovoid structure, uniformly bounded. They are seen as parallel to longitudinat axis. They are seen usually in a single bone. The most frequent localizations are C5-6 and C6-7. They occur in almost 7.5% of the population, with a male predominance of 3:1.

Case Report: A-66-year-old male patient was admitted to head and neck pain after hitting his head and fall down. The patient had no systemic diseases known. Vital signs were normal. On physical examination, there was dermabrasion head in the frontal region and nasal dorsum. Neck movements were normal. There was no neurological deficit, other system examinations were normal. Because of trauma, skull and neck radiographs was performed. Lateral radiographs of the cervical spine was shown two opaque lesions which was present at the level of C5 between spinous proces, in bone density, had longitudinal elongation. CT was performed to exclude avulsion fracture. CT was shown well-defined, ovoid, longitudinally extending parallel parts, in different sizes, 2 bony structures. These structures were considered as the nuchal ligament ossification. The patient was discharged with analgesics.

Conclusion: Age-related changes and the anatomical variations can be easily confused with pathological conditions, particularly at direct graphics. When clinicians have knowledge of such anatomical variations, that will help in patient assessment.


Ilker AKBAS (Erzurum, Turkey), Abdullah Osman KOCAK, Esra KADIOGLU, Mustafa UZKESER
11:00 - 18:00 #8111 - Bronchodilator treatment of patients with COPD at home in the emergency department and at discharge. Are clinical practice guidelines followed?
Bronchodilator treatment of patients with COPD at home in the emergency department and at discharge. Are clinical practice guidelines followed?

Introduction
Chronic obstructive pulmonary disease (COPD) is a health problem of great magnitude and intensification is a major cause of morbidity and mortality. Consumes many resources with increased incidence foreseeable in the immediate future.

Objective
Rate track clinical practice guidelines (CPG), analyzing bronchodilator treatment they receive at home in emergencies and at discharge.

Material and method
descriptive, observational and retrospective study General Hospital with population of 200,000 and 275 emergency / day. 1167 patients treated with COPD exacerbations from January 2012 to July 2015 with FEV1 <70% were included proven. home treatment in emergency and high: the variables were collected.

Results
Of the 1167 patients who met criteria for inclusion in the study, home treatment bronchodilator which were prior to the aggravation was: b2 inhaled short-rescue action in 285 (24.5%) patients, b2 inhaled long-acting 71 (6.1%) and 5 (0.4%) nebulized. 87 (7.5%) were receiving anticholinergic (AC) inhaled short-acting, 815 (69.8) AC long and 25 share (2.1%) nebulized. 855 (73.3%) were receiving inhaled corticosteroid treatment and 5 (0.4%) nebulized.
After evaluation in the emergency room, treatment was initiated in boxes with inhaled b2 in 19 (1.8%) patients and 781 (67%) nebulized. 131 (11.2%) patients were treated with inhaled anticholinergic and 854 (73.2%) with nebulized. 121 (10.4%) patients received inhaled corticosteroid, 440 (37.7%) nebulized and 838 (71.8%) Intravenous corticosteroid. Of the patients who consulted, 371 (36.1%) were discharged without income and bronchodilator prescribed treatment was: b2 inhaled short acting in 259 (22.3%) patients, b2 inhaled long-acting 50 (4.3%), b2 inhaled rescue 112 (9.6%) and 41 (3.5%) nebulised. 79 (6.8%) patients treated with short-acting inhaled AC, 212 (18.2%) AC long and 50 share (4.3%) with nebulized. In 252 (21.6%) were prescribed oral corticosteroids, 246 (21.1%) inhaled and 49 (4.2%) nebulized.

Conclusion
Against the GPC, where the main treatment are bronchodilators, in our series only 65-75% received bronchodilators (beta2 or anticholinergics). The use of systemic corticosteroids was largely as indicated by the GPC. We think that despite being a known disease requires training and dissemination of GPC for better management of this patients in the emergency room


Maria Consuelo QUESADA MARTINEZ, Nuria RODRIGUEZ GARCIA, Blanca DE LA VILLA ZAMORA, Danae FERNANDEZ-CAMACHO, Maria CORCOLES VERGARA, Pascual PIÑERA SALMERÓN (montepinar, Spain), Cesar CINESI GOMEZ, Jose ALONSO AGUILERA
11:00 - 18:00 #7667 - Brucellosis back pain as cause of acute emergencies.
Brucellosis back pain as cause of acute emergencies.

An 74 year old woman with a history of arterial and diabetic hypertension independent and active life, which refers in the last two months, multiple emergency room visits for lumbosacral pain of inflammatory and mechanical characteristics, which radiates to gluteal and lower limb right associating dysesthesia and gradually you have finished prostrating in bed in the last 7 days. It has repeatedly been diagnosed lumbosciatica right. She lives in an urban environment and eat dairy and meat supermarket. It has been treated with analgesics and anti-inflammatories several null responders them. Associated asthenia, hyporexia and weight loss. After being removed all anti-inflammatory medication, for mild renal impairment in a visit to the emergency room 48 hours prior to admission, begins with fever, reason leading to perform several differential diagnoses to symptoms of fever, acute low back pain.

On examination patient collaborator, overweight, fair general condition, fever 39.4Cº, on a stretcher. .Eupneic, Normotensive. Well hydrated and perfused.

 Auscultation and regular rhythmic tones, aortic systolic murmur IV / VI, hypoventilation in both bases. Mamas without findings.

Abdomen: globular, symmetrical, soft, depressible without mass or organ enlargement. Pain on deep palpation in the right iliac fossa, without peritoneal irritation.

Lower extremities signs of chronic venous insufficiency. No edemas.

Neurological examination: no focal neurological deficits of cranial nerves or sensory-motor pathways. No meningeal signs.

Locomotor: slight deformity of both knees in relation to degenerative changes. Acupressure pain of lumbar spinous dorsal distal and proximal movement Arcos de coxofemorales diminished by pain. bilateral negative fabers. bilateral negative brush with limited flexion no signs of arthritis or knee or ankle or metatarsophalangeal. bilateral flexor plantar skin with no signs of spasticity. Lassegue and positive Bragard Left 40 Cº.

Analytical hemoglobin 10 Leukocyte 6790.

Simple Thorax Radiography: costophrenic grip both breasts.

Radiography lumbosacral spine: listesis L5 and decreased joint space of the right sacroiliac joint.

 Rose Bengal test: positive.

Final diagnosis: right sacroiliitis with spondylodiscitis L5-S1 brucella source.

Evolution: The patient was admitted to the Infectious Diseases, evolve Doxycycline more favorably after start streptomycin.

 Discussion: Brucellosis is a disease transmissible to humans and capable of affecting various organs and tissues zoonoses. The most common in the human species is Brucella melitensis, whose main reservoir is cattle. The main mechanism of transmission is oral for dairy products. In our case we had to make several differential diagnoses as: degenerative causes, structural changes, infectious, inflammatory changes, tumors, metabolic bone diseases, gynecological problems, kidney or intra-abdominal. It should detect the so-called symptoms and signs of "alarm": the realization fever, toxic shock syndrome, weight loss, previous history of cancer, steroid use, age greater 50 years nocturnal severe pain that does not subside, pain exacerbated supine and standing.

The incidence rate in Andalusia Brucellosis is 7.17 cases per 100,000 inhabitants. Malaga is endemic Brucella infection.


Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #8079 - Buckingham Medical Students' Community First Responder Scheme.
Buckingham Medical Students' Community First Responder Scheme.

The Buckingham Medics’ Community First Responder (BMCFR) Scheme was started in August 2015, and was created by medical students following some research into average medical service response times, and the population demographic of the town.

The scheme allows medical students to complete additional training to enable them to respond to potentially life threatening cases on behalf of South Central Ambulance Service. The response is always within a ten-minute driving radius, and encompasses a range of ailments from minor injuries to cardiac arrest. Within the first 3 months, over 100 calls were attended and a much larger interest has been drawn; with hope to extend responder hours to 24/7 within the next few months.

This scheme helps the local community by providing first response medical cover, and it helps medical students to use and apply their knowledge first hand, which seems to be beneficial to the students are cursory data of OSCE performance between responders and non-responders suggests those who are responders do better in first year exams. More data is being collected to conduct a clinical audit by the end of 2018, looking at first hand clinical experience and examination performance.

 

 


Andrew NEVES (Buckingham, United Kingdom), Matthew BECK
11:00 - 18:00 #7258 - C is for confusion and consider CT.
C is for confusion and consider CT.

Title

C is for confusion and consider CT.

 Authors

F Mustafa, N S-Vainberg, P Gilligan

Introduction

Medical diagnosis is the process of determining which disease or condition explains a person's symptoms and signs. It is said that over 80% of diagnoses are made on history alone, a further 5-10% on examination and the remainder on investigations. Unfortunately, in the Emergency Department (ED), the clinicians often face the challenge of not having a detailed history available, and the diagnosis, investigations and management of the patient are very dependent on the clinical gestalt of the physician.

Methods

We present a case of a confused, withdrawn young female patient that presented to the ED with no clear history available but she admitted to taking paracetamol.

Results

A 24 years old female patient was brought in by ambulance to the ED with a suspected paracetamol overdose. She presented on her own and there was no clear history or collateral history available. She appeared withdrawn and had a GCS of 14/15.

A toxicology screen was sent with routine investigations that all came back normal. At this stage, a friend of hers arrived to the ED expressing concerns that he had contacted the ambulance after not hearing from her for more than 2 days and confirmed that the patient’s family was away. In the context of her confusion and altered mental state a  CT scan of her brain was performed which showed significant intracranial hemorrhage in left parietal and temporal lobes with significant surrounding edema, mass effect, sulcal effacement, compression of lateral ventricle and midline shift.

A CT venogram demonstrated thrombotic occlusion of the intracranial venous system from the level of the left internal jugular vein including left sigmoid and left transverse sinus.

Further evaluation and assessment revealed that the patient had admitted taking paracetamol to relieve the headache she had had for the last 2 weeks.

The patient’s subsequent management and progress are described in detail.

 Conclusion:

Cerebral venous thrombosis (CVT) is an uncommon presentation to the ED. CVT is believed to be more common in women than in men. In a study, 61% of women with CVT were aged 20 to 35 years. This difference may be related to pregnancy or the use of oral contraceptives.

Not having a history available, poses particular difficulty for EM clinicians to reach a diagnosis. Medical imaging used appropriately in conjunction with clinical gestalt can help significantly in investigating and managing patients.

References

  1. Ameri A, Bousser MG. Cerebral venous thrombosis. Neurol Clin. 1992 Feb. 10(1):87-111.
  2. Galarza M, Gazzeri R. Cerebral venous sinus thrombosis associated with oral contraceptives: the case for neurosurgery. Neurosurg Focus. 2009 Nov. 27(5):E5.

Farah MUSTAFA, Nikita SVIRKOV-VAINBERG (Dublin, Ireland), Peadar GILLIGAN
11:00 - 18:00 #7450 - C2 fracture with absence of neurological signs.
C2 fracture with absence of neurological signs.

Introduction

Falls are a common presentation to the Emergency Department (ED). In some cases, the symptoms and clinical examination may not correlate with the severity of the injuries sustained.

 

Case

An 81 year-old male was brought to our ED after tripping on a loose carpet and falling forward down 12 stairs. There was no loss of consciousness and he was able to mobilise with no limitations after the fall. He was immobilised by the ambulance crew based on the mechanism of injury.

Examination revealed tenderness to the left aspect of the neck, no midline cervical spine tenderness, a GCS of 15 and no neurological deficit.

In accordance with NICE guidelines, an urgent computed tomography (CT) scan of head and neck revealed a displaced fracture through the base of odontoid process with significant anterior and left lateral subluxation and dislocation of the body of C2 in relation to C1. There was surrounding haematoma with a degree of spinal canal compromise at C1-C2 level.

Due to the severity of the fracture and preserved neurology, the patient was transferred urgently to the regional neurosurgical unit for posterior C1-C2 fixation. He made good post-operative recovery and was discharged 5 days later with an Aspen collar to be worn for 8-12 weeks.

 

Discussion

Cervical spine injuries account for 3.7% of all trauma patients with an estimated incidence around 11.8 per 100,000 per year. Falls (60%) are the commonest mechanism of injury followed by motor related accidents. Involvement of the C1-C2 complex accounts for 19-25% of all cervical spine fractures with odontoid process accounting 55% of these.

Odontoid fractures are classified as Type I (upper tip of the odontoid process only), Type II (through the base of the odontoid process) or Type III (body of C2).

Patients usually complain of neck pain and inability to actively move the neck with a sensation of instability. Examination findings can be as severe as quadriplegia with respiratory involvement but more commonly (up to 79% of cervical spine fractures) no neurological deficit is identified.

Diagnosis relies on clinical examination and radiological imaging (plain X-rays or CT scans). However, NICE suggest that, as a minimum, CT scans should cover any areas of concern or uncertainty from X-rays or clinical examination. MRI may add important information about ligament and disc injuries.

Treatment for Type I fractures is immobilization with a hard-collar for 6-8 weeks whilst Type II and III fractures can be managed either conservatively or surgically (external immobilization with a halo vest, internal fixation/ odontoid screw fixation or posterior C1-C2 arthrodesis).

 

Conclusion

Significant cervical spine injury can be present with minimal signs and symptoms. Patients demographics (especially the elderly) and mechanism of injury should always be considered when deciding on choice of investigations.


Tom BARKER, Abdo SATTOUT (Liverpool, UK, United Kingdom)
11:00 - 18:00 #7802 - Can an “Ultrasound First” policy reduce incidence of CT scan use and radiation exposure in pediatric patients presenting to the Emergency Department for Evaluation of Abdominal Pain?
Can an “Ultrasound First” policy reduce incidence of CT scan use and radiation exposure in pediatric patients presenting to the Emergency Department for Evaluation of Abdominal Pain?

Background

 

Abdominal pain is a common complaint in presentation to the Emergency Department and acute appendicitis is the most common condition requiring emergent abdominal surgery. Early diagnosis to minimize the incidence of perforation is important to a successful outcome, however diagnosis can be challenging in the pediatric population who frequently do not have a classic presentation and to whom radiation exposure is a concern. 

 

The American Academy of Radiology recommends ultrasonography as the initial imaging modality of choice for children in whom appendicitis is suspected (1). The principles of as-low-as-reasonably-possible (ALARA), an approach to minimizing radiation exposure, suggest ultrasound be used in suspected cases of appendicitis, followed by CT only if the ultrasound results are equivocal.

 

In January 2013, New York Methodist Hospital instituted an “ultrasound first” policy for the evaluation of abdominal pain in patients presenting to the emergency room ages 18 years and younger.  All patients presenting with abdominal pain undergo an ultrasound examination performed by an ultrasound trained Emergency Medicine attending physician or an ultrasound performed by the radiology department prior to obtaining a CT scan.

 

Objectives

 

To demonstrate that a formal policy recommending ultrasound prior to CT scan in the diagnostic algorithm for acute appendicitis is effective at reducing CT usage and radiation exposure in the pediatric population.

 

Methods

 

A retrospective chart review was done of all pediatric patients who presented to the emergency room between January 1, 2013 and January 1, 2015 for abdominal pain and underwent an appendectomy. The rate of ultrasound use and CT use was compared to prior ultrasound and CT rates at our institution.

 

Results

 

In 2009, prior to the availability of POCUS at our institution, 116 cases of acute appendicitis were analyzed.  Four patients went to the OR solely based on clinical exam findings (3.4%). 10 of 112 (8.9%) cases of acute appendicitis underwent an ultrasound examination prior to CT and 3 of these went to the OR based on ultrasound alone (2.7%)

In 2011, after the introduction of POCUS, 140 cases of acute appendicitis were analyzed.  Six went to the OR based on clinical findings (4.2%). 36 of 134 (26.8%) underwent ultrasound prior to CT and 15 of these went to the OR based on ultrasound alone (11%).

From Jan 1 2013 to Jan 1 2015, there were 104 cases of acute appendicitis. None went to the OR based on clinical findings. 97 of 104 (93.2%) underwent ultrasound prior to CT and 38 of these went to the OR based on ultrasound alone (39.2%).

Introduction of bedside ultrasound followed by implementation of an “ultrasound before CT” policy in our ED has raised the rate of risk avoidance from 2.7% to 38.9%.

 

Conclusion

 

Implementation of an “ultrasound first” policy for the evaluation of acute appendicitis for pediatric patients presenting to the ED is associated with a significant reduction in CT utilization.  By decreasing CT use in the ED in the workup of acute appendicitis, it is reasonable to conclude that medical radiation exposure has decreased.


Chiricolo GERARDO (Holmdel, USA), Christopher RAIO, Lindsey BEHAN
11:00 - 18:00 #7073 - Can clinical evaluation determine the need for pelvic x-ray in awake and stable blunt trauma patients?
Can clinical evaluation determine the need for pelvic x-ray in awake and stable blunt trauma patients?

Aim: Pelvic fractures is common and can be potentially life threatening.  The early diagnosis of pelvic fractures resulting from blunt abdominal trauma traditionally relies on the anterior-posterior pelvic radiograph although sometimes it may not give a definitive diagnosis of pelvic fractures. So reliability of pelvic x-ray has been questioned and ways of removing pelvic x-ray from the ATLS protocol are being observed on the basis of finding the reliability of clinical examination in finding out pelvic fractures in alert and awake, hemodynamically stable patient and also to avoid the unnecessary exposure of radiation and reduce the financial burden.

Methods: This is a cross sectional study conducted in the department of surgery, Aga Khan University Hospital, Karachi. This study included patients with blunt trauma mainly the road traffic accident victims presenting the emergency department with GCS of 15, hemodynamically stable and alert and awake. Clinical examination of pelvis of these patients were done on three different examination maneuvers and assessment of pelvic made which was then compared to routine pelvic x-ray findings.

Results: Total of two twenty one (221) of blunt  trauma patients were reviewed having mechanism of injury being road traffic accident and history of fall. Of these 221 patients thirty two (32) were not entered in the study as they had GCS of < 15, fifteen patients were not included as they have abdominal tenderness, fourty one (41) patients had associated lower limb injuries. So the final of one thirty three (133) patients were included in our study. Of these 133 patients majority of patients were male around 91.7% and 8.9% were females. Mean age of patients included in this study 37 with standard deviation of +/- 14.2. Fourteen patients were positive for pelvic fracture on clinical examination and positive on PXR categorized as true positive (TP), fourteen patients were positive for pelvic fracture on clinical exam but negative on PXR and categorized as false positive (FP), two patients were negative for pelvic fracture on clinical exam but positive on PXR categorized as false negative (FN), one hundred and three patients were negative for pelvic fracture both on clinical exam and PXR and were labelled as true negative (TN).

Sensitivity, Specificity, Positive predictive value and Negative predictive value were calculated by using two X two table. Sensitivity of clinic examination was found to be 87.5%, Specificity 88.03%, Positive Predictive Value 50% and Negative predictive value 98.09%.

Conclusion: In relation to above mention findings new protocol can be advised for alert and awake patients and pelvic x-ray can be avoided helping in reducing the financial burden to patient, reducing emergency hassle and unnecessary radiation.  


Muhammad Asad MOOSA (Karachi, Pakistan), Hasnain ZAFAR, Raza SAYYED, Iqra JANGDA
11:00 - 18:00 #7840 - Can Failure Mode and Effects Analysis (HFMEA) improve the door to needle time in patients suspect of ischemic cerebral accident?
Can Failure Mode and Effects Analysis (HFMEA) improve the door to needle time in patients suspect of ischemic cerebral accident?

Background

The door to needle time (DNT), defined as time between arrival of an ischemic stoke patient and the deliver of the thrombolytic agent, is considered to be an important indicator of quality of care. Considering only one out of seven ischemic stroke patient leaves hospital with fully regained functions, it is paramount to deliver the agent to the right patient as fast as possible. Acceptable norm of door to needle time is considered to be within 1 hour. The DNT in Radboud university in 2014 was 41 minutes.  

Failure Mode and Effects Analysis (HFMEA) is systematic techniques for failure analysis. It was developed by reliability engineers in the late 1950s to study problems that might arise from malfunctions of military systems. It is often the first step of a system reliability study.

 

Methode

The current thrombolysis procotol is revised by utilizing HFMEA and the involvement of department of neurologie, radiologie and emergency medicine.

 

Patients who are suspect of stroke presented at our ED between 1/1/2015 and 31/12/2015 are included in the study. The time between arrival of ischemic stoke patients and deliver of alteplase is recorded and compaired to the same patient group in 2014.

Result

There are 359 stroke patients presented at our ED in 2015. 275 with ischemic stroke, 42 have hemorrhagic stroke and 42 with transient ischemic accident. The DNT in 2015 is 25 minutes compares to 41 minutes in 2014.

Conclusion

Failure Mode and Effects Analysis is able to identify and eliminate de delays in the thrombolysis protocol and effectively shortens the door to needle time by 40%.


Abel WEI (Cuijk, the Netherlands, Netherlands Antilles), Frank Erik DE LEEUW
11:00 - 18:00 #7148 - Can risk factors predict the likelihood of successful reduction of displaced wrist fractures in the emergency department?
Can risk factors predict the likelihood of successful reduction of displaced wrist fractures in the emergency department?

Background: The majority of displaced isolated wrist fractures in Australia are reduced in the Emergency Department (ED) and followed up as outpatients. Previous research has identified a number of risk factors for fracture instability.  Our aim was to describe the prevalence of instability risk factors, the rate of successful fracture reduction according to previously defined radiological criteria and whether the number of risk factors was associated with success of fracture reduction.

Participants and methods: This was a retrospective study performed by medical record review. All adult ED patients coded as having an isolated wrist fracture in 2014 were screened for eligibility. Data collected included demographics, history of osteoporosis, mechanism of injury and radiological features on initial and post-reduction x-rays.  Outcomes of interest were the prevalence of previously defined risk factors, the proportion of patients with good radiological outcome according to pre-defined criteria and any association between the number of risk factors and successful reduction.

Results: 2048 patients were screened for eligibility; 319 met inclusion criteria and had full data. Median age was 62 (IQR 48-74) and 77% were female. Most fractures (73%) resulted from a fall from level ground or height <30cm.  The median number of instability markers was 4 (IQR 3-5); 63% of patients had ≥4 risk factors. Good radiological position according to pre-defined criteria was achieved in 206 patients (65%; 95% CI 59-70%).  The number of instability markers was associated with success of reduction – the higher the number the less likely successful reduction (AUC 0.66, 95% Ci 0.59-0.72; p<0.0001). The previously suggested cut-off for number of risk factors to predict poorer outcome (≥4) had sensitivity of 67%, specificity of 57% and negative predictive value of 52%.

Conclusion: Instability markers are common in patients undergoing fracture reduction in ED. The number of risk factors is only moderately associated with successful reduction however the previously suggested cut-off of ≥4 risk factors had poor sensitivity, poor specificity and negative predictive value for successful fracture reduction in ED. 


Alyza GOSSAT, Amar WINAYAK, Klim SHARON, Jenny COOPER, Peter RITCHIE, Wei LIM, Anne-Maree KELLY (Melbourne, Australia)
11:00 - 18:00 #7577 - Can single dose of duloxetine induce hyponatremia in a middle-aged male patient? A case report.
Can single dose of duloxetine induce hyponatremia in a middle-aged male patient? A case report.

Can single dose of duloxetine induce hyponatremia in a middle-aged male patient? A case report

Abstract

Introduction: Duloxetine is a serotonin/norepinephrine reuptake inhibitor, used for treating major depressive disorder, diabetic neuropathy, fibromyalgia, generalized anxiety disorder and chronic musculoskeletal pain.[1] The cases of hyponatremia induced by duloxetine have rarely been reported. We report a case of hyponatremia induced by duloxetine developed rapidly after a single dose medication in a middle-aged male with somatic symptoms.

Case: A 28 years old male patient presented to the Emergency Department (ED) with fatigue and dizziness. The patient declared that he had a single dose of duloxetine which was he was prescribed for somatic complaints. A routine laboratory work-up showed a significantly low sodium level (Na= 121 mg/dl). The patient had no known predisposing factors for hyponatremia. Vital signs and physical examination, including neurological evaluation, were normal. The patient’s presentation complaints were completely resolved after duloxetine was ceased and normal saline treatment was given.

Discussion: When treating patients with depression and somatic symptoms, close monitoring for clinical and laboratory evidences of drug related adverse and side effects, such as hyponatremia, are essential. 


Tanzer KORKMAZ (IZMİR, Turkey), Funda KARBEK AKARCA, Selen URKE COME, Cem ERTAN
11:00 - 18:00 #8163 - Can suPAR add prognostic value in the assessment of surgical patients by predicting mortality and postoperative complications?
Can suPAR add prognostic value in the assessment of surgical patients by predicting mortality and postoperative complications?

Background

Risk assessment of surgical patients is in Denmark based on the American Society of Anesthesiologists (ASA) Physical Status classification. Routinely, no biochemical component is used in the prediction of mortality and postoperative complications.

In acute medical patients, studies have found soluble urokinase plasminogen activator receptor (suPAR) to be an independent predictor of 30-day mortality and adverse outcomes, such as readmission, admission to ICU, and longer admissions. Whether suPAR adds prognostic value to the customary preoperative risk assessment by predicting post-operative outcome in unselected patients in need of acute surgery has not been investigated.

In this study, we aimed to determine whether preoperative suPAR levels were able to predict mortality, postoperative complications, and reoperation in surgical patients.

 

Methods
Between 5 September 2013 and 7 December 2013, suPAR was measured in all patients admitted to the emergency department (ED; n=6,383) at Hillerød hospital, Denmark. Among these, 714 patients underwent various surgical procedures within 90 days from admission to the ED, and follow-up was 90 days. Of these, patients with missing suPAR (n=45) or minor, insignificant, and endoscopic diagnostic procedures (n=145) were excluded.

Complications and reoperations were registered by reviewing medical records of included patients. Complications included various types of pulmonary, thromboembolic, cardiac, renal, infectious, and neurological genesis. Furthermore, death was registered.

suPAR values are presented as medians with interquartile range (IQR), and statistical analysis was performed using Kruskal-Wallis test and receiver operating characteristics (ROC) curve analysis, presented as area under the curve (AUC) values with 95% confidence intervals (CIs).

 

Results

A total of 524 included patients (283 women (54%); median age 63.4 years, IQR 43.5 – 76.4) underwent significant surgery within 90 days after admission to the ED. Median suPAR for the entire population was 4.5 ng/ml (IQR 3.5 – 6.2).

Median suPAR for the general surgical patients was 4.2 ng/ml (IQR 3.2 – 5.5, n=215), for orthopedic surgical patients 5.2 ng/ml (IQR 3.9 – 6.6, n=201), and for all other surgical patients 4.4 ng/ml (IQR 3.3 – 5.8, n=108).

Out of all included surgical patients, 147 (28.1%) developed one or more complications during follow-up. These patients had significantly higher suPAR compared with patients without complications (5.8 ng/ml (IQR 4.1 - 8.1) vs. 4.2 ng/ml (IQR 3.3 – 5.5), p<0.0001). 71 patients (13.5%) were reoperated, and these patients had significantly higher suPAR compared with patients not reoperated (5.7 ng/ml (IQR 4.0 – 7.7) vs. 4.4 ng/ml (IQR 3.5 – 6.0), p<0.0001).

ROC curve analyses of suPAR for predicting development of complications or reoperation yielded AUCs of 0.69 (95% CI 0.64-0.74) and 0.64 (95% CI 0.57-0.72), respectively.

Results regarding mortality will be presented at the EuSEM 2016.

 

Conclusion

Among surgical patients, those who developed one or more complications or were in need of reoperation during follow-up had significantly higher suPAR levels, than those with no complications. These results suggest that suPAR may have a preoperative predictive value for development of complications in acutely admitted surgical patients. 

Morten Alstrup and Jeppe Meyer contributed equally to this work.


Morten ALSTRUP, Jeppe MEYER (Copenhagen Ø, Denmark), Line Jee Hartmann RASMUSSEN, Martin SCHULTZ, Jesper EUGEN-OLSEN, Kasper IVERSEN
11:00 - 18:00 #8098 - Can the efficiency of WBC be Increased by Using Hematologic Inflammatory Parameters on Acute Appendicitis Diagnosis?
Can the efficiency of WBC be Increased by Using Hematologic Inflammatory Parameters on Acute Appendicitis Diagnosis?

 

Purpose: The rate of negative appendectomy in patients suspected of appendicitis is still high. Here, we evaluated the efficiency of parameters like white blood cell(WBC), Neutrophil Leukocytes Ratio(NLR), Mean Platelet Volume(MPV) and Red Blood Cell Distribution Width(RDW) in decreasing the negative appendectomy ratios.

Material and Method: 804 operated acute appendicitis patients in seven years were examined retrospectively. The patients were divided into 2 groups according to the pathology reports (Group AA: Acute Appendicitis, Group NA: negative appendectomy). The age, gender, preoperative WBC, NLR, RDW and MPV values, intraoperative findings, postoperative pathology results and etiologies were recorded.

Results: Of the patients, 58.2 were male and mean age was 30.8±11.9. Logistic regression analysis using enter method and taking age, gender (dichotom) and NLR showed that being female (wald: 6.284, OR: 1.77, 95%CI: 1.133-2.765, p=0.012) and having high NLR (wald: 4.541, OR: 1.057, 95%CI: 1.004-1.111, p=0.033) were independent parameters for negative appendectomy. Area under the curve (AUC) for WBC and NLR to diagnose negative appendectomy patients among patients with prediagnosed appendicitis were 0.598 (95%CI:0.535-0.660; p=0.003) and 0.621 (95%CI:0.556-0.685; p<0.0001), respectively. 

Conclusion: Using WBC together with NLR might decrease Negative Appendectomy rates. 


Sukru ARSLAN, Erdem KARADENIZ, Mucahit EMET, Bunyami OZOGUL (Erzurum, Turkey), Sabri Selcuk ATAMANALP
11:00 - 18:00 #7586 - Can We Use High Sensitive Troponin T as a 30 Day Mortality Predictor in Pulmonary Embolus in Emergecnt Medicine Department?
Can We Use High Sensitive Troponin T as a 30 Day Mortality Predictor in Pulmonary Embolus in Emergecnt Medicine Department?

Introduction: Pulmonary Thromboembolism, almost (%90) originated from deep femoral veins as a complication of separated thrombus or fragments from deep vein thrombosis. PTE is second common, sudden and unpredictable cause of mortality who come to outpatient clinics. We aimed to investigate the predictive power of hsTnT in 30 day prognosis of PTE diagnosed patients.

Material and Method: This prospective cross-sectional clinical study has been carried out between 01.04.2012 and 31.03.2013 in Gazi University, Faculty of Medicine, Department of Emergency Medicine. High Sensitive Troponin T test was performed in all patients in Pulmonary Thromboembolism.

Results: Patients which had high mortality in 30 days were significantly tachycardia, tachypnea, lower pulse saturation and malignancy history (Mann Whitney U test, respectively p:0,041, p:0,002, p:0,027 and p:0,011). Patients that high levels of hsTnT were good correlation about 30 days mortality prediction. (correlation coefficient: rho: + 0,567). HsTnT has 88% sensitivity and 28% specificity about prediction of 30 days of mortality.

Conclusion: HsTnT can be used in patients that diagnosed a PTE,  which can predict right ventricle dysfunctioning.  HsTnT is easy applicable, repeatable and short duration test. Given the advantages of hsTnT, it seems to be appropriate for use prediction of bad prognosis which patients diagnosed a PTE. 


Volkan ÜLKER (ISTANBUL, Turkey), Ahmet DEMİRCAN, Hasan KARABULUT, Selahattin GÜRÜ, Ayça ÖZEL, Başak ALTINBAŞ, İsa KILIÇASLAN, Ayfer KELEŞ, Fikret BİLDİK
11:00 - 18:00 #7255 - Cannabinoid hyperemesis: An unusal cause of digestive symptoms.
Cannabinoid hyperemesis: An unusal cause of digestive symptoms.

Cannabinoid hyperemesis: An unusal cause of digestive symptoms

 Cannabis has been used recreationally for a long time  and is the third most commonly used drug after tobacco and alcohol. The therapeutic potential of cannabinoids has been recognized and utilized as anti-emetics. However, the  Cannabinoid hyperemesis syndrome has been described characterized by a paradoxical effect of hyperemesis in some susceptible chronic cannabis abusers. The etiology of cannabinoid hyperemesis is not known but some authors propose that the central effects of long-term cannabis use on the hypothalamic-pituitary-adrenal axis might play a major role in the development of CH.

It  would be essential for the diagnosis the regular use of cannabis for years, cyclic nauseas and vomiting , abdominal pain  and resolution of symptoms after stopping cannabis use. Compulsive hot baths with symptom relief would support the diagnosis.

 

We present  a case series  of 7 patients, admitted in  the Emergency Department of our hospital from May 2009 to May 2015, all of them  with long-term cannabis use and recurrent nausea, vomiting, abdominal pain  and, some of them, relieved with hot water bathing.

All patients, 2 females and 5 males,  were under 44 years of age and reported using of cannabis for more than 2 years before the  symptom onset. Two patients used it for 20 and 30 years.

The average attendance in the emergency department was 15.85. In one case, we counted 31 times.  In  3 of them  we found another drugs in urine (Heroin, cocaine).  5 reported weekly use of alcohol.

Diagnostic studies were performed in most patients and generated  negative results for  alternative diagnoses. These studies included complete blood cell count, glucose level, liver biochemistries, pancreatic enzyme level, abdomen X-ray and in two cases, abdominal computed tomography and upper endoscopy.

Standard treatment was used with fluid therapy, antiemetic  and proton-pump inhibitor in all of them, thus  achieving improvement in all cases after more than 12 hours of stay in the emergency room.  5 patients reported relief of symptoms with  hot baths or showers. 


The clinical improvement was confirmed in four patients  after cessation of cannabis use. The rest continue going to the emergency room  at the time of writing this article.

 

Because  of  the high prevalence and increasing consumption of Cannabis, it is likely that we will see an increased  number of patients with this syndrome in the Emergency Departments . Therefore,  it is necessary to collect the medical records of all patients who come with nausea and vomiting that are refractory to standard therapy but  improved  with hot baths. Cannabinoid hyperemesis should consequently be considered in these patients.

 


Rosario PEINADO (BADAJOZ, Spain), Miguel Angel RUIZ, Concepcion DE VERA, Alvaro MARTIN
11:00 - 18:00 #7685 - Cannabis-induced acute coronary syndrome.
Cannabis-induced acute coronary syndrome.

Introduction :

Smoking cannabis is a rare trigger of acute coronary syndrome but several cases of myocardial infarction have been increasingly reported during the last few decades. The physiological  pathway involves a coronary vasospasm but remains uncertain.

Observation :

We report the observation of a 20-year-old young male, regular cannabis smoker and alcohol consumer with no other medical history, who presented to the emergency department after complaining of paroxysmal recurrent episodes of retrosternal isolated chest pain occurring at rest and lasting longer than 20 minutes. The patient reported the use of cannabis during the three days before admission on ED with last consumption 12 hours before the beginning of chest pain. On examination : The patient was conscious; the blood pressure was 130/80 mmHg in both arms; The pulse rate was regular = 59 beats per minute and the evaluation of the pain was estimated over 30 mm. Otherwise, there were no  vascular left signs nor clinical findings of heamodynamic instability. The electrocardiogram at admission showed a regular sinus rythm at 60 bpm with an early repolarization in the inferolateral territories. The patient was admitted to the emergency ward for further decision clinical making  and therapeutic options. The evolution was marked by a dynamic T-wave negativation during the EKG monitoring and positive points of hypersensitive Troponins : 194 ng/ml to 452 ng/ml. A Non ST Elevation Myocardial Infarction diagnosis was made and the patient was transferred to the cardiology unit for further explorations. Echocardiography was normal. The coronary angiography revealed thight thrombotic stenosis of the proximal anterior interventricular artery with TIMI-3 flow and a  general spastic coronary system.

Discussion and Conclusion :

Several Cases of acute coronary syndrome due to the use of cannabis have been reported in the literature, especially among young people. However, the pathophysiological mechanism remains not completely understood with multiples hypothesis involving vasospasm, increased demand oxygen and decreased supply and plaque rupture. Actually, myocardial infarction may be more frequent than recognized by the literature. The medical taking history is the hallmark of the decision making.


Imen MEKKI (Tunis, Tunisia), Hamed RYM, Feten AMIRA, Ryef AMMAR, Bassem CHTABRI, Rym HAMMAMI, Bouhajja BÉCHIR
11:00 - 18:00 #7376 - Carbon monoxide poisoning due to water pipe smoking: case series.
Carbon monoxide poisoning due to water pipe smoking: case series.

Introduction:Hookah is a different form of tobacco consumption. In recent years, hookah usage has become increasingly widespread. The thought that it is less harmful than cigarettes increases its usage. Long-term exposure to high carbon monoxide (CO) levels due to hookah consumption may cause CO poisoning.

Case reports:A-18-year-old male patient admitted to emergency room. His complaint was syncope. He sat for 3 hours with friends in a café for hookah smoking, but he had to use hookah. After he had left the café, he said he had had head pain and dizziness then he could not remember what happened. He was described syncope lasted about 5 minutes. His physical examination and vital signs were normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 18,7% (normal range:0,5-1,5%) and other laboratory values were normal.

A-21-year-old male patient was admitted to emergency room with head trauma. At his anamnesis, he said he had felt dizziness after smoking hookah and bumped his head.  His physical examination and vital signs were normal. His cranial CT scan was normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 29,2%.

A-29-year-old male patient admitted to hospital with nausea, vomiting, dizziness and palpitation. At his medical history, the complaints had started after smoking hookah. His physical examination and vital signs were normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 34,1%.

A-28-year-old male patient was admitted to hospital by relatives due to confusion. Vital signs were normal. His Glasgow Coma Scale point was 12 (E: 3, V: 4, M: 5). He had no neurological deficit. Other systems were normal. At his arterial blood gas analyses, the level of carboxyhemoglobin was 35,5%. His cranial CT scan was normal.

All patients were administered a session of hyperbaric oxygen therapy and normobaric oxygen therapy during follow-up in the emergency room. After recovering their clinical status, they were discharged.

Conclusion:Hookah consumption is the most observed form of tobacco consumption in the Eastern-Mediterranean Region, and second in the US. Although it’s considered that all toxic agents are filtered while hookah smoke passes through water, hookah consumption increases levels of carcinogen, CO, nicotine, and tar in the blood compared to smoking. It’s striking that COHb values of our cases are as high as, even higher than stove poisoning cases. It must be kept in mind that non-specific symptoms following hookah consumption may be symptoms of CO poisoning.


Abdullah Osman KOCAK, İlker AKBAS, Zeynep CAKIR (ERZURUM, Turkey)
11:00 - 18:00 #7713 - Carbon monoxide poisoning in children during the years 2006-2015.
Carbon monoxide poisoning in children during the years 2006-2015.

Background: Carbon monoxide is an important cause of poisoning in children. We performed this study to clarify the epidemiology and clinical characteristics of patients with CO poisoning.

Methods: Retrospective analysis of medical records of patients hospitalised into Tallinn Children’s Hospital with suspected CO poisoning from 2006 -2015.

For the same time period, data of paediatric deaths from CO poisoning was acquired from Estonian Causes of Death Registry.

Epidemiological and clinical data were collected and analysed.

Results: A total of 97 children with suspected CO poisoning were admitted during the years 2006-2015.

Patient ages ranged from 1 month to 17 years. House fires were the most common cause of intoxication (46%), improper wood stove heating caused 27% of the cases, improperly ventilated exhaust produced by gas-fired water boilers caused 8%,  inadequately ventilated motor vehicle exhaust caused 7%, and 12% of the sources of the poisoning remained unknown.

62% of the events occurred during cool season.

Severe poisonings with loss of consciousness made up 11% of the cases. From other symptoms, the most common were nausea and vomiting (37%), headache (30%), dizziness (28%), and vertigo 11%.

Of the children admitted, 7.8% had CoHb levels over 20%, which is considered high. These high intoxication levels were mainly found to be caused by improperly ventilated gas-fired hot water boilers. None of the patients received hyperbaric oxygen therapy.

No mortality was seen in these hospitalised children. No neurological sequelae or pneumonitis were detected.

During these years, according to Estonian Causes of Death Registry data, 22 children died from carbon monoxide poisoning in Estonia, all of them were due to fires.

 

Conclusion: Children with CO poisoning had good outcomes in this series. Although improperly ventilated gas-fired hot water heaters were not the most common factor of carbon monoxide poisoning in children, it caused the most severe CO poisoning seen during that time.


Ulle UUSTALU (Tallinn, Estonia), Triin PERKSON, Gleb DENISSOV
11:00 - 18:00 #8218 - Cardiac arrest team or medical emergency team?
Cardiac arrest team or medical emergency team?

In Arad County Hospital, resuscitation team is a  cardiac arrest team from Emergency Department which is called only when a cardiac arrest is recognised. We evaluated this intervention during 2015 on neurology, internal medicine, haematology, gastroenterology, surgical, orthopaedic and paediatric fields.

Resuscitation team was called for 123 cardiac arrest situation, from which 111 were cardiac arrest while the other 12 were not.

 46 patients were resuscitated (41,44%) whereas 65 (58,55%) didn’t respond to the resuscitation measures. The initial cardiac rhythm was ventricular fibrillation in 28 cases (25,23%) and asystole and pulseless electrical activity in 83 cases (74,77%).  Patients’ rate of survival to hospital discharge after in hospital cardiac arrest was only 1,8% (2 patients).

Referring to those who were not in cardiac arrest (12 patients), the rate was higher: 6 of them (50%) survived and left the hospital. The number of discharged patients (alive) from the 123 interventions was 8 (6,5%).

 

Conclusion:

  1. Emergency medical team must be called not only for cardiac arrest situation, but also for deteriorating patients who are evaluated within early warning score.
  2. A strategy of recognising patients at risk of cardiac arrest may prevent some of these arrest.
  3. In order to prevent futile resuscitation attempt for those who are unlikely to benefit from Cardiopulmonary Resuscitation, a do-not-attempt-resuscitation (DNAR) policy should be implemented.

 


Monica PUTICIU (Arad, Romania)
11:00 - 18:00 #8059 - Cardiopulmonary resuscitation by emergency medical technicians in Austria - Results from the AURORA-registry (Austrian registry of resuscitation by ambulance-crews).
Cardiopulmonary resuscitation by emergency medical technicians in Austria - Results from the AURORA-registry (Austrian registry of resuscitation by ambulance-crews).

Background:
Out of hospital cardiac arrest (OHCA) is a leading cause of death in the western world, and an important field of operation for emergency medical services (EMS). EMS in Austria is organized as a two-tier system, with emergency medical technicians (EMTs) with basic training, many of them volunteers, usually arriving on scene first, and emergency physicians providing follow up-care on-scene later on. Currently, there is no nationwide acquisition of data on EMS-efforts in OHCA in Austria.

Methods:
The AURORA-registry was designed to prospectively collect data on resuscitation by EMTs of the Austrian Red Cross (providing the vast majority of EMS in the nation) according to Utstein-criteria. In addition, country-specific details on EMTs' level of training were recorded.

Results:
From January 2014 to September 2015 a total of 1,544 cases were recorded (546 (35%) female, mean age 71 +/- 17 years), 1,064 (69%) of them were observed cardiac arrests. A traumatic cause was evident in 103 (7%) cases. Bystander-CPR was provided in 596 (39%) cases, and a public access defibrillator was used in 21 (1.4%) cases. Upon arrival of EMS, a shockable rhythm was identified in 661 (43%) cases.

Regarding EMTs, 881 (57%) were volunteers, 1234 (80%) had only basic training ("Rettungssanitäter"), 307 (20%) had advanced training ("Notfallsanitäter"), including venous puncture and the use of drugs. For initial airway management, a laryngeal tube was used in 1019 (66%) cases, bag-valve-mask ventilation in the rest of cases.

Any return of spontaneous circulation (any ROSC) could be achieved in 319 (21%) cases. Rate of survival to hospital was 165 (11%).

Conclusions:
We present the first nation-wide data on OHCA from Austria. Outcomes of our volunteer-based, two-tier system are comparable to other similar countries.


Dominik ROTH (Vienna, Austria), Lukas LEHER, Wolfgang SCHREIBER
11:00 - 18:00 #7209 - Cardiotoxicity after overdose of korean medicine, Kyushin.
Cardiotoxicity after overdose of korean medicine, Kyushin.

Kyushin (Chinese, meaning "saving heart") pill, manufactured by Boryung pharmaceutics, Republic of Korea, is a dark brown pill with a unique scent and taste including toad venom 0.83 mg. Toad, Bufo venom, found in granular glands of the skin, parotid glands and eggs of some species of toads (Bufo gargarizans, Bufo stejnegeri in Korea) contains several toxins and bioactive alkaloids, such as bufadienolide (bufotenin and bufogenine, etc.), digoxin-like cardiac glycosides. We report a case of Bufotoxin intoxication in 87-year-old female patient who showed signs of digitalis intoxication and recovered from tachy-bradyarrhythmia and pulseless electrical activity cardiac arrest. 

81-year old, female patient presented in the ED with decreased mental status, occurred 3 hours ago. 2 hours 30 minutes before to ED presentation, a medical crew in a nursing facility found the patient in decreased mental status and empties of Kyushin next to the patient. Glasgow coma scale was 8 points, Systolic blood pressure was 104mmHg, heart rate 142 per minute, respiratory rate 24 per minutes and body temperature 36.0°C with IV dopamine infusion. The first 12-leads electrocardiogram on patient's arrival showed sinus tachycardia with heart rate 142/min and right bundle branch block. PR interval was 218msec, corrected QT interval was 429msec. After 3 minutes, suddenly heart rate dropped to 20s per minutes with SBP 96mmHg. IV atropine 1mg bolus was injected, IV dobutamine infusion started and activated charcoal of 50g was applied via nasogastric tube. 

After 30 minutes when patient arrived, ventricular fibrillation on ECG monitor was detected, cardiopulmonary resuscitation was started, defibrillations with energy of 200J were delivered 6 times, IV magnesium 2g and amiodarone 300mg and 150mg were injected. After 6 cycles of cardiopulmonary resuscitation, patient's of spontaneous circulation had returned, SBP was 134mmHg, ECG showed complete AV block with ventricular rate of 43/min. Mechanical ventilator and external cardiac transcutaneous pacing with 130mA, 60/min were applied. 

Plasma toxicologic test revealed the serum concentration of digitoxin 66.90 ng/ml, digoxin 0.76 ng/ml. 

After 9 hours of ED presentation, cardiac transcutaneous pacing was removed, SBP was 115 mmHg and mental status came to be alert. ECG showed sinus bradycardia with rate of 57/min, PR interval 413 msec and QRS interval 98 msec. After 10 hours of presentation, the patient had been weaned and transferred to the nursing facility according to the willing of guardians. 1 week later, the patient's recovery from arrhythmias without any serious complication was confirmed by telephone.

Kyushin overdose can cause serious arrhythmias similar to digitalis intoxication. 

Reference

1. Ko, R. J., et al. (1996). "Lethal ingestion of Chinese herbal tea containing ch'an su." West J Med 164(1): 71-75.


Byung Hak SO (Suwon, Korea)
11:00 - 18:00 #7609 - Care with fever in the psychiatric patient!
Care with fever in the psychiatric patient!

CASE REPORT Reason Query: 38 Patient brought to the ER for attempted suicide Personal history:

Mental and behavioral disorder opiate (methadone ), with dependence criteria , use of benzodiazepines , cannabis and cocaine dependence criteria . Personality Disorder Dissocial Chronic Treatment : Bupropion , Lormetazepam , Lorazepam , Olanzapine , pregabalin, Agomelatine . He went to the emergency room the last week, referred by his family doctor, by autolytic ideas. Rated by resetting Psychiatric treatment increases the dose of olanzapine and discharged .

Present Illness : Males 38 referring the family that has been missing 2 days and they find it in your hectic home , with 4 empty blister Olanzapine 5 mg , 4 of pregabalin 150 mg, one of   bupropion and  , lorazepam. Brought by the emergency outpatient service sedated with midazolam and  chlorpromazine and mechanical restraint
Upon arrival to emergencies:   Presure blood: 99/71 Temperature 35.4 ºC.  Well hydrated skin and mucous membranes, well perfused. Neurological Exploration: impossible to do on arrival at the emergency room for be the mechanical containment and patient sedated.
Complementary tests: Glucose 114, Urea 30, Creatinine 1.2, 25700 leukocytes (neutrophils 91%), hemoglobin 18.2 . . Platelets 310000 venous blood gases . 7.4 pH , pCO2 42.7  Toxic Urine positive for methadone and benzodiazepines
The patient was sedated and mechanical restraints, so passing observation area.
6:00 a.m. (5 hours after arrival to the emergency room ) Call from observation area for important psychomotor agitation and fever of 39 º. Come to assess the patient, further objectifying rigidity, diaphoresis , tachycardia 13o  and disorientation . Analytical requested in CPK and Procalcitonina. We started of intravenous midazolam perfusion and  administration of paracetamol and  saline Cranial CT is requested . We suspected neuroleptic malignant syndrome versus infectious process , are advised to intensive care unit, which decides admission to its Service
Physical exploration : Glasgow 13 Neurological examination : No nuchal rigidity, no meningeal signs Analytics : CPK 16627 , Procalcitonin 0.37 Cranial CT : No significant alterations lumbar puncture: clear liquid Leukocytes 2/mm3 , Glu 69, 34.8 Proteins
EVOLUTION: In intensive care unit te patient is stable, maintaining normal renal function despite frank rhabdomyolysis. Hyperthermia with physical measures and antipyretics, not objectified infected focus possession. Gradually infusion of sedatives with appropriate adaptation to the environment is suspended, so it is discharged with the diagnosis of neuroleptic malignant syndrome.
Conclusion: Thee is a serious complication of the use of neuroleptics, should be suspected. in a patient who uses such drugs ( olanzapine in our patient was the cause ), to present: hyperthermia, rigidity and impaired consciousness (all present in our case). They may be associated with rhabdomyolysis secondary leukocytosis and elevated CK . The differential diagnosis must be made with: lethal infectious process nervous system, lethal catatonia , heat stroke and malignant hyperthermia. Although rare , it is very severe with high mortality in untreated cases early, so early diagnosis is important and appropriate treatment in mild cases: maintaining hemodynamic stability, hydration and monitoring may be sufficient.


Daniela ROSILLO CASTRO (Murcia, Spain), Maria Dolores PASCUAL MUÑOZ, María De La Paz EGEA CAMPOY, Carmen HERNÁNDEZ MARTÍNEZ, Rocío LÓPEZ VALCARCEL, David FERNANDEZ GARRIDO, Alessandro GUASCHI CAGLIERI
11:00 - 18:00 #7705 - Case report – hypothermia after accidental intake of an antipsychotic agent and a tricyclic antidepressant.
Case report – hypothermia after accidental intake of an antipsychotic agent and a tricyclic antidepressant.

Introduction

Intoxications with antipsychotics and tricyclic antidepressants are recognized as a cause of hyperthermia in the setting of an anticholinergic syndrome. In this case report we describe an adult patient with an accidental administration of levomepromazine with clomipramine and furosemide, presenting with somnolence, hypotension and hypothermia.

 

Case description

A 55-year old, mentally retarded, woman was brought to the Emergency Department by ambulance with somnolence and hypotension. Five hours earlier, she had been accidentally given medication that belonged to another patient in her nursing home – levomepromazine 25mg (phenothiazine, antipsychotic agent), clomipramine retard 75mg (tricyclic antidepressant) and furosemide 40mg (loop diuretic).

One hour after administration of the medication, she became more somnolent than usual, with shaking hands and a hypotension (95/60 mmHg).

Her medical history consists of said mental retardation due to perinatal asphyxia, an anemia, obstipation and gastroesophageal reflux when supine. Her prescribed medication consists of cholecalciferol 400IE 1dd1, domperidone 10mg 3dd1, hydrochlorothiazide 25mg 1dd1, magnesium hydroxide 724mg 1dd1, omeprazole 40mg 1dd1, macrogol 1dd1 and dalteparin 2500IE 1dd1. Her usual dose of domperidon, hydrochlorothiazide, magnesium hydroxide and macrogol had not been given that day due to the accidentally administrated medication.

She had no known allergies.

 

On physical examination the patient was somnolent, with an Glasgow Coma Scale of E2M5V1, hypotensive (82/38 mmHg) with a bradycardia (56/min), and hypothermic (31 °C, rectally). Her respiratory rate was slow, with a SpO2 of 94% without supplementary oxygen. Her ECG showed a mild sinusbradycardia with a first degree AV-block, a small QRS-complex and a QTc of 0,51sec. Laboratory testing revealed a respiratory acidosis.

 

The patient was admitted with the diagnosis of intoxication with levomepromazine, clomipramine and furosemide. Aggressive fluid resuscitation was initiated, while the patient was simultaneously internally and externally warmed. Based on her history, current state and in consultation with her legal representative a DNR order was agreed upon. During admission, no further complications occurred. After two days, the patient was discharged to her nursing home in her previous condition.

 

Discussion

Thermoregulation is controlled in the preoptic area of the hypothalamus through regulation of shivering, peripheral vasodilation and diaphoresis - with serotonin and dopamine being the most important neurotransmitters. While the exact mechanism of action in this matter is not understood, both phenothiazines (levomepromazine) and tricyclic antidepressants (clomipramine) interact with these neurotransmitters and may promote hypothermia.

In this patient, multiple factors may have contributed to the development of hypothermia. Besides said medications, the perinatal asphyxia and consequent cerebral damage in this patient in combination with her somnolent state may have lessened her ability to shiver.

 

Conclusion

Although antipsychotics and tricyclic antidepressants are known for their abilities to cause hyperthermia, these agents should also be considered as a possible cause in patients presenting with hypothermia.


Laura ESTEVE CUEVAS (Dordrecht, The Netherlands), Eva SLAG, Barendina BAKKER
11:00 - 18:00 #7842 - Case Report.
Case Report.

4 patients presented to the ED with ingestion of Unknown Plants. They are from Nepal and one of them brought that plant from the forest in Nepal. They used it for headache, body pain, and flu symptoms (herbal). After ingestion, 3 of them started to vomit with abdominal pain.. They presented with hypotension, relative bradycardia, tingling sensation, and dizziness. The most critical patient has fluctuating rhythm (multi-focal PVCS, runs of non-sustained VT, R on T phenomena, PACs, change in the amplitude of the complex), hypotension, salivation, active vomiting, deep rapid respiration, GCS is 13/15, compensated metabolic acidosis. The 2nd one had the same presentation but milder and better ECG, GCS is 15/15. The 3rd one has no cardiac manifestations but hypotensive, less vomiting. The 4th one is asymptomatic. They have a piece of its root with him. All of them showed normal LAB. Results

difficulties are (language barrier, unknown poisoning, non-famous in the current community, resemble the manifestations of other toxidrome like cholinergic effect, multi-causality with only 1 senior staff, Unknown mechanism of action so difficult to decide about the use of any supportive medication)

By translator with some language barrier, safety to the patient from legal issues given to allow them to explore more about the nature of the plants As it is unbelievable that all of them have headache at the same time. Then they admitted that it was for energetic effect. Then I discovered the plant which is Aconitum Napellus and it was the root

Amoidarone given to control the arrythmias followed by ICU admission

Aconitum Napellus contains (Aconitine and mesaconitine)

MECHANISMS:

The cardiotoxicity and neurotoxicity are due to their actions on the sodium channels of the cell membranes of  he myocardium, nerves, and muscles. they bind with high affinity to the open state of the voltage-sensitive sodium channels at site 2, causing an activation of the sodium channels, which become refractory to excitation. The arrhythmogenic properties are due to its anticholinergic effects mediated by the vagus nerve. Aconitine has a +ve inotropic effect by prolonging sodium influx during the action potential. It has hypotensive and bradycardic actions due to activation of the ventromedial nucleus of the hypothalamus. they can induce strong contractions of the ileum through acetylcholine release from the postganglionic cholinergic nerves.

CLINICAL FEATURES:

Patients present with paresthesia and numbness of face, perioral area, and the four limbs, muscle weakness in the four limbs. hypotension, chest pain, palpitations, bradycardia, sinus tachycardia, vent. ectopics, VT, and VF. nausea, vomiting, abdominal pain and diarrhea. The main causes of death are refractory ventricular arrhythmias and asystole and the overall hospital mortality is 5.5%.

MANAGEMENT:

supportive, close monitoring of blood pressure and cardiac rhythm. Inotropic therapy is required if hypotension persists and atropine for bradycardia. vent. arrhythmias are often refractory to direct current cardioversion and antiarrhythmic drugs. Amiodarone and flecainide are reasonable first-line treatment. maintaining systemic blood flow, blood pressure, and tissue oxygenation by the early use of cardiopulmonary bypass.

more information are available but no place here.


Abdelmonim ELHAKIM (Jeddah, Saudi Arabia), Adeeb BUKHARI
11:00 - 18:00 #7619 - Case report: a rare cause of acute abdomen polyarteritis nodosa.
Case report: a rare cause of acute abdomen polyarteritis nodosa.

Introduction:

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis involving the small and medium arteries, that resulted in decreased the blood supply and ischemic damage. Middle-aged men are more frequently affected.  Clinical manifestations of PAN resulted from involved systemic and affected organs, for example, skin, kidneys, abdominal organs, nervous systems and heart. The level of disease severity is from mild to severe. There is no diagnostic laboratory test for PAN. The American College of Rheumatology(ACR) has established 10 criteria for the classification of PAN in a patient with a vasculitis. The sensitivity and the specificity for the diagnosis of polyarteritis is 82% and 87%, respectively. Arteriography and cross-sectional imaging, such as computed tomography (CT) and magnetic resonance (MR), can be used as alternatives to tissue biopsy for the diagnosis. The optimal therapy of PAN remains uncertain. We report a case of PAN presenting with abdominal pain.

Case report:

This 56-year-old woman with the past history of hypertension presented to our emergency department(ED) because of acute onset periumbilical and right flank pain for 1 day. The visual analog scale of pain was 9/10. Vital signs are as follows: blood pressure 159/104 mmHg, pulse rate 85/minute, respiratory rate 16/minute and body temperature 36.9 ℃. There was no fever, nausea, vomiting, diarrhea or abdominal operation history. Physical examination revealed soft abdomen without definite tender point and peritoneal sign. A hemogram and biochemical test results were as follows: white blood cell count 10.09×103/μL (3.04 to 8.54×103/μL), neutrophilic differential 64.4%, creatinine 0.77mg/dL(0.6 to 1.0mg/dL), total bilirubin 0.6mg/dL(0.2 to 1.0 IU/L), aspartate transaminase 17 IU/L (15 to 37 IU/L), and lipase 117 IU/L (73 to 393 IU/L). Because of the pain out of proportion to examination, implying the possibility of mesenteric ischemia, abdominal contrasted CT was done. It showed wall thickening with adjacent fat stranding along the superior mesenteric artery, which was indicated to vasculitis (Figure 1,2). Subsequently, she was admitted to our rheumatology ward for treatment.

Discussion:

Polyarteritis nodosa is a rare, but potentially life threatening, inflammation of the blood vessels. The emergency physician should keep this in mind. A high index of suspicion and prompt management should avoid catastrophic outcomes.


Pei-Shan WU (ROC, Taiwan), Po-Liang CHENG, Yi-Kung LEE
11:00 - 18:00 #7401 - Case report: Massive pulmonary embolism in pregnancy – Intra-arrest thrombolysis and resuscitative hysterotomy.
Case report: Massive pulmonary embolism in pregnancy – Intra-arrest thrombolysis and resuscitative hysterotomy.

Background

Massive pulmonary embolism is a leading cause of maternal death and may require intra-arrest thrombolysis as well as resuscitative hysterotomy.

 

Case Report

The case presented is that of a 35-year-old primigravida at 28 weeks gestation. The patient was brought to the Emergency Department in cardiac arrest with cardiopulmonary resuscitation (CPR) ongoing with a paramedic ambulance crew. Initial rhythm was PEA; return of spontaneous circulation (ROSC) was obtained following one cycle of the Advanced Life Support (ALS) protocol and adrenaline bolus. Spontaneous circulation was not sustained; episodic CPR with adrenaline boluses was required. Resuscitative hysterotomy was performed intra-arrest. The baby was given to the neonatal arrest team; it had no output and did not survive despite resuscitation attempts. Echocardiography was performed during maternal resuscitation using the Focused Echocardiography Evaluation in Life Support (FEEL) protocol revealing a grossly dilated right heart. The patient was thrombolysed intra-arrest with 100mg Alteplase. ROSC was obtained post thrombolysis and output was maintained thereafter. Inotropic support was initiated and surgical haemostasis was achieved in the resuscitation room. Repeat echocardiography showed good biventricular function. The patient was transferred to the Intensive Care Unit where despite improved cardiovascular status subsequent computed tomography (CT) brain revealed catastrophic irreversible hypoxic injury. Treatment was withdrawn with the support of family members. Post mortem examination confirmed massive pulmonary embolism as the cause of death.

 

Conclusion

Intra-arrest thrombolysis can significantly restore and improve cardiovascular status in cardiac arrest caused by massive pulmonary embolism. Thrombolysis is not contraindicated in maternal resuscitation where resuscitative hysterotomy may also be required.


Ngua CHEN WEN (CARDIFF, United Kingdom), John TAYLOR, Matthew CARWARDINE
11:00 - 18:00 #7760 - Cellulitis Audit.
Cellulitis Audit.

In our clinic We use to treat patients with cellulitis. It is important that every Doctor follows the same criteria in every pathology. 

The aim of this audit is to establish the current standard of treatment provided to patients with cellulitis.

*Method

This is a retrospective audit of patients with cellulitis coming to the clinic from 11th to 30th September 2015.

*Criteria

1-If patient afebrile and otherwise healthy, flucoxacillin 500mg QDS 7-14 days may be used as single drug treatment.

         -Number of patients including in audit without fever.

2-If febrile and ill send to Hospital for IV Treatment.

3-In facial cellulitis use co-amoxiclav 625mg TDS 7-14 days.

4-If penicillin allergic. Clarithromycin 500mg BD 7-14 days or Clindamycin 450mg QDS 7-14 days.

*Initial Standard Setting

-At least a minimum 80% of patients afebrile and cellulitis will have flucoxacillin treatment 500mg QDS 7-14 Days.

-At least a minimum 90% of patients febrile and ill send to Hospital for IV Treatment.

-At least a minimum 90% of patients with facial cellulitis use co-amoxiclav 625mg TDS 7-14 days.

-At least a minimum 90% of patients with penicillin allergic, Clarithromycin 500mg BD 7-14 days or Clindamycin 450mg QDS 7-14 days.

*Analysis and Findings

There were 23 patients aged 1-89 years old diagnosed with Cellulitis, and 2 patients excluded because, one of them had Pilonidal Abscess and the second one had an infected wound.

In 6 cases of 21 the temperature were not in the records.

1.- Criteria:In regards to the chosen antibiotic, patient afebrile and otherwise healthy, flucoxacillin 500mg QDS 7-14 days ,12 patients (71%) were prescribed with  Flucoxacillin, only 1(6%)was prescribe with  2 antibiotics:flucoxacillin and calvapen.

But 4 patient, that  flucoxacillin was prescribed the temperature is not  in the records.

2.-Criteria:In febrile and ill, send to Hospital for IV Treatment.

Only 2 patients were sent to A&E(28%), one of them was ill and without temperature in the records and the other one had fever.

But, I included 5 patients in which the temperature was not checked, because we do not know if they had fever or not(72%)

3.-Criteria:In facial cellulitis use co-amoxiclav 625mg TDS 7-14 days.

Only one case of facial cellulitis was reported and treated with co-amoxiclav

4.-Criteria:If penicillin allergic. Clarithromycin 500mg BD 7-14 days or Clindamycin 450mg QDS 7-14 days.

The are no patients penicillin allergic treated with Clarithromycin or Clindamycin. (0%) There is only one patient penicillin allergic treated with Erythromycin.

It´s always necessary to check temperature if there is a cellulitis because depends on this we will send patients for iv antiv¡biotics to A&E.

In the audit there are 6 patients without checked the temperature and then we don´t know how it is.

We need to see in the records that the patient is allergic to penicillinIf we have to give other antibiotic.

*Conclusions and Reflections

- In cellulitis we need to check vitals and temperature.

- If temperature is normal, no penicillin allergic : flucoxacillin 500 mg QDS 7/14 days

- If fever/ill :send to A&E for iv antibiotics


Maria Angela CANAS BARRANCO (Malaga, Spain), Enrique CARO VAZQUEZ, Maria Del Carmen RODRIGUEZ CASIMIRO
11:00 - 18:00 #8050 - Cerebral oedema in diabetic ketoacidosis : case report.
Cerebral oedema in diabetic ketoacidosis : case report.

 

Introduction:

cerebraloedema is a rare but potentially lethal complication of diabetic ketoacidosis (DKA). It is more common among children with DKA than with adults.

 

Case report:

A 23-years-old male patient presented to the emergency department (ER) for asthenia, vomiting, drowsiness and (high sugar blood level/hyperglycemia). He had no medical history. Diabetic ketoacidosis state has been confirmed. Correction with continuous itra-venous insulin and fluids rescucitation has been started. 2 hours after, he altered his state of consciousness. His vital signs were as follow GCS of 3, blood pressure of 70/40, pulse rate of 45 beats/min, respiratory rate of 10 breaths/min. his laboratory tests were pH at 7.09, lipase level at 60 times the normal and albumin level at 19,3. Abdominal computed tomography (CT) showed acute pancratitis grade E of Balthazard scoring. Cerebral CT showed cerebral oedema with bilateral Uncal herniation. The patient has been intubated. He received mannitol and catecholamine. He deceased 48 hours later.

Discussion: 

Brain swelling can be revealed when a major sign occurs but it has to be suspected when minor signs such as drowsiness and vomiting are presented. Cerebral oedema for this patient can be enhanced by hypovolemia caused by ketoacidosis, pancreatitis and hypo albuminea.

Conclusion:

Cerebral oedema in DKA can be suspected and confirmed rapidly by cerebral CT. however, it remains difficult to mamage and its mortality remains high.


Houcem OUNI (tunis, Tunisia), Mohamed Ali CHERIF, Ons ANDOLSI, Khaled SAIDI, Youssef Zied EL HECHMI, Mohamed MEZGHENI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #8072 - Cerebral thrombophlebitis following head injury: a case report.
Cerebral thrombophlebitis following head injury: a case report.

Introduction:

Cerebral venous thrombosis is a rare complication of head trauma which is sometimes difficult to diagnose. We report a medical observation who presented post-traumatic cerebral venous thrombosis revealed by signs of intracranial hypertension and psychiatric disorders.

Case report

A 24-year-old man presented to the emergency department (ED) one hour after a head traumatic injury. He had head and chest trauma and lost consciousness for undetermined period after a bicycle accident. At physical examination, he was conscious with no neurological abnormalities. He could not move his left arm because of shoulder dislocation. Computed tomography, performed 6 hours later, showed right fronto-temporo-parietal acute subdural hematoma without midline shift, right temporal petechial contusion, displaced fracture of the occipital condyle and non-displaced fracture of the scapula. There was no need for neurosurgery and the shoulder dislocation was reduced.

The patient was admitted in the emergency observational unit and was discharged after 24 hours. Two days later, he complained severe headache and multiple episodes of vomiting, dizziness and visual illusions. Computed tomography scan of the brain with contrast injection revealed left lateral sinus thrombosis extending to homolateral internal jugular venous. The patient was given anticoagulation and admitted in the neurology intensive care unit.

Comments:

Repeating CT scan of the head is recommended in the management of traumatic brain injury if there is a worsening of neurological disturbances and a contrast injection may be required to rule out cerebral venous thrombosis which requires specific treatment.


Majed KAMEL, Mghirbi ABDELWAHEB (Tebourba, Tunisia), Zaouche KHEDIJA, Kilani MOHAMED, Khelil MOHAMED HASSEN, Maghraoui HAMIDA, Modhaffer MOHAMED, Hamouda CHOKRI, Borsali Falfoul NEBIHA
11:00 - 18:00 #7119 - Cervical cancer prevention in a family planning consultation of urban health center.
Cervical cancer prevention in a family planning consultation of urban health center.

OBJECTIVES

Evaluate the data record in the clinical records of patients attending family planning consultation according to the integrated cervical cancer care protocol. 

DESIGN

Cross-sectional retrospective

POPULATION AND SAMPLE

A total of 97 patients attending family planning consultation during 2010 in a health center, single randomly chosen were assessed. This sample size allowed us to study the main objective of the research with an accuracy of 0.09 with a confidence level of 95%

 INTERVENTIONS

The variables age, record of PAI of cervical cancer registry sampling, communication record results, anamnesis, physical examination and compliance with the timing of cytology as risk factors were evaluated.

 RESULTS

Of the 97 patients evaluated, 16 did not attend your appointment cytology. Of the remaining 81 the average age was 38 years. Only 5% were derived gynecology by pathological cytology. The largest deficit record occurred in variables anamnesis (not registered in 37% of cases, if 63%), physical examination (not collected in 47% of cases, if 53%). The sequential implementation of smears according to PAI was correct in 75.3% of cases.

 CONCLUSIONS

Despite the decline in the incidence of cervical cancer, a deficit in medical uptake (16%), especially in people over 65 with FR, with little awareness on the part of patients still persists. The collection of data on clinical history is scarce, mainly in the anamnesis (FR) and physical examination.

If we improve the recruitment and data collection will improve the quality of the care process.


Carolina GARRIDO CANNING, María Victoria ALARCÓN MORALES (BCN, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7379 - Changes in urine biomarkers of acute kidney injury among amateur long-distance runners: a prospective cohort study.
Changes in urine biomarkers of acute kidney injury among amateur long-distance runners: a prospective cohort study.

Objective
Running is associated with a healthy lifestyle and improves quality of life. The “Weir Venloop” is a yearly running event and several collapsed runners were admitted to our Emergency Department. Studies with (ultra)marathon participants have shown that long-distance running can be associated with exertional rhabdomyolysis and acute kidney injury (AKI). The level of neutrophil gelatinase-associated lipocalin (NGAL) in urine has shown potential for use as an early biomarker of AKI. The aim of this study was to investigate AKI among amateur long-distance runners by analyzing urinary biomarkers and if these parameters can be related to performance.

Methods
In this observational prospective study we collected urine samples of participants of the 10km and half marathon competing the “Weir Venloop 2015”, immediately before and after the finish. An urine dipstick analysis of hemoglobin, glucose and ketones concentrations was directly performed. Furthermore, the levels of albumin, creatinine, uric acid, sodium and NGAL were measured on the Architect® c8000 and i2000 analyzers. Race times were documented.

Results
A total of 35 urine samples (18 male, 17 female) from the 10-km participants and 45 samples (21 male, 24 female) from the half marathon participants were collected. Significant increase in creatinine, albumin, hematuria (dipstick) were found after the race. Urine levels of albumin, hematuria, creatinine and uric acid showed significant correlation with the race times, i.e. exertion. Urinary NGAL significantly increased in male participants, most pronounced after running a half marathon, and uNGAL showed significant correlation with race times but only in the male participants.

Conclusions
Long-distance running was found to be associated with microalbuminuria and hematuria among both male and female participants. A significant increase in uNGAL and significant decrease of sodium was only found in male runners. With this knowledge, we can take better care of the collapsed runner in our ED.


Monique VAN DER LUGT (Venlo, The Netherlands), Rick VAN DER DOELEN, Nathalie PETERS, Loes JANSSEN, Jos LE NOBLE
11:00 - 18:00 #7924 - Changes of emergency department workers’ perceptions of effectiveness and reported compliance of infection control measures after middle east respiratory syndrome outbreaks.
Changes of emergency department workers’ perceptions of effectiveness and reported compliance of infection control measures after middle east respiratory syndrome outbreaks.

Emergency department workers’ perceptions of effectiveness and reported compliance of infection control measures after middle east respiratory syndrome outbreaks 

Purpose : Middle east respiratory syndrome (MERS) outbreaks occurred in Korea on 2015 with 186 patients in relatively short time. The epidemiological pattern in South Korea was hospital-associated. Infection control plans for all hospitals was implemented to stop the spread of MERS infection and to protect healthcare workers from infections. Enhanced guidelines for infection control measures might affect healthcare workers. The purpose of this study was to determine changes of tertiary emergency department healthcare workers’ perception and compliance to hand hygiene and personal protective equipment (PPE) before and after MERS outbreaks.

Methods : A written questionnaire was administered to members in the emergency department at the Samsung Medical Center. Participants were asked to rate the combined overall effectiveness of hand hygiene and PPE and to report compliance on a 5 point scale. This survey conducted during 11-26 September 2015.

Results : The number of participants was 123. Perception of effectiveness before and after MERS outbreaks was that hand hygiene (4.05 vs 4.44, p<0.05), N-95 mask (4.02 vs 4.44, p<0.05), gown (3.03 vs 3.53, p<0.05), eye protection (2.98 vs 3.70, p<0.05), glove (3.30 vs 3.87, p<0.05) and surgical mask (3.65 vs 3.68, P=0.714). Respondents showed statistically higher compliance with hand washing and PPE after MERS outbreaks, specifically, hand hygiene (3.79 vs 4.50), surgical mask (3.37 vs 4.43), N-95 mask (2.23 vs 4.06), gown (2.12 vs 4.45), eye protection (1.72 vs 4.28), glove (2.61 vs 4.09). Compliance with hand hygiene and PPE depending on patient symptoms - only fever or fever with upper respiratory symptom compared to no fever and no respiratory symptom – reported statistically increased except surgical mask. The most highly rated reason for doing hand hygiene and using PPE before and after MERS outbreaks was to protect oneself from respiratory infectious disease, which was 50.41% and 82.11%, respectively. Protection guideline of hospital was secondly rated reason, which decreased 39.80% to 11.80% after MERS outbreaks. But regarding reference source for choosing specific infection control measures, hospital guideline was 89.43% and individual decision was 9.76%.

Conclusion : Infection control measures except surgical mask was perceived to be more effective than before MERS outbreaks. Emergency department’s workers reported increased compliance on hand hygiene and PPE except surgical mask. Even though reported compliance for eye protection was statistically higher after MERS outbreaks, its compliance rate was relatively low compared to other PPE measures. 


Gabyong JEONG (Seoul, Korea), Tae Rim LEE, Min Sub SIM, Sung Yeon HWANG, Won Chul CHA, Tae Gun SHIN, Ik Joon JO, Keun Jeong SONG, Joong Eui RHEE, Yeon Kwon JEONG
11:00 - 18:00 #7260 - Chaperones in the emergency department – an audit of clinical practice.
Chaperones in the emergency department – an audit of clinical practice.

Title

Chaperones in the emergency department – an audit of clinical practice.

Introduction

The Royal College of Emergency Medicine, UK has established best practice guidelines for chaperones in the Emergency department, summarised as follows:

  1. The presence of a chaperone should be offered to all Emergency Department patients undergoing a "Sensitive Area Examination", regardless of patient or practitioner genders.
  2. The presence or absence of a chaperone should be appropriately documented. 
  3. If an Emergency Department patient declines a chaperone, the fact that one was offered and declined should be documented in the ED record.

We present an audit of clinical practice in our ED regarding the use of Chaperones.

Methods

We conducted the first cycle of the audit over a 3 month period with 12359 attendances out of which 476 patients needed “Sensitive Area Examination”.

After analysing the results of the first cycle, we are presenting the findings to the medical and nursing staff in the ED, and are reiterating the importance of the presence of Chaperones as well as the importance of clear documentation of the presence or absence of a Chaperone and/or if one was offered but declined by the patient. We are using the delivered lectures and electronic medium for educating the staff in ED and will proceed to complete the audit cycle.

Results

The results of the first cycle of the audit showed a very poor compliance of documenting the presence or absence of a chaperone and/or if the patient had declined one for “Sensitive Area Examination”. We are in the process of educating medical and nursing staff in the ED currently to improve practice and will complete the audit cycle shortly.

Conclusion

The Emergency Department is an environment in which the entire range of physical examinations may be clinically necessary, and so a hospital should recognise the need for a clear chaperone policy tailored to the Emergency Department setting. With the help of this audit, we have tried to improve our current practice relating to the management of patients that require “Sensitive Area Examination” in our dept.

References:

The Royal College of Emergency Medicine best practice guideline – Chaperones in Emergency Deparments. C--inetpub-wwwroot-medical-cem-Upload-documentz-CEM8291-Chaperones in EDs


Farah MUSTAFA (Drogheda, Ireland), Andrew CASEY, Peadar GILLIGAN
11:00 - 18:00 #7990 - Characteristics of and the Factors Affecting the Morbidity and Mortality of Malignancy Patients Presenting to the Emergency Department: A Prospective Epidemiological Study.
Characteristics of and the Factors Affecting the Morbidity and Mortality of Malignancy Patients Presenting to the Emergency Department: A Prospective Epidemiological Study.

Objective: Death due to malignancy is the second cause of mortality after cardiovascular system diseases. Because technological developments allow early diagnosis and new treatment modalities extend follow-up periods, emergency department presentation of malignancy patients with disease- and treatment-related complications has been rising. The objective of this study is to identify the clinical characteristics of the patients with malignancy, who constitute the majority of the emergency department admissions, and to increase the quality of care and raise awareness of rapid targeted-therapy.

Materials and Methods: Cancer patients 18 years of age and older who presented to the Istanbul University Cerrahpaşa Medical School Emergency Department between October 6, 2014 and May 6, 2015 were evaluated prospectively. Patients’ demographics, vital signs, characteristics associated with malignancy, examinations performed and their results, treatments and length of stay were evaluated.

Results: A total of 1283 patients and 1522 presentations were recorded. In nine patients, the initial diagnosis of cancer was made in the emergency department. 51.99% of the patients were male (mean age: 57.52±13.12), and 48.01% were female (mean age: 69.05±15.15). The overall mean age was 63.05±14.08. The most prevalent symptom was dyspnea (17.94%), and the most common type of cancer was lung cancer (16.23%). In male patients, the most prevalent complaint was fever, and the most common type of cancer was lung cancer (34.63%) (p<0.001). In female patients, the most prevalent complaint was dyspnea, and the most common type of cancer was breast cancer (35.25%) (p<0.001). Distant metastasis was present in 64% of the patients. The influence of mean arterial blood pressure, pulse, hemoglobin levels, uremia and hypoalbuminemia on mortality and ICU admission was significant (p<0.001). Overall, 41.46% of the patients were hospitalized, and 1.05% of the patients died. The average length of stay was 4.64±6.73 days. The average length of stay in the emergency department until the patient was admitted to the relevant department was 3.04±1.91 days.

Conclusion: Patients with malignancy constitute a significant portion of the emergency department admissions. Promoting the emergency physicians’ insight into and experience on oncological emergencies would contribute to decreasing the mortality and morbidity of these patients. 


Onur TOKOCIN, Afsin IPEKCI, Deniz Necdet TIHAN, Fatih CAKMAK, Didem CEYLAN, Mehmet Necmettin SUTASIR, Canturk EMIR (istanbul, Turkey), Ozgur DANDIN, Merve TOKOCIN, Ibrahim IKIZCELI
11:00 - 18:00 #7504 - CHEST COMPRESSION QUALITY MONITORING BY PEAK SYSTOLIC VELOCITY OF FEMORAL ARTERY.
CHEST COMPRESSION QUALITY MONITORING BY PEAK SYSTOLIC VELOCITY OF FEMORAL ARTERY.

The chest compression is a key of High-quality cardiopulmonary resuscitation (CPR), for this reason the current Guidelines for Cardiopulmonary Resuscitation recommends ensuring chest compressions of adequate rate, adequate depth, allowing full chest recoil between compression and minimizing interruptions. Apparently feedback methods could improve the quality of chest compressions, however, subjective analysis showed poor accuracy to qualify adequate rate and depth of chest compressions, and a more complex methodology for evaluation is necessary. Physiological parameters such as quantitative waveform capnography or arterial pressure monitoring could assess the response to treatment and guiding interventions to improve the quality of CPR. In our work we measured the peak systolic velocity of femoral artery (FPSV) by ultrasound during chest compressions, as an indirect indicator of cardiac output and a quantitative measure of the quality of chest compressions.

 

Objective

Determine if is possible to measure the FPSV produced by chest compressions during CPR

 

Methodology

In 6 cases of cardiac arrest the conditions to perform the measurement were obtained. Patients were younger than 75 years and had nontraumatic cardiac arrests, patients with signs of abdominal vascular diseases were discarded. The FPSV measurements were performed in the common femoral artery,  at the beginning and 30 seconds before the end of the compression cycle. Additionally a description of chest compressions quality was performed during each measurement.

 

Results

45 measurements were obtained, 9 were discarded due to poor quality of ultrasound view. The highest FPSV was 145 m/s, adequate chest compression techniques were associated with an average measurement of 110 m/s (range 90 to 120 m/s), most FPSV decreased to 90 m/s  (range 80 to 100 m / sec) at the end of each cycle. Poor quality techniques were associated with FPSV between 60 to 80 m/s. One resuscitator with a history of elbow trauma, performed a poor quality compressions according to quantitative evaluation, however the FPSV during chest compressions resulted greater than 90 m / s

 

Conclusions

Measurement of FPSV is possible during CPR and could provide quantitative information about the quality of chest compressions, even provide a real-time feedback to improve the technique. Further studies are needed to confirm these findings


Luis Arcadio CORTES-PUENTES (BOGOTA, Colombia), Gustavo Andres CORTES-PUENTES, Gerardo LINARES-MENDOZA, Carlos Hernan CAMARGO MILA
11:00 - 18:00 #5128 - Chest pain and risk stratification in the emergency department.
Chest pain and risk stratification in the emergency department.

Introduction:

Chest pain is a commonly presenting symptom in the emergency department with multiple aetiology. The need to distinguish between life threatening conditions and the less severe is critical. In many cases history and clinical examination can provide only limited information and most patients will undergo further investigations into the cause of their symptoms. We looked at a sample of 92 patients attending the emergency department and have analysed outcome associated with individual risk-profile.

Results:

92 patients presented to the emergency department (43 male, 49 female) between June-October 2014. In total, 33 patients described symptoms of cardiac chest pain (as described by NICE 2010 guidelines) with 59 patients presenting with non-cardiac chest pain. Of all patients, 34 presented within four hours of onset - of which 18 were from the cardiac chest pain group. The majority - 25 of cardiac chest pain patients had cardiovascular risk factors and were admitted to hospital. In addition most of those deemed low risk were also admitted for further investigation. None of the patients presenting with non-cardiac chest pain had a positive troponin and the majority were discharged from the emergency department. Only a small number of patients - 3, were deemed suitable for referral to the ambulatory care day unit (ACU) to await a second assessment, and all were eventually discharged.

Discussion:

The majority of patients attending the emergency department with symptoms of cardiac chest pain presented within four hours of onset and were associated with cardiovascular risk factors. Of those admitted most had serious underlying pathology ruled out by repeat troponin and were later discharged. Most patients with non-cardiac chest pain presented later and had cardiac aetiology ruled out by negative troponin. The use of the ambulatory care unit in management of chest pain was limited as patients were often admitted to a medical bed for a repeat blood test and suitable patients for the ACU would often present out of hours.

Conclusion:

All patients admitted with chest pain should have cardiovascular risk factors clearly documented. A clear pathway for low-risk patients would be of benefit and could avoid unnecessary admission. With many patients describing cardiac-like chest pain presenting early there may also be benefit of the use of newer high-sensitivity troponin assays for early diagnosis or exclusion.


Craven HENRY (London, United Kingdom)
11:00 - 18:00 #7423 - Chest pain in young man after car accident.
Chest pain in young man after car accident.


Mediastinal hematoma with compressive effect on cardiac cavities is a rare and serious complication of blunt chest trauma. For a man of 21 years, with no history of interest who suffers an accident by frontal crash at 50 km / h, occupying the passenger seat with the seat belt it is presented. He went to the emergency room for their own reporting a central chest pain of moderate intensity.
At that time, constants and physical examination were normal, with the only data of pressure pain on the lower third of the sternum. A study of plain radiography were performed, appreciating posterior dislocation of the xiphoid process, an electrocardiogram showed sinus rhythm with an incomplete right bundle branch block, and an analytical, resulting normal blood count and levels of troponin not high. Three hours after his arrival to the emergency room, the patient presented a progressive malaise, with pallor, and hypotension. A chest scan was performed finding a voluminous anterior mediastinal hematoma with compression effect on right heart chambers due to active bleeding from the left internal mammary vein. The patient underwent emergency VATS with bleeding vessel closure and placement of pleural drainage, presenting a favorable evolution. Mediastinal hematomas are caused by injury of mediastinal vessels, sometimes secondary sternal or vertebral fracture. In severe cases can lead to cardiac tamponade extrapericardial origin, a potentially fatal complication. In the early stages, symptoms and physical examination may not be relevant, in the absence of symptoms of both acute bleeding and cardiac tamponade classics (bradycardia, jugular venous distension, paradoxical pulse).
The case highlights the importance of maintaining a high degree of suspicion of mediastinal hematoma, despite an initial period of hemodynamic stability, in a patient with blunt chest trauma. Regarding our case, it should also remember the relationship between the use of seat belts and sternal fracture. Early diagnosis facilitates rapid handling of this potentially serious situation.

 

 




Valentina ACOSTA RAMÓN, Emilio PARIENTE RODRIGO, Maria Pilar CARLOS GONZALEZ (santander, Spain), Nuria OVALLE GONZALEZ, Walter Roberto FERRERO OHSE, Noelia SANTOS MENDEZ, Maite Estibaliz LÓPEZ DE GOICOCHEA-SAIZ., Joel ANDINO LOPEZ
11:00 - 18:00 #7146 - Chest pain, syncope, hypotension and left hemiparesis, all in one diagnosis: aortic dissection.
Chest pain, syncope, hypotension and left hemiparesis, all in one diagnosis: aortic dissection.

Acute aortic dissection (AD) is a surgical emergency with a high mortality rate, that requires quick diagnosis and emergency surgical intervention. This disease was first described by Morgagni in 1761. Aortic rupture is catastrophic and has an 80% mortality. We present a 58-year-old woman with history of chronic hypertension, brought to ED by ambulance with a one-day history of chest pain and syncope. Shortly after presenting to ED, the patient developed a transient episode of left hemiparesis and aphasia. On physical examination her blood pressure in the right arm was 95/55 mmHg and in left arm was 70/40, pulse 110/per minute. She had tenderness on palpation over the upper abdomen, especially in the epigastrium. Electrocardiogram showed minor transient right bundle branch block, but no acute ischemic changes. Abdominal ultrasound did not detect free fluid in the abdominal cavity, no cardiac tamponade, but echocardiography showed enlargement of the ascending aorta. CT angiography of thorax was performed which showed a Stanford type A aortic dissection, with doubled lumen extending from ascending aorta to aortic bifurcation. Emergency physicians must be aware of atypical presentations of acute aortic dissection. Association of chest pain, syncope, hypotension and neurological signs may be suggestive of aortic dissection.


Vasile GAVRILA, Alexandru Nicolae CARSTEA (Timisoara, Romania), Rodica Daniela GAVRILA, Gabriela FILIP
11:00 - 18:00 #7534 - Child abuse and neglect in the emergency department of a northern Taiwan community hospital.
Child abuse and neglect in the emergency department of a northern Taiwan community hospital.

Background:

Emergency department(ED) is one of the most important port for child abuse and neglect (CAN) victims to seek medical attention. As CAN would recur, an ED mandatory CAN report system was implemented in Taiwan in a hope that timely intervention can prevent avoidable mishaps. Though previous studies revealed that nursing training in CAN reporting may not be adequate, the efficacy of the report system was not widely reported. The purpose of the study was to explore the demographic characters of CAN cases reported from the ED of a northern Taiwan community hospital. The compliance of ED nurses-oriented report was examined.

Methods:

Child abuse and neglect (CAN) cases who presented to the ED of a northern Taiwan community hospital in 2015 were retrospectively examined. The report was either by a social worker or by an ER nurse. During office hour, while the patients with suspected CAN being evaluated in the ED, the social worker will be notified to come to the ED and evaluate the patients. The CAN report will be completed with 24 hours. When the patients presented during the hours when social workers are usually not on service, the ED nurses will complete the report as the system required.

Results:

The CAN reported cases numbers in 2015 was 93. Compared to the annual patients visit number of 60,458 in the same year, the CAN repot cases constitute only a small fraction of total visits. Among the victims, 57 cases (61%) were male, while 36 (39%) of them were female. The age distribution spanned all the pediatric group, yet almost half of the patients (49%) were younger than 6 years old. Thirty-five cases (38%) were reported by ED nurses, while 58 cases (62%) were reported by social workers. The report form compliance, either by ED nurses or social workers, was satisfactory.

Discussions:

Child abuse and neglect (CAN) is a serious threat to the children and the whole society. It carries not only immediate mortality and morbidity to the victims, the long term negative impact may be even difficult to estimate. The study revealed   satisfactory CAN report compliance by both ER nurses and social workers. However, it is far from concluding that the current report system was satisfactory. It can be easily identified that if the symptoms and signs of a CAN case is missed in the front line, the social worker and even the report mechanism will not be activated.  Although the magnitude of missed CAN cases is difficult to assess, these vulnerable patients deserve more of our devotion.


Po-Sheng CHIH (Taipei, Taiwan)
11:00 - 18:00 #7509 - Children and adolescents presenting to pediatric emergency department with chest pain.
Children and adolescents presenting to pediatric emergency department with chest pain.

INTRODUCTION: Chest pain is a common presenting symptom in pediatric practice but, unlike in adults, the cause is rarely cardiac. The aim of this study was to assess the etiology and various factors related to childrens’ and adolescents’ visits to pediatric emergency department (PED) due to a chest pain.

METHODS: Retrospective hospital based study was conducted during one year - all visits to the PED because of a chest pain, recorded in a hospital database, were analyzed. For data analysis descriptive statistics and Fisher exact two tailed test were used.

RESULTS: Of 12.068 admitted children, the chest pain was presented in 138 patients (1.14%): 79 boys, 59 girls; age range 3-18 yrs, mean 12.4 yrs. There was no significant difference in age between the boys and girls (12.47±3.82 vs. 12.37±3.55 yrs; t=0.149, p=0.881). Most of them arrived as an emergency (81%), while 19% were sent by their primary pediatrician.

Most of the patients arrived between 14-22 hrs. The boys arrived more frequently at night and during the morning but the differences were not statistically significant (Fisher two-tailed test p=0.288). During the school year 2.85 child per week reported chest pain, and only 1.81 per week during vacations. Attendance was relatively more frequent during the weekend. Pain occurred mostly at rest (82%), less frequently during and immediately after physical activity (18%).

Out of all diagnostic procedures, the only significant gender difference was in ECG, which  was performed more often in  boys (p<0.05).

After the pediatrician’s exam, 44% were sent to another specialist: cardiologist (21%); pulmonologist (commonly because of asthma attack) and gastroenterologist (both 5%); orthopedic surgeon (4%) and seldom to others. Most of the children were released home (69%), while 20% were kept in day hospital. Only 12% (17/138 patients) were hospitalized, mostly at the Cardiology Unit (15/17); only five diagnoses (5/138; 3.6%) could be potentially life-threatening: pneumothorax, cardiac arrhythmia, myopericarditis, chest trauma and electrical shock.

The etiology of the chest pain according to the diagnosis revealed that 34% were of musculo-skeletal etiology; 18% were discharged without specific etiology; 12% of them had idiopathic pain and only 6% of them had some cardiovascular disturbances: pericarditis, myocarditis, irregular heart rhythm with premature atrial beats, and mitral valve pathology.

CONCLUSIONS: The most of the children (over 95%), who present to the emergency department with the chest pain symptom are not life endangered by a cardiac or other underlying etiology, and the chest pain is of benign etiology. Still, the best practice in the emergency department would be a systematic approach including the detailed history and the meticulous clinical examination which could rule out the more serious etiology and identify the conditions that require the specific goal-oriented diagnostic procedures.


Zdenka PLESA PREMILOVAC (Zagreb, Croatia), Maja BATINICA, Filip RUBIC
11:00 - 18:00 #7984 - Chondrosternal pain in a young patient.
Chondrosternal pain in a young patient.

48 years old male patient with a history of hypertension and mellitus diabetes in dietary treatment. He doen not consume alcohol, he is a 10 years ex-smoker.He goes to the Emergency Service due to pain on the left chondrocostal joint, at the 2nd left costal arch level, of mechanical character and two days evolution. He reports that he has lost weight in recent months on a voluntary basis, as a treatment for his hypertension and diabetes. He practises aerobic exercise regularly.A physical examination is performed, presenting the patitent normotension, he is afebrile .The resulting cardiac and pulmonary auscultation has not notable changes. The abdomen is soft, depressible, without masses or signs of peritoneal irritation. The lower limbs don't show nor signs of DVT.



In the analysis performed, it shows a normal blood count differential count (leukocytes 9000, 74 % neutrophils, lymphocytes 10.3%), 14.3 hemoglobin and 43% hematocrit with 289000 platelets. Biochemistry is normal with blood glucose levels of 116, creatinine 0.76 , with glomerular filtration rate of 98 ml/min, liver and thyroid ions and enzymes were normal. CEA tumor markers, alpha fetoprotein, beta 2 microglobulin, Ca 19.9 and neuron-specific enolase were normal.Chest radiography, was reported with a mediastinal mass.Bronchoscopy identified a lymph node in the 10R node station with performing FNA .



Chest CT described the images as anterior mediastinal mass, with aggressiveness criteria, which could correspond to an invasive thymoma and less likely by their characteristics, to a lymphoma or germ cell tumor. Superior vena cava thrombosis. Multinodular goitre at the expense of the right lobe.Chest CT biopsy was performed, resulting in pathology of mediastinal large cells B lymphoma.The abdominal CT scan was normal.The patient was referred to the Hematology Service which graded the tumor as II-B-BULKY and began chemotherapy treatment ( REPOCH ) and low molecular weight heparin at therapeutic doses.The patient is currently undergoing treatment.




Ana Belén MARÍN FLORÍA, Sonia BALLESTÍN SOROLLA, Elisa RUIZ OLIVARES, Pilar SARASA CLAVER, Carola MEDINA SAINZ, Silvia GANGUTIA HERNÁNDEZ, Begoña GARGALLO PLANAS (ZARAGOZA, Spain)
11:00 - 18:00 #7386 - Circadian variation of pre-hospital occurence of cardiogenic pulmonary oedema.
Circadian variation of pre-hospital occurence of cardiogenic pulmonary oedema.

Introduction: Circadian variation of in-hospital acute cardiogenic pulmonary oedema (CPE) with the highest occurrence in the early morning has been reported repeatedly. However, no study evaluating circadian variation of CPE in the field has been published. Therefore, we decided to evaluate the circadian variation of CPE in the Central Bohemian Region of the Czech Republic in the patients treated by regional emergency medical service (EMS) and analyse its association with baseline blood pressure in the field.

Methods: We extracted all dispatches to CPE cases from EMS database for the period from 1.11.2008 to 30.6.2014 and analysed for circadian variation. We identified the patients presenting with CPE coupled with arterial hypertension (systolic blood pressure >140mmHg) and hypotension (systolic blood pressure <90mmHg) and compared the subgroups (both subgroups include 2744 subjects).

Results: In 4747 episodes of CPE, maximal occurrence was detected in the ninth hour in the morning, representing 7.7% of all CPE episodes (p<0.05). While CPE with hypertension (2463 subjects) reached maximal occurrence also in the ninth hour (7.4% of all cases, p<0.05), CPE with hypotension (281 patients) was most frequent in the fourteenth hour (8.6% of all cases, p<0.05).

Conclusion: The highest occurrence of CPE was observed in the ninth hour in the morning in our study. Moreover, differences in circadian variation between CPE with hypertension and hypotension were identified. Knowledge of these patterns may have an impact on the logistic of prehospital emergency care and on preventive measures in the patients who have previously undergone CPE.


Jitka CALLEROVA (Kladno, Czech Republic), Roman SKULEC, Jiri KNOR, Patrik MERHAUT
11:00 - 18:00 #7512 - City or suburb, 15-call to angioplasty, management delays of ST elevation myocardial infraction (STEMI).
City or suburb, 15-call to angioplasty, management delays of ST elevation myocardial infraction (STEMI).

Introduction : In the strategy of ST-segment elevation myocardial infarction (STEMI) management, response time of a mobile care intensive unit (MCIU) may be influenced by urban population density, and accessibility to the catheterization laboratory (cath-lab).

Primary outcome: Evaluate delays in STEMI management, for each stage, from onset chest-pain to the catheterization.

Methods : Data derived from a prospective register including non-complicated STEMI having primary percutaneous coronary intervention (PCI), managed by 6 medical care intensive units (MCIU) of a French city: 3 in town (T) and 3 in suburb (S). The observed variables were the place of management (T or S), the time delays of the various stages: time delay from chest-pain onset to the first medical contact (FMC) by the patient to the pre-hospital despatching emergency medical service – time delay FMC to MCIU arrival – cath-lab door (cath-lab) – needle – catheterization (KT). We compared delays between MCIU T and S using the Wilcowon test (p value<0,05).

Results : Over three years (2012-2014), 547 STEMI have been included, T= 228 (42%), S= 319 (58%). Chart reports time delays of various stages. The median time delay from chest-pain onset to the first medical contact was significantly (p = 0.016) faster in town with less dispersion: T = 45 [20;115] min, S = 65 [23;152] min. By stage, after the FMC, there was no significant statistical difference.

Discussion : The town patients are taken care of a few minutes faster than in the suburbs. The more dispersed distribution of cath-lab in the suburbs, but more accessible than in the city does not seem to influence the time delay of MCIU and does not affect the STEMI management.

Conclusion : City or suburb, management delay of the emergency chain is not affected. However patients in the suburbs should call the emergency medical dispatch center quickly, that can be a prevention campaign.


Alexandre ALLONNEAU, Alain COURTIOL (Paris), Aurélie LOYEAU, Jonathan GONZVA, Isabelle KLEIN, Olivier YAVARI, Amandine ABRIAT, Jennifer CULOMA, Catherine RIVET, Yann-Laurent VIOLIN, Olga MAURIN, Hugues LEFORT
11:00 - 18:00 #7463 - Clinical activity of the resuscitation room in an emergency department.
Clinical activity of the resuscitation room in an emergency department.

Introduction:

The assessment of the functioning of the emergency room in an emergency department   is essential to identify the deficiencies and help providing high quality patient care.

Objective:

Assess the functioning of the emergency room in an emergency department.

Methods:

Observational prospective study conducted in an emergency department including all patients who were admitted in the emergency room from July 1 to august 31th 2015.  Epidemiological and clinical features as well as patient’s outcomes were recorded.

Statistical analysis was performed with SPSS software.

Results:

We enrolled 150 patients, sex ration was 1,5 , age mean was 60 years   , 81,5 % of the patients had a medical history. Chief complaint was chest pain in 23,2 % , dyspnea  in 21,2% , altered state of conscience in 19,2 %, bleeding in5,3% and trauma in 4% of the patients .

We performed blood tests for 98,6% of the  patients and radiological investigations was  required in 30% of the cases.

 A specialist was requested for 27% of the  patients.

Cardiovascular diseases were   diagnosed in 56,6% of the cases,  14% of the patients  had pulmonary disease, 13% had metabolic disease, 7% had nervous disease and  5% had surgical disease.  

43,2% of the patients were discharged, 23% needed  a short term observation in the emergency  department,  12% were hospitalized in the intensive care unit and 17,6 % were  hospitalized in other department.

Conclusion:

The emergency room is crucial for the management of critical patients, an appropriate technical support and the collaboration with other hospital department are necessary for its good functioning.  


Mohamed Ali CHERIF, Farah RIAHI (Belfort), Mohamed MEZGHENI, Asma BEN ALI, Walid MHAJBA, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7276 - Clinical and analytical evaluation of the Philips Minicare cTnI assay.
Clinical and analytical evaluation of the Philips Minicare cTnI assay.

Introduction

Cardiac Troponin-I (cTnI) testing is a powerful tool to aid in the diagnosis of acute myocardial infarction (AMI). When the assay can be performed next to the patient, efficient workflows in the Emergency Department (ED) can be realized enabling rapid clinical decision making.

We present the results of first analytical and clinical studies of the new Minicare cTnI assay on the Philips Minicare I-20, which has been designed as a point-of-care immunoassay system for near-patient testing in the acute care setting.*

Methods

The analytical performance of the Minicare cTnI assay was evaluated based on recommendations of the Clinical Laboratory Standards Institute (CLSI). Li-heparin whole blood and Li-heparin plasma samples were used to perform analytical sensitivity, precision, and matrix comparison studies. The 99th percentile upper reference limit (URL) study was performed using Li-heparin plasma, Li heparin venous whole blood and capillary blood samples from in total 750 healthy male (n=373) and female adults (n= 377) , ranging from 18 to 86 years.

To evaluate the clinical performance of Minicare cTnI for the diagnosis of AMI a European multi-center, prospective, non-randomized study was performed in 7 hospitals from 4 European countries, on 465 patients suspected of NSTE-ACS at the ED or CCU. Both Li-heparin whole blood and Li-heparin plasma samples, were drawn at three time points: at presentation at the ED, 2 – 4 hours and 6-24 hours after first blood draw. Diagnosis of AMI was done by external adjudication board of cardiologists.

Results

Limit of detection was determined in Li-heparin plasma at 18 ng/l. The 20% limit of quantification was calculated at 38 ng/l with no significant difference between sample types. Total imprecision was 7.7% - 12% between 109.6 ng/l – 5087 ng/l. The sample type comparison study between capillary whole blood, venous Li-heparin whole blood and Li-heparin plasma samples (n=104) demonstrated a correlation coefficient (r) of 0.99 and a slope between 1.03 – 1.08.

The overall 99th percentile URL was calculated to be 43 ng/l with no significant difference between genders, or sample types.

The incidence of AMI in the studied population was 16%. The clinical sensitivity for the diagnosis of AMI of the Minicare cTnI was 92% and 91% at the 2-4 hour and 6-24 hour time points respectively, with and NPV of 98% and 96%, and AUCs of 95.3% and 96.1%; there were no significant differences in clinical performance (AUC) between sample types (Li-heparin plasma and Li-heparin whole blood).  

Conclusion

The Minicare cTnI assay is a sensitive, easy-to-use and precise test that can be used in the ED near the patient. With an AUC of 95%, a sensitivity at 92% and a NPV of 98% for a cutoff at the 99th perc. URL value, Minicare cTnI can be used as an aid in the diagnosis of AMI in a diagnostic protocol including a cTn test at presentation of the patient at the ED and 2-4 hour later (0/3h diagnostic protocol) as recommended in the 2015 ESC guidelines for the management of NSTE-ACS patients.  

 

* Product available in selected countries only


Diederick KEIZER (Eindhoven, The Netherlands), Lian VAN LIPPEN, Femke DE THEIJE, Danielle KEMPER, Dave DEKKERS, Jeroen NIEUWENHUIS, Veronique SEMJONOW
11:00 - 18:00 #7549 - Clinical and demographic characteristics in NSTEMI for younger and elderly patients.
Clinical and demographic characteristics in NSTEMI for younger and elderly patients.

 Acute coronary syndrome significantly contributes to mortality and morbidity in developed and developing countries. ECG can readily diagnose ST-elevation myocardial infarction (STEMI) to allow myocardium-saving interventions; however, ECG is not effective for diagnosing patients with non-ST-elevation myocardial infarction (NSTEMI). Clinical feature can be not specific especially for elderly patients making diagnosis more difficult. More attention is now paid for NSTEMI to detect those patients especially the older one and stratify their prognosis risk for adequate strategy. The aim of our study was to identify demographic and clinical characteristics of patients (both elderly and younger patients) having NSTEMI in emergency department.

It is a prospective analytic study that enrolled 150 patients in the emergency department in a period of 3 months in 2016. We consulted our local acute coronary syndrome registry. All the socio demographic and clinical characteristics are collected. The score of chest pain was  noted.

We enrolled 150 patients. The sex ratio = 2.12. We made 2 groups: young patients: age<65 years (52%) and elderly patients: age>65 years (42%). For the younger group, a history of STEMI was noted in 21% of cases,   and a history of NSTEMI in 39% of cases. We found that 32% of this group had a history of angioplasty. Cardiovascular risk factors were found in this group: diabetes in 41% of cases, hypertension in 41% and dyslipidemia in 17% of cases. The Average score of chest pain was: 4.1 ± 1.9. electrocardiographic abnormalities were found in 83% of our confirmed NSTEMI.

 For the group of elderly patients, the mean age = 73 ±6.15 years ranging from 66 to 83 and a sex ratio =1.48. In 24% of cases, a history of STEMI was noted. 38% of this population had a history of angioplasty. In this group we found the some cardiovascular risk factors. Indeed, a history of diabetes was noted in 61% of cases, hypertension in 69% and dyslipidemia in 21% of cases, 28% of those patients were active smokers. An electrocardiographic abnormality (ST depression and T wave abnormalities) was noted in 77% and the average scores of chest pain were: 4.2 ± 2.03. In those two groups, the diagnosis of NSTEMI was confirmed and we noted a significant elevation of troponin. More than 83% of those patients were hospitalized in cardiology department. Our two groups were not similar regarding the cardiovascular risk factors with significant p (The history of diabetes with p = 0.015 and Hypertension p = 0.004, active smoking with p = 0.007). But there were no significant differences in the pain scores between the two groups. For the two groups, chest pain was specific for coronary syndrome.

The results of this study show that there were no statistical age- related differences in chest pain scores. Elderly patients having NSTEMI had specific chest pain and clinical diagnosis was as evident as for younger patients.   

 

 

 

 

 


Sana BOUKADIDA (sousse, Tunisia), Asma ZORGATI, Naouefel CHEBILI, Wael CHAABANE, Ali OUSJI, Riadh BOUKEF
11:00 - 18:00 #7964 - Clinical Bedside Teaching – educati.
Clinical Bedside Teaching – educati.

This poster reviews the many different techniques/tools which can be adopted and used by clinical faculty in a patient care environment to teach junior physicians in training.  The techniques/tools include 1 minute preceptor, SNAPSS, ED STAT, MiPLAN, Aunt Minnie Model, SPIT and others.  

The objective of this poster is to put published and commonly use techniques into one single handy resource (when produced as a card) for clinical faculty use as appropriate.  


Mark LEONG (SINGAPORE, Singapore)
11:00 - 18:00 #7208 - Clinical development fellowship posts – A novel way to save an emergency department?
Clinical development fellowship posts – A novel way to save an emergency department?

Background:  

With more Emergency Medicine (EM) doctors moving to work abroad, fewer Foundation Doctors (FY2) moving directly into training posts and dwindling numbers of middle-grade tier doctors in Scottish Emergency Departments (ED), rota gaps are being filled in-part by locum doctors. This is a waste of precious funds at a time when National Health Service (NHS) resources are scarce.

 

In 2013 St John’s Hospital (SJH) ED, a medium-sized ED with a ~50,000/year footfall in Livingston, Scotland, was facing an out-of-hours staffing crisis. Year long Clinical Development Fellowship (CDF) posts were introduced to solve this staffing shortfall, save resources and to develop post-FY2 trainees in clinical skills, teaching, simulation, leadership and quality improvement. So far three cohorts have been undertaken.

 

Aim:

The aim of this project was to investigate the impact of EM-specific CDFs within SJH ED and potential benefits for future EM training.

 

Methods:

Using online questionnaires from the 18 previous and current CDFs as well as semi-structured interviews with ED Consultants we explored whether CDF posts in EM made the specialty more or less appealing as a future career, as well as uncovering benefits that the programme provided to the ED and CDFs themselves.  

 

Results:

Initial results indicate 100% of CDFs were involved in simulation projects, including the set up of in situ point-of-care multidisciplinary simulation. The majority of CDFs also achieved publications or presentations of projects undertaken as part of their post and were trained in and practiced QI methodology. Several projects have resulted in introduction of new pro-formas within the ED, improving patient care.  

 

All CDFs had exposure to teaching, gaining a positive experience regardless of future career direction and achieved teaching qualifications, either in the form of a Post Graduate certificate or from the Clinical Educator Programme, a local teaching qualification, CPD accredited by the Royal Colleges. 100% of CDFs also undertook an accredited Medical Leadership courser, all stating this was beneficial in their day-to-day work and that this improved confidence in becoming a Clinical Supervisor in the future. With skills learnt from these courses, several CDFs set up teaching programmes within the ED to help facilitate junior doctor and undergraduate learning.

On the whole consultants viewed the safety profile of CDFs working in combination with FY2 doctors overnight positively, and acknowledge other benefits including resource saving and rota filling.  This is supported by extrapolated data that shows an estimated saving of £33,000 per annum for each CDF post, if compared to use of non-permanent staff; an estimated total saving of £630,000 over 3 cohorts.

 

Conclusion:

CDF posts confer financial and skills-based benefits to EDs that are heavily reliant on locums. They have shown a promising start within NHS Lothian, and now other Boards within Scotland run the same programme supporting a variety of acute areas. It appears that these posts not only provide the clinical and development experience which post FY2 doctors desire, but also have a positive impact on the Department as a whole in terms of reliable staffing and value.


Andrew SAUNDERS, Victoria BRADFORD (Edinburgh, United Kingdom), Andy STEVENSON, Beth HARRISON, Hannah MONAGHAN
11:00 - 18:00 #7462 - Clinical features of elderly patients admitted in the emergency department short stay unit.
Clinical features of elderly patients admitted in the emergency department short stay unit.

Introduction:

Elderly patients are an increasing population in emergency departments (ED).Dealing with elderly patients often requires hospitalization in the emergency department short stay unit (EDSSU). The aim of our study is to assess the epidemiological and clinical features of elderly patients admitted into the EDSSU of Habib Thameur hospital.

Methods:

A retrospective study including all patients aged 65 years or older who were admitted during more than 24 hours into the EDSSU starting from January 1st, 2014 to December 31, 2015.

We collected data regarding age, gender, past medical history, length of stay, diagnosis, intra-hospital mortality andreferralat the end of hospital stay to study the epidemiological and clinical features of this population.

Results:

Among 57711 of all emergency department visits during 2014 and 2015, 1769 patients were admitted into the EDSSU from whom 1285 stayed for more than 24 hours (2.22%).

Elder patients aged 65 years and older account for 55.09% (n=708). Mean age was 77±7 years with a sex ratio of 0.84. Past medical history included:high blood pressure (60.9%), diabetes (42.9%), atrial fibrillation (21.2%), stroke (18.2%), coronary artery disease (17.5%), heart failure (11.7%), dyslipidemia (10.9%), renal failure (9.2%), COPD (8.6%), asthma (1.3%).

Median hospital stay was 72 hours. Intra-hospital mortality was 15%. Patients were referred to another department in 7.9% of all cases. 77% of patients were entirely taken care of in the EDSSU and returned home at the end of hospital stay.

Conclusions:

The elderly are an ever increasing population in emergency departments. Atypical clinical presentation of illness and the presence of multiple comorbidities complicate their evaluation and management. A greater knowledge of the epidemiological and clinical features of such patients can help emergency physicians provide high-quality care, better quality of life and less morbidity to this increasing population.


Mohamed MEZGHENI, Mohamed Ali CHERIF, Farah RIAHI (Belfort), Walid MHAJBA, Youssef Zied EL HECHMI, Ines SEDGHYENI, Malek HSOUNA, Zouhaier JERBI
11:00 - 18:00 #6068 - Clinical outcomes of three-years-of-experience, targeting temperature management (TTM) in patients with out-of-hospital cardiac arrest (OHCA) in Songklanagarind Hospital, Southern Thailand: the analysis of MICU-TTM registry.
Clinical outcomes of three-years-of-experience, targeting temperature management (TTM) in patients with out-of-hospital cardiac arrest (OHCA) in Songklanagarind Hospital, Southern Thailand: the analysis of MICU-TTM registry.

Background:

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes for ICU admission, which causes a high in-hospital mortality. From our recent records, the survival to hospital discharge rate, after cardiopulmonary resuscitation, (CPR) was only 8.2%. Fortunately, TTM has been introduced over  many years to improve neurological and mortality outcomes, particularly in cardiac arrest patients from cardiogenic causes with shockable rhythms. TTM has been implied to our hospital since the year 2012 which, expectedly  improved the standard of care in OHCA patients. This is a  report of the clinical  and mortality outcomes after TTM was  introduced to our hospital over the past 3 years.

Method:

A retrospective study was performed using MICU-TTM registry in 2012-2015. Standard CPR was performed. TTM had been performed on every OHCA patient, either due to cardiac or non-cardiac causes, if no contraindication. After the return of spontaneous circulation (ROSC), an Arctic Sun®surface cooling machine was connected to  rapidly controll body temperature to a target of 33 degree Celsius for 24 hours. Afterwards, the re-warming process was started to slowly return the body temperature to 37 degree Celsius. The Cerebral Performance Category (CPC) scale along with the  clinical outcomes were recorded into the MICU-TTM registry.

Results:

From  23 cases, those of male gender were  the majority of patients (20/23, 87%) with the mean age of 54.48+/- 18.1 years. The OHCA from cardiac causes was only 52.2%.  The initial ECG rhythms were ventricular fibrillation (47.8%), asystole (39.1%), and pulseless electrical activity (13.0%), respectively. The mean time from arrest to ROSC was 40.3 +/- 2.0 minutes. Survival rate to hospital discharge was 47.8% (11/23), but neurological outcomes were in a persistent vegetative state (8/11, 72.7%). Ventilator associated pneumonia (VAP) occurred in 43.5% of the total TTM-treated patients. In multivariate analysis, initial shockable rhythm was positively associated with survival at hospital discharge (OR 10.1, 95% CI 1.1-94.3, p 0.04). The group of poor neurological outcomes had a significantly higher APACHE II score than another group (22.9 +/- 4.2 vs 16.0 +/- 3.6, p 0.01).

Conclusion:

In our practice, TTM in OHCA patients demonstrated better mortality benefits compared to our previous recordings, despite the poor neurological outcome. VAP was the major complication of TTM. Nevertheless, TTM should be considered in every cases of OHCA, regardless of causes, after obtained ROSC.


Veerapong VATTANAVANIT (Hat Yai, Thailand), Rungsun BHURAYANONTACHAI
11:00 - 18:00 #8212 - CMV infection in a non-immunocompromised patient : case report.
CMV infection in a non-immunocompromised patient : case report.

Introduction :

Viral infections have usually good outcome for non-immunocompromised patient. Especially CMV infection. We report a case of a patient with CMV infection

Case report :

A 57-year-old male patient with hypertension and type 2 diabetes presented to the emergency department (ER) for asthenia, arthralgia associated to fever. He experienced 2 weeks ago headache, myalgia and diarrhea.

On physical examination, he had fever. He had GCS of 13, no signs ofmeningism no neurological impairement. He was hemodynamically stable. The abdomen was soft, non-distended, and mildly tender.he had a gangrene in his right pinky toe.On the fourth day after admission, the patient developed bullous lesions in both legs. The laboratory tests revealed elevated values of transaminase and bilirubine values, lymphocytopenia, thrombocytopenia and an elevation of inflammatory marker. Cerebral computed tomography (CT) was normal. Abdominal CT showed peritoneal effusion and a hepathomegaly. The cardiac ultrasounds revealed no signs of endocarditis. The test results were negative for antinuclear antibodies, perinuclear antineutrophil cytoplasmic antibodies, and cytoplasmic antineutrophil cytoplasmic antibodies. Serological testing showed that CMV IgM and IgG levels were elevated.

The patient did not receive Ganciclovir because of thrombocytopenia (27000 controlled to 12000). He presented dyspnea then a cardiac arrest. He died.

 

 

Conclusion:

The CMV infection is a rare but potentially significant cause of arterial and venous thrombosis in otherwise healthy individuals as well as in immunocompromised hosts. Which represent a challenge to diagnose for emergency physicians.


Houcem OUNI (tunis, Tunisia), Mohamed Ali CHERIF, Ons ANDOLSI, Khaled SAIDI, Mohamed MEZGHENI, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7395 - Colonoscopy-associated pneumoperitoneum, pneumothorax and pneumomediastinum.
Colonoscopy-associated pneumoperitoneum, pneumothorax and pneumomediastinum.

Colonoscopy-associated pneumoperitoneum, pneumothorax and pneumomediastinum

KIAN-CHING ER, YI-KUNG, LEE

EMERGENCY DEPARTMENT, DALIN TZU CHI HOSPITAL, TAIWAN(R.O.C)

 

Introduction: Colonoscopy is used both diagnostically and therapeutically and permits examination and treatment of the colon, rectum, and a portion of the terminal ileum. As a rare but serious complication, colonic perforation appears to occur in 0.2% to 0.5% of diagnostic colonoscopies with up to a threefold increase with therapeutic colonoscopies. Intraluminal air may pass through the abdomen and/or thorax. To date, there have been only rare reported cases of combined pneumoperitoneuma, pneumothorax and pneumomediastinum resulting from colonoscopy.

Case report: Our patient, an eighty three year-old man with past hx of transverse colon cancer over hepatic flexture s/p right hemicolectomy, underwent colonoscopy with procedural sedation for regular workup. During the procedure, subcutaneous emphysema developed. Patient was immediately sent to ED. Due to respiratory distress, endotracheal intubation was done. Image studies showed pneumothorax, pneumomediastinum and pneumoperitoneneum. Chest tube insertion was done. As patient’s family refused aggressive surgical intervention, patient was then sent to ICU for further treatment. Patient was transferred to original ward from ICU and discharged smoothly under the conservative and antibiotic treatment.

Discussion: Colonoscopy-associated perforations typically occur by barotrauma, mechanical trauma and electrocautery injury during polypectomy. Depending on the site of injury, it is also possible for air to enter the retroperitoneum. This occurs when a visceral wall defect results in pneumotosis coli. The air will track back the bowel wall and omentum and subsequently reach the retroperitoneum. When this happens, direct communication to the mediastinum existed. Due to the rupture of mediastinal parietal pleural, concurrent penumothorax will developed. Despite a relative rare reports of iatrogenic pneumothorax and pneumomediastinum after colonoscopy, this potential complication happens whenever a colonic perforation occurs. Due to the potentially devastating consequences, clinician should more alert of these iatrogenic complications.


Er KIAN-CHING (Chiayi, Taiwan)
11:00 - 18:00 #4532 - Combination of a low dose ketamin and midazolam in adult ED trauma patients.
Combination of a low dose ketamin and midazolam in adult ED trauma patients.

Authors discuss practice of monitoring, treatment and evaluation of pain in trauma patients at the emergency department. They describe their departmental policy of pain management. They discuss known literature and studies of ketamin and benzodiazepine usage in emergency department settings. They describe new departmental ketamin/midazolam recommendations. They show how ketamin is safely used in case of opioid/NSA treatment failure or as first line analgosedation for trauma patients with pain. They describe suitability of this combination for small procedure (drilling, reposittion etc.) analgosedation.They show compliance of non anesthesiologist physicians in ED team to this policy. Further, they show change of pain level,  change in levels of patient and personnel satisfaction with this new policy implementation. They discuss occurrency of side effects and possible pitfalls. Finally, they discuss further development of analgesia and analgosedation in their ED (ultrasound guided regional anesthesia).


Jiri SOUPAL (PRAGUE, Czech Republic), Jan BYDZOVSKY, MD, PHD.,DOC., Jaroslav, Md KRATOCHVIL
11:00 - 18:00 #7388 - Combined treatment of artificial dermis and vacuum-assisted closure for huge developing necrotizing fasciitis with severe sepsis.
Combined treatment of artificial dermis and vacuum-assisted closure for huge developing necrotizing fasciitis with severe sepsis.

Surgical debridement for necrotizing fasciitis leaves patients with extensive defects. Various treatments and surgical techniques have been developed for functional and aesthetic restorations in affected cases. Artificial skin substitutes have widely been in use for repairing complex tissue defects. These substitutes serve as scaffoldings for the fibroblasts and endothelial cell ingrowth and provide good dermal regeneration templates. However, engraftment of artificial skin substitutes remains slow and incomplete. To overcome these weaknesses, vacuum-assisted closure (VAC) systems have been used over the artificial dermis, and this combined treatment seems efficient and less invasive. We used this combined method in a few cases of severe necrotizing fasciitis concurrent with various intensive treatments for systemic septic shock. Case 1 was a 67-year-old woman with necrotizing fasciitis in her left inguinal region. She had septic shock caused by streptococcal infection and untreated diabetes. Multi-antibiotic therapy and direct haemoperfusion with polymyxin B-immobilized fibre column (PMX-DHP) were administered in the intensive care unit. The combination of artificial dermis and VAC performed after minimal invasive debridements. Her general condition gradually recovered. Finally, the autologous skin engrafted completely without joint contractures. Case 2 was a 49-year-old man with necrotizing fasciitis on his right leg, which had resulted in complex tissue defects involving multiple tendons and the exposure of tibia. He was also sepsis with poorly controlled diabetes, and his wound culture had revealed both fungi and bacteria. He was treated with antibiotics and antimycotic agents in the intensive care unit. After serial debridements, he underwent the combination of artificial dermis and VAC. His wound healed and his general condition improved. After the autologous skin engrafted, he was discharged in an ambulant state. The combined use of artificial dermis and VAC is less invasive than conventional tie-over dressing and makes it possible to treat bedside. VAC sucks up the inflammatory exudation. We are likely to immobilize the artificial dermis and enables patients to receive early rehabilitation. Because of VAC suctioning bacteria themselves, this combination is more effective than artificial dermis alone from the perspective of infection control. The quality of the treatment not only increases the engraftment rate but also decreases the complications and the risks of infection due to the use of artificial dermis, which is vulnerable to infection. Our results suggest that VAC combined with artificial dermis is an effective method for repairing refractory soft tissue necrosis and useful even in a severe condition.


Kaneko MAYUKO (kosigaya, Japan), Chijiwa TSUYOSHI, Matsuoka TATSUKI, Yoshioka HAYATO, Hasegawa EIJU, Kato HIROSHI
11:00 - 18:00 #7417 - Combining E-Learning, Mastery Learning, Peer Teaching, and Remote Monitoring in a Hybrid Program.
Combining E-Learning, Mastery Learning, Peer Teaching, and Remote Monitoring in a Hybrid Program.

Background

Skills teaching in healthcare can be challenging in the best of conditions. Add in a lack of instructors or faculty and remote locations, and the difficulty is multiplied. The Crisis Research Centre at the Lithuanian University of Health Sciences was tasked with teaching or updating a wide variety of practicing clinicians in Kazakhstan with skills essential to newborn, pediatric, and adult resuscitation. The lack of access to experienced faculty and geographically isolated locations made this task more difficult. The Centre developed a hybrid approach to teach these skills that included four key components: Review of online, video driven descriptions and instructions of skills. Breaking each complex task into essential elements in an educational program that built mastery by having learners progress through fundamental tasks to complete simulations of the tasks in increasingly difficult increments.  Devising a teaching methodology that relied on peer-to-peer teaching using procedural checklists that forced learners down correct pathways during learning exercises. Remote video monitoring of final performance tests of learners in Kazakhstan by the Centre’s staff in Lithuania.

Educational goal

Limitations in faculty availability at the local level forced a creative approach to the problem. The system has been developed and tested with over 2,500 resuscitation team members in Kazakhstan since 2013. Operationally, the system is working well. However, no formal test of its efficacy compared to standard faculty-led teaching has been done. A randomized controlled study comparing the hybrid model against standard instruction is planned with expected initiation in summer 2016.

Proposed Approach

The proposed study will randomize medical students on anesthesia rotation at the Penn State Hershey Medical Center to either receive the hybrid training or standard instruction in basic and advanced airway procedures. Three primary data points are: Initial post-instruction skills test, faculty assessment of skills in actual OR patient cases, and exit skills test at conclusion of rotation. Additional data points will include learner and faculty time spent on instruction, learner evaluation of instructional methodologies, and learner perceptions of competence.

Discussion

While the Centre’s work has targeted low resource areas, findings of this study would have implications in all areas as faculty time could be better allocated to more productive functions. The use of a mastery learning model is not in itself unique in medicine, but combining it with e-learning and peer teaching is unique. If the study hypothesis that the hybrid bundle will produce performance results equal to or greater than instructor led skills training is supported, this model of instruction will be a valuable tool for not only resource limited areas but also for healthcare education in general. 


David RODGERS, Nedas JASINSKAS (Kaunas, Lithuania), Dinas VAITKAITIS, Paulius DOBOZINSKAS, Laima JUOZAPAVICIENE, Birute KUMPAITIENE, Elizabeth SINZ, Kevin MCVEIGH
11:00 - 18:00 #5005 - Communication deficits lead to critical incidents in prehospital emergency medicine.
Communication deficits lead to critical incidents in prehospital emergency medicine.

Background: Communication failure in prehospital emergency medicine can affect patient safety as it does in other areas of medicine as well. We analysed the database of the critical incident reporting system for prehospital emergency medicine in Germany retrospectively regarding communication errors. Methods: Experts of prehospital emergency medicine and risk management screened the database for verbal communication failure, non-verbal communication failure and missing communication at all. Results: Between 2005 and 2015 845 reports were analysed of which 247 reports were considered to be related to communication failure. An arbitrary classification resulted in six different kinds: 1) no acknowledgement of a suggestion 2) medication error 3) miscommunication with dispatcher 4) utterance heard/understood improperly 5) missing information transfer between two persons 6) other communication failure. Conclusion: Communication deficits can lead to critical incidents in prehospital emergency medicine and are a very important aspect in patient safety.


Sophia WILK, Peter RUPP, Johannes WINNING, Thomas FLEISCHMANN, Christian HOHENSTEIN (BAD BERKA, Germany)
11:00 - 18:00 #7796 - Comparison of Parasternal Long Axis and Carotid VTI measurements to Apical 5 Chamber VTI for the assessment of Fluid Responsiveness.
Comparison of Parasternal Long Axis and Carotid VTI measurements to Apical 5 Chamber VTI for the assessment of Fluid Responsiveness.

Background

Accurate assessment of fluid responsiveness remains a significant challenge in critically ill patients.  Doppler measurements of stroke volume [SV] using left ventricular outflow tract — velocity time integral [LVOT VTI] have been utilized to predict fluid responsiveness when combined with a passive leg raise maneuver [PLR].  Traditionally, the apical 5 chamber [A5C] view has been used for LVOT VTI; but its usefulness remains limited due to the considerable skill required to obtain it.  The primary objective of this study is to determine if easier-to-obtain VTI measurements from alternative sites such as parasternal long axis [PLAX] and carotid artery [CA], are equivalent to the A5C.  A secondary objective is to evaluate CA Blood Flow as a measure of fluid responsiveness.

 

Methods

Healthy adult volunteers were recruited and consented.  Subjects were placed in supine position with the head of the bed at 45 degrees and peripheral IV lines placed.  Non-invasive baseline measurements of CO (NICOM), HR and SV were made.  Five sets of Doppler tracings were obtained in the CA, PLAX, and A5C views at baseline.  Doppler and NICOM measurements were repeated 3 minutes after PLR and again 3 minutes after an IV fluid bolus (IVFB) of 10cc/kg.  The change (Δ) in all parameters were compared after PLR and IVFB. Pearson correlation coefficients were calculated.

 

Results

15 volunteers were recruited and 1080 data points generated.  Doppler measurements were made after all participants were scanned and blinded to the examiner during the study.  Our data shows that baseline CA VTI and CA Flow measurements correlated well with A5C [r=0.65].    ΔCA flow also compared very well to ΔA5C after PLR [r=0.74] and correlated well with ΔA5C after IVFB [r=0.65].  Both correlated well with ΔCO [r=0.69].  PLAX Doppler tracings suffered significant motion artifact and measurements did not correlate as well as CA with A5C.

 

Conclusion

PLAX views were easier to obtain than A5C but VTI measurements from this view did not correlate as strongly with A5C compared to those from CA.  The PLAX Doppler tracings were of limited quality due to motion artifact making measurements from this site less reliable.  In contrast, high quality Doppler tracings from CA were easily obtained in all cases.  CA VTI and Blood Flow was comparable to A5C.  The ΔCA Flow consistently correlated well with ΔA5C.  The simplicity of obtaining measurements from this site and minimal skill level required suggests that CA Doppler may be a highly reproducible and useful marker of fluid responsiveness. 


Chiricolo GERARDO (Holmdel, USA), Christopher RAIO, Ryan GIORGETTI
11:00 - 18:00 #7053 - Comparison of proposed d-dimer age-related cut-offs for the accurate identification of pulmonary embolism.
Comparison of proposed d-dimer age-related cut-offs for the accurate identification of pulmonary embolism.

Background:  Previously, a fixed cut-off for d-dimer (< 500 μg/L) was used as part of a ‘rule out’ pulmonary embolism (PE) diagnostic pathway however evidence suggested that this approach lacked specificity in patients aged over 50 years resulting in a high proportion of false positive tests. A range of age-specific d-dimer cut-offs have been proposed (age x 10, age x 16 and decade-stratified), aimed at increasing specificity without reducing sensitivity of d-dimer testing in older patients. Our objective was to compare the diagnostic performance of the conventional cut-off with the three proposed alternatives.

Participants and methods: This was a retrospective cohort study conducted by medical record review of patients investigated for PE with both a d-dimer assay and CT pulmonary angiography (CTPA) in a university teaching hospital. Data collected included demographics, clinical parameters, PE risk score data and CTPA results.  The assay used was Innovance d-dimer (Siemens Medical Solutions).  Outcomes of interest were diagnostic performance (sensitivity, specificity and negative predictive value (NPV)) for PE. 

Results: 226 patients met inclusion criteria. Median age was 65 (IQR 57-75) and 52% were female. Twenty three patients had confirmed PE (10.2%, 95% CI 6.9-14.8%). Sensitivity for conventional cut-off versus the decade-stratified, age x 10 and age x16 cut-offs were 100%, 96%, 96% and 87% respectively with specificity of 12%, 28%, 36% and 66% respectively and NPV of 100%, 98%, 99% and 98% respectively. Adoption of the age x 10 cut-off would result in 28% fewer patients requiring CTPA to rule out PE (95% CI 22-35%).

Conclusion: Both the decade-stratified and age x 10 cut-offs had acceptable diagnostic accuracy and would result in few fewer patients requiring CTPA, although the small number of PE makes the confidence intervals wide.  Further data is required to confirm these findings.

Sources of funding: This project was by The University of Melbourne Scholarly Selective Program.


Imogen ACKLERLY, Anne-Maree KELLY (Melbourne, Australia), Klim SHARON
11:00 - 18:00 #7169 - Comparison of simple stylet versus lighted stylet for tracheal intubation with direct laryngoscopy.
Comparison of simple stylet versus lighted stylet for tracheal intubation with direct laryngoscopy.

Background: The purpose of this study was to investigate the effectiveness of lighted stylet during tracheal intubation with direct laryngoscopy.

Methods: Two hundred eighty four patients undergoing general anesthesia were randomly assigned to either simple stylet (group S) or lighted stylet group (group L). In both groups, stylet-assisted tracheal intubation was performed with direct laryngoscopy. In group S, simple stylet was used. During intubation, the stylet was removed when the tip of the endotracheal tube was supposed to pass the larynx. In group L, lighted stylet was used and removed after confirming transillumination of soft tissue above the suprasternal notch. The success rate at the first attempt, total intubation time, the incidence of mucosal bleeding and the degree of postoperative sore throat were compared.

Results: Compared with simple stylet, lighted stylet significantly increased in the success rate of tracheal intubation at the first attempt (128 [90%] vs.142 [99%], P < 0.001, Group S and L, respectively). The incidence of mucosal bleeding was significantly lower in Group L (35[25%] vs. 19[13%], P: 0.011, Group S and L, respectively). Total intubation time and the degree of postoperative sore throat were not significantly different between the two groups.

Conclusions: Lighted stylet increases in the success rate of tracheal intubation during stylet-assisted tracheal intubation with direct laryngoscopy.

References: Götz Serocki,, et al. (2010). “Management of the predicted difficult airway: a comparison of conventional blade laryngoscopy with video-assisted blade laryngoscopy and the  

                                                              GlideScope”   European Journal of Anaesthesiology (27): 24–30

                    Richard M. Levitan, et al. (2011). “The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices” Ann Emerg Med.(57):240-247


Kim JIN HEE, Park SEONG JOO, Lee YEA JI (Seoul, Korea)
11:00 - 18:00 #7518 - Comparison of ST elevation myocardial infarction (STEMI) : mobile intensive care unit (MICU) immediately after emergency call or after first aid assessment.
Comparison of ST elevation myocardial infarction (STEMI) : mobile intensive care unit (MICU) immediately after emergency call or after first aid assessment.

Introduction : Any patient with suspicious chest pain has to immediately call the emergency medical dispatch center to any suspicious chest pain. As part of a risk of ST elevation myocardial infarction (STEMI), regulator doctor decided to send a mobile intensive care unit (MICU) immediately after emergency call or after first aid assessment (FAA).

Primary outcome : Compare the characteristics of STEMI between when MICU is immediately triggered after emergency call (EC group) or after first aid assessment (FAA group).

Methods : Data derived from a prospective register including non-complicated STEMI

Results : 1310 STEMI were included, 67% in EC group. The only significant difference between the 2 populations is when the caller is a healthcare professional (p<0,05). Chest pain – catheterization laboratory (cath-lab) delay and mortality do not show significant difference.

Conclusion : The regulator doctor’s decision is influenced when the call is made by a health care professional, contrary to history and cardiovascular risk factors. However it does not increase the risk for patients in terms of management delay and survival.


Jonathan GONZVA, Alexandre ALLONNEAU (Paris), Aurélie LOYEAU, Amandine ABRIAT, Olivier YAVARI, Jennifer CULOMA, Catherine RIVET, Yann-Laurent VIOLIN, Isabelle KLEIN, Alain COURTIOL, Olga MAURIN, Hugues LEFORT
11:00 - 18:00 #7328 - Comparison of theoretical clinical approach and validated clinical predictive tools in the diagnose of acute pulmonary thromboembolism.
Comparison of theoretical clinical approach and validated clinical predictive tools in the diagnose of acute pulmonary thromboembolism.

Background / Introduction: Validated clinical predictive tools for acute pulmonary thromboembolism (PTE) have shown their efficacy in estimation pretest probability for patients whom acute PTE is considered. Latest best practice advice (European Society of Cardiology, 2014), (American College of Physicians, 2015), recommend the use of such tools as a main estimation tool for acute PTE. However, some doctors still prefer a clinical theoretical approach to acute PTE as the main strategy, this same approach is used at the emergency department (ED) of Riga East Clinical University Hospital (RECUH).

Objectives: To evaluate the possibility of using recommended validated clinical predictive tools in the diagnosis of acute PTE at ED. To improve patient safety and to save time in diagnosing by avoiding excessive examinations when not required.

Participants and Methods: Retrospective analysis of 220 cases, when Computer Tomography Pulmonary Angiography (CTPA) performed to suspected acute PTE at the ED during one year (2014). Calculation of Wells’ score risk groups, for each case. For each risk level D-dimers and CTPA results were analyzed to estimate the number of possible unnecessary CTPA and/or D-dimers.

Results: From 220 CTPA cases, 100 (45,5%) were male and 120 (54,5%) female patients. Mean age 66.20 for male and 77.18 for female. 149 (67,7%) cases were PTE negative and 71 (32,3%) – positive. Wells’ risk scoring showed 22 (10 %) low risk cases, 139 (63,2%) intermediate risk cases and 59 ( 26,8%)  high risk cases. From 22 low risk patients 1 was PTE positive and 21 – negative, D-dimers were elevated in 21 out of 22 low risk patients. From 139 intermediate risk patients 103 (74,1%) were PTE negative ( with elevated D-dimers in 96 ( 93,2%) cases) and 36  ( 25,9%) positive ( all with elevated D-dimers). From 59 high risk patients 25 ( 42,4%) were PTE negative and 34 ( 57,6%) positive ( all with elevated D-dimers). From 71 PTE positive cases 68 ( 95,8%) were with elevated D-dimers ( in 3 cases D-dimers were non-taken).  From overall 149 (67.7%) negative to PTE with d-dimers elevated in 140 (94.0%) and non-elevated in 4 (2.7%), non-taken in 5 (3.4%) cases.

Conclusion: For low and intermediate risk groups if “Wells’ score” was used the non-elevated D-dimers should not undergo CTPA. Negative D-dimers match the international data supporting a predictive negative CTPA (NICE, 2015). In our data all CTPA done within high risk group the D-dimers where hundred per cent elevated, but D-dimers elevated do not predict a positive CTPA (P = 0.630). Recommendation for use of validated clinical predictive tools in estimation pretest probability for patients whom acute PTE is considered.


Bruno SOUSA DOS SANTOS (Riga, Latvia), Ieva KRIEVA, Sandra SEIMANE, Aleksejs VISNAKOVS
11:00 - 18:00 #7369 - Comparison of tibia and humerus infusion rates using the NIO Intraosseous Infusion System on the adult cadaver model.
Comparison of tibia and humerus infusion rates using the NIO Intraosseous Infusion System on the adult cadaver model.

Background.

Rapid intravascular (IV) access is a prerequisite component of emergency care and cardiopulmonary resuscitation (CPR). However, attempting to establish IV access in patients with low cardiac output (CO) is more difficult without interrupting CPR. Gaining intraosseous (IO) access during CPR is relatively easy because IO space as well as marrow cavity, unlike peripheral vessels, does not collapse in the presence of circulatory failure.Therefore our goal was to compare the IO access success rates of the proximal tibia and the proximal humerus using NIO intraosseous device (NIO; Waismed Ltd., Herzliya, Israel) in an adult cadaver model during simulated CPR.

Participants and methods.

We performed a randomized crossover interventional study in 15 cadavers. Fifty paramedics participated and performed IO access in proximal tibia and proximal humerus using NIO device in random order. Outcome variables were IO insertion success rates, location of IO access and procedure related problems. Procedure time was defined as the duration of picking up the prepared set of IO device from the shelf, to first successful administration of infusion solutions through the newly established vascular access. To simulate CPR we use LifeLine ARM (ARM; DefibTech; Guilford, USA) mechanical CC device.

Results.

Success rates on first attempt were higher for tibial IO access than humeral (93.3% versus 73.3%, p=.108) and procedure times were significantly lower for tibial access (20 [IQR,14-31]sec) compared to humeral 27[21-31 sec] (p=.038). Smaller effectiveness to humeral IO access due to the incorrect location of the humeral head. No mechanical problems were encountered in any of the groups.

Conclusion.

In our study, tibial IO access was found to have the highest first-attempt success for vascular access and the most rapid time to vascular access compared with humeral IO access.


Szarpak LUKASZ (Warsaw, Poland), Truszewski ZENON, Smereka JACEK, Krajewski PAWEL, Fudalej MARCIN
11:00 - 18:00 #8018 - Comparison of Tris-hydroxymethyl Aminomethane (Tham) and Sodium Bicarbonate (NaHCO3) on mortality in Metabolic Acidosis Caused by Methanol Toxicity in a Rat Model.
Comparison of Tris-hydroxymethyl Aminomethane (Tham) and Sodium Bicarbonate (NaHCO3) on mortality in Metabolic Acidosis Caused by Methanol Toxicity in a Rat Model.

Comparison of Tris-hydroxymethyl Aminomethane (Tham) and Sodium Bicarbonate (NaHCO3) on mortality in Metabolic Acidosis Caused by Methanol Toxicity in a Rat Model

Background and Purpose

Methanol entoxication is a health problem in developing countries since metabolic acidosis is serious complication of it. It is anticipated to correct acidosis rapidly. We aimed to compare the effects Tham and NaHCO3 theraphy in rats with metabolic acidosis, created by intragastric ingestion of methanol.

Methods

21 male rat was used following anesthesia. A Carotis was cannulated, esophagus penetrated with intracath, baseline blood gas sample was taken, and methanol was injected into the esophagus through the cannula. At the 30 minute of injection, blood gas samples were taken. Rats developed acidosis were randomly assigned to 3 groups:

Group A: Treated by infusion of Tham,

Group B: Treated by infusion of NaHCO3

Group C: No therapy.

At 30 and 90 minutes of therapy, blood samples were drawn again. At the 120 minute, the study was over and mortality rates were investigated.

Results

Four rats in group B, and 6 in C dead before the study was over. All were alive in Group C, results were statistically significant. When Group A and C were compared, there was no statistically significant difference in terms of body temperature, blood pressure and heart rate, PaO2, Na+, K+ and base deficit values.

For pH values of group A and B, there was no statistically significant difference at 30th and 60th minutes (Mann-Whitney U, p< 0.05). However, there was a meaningful difference between their baseline pH values (Mann-Whitney U, p:0,01). While the average baseline pH value of Group C was 7,35±0,08, it was 7,28±0,01 in Group A. When compared the lifetimes of rats in Group A and B, there was statistically significant difference (p<0,05) (Group A was better), however no difference was detected between Group B and C (p>0,05).

Conclusions

We percieved that rats in group lived longer compared to NaHCO3 and control groups. 


Mustafa BOLATKALE, Gurkan ERSOY (Izmir, Turkey), Sedat YANTURALI, Osman YILMAZ, Necati GOKMEN, M Can GIRGIN, Ahmet Cagdas ACARA
11:00 - 18:00 #8132 - Comparison of two scores in the rule out of cardiac cause of syncope in the emergency department.
Comparison of two scores in the rule out of cardiac cause of syncope in the emergency department.

Introduction:

Syncope is a major health care problem that accounts for many emergency departments (ED). Physicians’ approaches to this condition are varied due to lack of methodical approach. The challenge for the emergency physician is to distinguish between cardiac and non-cardiac syncope. Scores are designed to simplify hospitalization decision. The Evaluation of Guidelines in Syncope Study (EGSYS) score and the San Francisco Syncope Rule (SFSR) score are developed to determine patients with syncope of a cardiac cause.

Objective: The aim of our study was to compare the SFSR and the EGSYS scores in the exclusion of cardiac syncope in ED.

Methods:

Prospective, observational study over 4 years. Inclusion of adult patients admitted to the ED with a diagnosis of syncope. Exclusion criteria: no consent, neurological deficit suggestive of stroke, previous recruitment into the study, collapse related to alcohol consumption, trauma, or seizure activity. A physical examination, an electrocardiogram (ECG) and an orthostatic hypotension test were performed. All patients were explored in the cardiac unit. The final cause of the syncope has been determined after investigations. Patient’s management was based on the EGSYS and SFSR score. We compared the two scores using the ROC method.

 

Results:

Inclusion of 168 patients. Mean age: 52 ± 20 years. Sex ratio=1.62. No medical history was observed in 65 patients (39%). Thirty four patients (20%) had a previous syncope. ECG was normal in 53% of patients.

EGSYS≥3 was found in 44% of cases. 
The specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV) and negative likelihood ratio of EGSYS score were: 73, 70, 55, 84% and 0, 38 respectively. The Area under the curve (AUC) was equal to 0,715; p<0,001; 95% IC [0,828-0,902].

SFSR score was positive in 50% of patients. The specificity, sensitivity, PPV, NPV and negative likelihood ratio of SFSR score were: 64, 77, 52, 84% and 0, 41 respectively. AUC was equal to 0,705; p<0,001; 95% IC [0,619-0,791].

 

Conclusion:

The EGSYS and SFSR score had good NPV. Outpatient monitoring can be considered if these scores are negative. The EGSYS score seems more performant to rule out of cardiac cause in syncope.

 


Ines CHERMITI (Ben Arous, Tunisia), Hanen GHAZALI, Ahmed SOUYAH, Anware YAHMADI, Aymen ZOUBLI, Syrine KESKES, Monia NGACH, Sami SOUISSI
11:00 - 18:00 #7510 - Comparison with a prospective registry of management delay for patients presenting an early 2 hours ST segment elevation myocardial infarction (STEMI) in city or suburb. Should you avoid the suburbs?
Comparison with a prospective registry of management delay for patients presenting an early 2 hours ST segment elevation myocardial infarction (STEMI) in city or suburb. Should you avoid the suburbs?

Introduction: The European Society of Cardiology recommends primary percutaneous intervention (pPCI) for early presenters (<2 h) of ST-elevation myocardial infarction (STEMI) when the delay between the first medical contact (FMC) and the balloon inflation is expected to be <90 min with a target of 60 min. Our outcome was to compare the management delay for uncomplicated STEMI “early presenters”, by a mobile intensive care unit (MICU) in a city (C) or in a suburb (S) according to the recommendations.

Materials and methods : Data came from a prospective registry that includes all STEMI collected by one out-of-hospital emergency care services (6 MICU) in the greater Paris area. Early presenters (<2 h) of an uncomplicated STEMI with a reperfusion strategy were studied according to the place of management: city or suburb (C or S). The Khi2 test was used for testing the trends (statistical significance p< 0.05).

Results : Between 2012 and 2014, 289 early presenting STEMIs, uncomplicated and primary cared by MCIUs were included. Four (2,7%) had benefited from an out-of-hospital fibrinolysis, other patients pPCI. The distribution of patients according to the ESC objectives is reported in the chart : 45% (n=130) in the city and 55% (n=155) in suburb, no significant difference was found between the two groups. Patients treated by primary pPCI out of delay were in more than one third (35%).

Conclusion : There is not any significant difference in FMC-pPCI times between subgroups. Even if MICU in suburb tend to be faster than in city, we cannot show a lack of chance for the city patients. For the third of patients, fibrinolytic therapy remains a choice that should be considered.


Alexandre ALLONNEAU (Paris), Amandine ABRIAT, Aurélie LOYEAU, Jonathan GONZVA, Yann-Laurent VIOLIN, Isabelle KLEIN, Olivier YAVARI, Jennifer CULOMA, Catherine RIVET, Olga MAURIN, Alain COURTIOL, Hugues LEFORT
11:00 - 18:00 #8085 - Compensation of shock following Injury.
Compensation of shock following Injury.

An 18 year old boy presented to the emergency department. He was hit by a moving arm of a machine over his right lower chest. There was a large bruise over the lower part of the chest. His pulse rate was 100bpm with a BP of 120/80. He was tender in the right hypochondrium. The diagnosis of a ruptured liver was made and he was booked for theatre. He was given 10mg of morphine and was admitted to the ward. He was seen by a senior Consultant. At that time he was noticed to have been sitting in bed comfortably while his pulse rate was 80 bpm and his blood pressure of 120/80. It was decided to delay the surgery because of his present condition.

 

Two hours later the patient became ill. He became breathless; pulse rate was recorded to be 110 bpm and he had a BP 90/50. He was transfused blood and a chest x ray was performed which showed fluid in the right of the chest. A diagnosis of a ruptured diaphragm was made and he was taken to theatre. A right thoracotomy was performed. Upon opening the chest his liver popped out which was in two pieces. On further exploration it transpired that his right kidney was separated from the renal artery and vein, and was only attached to the right urethra. An incision was extended to the abdomen; and a right nephrectomy was performed. The liver was repaired.

 

The patient recovered and was discharged home.

 

Conclusion:

Young patients compensate well for a time before collapsing suddenly which is exactly what happened in this case.


Mohammad ANSARI (Birmingham, United Kingdom), Qazi ZAMAN, Ahmad ISMAIL
11:00 - 18:00 #7427 - Complications developed after perioperatory anticoagulation withhold , presentation in emergency department.
Complications developed after perioperatory anticoagulation withhold , presentation in emergency department.

INTRODUCTION

Correctly withhold of anticoagulation treatment perioperatory, even for short periods, can be unprotective against thrombuses formation, with negative consequences for the patient's evolution  postoperatory.

EMERGENCY DEPARTMENT PRESENTATION

Male patient of 78 years old presented by ambulance to Emergency Department(ED) with 24 hours history of shortness of breath, fatigue, nausea , vomiting, anuria.

Past medical history- Atrial fibrillation, asthma, Diabetes mellitus, right knee replacement 1 week prior ED presentation.

Medication-Warfarin( stopped 1 week prior knee replacement), beta blocker, Digoxin, inhalers, oral antidiabetics.

On examination: patient was drowsy(GCS14/15),  presented crackles pulmonary bilateral, polypnoea, distended abdomen.

Initial vital signs: HR=140bpm irregular, BP=80/45mmHg, SpO2=92% with 15l O2 100%, GCS=14/15.

ED management: 2 intravenous(iv) large bore cannulas, ECG, chest x-ray, urinary catheter(anuria), iv fluids, blood tests, CTPA.

Bood  tests – urea=35.6, creatinine=435, eGFR=12, INR=1.5, WCC=12.7, Neutrophiles=10.37.

CTPA-bilateral pulmonary embolism(PE), distended stomach fluid filling, ileus.

Diagnosis:Biateral PE post perioperatory Warfarin withhold. Acute kidney injury. Ileus. Recent right knee replacement

Plan-patient admitted on Intensive Care Unit.

 

INTENSIVE CARE UNIT( ITU) MANAGEMENT

The patient was admitted on  ITU for 1 month.

He received: arterial line, left internal jugular vas cath, full monitoring( HR, BP, SpO2, pCO2, CVP, ECG, urinary output), NG tube ( with more than 2 L fluid aspirated)

Required CVVH, intubation, ventilation.

Developed left haemothorax which required left chest drain insertion, vas cath was changed on the right internal jugular vein.

He went to  theatre for laparotomy for splenic rupture and intraabdominal bleeding, successfully treated.

He developed hospital acquired pneumonia, which was treated with antibiotics, secondary to which he developed diarrhoea.

Discussion

The anticoagulation treatment for atrial fibrillation was correctly withheld prior the right knee replacement. Despite of that, the patient developed bilateral PE, which received heparin infusion;acute kidney injury which required haemofiltration. Because  of anticoagulation therapy he developed left sided haemothorax  resolved with chest drain insertion and splenic rupture with secondary intraabdominal bleeding,which required laparotomy and splenic repair.

Due to his prolonged hospital staying, he developed hospital acquired pneumonia, with antibiotherapy and secondary diarrhoea.

The right knee replacement healing process went well, the patient requiring Physiotherapy in order to help the patient’s mobilization after his prolonged hospital admission.

CONCLUSION

Even the perioperatory anticoagulation treatment is correctly withhold following the protocols, sometimes the patients can develop complications related with this process, with secondary prolonged hospital staying and with risk of acquiring hospital pathogens infections, with high emotional impact on the medical staff that is treating this patients as for the patient’s family.

Dr Nicoleta Cretu ACCS ST1 Emergency Medicine trainee

Dr Ben Teasdale, Emergency Medicine Consultant

Leicester Royal Infirmary Hospital, Leicester, UK

 

 

 

 

 


Dr Nicoleta CRETU, Dr Nicoleta CRETU (Leicester, United Kingdom), Ben TEASDALE
11:00 - 18:00 #7744 - Complications of Rapid Sequence Intubation in Emergency Department: A Propensity-matched Analysis.
Complications of Rapid Sequence Intubation in Emergency Department: A Propensity-matched Analysis.

Background and Objectives

            Rapid sequence intubation (RSI) was used to facilitate emergency intubation. However, concerning about complications prevents its general used. This study aimed to compare the acute major complications between RSI and other methods of intubation.

Methods

            Retrospective cohort study was done in emergency department of Thammasat hospital, from 2012-2015. Acute major complications after intubation were observed, included; cardiac arrest, airway injury, dysrhythmia, hypotension, laryngospasm, malignant hyperthermia, pneumothorax, and aspiration. We excluded patients presented with cardiac arrest before intubation, age below 15-year-olds, severe maxillofacial injury, contraindication to RSI medications, and failed intubation. We compared the complications between RSI vs Sedation-only intubation and RSI vs No-medication-assisted intubation. Propensity score matched one-to-one analysis were used for adjusting baseline characteristics. Regression analysis were used for adjusting confounders.

Results

            For RSI (N=380) vs Sedation-only-intubation (N=502), 343 patients intubated with RSI were matched to 343 patients with Sedation-only intubation. A total of 60 complications were observed. After adjusted with glottic exposure, numbers of attempt, and experience of intubator, RSI had lower risk of acute major complication compared with Sedation-only intubation (6.41% vs 11.08%; risk difference, 4.24%; 95% confidence interval (CI), 0.05,8.44; P=0.04). For RSI (N=380) vs No-medication-assisted intubation (N=324), 182 patients intubated with RSI were matched to 182 patients with No-medication-assisted intubation. A total of 28 complications were observed. After adjusted with regression analysis, RSI had lower risk of acute major complication, but insignificantly (4.95% vs 10.44%; risk difference, 5.35%; 95% CI, -10.99,2.92; P=0.06).   

Conclusions

            The risk of complication after intubations from RSI method was lower than other methods of emergency intubation. As the standard for emergency airway management, emergency physicians should have expertize with this method.


Winchana SRIVILAITHON (Bangkok, Thailand)
11:00 - 18:00 #8071 - Consultus Interruptus: Unscheduled Interactions within the Emergency Department.
Consultus Interruptus: Unscheduled Interactions within the Emergency Department.

Introduction

It is well recognised that the job of an EM consultant involves multitasking and dealing with multiple unscheduled interactions (UI). The fluid, unpredictable, time pressurised and multi-professional nature of EM makes it particularly susceptible to UI. An increasing number of UI can result in increased error. An Increasing number of decisions, irrespective of complexity can lead to error and decision fatigue. We aim to map the number of UI an EM consultant faces when on shift.

Objectives

This study attempted to answer the following questions:

  • In a day how many unscheduled interactions does the senior EM physician deal with?

  • How many of these are interactions are clinical interactions?

  • What is the average length of time spent dealing with these unscheduled interactions?

Methods

This prospective observational study took place at a single centre urban ED in the West Midlands. The study period was from 1.12.15 to 23.12.15. An EM consultant was trailed on shift by a medical student who noted down all the non-patient interactions that the consultant had. The consultant had no input into data collection. The nature of the UI, the time spent and the outcome was recorded on a simple data collection form. This was then collated and analysed.

 Results

  • A total of 23 shifts over 135hrs 34min were observed.

  • There was a mix of early (0800-1600), late (1600-2100) and weekend shifts.

  • All 10 members of the consultant body were followed.  

Total Number of UI in study period:  2082

Average Number of UI per hr:  17.95 UI/hr.

UI rate (time per UI) 3min 21seconds

Average time per UI 87.5sec   (Range 10s–34 mins)

Clinical Interaction vs Non Clinical Interactions: 94% vs 6%

Conclusion

In this single centre study of an urban UK emergency department 40% of shop floor consultant time is spent dealing with UI. The majority (94%) of these UI related to clinical interactions. In this study this equates to 17.95 UI per hour with an average time spent dealing with each interaction of 87.5 seconds

Discussion

The nature of modern EM necessitates a senior EM physician running a shift on order to cope with the vast number of UI that must be resolved. Combining the intensity of this role with an individual patient load  is not feasible and departments should consider the initiation of a ‘captain of the ship’ ‘Fat Controller’ role along with a second senior EP to provide individual consultant level care to the sickest individuals who require senior input.

 


Sandeep GILL (Smethwick, United Kingdom), Raj PAW, Peter DOYLE, Ameer SHAH, Sarah SHAKKSHIR, Munir ABUKHDER
11:00 - 18:00 #7327 - Contrast induced nephropathy after computer tomography of the pulmonary arteries in emergency settings.
Contrast induced nephropathy after computer tomography of the pulmonary arteries in emergency settings.

 Introduction

Contrast-induced nephropathy (CIN) is defined as iatrogenic deterioration of renal function following intravascular contrast media administration in the absence of another nephrotoxic event. CIN is one of the leading causes of hospital-acquired acute kidney injuries.

Contrast-enhanced computed tomography (CECT) of the pulmonary arteries is one of the most common imaging studies performed in the emergency department to evaluate patients with suspected pulmonary embolism (PE). The aim of this study was to define if CIN followed CTPA.

Methods

We analyzed medical records of patients who received intravenous contrast for CECT in the emergency department (between January 2016 and April 2016). The outcomes measured were as follows: an increase in serum creatinine ≥ 44.2 mkmol/l or ≥ 25% 2 to 7 days after the contrast administration, severe renal failure with or without acute hemodialysis and renal failure as a contributing cause of death.

Results

A total of 137 patients underwent CTPA, with acute PE in 46 patients (33,6 %) and 112 patient being hospitalized after CECT. We analyzed 90 hospitalized patient’s medical records and measured post procedural  serum creatinine level. Preliminary data shows that the incidence of CIN is 14.4 % (n=13 of 90), including 4 with acute PE. One patient (1.1 %) developed acute renal failure which required acute hemodialysis. 7 patient died and  the development of CIN was observed in 3 of deceased patients. CIN developed in 4 patients ( 9.3 %) with acute PE. Risks factors for CIN including age over 70, anemia, arterial hypertension, coronary artery disease associated with higher  CIN development ; whereas other vascular diseases (peripheral, renal or cerebral), congestive heart failure, pre-existing renal disease, diabetes mellitus, the malignancy associated with CIN was not significant.

 

Discussion/conclusion

The number of CIN incidences is high among emergency department population undergoing CTPA. CIN should be considered before emergency imaging requires intravenous contrast media in patients with suspected PE. Alternative investigation method must be applied when dealing with patients having pre-existing risk factors.

 


Jevgenijs KRAVCUKS (JURMALA, Latvia), Olegs SABELNIKOVS
11:00 - 18:00 #7857 - CORE CONTENT IN EDUCATION FOR NURSES IN AMBULANCE CARE IN SWEDEN, FINLAND AND BELGIUM – A CASE STUDY.
CORE CONTENT IN EDUCATION FOR NURSES IN AMBULANCE CARE IN SWEDEN, FINLAND AND BELGIUM – A CASE STUDY.

There is no general agreement regarding education and competence for working in emergency medical services in Europe. A few countries staff ambulances with registered nurses (RN), but there is no consensus on specific knowledge needed for RNs in ambulance care. The objective of the study was to explore the content in Swedish, Finnish and Belgian advanced level education for RNs in ambulance care. A deductive case-study research design was used. Three Universities, one from each country of Sweden, Finland and Belgium participated. Data was generated from curricula and interviews with teachers, analyzed with different approaches of qualitative content analysis.  The result showed that common content of the curricula can be described as pharmacology, medical science, medical care and treatment, clinical judgment, nursing practice, patient relationship, knowledge transfer, ethical views, contextual skills, management, and employment factors. Content concerning medical knowledge, especially medical science, medical care and treatment, and clinical judgment, dominated. Clinical reasoning, applied knowledge, personal abilities and scientific awareness were described by the teachers as essential in the education.

Conclusions: The need for medical knowledge dominates the educational content with an obvious focus on medical science, medical care and treatment, and clinical judgment. The teachers aim to meet the need of broad competence in clinical reasoning by implementing theory into practice, as well as to develop the students’ personal abilities and instilling a scientific awareness.


Helena SJÖLIN, Veronica LINDSTRÖM, Håkan HULT, Charlotte RINGSTED, Pr Lisa KURLAND (Örebro, Sweden)
11:00 - 18:00 #7245 - Coronary angiography is related to improved clinical outcome of out-of-hospital cardiac arrest with initial non-shockable rhythm.
Coronary angiography is related to improved clinical outcome of out-of-hospital cardiac arrest with initial non-shockable rhythm.

BACKGROUND: Coronary angiography (CAG) for survivors of out-of-hospital cardiac arrest (OHCA) enables early identification of coronary artery disease and revascularization, which might improve clinical outcome. However, the role of CAG has not been validated against initial non-shockable rhythm.

METHODS: From March to December 2014, we assessed clinical outcome of 665 adult OHCA patients at 27 hospitals registered in a Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES), a prospective nationwide multicenter registry. The primary outcome was survival with good neurological outcome at hospital discharge.

RESULTS: Initial shockable rhythm and non-shockable rhythm were found in 259 (38.9%) and 406 (61.1%) patients, respectively. Patients with non-shockable rhythm were older, more likely to be female, less likely to underwent a bystander resuscitation or pre-hospital defibrillation (p<0.001, all). CAG was performed in 143 (55.2%) and 53 (13.1%) of shockable and non-shockable rhythm, respectively. Performing CAG was associated in better clinical outcome not only in patients with shockable rhythm (74.1% versus 28.4%) but also in patients with non-shockable rhythm (34.0% versus 3.1%, log-rank p<0.001, all).

CONCLUSION: Among OHCA survivors, we found coronary angiography was related to better survival and good neurological outcome of patients with initial non-shockable as well as shockable rhythm.


Eunsil KO, Eunsil KO (Seoul, Korea), Ji Kyoung SHIN, Min Seob SIM, Ik Joon JO, Jin-Ho CHOI
11:00 - 18:00 #7318 - Coronary Artery Aneurysms after Adult-onset Kawasaki Disease.
Coronary Artery Aneurysms after Adult-onset Kawasaki Disease.

We encountered a rare case of adult-onset Kawasaki disease (KD), with coronary artery abnormalities, in a 24-year-old Japanese man. The patient presented with recent-onset chest pain that occurred when he was at rest and no other symptoms. His medical history included hospitalization 2 years previous to the present admission, at another hospital, due to a fever of unknown origin that lasted for 2 weeks, accompanied by polymorphic exanthema, cervical lymphadenopathy, nonpurulent conjunctivitis, strawberry tongue, and finger tip desquamation. At that time, the patient was diagnosed with adult-onset Still’s disease. Based on that diagnosis, he was treated with steroid pulse therapy, alone, and his symptoms were alleviated. After 2 months, he received oral steroid therapy, and was assumed to have been successfully treated. However, the patient was admitted to our hospital 20 months after concluding the oral steroid therapy.

Upon admission to our hospital, KD was suspected because of his past history of “strawberry tongue” which is unique to this disease. The chest pain was associated with an abnormal electrocardiogram that showed an abnormal Q wave in the inferior (II, III, aVF) electrocardiographic zones. A cardiac three-dimensional computed tomography scan showed an aneurysm of the proximal right coronary artery, with tight postaneurysmal stenosis. The scan also showed proximal aneurysms of the left anterior descending artery and the proximal circumflex artery. He was treated with percutaneous coronary intervention and discharged on day 28, without any complications.

Typical KD findings in both adults and children include fever, conjunctivitis, pharyngitis, skin erythema progressing to a desquamating rash on the palms and soles, and strawberry tongue. Adults more frequently present with cervical adenopathy, hepatitis, and arthralgia. In contrast, adults are less frequently affected by meningitis, thrombocytosis, and coronary artery aneurysms.

KD is a common vasculitide of childhood, but adult-onset KD is extremely rare. No specific diagnostic tests are available for KD; the diagnosis is based on the presence of characteristic clinical findings. Once a differential diagnosis excludes the possibility of rheumatologic disorders or autoimmune disease, steroid therapy is often administered. However, treatment with steroids, alone, might have adverse effects in KD patients, causing progression of coronary lesions. In the present case, only steroid therapy was administered to the patient at the time of his initial hospitalization, 2 years earlier, and may have resulted in an exacerbation of the patient’s coronary artery abnormalities. Thus, the present report suggests that adult-onset KD should be considered as a differential diagnosis in cases presenting as rheumatologic disorders or autoimmune disease to prevent adverse effects caused by steroid treatment in adult-onset KD patients.


Ryota INOKUCHI (Bunkyo-ku, Japan), Takahiro HIRUMA, Kensuke NAKAMURA, Yuta AOKI, Takehiro MATSUBARA, Masataka GUNSHIN, Kent DOI, Susumu NAKAJIMA, Naoto MORIMURA
11:00 - 18:00 #7269 - CORRECT IDENTIFICATION OF THE SEMIOTICS OF CHEST PAIN IN THE EMERGENCY TRIAGE.
CORRECT IDENTIFICATION OF THE SEMIOTICS OF CHEST PAIN IN THE EMERGENCY TRIAGE.

Triage is a tool for the classification of patients in the emergency department. Acute Coronary Syndrome (ACS) is the leading cause of death in our country and needs early diagnosis and treatment. Chest pain is the main symptom of ACS, and a frequent reason for consultation in the emergency department. This study describes the importance of a correct identification of the semiotics of chest pain triage by nurses, based on a sample of 548 who demanded urgent attention for this problem in the emergency department at the Hospital Universitario de La Ribera.

To assess the correct semiotics of chest pain by nurses during triage at the Hospital Universitario de La Ribera, Department 11.

This work is a retrospective, observational and descriptive study that was conducted on 11 patients in the health area department at the Hospital Universitario de La Ribera. These patients turned up to triage at the Emergency Department by any susceptible complaint potentially related to ischemic heart disease between 1 August and 31 October 2015. The data were collected using the program “clinical SIAS” with 548 patients included in the study. The variables that we have raised will analyse age, sex, EKG, the priority assigned by the triage nurse DEIMOS, the discharge diagnosis and performing triage EKG.

The average age was 60.13 and a 53.1 percentage of men. 61.13% of patients demanded urgent attention “chest pain”. The most used discriminator was “recent problem” in 54.9% of the cases. The most representative priority assigned was 63.2% from P4. Among the study patients, 37.4% of the total had a history of ischemic heart disease. 50.7% of patients underwent an electrocardiographic test. 68.9% of patients were treated in the query area (examination room); being “chest pain” the most representative discharge diagnosis in 56.93% of the cases studied. 78.6% of the patients were discharged.

Most of the patients in our study were men with an average age of 60.13, but no significant differences were observed regarding sex.

Regarding the electrocardiographic test, the realization of it was not significant among patients in the sample.

            The most prevalent priority assigned in most of the cases for the diagnosis of chest pain was “P4”. The most representative reason for consultation was “chest pain” while making the most prevalent high diagnosis.

            In the study, the most common discharge diagnosis used was “chest pain”, to which a priority P4 was mostly assigned.

            The diagnosis of “anxiety” was most prevalent at a younger age on average. The highest average age belonged to the final diagnosis of “I.A.M.”

            In the cases studied, the discharge diagnosis made with electrocardiograms was mainly “chest pain”, while the final diagnosis made with fewer electrocardiographic tests was “anxiety”.

            When performing the electrocardiogram, the history of ischemic heart disease was not taken into account, not being significant the realization of the same between both groups of patients.

            Emergency nursing did not correctly identify the semiotics of chest pain.


Ainhoa SÁNCHEZ CORTÉS, Antonio PRIETO DAVIA, Maria CUENCA TORRES (VALENCIA, Spain), M Jose CORTÉS GÓMEZ
11:00 - 18:00 #4507 - Correlation of Central Venous Pressure with Venous Blood Gas Analysis Parameters; a Diagnostic Study.
Correlation of Central Venous Pressure with Venous Blood Gas Analysis Parameters; a Diagnostic Study.

Introduction: This study was conducted to assess the correlation between the amounts of central venous pressure (CVP) with venous blood gas (VBG) analysis parameters to facilitate septic shock management in emergency department.

Methods: This diagnostic study was conducted from January 2014 until June 2015 in three main educational medical centers, Tehran, Iran. All patients with diagnosis of septic shock were enrolled and those with known heart failure, renal failure, initial CVP more than 8 cmH2O, and raising CVP more than 3 cmH2O following fluid challenge test were excluded. For selected patients, peripheral blood sample was taken for testing the VBG and anion gap (AG) was calculated. All mentioned parameters registered again after infusion of 20 cc/kg normal saline 0.9% in 30 minutes.

Results: Totally 93 patients with septic shock were enrolled including 63 males & 30 females. T he mean age was 72.53±13.03 and the mean Shock Index (SI) was 0.79±0.30. PH & AG showed significant reverse correlations with CVP, While HCO3 showed a significant straight correlation with CVP. These relations can be affected by the treatment modalities used in shock management as fluid therapy, mechanical ventilation & Vasopressor treatment.

Conclusion: It is likely that there is significant statistical correlation between VBG parameters with CVP, but for being clinically practical, still needs further research.


Alireza BARATLOO, Alaleh ROUHIPOUR (Tehran, Islamic Republic of Iran), Saeed SAFARI, Mohammad Mehdi FOROUZANFAR, Sima RAHIM TALEGHANI
11:00 - 18:00 #7894 - Correlation of P-wave dispersion with pulmonary embolism in emergency medicine patients.
Correlation of P-wave dispersion with pulmonary embolism in emergency medicine patients.

AIM: P wave dispersion is caused by underlying heterogeneity of atrial myocardial conduction, which leads to P wave variations on surface ECG. This suggests that it is a valuable parameter to predict risk of atrial fibrillation in different patient groups. Patients diagnosed as having pulmonary embolism represent a considerable part of all applications to emergency services. P-wave dispersion (Pwd) was researched in pulmonary embolism cases with a randomized controlled study.
MATERIAL-METHOD: After local ethics committee approval, patients with pulmonary embolism (group A, n: 101) and those without pulmonary embolism (group B, n: 50), who applied to emergency service of Abant Izzet Baysal University Training and Research Hospital, were included to the study. Their ECG papers were transferred to computer after scanning by high resolution and measurements were done in this way. The beginning of P-wave was defined the point of the first abrupt from isoelectric line and the end of P-wave was described where it returned to the isoelectric line. The duration of P-wave was counted from all leads. The longest P-wave was named as Pmax whereas the shortest one was Pmin. Pwd was calculated by subtracting Pmin from Pmax. The formula of Pwd/ was used to calculate corrected Pwd.
RESULTS: For age and gender, there wasn’t statistically significant difference between A and B groups. In group A, Pwd and corrected Pwd values were 51.86±20.72 ms and 65.57±27.61 ms, respectively. On the other hand, for group B, Pwd was 42.59±20.21 ms and corrected Pwd was 52.69±19.87 ms. There was a statistically significant difference between two groups for both Pwd (p:0.029) and corrected Pwd (p:0.003) values. Furthermore, a significant difference was determined also for heart rates of two groups.
CONCLUSION: Atrial fibrillation has an important place for etiology of pulmonary embolism. Pwd gives an idea about atrial dilatation. Even if ECG on presentation doesn’t reveal atrial fibrillation and atrium size isn’t known, Pwd may have an important role as a marker.


Arif DURAN, Serkan ÖZTÜRK (Bolu, Turkey), Mansur Kürşad ERKURAN, Tarık OCAK, Musa KAYA
11:00 - 18:00 #7958 - Cost of delivering intravenous opioid analgesia in emergency departments throughout the United States.
Cost of delivering intravenous opioid analgesia in emergency departments throughout the United States.

OBJECTIVES

The majority of Emergency Department (ED) patients require treatment for painful medical conditions or injuries.  While IV opioids have been utilized for decades to rapidly treat moderate-to-severe acute pain in the ED, very little data exists regarding the costs of administering a typical dose of IV opioid in this setting.  This study analyzed the current costs to administer a single dose of commonly utilized IV opioids in EDs throughout the United States.

METHODS

Descriptive analyses using the Premier database (2013-2014) of > 600 US hospital EDs were conducted on the cost of starting an IV and delivering an initial dose of an IV opioid in EDs.  Average costs of each component were aggregated for total costs.  Direct acquisition and indirect cost (labor, pharmacy, etc.) were included.

RESULTS

Over 24 months, 7,327,299 patients received IV opioids in 614 EDs in the US (approximately one-tenth of EDs in the US).  Of these patients, 58% were not admitted to the hospital.  Morphine (56%), hydromorphone (45%) and fentanyl (25%) were the most frequently administered IV opioids.  Average [median; interquartile range] costs include initiating an IV ($62 [$62; $60-66]), IV catheter ($4 [$3; $2-3]), infusion pump tubing ($15 [$18; $8-21]), infusion pump to maintain IV patency ($37 [$26; $23-64]), 250 mL saline bag ($15 [$13; $9-19]), 2% lidocaine for local anesthesia for line placement ($5 [$4; $3-6]) and the cost of a single dose of morphine 5 mg ($6 [$4; $2-7]), hydromorphone 1 mg ($7 [$5; $3-9]) or fentanyl 100 mcg ($7 [$6; $4-10]).  Aggregated mean IV opioid total costs per patient for a single standard dose of opioid were $143 (morphine), $144 (hydromorphone) and $145 (fentanyl). 

CONCLUSIONS

The cost of setting up an IV line to administer an opioid is substantial. Since the majority of patients receiving IV opioids are discharged from the ED, the ultimate use for this IV line is limited.  The development of a rapid-acting, non-invasive analgesic for ED use could be advantageous from both a cost and patient-benefit standpoint.


John HOUSE, Karen DIDONATO (Burlingame, USA), Pamela PALMER
11:00 - 18:00 #7374 - Could bitter melon extract decreaseblood sugar in case of emergency hyperglycemia? A randomized clinical trial.
Could bitter melon extract decreaseblood sugar in case of emergency hyperglycemia? A randomized clinical trial.

Could bitter melon extract decreaseblood sugar in case of emergency hyperglycemia? A randomized clinical trial

Authors:

Farangis Ghanavati, Associated professor of Botany, Seed and Plant Improvement Institute (SPII), Karaj, Iran

Foad Moradi, Assistant professor of Plant Physiology, Agriculture Biotechnology Research Institute of Iran (ABRII), Karaj, Iran

Reza Mosaddegh, Assistant professor of Medicine, Emergency Department, Firoozgar Hospital, Emergency Medicine Management Research Center, Rasoul-e-Akram Hospital, Iran university of Medical Sciences, Tehran, Iran

Introduction: Diabetes Mellitus is a common metabolic disease in Iran and its prevalence is about 10%. Emergencies related to diabetes are common causes of referring patients to the Emergency Departments. In traditional medicinal plant of Iran, bitter melon (Citrullus colocynthis) is used to treat and control diabetes. This experiment was conducted to use bitter melon extract for decreasing blood sugar level in type 2 diabetic patients when they do not respond to other prevalentmedications.

Methods: One kilogram of dried fruit bitter melon was mill and 10 liters 50:50 water – alcohol was added and placed in 60° C water bathfor 4 hours, then filtered. Extract was concentrated to one liter at 30° C. Obtained solution was poured in 50 ml spray bottles and was given to 20 type 2 diabetic patients while control solution (without the extract) was given to 20 other patients. All the patients asked to if their blood sugar level were above 350 mg/dL, to spray solution (10-12 puffs) on their feet and then wear socksafter drying.Blood sugar level was measured at times of spray (0), 15, 30, 60, 180 and 360 minutes after.

Results: In patients who used this extract, blood sugar level after 15, 30 and 60 minutes wasdecreased respectively by 12.3 ± 4.1, 32.1 ± 6.3, 53.7% ± 6.5 with P-value <0.05 to its initial level, but after 180 and 360 minutes, blood sugar level rose again and reached to 24.9 ± 7.1 and 20.9% ± 2.3 of  its initial level (P-value <0.05).

Conclusion:The survey results show that this treatment modality can be used as an emergency treatment to decrease blood sugar level in diabetic patients who do not respond to other medications, but to hold down blood sugar level in these patients other methods are needed as well.

Keywords:bitter melon, diabetes mellitus, hyperglycemia


Farangis GHANAVATI (Tehran, Islamic Republic of Iran), Foad MORADI, Reza MOSADDEGH
11:00 - 18:00 #7200 - Could serial hematocrit measurement be as an alternative diagnostic method for Abdomino-pelvic CT scan in blunt abdominal trauma?
Could serial hematocrit measurement be as an alternative diagnostic method for Abdomino-pelvic CT scan in blunt abdominal trauma?

Introduction: Assessment for blood loss is the third priority in the primary survey of multiple trauma patients. Serial physical examination, radiologic and ultrasound investigations may be helpful in diagnosing blood loss in patients with Blunt Abdominal Trauma (BAT). Generally, serial hematocrit measurement is performed in many hospital to detect probable blood loss in BAT patients. We undertook this study to find out the accuracy of serial hematocrit measurement in detection of intra-abdominal injuries in BAT patients with different severity without obvious findings of blood loss.

Methods: We enrolled trauma patients presented to our Emergency Departments (EDs) from 2013 to 2015 prospectively. All trauma patients who sustained BAT and candidate for abdomino-pelvic CT scan entered the study and two blood samples (0 and 6 hours after admission) were drown from them. Severity of injury determined by use of Injury Severity Score (ISS). Laparotomy or CT scan considered as a gold standard diagnostic methods in this study.

Results: Nine hundred and sixty-five patients were entered the study and 44 (4.5%) suffered from intra-abdominal hemorrhage. The drop of hematocrit in hemorrhage group was not significantly lower than non-hemorrhage group (4.1±0.9 vs 3.3±1.4 respectively, P=0.08).The sensitivity and specificity of serial hematocrit (drop >2 levels) for detecting intra-abdominal hemorrhage were 0.59 and 0.79 respectively. Changing of Hct was a weak predictor for intra-abdominal bleeding (area under receiver operator curve (AUC: 0.6)).

Conclusion: BAT is a major cause of morbidity and mortality among all age groups and regularly encountered in EDs. Identification of intra-abdominal hemorrhage is often challenging. Our study showed that serial hematocrit measurement had not enough accuracy to detect intra-abdominal hemorrhage in BAT patients. 


Dr Reza MOSADDEGH (Tehran, Islamic Republic of Iran), Mahdi REZAI, Nasrin NOOHI
11:00 - 18:00 #7500 - Critical Incidents reported in a Department of Emergency Medicine in Germany within 3 years.
Critical Incidents reported in a Department of Emergency Medicine in Germany within 3 years.

Backround. Errors in healthcare put patient safety at significant risik. To err is human, but it is unnecessary to make the same mistake twice! It has been proven that a detailed analysis of medical errors is important, especially circumstances of preventable errors are helpful to develop preventive strategies.

What kind of incidents might harm patients during hospital care in the Emergency department?

 

Methods. Our intranet webside offers an anonymous reporting system any staff member of the hospital may use. We analyzed all reported incident reports related to the Emergency Department, University of Jena and classified them arbitrarily.

 

Results. From 2013 until 2016, the 3-year period of database relate to critical incidents in the Emergency Departement Jena includes 61 reports. We classified the main factors, which leaded to potential safety hazards into 9 groups: medical equipement errors (n=15), adequately qualified personnel availability (n=12), inadequate treatment concepts (n=11), data logistics and insufficient communication (n=8), medication (n=6), transport logistics (n=3), monitoring (n=3), mistakes (n=2), hygienics (n=1).  

 

Conclusions. With the help of critical incident reporting system we were able to identify causes, which potentially threat patient safety in the setting of innerhospital emergency medicine. Frequently critical incidents were caused by technical errors, insufficient personnel availability and insufficient communication.

To improve patient safety in the emergency departement and consequently invest into a lifesaving project, we need to enhance the limited allocation of qualified staff, particularly in the care sector. The possibility of attending further education and special skill training for all staff members as well as investigating into high quality equipement seems to have high impact on patient safety.


Lisanne KOSTEK, Christian HOHENSTEIN (BAD BERKA, Germany)
11:00 - 18:00 #8027 - Crohn's disease with acute appendicitis: a case report.
Crohn's disease with acute appendicitis: a case report.

Introduction

Crohn’s Disease is confused with the appendicitis in young patients. Especially between 15-35 years of age, Crohn’s Disease shows similar clinical findings with acute appendicitis in cases that have terminal ileum involvement. Appendicitis is observed frequently in the same age group patients. However, the two diseases being observed together are extremely rare. We would like to present a case that was pre-diagnosed with acute appendicitis and then was diagnosed with Crohn’s Disease.

The Case

Thirty-three-year-old male patient applied to the Emergency Service with stomachache complaint. In his history, he told that the stomachache started 2 days ago around the belly and localized to the lower-right quadrant. At first, he had qualm, but not vomiting. He also mentioned that he had epigastric pain, which lasted for nearly one year, and sometimes diarrhea. In his physical examination, it was determined that he had sensitivity in his lower-right quadrant, muscular defense and rebound. The white blood cell count of the patient was 14000/mm3. In the abdominal ultrasonography, it was reported that he had acute appendicitis. It was observed that the diameter of the appendix of the patient was increased, and was gangrene. There was mural thickening at a further level in the terminal ileum. In addition, there was increase in the thickness of the terminal ileum meso, and lymph nodules. In this case, appendectomy was applied to the patient, and biopsy material was taken from the lymph nodules. The patient was re-operated because there was abscess in the incision area in the postoperative 3rd week. It was observed that the terminal ileum and cecum wall thickness were increased, and there was a perforation. In this situation, right hemicolectomy was applied to the patient. In postoperative period, no complications developed in the patient and he was discharged from the hospital on 6th day.

Conclusion

Acute appendicitis and Crohn’s Disease are among the causes that lead to acute abdomen, and may cause confusion in diagnosis. They are observed together extremely rarely. There is the possibility of developing fistula and obstruction after appendectomy.


Bünyami OZOGUL (Erzurum, Turkey), Sukru ARSLAN, Esra DISCI, Erdem KARADENIZ, Mesut YUR, Atıf BAYRAMOGLU, Mehmet Ilhan YILDIRGAN
11:00 - 18:00 #7871 - Current specialists training of Emergency Medicine in Kanta-Häme Central Hospital, Finland.
Current specialists training of Emergency Medicine in Kanta-Häme Central Hospital, Finland.

Background

Emergency medicine (EM) became a full-length specialty in Finland in the beginning of 2013. To date, more than 10 hospitals are offering EM specialist training. Our EM specialist training is based on the European Curriculum for Emergency Medicine and comprises a six-year program including systematic theoretical and practical training.

The Kanta-Häme Central Hospital (KHCH) is the fifth largest secondary hospital in Finland offering EM services for 175 000 people and having annually 42 000 visits in the Emergency Department (ED). In KHCH, the EM specialist tuition started on October 1st, 2012, and the hospital is privileged to have the first EM specialist in Finland. Our first-year experiences in EM specialist training have been published earlier (1). In this descriptive study, we present the current situation of the EM training in the KHCH, Hämeenlinna, Southern Finland.

 

Methods

We analyzed the weekly time table of physicians specializing in EM. The study was carried out in the KHCH.

 

Results

In our ED trainees are working in shifts for 18 to 24 hours/week. They are working in the fields of Internal Medicine, Surgery, Neurology, Traumatology, ENT and Paediatrics. The rest of the working week is practiced in education by “learning and doing”. There is one day per week for further theoretical and practical training which is led by specialist of EM or Anesthesiology.

The theoretical part of the day consists of a lecture of Internal Medicine with changing topics.  There are also one to two lectures presented by our own trainees or an appropriate specialist depending of the main topic of the day. The weekly changing main topics are followed by the book of Tintinalli’s Emergency Medicine (2). Since 2008, in the ED of KHCH, there have been lunch time lectures in EM covering both conservative and operative specialties.  The lectures are included in the EM trainees day, but are also mentioned and been popular among the other physicians of the hospital.

To ensure the further practical skills there is hands-on sonography training with on duty Radiologist or EM or Internal Medicine specialists. The main focus of sonography training is in the Focus Assessment with Sonography for Trauma (FAST) and Focus Assessed Transthoracic Echo (FATE). The trainees have the log books to ensure sufficient amount of sonography examinations. Simulations are also a crucial part of the day. These are usually led by Anesthesiologist, and the topics are changing from the care of critically ill patients in ED or pre-hospital emergency services to equipment training or ED protocol testing. In addition, procedural education program includes training by using cadavers for four times a year.

 

Conclusion

The present systematic education program covers well the demands of the EM specialist training.

References

  1. Naskali J., Palomäki A., Harjola V-P., et al. Emergency Medicine in Finland: First Year Experiences of Specialist Training. JAEM 2014; 13: 26-9.
  2. Tintinalli JE., Stapczynski JS., Ma JO., et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th edition, 2015.

Jari YLÄ-MATTILA (Tampere, Finland), Teemu KOIVISTOINEN, Ari PALOMÄKI
11:00 - 18:00 #7486 - Danger in the shopping malls – Escalator related injuries in children.
Danger in the shopping malls – Escalator related injuries in children.

Introduction

Escalator-related injuries are a significant cause of morbidity in highly urbanized Singapore. This study aims to describe the types of escalator-related injuries sustained in children and the circumstances under which they occur so that preventive measures can be put in place

 

 

 

 

 

Methods

This is a retrospective study. The KKH injury surveillance database was reviewed from January 2012 to May 2015 for all patients who presented to the Emergency Department with an escalator related injury. Data on patient demographics, mechanism, nature, site and severity of injury, treatment given and disposition of patients were collected and analyzed.

 

 

 

 

 

Results

92 cases were identified (2.2 incidents per month) during the study period. 63% were males and the mean age was 5.34 years.  61.9% of the injuries involved falls, followed by entrapment (31.5%) and mechanical failure of the escalators (2.2%). The injuries sustained included open wounds (45.7%), sprains/contusions (40.2%), superficial injuries (20.7%) and fractures (13%). 22.8% of the escalator related injuries involved the use of strollers and the majority of incidents occurred at shopping centres (53.3%) and MRT Stations (15.2%). 23.1% of patients required admission to hospital of which 4 patients required inpatient surgical intervention

 

 

 

 

Conclusion

Despite the measures already in place to ensure escalator safety in Singapore, there is still a significant number of escalator related injuries in children, most of which are preventable. The stroller is the commonest object involved in escalator related injuries and simple measures can be put in place such as the installation of barriers to prevent the use of strollers on escalators

 


Sharon, Si Min GOH, Sharon, Si Min GOH (Singapore, Singapore), Arif TYEBALLY, Shu-Ling CHONG
11:00 - 18:00 #8215 - De Winters ST-T syndrome : an early sign of ST segment elevation myocardial infarction.
De Winters ST-T syndrome : an early sign of ST segment elevation myocardial infarction.

INTRODUCTION :

An ST-segment elevation is usually predictive of myocardial infarction. Several other electrocardiogram abnormalities, referred to as ST segment elevation myocaridal infarction (STEMI)equivalents", should also alert the clinician to early identification and aggressive intervention.

CASE REPORT:

A 52 year old female patient presented to the emergency department (ED) with chest pain occured 1 hour before ED admission. She had a past history of  hypertension. She had no other cardiovascular risk factors. On physical examination : the patient was alert, the blood pressure was 110/66 mm hg, the heart rate was 98 bpm and respiratory rate was  22 breaths per minute, the oxygene saturation was 97% on air room.  The Admission electrocardiogram (ECG)  showed  an ST segment depression of 1 mm in the lateral leads.  Within 40 minutes the patient presented recurrence of a typical constrictive chest pain with nausea and vomiting . The concomittant ECG showed an ST elevation in DI and AVL leads and in the AVR lead of 1 mm, an ST depression in inferior leads and an up sloping ST depression at J point  with peaked  T waves in the anterior precordial leads. The diagnosis of De winter complex, a STEMI equivalent, was made. She received 250 mg of aspirine, low weight subcutaneous heparine and 300 mg of clopidogrel.  Monitoring of ECG showed an ST elevation of 4mm  in V1-V6 leads confirming an obvious STEMI diagnosis. The patient successfully underwent pharmacological reperfusion. Coronary  angiography  showed a  95% subocclusive lesion in the Proximal left anterior descending (LAD) artery.

CONCLUSION :

De winters syndrome on ECG is a specific pattern of STEMI equivalent. Approximately 2% of similar cases have proximal LAD occlusion.  Identifing this specific ecg pattern is challenging for the emergency physician. Thus, recognizing De winter syndrome is important,  and adequate treatment should not be delayed or missed.


Ahmed SOUYEH (tunis, Tunisia), Anware YAHMADI, Rania JEBRI, Hanane GHAZALI, Cyrine KESKES, Mohamed MGUIDICH, Bouthaina LOUHICHI, Sami SOUISSI
11:00 - 18:00 #8073 - Dear SIRS, you can be SWEET but I hate you! A sweet syndrome mimiting severe sepsis.
Dear SIRS, you can be SWEET but I hate you! A sweet syndrome mimiting severe sepsis.

Introduction

Skin disorders are common on emergency department especially when associated with fever. Twenty five percent to forty percent are related to a decompensation of a preexisting skin disorder [1]. In 1964, Sweet describes a “strange eruption” which is immunologically mediated and since that date the dermatitis bears his name [2].In the emergency department, the diagnosis of this pathology may be difficult especially when the presentation is severe or associated with fever since it face the physician to a therapeutic dilemma: giving antibiotics or steroids.

Case presentation

 

A 43 years old man with no past medical history was transported to the emergency department by the mobile emergency service with a chief complaint of weakness and fever associated with a disseminated skin eruption. he was conscious but very weak and he has fever about 28.5°C. SBP/DBP was about 90/60 mmHg and HR about 96 per minute. Initially he was managed as severe septic syndrome since we found nitrites in urine sample associated with SIRS. A PCT was performed and the amount was less then 0.5ng/ml so we performed a skin biopsy which showed a neutrophilic infiltration consistent with Sweet syndrom. The patient was given steroids and had noticeable improvement of his complaints. 

 

Conclusion

 

Sweet syndrome is a possible diagnostic in patient with skin eruption and non infectious SIRS in the emergency department

 


Majed KAMEL, Mohamed Amine KALLEL (tunis, Tunisia), Khedija ZAOUCHE, Hamida MAGHRAOUI, Chekib BOUALI, Jobrane MANSOURI, Chokri HAMMOUDA, Nebiha FALFOUL BORSALI
11:00 - 18:00 #8117 - Defibrillation success in out-of-hospital cardiac arrest: How important is recurrence of ventricular fibrillation after successful shock?
Defibrillation success in out-of-hospital cardiac arrest: How important is recurrence of ventricular fibrillation after successful shock?

Purpose of the study
In out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) guidelines recommend defibrillation with biphasic shock[1], followed by chest compressions for two minutes before analyzing shock success. If then VF is detected again, it is unclear whether VF sustained or - after being terminated by defibrillation - recurred within the two-minutes-cycle of chest compressions[2]. We investigated the frequency of persistent versus recurrent VF under chest compressions after defibrillation with rectilinear biphasic shock.

Materials and Methods
In Marburg-Biedenkopf-County, Germany (252,000 inhabitants), we enclosed 20 consecutive cases (starting March 2015) in a retrospective study of resuscitation attempts by ALS-ambulance in OHCA with initial VF. ECG recordings of the defibrillator corpuls3 were analyzed by three independent investigators from the beginning of the CPR until two minutes after the third shock. ECG was edited with filters from 2-10 Hz to reduce chest compression-artifacts.  Successful shock was defined as termination of VF within 5 seconds after the shock[3]. A relapse was defined as recurrent VF in the interval between 5 seconds after a shock and the following shock.

Results
We analyzed 54 shocks of 20 patients. 68.5% of the shocks were successful (n=37), but the recurrence-rate of VF was 81.1% (n=30). Shock 1 (n=20) was successful in 75% (n=15), VF-recurrence-rate 86.7% (n=13). Shock 2 (n=18) was successful in 72.2% (n=13), VF-recurrence-rate 84.6% (n=11). Shock 3 (n=16) was successful in 56.3% (n=9), VF-recurrence-rate 66.7% (n=6).

Conclusions
Although VF was terminated by rectilinear waveform defibrillation in 69%, VF recurred within the two minutes of chest compressions in 81%. Since it is unclear to which extend chest compressions influence the risk of VF-relapse after successful shock, further studies need to re-evaluate the best shock-compression-analysis algorithm for OHCA with initial VF.

References
1. Resuscitation. 2005 Aug;66(2):149-57.
2. Circ Arrhythm Electrophysiol. 2010 Feb;3(1):72-8.
3. Resuscitation. 2011 Jun;82(6):685-9.


Martin C. SASSEN, Dana M. SPIES, Birgit PLÖGER, Susanne SCHAUMBERG, Clemens KILL (Essen, Germany)
11:00 - 18:00 #7275 - DEGREE OF KNOWLEDGE AND ACCEPTANCE OF THE BULLETIN ABOUT MICROBIOLOGICAL INFORMATION AND CONSUMPTION OF ANTIBIOTICS AMONG HEALTH PROFESSIONALS OF AN EMERGENCY SERVICE.
DEGREE OF KNOWLEDGE AND ACCEPTANCE OF THE BULLETIN ABOUT MICROBIOLOGICAL INFORMATION AND CONSUMPTION OF ANTIBIOTICS AMONG HEALTH PROFESSIONALS OF AN EMERGENCY SERVICE.

INTRODUCTION

The National Action Plan on Antibiotic Resistance includes up to 12 vital actions in the fight against bacterial resistance, including local dissemination of information among health professionals is included. Since 2008 the Department of Microbiology broadcasts, biannually and in digital formats and paper, the Microbiological Information Bulletin and consumption of antibiotics, which collects information on the percentages of sensitivity to major antibiotics for clinical use in the most prevalent bacterial species in infectious disease. The aim of this study was to describe the degree of awareness and acceptance of the Microbiological Information Bulletin and consumption of antibiotics among health professionals of an Hospital Emergency Department

 

MATERIAL AND METHODS

Observational, descriptive and prospective study carried out between January-March 2016 at the Emergency Department of Univeristario Hospital de La Ribera (Alzira-Valencia-Spain)

The information source for data collection was a survey designed specifically for the study consisted of 10 questions developed in order to know the habits of antibiotic prescriptions from the facultative at the emergency department, their degree of concern in relation to the rational use of antibiotics and bacterial resistance, the knowledge of the levels of resistance to two prototype bacteria (Staphylococcus aureus y Escherichia coli), the Microbiological Information Bulletin and consumption of antibiotics knowledge and the usefulness of its format.

RESULTS

The study involved 83% of the staff, 77.3% men with a mean age of 46±8 years. The 82% of them indicated the prescription of antibiotics more than 3 times a day

The degree of knowledge of BIMCA was 91%, but only 18% knew the resistance levels of ciprofloxacin resistance against Escherichia coli and 36.4% knew the percentage of de S. aureus methicillin-resistant.

A 82% of the facultative interviewed considered useful, quite useful or very useful for daily clinical practice the Microbiological Information bulletins and consumption of antibiotics. The most suitable formats were the electronic (59%), followed by pocket format (41%) which are the currently employed in the Health Department of La Ribera.

CONCLUSIONS:

There is a high degree of awareness and acceptance of Microbiological Information bulletins and consumption of antibiotics by health staff; however a significant proportion of professionals are unaware of the rates of resistance to commonly used antibiotics in bacteria usually frequent. Other complementary measures are necessary to improve the dissemination of information on bacterial resistance in our Health Area.


Maria CUENCA TORRES (VALENCIA, Spain), Javier COLOMINA RODRIGUEZ, Luis MANCLÚS MONTOYA, Miguel MURCIA SOLER, Blanca FOLCH MARIN
11:00 - 18:00 #7058 - Delta neutrophil index as an early predictor of acute appendicitis in adults.
Delta neutrophil index as an early predictor of acute appendicitis in adults.

Background.

The delta neutrophil index (DNI) is new inflammatory marker and this retrospective study aimed to evaluate the ability of the DNI to predict acute appendicitis pre-operatively and to differentiate between simple and complicated appendicitis.

 

Methods.

A data of 650 patients who underwent surgical appendectomy was evaluated. Based on postoperative histopathological examination, the patients were divided into positive and negative appendectomy groups. The patients in the acute appendicitis group were further sub-divided into simple and complicated (perforation, abscess, peritonitis) appendicitis groups.

 

Results.

DNI was significantly higher in positive group than negative appendectomy group (0.4 vs. -0.4, p<0.001). DNI independently predicted positive appendectomy [odds ratio (OR) 2.62, 95% confidence interval (CI) (1.11~6.16), p=0.028]. The optimum cutoff for initial DNI was 0.2, giving a sensitivity of 59.8% and specificity of 77.1% (AUC 0.709). Also, DNI was significantly higher in complicated group than simple appendicitis group (1.2 vs. 0.3, p<0.001). DNI independently predicted acute complicated appendicitis [odds ratio (OR) 4.10, 95% confidence interval (CI) (2.94~5.80), p<0.001]. The optimum cutoff for initial DNI was 0.6, giving a sensitivity of 65.0% and specificity of 71.0% (AUC 0.727).

 

Conclusions.

We suggest that preoperative DNI is a useful parameter to aid in the diagnosis of acute appendicitis and differentiate between simple and complicated appendicitis.


Young Hwan LEE (Anyang, Korea), Hee Cheol AHN, Seung Min PARK, Young Taeck OH, Ji Hun KIM, Moon Sik KIM
11:00 - 18:00 #7061 - Delta neutrophil index as an early predictor of acute appendicitis in the elderly.
Delta neutrophil index as an early predictor of acute appendicitis in the elderly.

Background.

About half of elderly patients with acute appendicitis present with perforation, and the early diagnosis of perforation is known to improve outcome. Serum delta neutrophil index (DNI) is a new inflammatory marker and the present study aimed to evaluate the predictive value of the DNI for the presence of a perforation in elderly with acute appendicitis.

 

Methods.

This retrospective observational study was conducted on 108 consecutive elderly patients (≥ 65 years old) with acute appendicitis treated over a 24-month period. DNI, C-reactive protein (CRP), and white blood cells (WBCs) were measured in an emergency department and investigated with respect to their ability to predict the presence of appendiceal perforation.

 

Results.

Sixty-nine of the 108 patients (median age, 72 years) were allocated to the perforated appendicitis group (63.9%) and 39 to the non-perforated appendicitis group (36.1%). WBC, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and DNI were significantly higher in the perforated group. In multiple logistic regression analyses, initial DNI was the only independent marker that can significantly predict the presence of perforation in multiple regression [odds ratio 9.38, 95% confidence interval (2.51~35.00), p=0.001]. Receiver operator characteristic curve analysis showed that serum DNI is a good predictor for the presence of appendiceal perforation at an optimal cutoff for DNI being 1.4% (sensitivity 67.7%, specificity 90.0%, AUC 0.807).

 

Conclusion.

Clinicians can reliably differentiate acute perforated appendicitis from non-perforated appendicitis by DNI level of more 1.4 or more in elderly patients.


Ji Hun KIM (Anyang, Korea), Young Hwan LEE, Hee Cheol AHN, Seung Min PARK, Oh YOUNG TAECK, Moon Sik KIM
11:00 - 18:00 #7913 - Descriptive analysis of the comorbidities associated with acute heart failure patients who consult our Emergency Department.
Descriptive analysis of the comorbidities associated with acute heart failure patients who consult our Emergency Department.

Introduction:

Acute heart failure is a common reason for consultation in the emergency department (ED), and the leading cause of hospitalization in the elderly. With high mortality and large number of reconsultations that impact both economically and in the health of patients visiting EDs.


Objective:

Describe the co-morbidities associated with acute heart failure patients who consulted in our Emergency Department.


Material and methods:
Prospective observational study without intervention was performed in patients who came to our SU for acute heart failure (AHF) according to Framingham criteria in the period 2012-2014 choosing two randomized months per year. Inclusion criteria: patients older than 18 years with ICA and give their written consent. The study variables were: Hypertension (HTN), diabetes mellitus (DM), dyslipidemia (DLP), ischemic heart disease (IHD), chronic kidney disease (CKD), Fibrillation Blood (FA), Arteriorpatia, atheromatous plaques in supra-aortic trunks , valvular heart disease, chronic obstructive pulmonary disease (COPD), dementia, neoplasia, cirrhosis and the presence or absence of episodes of previous heart failure.

Results:
During the 2012-2014 selected 119 patients consulted by ICA of which 115 patients (96.6) were hypertension, 64 patients (53.7%) DM, 52 patients (43.6%) DLP, 45 patients (37 , 8%) CI, 48 patients (49.1%) CKD, 23.5% ACV 28 patients, 65 patients (54%) FA, 15 patients 12.6% of supra-aortic trunks artery disease, valvular heart disease 24 patients 20,1% 35 COPD patients 29.4%, 16.8% dementia 20 patients, 17 patients 14.2% neoplasms, 1 patient 0.84% cirrhosis and 94 patients 78.9% prior ICC.

Conclusions:
- The main pathologies associated with acute heart failure high to low frequency were hypertension, episodes prior to consultation FA, diabetes, dyslipidemia and ERC
- The existence of a previous diagnosis of heart failure appear to be a factor favoring new episodes of acute heart failure.


Paula LAZARO-ARAGUES, Jose Andres SANCHEZ-NICOLAS, Patricia SUAREZ-BEKE, Irene PAGAN-GOMEZ, Juan Jose BALLESTER LOPEZ, Emilio SANCHEZ-PARRA, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7416 - Descriptive analysis of the complaint letters sent to two emergency departments.
Descriptive analysis of the complaint letters sent to two emergency departments.

Introduction: Over the last few years there has been an increase in litigation against doctors. In the USA, one out of six physician is facing malpractice claims. Emergency departments (ED) are particularly vulnerable to this risk. This phenomenon causes modifications in the ways of practicing medicine, among those, over-prescription of complementary exams. Too few studies exist on the analysis of the content of complaints letters. Even though, it is now admitted that the number of complaints is a good indicator of the quality of care. Structural evolution of two EDs motivated the qualitative analysis of complaints.

Methods:  We conducted a retrospective multicenter within a hospital group of two EDs from June 2014 to June 2015. The letters were anonymised allowing a blind analysis of their content. Results are expressed in means and interquartile, median and standard derivations, and percentages.

Results: A total of 43 letters were analysed. The patient’s median age 19 was 56,4 +/- 21,2 years old with a majority of women (62,7%). The patients wrote the letters themselves in most cases (60,5%). The main reasons for writing were communication default (32,7%), a suspicion of medical error (30,2 %), malicious act (stealing or loosing of personal objects) (23,3 %). The waiting time was only mentioned in one complaint letter. The patients concerned by these complaints were managed in the medical ward (44,3%), the traumatology ward (41,7%), gynaecology (5,6%) and psychiatry (2,8%). The analysis of the repartition over time did not show a correlation between the number of complaints and the residents shifting period or the more crowded periods in the EDs. Sub group analysis according to age or care ward did not show a difference in the number of complaints.

Discussion: Our results are concordant with the current literature. Communication remains the main reason for writing a complaint letter. One of the limits of this work is the necessity to write, during this period, 11 patients transmitted their complaints during a visit and not by writing. The small number of complaints did not allow pertinent sub groups analysis. The blinded analysis did not allow to confirm the suspicion of medical errors. 

Conclusion: The principal reasons for writing a complaint letter were human factors for which an intervention such as specific staff education sessions could be suggested. Communication in the ED remains a key element to improve.


Jennifer TRUCHOT (Paris), Anthony CHAUVIN, Bertrand GALICHON, Gina KRUNIC, Fabien MARTINEZ, Jean Paul FONTAINE, Patrick PLAISANCE
11:00 - 18:00 #8213 - Descriptive population-based study of emergency medical services-attended out-of-hospital cardiac arrests in children in Belgium.
Descriptive population-based study of emergency medical services-attended out-of-hospital cardiac arrests in children in Belgium.

 

OBJECTIVES: Analysis of real-life clinical data to obtain more information about the circumstances and outcome of paediatric out-of-hospital cardiac arrests (OHCA) in Belgium.

 

METHODS: Retrospective study of a prospective population-based registration of all physician-attended (MUG) emergency medical services (EMS) interventions concerning paediatric OHCA in Belgium between 2010 and 2012.

 

RESULTS: During a 3-year period we noted 365 OHCA in 18295 paediatric MUG interventions (2%). In 260 cases (71.2%) CPR was performed. The initial rhythm was shockable (ventricular fibrillation) in only 13 cases (5%), all other presented with an initial non-shockable rhythm. Overall, defibrillation with one or more shocks was performed in 37 cases (14.2%).

In the majority of cases (59.2%) a medical problem was presumed to be the underlying aetiology, of which respiratory failure was the most registered (n = 69). In 106 cases (40.7%), an ‘external’ cause was reason for the OHCA: traffic accidents in 30 cases, followed by drowning (n = 22), strangulation (n = 16) and falls from height (n = 11).

Eventually 133 children were transported to the emergency department (ED), with return-of-spontaneous-circulation (ROSC) obtained in 42 cases. Only 79 children reached the ED ‘alive’, either after ROSC or with ongoing CPR. Of those 79 children, 70 had an non-shockable and 9 a shockable rhythm on arrival of the EMS team. The percentage of ROSC in those children with an initial shockable rhythm was 69.2% (9 out of 13).

 

DISCUSSION: Paediatric OHCA luckily remains a relatively rare event. It is estimated that each Belgian medical EMS team (MUG) will encounter less than 2 paediatric cardiac arrests yearly. There is therefore a clear risk for team members of being insufficiently prepared if not regularly retrained.

In about 30% of paediatric OHCA the child is considered beyond rescue and no CPR is started. In children where CPR was started, only a small group had an initial shockable rhythm. This resulted in an excellent short-term prognosis with sustained ROSC in 69.2%.

However for the larger group with initial non-shockable rhythm prognosis is much more reserved (13.4% sustained ROSC). This number is in contrast to the number of children that are transported from scene to the ED (51.2%). Importantly 40.6% of the latter were proclaimed dead during transport. In another 27.8% CPR was ongoing at ED arrival. We presume these numbers partially can be explained by ‘slow code’ (Bossaert et al., Resuscitation 95 (2015) 306).

The principal underlying identified aetiology is a medical problem, more specifically respiratory failure. Presumably this also includes cases of sudden unexplained death of infancy (SUDI). Importantly, external causes make up more than 40% of all OHCA (with CPR). Initiatives focussed on prevention might therefore save more lives than any CPR ever will.

This study gives insight into the circumstances and short-term outcome of paediatric OHCA in Belgium. It is however based on an administrative database and lacks important information on long-term outcome or more concrete information of individual cases. Large population-based registries are needed to guide our efforts and decision making. 


Sophie VANDEPLASSCHE (Dentergem, Belgium), Patrick VAN DE VOORDE
11:00 - 18:00 #7687 - Descriptive study of the assistant activity of a dispositive of emergencies and critical care.
Descriptive study of the assistant activity of a dispositive of emergencies and critical care.

Introduction: Primary health care is the first level of access of the population to the health system in which the Dispositive of Emergencies and Critical Care (DECC) is the first link of the assistant chain to out-of-hospital emergency services.

In these requests of emergency situations, a quality health assistance must be guaranteed as quickly as possible. All together, along with the poor bibliography on this topic, led us to outline this study.

Objectives: To describe the health care activity of the DECC of La Rinconada, according to its demographic features, assisted pathologies, ambulance arrival time, and concordance between the DECC and hospital diagnoses. As well as the relation between the analyzed variables.

Methodology: Descriptive, transversal and retrospective study carried out during the year 2014 .To calculate the sample size stratified probability sampling , depending on the seasons was performed .The size of the sample determined to a confidence level of 95% and an accuracy of 3 % , was 185 subjects . Finally, a representative sample of 206 patients of all patients seen was selected.

Conclusions: The highest percentage of assistances is: people over 60; female; day of the week: Monday; time, from 8 to 12 a.m.; seasons: autumn and winter. The most frequent pathologies are: neurological, cardiovascular and respiratory, in that order (there are slight differences of percentage in terms of age and season). Most cases are priority 2 (no emergency demorables), there is also a percentage of cases Priority 3 which wouldn’t be attended by the DECC. Arrival times is right, but in Priority 1, it can be improved. The percentage of patient referrals might seem high but more than 50% of those are hospitalizations. The diagnostic agreement between DECC and the hospital is high, but only to a limited extent. On the basis of the results; preventive, instructive and organizational measures should be introduced in order to respond to the needs of the attended population and also to set up other lines of research, allowing a better understanding of the emergency care.


Maria GIL LOPEZ (OSUNA, Spain), Elena PRADO MEL, Almudena LOZANO VICENTE, Jose Ignacio VILLAR NAVARRO
11:00 - 18:00 #4959 - Detection of pneumothoraces in patients with multiple blunt trauma: Use and limits of eFAST.
Detection of pneumothoraces in patients with multiple blunt trauma: Use and limits of eFAST.

Background:

Trauma patients are commonly evaluated in the trauma room by extended focused assessment with sonography for trauma (eFAST), but pneumothoraces (PTXs) are often missed. Little is known about the location or size of these missed PTXs in trauma patients with multiple blunt trauma and clinical predictors for successful detection are unclear.

Methods:

This cross-sectional study includes all patients with multiple blunt trauma and PTX who were admitted to the emergency department of a level 1 trauma centre in Bern, Switzerland between June 1, 2012 and September 30, 2014 (n=109). eFAST was performed in the trauma room by consultants in emergency medicine. Demographic data, imaging modalities, medical data on admission and preclinical suspicion of pneumothorax were compared in patient groups with and without PTXs detected in eFAST, compared with CT, using the Mann-Whitney U or Pearson’s chi-square tests. Univariate binary logistic regression models were used to identify predictors for detection of PTXs.

Results:

The patients with missed PTX were younger (51.6±18.5 vs. 44.3±19.8 years, p=0.049). The group of missed PTXs contained significantly fewer ventral PTXs (30 (47.6%) vs. 4 (9.3%), p<0.001), but more apical and basal PTXs (7 (11.1%) vs. 15 (34.9%), p=0.003;11 (17.5%) vs. 18 (41.9%), p=0.008, respectively) .  The PTXs missed in the eFAST examination were smaller on both sides (left side: 30.7±17.4  vs. 12.1±13.9 mm; right side: 30.2±10.1 vs. 6.9±10.2mm, both p<0.001). More rib fractures were found in patients with detected PTXs (54 (84.1%) vs. 30 (69.8%), p<0.046) In univariate analysis, we found that the preclinical suspicion of PTX was associated with the detection of PTXs in eFAST in all PTXs  (p<0.001, OR 7.002 (2.801; 17.507)) as well as in the subgroup analysis of patients who needed thoracic drainage (p=0.004, OR 10.487 (2.117; 51.944)).

Conclusion:

Our study demonstrates that missed PTXs are smaller and in more atypical locations than those detected in eFAST. Missed PTXs less often need treatment with thoracic drainage. There was no example of an unstable patient whose instability was linked to the missed PTX. Preclinical suspicion of PTX is strongly associated with the detection of PTX in eFAST and deserves special attention.


Thomas C SAUTER (Bern, Switzerland), Simon HOESS, Beat LEHMANN, Aristomenis EXADAKTYLOS, Haider DOMINIK
11:00 - 18:00 #8012 - Determination Of Knowledge, Attitudes and Behavior of Emergency Medical Service Employees About Ecg in Edıirne.
Determination Of Knowledge, Attitudes and Behavior of Emergency Medical Service Employees About Ecg in Edıirne.

One of the most important factors in the management of emergent cardiac diseases is early diagnosis. In this context,one of the the most important helpful tool of  emergency medical personnel in the diagnosis is electrocardiography. It is very important to  have sufficient experience and knowledge of health personnel in the unit which they work. Correct record and interpretation of ECG is very important for the detection of forming life-threatening cardiac pathologies. In this study, it is aimed to investigate the knowledge, attitude and behavior of emergency mecial staff  who work in Edirne and counties. This study was conducted through face to face interviews with paramedics and emergency medical technicians who work in112 emergency stations of Edirne and provinces. The data of questionnaire were entered into SPSS statistical analysis package and statistical analysis was performed. When the answers were evaluated on the questions asked about the recognition of  and performing electrocardiogram; it was seen that; a majority of them evaluate themselves enough about electrocardiograph and electrocardiogram performing, while a relatively small part of them think that; they are not enough about evaluating electrocardiogram paper. But only two-thirds of  them declared that; they perform electrocardiogram in a situation of  abdominal pain that can be a sign of life-threatening acute inferior myocardial infarction. In light of the data obtained from this study; paramedics and emergency medical technicians who work in 112 stations of Edirne city center and towns know rhythm analysis, speed measurement, wave patterns and questions for assessing ST-segment abnormalities and electrocadiogram performing purpose of the, were correctly at high rates. The importance of continuity of education on this issue has arisen once again.


Ozan OZISIK, Mustafa Burak SAYHAN (EDIRNE, Turkey), Omer SALT
11:00 - 18:00 #7236 - Detoxification with endoscopy – removal of metallic mercury from the gastrointestinal tract.
Detoxification with endoscopy – removal of metallic mercury from the gastrointestinal tract.

Background: Ingestion of metallic mercury was thought to be innocuous until the middle of 20th Century. Several cases proved the opposite, when aspirations, acute renal failure, liver function impairment and memory deficits developed after mercury ingestion. Management includes gastric lavage, use of osmotic laxatives and chelating agents. Despite the treatment, systemic intoxication may occur, therefore more efficient method of treatment is needed to avoid the possible negative consequences. Case report: We report a case of an 18-year-old man, who attempted suicide with drinking 1000 g of elemental mercury. He was brought by ambulance 3 hours after ingestion to our emergency department. He complained of periumbilical pain, vital signs were normal. Physical examination revealed abdominal tenderness. Laboratory values were normal, except from elevated AST and ALT, which were the same as the laboratory results a year ago. His blood mercury level was normal, while urine mercury level was slightly elevated when measured on day 3 from exposure. Radiograph was performed and showed one large opacity at the region of the stomach or in the jejunum. The National Toxicology Information Center was consulted, and based on the information given we decided to remove the mercury from the gastrointestinal tract with gastroscopy. During gastroscopy, one large and several smaller mercury beads were seen and removed with suction. The food debris prevented the complete removal of mercury. The follow-up radiograph showed scattered opacities in the small bowels. After the removal, the patient was transferred to intensive care unit, then to psychiatry. During the 3 month follow-up period no symptoms or any physical problem developed. Discussion: We applied gastroscopy as management of massive metallic mercury ingestion, which has not been published yet in the literature. With endoscopy we could prevent aspiration, shorten exposure time, therefore we minimalized the risk of intoxication. We conclude that endoscopy is a safe way to manage massive elemental mercury ingestion.


Zag LEVENTE, Zag LEVENTE (Kecskemét, Hungary), Berkes GABOR, Takacs IRMA, Szepes ATTILA, Szabo ISTVAN
11:00 - 18:00 #7908 - Developing a European Geriatric Emergency Medicine Curriculum.
Developing a European Geriatric Emergency Medicine Curriculum.

Introduction
Older people represent a growing proportion of attendees in Emergency Departments across Europe. Traditionally Emergency Departments have not focused on care for older people especially those with frailty. Similarly, geriatric services have not traditionally focused upon the care of older people in Emergency Departments. This work seeks to bring together the two disciplines of Geriatric and Emergency Medicine through a defined and validated curriculum on Geriatric Emergency Medicine.

Methods
Domains and items for inclusion in the curriculum were derived through a combination of literature reviewing and a nominal group workshop. The domains and items underwent validation using a Delphi technique involving the European Societies of Geriatric and Emergency Medicine.

Results
 In the development stage, 100 individual learning outcomes were identified, reflecting 16 domains. Following the stage 2 validation process, 98 items remained.
All items were approved by the relevant EU societies. In the final validation step, the curriculum was formally approved by the UEMS sections for Geriatric Medicine and Emergency Medicine (responsible for curriculae in the respective disciplines).

Key Conclusions
This curriculum was developed as a formal collaboration between EUSEM and EUGMS (European Task Force in GEM) and reflects the need to match the educational development of a workforce with the changing demographic of the patient population. The next challenge is ensuring it is embedded into practice. Future work to address these challenges is underway through the development of a GEM conference, GEM textbook and dissemination of information through journal publication and conference presentations.


Sarah TURPIN (London, United Kingdom), Simon CONROY
11:00 - 18:00 #8170 - Developing patient information leaflets in the emergency care setting.
Developing patient information leaflets in the emergency care setting.

Attendance at Accident and Emergency departments (ED) in the United Kingdom has reached an all time high with 2 million/month for the first time on record(). Now, more than ever, it is key to ensure patients receive timely care. Patient information leaflets (PILs) for common presentations allow health care professionals to disseminate accurate information to patients regarding their diagnosis and aftercare in the fast-paced setting of emergency care.

Junior trainees rotating through emergency medicine training post at Imperial College Healthcare Trust are recruited to develop PILs. Key subjects pertaining to common reasons for attendance are selected and leaflets are developed through experience and by liaising with relevant specialties. The leaflets are initially reviewed by an Emergency Medicine consultant and the patient information management team for suitability.

A plan/do/study/act (PDSA) methodology is employed to trial the PILs on patients who present with relevant conditions. They undergo a questionnaire that includes questions on how useful they find the information, whether accessible language is used and any common questions that remain after reading the leaflet. Based on the results of these questionnaires the leaflets are amended and improved.

The project focuses on empowering patients with information about their reason for attendance and uses a PDSA cycle methodology to ensure continued relevance of the leaflets to patients from year to year. The continued allocation of trainees to this quality improvement project ensures its sustainability while promoting the education in common ED presentations to trainees and inclusion of training doctors in quality improvement projects.


Elaine MORSMAN (London, United Kingdom), Kush JOSHI, Cara LEWIS, Robin CHATTERJEE, Anu MITRA
11:00 - 18:00 #7444 - Developing the mental health aide memoire for adults – A succinct tool for the emergency department psychiatric history.
Developing the mental health aide memoire for adults – A succinct tool for the emergency department psychiatric history.

Background and Aims

 

Between late 2010- early 2012 there were more than 114000 inpatient admissions each year in England for intentional self-harm, a 7% increase on the previous year. Our hospital is a district general hospital which sees between 500-600 adult patients each year who present with a mental health (MH) issue. In 2015 the Royal College of Emergency Medicine (RCEM) in the United Kingdom released results of a national survey looking at admissions to the Emergency Department (ED) with MH issues. The work by RCEM looked at 9 standards that it believed were important when seeing patients with MH issues. This included a risk assessment through to patients after referral being seen by a MH practioner within one hour. Locally and nationally the results across most of these standards were poor.

 

Aims

 

Consequently, we wanted to develop a tool that could be used to capture this key data. It would need to be quick, easy and not onerous to a busy emergency medicine (EM) doctor.

 

Methods

 

We audited the department against the RCEMs standards pre development of the tool. We then with our psychiatric liaison colleagues designed a 2 paged, A4 size document encompassing what was required by RCEM.  It also includes tailored questions, sensitively written to identify those highest at risk. The form takes between 2-3 minutes to fill in. Subsequently we re audited the use of the tool.  

 

Results

 

We saw a 40% improvement across the whole spectrum for documentation for the RCEM standards. Also, overall documentation for psychiatric patients has improved dramatically.

An unexpected benefit, was our junior doctors who often have never worked in a psychiatric job found the form very useful. They found the wording of the questions, helpful when seeing MH patients. Our psychiatric liaison team report improved referrals and thus helping them with patient management.

 

Conclusion

 

Our 2-page form has helped to revolutionise how we receive a MH history from our patients. Its quick, friendly for the psychiatric novice and hopefully is assisting with patient care. The form is being further updated and improved, with aim to role it out trust wide. 


Sarah EDWARDS (Leicester, United Kingdom), Helen SALTER
11:00 - 18:00 #7733 - Development and validation of The Copenhagen Triage Algorithm (CTA).
Development and validation of The Copenhagen Triage Algorithm (CTA).

Background

The aim of triage is to quickly identify the most urgent patients in the emergency department (ED) and to secure that they are treated first, thereby minimizing the risk of adverse outcomes. However, the triage models are time consuming and supported by limited evidence and could potentially be of more harm than benefit. Our aim is to develop a quicker triage model that is able to identify high risk patients.

Methods

The CTA was developed using datasets from two large cohorts of patients admitted to an ED. The first cohort (Triage I study) included 6005 admissions and the second cohort (Acute Admission Database) included 6279 patients) Triage I was used to construct the score, and the Acute Admission Database was used as the validation cohort. We used the vital signs as measured on admission in the ED, separating the normal values from the 10 % most extreme values of each vital sign. These were entered into a multiple logistic regression with backwards elimination to determine the significant risk factors of higher 30-day mortality. The odds ratios (OR) for each factor were rounded to construct a clinical risk score. The respective scores were divided into a 4-level score according to the patients’ risk of 30-day mortality.

Results

The significant (all P <0.01) risk factors were: Treatment with oxygen (OR 4.3, corresponding to a score of 4 points), systolic blood pressure <100 mmHg (OR 3.3, 3 points), heart rate >110 beats per min (OR 2.1, 2 points), respiratory rate >22 per min (OR 2.7, 3 points), and arterial oxygen saturation < 94 % (OR 1.7, 2 points). On a Receiver Operating Characteristic curve the resulting score has an AUC of 0.78. That is significantly (P < 0.01) higher than DEPT for the same population (AUC 0.64). This significant improvement persisted in the validation cohort.

The resulting CTA stratifies patients in 4 acuity levels (patients with minor injuries (level 5) are excluded) and this is done in two steps. (1) A scoring chart based on vital signs is used to classify patients in a category, and (2) a clinical assessment by the ED nurse can alter the result suggested by the score up to two classes up or one down.

Conclusion

We have constructed and validated a new quicker triage model with a stronger ability to predict 30-day mortality than the existing DEPT model. CTA still needs prospective validation in a randomized controlled trial to evaluate the effect on mortality and flow in an ED.


Rasmus Bo HASSELBALCH (Copenhagen Ø, Denmark), Mia PRIES-HEJE, Louis LIND PLESNER, Lisbet RAVN, Morten LIND, Rasmus GREIBE, Birgitte NYBO JENSEN, Lars S. RASMUSSEN, Kasper IVERSEN
11:00 - 18:00 #4564 - Development of a collaborative competency-based emergency nursing education program in Region Sjaelland, Denmark.
Development of a collaborative competency-based emergency nursing education program in Region Sjaelland, Denmark.

Emergency nurse skills-based education in Region Sjaelland, Denmark is not standardized between its four hospitals, resulting in variability of emergency nursing practice. To address this lack of standardization and raise overall competency levels, emergency nursing leaders from Region Sjaelland partnered with nurse specialists from Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, forming a task force to develop a standardized approach to regional ED nurse education. 290 nurses who staff the four EDs in Region Sjaelland, which serve a population of 817,000, will participate in the regional program.

Initially, a needs assessment was conducted to assess nurse competency in 202 essential ED nurse clinical and administrative skills. Nurses and their supervisors were asked to rate skills competency on a scale of 0 to 4, with proficient being a score >=3. On average, nurses scored themselves proficient in 20.8% of skills; while leadership scored their nurses as proficient in 30% of skills. At the time of the survey, 26% of staff nurses felt they were not adequately prepared to perform their job without supervision.

The task force identified the AACN’S Synergy Model as a theoretical framework for their work. Synergy occurs when emergency nurses competencies align with the needs of the patients they care for. To address the regional competency gap, the task force decided to implement a standardized educational program, that uses skills stations, taught during “nurse competency days,” to review and validate skills. In the first year, 34 competencies and assessments will be validated through 5 themed skills stations, taught during competency days scheduled at each hospital. A team of 32 nurse trainers completed a regional train-the-trainers course and will facilitate the education. Additional basic or lower risk competencies will be addressed through eLearning, simulation, and frontline education.

Through the empowerment of the task force, Region Sjaelland has developed the first standardized, competency-based emergency nursing education program in Denmark.


Shelley CALDER, Jette JENSEN, Poul MOSSIN, Gitte Juul HANSEN, Tove FUGLEVIG, Stive Lovise NIELSEN, Tom HANSEN (Nykøbing F., Denmark), Christina Ørsted RASMUSSEN, Iben RIIS, Peter SCHLIEMANN, Meaghan CUSSEN, Jonathan EDLOW
11:00 - 18:00 #7614 - Development of a nurse led pathway for patients presenting to the emergency department with renal colic.
Development of a nurse led pathway for patients presenting to the emergency department with renal colic.

 

Introduction

Following the successful introduction of a nurse led PV bleed pathway into a District Hospital Emergency Department the authors decided to examine other conditions whereby the patient can be safely discharged by a nurse following a strict inclusion/exclusion criteria and discharge plan. Having been successfully implemented elsewhere in the UK (Cherry 2005) the authors decided to develop a pathway for Renal Colic.

Method

In establishing exclusion criteria the authors agreed on the following presentations; evidence of hypovolaemia or shock, urinalysis positive to leucocytes or nitrites, positive pregnancy test, pyrexia, testicular pain, pre existing aortic aneurysm or over 50 years age. This criteria was established as a safety net to ensure other potential causes of the pain are not overlooked, some of which could be life threatening. This follows a similar criteria used by Cherry (2005) who found their approach to be safe and effective. Kartal et al (2006) suggests using major symptoms in a renal colic algorithm so the inclusion criteria was established as unilateral abdominal/back/flank pain with a urinalysis positive to blood.

The pathway then moves on to a plan of care including pain management based on recommendations in the literature (Kastner & Tagg 2003) to give 100mg diclofenac PR and cocodamol 30/500 x2 PO or alternatively tramadol and paracetamol for those sensitive to the previous.

The pathway also includes taking routine bloods which if found to be abnormal the patient should be referred to ED physician. The end of the nurse led protocol is to book a CT KUB or ultrasound KUB (females of child bearing age). These investigations will provide a definitive diagnosis of renal colic.

Discussion and implications for practice.

The protocol will be rolled out in a district hospital emergency department where renal colic is a common presentation. Prior to implementation the list of medications nurses can prescribe on a Patient Group Directive will need to be addressed and liaison with radiology to accept nurse led referrals based strictly on this protocol.

Conclusion

It is anticipated the use of the protocol will be audited to ensure its safety and efficacy.

 

References

Cherry,M (2005) A nurse led fast track service for patients with renal colic. Emergency Nurse. Vol.13, no.8, pp.26 – 29

Kartal,M et al (2006) Prospective validation of a current algorithm including bedside US performed by emergency physicians for patients with acute flank pain suspected for renal colic. Emergency Medicine Journal. Vol.23, pp.341 – 344


Mohammed IRBASH (IPSWICH, United Kingdom), Wendy DUARRI
11:00 - 18:00 #7610 - Development of a proforma for patients presenting to the emergency department following overdose.
Development of a proforma for patients presenting to the emergency department following overdose.

Introduction

An audit was undertaken in a District Hospital Emergency Department on all patients presenting with an overdose to evaluate if paracetamol and salicylate levels are required on all patients. The conclusions drawn from the audit suggested that given both the potential lethality of paracetamol and the high incidence of ingestion in overdoses, levels should still be taken. In the case of salicylate, however, due to the relatively low rates of salicylate poisoning and the overt signs and symptoms in the case of poisoning, the authors questioned whether they should continue to routinely take salicylate levels on all overdoses. Indeed, it has been suggested that there is no need to take salicylate levels in conscious patients who deny taking salicylates and have no clinical features of toxicity (Watson et al 2002). However, due to the wide variations in practice in recording clinical manifestations it has been suggested that a preformatted admission chart is utilised on all overdoses (Buckley et al 1999).

Method

The authors have developed a proforma to be introduced for all patients presenting with overdose. The proforma includes a section on presenting history with time of ingestion of substances. In addition the authors have included a detailed list of signs and symptoms of salicylate poisoning including sweating, nausea, vomiting, bounding pulse, tinnitus, agitation, fitting and reduced GCS (Wood et al  2009). The proforma recommends if any of these signs are present bloods should be taken for salicylate levels. In addition, a blood gas is also recommended as salicylate poisoning initially produces a respiratory alkalosis leading to a metabolic acidosis in severe poisoning (Wood et al 2009).

The authors have also included other prompts on the proforma that are necessary in patients presenting with an overdose. These include gaining information from Toxbase, Mental Health Risk assessment and referral to Pyschiatric Liaison.

Discussion and implications for practice.

It is anticipated that the use of this chart should standardise documentation within the department. Indeed during the audit one of the findings was that documentation in the department was poor for patients presenting with overdose.

Conclusion

The profoma will be rolled out into practice and it is anticipated that further audit work will be carried out to determine its effectiveness in terms of cost of laboratory work and documentation.

References

Buckley,NA, et al (1999) Preformatted admission charts for poisoning admissions facilitate clinical assessment and research. Annals Emergency Medicine. Vol.34, pp.476 – 82

Sporer,KA and Khayam-Bashi,H (1996) Acetaminophen and salicylate serum levels in patients with suicidal ingestion or altered mental status. American Journal of Emergency Medicine. Vol.14, no.5, pp. 443 – 46

Watson,I et al (2002) Laboratory analyses for poisoned patients: joint position paper. Annals Clinical Biochemistry, vol.39, pp.328 - 339

Wood, DM, Dargan, PI and Jones AL (2005)  Measuring plasma salicylate concentrations in all patients with drug overdose or altered consciousness: is it necessary? Emergency Medicine Journal. Vol.22, pp.401 - 03


Mohammed IRBASH (IPSWICH, United Kingdom), Wendy DUARRI
11:00 - 18:00 #7582 - Development of a web-based tool to facilitate the admission process at Swedish emergency departments.
Development of a web-based tool to facilitate the admission process at Swedish emergency departments.

Emergency department (ED) crowding is an internationally increasing problem that has negative effects on clinicians’ workload, patient experiences of the quality of care provided and ultimately patient safety. Previous research concludes that there is need for new innovations in order to get an overview of ED crowding and find solutions to deal with it. One aspect contributing to ED crowding is long boarding times (the time interval from where a decision about admission to in-hospital care is taken until the patient physically leaves the ED). However, it is often difficult to easily overview the amount of ED boarders.  In order to visualize ED patients boarding time and to facilitate the admission process of ED patients to in-hospital care a computerized web-based tool has been developed at the department of emergency medicine at Karolinska University Hospital in Stockholm, Sweden.

The web-based tool is easily reached from a computers web browser it visualizes and logs different activities during the patients’ ED visit. For example the amount of patients that are currently registered at the ED, time to triage, time to physician, ready for admission and the boarding time that follows before physically leaving the ED. When a physician makes a decision that a patient shall be admitted to in-hospital care the physician creates an activity log in the electronic patient record that says “ready for admission”. Since the tool is linked to the patient record, the patient will now show up in the tool along with information such as personal number (not accessible for all users, depends on their level of security), triage level, chief complaint, ED medical section, which in-hospital ward that is preferred, current boarding time, length of stay at the ED and name of responsible physician. This is a cue for the hospital-bed managers at the ED to start searching for an in-hospital bed. The web-based tool draws most of the previously mentioned data from the hospitals electronic patient record (EPR), therefore very little input is required by the physicians and hospital-bed managers to get information into the system.

The web-based tool has been implemented at the department of emergency medicine at Karolinska University Hospital and is primarily used by the hospital-bed managers at the ED. The tool has improved their working environment, workload, and communication with the admitting physician. The tool has also proven to be effective to departments that do not use hospital-bed managers since these departments easily can retrieve information about which patients that are waiting for a bed at their in-hospital wards. All information from the web-based tool is stored in a central data warehouse, outside the EPR, from which data is quick and easy to extract and analyze. This facilitates the possibility to make continuous organizational improvements based on real-time data in a cheap and easy way. The next step is to develop the tool so it can be used for distribution of all in-hospital beds and not only for beds allocated to patients admitted via the ED.


Osvaldo Gonzalez GONZALEZ BALLADARES (Stockholm, Sweden), Lena BERG, Björn AF UGGLAS
11:00 - 18:00 #8131 - Development of compartment syndrome in post resuscitation period: an unusual complication of carbon monoxide poisoning.
Development of compartment syndrome in post resuscitation period: an unusual complication of carbon monoxide poisoning.

Purpose of the study: Carbon monoxide (CO) poisoning is a significant cause of morbidity and mortality worldwide. CO is a colorless, odorless, nonirritating, toxic gas produced by the incomplete oxidation of hydrocarbons. CO poisoning is associated with ischaemia/reperfusion injury and systemic circulation of inflammatory cytokines, which can increase capillary permeability and visceral oedema, ultimately resulting in distant organ injury and development of compartment syndrome. Therefore, CO poisoning constitutes momentous diagnosis in patients admitted to Emergency Departments (ED) and Intensive Care Units (ICU). We report a case of out of hospital cardiac arrest (OHCA) survivor after CO poisoning who developed an atraumatic compartment syndrome of the left lower leg. Case report: A 32-year-old female was admitted to our Institution’s Emergency Department (ED) after OHCA due to CO poisoning. Pre-hospital medical records revealed initial rhythm of asystole that progressed to ventricular fibrillation. Further on the field, she was defibrillated two times, with the return of spontaneous circulation after 30 minutes of advanced-life-support measures being performed. Upon the arrival to the ED, the patient was analgo-sedated, intubated, and mechanically ventilated. Neurological examination revealed GCS 7 (E2, V1, M4), equal pupils (mydriasis), reacting sluggishly to light, and equal left and right motor response. Initial laboratory results conceded of HbCO 33%, pH <6.80, lactate >20, and undetectable pCO2, HCO3 and BE values. In the post-resuscitation period therapeutic hypothermia was maintained for 24 hours. CT angiography demonstrated deep venous thrombosis of right vena poplitea, together with narrowing of left popliteal artery. Therefore, an atraumatic isolated left lower leg compartment syndrome was suspected. Extended laboratory results showed high concentrations of myoglobin (59660), creatine kinase (48469), and troponin T levels (765). The treatment included fasciotomia of the left lower leg, and hyperbaric oxygenation. The patient was discharged from our institution two months after initial assessment to another facility for further treatment, which consisted of multidisciplinary management of various medical specialists. Conclusions: The diagnosis of compartment syndrome requires a high index of suspicion, especially in OHCA survivors, with altered consciousness levels that confound the neurological examination, since it may lead to a vicious cycle that increases morbidity and mortality.


Dr Dinka LULIC (Zagreb, Croatia), Ivan GORNIK, Anita LUKIC, Mirjana MIRIC, Nina CVJETICANIN, Boris TOMASEVIC, Ileana LULIC
11:00 - 18:00 #7084 - Diabetic control and risk of colon cancer: a population-based cohort study.
Diabetic control and risk of colon cancer: a population-based cohort study.

Introduction: The relationship between diabetes and colon cancer has been discussed. However, the effects of glycemic control on colon cancer have never been evaluated. We evaluate the possible relationshipo between glycemic control and colon cancer.

Methods: One million patients from National Health Insurance beneficiaries in Taiwan were sampled. There were 46,804 diabetic patients and 651,759 unexposed subjects. Among patients with diabetes, 1108 had been admitted for hyperglycemic crisis episodes and were defined as diabetes with poor control. All adult patients were followed from 1 January 2005 to 31 December 2013 to evaluate if colon cancer was diagnosed. Cox regression models were applied to compare the hazards adjusted for potential confounders.

Results: After controlling for age, gender, urbanization level, socioeconomic status, chronic liver disease, hypertension, coronary artery disease, hyperlipidemia, malignancies, smoking, chronic obstructive pulmonary disease, obesity, history of alcohol intoxication, chronic renal insufficiency, Charlson Comorbidity Index score and high-dimensional propensity score, the adjusted hazard ratio of colon cancer was 1.90 (95% confidence interval, 1.68—2.15) in patients with diabetes. In diabetic patients with poor control, the hazard ratio of colon cancer was not significant. (hazard ratio, 1.39; 95% confidence interval, 0.72—2.68)

Conclusions: This cohort study reveals a possible relationship between diabetes and colon cancer. However, poorly-controlled diabetes did not seemed to be associated with a higher risk of colon cancer


Chiou Ping CHEN (Chiayi County, Taiwan)
11:00 - 18:00 #7896 - Diagnostic Importance of Hypocalcemia for Pulmonary Emboli in the Emergency Department.
Diagnostic Importance of Hypocalcemia for Pulmonary Emboli in the Emergency Department.

AIM: An acute pulmonary embolism (APE) is a life-threatening cardiopulmonary condition, and diagnosis of the disease in the emergency department is difficult. The aim of this study was to conduct a retrospective analysis of the plasma Calcium (Ca) levels of patients with an APE diagnosis in the emergency department.
MATERIALS-METHODS: Patients presenting to the Abant University Education and Research Hospital emergency clinic with a PE between January 1, 2008, and December 2012 were included in the study. The values of patients with an APE diagnosis and those who presented to the emergency clinic with dyspnea but who were diagnosed with an APE were analyzed.
RESULTS: Two hundred twenty-one patients 67.94±15.49 (112 men and 109 women) with a diagnosis of APE and 165 patients 54.80±18.76 (94 men and 71 women) without APE diagnosis (NPE) were included in the study. The group with the APE diagnosis displayed lower serum electrolyte values compared to NPE diagnosis. In relation to Calcium Levels, the values of the APE group were statistically significant (p<0.05).
CONCLUSION: Abnormalities in serum electrolyte levels are more frequently observed in APE patients, and hypocalcaemia is a frequent occurrence in these patients. There is a relationship between Calcium Levels and PE.


Arif DURAN, Tarık OCAK, Fahrettin TALAY (Bolu, Turkey), Mansur Kürşad ERKURAN, Zehra YAŞAR
11:00 - 18:00 #7490 - Diagnostic Importance Of “Neutrophil Gelatinase-Associated Lipocalin” and “Semaphorine 3A” at “Acute Kidney Injury” Developed Secondary to Experimental Rhabdomyolysis at Rabbits.
Diagnostic Importance Of “Neutrophil Gelatinase-Associated Lipocalin” and “Semaphorine 3A” at “Acute Kidney Injury” Developed Secondary to Experimental Rhabdomyolysis at Rabbits.

Introduction and Objective

         Earliest increase of serum cretinine levels occur within 24 hours, which is used at the diagnosis of acute kidney injury (AKI), and the increase does not happen until 50% of renal functions are lost. This prolonges the time to diagnosis. “Neutrophil gelatinase-associated lipocalin” (NGAL) and “Semaphorin 3A” are new biomarkers for the diagnosis of AKI at early stage. Here, in our study, we aimed to compare the diagnostic importance of “neutrophil gelatinase-associated lipocalin” and “semaphorine 3A” at “acute kidney injury” developed secondary to experimental rhabdomyolysis at rabbits

 Material and Method:

Here in this study, 14 New Zealand male rabbits were used. All rabbits are placed in cages and IV line was established through their right auriculer vein with 20G branule. Blood samples of 3 cc were drawn from each rabbit for the basal values of “serum cretinine”, “serum NGAL” and “serum semaphorin 3A” levels. Later, all rabbits were randomly divided into to 2; “study” (n=7) and “control” (n=7) groups. While 10 ml/kg, 50% glycerol was injected IM on the both back foot of rabbits in the study group in order to create experimental rhabdomyolysis (n=7), no additinal procedure was done for the control group. For to prevent development of acute renal failure due to hypovolemia, 20 cc normal saline solution was infused to all animals. At both groups, 3rd, 12th and 24th hour, “serum NGAL”, “semaphorin 3A” and “cretinine” levels were studied. At the end of the study, following left unilateral nefrectomy, the rabbits were sacrified under high dose of ketamine injection. The development of AKI through kidneys were examined in the pathology department and were classified in 4 levels (such as 0-I-II and III. degree).

Results:

According to pathological findings, AKI did not develop at rabbits in control group, however, in the study group “I. degree” AKI developed at six rabbits and “III. degree” AKI at one rabbit was developed. One of the rabbits in the study group developed “III. degree” AKI, and died before reaching 24th hour. No difference was found at 0. hour “serum creatinine”, “serum NGAL” and “serum semaphorine 3A” median levels between “control” and “study groups”. At 3rd hour of the study, while there was no statistically significant difference between “serum creatinine” and “serum NGAL” levels the difference between “serum creatinine” and “serum semaphorine 3A” levels were significant (p=0.01). At the 24th hour of the study, the difference between “serum creatinine” and “serum NGAL” levels was significant (p=0.03), however, the difference between “Semaphorine 3A” “serum creatinine” average levels were not.

 Conclusion:

Here in this study model, we found that serum “Semaphorine 3A” is a more valuable biomarker than “serum creatinine” and “serum NGAL” at the early stage diagnosis of acute kidney injury developed secondary to experimental rhabdomyolysis created by intramuscular injection of glycerol.


Ayhan KORKMAZ, Gurkan ERSOY (Izmir, Turkey), Osman YILMAZ, Emel ALTEKIN, Sadiye Mehtat UNLU, Leyla Seden DURU, Emre KARSLI, Elvan OCMEN
11:00 - 18:00 #7558 - Diagnostic value of scube1 protein in patients diagnosed with acute appendicitis in emergency department.
Diagnostic value of scube1 protein in patients diagnosed with acute appendicitis in emergency department.

Objective: SCUBE1 (Signal peptide - CUB (complement C1r/C1s, Uegf, and Bmp1) - EGF (epidermal growth factor) - like domain - containing protein) is recently studied in researches as a diagnostic biomarker for acute coronary syndrome, various cancers, ischemic stroke and Crimean-Congo Haemorrhagic Fever (CCHF). The aim of this study is to evaluate the value of SCUBE1 in patients diagnosed with acute appendicitis.

Material and Method: We evaluated 150 patients with initial diagnosis of acute appendicitis (AA) who admitted to the emergency department. 103 patients were excluded from the study for various reasons. 47 patients with definitive diagnose of AA as patients group and 43 volunteers as healthy controls were enrolled to the study. SCUBE1, Alvarado scoring (ASK), C-reactive protein (CRP) values and routine tests are compared between two groups.

Results: SCUBE1 plasma levels were not statistically significant between two groups (p=0, 209). SCUBE1 values were found significantly higher in CRP (+) patients (p=0, 048). There was no correlation between SCUBE1 values with ASK (p=0, 304). Both the diameter of appendix on CT (computed tomography) and SCUBE1 values were increasing proportional. (p=0, 043). CRP levels were significantly higher in the perforated appendicitis (PA) group when compared with non-perforated appendicitis (NPA) group (p=0, 007). White blood cells (WBC) values were found insignificant to distinguish perforation (p=0, 06).

 Conclusion: In this study SCUBE1 values were not diagnostic in AA, although SCUBE1 was significantly higher in CRP positive patients. There was positive correlation between SCUBE1 values and diameter of appendix which measured on CT. 


Ertan SONMEZ, Dursun AKBAY (Istanbul, Turkey), Bedia GULEN
11:00 - 18:00 #7897 - Diagnostic value of Tpeak-to-Tend interval in patients with acute pulmonary embolism in emergency medicine.
Diagnostic value of Tpeak-to-Tend interval in patients with acute pulmonary embolism in emergency medicine.

AIM: Acute pulmonary embolism (APE) is a common and potentially lethal condition. Despite diagnostic advances, delays in diagnosis of pulmonary embolism are common and it is an important subject. The aim of this study was to examine the Tpeak-to-Tend interval (Tpei) and corrected Tpeak-Tend interval (cTpei), which is an indicator of via electrocardiogram in patients with APE.
MATERIAL-METHODS: The study consist of 148 subjects which they applied emergency service because of dyspnea. Study population divided two groups according to diagnosis. Eighty nine patients diagnosed with APE (group name: APE) and 59 patients not diagnosed with APE (group name: normal). Tpe/cTpe intervals were calculated from the electrocardiograms with a computer program after using a ruler or vernier caliper manual measuring tool to obtain highly sensitive measurements. cTpei was calculated through the formula (cTpei = Tpei / ). Two groups were compared Tpei and cTpei and this parameters were statistically (Roc curve) analyzed for diagnostic value.
RESULTS: APE group consist of 36 females and 53 males, with a mean age of 66.9 ± 17.2 years. Normal group were consist of 21 females and 38 males, with a mean age of 64.3 ± 11,7 years. Tpei was founded 92.85 ± 25.49 ms and cTpei was founded 114.86±33.76 ms in APE subjects. Tpei was founded 80.68 ± 21.32 ms and cTpei was founded 93.92±27.60 ms in normal subjects. A statistically significant relationship were found between the groups) for Tpei and cTpei (p=0.007 and p=0.001). Optimal cTp-e cutoff value for diagnosis of APE was determined as 85 ms with ROC analysis. cTp-e cutoff value of 85 ms had %78.6 sensivity and %64.4 specificity for acute pulmonary embolism.
Conclusıons: Corrected Tpe interval could be a useful tool in early diagnosis and risk stratification in patients with APE


Arif DURAN, Serkan ÖZTÜRK (Bolu, Turkey), Tarık OCAK, Mansur Kürşad ERKURAN, Musa KAYA
11:00 - 18:00 #7459 - Different kind of ileus: Internal hernia.
Different kind of ileus: Internal hernia.

Introduction: Internal hernia is a rare condition of small bowel obstruction. Ileus of small intestines are important for mesenteric iscemia and perforation.

Case report: Our patient is 87 years old woman with abdominal pain and constipation. She is immobil and she has hypothyroidea, Alhzeimer, hypertension, hyperlipidemia, DM, osteoporosis. Cholesistectomized patient has tenderness in abdomen and defansive. Her laboratory findings are normal. Computer tomography imaging is reported as in the left upper quadrant a focal area of intestines with contrasted wall, inflammatory findings on the surrounding mesenteric fatty tissue and dilatation with suspection of internal hernia. She is hospitalized in surgery department for laparotomy.

Discussion: Internal hernia seen as encapsulation of enlarged small intestinal loops and composed in a herni sac. With obstruction ileum segmental dilatation occurs. Without computer tomography, x-ray may not give a clue of obstruction as air-fluid level. For complications as incarceration, necrosis,  internal hernia should be kept in mind for patients suspected as ileus with abdominal pain. While symptoms like constipation, abdominal pain which lead us to ileus, mesenteric iscemia; internal herni should be kept in mind in differential diagnosis

References: 1.Agarwal, Monica D., et al. "Limited added utility of performing follow-up contrast-enhanced CT in patients undergoing initial non-enhanced CT for evaluation of flank pain in the emergency department." Emergency radiology22.2 (2015): 109-115.

2.Katagiri, Hideki, Kenji Okumura, and Junji Machi. "Internal hernia due to mesenteric defect." Journal of surgical case reports 2013.5 (2013): rjt037.

Acknowledgments: There is no conflict of interest in this study.


Goksu BOZDERELI BERIKOL (Istanbul, Turkey), Gurkan BERIKOL, Mehmet Serkan YURDAKUL, Attila BESTEMIR, Firat KIZILKAYA
11:00 - 18:00 #8011 - Differential Effectiveness of Three Airway Management Techniques for Trapped Pre-hospital Patients: A Simulation Study.
Differential Effectiveness of Three Airway Management Techniques for Trapped Pre-hospital Patients: A Simulation Study.

Backround: Pre-hospital airway management is a critical skill, demanding a lot of training and experience. Difficult airway management may require various measures to be taken to ensure tracheal intubation. Few studies have evaluated the performance of airway devices and the time needed to achieve endotracheal intubation in trapped road traffic accidents victims.

Objective: The aim of the present study was to evaluate the effectiveness of two video laryngoscopes in comparison with conventional laryngoscopy, used for face-to-face endotracheal intubation of a manikin simulating an entrapped patient.

Material and methods: The study was designed as a prospective, controlled, randomized crossover trial.

The entrapped patient was simulated using an airway manikin placed on left front seat of a special prepared car for extrication training. Access to the patient was possible only through the front windshield that broke during the accident.

Twenty-five physicians out of which, fifteen emergency medicine specialists and ten emergency medicine residents were trained in the use of Storz C-Mac D-Blade DCI (Direct Coupled Interface) and Airtraq Prodol Mediteq video laryngoscopes, on a standard airway trainer manikin. Participants were then asked to perform tracheal intubation in a simulated trapped patient using video laryngoscopes in a typical out-of-hospital setting.

We compared intubation times and success rates for tracheal intubation by measuring the times to achievement of a view of the glottis, tracheal intubation, cuff inflation, first ventilation and tracheal tube position using a standard Macintosh laryngoscope or Storz C-MAC and Airtraq video laryngoscopes in a randomised order. GraphPad Prism 6 was used for statistical analysis of the collected data. A p value of less than 0.05 was considered statistically significant.

Results: Twenty-five emergency physicians, mean age 39 years, 15 female, 10 male took part in the study as volunteers. No significant differences in failure rates were found between the Macintosh and Airtraq laryngoscopes (p = 0.38) or the Storz C-MAC (p =  0.072).  A better view of the larynx was obtained with both video laryngoscopes (p < 0.05) while the tracheal intubation, cuff inflation and first ventilation were not performed significantly faster when Airtraq was used.

Conclusion: The use of video laryngoscopes for face to face endotracheal intubation in simulated patients who are trapped in a vehicle involved in a road traffic accident does not improve efficacy of airway management. Times measured for endotracheal intubation were not significantly shorter and success rates were not higher compared with conventional laryngoscopy.


Cristian BOERIU, Luciana ROTARU (Craiova, Romania), Teodora Sorana TRUTA, Emilia TURUCZ, Alina BOERIU
11:00 - 18:00 #7308 - Difficulties of nurses in the use and handling of port-a-cath in emergency department.
Difficulties of nurses in the use and handling of port-a-cath in emergency department.

Every day the emergency department receives patients who are being treated with chemotherapy or other chronic therapies via their por-a caths.   

Non channeling of such reservoirs by nurses in emergency departments are often partly due to ignorance and difficulties in handling such devices; trying to make peripheral venous access by way of difficult approach to the technical difficulty involved and the suffering it inflicts the patient.

OBJECTIVE:

Describe the knowledge among nurses about the approach and handling of the Port-a-cath systems when using a central vascular access in the emergency department.

MATERIAL AND METHODS:

A prospective, observational and analytical study was conducted at the University Hospital de la Ribera (Alzira-Valencia-Spain) and health centers in the area of influence emergency service. The hospital has Oncology Service and Day Hospital where they routinely use these devices.

The study population consisted of nurses working in the emergency services of the Hospital de la Ribera and health centers of influence. The main variables analyzed were: gender, age, seniority and knowledge on the use and management of the Port-a-cath before the arrival of a patient with urgent priority.

 

The data collection procedure was based on the distribution of a specific questionnaire not validated, distributed by researchers and auto completed by the nursing staff. The questionnaire exist about 3 points to fill and 10 closed questions dichotomous. For the distribution of the questionnaire conformity of the Ethics Committee of Research-Investigation Commission it requested the Health Department.

RESULTS:

100% of respondents nurses know what a Port-a-cath or subcutaneous reservoir, because they have well studied in their education.

Nurses with less work experience are those that have not used this reservoir.

Most respondents would choose the peripheral route as a way to channel in a patient presenting with urgent priority, not having skill in handling a reservoir Port-a-cath.

Those who chose Port-a-cath choose this option to ensure a safe and high-caliber track, but here you can see that we only chose those nurses with more work experience and handling of the reservoir.

100% ask for help a colleague if he found any difficulty in addressing and reservoir management.

100% would be willing to take a course of theoretical and practical training

 CONCLUSIONS:

Given the volume of cancer patients treated in the emergency department with these devices is increasing; It should be provided on a regular basis training courses and training. So the risk of complications and insecurity staff are minimized.


Raquel PEREZ CASTILLO, Pedro GARCIA BERMEJO, Maria CUENCA TORRES, Jose Luis RUIZ LOPEZ (VALENCIA, Spain), Asif MUHAMMAD
11:00 - 18:00 #4964 - Direct new oral anticoagulants in general practice: A survey of Swiss general practitioners.
Direct new oral anticoagulants in general practice: A survey of Swiss general practitioners.

Purpose:

New direct oral anticoagulants (NOACs) are of increasing importance in clinical work in general practice. It is currently unknown to which extend existing guidelines regarding follow-up tests, dosing adjustments and indications are implemented. We therefore aimed to investigate the real-life handling and complications of patients treated with NOACs in general practitioners' clinical practice.

Methods:

We conducted a paper-based survey of general practitioners attending a congress at Inselspital, Bern University Hospital, Switzerland. Our questionnaire assessed preference of NOACs to vitamin-K-antagonists (VKA), prevalence and choice of NOAC, clinical follow-up including follow-up blood testing, and bleeding complications.

Results:

53 GPs participated in our survey. They treated 32.7%±19 of their patients requiring oral anticoagulation with NOACs. New patients who had started oral anticoagulation received NOACs from 49 GPs (92.5%) but most GPs would not switch patients from existing VKA therapy to NOACs. Clinical controls are scheduled by a majority of GPs (67.9%) at least every 3 months; creatinine and haemoglobin are monitored by most GPs (51 (96.2%)  and 39 (73.6%), respectively). In the preceding 2 years, GPs had seen 1.9±2.87 bleeding complications in patients with NOACs. 0.5±0.95 (range 0-5) of these required hospital treatment.

Conclusion:

NOACs are broadly accepted in Swiss general practice as first choice over VKAs for patients newly requiring oral anticoagulation. Because only about two-thirds of GPs adhere to recommendations on clinical and blood test follow-ups, further efforts to implement follow-up guidelines are necessary. Bleeding complications are rare and can mostly be handled in general practice without hospital admission.


Thomas C SAUTER (Bern, Switzerland), Wolf E HAUTZ, Meret RICKLIN, Aristomenis EXADAKTYLOS
11:00 - 18:00 #7506 - Disaster medical report in Nepal as NPO TMAT.
Disaster medical report in Nepal as NPO TMAT.

An earthquake of magnitude 7.8  was struck on April 25 2015, which brought serious damage  in Nepal.

NPO medical assistant team ,known as TMAT in Japan, watch the circumstances carefully and and sent advance medical team to check the situation and the nessesity of medical needs on 26th April for further damage expansion, and based its activity in Barabise ,Sindhupalchowk area, with Iwamura Memorial Hospital  as  a counterparts on 30th April.

and as medical assistant team, FMTclass 1  type team ,TMAT performed medical treatment activity for approximately 10 days .Especially worth mentioning is  about mobile clinic in mountenous area in Nepal. TMAT member carried medical equipment  in backpack and gave medical care  where vihicle can not access.

Over 500 patients in this period visited our clinic from serous case to rare case. this presentation is about disaster medical  report of TMAT.


Dr Sakamoto TAKAMITSU (fukuoka, Japan)
11:00 - 18:00 #7962 - Disaster Preparedness and Emergency Management within Turkish Healthcare System.
Disaster Preparedness and Emergency Management within Turkish Healthcare System.

Turkey is facing regular natural and man-made disasters because of its geological and geographical position. Earthquakes, landslides and floods are the most frequent natural disasters. In addition to these Turkey had terrorism problems and lost more than 35000 people to terrorist events since 1980s. Since the beginning of Syrian civil war in 2011 Turkey experienced an increased number of terrorist bombings, including the deadliest attack in its history at the capital on October 2015, with more than 100 casualties. This paper aims to describe disaster management and emergency preparedness within healthcare system of Turkey and review recent mass casualty events.

Disaster management policies in Turkey have developed following major disasters and focuses mainly on response and recovery. Disaster and Emergency Management Authority has been developed after 1999 Golcuk earthquake and currently has 81 provincial branches across Turkey and coordinates all emergency response and recovery efforts during disasters. In addition, Ministry of Health has its own disaster and emergency response directorates and has multiple medical management and training responsibilities.  National Emergency Response System is working under Ministry of Health and responsible for medical care during emergency situations and disasters. National Medical Rescue Team is responsible for on-site medical management and rescue efforts during disasters also a part of Ministry of Health. In addition to these government organizations local municipalities have their own emergency response centers.

Major shortages within healthcare system for disaster preparedness and management were described as lack of investment on building infrastructure and deficiency of preparedness levels of the healthcare workers.

In order to improve disaster readiness capabilities of the hospitals Ministry of Health provided hospital disaster plan templates and materials for healthcare facilities by the end of 2015. Hospital administrations are required to ensure the safety of the facilities according to this plan and improve resiliency to all hazards. In addition to these plans major investments were planned for improving healthcare facility infrastructures.

The results of the studies that investigated disaster preparedness levels among Turkish healthcare workers revealed that disaster preparedness levels are less than desired and lack of training was an important anxiety factor for healthcare workers at a possible disaster response involvement. Increased number of terror related incidents since 2013 emphasized the importance of a developed all hazards approach for healthcare systems and adequate training for healthcare workers.

In order to improve healthcare system readiness number of issues should be addressed. Implementation of new disaster plan templates within hospitals should be investigated. Quality and practicality of hospital disaster plans and readiness levels of the healthcare facilities and their workers need further research. National disaster plan should be revised with an all hazards approach addressing healthcare readiness problems including infrastructure issues and training deficiencies of healthcare workers. Lack of training for disaster preparedness within healthcare professionals is a major problem. This may be addressed by creating advanced disaster medicine programs in order to improve scientific developments and increase disaster preparedness levels among healthcare workers.


Erkan GUNAY, MD MPH (Istanbul, Turkey)
11:00 - 18:00 #7621 - Disaster preparedness effort in south-tama, Tokyo region.
Disaster preparedness effort in south-tama, Tokyo region.

In Tokyo the occurrence of countermeasures against Tokyo inland earthquake has been a concern. In Japan’s disaster medical system, Disaster medical assistance team (DMAT) has been trained for the responsibility for the acute phase of disaster medicine. Disaster medical coordinator has been appointed in most of the municipalities. At the level of the Tokyo Metropolitan Government, 3-disaster medical coordinator has been appointed. Disaster medical coordinator has been also appointed to every 12 region and each municipality under the lever of Tokyo Metropolitan Government. This time, we introduce effort of preparedness for disaster medical measures of south-tama region, one of above 12 regions. In Minami-Tama region launched a voluntary group called Disaster Medical Working Group, which was representative of the disaster medical coordinator in the region. Major objective of this group is to make a database of disaster training carried out in each hospital and it can be shared with other organizations. Expected effects is that, it is possible to search according to the purpose of disaster drills, so can perform disaster training easily in other medical institutions. It will ultimately be able to prepare for the disaster in the entire south-tama region. By the effect of the working group, great deal of progress in this region is that each other's cooperation can be taken. Thanks to that, systems that can share information using a common chronological recording via web in the region, during extensive training was built. I would like to report on the progress of the database and use experience of chronological record of an information sharing system.


Masamune KUNO, Arai TAKAO, Suzuki KENSUKE (Yokohama, Japan), Harikae KEN
11:00 - 18:00 #7960 - Disaster Training Needs and Expectations among Turkish Emergency Medicine Physicians – a National Survey.
Disaster Training Needs and Expectations among Turkish Emergency Medicine Physicians – a National Survey.

Natural disasters, especially earthquakes, landslides and floods are the most frequent natural disasters in Turkey. In addition, the Turkish people have been dealing with terrorist related events since the beginning of the 1980’s compounding their need for disaster preparedness. Residency trained emergency physicians have played important roles in the management of past disasters in Turkey, and Disaster Medicine is an important area of research for the country to improve future disaster management and preparedness efforts. The main purpose of this study is to understand the expectations of Turkish attending emergency physicians for Disaster Medicine training programs and to evaluate their residency training in adequacy of Disaster Medicine topics.

A study questionnaire was administered by the research team and an online survey tool was used for survey administration after receiving Institutional Review Board approval. A total of 937 emergency physicians were contacted to participate the study using the most recent database of emergency medicine physicians in the Emergency Medicine Association of Turkey.

There were 191 survey responses (20.4% response rate). Most participants (68.1%) were from an academic institution and 69.2% had practiced as an attending for 5 years or less. Mass immigration, refugee problems and War/Terror attacks were considered higher risk topics for the country by the participants. A majority (94.8%) of the participants agreed that Disaster Medicine trainings should be given during residency trainings. Regular drills, exercises, and weekly/monthly trainings were the most preferred educational modalities. A high percentage (84.8%) of respondents declared that they would be interested in advanced training in Disaster Medicine. This was higher for those who have worked less than five years as an attending. Academic residency programs were not considered adequate for various Disaster Medicine topics.

Disaster medicine and emergency preparedness shown to be crucial for Turkey with increased conflicts around its borders, and terror/war attacks within the country. This study demonstrated that residency trained emergency physicians especially those who work less than five years are interested in getting advanced training in disaster medicine and emergency preparedness. On the contrary UH and TRH EM residency programs were evaluated as not adequate for various related topics. Current residency training programs should be improved in order to fulfill these interests within the specialty. Regular drills and exercises weekly/monthly regular training programs are the preferred training methods and participants declared these trainings should be organized by Ministry of Health in collaboration with all of the responsible groups. Earthquakes are considered highest risk for facility level risk perception but additional research is needed to understand this apprehension including the structural preparedness of the healthcare facilities.

These results can be used as first step to understand the needs of Turkish EM physicians about the implementation of disaster medicine training programs. Future academic trainings can be developed with the guidance of these results in order to increase disaster preparedness levels of healthcare workers.


Erkan GUNAY, MD MPH (Istanbul, Turkey), Murat ERSEL, MD PHD, Justin A YAX, DO DTMH, Kerim CAR, MD, Gunnur KARAKURT, PHD LMFT, Johnathan SHEELE, MD MPH MHS, Scott H FRANK, MD MS
11:00 - 18:00 #6301 - Dispatcher-Assisted CPR Time-To-First-Compression Using the MPDS v13.0 Obviously Not Breathing Fast Track Feature.
Dispatcher-Assisted CPR Time-To-First-Compression Using the MPDS v13.0 Obviously Not Breathing Fast Track Feature.

Introduction: Rapid identification of out-of-hospital cardiac arrest (OHCA) and delivery of bystander chest compressions in patients with ventricular fibrillation are key elements in the chain of survival. The timeliness of dispatcher-assisted CPR may improve survival in such patients. The Medical Priority Dispatch System (MPDS®) has recently introduced a streamlined process for emergency medical dispatchers (EMDs) that provides early identification of OHCA and rapid delivery of chest compression instructions in version 13.0, known as the Obviously Not Breathing Fast Track feature.

Objective: The primary objective was to determine elapsed time to start of instructions and time to initiate chest compression by bystanders where EMDs used the MPDS v13 Obviously Not Breathing Fast Track feature. A secondary objective was to identify barriers encountered by bystanders in completing the delivery of prompt chest compressions.

Methods: A retrospective, observational study of 30 cases of (adult cardiac arrest) dispatcher-assisted cardiopulmonary resuscitation (CPR) using the MPDS v13 Fast Track feature was performed. Case audio was downloaded from the emergency medical dispatch system. Elapsed time was recorded for 7 key steps in the call. Barriers that impeded progress of bystander to deliver prompt chest compressions were identified.

Results: 60% (18/30) had barriers that impeded the time to chest compression instructions and bystander delivery of chest compressions. The most frequent barrier 36.7% (11/30) was difficulty getting the patient from a bed to the floor. Overall elapsed time from call pickup to address/phone verification was 28 seconds (26 seconds without barriers, 29 seconds with barriers, p=0.456). Elapsed time from address verification to completion of patient description was 23 seconds (15 seconds without barriers, 26 seconds with barriers, p=0.007). The median elapsed time from address verification to identification/entry of cardiac arrest (CA) chief complaint was 65 seconds (with or without barriers). The median time to start chest compression instructions was 140 seconds overall (89 seconds without barriers, 182 seconds with barriers, p<0.001). The median time for bystander to initiate first compression as instructed was 177 seconds overall (120 seconds without barriers, 218 seconds with barriers, p<0.001). Elapsed time to complete address verification, to CA identification, to start CPR instruction, and to responders arrival by patient side were significantly different (p=0.046 each) statistically where there was 1 barrier vs. >1 barrier.

Conclusion: Use of the MPDS v13 Fast Track feature improves time to first compression, when compared to previous MPDS versions. Many cases had barriers that impeded time to chest compression instructions and bystander delivery of chest compressions. A significant difference exists in both time to compression instructions and time to compression delivered between cases with no barriers and those with barriers. Getting the patient from a bed to the floor was the most common barrier. Future studies that evaluate dispatcher-assisted CPR should identify these barriers and report on how they impacted elapsed times. Address and phone number verification is a requirement for dispatch, and time to complete this step varies from case to case. Therefore this time must be considered when evaluating time to first chest compression. dFragment--> ssion.


Greg SCOTT, Clawson JEFF, Olola CHRIS, Barron TRACEY (Bristol, United Kingdom)
11:00 - 18:00 #7483 - Diverticulitis in the Emergency Department: An Analysis of 35 Emergency Departments over 5 years.
Diverticulitis in the Emergency Department: An Analysis of 35 Emergency Departments over 5 years.

Introduction: Diverticulitis is a common disease encountered in the emergency department presenting with a spectrum of illness ranging from acute vs chronic, uncomplicated vs complicated.  The decision to admit diverticulitis has both subjective and objective components.  We set out to determine the admission rates for patients with diverticulitis and the 30 day ED return rate.  We predict that the rates of admission will correlate with the age of the patient.

Study Objective: To determine the admission rates for patients with diverticulitis and the 30-day ED return rate.  Methods:  Design: A multi-center retrospective cohort study. Setting: 35 urban, suburban, and rural emergency departments (ED) in the Rhode Island/New York/New Jersey area. Participants: Consecutive patients with the final primary or secondary ICD9 or ICD10 diagnosis of diverticulitis from January 1, 2011 to December 31, 2015.  We “a priori” decided to look at repeat visits, which were defined as unplanned ED encounter for diverticulitis up to 30 days.  Statistics: Chi-square and Mann-Whitney for analysis with a significant P-value < 0.05.  Results:   A total of 6,540,668 patients were seen during the study period.  A total of 21,221 patient visits were identified of which 2,212 were excluded for diagnosis of diverticulosis and missing disposition leaving 19,009 patient visits.  Of those, 17,691 (0.3%) unique patients were diagnosed with diverticulitis. Overall median age was 57.2 yrs (IQR 21.3-92.5 yrs).  Female gender comprised 56% (N=9,955) of patients. 49% (N=8700) were admitted.  The number of patients for total number of visits were: 15,979 (initial visit only), 742 (2 visits), 58 (3 visits), 11 (4 visits), and 2 (5 visits) in 30 days.  The age of the patient was found to be statistically significant for admission (61.1 yrs, 95%cI 60.7-61.4) vs discharge (55.6 yrs, 95%cI 55.3-55.9) p<0.001.  We found there was a statistically significant difference in the odds of being admitted on the first visit versus for patients that have repeat visits.  OR 1.62 (95%cI 1.4-1.9) p<0.001.  There was also a statistically significant difference of gender admissions, with women having higher rates.  OR 1.2 (95%cI 1.1-1.3) p<0.001. Conclusion:  Diverticulitis is a common emergency department diagnosis with a high admission rates.  Patients more likely to be admitted are older, and most patients that need to be admitted are admitted on their first visit.  Diverticulitis appears to be more prevalent in women, who also have a higher admission rates.


Hetal PATEL (Bridgewater, USA), David SALO, Taylor SMITH
11:00 - 18:00 #7362 - Do not ask me again, I have not give me a Knock!!!
Do not ask me again, I have not give me a Knock!!!

A 80-year-old men with diabetes was attended in A&E department for pain and hematoma in his right shoulder that appeared ten days earlier and was treated with antibiotics for suspected cellulite. Despite treatment the hematoma volume was increasing without pain or inflammatory signs. The patient denied trauma, effort or bite at that location. No pain in the rest of the right limb or volume increase .No fever. No dyspnea or chest pain. No palpitations.

 

PHYSICAL EXAMINATION

Temperature: 36,5ºC  Heart rate: 85lpm  Blood pressure: 138/70mmHg SpO2: 98%.


Hematoma with varicose veins in supraescapular región(10x10cm). No tenderness of bony prominences. Normal joint mobility . Painful abduction. No loss of strength and sensitivity. Pulses present. No swelling or erythema in right forearm.
Mobile painless lump in infraescapular region(5cm).

 

TEST

* Laboratory test: Glucose 368mg/dl, Creatinine 1.29mg/dl, Creatinine Kinase 129U/L, PCR 140mg/dl, Hemoglobine 13,3mg/dl, Leucocites 20230.

* Chest X-Ray: No atelectasis, no edema.

* Right shoulder X-Ray : no acute bone injury

*Ultrasonography: homogeneous solid lesion, encapsulated, unfilled. No hematomas or abscess.

 

EVOLUTION
He was discharged from hospital with antibiotic and we request a resonance to complete the study. After 12days the patient returned to the hospital by worsering of his condition. We perform MRI. The result was: Piomiositis abscessed / Abscess Hematoma in right deltoid and supraspinatus complicated with osteomyelitis of the right acromioclavicular joint.

 

 

Pyomyositis is an acute infection of skeletal muscle common in the tropics. In primary forms it is accepted that muscle abscess is formed from hematogenous spread of a muscle previously altered. Usually occurs in children or young adults (20-45years).

 

There are predisposing factors such as diabetes mellitus, alcoholic liver disease, treatment with corticosteroids, immunosuppressive diseases and HIV infection among others.

The pathogen most often implicated is Staphylococcus aureus , followed by Streptococcus group A.

The clinic is usually subacute and early stage only produces localized muscle pain. In the late phase signs of muscle inflammation, erythema, edema, fluctuation and functional impotence, fever and malaise. Fulminant forms are rare and when they occur, the organism involved is most often Streptococcus group A.

 

Among the highlights laboratory abnormalities neutrophilic leukocytosis, unlike tropical forms is rare eosinophilia and increased sedimentation rate. It is not often elevated muscle enzymes despite the extensive muscle destruction. In non-tropical piomiositis bacteremia ranges from 5-35%.

Imaging techniques such as ultrasound, CT scan and MRI are useful to identify the number, size, extension, location of abscesses and guide the needle stick.

The microbiological diagnosis is based on blood cultures and culture of the sample of muscle abscess whose sensitivity is 100%. The differential diagnosis includes muscle trauma, DVT, osteomyelitis, cellulitis, septic arthritis and malignant tumors.

Treatment is medical-surgical, antibiotic therapy and surgical drainage of abscesses; The prognosis is favorable with appropriate treatment. Mortality ranges from 1-10% depending on the underlying disease, rapid diagnosis and initiation of treatment.

 

Is an unusual case that happens in a male in the eighth decade of life which have predisposing factors, but we have not been able to filial origin.


Marta MERLO (MADRID, Spain), Juan LUQUE, Patricia BAZÁN, Raquel CASERO, Elena AZNAR, César VERGARA
11:00 - 18:00 #8232 - Do we follow the recommendations of the INFURG-SEMES when treating community-acquired pneumonia?
Do we follow the recommendations of the INFURG-SEMES when treating community-acquired pneumonia?

Title Do we follow the recommendations of the INFURG-SEMES when treating community-acquired pneumonia?

Introduction The working group on infectious diseases of the Spanish Society of Emergency (INFURG-SEMES) recommends an empiric approach in pneumonia acquired in the community (CAP) based on the score Pneumonia Severity Index (PSI), embodied in the consensus document SEMES-SEPAR "management of community-acquired pneumonia in the emergency" and the monograph "INFURG-SEMES Recommendations for the management of respiratory infection in the ER."

Objective To evaluate the empirical treatment administered to patients with CAP compared with the recommendations proposed by the INFURG-SEMES group.

Patients and methods

descriptive prospective observational study. 383 days subject for 14 or more years with clinical and radiographic diagnosis of CAP and evidence of antibiotic treatment were included in the emergency room. Sociodemographic variables, prognostic scales of gravity, evolution and the antibiotic treatment were collected. Categorical variables as absolute value and percentage were described. Pearson chi square test was used for trend assessment.

Results

They were included in the study 273 patients. 66.7% (48/72) of patients PSI risk group I were treated following the indications of INFURG-SEMES group while they were not followed in 33.3% (24/72). 67.5% (27/40) PSI II were treated following the indications, and 32.5% (13/40) no. 56.9% (33/58) III PSI were treated following the indications, while 43.1% (25/58) no. 50% (34/68) PSI IV were treated following the indications, and 50% (34/68) no. 22.9% (8/35) of patients were treated PSI V following the indications, but 77.1% (27/35) no. A significant linear trend was observed in analysis (p <0.001).

Conclusion

The higher score PSI has the NAC and therefore manifests itself most severe form, the lesser adaptation to INFURG-SEMES indications was observed, with significant linear trend. It may be because clinicians do not follow these guidelines. It could also be related to not having assessed the adequacy of treatment in special situations such as suspected anaerobic infection, aspiration pneumonia, lung abscess or suspected Pseudomonas infection.


Manuel Antonio TAZON-VARELA, Hector ALONSO-VALLE (, ), Pedro MUÑOZ-CACHO, Jaime GALLO-TERAN, Luis Angel PEREZ-MIER, Maria ANDRES-GOMEZ
11:00 - 18:00 #7916 - Do we treat the men like women with acute heart failure in our emergency department ?.
Do we treat the men like women with acute heart failure in our emergency department ?.

Introduction:
Acute heart failure (AHF) is a common reason for consultation in the emergency department (ED), it is generally characterized by pulmonary congestion, although in some patients decreased cardiac output and tissue hypoperfusion may occur. Is the leading cause of hospitalization in the elderly, with high mortality and reconsultations producing a large increase in health spending.

Objective:

Determine whether there are differences in the acute treatment received in our emergency department about sex.


Material and methods:
Prospective observational study without intervention in patients who come to our SU in the period from 2012-2014 choosing two randomized months per year for ICA according to the criteria of Framingham. Inclusion criteria: age 18 years with ICA and give their written consent. The variables studied were: Sex: Male (M), Female (M), applied therapy: vasoactive drugs (dobutamine, dopamine, norepinephrine), beta blockers, diuretics, nitrates, morphine, bronchodilators B2, antibiotics, steroids, digoxin, amiodarone, antiplatelet agents, oral anticoagulants, statins, ACE inhibitors, ARBs, transfusion.

results:

During the 2012-2014 selected 119 patients consulted by ICA of whom 57 were women (F) (47.9%) and 62 men (M) (52.1%).

Vasoactive drugs (dobutamine, dopamine, norepinephrine) did not say no patients, beta blockers 6.45% M, 26.31% F, diuretics 75.8% M 87.7% F, nitrates 12,9 M 7,01 F, morphine 3 22% M, 1.35% F, bronchodilators B2 38.7% M,% ", 63 F, antibiotics 36.8% M 16.1% F, corticosteroids 25.8% M, 29.8% F, statins 16,1% M 14.03% F, digoxin 16.1% M, 17.54% F, amiodarone 7.01% M, 3.22% F, transfusion 1.61% M, 3.5 F, antiplatelet agents 27,4%M 27,4% F,  ORAL ANTICOAGULATION 32,25% M 42,1% F, ACE inhibitors 35.08% M 24.19% F

conclusions:
• The most widely used treatment in our emergency department are diuretics, both men and women. The second most frequently used drug are bronchodilators B2, while receiving twice as many women than men
• None of our patients required vasoactive drugs in the acute episode
• There is a difference in the use of beta-blockers on sex, indicated 4 times more beta-blockers in women than in men.
• 4 out of 10 women consulting in the emergency department treated with antibiotics and only 2 out of 10 men.


Jose Andres SANCHEZ-NICOLAS, Patricia SUAREZ-BEKE, Paula LAZARO-ARAGUES, Irene PAGAN-GOMEZ, Elena SANTAMARIA-HERNANDEZ, Emilio SANCHEZ-PARRA, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #8122 - Do you even listen to me? Gender-related differences in the perception of prodromes of out-of hospital cardiac arrest caused by myocardial infarction.
Do you even listen to me? Gender-related differences in the perception of prodromes of out-of hospital cardiac arrest caused by myocardial infarction.

Background: Out-of-hospital cardiac arrest (OHCA) is still one of the main reasons of death in the western world, 70% caused by cardiovascular complications. While bystander CPR and early defibrillation proved to be most beneficial for favorable positive outcome, these measures are often delayed due to neglect and ignorance of leading cardiac symptoms. This implies a crucial role for relatives and friends to recognize symptoms early.  

Objectives: We aimed to assess differences in the perception of prodromes by relatives and friends of male and female victims of OHCA due to acute myocardial infarction (AMI).

Methods: From January 1, 2006 to December 31, 2015, we prospectively collected data of all patients treated for OHCA due to AMI at our high-volume tertiary care centre. Demographic and clinical characteristics, as well as details on history, diagnostic findings and therapy were analyzed. The frequency of any suspected cardiac prodromes observed by relatives was compared between women and men using the chi-square test.

Results: In total, 531 patients (101 (19%) women; age 59+/-12 years) met the inclusion criteria. Cardiovascular risk factors, risk profile according to GRACE score (182 (IQR 161-210) in women vs. 178 (151-204) in men), cardiac arrest-related factors (e.g. witnessed arrest 38% vs. 37%; lactate level on admission 7 (IQR 4-9) vs. 6 (4-9) mmol/l) as well as AMI-related characteristics (e.g. STEMI 63% vs. 62%; most frequent location of infarction anterior wall 45% vs. 44%) were very similar between women and men. 

Suspicious prodromes were, however, remembered significantly more often in male than in female patients (10% vs. 3%, p=0.03).

Conclusions: Despite very similar risk profiles to male victims, family and friends of female victims with OHCA far less often remember prodromes which were interpreted as potentially of cardiac origin. The general public thus needs to be encouraged further to listen attentively, especially to women with cardiac risk factors.


Elisabeth LOBMEYR (Vienna, Austria), Fritz STERZ, Wolfgang SCHREIBER, Harald HERKNER, Raphael VAN TULDER, Michael POPPE, Patrick SULZGRUBER, Dominik ROTH
11:00 - 18:00 #7630 - Does mechanical ventilation affect quality of chest compressions during resuscitation? A simulation study.
Does mechanical ventilation affect quality of chest compressions during resuscitation? A simulation study.

Objective

Quality of chest compressions critically influences outcome following resuscitation in cardiac arrest. Although ventilation during resuscitation is recommended, the number of studies evaluating the interactions between ventilation and chest compression is still very limited.

The goal of this study was to determine if there is a difference in the influence of the three different ventilation patterns Intermittent Positive Pressure Ventilation (IPPV), Bilevel Positive Airway Pressure Ventilation (BiLevel) and the novel ventilation mode Chest Compression Synchronised Ventilation (CCSV) [2] on depth and compression rate of manual chest compressions during cardiopulmonary resuscitation (CPR) using a simulation model. CCSV was explicitly developed for the use in cardiac arrest. CCSV is triggered by manual chest compressions, which lead to a short pressure controlled insufflation synchronised with each compression phase.

 

Participants and methods

After approval by ethics committee informed consent was obtained. 90 paramedics were included in this study. Participants performed uninterrupted, manual chest compressions for two minutes in a modified ALS mannequin with a realistic lung model. IPPV, BiLevel and CCSV were applied in a randomised order for 30s using the ventilator Medumat transport in a cross-over design. Ventilator presets were (FiO2=1.0): IPPV: Vt=450ml, PEEP=0mbar, f=10/min, Tinsp=2.4s, Texsp=3.6s; BiLevel Pinsp=19mbar, PEEP=5mbar, f=10/min, Tinsp=2.4s, Texsp=3.6s; CCSV: Pinsp=60mbar, PEEP=0 mbar, f=chest compression rate, Tinsp=0.2s. Control phases (no ventilation) of 10s each were set up at the beginning and between two modes of ventilation.  Depth and compression rate were compared to ILCOR-Guidelines (depth>50mm, compression rate=100-120/min) [3], results as median (25/75% percentiles). Relative frequencies (RF) of matching were tested for significance using Chi-squared test (chi) and Friedman (Friedm) test.

 

Results

Depth (mm): IPPV 56(48/63), BiLevel 57(48/63), CCSV 60(52/67); RF (match) IPPV 1.0 (0.23/1.0) vs. CCSV 1.0 (0.9/1.0), p < 0.0001 (chi), p = 0.0036 (Friedm); BiLevel 1.0 (0.28/1.0) vs. IPPV, p = 0.59 (chi), p = 0.73 (Friedm) and BiLevel vs. CCSV p < 0.0001 (chi), p < 0.001 (Friedm).

Compression rates (1/min): IPPV 117(105/124), BiLevel 116(107/123), CCSV 117(107/125). RF (match) IPPV 0.5 vs. BiLevel 0.49, p = 1.0 (Friedm) and vs. CCSV 0.47, p = 1.0 (Friedm). BiLevel vs. CCSV p = 1.0 (Friedm).

 

Conclusion

Chest compression rates did not differ between the three mechanical ventilation patterns IPPV, BiLevel and CCSV during cardiopulmonary resuscitation with manual chest compressions in a simulation model. Mechanical ventilation with CCSV lead to improved compression depth compared to IPPV and BiLevel ventilation.

Literature

[1] Abella BS. The importance of cardiopulmonary resuscitation quality. Curr Opin Crit Care 2013;19: 175–180

[2] Kill C, Hahn O, Dietz F, Neuhaus C, Schwarz S, Mahling R, et al. Mechanical Ventilation During Cardiopulmonary Resuscitation With Intermittent Positive-Pressure Ventilation, Bilevel Ventilation, or Chest Compression Synchronized Ventilation in a Pig Model. Crit Care Med 2014;42(2):e89-95

[3] Nolan JP, Hazinski MF, Billi JE, Boettiger BW, Bossaert L, de Caen AR et al. Part 1: Executive summary: 2010 International Consensus on Cardiopulmonary Resuscitation


Tillmann SPEER, Wolfgang DERSCH, Björn KLEINE, Christian NEUHAUS, Clemens KILL (Essen, Germany)
11:00 - 18:00 #7158 - Does Priapism Etiology Significantly Change Outcomes in Those Patients Presenting to the Emergency Department?
Does Priapism Etiology Significantly Change Outcomes in Those Patients Presenting to the Emergency Department?

Introduction: Priapism is a sporadic disease, which requires prompt evaluation/treatment to avoid significant sequelae. Treatment of this disease is highly variable and is dependent upon the etiology.

Objective: To determine the outcomes of patients (pts) presenting to the emergency department (ED) with priapism based upon the suspected etiology.  

Design: Retrospective cohort study utilizing an electronic database. Charts were extracted using ICD9 diagnosis over 2 yrs.  Enrolling hospitals (N=15) represent urban, suburban, academic, and community settings.  Charts were de-identified and reviewed for predetermined data points by blinded study personnel.  Exclusion criteria: non-priapism diagnosis or chart unavailability. Pediatrics included those < 21 yrs old. Intrapenile procedures included any bedside aspiration/injection of medication.  Statistics: Chi-square test, with a significant P-value of <0.05.

Results: During the study period 236 charts were analyzed. Exclusion: unavailability(N=8) and non-priapism diagnosis(N=6), leaving 222 charts.  Median age overall was 39 yrs(IQR 22-52). Pediatrics comprised 4%(N=9). Multiple visits occurred in 8%(N=18). Regarding etiology: erectile dysfunction medications(EDM) involved 23%(N=52) with 75%(N=39) being intrapenile, sickle cell comprised 20%(N=45), antipsychotic medications 14%(N=30), cocaine utilization in 2% of cases(N=4), and 41%(N=91) had no identifiable etiology. Admission occurred in 15%(N=34) overall.  Admission rates of those on EDM was 2%(N=1)(p=0.009), sickle cell comprised 20%(N=9)(p=0.43), antipsychotic medications 13%(N=4)(p=0.77), and in 50%(N=2)(p=0.06) of cocaine associated cases. Intrapenile procedure occurred in 56%(N=125) overall. With regards to this 15% (N=8)(p<0.009) were on EDM, 42%(N=19)(p=0.08) with sickle cell, 67%(N=22)(p=0.7) on antipsychotic medication, and 50%(N=2)(p=0.06) of cocaine users underwent ED intrapenile treatment.  Emergent operation occurred in 7%(N=16): EDM were implemented in 2%(N=1)(p=0.38), antipsychotic 10%(N=3)(0.59), and cocaine/sickle cell 0%.

Conclusion:Priapism caused by EDM, the most common etiology, were associated with significantly less admissions and need of emergent intrapenile procedures.


Fred FIESSELER, Dave SALO, Brian WALSH, Renee RIGGS (New Brunswick, USA)
11:00 - 18:00 #7521 - Does the pefect doctor exist?
Does the pefect doctor exist?

It was made in our Emergency Department, for one month period, an interview to the patients while they were in the Waiting Room. It was voluntary and anonymous, and we asked about the characteristics that they thought the "Perfect Doctor" should have. The total survey respondent were 106, 58 males and 48 females, the age median was 44 years old. 89% were Spanish, 4% came from UE countries, 4% from Latin America and the other 3% were from unknown origin. The academic level was: 53% universitary level, 42% basic level and 5% none.

We asked these patients about the kind of physician they should prefer to have. The answers were:

-Sex: 15% prefers a man (62,5% were males), 12% prefers a woman, 73% irrelevant.

-Age: 17% younger than 40 years old, 33% between 40 and 50 years old, 8% between 50-60 years old, 2% older than 60 years old and 40% irrelevant.

-Status: 47% staff doctors, 13% residents and 40% irrelevant.

-Nationality: 63% Spanish doctors, 2% foreigners and 35% irrelevant.

-Physical appearance:

-Weight: 1% fat, 4% thin, 29% well proportioned and 66% irrelevant.

-Dressing: casual clothes 7%, white coat 53%, surgical pyjama 18%, 22%irrelevant.

-Identity card: 90% yes, 1% no, 9% irrelevant.

-Tatoos: 11% yes, 42% no, 47% irrelevant.

-Piercings: 8% yes, 47% no, 45% irrelevant.

-If the doctor is a man:

-Hair: Short hair 33%, long hair 6%, irrelevant 61%.

-Beard: 8% yes, 20% no, 72% irrelevant.

-Perfume: 28% yes, 17% no, 55% irrelevant.

-If the doctor is a woman:

-Hair: upsweep 45%, unleashed 6%, irrelevant 49%.

-Make up: yes 17%, no 17%, irrelevant 66%.

-Perfume: 34% yes, 17% no, 49% irrelevant.

-Nail´s length: short 62%, long 4%, irrelevant 34%

-Nail´s colour: painted 5%, non painted 32%, irrelevant 63%.

-Jewels: 8% yes, 38% no, 54% irrelevant.

-Medical Interview:

-Position while reception: sitting 15%, up 34%, irrelevant 51%.

-Greeting: physical 20%, verbal 41%, irrelevant 39%.

-Introduction: Yes 67%, No 4%, irrelevant 29%.

-Visual contact: 82% yes, 2% no, irrelevant 16%.

-Manner: Close 76%, cool 4%, irrelevant 20%.

-Detailed explanations: Always 81%, Never 2%, it depends 17%.

-Information: Alone 17%, with family/friends 42%, irrelevant 41%.



The "Perfect Doctor" for the patients who were asked in Guadalajara (Spain) should be a 40-50 years old person, staff doctor with irrelevant sex, not foreigner, the weight shouldn´t matter, dressed with white coat and who wears an identity card, without piercings or tatoos. They would like that the doctor stands up while reception, a short introduction to know his/her name and a greeting without physical contact; they prefer visual contact and close manners, and they want to have detailed explanations of their disease, and, if it is possible, with companion.

Our conclusion is that, in despite that some of the questions were answered as "irrelevant", we could say that the appearance of the doctors is very important for the people who use our Health System. It could be very interesting to make similar interviews in another hospital in the world to compare our results.


Félix Manuel DOMINGO SERRANO, Sergio SÁNCHEZ RUIZ (Guadalajara, Spain), Maria José. JIMÉNEZ MELÉNDEZ, Eulalia LÓPEZ NAHARRO, Amor GIL DÍAZ, Eduardo FERNÁNDEZ VERSTEEG, María Pilar LOZANO GARCÍA, Mercedes FERNÁNDEZ-ESCRIBANO HERNÁNDEZ, Jose Antonio LAPERAL MARTÍN
11:00 - 18:00 #8266 - Does the triage systems classification meet the expectations of the emergency medical staff.
Does the triage systems classification meet the expectations of the emergency medical staff.

Introduction

 

When the emergency demand exceed the resources, the triage system, helps to manage the patients clinical risk into a properly and safety patient flow through the Emergency Department. As far as the triage is not based on diagnosis, it is usually in charge of the nursing staff, although there are groups in the health system who believes there would be important differences if the triage were run by the physicians.

 

Objetive

 

The proposal of the study was to assess whether the standardized  system classification meet the expectations of medical staff, studying a group of patients which were classified and allocated in the Emergency Department areas by de Nursery with the Triage  Manchester System (STM) and then clarified and allocated in the Emergency Department areas by the physicians of an Emergency Department.

 

Methodology:

 

Observational, descriptive-comparative study, in which data from a sample of patients over 18 years old that attended the emergency department of the Hospital Universitario de La  Ribera for a month were collected; where currently the Manchester triage system is used. The complaint and vital signs were passed after to the physicians who classified the patients giving a priority and a location in one of the emergency department areas

 

Results

 

   We analyzed 52 cases of patients of both sexes who attended the emergency department. No percentage differences found between men and women. Regarding priority established the triage system as physicians were P4 (little urgent) was the most coincidence with 68.8% of them; the priority P2 (urgent)  appeared in the STM, while the emergency physician did not establish it,  but if  established  priority  P5 (nonemergency) which did not occur with the STM. In locations established between the STM and established by the physicians the largest choice was consultation (low complexity patients); however the location resuscitation (high complexity) was in the STM.

 

Conclusions

 

There was no full agreement between the classification of patients from the degree neither of urgency, nor as to the location of the patient by the Manchester Triage System and patient care priority assigned by the physician. The start up of improvement groups of triage that establish modifications to Manchester Triage System can get closer to the expectations of emergency physicians in relation to the severity of the patient requesting assistance.


Pedro GARCIA BERMEJO, Luisa TARRASO GOMEZ, Asif MUHAMMAD, Maria CUENCA TORRES (VALENCIA, Spain), Jose Luis RUIZ LOPEZ
11:00 - 18:00 #7123 - DOES THE TYPE OF CARDIAC COMPRESSION CONDITION THE MAINTENANCE OF UNCONTROLLED DONORS AFTER CARDIAC DEATH?. THREE YEARS REVIEW.
DOES THE TYPE OF CARDIAC COMPRESSION CONDITION THE MAINTENANCE OF UNCONTROLLED DONORS AFTER CARDIAC DEATH?. THREE YEARS REVIEW.

INTRODUCTION.
Our hospital has settled from 1989 a specific protocol to obtain donors from people who die in the street or at home from sudden or unexpected death. Even this program is established, the improve procedures for the CPR have change the maintenance of the potential donor. These new variables need to be studied.
OBJECTIVES.
To evaluate  the quality of cardiocompression in uncontrolled donor after cardiac death (uDCD) as preservation maneuvers
METHODS: After 30 minutes of unsuccessful CPR maneuvers, death is declared through cardiovascular criteria. The only preservation method until ECMO is cardiac massage and mechanical ventilation. In addition to general procedure we analyze the cardiac massage (manual versus mechanical) as preservation maneuver
RESULTS. 122 donors were included during 2013-2014-2015.  157 kidneys were desestimated for transplant. We analyze cuantitative variables through t student and cualitative through squared chi .We found that kidneys from patients younger than 45,6 years  with manual compression were desestimated 7,1% vs the ones that were reanimated with mechanical compression (45,2%) p=0,002. We found

association between age and discharged kidneys (51,3 years for discharge(IC 95% 1,5 a 5,7)  and for warm ischemia time (118 minutes for discharged kidneys, p=0,004.  Among real donor 87  kidneys were transplanted. Eight were explanted (7 because ischemia reperfusion injury, 1 due to surgical incident) . The rest remains normofunctional and free of complications
CONCLUSIONS.

  1. uDCD program constitutes 40% of the total donor amount of Madrid      (35,1 d.p.m.p)and more than the 11% of the total amount of donor in Spain
  2. There is a trend type of cardiac compression (manual versus      mechanical), being favorable to       manual in the group of patients younger than 45,6
  3. There is association between age, warm ischemia and discharged      kidneys

Maria BRINGAS BOLLADA (Madrid, Spain), Nieves DE LUCAS, Sara DOMINGO MARIN, Candido PARDO REY, Antonio Trino SALTO, Francisco Jose DEL RIO GALLEGOS
11:00 - 18:00 #8255 - Dogs, a man’s best friend?
Dogs, a man’s best friend?

Pets are belonging to our community. Due to this there are occuring a lot of bite wounds. Most of them didn’t causing any infection.

A 37-year old man, with a prior history of Morbus Graves, presented at our ermergency department with progressive headache, neck pain, erythema and fever. One week prior to presentation he was bitten by a dog. The wound was rinsed. He didn’t start with antibiotic therapy.  We saw a hemodynamic stable man without fever. He had an erythema at his extremities and his back, but no petechia. Neurologisch examination didn’t show any abnormalities. Kernig’s and Brudzinski’s sign were negative.  Blood results showed a leucocytosis of 24x10^9/L and an elevated CRP of 273 mg/L. Lumbar puncture opening pressure was elevated. Cerebrospinal fluid was cloudy and showed elevated leucocytes. Under suspicion of a meningitis treatment was initiated with intravenous amoxicilline, ceftriaxon, aciclovir and dexamethason. Cerebrospinal fluid culture was positive for Capnocythophaga Canimorsus. Patient was discharged to home continuing with ceftriaxon monotherapy.

Capnocythophaga canimorsus is commensal bacterium in the oral flora of dogs and cats. Bite wounds, scratching wounds and even licks can cause an amount of infections, like meningitis and endocarditis. Mortality rates are up to 30 percent when causing a sepsis. Incidence in the Netherlands is 0.67 infections per million. The main risk for getting infected is alcoholism and asplenia. Incubation period is between one and eight days. Infections can cause a variety of symptoms at physical examination. It is a slow growing micro-organism and may not be visible for the first 48 hours at cultures. Antibiotics are needed for treatment. Those containing beta-lactamase inhibitors will cover Capnocytophaga Canimorsus, but also cephalosporins are used.

Doctors should be aware of less common infections caused by animal bites. When thinking of a Capnocytophaga Canimorsus infection initiate treatment and remember that is takes time to get a positive culture.


Jannette VAN SOEST (Utrecht, The Netherlands), Alet PFAFF
11:00 - 18:00 #7133 - Dorsal elevation and peep for catheterization of internal jugular vein in critically ill patients in emergency departments (DECIZIVE) - many patients do not tolerate the recommended position.
Dorsal elevation and peep for catheterization of internal jugular vein in critically ill patients in emergency departments (DECIZIVE) - many patients do not tolerate the recommended position.

Introduction

Some patients in emergency departments (ED) need a catheterization of internal jugular vein (IJV. The application of a central venous catheter is typically performed while the patient is in Trendelenburg-Position (TP). The main cause for this purpose is the benefit of increasing the IJV – diameter, which results in a securer application of the central line wire.

However, in the daily practice the TP poses a challenge in the ED since many patients do not tolerate the head tilt position or have contraindications.

The aim of the study is to determine how many critically ill patients in an emergency department do not tolerate the Trendelenburg position.

Methods

From October to December 2015 we enrolled 108 non intubated patients >18 years admitted by EMS with a ESI score <4. We allocated the patients either to the TP-group (trendelenburg position possible) or non-TP-group (trendelenburg position impossible).

Using a goniometer participants without any contraindications for Trendelenburg-position were tilted 15° head down while lying in bed for 10 consecutive minutes. When the patient perceived any discomfort like dyspnea, vertigo, nausea, pain or a consultant of the ED decided that there is a contraindication for the head down position, the patient was allocated to the non-TP-group.

Results

23,8 % of all enrolled patients could not be positioned in TP because of contraindications, such as cardio-pulmonary deficits (61,9%) or in condition of CNS-pathologies (28,6%). Furthermore, 23,8% did not tolerated this position – 8 patients stopped the procedure during positioning and 14 within the 10 minutes of head tilt due to various reasons (exact numbers will follow).

Conclusion

To secure a safe central vein catheterization, TP is seen as the gold standard according to the guidelines. This survey is the first which reveals the limitations of this positioning for critically-ill patients. Almost 50% of the patients were not able to be tilted 15° head-down as the gold-standard requests. A previous survey of our working group already showed that 30° head-up elevation combined with non-invasive ventilation demonstrates a safe and well-tolerated alternative to the head-down-tilt. This will be reviewed in the context of our study.

References

Fahy BG, Barnas GM, Nagle SE, Flowers JL, Njoku MJ, Agarwal M. 1996. Effects of Trendelenburg and reverse Trendelenburg postures on lung and chest wall mechanics. J Clin Anesth, 8 (3):236-244.

Keusch DJ, Winters S, Thys DM. 1989. The patient's position influences the incidence of dysrhythmias during pulmonary artery catheterization. Anesthesiology, 70 (4):582-584.

Mavrocordatos P, Bissonnette B, Ravussin P. 2000. Effects of neck position and head elevation on intracranial pressure in anaesthetized neurosurgical patients: preliminary results. J Neurosurg Anesthesiol, 12 (1):10-14.

Reich DL, Konstadt SN, Raissi S, Hubbard M, Thys DM. 1989. Trendelenburg position and passive leg raising do not significantly improve cardiopulmonary performance in the anesthetized patient with coronary artery disease. Crit Care Med, 17 (4):313-317.


Cornelia Mareike BURGHOLD (Jena, Germany), Christian HOHENSTEIN, Hendrik RÜDDEL
11:00 - 18:00 #8102 - Double referral in the combined front office policy: can triage be improved to prevent double referral?
Double referral in the combined front office policy: can triage be improved to prevent double referral?

Background: Of the patients presenting to the Emergency Department (ED) of our hospital, 53% are self referred. Approximately 80% of these patients present with a low emergency complaint which could be treated by the general practitioner. The Netherlands has an unique system of combined front office policy. Self referral patients are registered at the front desk of the ED and are triaged to either the ED or to the general practitioner (GP). Theoretically, patients can be triaged to the GP initially with a second referral to the ED by the GP, based on their complaint and need for further specialist care. This activity is time consuming for both healthcare professionals and patients and neither cost-effective nor patient friendly.

Objective: To identify patients characteristics in the double referral group on which primary triage could be improved to prevent double referrals.

Methods and Results: In a retrospective study of all patients presented to the ED of the Spaarne Gasthuis Haarlem in 2014, 20.801 patients were self-referral. In this group, 6925 patients were triaged to the GP initially and eventually 430 patients (6%) were referred secondary to the ED. From this 430 patients, 147 had complaints of the extremities (34%), 62 came with abdominal pain (14%) and 24 patients present with a syncope (6%). In comparison with the total amount of initial GP presentations, 10% (147/1426) of the extremity presentations were  double referred. In the syncope group this was 17% (24/136) and for abdominal complaints the ratio is 20% (62/302). Of these patients with abdominal complaints, 36% are triaged as urgent and 53% are admitted to hospital.

Conclusion: Combined front office policy works well and reduces the amount of self referral patients to the ED, only 6% of self referred patient triaged to the GP is double referred to the ED. Recording to their complaints, patients with abdominal complaints and syncope are more likely to need further specialist care. More specific analysis of these patient groups and the triage definitions could improve overall performance of the triage system in the combined front office.

 


Lutfullah NABIZADAH, Elke LUNSHOF-HOBBELINK (Amsterdam, The Netherlands), Maarten KOK
11:00 - 18:00 #7213 - Dual-energy computed tomography shows brain ischemia and hyperbaric oxygen therapy efficacy in acute carbon monoxide intoxication.
Dual-energy computed tomography shows brain ischemia and hyperbaric oxygen therapy efficacy in acute carbon monoxide intoxication.

In carbon monoxide (CO) poisoning, the oxygen carrying capacity of blood is reduced; the amount of oxygen (O2) delivered to the tissues decreases and it leads to hypoxia at the tissue level. The most affected organs are the ones which use plenty of O2 such as the brain and heart. By imaging methods, these effects can be shown to some extent in the acute phase. Radiologic findings appear later, leading to delays in diagnosis. Rapid diagnosis and treatment increases the chance of a successful discharge. Here, we present a young man who was found unconscious possibly due to CO exposure. When he arrived to the emergency department (ED), there was no neurologic finding. Initial brain computed tomography (CT) failed to show any damage. However, dual-energy CT (DECT; as far as we know, first in the literature) revealed perfusion defect on the temporal lobe. Dual-energy CT was also efficacious in showing the healing in the brain after hyperbaric oxygen treatment (HBOT). A 20-year-old male patient was found unconscious and delivered to our emergency department by ambulance for suspected carbon monoxide poisoning. When he arrived to the emergency department, there was no neurologic finding. Initial brain computed tomography failed to show any damage. His laboratory results were within reference range, except carboxyhemoglobin being 40%. Dual-energy computed tomography (DECT; as far as we know, first in the literature) revealed perfusion defect as it showed hypodense areas on the right temporal lobe. He was transferred in the emergency intensive care unit. In addition to normobaric oxygen treatment, 2 sessions on the first day and 1 session on the second and thirds days of hyperbaric oxygen treatment were performed. Control DECT was taken on the fourth day of hospitalization after hyperbaric oxygen treatment was completed. Control DECT revealed a decrease in iodine uptake and relative recovery in perfusion on the same region. After relief of his complaints and with total recovery in neurologic examination, the patient was discharged to follow-up with recommendations on his fourth day of admission. We conclude that brain DECT may be useful for both the diagnosis and the effectivity of treatment in patients with carbon monoxide intoxication who had neurologic symptoms.

(This case report is accepted in American Journal of Emergency Medicine with doi number as: 10.1016/j.ajem.2015.12.031)


Mustafa UZKESER (Erzurum, Turkey), Abdullah Osman KOCAK, Ilker AKBAS, Gokhan POLAT, Mecit KANTARCI, Mucahit EMET, Sahin ASLAN
11:00 - 18:00 #7121 - Dyspnea and cough secondary to Lymphoma.
Dyspnea and cough secondary to Lymphoma.

MEDICAL HISTORY:

A 25 years old man , with no medical history of interest , except for smoking , who comes to  the emergency service  with cough , ribs pain , effort dyspnea ,and low-grade fever ,for a week of evolution , besides he was treated with ibuprofen and acetaminophen.

Familyhistory: 4 asthmatic brothers, motherwith C hepatitis , maternal grandmother with DM. Father´s family history is unknown.

EXPLORATION:

Acceptable general condition. Normal hydrated, paleness of skin and mucous, Straw-colored, Haggard. Non fever.

Head and neck: normal.

AC: rhythmic beat without blowing, 84 beats per minute

AP: vesicular murmur preserved, with 98% O2 saturation

Abdomen: soft, depressible, not painful lyin touching, no masses or megalies. Not inguinal nodes.

COMPLEMENTARY TESTS:

Chest X-Ray: widening mediastinum. Elevation of left hemidiaphragm.

Blood analysis: blood count, biochemistry, venous blood gas and coagulation without alterations, with PCR 14.3

The patient was admitted to internal medicine área in order to study mediastinum mass.

EVOLUTION: 

During his permanence in hospital, a neck and abdomen scanner was made without findings, thorax scanner resulted with mediastinum mass that affects all the mediastinum, with anterior predominance and compressing the left main bronchus, with defect of repletion in the right lower lobar  artery (acute PTE/SUBACUTE).

Multiple biopsy of anterior mediastinum mass was made, and after that patient starts with pain and tumefaction on right side, relationed with small right pneumothorax and subcutaneous emphysema

Result of the biopsy: LYMPHOBLASTIC T cell Lymphoma

Patient is under responsibility of haematology, with steroid treatment till getting G-6PD results , and then starts treatment with chemotherapy.


José Ignacio VALERO ROLDÁN, Iván VILLAR MENA, María Victoria ALARCÓN MORALES (BCN, Spain)
11:00 - 18:00 #7666 - Dyspnea secondary to acute sarcoidosis.
Dyspnea secondary to acute sarcoidosis.

An 28 year old woman, 3 children, housewife. Smoking 10 cigarettes a day. No previous disease or family history of interest. Hospital emergency derived by family doctor dyspnea at 20 days of evolution, little cough, general malaise and striking afebrile basal saturation 94%. It has become symptomatic treatment with paracetamol and cough suppressants. Children with upper tract respiratory infections. Do not trip. A bird Lovebirds at home for months.

On examination, normotensive 75 pm in sinus rhythm, no fever, good general condition, eupneic, basal saturation 95%. Auscultation rhythmic sounds and breath sounds without murmurs preserved without pathological noises. Wandering 50 meters began with increased dyspnea, lip cyanosis, increased respiratory rate and saturation to 92%, all with acceptable tolerance. Abdomen without findings. Right leg elevated erythematous lesion 5 cm anterior tibial diameter.

Our first suspected diagnosis of pulmonary embolism was screening or hypersensitivity pneumonitis lovebirds, less likely sarcoidosis or atypical pneumonia.

Radiography ask where drew attention infiltrated diffuse bilateral alveolar-interstitial pattern. Analytical leukocytosis 11,800 (69% N) PCR dimer D 28 917 normal EKG and CT angiography negative for TEP with hilar lymphadenopathy and bilateral interstitial pattern and ground glass consolidation patched Thorax. blood cultures, legionella Ag and pneumococcus, HIV, Chlamydia and Mycoplasma Ag, PCR Influenza, growing M tuberculosis, immunity and angiotensin-converting enzyme (rises in 50-80% of patients with sarcoidosis) study were extracted.

For suspected hypersensitivity pneumonitis Sarcoidosis versus enters Pneumology, with a final diagnosis of Sarcoidosis by lung biopsy (non-necrotizing granulomatous inflammation).

 Sarcoidosis is a granulomatous multisystem disease characterized by the accumulation in various organs, especially the lung, granuloma formed by T lymphocytes and macrophages, distorting normal tissue structure in the seating. It is of unknown cause, the current hypothesis relates it appears in genetically susceptible people, adults more common in women younger than 50 years. Often it presents bilateral hilar lymphadenopathy, pulmonary infiltration (90%), skin lesions and ocular erythema nodosum type. The prevalence of erythema nodosum sarcoidosis is highly variable, ranging between 3 and 53% of cases, due to racial, geographic and genetic factors. The diagnosis is established when clinical and radiologic findings are supported by pathology. The most commonly used treatment options are corticosteroids, methotrexate, antimalarials.

Forecast 60% have spontaneous resolution of the disease, while the rest evolve chronically, the most serious complication is pulmonary fibrosis. Mortality 1-5%, mainly due to respiratory failure.

 


Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #7352 - e-cigarettes acute intoxication: a retrospective study from a french control poison center.
e-cigarettes acute intoxication: a retrospective study from a french control poison center.

Introduction:

The electronic cigarette is a nicotine-delivering device available since 2003. The e-liquids contain glycerol, propylene glycol, flavoring agents and nicotine, at concentrations below 20 mg/ml in France. The purpose of this study was to analyze the cases of acute intoxication by e-liquids reported to a french poison center.

Methods:

We conducted a monocentric and retrospective study, of the e-liquid poisoning cases collected at the poison center of Strasbourg from 01/01/2014 to 31/12/2014.

Results:

53 cases were registered during the study period. The intoxications were more frequent among children aged less than 11 years (39%) and adults (56%). Unintentional poisoning represented 81% of the cases, and voluntary intoxications represented 19%. The sex ratio was 3.6 among adults and 0.6 for children. Exposures occurred through ingestion (73%), dermal exposure (15%) and ocular exposure (9%). 74% of the patients were symptomatic. Poisoning occurred via the device for 65% of adults and via refills for 68% of children. 85% of poisonings were of low severity regardless of the concentration of nicotine in the liquid. 75% of patients were monitored at home and 19% consulted at an emergency department. On voluntary intoxications, exposure was mainly oral: women were more concerned than men (SR 0.25). 60% of these patients were symptomatic. 20% of these intoxications were of mild severity, according to the Poison Severity Score. 

Discussion:

The amount of e-liquid responsible of poisoning was often not available. The lethal dose of nicotine by ingestion, estimated previously about 60 mg for adults, is currently being revised. The majority of e-liquid poisonings are usually accidental and mild. Children are poisoned via refills because of the attractiveness of these small bottles without safety device. For adults, it is often mishandling or poor quality of the devices that are responsible for the poisoning.

Conclusion:

In our study, regardless of the circumstances, acute poisoning by e-liquid mostly have mild consequences, as found in the literature review. We noted that after a raise in the number of acute intoxications with a peak in 2014, the numbers are levelling down (27 cases in 2015). The medium and long-term effects are still unknown due to the recent introduction of this product on the market and the relative lack of knowledge about the combustion products of e-liquids.


Amish SEERUTTUN, Christine TOURNOUD, Eric BAYLE, Pierrick LE BORGNE (Strasbourg), Charles-Eric LAVOIGNET, Hakim SLIMANI, Claire KAM, Pascal BILBAULT
11:00 - 18:00 #7292 - Early detection of sub massive pulmonary embolism by electrocardiogram.
Early detection of sub massive pulmonary embolism by electrocardiogram.

Introduction: Clotted blood in pulmonary arterial circulation results in PE (pulmonary embolism) [1]. It is presented with various and heterogeneous symptoms [2]. identifying poor prognosis patients with PE is very important and challenging [3]. There are numerous risk stratification scores to identify high risk PE. Electrocardiogram characteristic as the first step for diagnosis of PE is valuable [4]. Common ECG finding in pulmonary embolism are sinus tachycardia, RBBB, T-wave inversion in V1-V4 and S1-Q3-T3 pattern. Here we consider the role of aVR ST-segment elevation in detecting right ventricular dilation.

Method: This is a case control study in Imam Reza hospital Mashhad. Case group were 30 patients with wells score more than 3 who were hemodynamically stable and had ST-segment elevation in aVR lead. Patients who had chronic pulmonary disease, structural heart disease, renal failure and cardiac surgery were excluded. Control group consist of 30 patients selected from patients who presented to the same department with wells score more than 3 who were hemodynamically stable and didn’t have ST-segment elevation in aVR lead. They were all matched with case group from age, gender, diabetes mellitus, hypertension, ischemic and valvular heart disease. Both group had gone under chest CT Angiography and echocardiography. Then RV (right ventricular) dilation was evaluated in both groups.

Results: in case group 73.3% had dilated right ventricle bun in control group only 30% had it (p<0.05, OR=6.41).

Conclusion: ST-segment elevation in aVR is a good prognostic factor for RV dilation in pulmonary thromboembolism.


Majid JALALYAZDI, Azadeh MAHMOUDI GHARAEE (Mashhad, Islamic Republic of Iran)
11:00 - 18:00 #6406 - Early identification of septic patients in the Emergency Department: role of lactates at Triage.
Early identification of septic patients in the Emergency Department: role of lactates at Triage.

Early indetification of patients with severe infection tha can rapidly evolve to sepsis (formerly called severe sepsis) is crucial as it has been proven that "aggressive" treatment of these patients reduces mortality.

In 2013 we conducted a retrospective study in our Emergency department with these goals: 1) analysis of correlation between: -symptoms at admission (fever, tachycardia, arterial hypotension), - vital signs at traige (SBP, MBP, HR), - presence of Sistemic Inflammatory Response Syndrome (SIRS), - Shock Index at triage, with a) hyperlactatemia (>4 mmol/l)-primary outocome; b) 28-day mortality-secondary outome.

In that study we found that non anamnestic or clinical element was individually associated neither with hyperlactacidemia nor with mortality, except pronounced arterial hypotension. SIRS criteria weren't associated neither with lactate>4 mmol/l nor with 28 day mortality. We suggested that Shock Index could be used as an early warning at triage. In our retrospective study SI>0,7 was predictor of lactate>4 mmol/l ans SI>1 was predictor of both lactate>4 mmol/l adnd 28 day mortality, both with an elevated Ngative Predictive Value.

In 2016 we started a multicentric observational study using Shock Index at triage in patients presenting to our Emergency Departments with suspicion of infection. With a SI>0,7 lactates are measured immediately and if the value is >4 mmol/l the patient is immediately monitored and seen by an Expert Emergency Physician. Iflactates are >2 mmol/l the patient is seen within 15-30' by an expert team.

The objects of our study are: 1) to reduce the delay between triage and treatment (door-to-antibiotic/fluids time) of patients with sepsis; 2) to increase the capacity of recognizing sepsis in the Emergency Department and allow the admission to the adequate setting.

Our preliminary data show thata Shock Index at triage correlates with lactates and that the rapid lactates assessement gives a rapid awarenessot the clinical situation of the patient with consequent early aggressive treatment.


Germana RUGGIANO (FIRENZE, Italy), Luca NALDI, Alessio BERTINI, Renzo CAMAJORI TEDESCHINI, Andrea CAMARRI, Aurelia GUZZO
11:00 - 18:00 #8121 - Early rule-out of acute coronary syndrome at the emergency department before and after implementation of the new European Society of Cardiology guidelines.
Early rule-out of acute coronary syndrome at the emergency department before and after implementation of the new European Society of Cardiology guidelines.

Background:
Thoracic pain is one of the most frequent symptoms encountered at emergency departments, and the early diagnosis or rule-out of life-threatening causes, such as acute coronary syndrome (ACS) is a key competence of emergency medicine. Fast and safe diagnosis is crucial for patient safety, whereas quick rule-out is essential to deal with increasing overcrowding of emergency departments.

In August 2015, the European Society of Cardiology (ESC) published new guidelines for the management of non-ST-elevation ACS. The rise of high-sensitivity Troponin T (hs-Tnt) assays allowed the introduction of “early rule-out” algorithms but might also lead to an increasing number of patients with “low positive” baseline hs-Tnt levels who require further observation.

We aimed to assess the impact of the implementation of the new guidelines on the frequency of early rule-out and prolonged observation/repeated testing at the setting of a high-volume tertiary care emergency department.

Methods:
At our emergency department at a 2,200-bed tertiary care university hospital, approximately 90,000 patients are seen per year. We conducted a pre- and post-changeover analysis 3 months before (July to Sept 2015) and 3 months after (Oct to Dec 2015) transition from old (hs-Tnt cutoff 30ng/l, 3-hour rule-out) to new (hs-Tnt cutoff 14ng/l, 1-hour rule-out) guidelines, comparing proportions of patients requiring repeated testing using the chi-square test.

Results:
During the study period a total of 5,448 cases of symptoms suspicious of acute cardiac origin were treated (3,451 before; 1,997 after (consistent with previously observed seasonal variation in cardinal symptoms at our department); 2,370 (43.5%) female; age 55 (+/-19) years).

The proportion of patients fulfilling early-rule out criteria decreased from 68.0% (2,348 patients) before to 59.8% (1,195 patients) after implementation of new cutoffs. Due to the new guidelines, the proportion of patients requiring repeated testing significantly (p<0.01) increased from 21.5% (743 patients) to 24.7% (494 patients), whereas the proportion of positive results in repeated testing significantly (p=0.02) decreased from 43.1% (320 patients) to 36.7% (181 patients).

Conclusions:
In our high-volume, real world setting implementation of the new ESC guidelines led to a minor rise in prolonged observation, mainly explained by an increase in eventually negative repeated testing.


Calvin Lukas KIENBACHER (Vienna, Austria), Verena FUHRMANN, Raphael VAN TULDER, Christof HAVEL, Wolfgang SCHREIBER, Harald HERKNER, Dominik ROTH
11:00 - 18:00 #7758 - Eating disorders and diagnosis in Emergency department.
Eating disorders and diagnosis in Emergency department.

Background & Aim

 

16 year old brought to the emergency department of AP by unconsciousness while she was dancing. Before she comments her partners  dizziness, but not palpitations or visual disturbances.

She Refer cramps and headache in the past two weeks. Six months ago presented an episode of abdominal and precordial pain .5/30 menstrual cycle, but 8 months ago it dissapear. Very good student, above average ratings. She has many friends and social relationships. Recent divorce of parents. Good student in the dance academy which since seven years ago, she loves dance and she refers the mother to be a  professional.

 

Method

We conducted a clinical interview when she arrive at our Emergency Department. In the physical examination was highlighted a pale skin, thinness and The body mass index16.Tanner 3.

Asymptomatic when she arrived, we decided to refer the following  analitic dates to her Family Physician because we suspect a disorder in her Eating behaviour.

Results:

Potassium 2.5 mEq / L

CO2: 29 mEq / L

Calcium: 8.2 mEq / L

Phosphorus: 4.2 mEq / L

 

A history of chest and abdominal pain can be able to a possible esophagitis, which may be secondary to vomiting . Amenorrhea by excessive exercise, caloric restriction and loss weight. La hypokalemia and / or low levels of ionized calcium can be the cause of  cramps, headache, dizziness and heart rhythm disturbances.

 

Treatment and Action Plan

Requires family education, nutritional counseling and psychiatric treatment. It is derived endocrinology and to our Mental Health Unit.

 

CONCLUSIONS

Eating disorders appears in adolescents above 14-18 years. Clinics and a good doctor-patient relationship  is essential to reach the diagnosis. The goal of the therapy in patients with Ealing disorders is to get weight regain and the own awareness of the disease.


Veronica PARENT MATHIAS (MALAGA, Spain), Lorea DE UNAMUNO LUMBRERAS, Juan Manuel GARCIA LOPEZ, Maria Del Mar BECERRA MAYOR, Maria Isabel CORREA ROSALES
11:00 - 18:00 #7879 - ECG Lead Misplacement - Fool Me Once Shame on You,Fool Me Twice Shame On Me.
ECG Lead Misplacement - Fool Me Once Shame on You,Fool Me Twice Shame On Me.

ECG lead misplacement can dramatically alter the appearance of the ECG. if this is not detected significant and profound errors in treatment can ensue. We report the case of a 42 year old male who presented following a fall down a flight of stairs. An ECG was performed and this was compared with a previously recorded ECG which was filed in the patient's hospital record. Two separate limb lead misplacement were present on this ECG even though classical features of both limb lead misplacements were present. Not only was this ECG filed in the in-patient records the ECG was not signed off by a senior doctor.

A Review of the ECG appearence of both examples of misplacement is present together with tips on how to recognise these lead misplacements.

ECG lead misplacement can alter the diagnosis in approximately 25% of cases and represents an avoidable risk in patient management.


Irene GROSSI (Bristol, ), Richard M LYNCH
11:00 - 18:00 #7643 - Economic and operational impact of the Alere™ i Influenza test in a German emergency department.
Economic and operational impact of the Alere™ i Influenza test in a German emergency department.

Objective

Among all infectious diseases, the influenza (flu) is especially difficult to deal with due to the unpredictability of its outbreak. A flu season strains the resources of Emergency Departments (ED) and hospitals. The isolation management is a key challenge as the uncertainty about the patients’ health status makes isolation necessary for influenza and influenza-like-Illness (ILI) patients alike, until a definite test result is available. This uncertainty has a significant impact of the process efficiency and costs within an ED and also affects the hospital’s normal wards.

Method

In order to determine the process efficiency and cost impact of using a new rapid molecular test for influenza, the Alere™i Influenza A&B test, the patient’s care process with the PCR pathway was compared to a new pathway including the Alere™i Influenza A & B test. Further, a calculation model was designed using data from the 2014-2015 flu season from the University Hospital of Marburg and Gießen. Focus was on the potential operational and economic effects for the ED as well as for the hospital in general for the entire flu season.

Results

Several effects were found in the analysis: the patient care process using the PCR pathway takes several additional steps to reach the test result and the diagnostic uncertainty prior to obtaining the result makes isolation necessary for each step. In addition, the process takes longer; the time to decision and thereby also the necessary isolation time, can be shortened by an average of 9 hours, going from 10 hours to about 1 hour, using the Alere™i test. Upon streamlining and accelerating the process, costs fell from €94 to €53 per patient when using the Alere™ i test, extrapolating to an overall process cost reduction of €31,891 in one flu season (812 tested patients within the season). In addition, due to the fewer necessary isolation hours, additional room capacity is generated within the ED, and a saving of 1 examination room per day was estimated. On the normal wards, the new pathway freed up bed capacity for an estimated 8 additional inpatients during the crowded flu season.

Conclusion

The analysis shows that the management of ILI-patients during a flu season can benefit greatly from integrating the rapid molecular AlereTM i Influenza A&B test into the ED. Speeding up the diagnostic pathway results in both, economic, as well as procedural effects for the ED, and for the hospital.

Acknowledgements

The economic evaluation was supported by a grant to bcmed from Alere. Susanne Schaumberg and Clemens Kill received no payment for this work. 


Matthias BRACHMANN (Ulm, Germany), Katja KIKULL, Kill CLEMENS, Schaumberg SUSANNE
11:00 - 18:00 #7939 - Ectopic Pregnancy After Tubal ligation.
Ectopic Pregnancy After Tubal ligation.

 

Introduction

Abdominal pain is the most common cause of emergency room visits. Ectopic pregnancy is one of the most important cause of abdominal pain that have thousands causes should be considered in female patients of childbearing age.  Ectopic pregnancy is among the leading causes of mortality among pregnant women Ectopic pregnancy, has been increasing in number and approximately accounts for 1-2% of all pregnancies. While these patients are evaluated considering of risk factors are important. Risk factors of ectopic pregnancy are conception with an intrauterine device (IUD) in place, conception while using a progesterone only contraceptive method, genital tract infection, genital tract surgery, previous ectopic pregnancy, and in utero exposure to diethylstilbestrol. İn this case we aimed to remind that tubal ligation is used as protection methods is one of the risk factor for ectopic pregnancy rarely.

Case report        

A 28-year-old woman presented with acute lower abdominal pain and dysuria. She was admitted to the Emergency Department of the Bülent Ecevit University, Faculty of Medicine (Zonguldak, TURKEY). In the previous year, her fallopian tubes were ligated for sterilization. Patient was examined, her vitals were stable. Abdominal palpation revealed only mild tenderness in the right upper and lower abdomen. Other physical examinations were normal.

Her laboratory exams had, mild leukocytosis; 11100 K/mm³, mild anemia: 10,8 g/dL,   platelets:321000 /µL, urinary examination; leukocyturia and no pregnancy. We made transvaginal ultrasonography, she had 3 cm cyst and surrounded hematoma at left ovary and right ovary was normal. She had also 54 x 30 mm hematoma at rectovaginal space.

The patient underwent emergency surgery with the diagnosis of ectopic pregnancy.

Conclusion

Childbearing age patients are should be regarded as risk factors for acute abdominal pathology that need emergent surgery like ectopic pregnancy. Women's pregnancy status should be evaluated by emergency physicians.


Levent KOCA, Volkan ÜLKER (ISTANBUL, Turkey), Abdullah Cüneyt HOCAGİL, Hilal HOCAGİL
11:00 - 18:00 #7310 - ED Presentation of Post Traumatic Appendicitis.
ED Presentation of Post Traumatic Appendicitis.

ED Presentation of Post Traumatic Appendicitis

Appendicitis and trauma both present in emergency department commonly but their presentation together in same patient is unusual. We present a case of 43years old man brought by emergency medical services (EMS) to the emergency department with complaints of abdominal pain after he was involved in motor vehicle collision, two hours earlier. He was perfectly fine before the accident. His primary survey was normal. Secondary survey revealed tenderness in right iliac fossa with seat belt mark overlying it. Computerized tomography (CT) of abdomen and pelvis was performed which showed 8mm thickening of appendix with minimal adjacent fat stranding. There is also subcutaneous fat stranding of anterior lower abdominal wall possibly due to bruising. Impression of post-traumatic appendicitis was made. Laproscopic appendectomy was done and patient recovered uneventfully. Histopathology showed inflamed appendix.

 


Muhammad Faisal KHILJI (MUSCAT, Oman), Qazi ZIA ULLAH
11:00 - 18:00 #7570 - Education in the shockroom – daydream or reality?
Education in the shockroom – daydream or reality?

Background; Medical education underwent significant changes in the last ten years. Today, interactive learning methods replace traditional lectures. Triggered by reports like the Institute of Medicine IOM´s publication “To Err Is Human”, team trainings and interprofessional education in combination with constructive feedback are highly recommended to improve patient safety. Simulation training has become widely accepted, and many hospitals built simulation centers for their trauma teams and other groups in highly dynamic sectors of health care. 

Methods: Since 2009, the Emergency Department of the Inselspital, Bern University Hospital, disposes of a dedicated interprofessional trainer team with a focus on collaboration, coordination and communication. In 2012, the ED moved into a new building, and this was the start of regular interdisciplinary and interprofessional simulation trainings in our shockroom. Since then we offer simulation trainings for the introduction of new collaborators, have regular team trainings with our colleagues from the anesthesia department and make repetitions of a sedation course which we organize together with the anesthesia department.

Results

In 2012 we were able to test the new environment with simulations. With the help of the simulation training we were able to initiate several structural adaptations. Processes could be adapted, and the participants recognized the importance of team briefings and CRM criteria. Moreover they found the training beneficial for the support within their own and other professional groups, and for fostering a safety culture, respect and empathy.

Discussion: Education in a shockroom is possible, but it needs good methodology with a focus on interactivity. The success largely depends on a dedicated team of trainers, and they need regular faculty development. Support from top-down and bottom-up is crucial, meaning that for example clinical directors must be willing to invest money and to declare the training compulsory. Coordination for teams from different professions and disciplines is challenging, but possible. The feedback of the shockroom simulation is excellent, and in the special situation of testing a new environment, simulation training helped not only for the orientation in the new rooms but also to directly make structural adaptations.


Dr Monika BRODMANN MAEDER (Bern, Switzerland), Wolf HAUTZ, Uwe MEYER, Thomas SAUTER, Aristomenis EXADAKTYLOS
11:00 - 18:00 #7928 - Educational Experiences in Disaster Medicine.
Educational Experiences in Disaster Medicine.

Experiences with education in the field of disaster medicine, which we gained during the previous four years, enable us to provide other institutions facilitating similar education with useful information. Bachelor programme “emergency pre-hospital care” trains students as paramedics, which qualifies them for providing Emergency and Disaster Medicine. 

The major part of the education is focused on the subjects as Emergency Pre-hospital Care, Emergency Medicine and Disaster Medicine. Education of Disaster Medicine is included in the presentations called Health and Crisis Management, precisely during the second and third year of study. Full-time students attend 72 hours in sum and 12 hours of practical training. It includes also 40 hours which focusi on the Integrated Rescue System. External students have to complete 40 hours. Besides formal education we usually manage to convince 33,4% of students to participate in competitions, practices related to mass disasters. Generally we can conclude, that students can handle the theoretical part of their studies. According to the results of simulated tasks focused on triage, the problem is caused by incorrect triage of patients. They tend to have doubts concerning the likelihood of their own decision.

The main aim of this poster is to contribute with our experiences in the field of education, which is focused on the triage of injured patients at mass casualty incidents. 

In 2012 we received an instrument from a medicine student in Olomouc, which was designed to simplify the education of triage of injured people while applying START method. From that year, we have started to use this instrument and gradually we can confirm its positive effect. Our results of triage are at the level of 98,94%. The significance of results lies in the evident improvement in the accuracy of triage after using the instrument at different levels of difficulty. We can say that Bill Bowerman´s claim (2016), turned out to be accurate: “No teacher is smart enough to not be able to learn from their students.”  To contribute and compare our results, we have decided to move our students in a centre of a military training camp called Lešť. The camps main tasks are: “to fulfil tasks related to the security and defence of the state, conducting health care, sound assurance of special preparations, especially in the case of special armed  forces. The camp’s are has 145,5 km2 and its temperature is around 6-8 C (Lešť,2012). On the basis of evaluating forms, which were filled by them during different types of tasks, we will evaluate the results of practices and competitions attended in the training area.

The results of percentages of absolute and relative frequency we have arranged in transparent graphs and tables. The significance of the results we see in the description of education in the field of emergency health care and in the evaluation of theory and practice in the education of triage of injured. Education at universities show that its direction is balanced and the educational institutions should improve the form of education by active practice together with professional organizations. 


Alena DUDEKOVA, Viliam DOBIAS (Bratislava, Slovakia)
11:00 - 18:00 #7725 - Effect of Acute Chest Pain Fast Track to Quality Improvement of Ramathibodi Emergency Department.
Effect of Acute Chest Pain Fast Track to Quality Improvement of Ramathibodi Emergency Department.

Background : Acute coronary syndrome is one of the most common health problems worldwide, and is one of top five causes of death in Thailand from 2006-2010. American heart association recommends that immediate emergency department assessment of 12-leads EKG within 10 minutes. If STEMI is found, the patient must be treated with fibrinolytics within 30 minutes of arrival or perform PCI within 90 minutes of arrival. In Emergency department of Ramathibodi hospital has an acute chest pain fast track since 2010. This fast track guideline was implemented to improve the quality of treatment. 

Objective : To assess the quality of acute chest pain fast track and study factors affecting and the incidence of major adverse cardiac event in the patients with acute coronary syndromes in Ramathibodi Hospital. 

Method : This retrospective study included all patients age older than 20 who present with chest pain symptom, but with no history of accident in Ramathibodi emergency department between January to June 2013. Descriptive and analytic statistics were used to analyze quality of acute chest pain fast track service. 

Result : A total of 620 patients were included this study. There were 352 patients went through the acute chest pain fast track, and 89.49% of them underwent 12-leads ECG assessment within first 10 minutes. Epigastric pain patient is the only statistically significant factor to be restrained from the fast track. 90.01% of the STEMI patients, who went through this fast track, had been sent to PCI within 90 minutes and no mortality after 30-day follow up. 

Conclusion : Acute chest pain fast track guideline of Ramathibodi hospital is effective to improve the quality of suspected acute coronary syndrome treatment in emergency department.


Kasamon ARAMVANITCH (Bangkok, Thailand), Yuwares SITTICHANBUNCHA, Thidathit PRACHANUKOOL
11:00 - 18:00 #7052 - Effect of Capsaicin in Acetaminophen Poisoning: An Experimental Rat Model.
Effect of Capsaicin in Acetaminophen Poisoning: An Experimental Rat Model.

 

              

Objective: Plants have been used as a medicine in thetreatment of diseases among peopleforcenturies. The hot pepper which containing capsaicin  is one of theseplants. It has ben shown that the capsaicin haveanalgesic, antitumoral, antioxidant, antimicrobial, anti-inflammatoryan dimmunomodulatory effects. Theaim of this in vivo study was to investigate the positive effects of capsaicin on acetaminophen poisoning using a rat model.

Material and Methods: 21 female weight sranging from 280-300 g Wistar-Albino rats were included to study. Wistar rats were randomized into 3 groups of 7 each: group 1, control, no treatmentand no poisoning; group 2, paracetamol poisoning; group 3, paracetamol poisoning and treated with capsaicin(Table1). All therats rats were anesthetized with intramuscular injection of 90 mg / kg ketamine (ketamine 50 mg / mL, 10 mLvials, Pfizer) and 10 mg / kg xylazine (Basilaz 2% 25 mL, bavette). Blood samples and liver tissue were taken for biochemical and pathological examination. The study protocol was approved Dollvet Inc. Animal Experiments Ethics Board (Dollvet-HADYEK) supervised by Harran University Animal Experiments Local Ethics Committee. All statistical analysis was performed using Statistical Package for the Social Sciences 20.0 (SPSS ) software program. The results were expressed as median±IR. Analysis was performed using the ANOVA, Mann-Whitney U andchi-squaretests. P valueslessthan 0,05 were considered statistically significant.

Results:  Any inflammation were not observed by pathological examination in the group 1 (controlgroup) and group 3 (poisoning and treated with capsaicin ). However inflammation was significantly observed in the grup 2 (paracetamolgroup grup)   (p=0,007).Compared to the group of poisoning,reduction of biochemical parameters were observed in the capsaicin group. But no significant difference has been noted between the  3 groups for ALT, ALT,  ALP or CRP  median valuelevels in biochemical examination.

Conclusion: Inconclusion, according to the histopathological examination of the liver samples ,capsaicin have a preventive inflammation effect in therat  model. Further studiesare necessary fore valuating the benefits effects of the capsaicin  on paracetamol poisoning.

 


Ahmet Can DENIZ, Pr Gul Sahika GOKDEMIR (SAĞLIK BİLİMLERİ ÜNİVERSİTESİ,GAZİ YAŞARGİL EĞİTİM ARAŞTIRMA, Turkey), Hasan BÜYÜKASLAN, Halil KAYA
11:00 - 18:00 #7579 - Effect of crowding on length of stay for common chief complaints in the ED.
Effect of crowding on length of stay for common chief complaints in the ED.

Introduction: Increasing patient numbers is a growing problem in emergency departments (ED’s) all around the world. In Stockholm, the capital of Sweden, the number of patients acquiring emergency care is increasing by 4.5 % annually. However, the resources of the ED’s are not increasing at the same rate. The growing workload, further enhanced by difficulties in finding inhospital beds for patients in need of further medical attention, causes crowding to arise in the ED. Crowding is amongst other things associated with a long length of stay (LOS), as well as a prolonged time to administration of analgesics and antibiotics. It is not known whether the effect of crowding on length of stay is equal across different chief complaints.

Aim: To determine the effect of crowding on LOS in the 10 most common chief complaints in the ED.

Materials and methods: All adult visits (n=19,200) on weekdays between 8 a.m. and 9 p.m. to the ED at Karolinska University Hospital in Solna, Sweden, in 2012 were divided into groups based on chief complaint (the ten most common or others), priority given at triage (acute or non-acute) and occurrence of crowding at the time of arrival to the ED or at a later time during the visit (yes or no). Crowding was measured by the patient/bed-ratio. By calculations of the median LOS, comparisons were made between the different crowding subgroups for each chief complaint.

Results: The greatest increase of LOS was seen in the group with swelling/pain in extremity (145 % amongst high-acuity patients, 125 % amongst non-acute patients), non-acute patents where chief complaint had not been recorded (119 %) and patients with flank pain (87 % amongst high-acuity patients, 117 % amongst non-acute patients). The smallest increase of LOS was seen amongst the high-acuity patients with wounds (6,5 %), high-acuity patients with unspecified chief complaint (30 %) and patients with chest pain (32 % amongst high-acuity patients, 45 % amongst non-acute patients).

Conclusions: The effect of crowding on LOS is not equal across different chief complaints. Chest pain is associated with a smaller impact on LOS, while swelling/pain in extremity and flank pain is associated with the greatest increase of LOS. Non-acute patients are more greatly affected by crowding.


Linnéa WICKMAN (Bandhagen, Sweden), Per SVENSSON, Therese DJÄRV
11:00 - 18:00 #7339 - Effect of intranasal ketamine on patients with musculoskeletal pain, a double blind randomized clinical trial.
Effect of intranasal ketamine on patients with musculoskeletal pain, a double blind randomized clinical trial.

Background Ketamine was developed in the 1960s as an anesthetic agent, and is given intravenously or intramuscularly for procedural sedation and anesthesia especially in children. It is also used as an adjuvant to opioids in the treatment of none-acute refractory pain. Recently ketamine uses via other routs, such as intranasal.

Objectives The main goal of this study was determining the pain reducing effect of intranasal ketamine on musculoskeletal injuries at emergency department.

Methods A prospective double-blind randomized clinical trial was performed on alert hemodynamically stable patients arriving at the ED of a teaching hospital during March and August 2013. The subjects had musculoskeletal pain with NRS ≥4 in extremities, limbs, back, and hips. The patients were divided into two groups; the ketamine group received 25mg intranasal spray of ketamine, while distilled water was sprayed in the nasal cavity of the control group. Also, to alleviate the pain of all patients the physician administered a 325 mg acetaminophen tablet to every patient. Then, the NRS would be assessed along with reporting any complication or side effect during consecutive 15-minutes time periods until 45 min after the initial administration of the ketamine or placebo. Vital signs and O2                                                                                                                      saturations of patients were measured every 15 minutes.

Results One hundred and thirty three patients passed the inclusion criteria and 124 remained after excluding base on exclusion criteria. Four  of them did not sign written consent form and finally one hundred and twenty subjects were enrolled in the study, 60 in each group. 84 of them were female. There was a significant difference between the pain score of the ketamine and control groups (3.37±1.87 vs. 0.85±1.01). Both groups experienced equal complications such as nausea and vomiting, which have controlled spontaneously.

Conclusion Intranasal ketamine spray is an effective agent in reducing musculoskeletal pain among patients without serious underlying illness. Although the drug is moderately efficient, complications are negligible.


Amir NEJATI (Tehran, Islamic Republic of Iran), Seyed Hossein HOSSEINI DAVARANI, Zohreh FEILI
11:00 - 18:00 #7289 - Effect of physiologic dose of intravenous hydrocortisone in patients with refractory septic shock.
Effect of physiologic dose of intravenous hydrocortisone in patients with refractory septic shock.

Objectives: Septic shock is a systemic response to infection with tissue hypoperfusion which does not responding to fluid therapy and eventually lead to organ dysfunction. Diagnosis and treatment of septic shock is an emergency. Clinical suspicion and aggressive treatment of broad-spectrum antimicrobial and supportive measures is the cornerstone of successful treatment. In addition to the main treatment, there are adjunctive therapies. Steroids are one of the treatments being studied septic shock management. Despite numerous studies on the role of steroids in the mortality of severe sepsis and septic shock, still lots of controversies exist. These conflicts are often about the steroid dose and duration of administration.

Method: This is a double-blind clinical trial. Patients referred to Imam Reza (AS) in Mashhad who had refractory septic shock criteria were divided into two groups: 80 patients were included in each group. After obtaining the baseline cortisol level and cosyntropin test, one group treated with intravenous hydrocortisone, and the other group treated with placebo. The response to hydrocortisone and return of shock and mortality at 28 days was studied.

Results: The return of shock and mortality in intervention group patients was more than control group, but it was not statistically significant.

Conclusion: Despite numerous studies in this field, there are various outcomes (mortality rate, rate of return of shock, time of return of shock). These differences can be attributed to high degree of heterogenesity. Perhaps considering the underlying disease and more differentiation could change return of shock and mortality rate.


Morteza TALEBI DOLUEE, Azadeh MAHMOUDI GHARAEE (Mashhad, Islamic Republic of Iran), Majid JALALYAZDI, Maryam SALEHI
11:00 - 18:00 #7593 - Effective knowledge translation in the paediatric emergency department.
Effective knowledge translation in the paediatric emergency department.

There is often a gap between knowledge and clinical practice. Knowledge translation seeks to bridge that gap through recognition of the barriers faced by clinicians and identifying strategies to overcome them, thereby facilitating the implementation of evidence-based practice. We explored the effectiveness of a number of knowledge translation techniques in revising the care given to patients requiring peripheral intravenous cannula (PIVC) insertion in the Emergency Department.

PIVC insertion is an invasive procedure causing significant distress in children. NSW Health guidelines aimed at monitoring the procedure require that the details of PIVC insertion are documented in the patient record. Prior to this study, there was no standardised procedure for recording PIVC insertion on the electronic patient health record in the emergency department at The Children’s Hospital at Westmead.

The aim of this observational study in the Emergency Department at The Children’s Hospital at Westmead is to determine the effectiveness of strategies to influence the practice of clinicians in relation to recording details of PIVC insertion.   A template for recording details of the placement of an intravenous cannula was introduced into the medical record.   The use of the template was quantified every week over a 6 week period.  Approval for the study was given by the Sydney Children's Hospital Network Ethics Review Committee.

Data was collected prospectively on patients who were cannulated whilst in the emergency department and then analysed looking for completion of the template.  The interventions were introduced every two weeks over a 6 week period.  Interventions were employed in a staggered fashion to facilitate assessment of the effectiveness of each individual component as well as the effectiveness of the overall multi-faceted approach. The interventions included the placement of laminated notice in key clinical areas where venous access procedures are carried out; an education session aimed at medical and nursing staff alongside a brief education tool at medical and nursing handovers; notification of the template use in the departmental newsletter; and audit performance report provided by email.

A total of 1477 patients were included over the 8 week study, of which 705 (48%) had completed PIVC insertion templates. Staff education resulted in a 43% increased use of the template in week 1 which was sustained in week 2. The placement of laminated notices in key clinical areas saw a further 10% increase in template use in weeks 3 and 4. There was an overall decline in template use in subsequent weeks of the study despite the audit performance report.

The interventions used aim to address common barriers to knowledge translation such as lack of staff awareness, no engagement of staff, lack of relevance to individual practice and fading of initial enthusiasm. Staff education is a successful tool for implementing change in clinical practice. However, there exist difficulties in maintaining staff engagement and enthusiasm for the change in practice. Scope for further research should include identifying the causes of this decline. Innovative tools for addressing this loss of engagement and enthusiasm are required.


Michael MCCARRON (Glasgow, United Kingdom), Adrian BONSALL, Mary MCCASKILL
11:00 - 18:00 #7501 - Effectiveness of non-invasive ventilation in patients with acute respiratory failure in improving distress and reducing need for intubation.
Effectiveness of non-invasive ventilation in patients with acute respiratory failure in improving distress and reducing need for intubation.

Background: Non Invasive Ventilation ( NIV) has turned to have a wide role in the management of acute respiratory failure, above all in patients suffering from recurrences of chronic obstructive pulmonary disease. NIV is effective in reducing the need for invasive ventilation and preventing the relapse of respiratory failure after intubation removed. Although its confirmed usefulness in the clinical practice, data are still limited and not conclusive.

Aim: To evaluate the effectiveness on NIV in the management of acute respiratory failure in the “real life” of  Emergency Department and to identify factors that predict the need for ventilation to be continued.

Methods: We retrospectively considered all patients observed for acute respiratory failure and submitted to NIV in the Emergency Department of the University Hospital of Verona (Italy)  from October 2014 to March 2015. Clinical history, morbidity, vital parameters, blood gas analysis and blood examinations were registered and used to calculate the APACHE II score. Data about aetiology of acute respiratory failure, chest x-ray findings, type and duration of NIV were further gathered. The effectiveness of NIV was evaluated in terms of improvement of respiratory distress, trend of blood gas analysis, early and late intubation rate, mortality rate. 

Results: In the scheduled period we observed 93 patients (37 males, 56 females, mean age 80 years) with several morbidity (heart disease 86%, chronic obstructive pulmonary disease 47%, diabetes 28%, chronic renal failure 38%). Out of the, 84 patients (90%) were admitted with severe respiratory distress, due to heart failure in 61 (66%) and to pneumonia in 23 cases (24%). APACHE II score median value was 19.8. NIV was performed in PSV mode in 77 patients (83%) and in CPAP mode in 16 patients (17%). Median length of treatment was 3.5 hours. Ventilation had to be continued in 33 cases (37%), but only 6 patients required an invasive procedure. Predictive factors for prolonged ventilation resulted to be: APACHE II score, pH after ventilation, trend of blood gas analysis, diagnosis of acute pulmonary oedema or pneumonia (p<0.05). NIV proved to be effective in recovering respiratory distress in 67 patients (80%) and improving blood gas analysis in 77 patients (93%). Overall intubation rate was 6.4% and mortality rate 20%.

Conclusions: The improvement of respiratory distress plays as a reliable parameter to evaluate the effectiveness of NIVwhile its persistence as a risk factor as regards mortality. Furthermore, the cause of acute respiratory failure and the trend in blood gas analysis resulted to be well related with the need for ventilation to be prolonged.


Elisa PERON, Dr Antonio BONORA (VERONA, Italy), Valentina SERAFINI, Gianni TURCATO, Domenico VERALDI, Massimo ZANNONI, Giorgio RICCI, Mariano BELLONI, Francesco BUONOCORE
11:00 - 18:00 #4707 - Effects of bed height standardisation using the rescuers’ average knee height during in-hospital cardiopulmonary resuscitation.
Effects of bed height standardisation using the rescuers’ average knee height during in-hospital cardiopulmonary resuscitation.

Objective: This study evaluated whether chest compression in a standardised in-hospital cardiopulmonary resuscitation (CPR) setting can be performed as effectively by using the rescuers’ average knee height as by kneeling beside a patient lying on the floor.

Materials and methods: We devised the following standardised in-hospital CPR setting. First, bed height was fixed at 70 cm. Second, the gap between the bed and a step stool was set to the average knee height of the CPR team members (45 cm). Thirty-eight medical doctors on the CPR team each performed 2 min chest compression in tests 1 (experiment setting) and 2 (kneeling on the floor) in random order (cross-over trial). A Little Anne was used as the simulated cardiac arrest patient. Chest compression parameters, such as the average depth and rate, were measured using CPRmeter.

Results: In all tests, average depths were those recommended in the recent CPR guidelines (50–60 mm), with no significant difference between tests 1 and 2 [95% confidence interval (CI), 51.7–54.5 vs. 51.0–54.2 mm; p = 0.398]. The average rate in test 2 (95% CI, 115.0–123.2) was slightly faster than the recommended rate (100–120 compressions/min) and differed significantly from that in test 1 (95% CI, 113.0–119.7; p = 0.028).

Conclusion: The quality of chest compression in a standardised in-hospital CPR setting using the rescuers’ average knee height did not differ from that performed in the kneeling position on the floor.


Je Hyeok OH (Seoul, Korea), Tae Soon PARK, Dong Hoon LEE, Chan Woong KIM, Sung Eun KIM, Jun Young HONG
11:00 - 18:00 #8115 - Effects of Dispatcher-assisted Cardiopulmonary Resuscitation on Survival Outcomes by Age Group in Pediatric Out-of-hospital Cardiac Arrests.
Effects of Dispatcher-assisted Cardiopulmonary Resuscitation on Survival Outcomes by Age Group in Pediatric Out-of-hospital Cardiac Arrests.

Objective

We studied the effect of a dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) program on pediatric out-of-hospital cardiac arrest (OHCA) outcomes by age groups.

Methods

All emergency medical services (EMS)-treated pediatric OHCAs in Korea were enrolled between 2012 and 2014, excluding cases witnessed by EMS providers and those with unknown outcomes. Exposure was bystander CPR (BCPR): BCPR-with-dispatcher assistance (DA), BCPR-without-DA, and No-BCPR. Endpoint was survival to discharge. Multivariable logistic regression analysis was performed. The final model with an interaction term was evaluated to compare the effects across age groups.

Results

A total of 1529 patients (32.8% BCPR-with-DA, 17.3% BCPR-without-DA, and 54.6% No-BCPR) were included in the final analysis. BCPR-with-DA and BCPR-without-DA were 43.2% and 15.5% in 0-12 months old, 33.1% and 21.8% in 1-8 years old, and 25.7% and 16.0% in 9-18 years old group, respectively. Both BCPR-with-DA and BCPR-without-DA were more likely to have higher survival to discharge (8.8% and 12.1%) compared with No-BCPR (3.9%). The adjusted ORs (95% CIs) for survival to discharge were 1.77 (1.04-3.00) in BCPR-with-DA and 2.86 (1.61-5.08) in BCPR-without-DA compared with No-BCPR. By age groups, the adjusted ORs (95% CIs) in BCPR-with-DA and BCPR-without-DA were 2.18 (1.07-4.42) and 2.27 (1.01-5.14) for 9-18 years old group; 2.32 (0.64-8.44) and 6.21 (1.83-21.01) for 1-8 years old group; 1.06 (0.41-2.77) and 2.00 (0.64-6.18) for 0-12 months old group, respectively.

Conclusions

BCPR regardless of DA was associated with improved survival outcomes after OHCA in pediatrics. However, the associations between DA-BCPR and survival outcomes were different by age groups.


Ki Bong BAEK (Seoul, Korea), Sang Do SHIN, Kyoung Won LEE, Young Sun RO
11:00 - 18:00 #7144 - Effects of Momordica Charantia In A Burn Wound Healing Rat Model.
Effects of Momordica Charantia In A Burn Wound Healing Rat Model.

INTRODUCTION: Momordica charantia (bitter gourd) is a herb, whichs leafs and fruits are used for production of the antibacterial, antiviral, larvacidal and chemotherapeutic drugs. M. charantia has also antioxidant effects. Its ripe fruits were used for wound healing and as antiulcer in traditional Turkish medicine. The literature review shows only a few animal experimental studies designed to evaluate wound healing effects of M. charantia. None of those studies were designed to investigate healing effect of M. charantia in burn wounds. It is aimed to determine whether M. charantia has an effect on healing of experimental contact type burn models and to compare its effects on burn healing with silver sulfodiazine (SSD) which is accepted as a commonly used topical treatment agent for burns. 

METHODS: This study is started after approval of Ege University Animal Experiments Ethics Board. Thirty-five Sprague –Dawley breed rat from female sex which reached sexual maturity weighing 200-220 gr were separated into 5 groups. After intraperitoneal xylazine and ketamine anaesthesia, a standartized burn model applied previously shaved solid skin areas of the rats. Any procedure or treatment was applied to Group I, in group II only normal saline, in group III 1% SSD, in group IV 2% M. charantia extract containing gel and in group V a placebo gel (7.5 % Na-carboxymetylcellulose) were applied to the burned skin area at the hours 0, 6, 12 and 18. Full-thickness skin biopsies, which are taken from three burned areas of the rats at the hours 4, 8 and 24 were examined under a light microscope with hematoxylin and eosin (H&E) staining.
RESULTS: Epidermal thickness was increased in M. charantia group in comparision with burn, SSD and placebo groups. Similarly, number of degenerated hair roots was decreased in M. charantia group in comparision with all groups. The number of intact vessels was found to be as increased in M. charantia group in comparision with burn, placebo and SSD groups at 4th, 8th and 24th hours while SSD has any positive effects in comparision with placebo. 

In histological evaluation which was made with Modified Verhofstad Score; scores for edema in 4th, 8th and 24th hour were distributing at lower scores in M. charantia group in comparision with SSD and placebo groups, and also all scores for PMNL infiltration were found to be as lower than SSD and placebo group in 4th, 8th and 24th hours. In terms of collagen discoloration, M. charantia group has significantly lower scores in all hours than SSD and placebo. Scores of M. charantia were markedly distributing in lower stages for vascular damage, hair root damage and glandula sebacea damage  in comparision with SSD and placebo groups in 4th, 8th and 24th hours. 

CONCLUSION: M. charantia has protected epidermis, hair roots and vessels better than SSD and placebo and reduced gl. sebacea damage in acute contact termal burns. M. charantia has reduced tissue edema and PMNL infiltration with application on burned skin more effectively in comparision with conventional burn topical agent SSD and also placebo gel. 


Fatih TEPE, Pr Murat ERSEL (IZMIR, Turkey), Emel Oyku CETIN, Yigit UYANIKGIL, Turker CAVUSOGLU, Fatih KARABEY, Selahattin KIYAN, Yigit TIFTIKCIOGLU, İlhan UZ
11:00 - 18:00 #6185 - Efficacy and Safety of Sufentanil Sublingual 30mcg Tablet for Management of Acute Traumatic Pain in the Emergency Department.
Efficacy and Safety of Sufentanil Sublingual 30mcg Tablet for Management of Acute Traumatic Pain in the Emergency Department.

Introduction: Pain is the most common reason people visit the emergency room. A review of emergency department (ED) pain management practices however demonstrates treatment inconsistency and inadequacy that extends across all demographic groups. This discrepancy appears to stem from a multitude of barriers including lack of educational emphasis on pain management in nursing and medical school, failure to implement ED-specific pain management guidelines, clinicians’ inappropriate attitudes toward opioid analgesics and a paucity of rigorous studies of populations with special pain management needs (ie pediatrics and the elderly). Specifically, many patients still suffer from acute pain while waiting to be evaluated, waiting for intravenous (IV) access to be established and/or waiting for treatment or procedures. There remains a clinical need for rapid-acting, potent analgesics that do not require an invasive route of delivery.  A sublingual sufentanil 30mcg tablet is in development for treatment of acute pain in emergency medicine or field trauma settings.The primary objective of this study was to evaluate the safety and efficacy of the sufentanil sublingual 30mcg tablet for the management of moderate-to-severe acute pain in patients in an ED setting. 

Methods: This is a phase 3, multi-center and open label study for up to 5 hours in adult patients presenting to the ED with acute pain brought on by recent trauma or injury. Following IRB approval and patient informed consent, approximately 120 patients who met all inclusion and none of the exclusion criteria were administered up to four individual doses of the sufentanil sublingual 30mcg tablet, given at least 60 minutes apart.  Efficacy was assessed by patient reports of pain intensity on an 11-point numerical rating scale, (0 = no pain, and 10 = worst possible pain) and a five-point pain relief scale (0 = no relief, 4 = complete relief) as well as patient and healthcare professional global assessments (PGA and HPGA).  Primary efficacy variable was the summed pain intensity difference to baseline over the first hour (SPID1). Safety was assessed via vital signs, oxygen saturation monitoring and adverse event reporting (AEs).

Results: Enrollment is on-going with approximately 43 of the 120 patients enrolled to date.  An interim analysis was performed following patient #40, indicating statistically significant and clinically meaningful reductions in pain intensity following a single dose of sublingual sufentanil 30mcg.  A low number of adverse events have been reported, most of which are mild in severity. Nausea and somnolence are the only events reported by more than one patient. If selected for presentation, complete top line results will be presented in Vienna at the EuSEM meeting, including a detailed breakdown of the demographics and type of trauma (ie broken bone, laceration, burn, etc). 

Conclusions: Sufentanil 30mcg tablets are in phase 3 development for treatment of moderate-to-severe acute pain in an adult ED population.  Early efficacy and tolerability results from this study suggest that when dispensed sublingually, sufentanil 30mcg may offer a viable alternative to IM or IV dosing.


James MINER, Harold MINKOWITZ, Zubaid RAFIQUE, Karen DIDONATO (Burlingame, USA)
11:00 - 18:00 #7873 - Efficacy of Web-based logbook System on Emergency Medicine Residents Recorded Activity and Satisfaction.
Efficacy of Web-based logbook System on Emergency Medicine Residents Recorded Activity and Satisfaction.

Background
logbooks are useful materials in registering activities, defining goals and evaluation in any residency program. The
purpose of this study was to evaluate efficacy of a newly initiated web-based electronic logbook system in compared
with paper-based logbook based in registration of activities of emergency medicine residents activities and satisfaction
of residents and faculty members.
Methods
A new web-based electronic logbook system developed inside our emergency medicine department. This crosssectional descriptive evaluation study was performed after 3 month initiation of the web-based electronic logbook
system. Two major activities of PGY1 and PGY2 residents, procedures and shift activities were compared with
previous year recorded activities in paper logbooks in same period of time. Also satisfaction of faculty members and
residents was evaluated via separated survey.
Results
40 residents paper logbooks and 47 residents web-based logbooks were evaluated. mean number of confirmed and
registered cases of shifts and procedures per each resident in web based logbook were significantly more than paper
based logbook (paper-based and web-based confirmed recorded shifts 10.4 and 20.1 respectively and paper-based
and web-based confirmed recorded procedures 104.5 and 147.2 respectively , p-value<.005). Data analysis in
satisfaction survey showed that most faculty members and residents prefer using web-based over paper-based
logbook.
Conclusions
Our study showed that web-based logbooks can influence on quantity of recorded activities in residency program.
Moreover, it is possible to record activities at any time in any place by residents and to verify by their teachers online
in web based logbook system. Evaluation of the electronic system is more accurate and very time-saving than paper
based system. It is crucial to evaluate effect of web-based systems on quality of residency programs in future.


Javad SEYEDHOSSEINI (Tehran, Islamic Republic of Iran), Ali LABAF, Maziar ASHRAFI, Narges MOHAMMADREZAEI
11:00 - 18:00 #8028 - Eight years (2008-2016) in-hospital Basic Life Support Training for all nurses: We keep going!
Eight years (2008-2016) in-hospital Basic Life Support Training for all nurses: We keep going!

Objective

The first 2 links in the “Chain of survival”, and thus cardiopulmonary resuscitation training, are mandatory for a good patient outcome. Poor knowledge and skill retention following resuscitation training has been documented over the past 25 years.

We developed a basic life support training program for clinical nurses and we composed a six-stage plan based on the ERC algorithm for in-hospital resuscitation.

We defined two quality standards (which we had to modify, as the guidelines changed in 2010) to measure if there was an improvement in the resuscitation skills after four sessions.

Methods

The whole nursing staff (ca. 400 individuals) in our hospital had to register for a fourth obligatory basic life support session, with the consent of the Board of Directors.

The performance of the nurses was recorded on an Ambuman manikin (with Ambu CPR software version 2.3.9), lying in a hospital bed.

Several variables were recorded, e.a. the correct execution of the sequence of the six-stage-plan, the compression rate, the compression depth and the ventilation volume. Using two quality ‘standards’, we compared the results session.

Results

The attendance to those sessions is significantly lower when the nursing staff had to enrole themselves.

For the first two sessions (2005 guidelines), we saw a compression depth between 40mm and 50mm was achieved by 120 or 37% (vs 95 or 31% in first session) (p=0,09) (fig. 2); a compression rate between 80/min and 120/min was achieved by 254 or 79% (vs 221 or 72% in first session) (p=0,03) (fig. 3); a ventilation volume between 400ml and 700ml was achieved by 148 or 46% (vs 97 or 31% in first session) (p<0,001) (fig. 4).

Optimal resuscitation (defined as a combination of those three determinants) was achieved by 44 or 14% (vs 25 or 8% in first session) (p=0,03). Satisfying resuscitation (defined as a combination of a compression rate between 70/min and 130/min, a compression depth more than 35mm and a ventilation volume more than 300ml) was achieved by 228 or 71% (vs 98 or 32% in first session) (p<0,001) (fig 5.)

For the third, fourth, fifth, sixth and seventh session, we defined  optimal resuscitation as a compression depth >50mm, compression rate 100-120/min and ventilation volume between 400ml and 700ml. We defined satisfying resuscitation as a compression depth >45mm, compression rate 90-130/min and a ventilation volume more than 300ml. The 2016 session showed that 70% achieved a satisfying compression depth, 95% achieved a satisfying compression rate and 96% achieved a satisfying ventilation volume. This is, so far, our best result in 8 years.

Using Fisher exact test, we found a significant improvement (p<0,001) for ventilation volume and for satisfying resuscitation.

 

Conclusion & perspectives

We need to thank the team of BLS instructors for their efforts to keep the resuscitation knowledge of the whole nursing staff at this level. We will continue to support this project on director’s level.


Thierry SCHISSLER, Dr Bart LESAFFRE (OOstende, Belgium), Ellen DESCHACHT
11:00 - 18:00 #7991 - ELECTRIC SHOCK: SOMETIMES IT SAVES, SOMETIMES IT KILLS.
ELECTRIC SHOCK: SOMETIMES IT SAVES, SOMETIMES IT KILLS.

53 year-old patient who is brought in mobile ICU for an episode of electrocution while he was working with electrical cables. The patient was unaware of the type of power that was.  It concerns fall back of approximately 1.5 meters height without loss of consciousness with low back pain. General exploration objective burn in hand right suggestive of entrance of the electric shock. Cardiac auscultation to arrhythmic heart tones at a frequency of 80 can be seen.  ECG is performed confirming atrial fibrillation to 114 beats per minute without alterations in repolarization. 989 CK stands out in blood. Rx of unaltered assessable chest.   Patient concerns have made medical review in April where it was sinus rhythm.

 

Heart rate, blood pressure and saturation is monitored and we initiated treatment with Amiodarone 300 mgr in bolus and infusion to try to pass to sinus rhythm.  The patient presents alternation of frequency between 110 to 160 beats per minute.  After 6 hours of initiating the treatment, the patient presents with 77/40 blood pressure, hemodynamic instability held despite volume overload.  Therapeutic failure, it was decided to make cardioversion electric synchronized with 100 joules prior sedation of the patient with 6 mg of propofol 1% iv, turning the patient to sinus rhythm with FC 60 per minute and blood presure 110/60 mm Hg

 


Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Sonia Sofía BALLESTIN SOROLLA, Elisa RUIZ OLIVARES, Elisa ALDEA MOLINA, Ana Belén MARÍN FLORÍA, Carola MEDINA SAINZ, Silvia GANGUTIA
11:00 - 18:00 #7698 - ELGE - ESI and Chief complaint triggered ECG [ESI & Leitsymptom getriggertes EKG].
ELGE - ESI and Chief complaint triggered ECG [ESI & Leitsymptom getriggertes EKG].

Background:

The number of patients at German emergency departments (ED) rises steadily. To identify critical ill patients immediately, clinical triage systems are used. Although the validity and reliability of the Emergency Severity Index (ESI) is quite good, there are still gaps, e.g. for patients with an ST segment elevation myocardial infarction (STEMI).

We tried to answer the question whether the combination of ESI level and a subsequent list of chief complaints could increase the sensitivity of identifying the “high risk situation” STEMI by performing an ECG diagnosis within 10 minutes after triage. This list contained: chest pain (CC1), dyspnea (CC2), arrhythmias (CC3), upper abdominal pain (CC4), syncope (CC5), suspected diagnosis of an ACS as pronounced by the pre-hospital emergency physician (CC6).

 

Methods:

We conducted a retrospective analysis of patients presenting to the ED of the Klinikum Fuerth in 2013 and 2014. Patients were analyzed by ESI level, a chief complaint list, and the corresponding diagnosis. If patients were dismissed with a diagnosis of acute myocardial infection (ICD I21.0-9 excluding ICD I21.4) we defined them as STEMI patients. We calculated sensitivity, specificity, and number needed to screen (NNS, defined as number of patients who need to be ECG-tested in order to get 1 positive result) for different combinations of symptoms and ESI levels, to find the most effective method in identifying possible STEMI-patients.

 

Results:

40505 patients (mean age 50.2y, sd ±25.9y, min 0y, max 105y, median 51y, 50% female) who presented to our ED in 2013 were enclosed in our analysis. Out of all ED patients in 170 cases, i.e. 0.4%, a STEMI was diagnosed. ESI levels at triage where distributed as follows: ESI1 1.3%, ESI2 21.2%, ESI3 35.0%, ESI4 39.7%, ESI5 2.9%; and the six chief complaints taken into account as: CC1 5.0%, CC2 6.1%, CC3 2.1%, CC4 2.1%, CC5 4.6%, CC6 0.5%.

In the unselected ED-population no patient triaged as ESI5 and only one as ESI4 suffered from a STEMI. Within ESI levels alone, the highest sensitivity of 74.1% was found for ESI2 patients (specificity 79.0%).  Regarding chief complaints, the highest sensitivity of 50.6% was calculated for CC1 (specificity 95.2%).  The lowest NNS of 6 was found for patients with CC6.

Combining ESI1, 2, and 3 patients with CC1, CC2, CC3, and CC6 resulted in a group 5436 patients (13.4% of all ED patients). Within this group 82.9 % of all STEMI patients could be detected with a specificity of 86.9% (NNS 39).

 

Conclusion:

By using ELGE within an unselected group of emergency patients it is possible to identify a high proportion of STEMI patients by also keeping the number of screened patients as low as possible. However, the best symptoms to enter the ELGE algorithm have to be evaluated in a prospective analysis. Given our current results, we would advice a group of ESI1-3 patients who present with one of the following chief complaints to an ED:  chest pain, dyspnea, arrhythmias, and suspected diagnosis of an ACS as pronounced by the pre-hospital emergency physician. 


Ronny ENK (Fürth, Germany), Stephanie MÜLLER, Harald EISENBARTH, Harald DORMANN
11:00 - 18:00 #8219 - Elongation the time for trombolysis in emergency neurological deficits - widespread occurance of intracranial vessel occlusion in awakening stroke patients.
Elongation the time for trombolysis in emergency neurological deficits - widespread occurance of intracranial vessel occlusion in awakening stroke patients.

Background: Elongation is an investigator-initiated, randomised, double-blind and placebo-controlled Phase III trial of intravenous alteplase vs placebo in patients with ischemic stroke 4.5-9 hours from stroke onset or awakening stroke (AS). The prevalence of intra-cranial vessel occlusion in AS patients remains to be determined and can guide the development of optimal therapy for this unique group of stroke patients.

Objective: To study the prevalence and characteristics of intra-cranial vessel occlusion in this AS cohort.

Methods: Ischemic stroke patients within 4.5-9 hours from stroke onset or with AS (time of AS onset defined as the midpoint between time to sleep and awakening with the stroke symptoms) are eligible for enrollment. Criteria for entry into the trial include perfusion-diffusion mismatch using a perfusion threshold of Tmax>6sec and a perfusion:diffusion lesion volume ratio of >1.2. Diffusion lesion volume must be <70mL based on assessment by automated RAPID software. Intra-cranial vessel occlusion was assessed on MSCT angiogram performed at randomisation and 24 later. Three expert readers assessed these images independently.

Results: 67 patients had images with adequate quality, including 53 (65%) in the AS group with median age of 77.0 yrs (IQR 67.0, 81.0) and NIHSS of 14.0 (9.0, 19.0). 62 of 63 patients (98%) had vessel occlusion with 44.4% involving M1 of the middle cerebral artery, 17.5% M2, 4.8% M3, 25.4% both internal carotid artery (ICA) and M1, 4.8% ICA alone and 3.1% the posterior cerebral artery. The median ischemic core volume was 15.0 ml (6.5, 31.5), Tmax>6 volume 88.5ml (58.0, 122.0), mismatch volume 65.5ml (42.8, 92.0), and ratio of 4.8 (2.5, 8.7). 19 patients (30%) demonstrated recanalization on follow-up imaging.

Conclusion: In AS patients there is a very high rate of intracranial vessel occlusion with relatively large volumes of salvageable penumbral tissue. Intravenous thrombolytic therapy followed by thrombectomy in selected cases may be an appropriate therapeutic option with safety and efficacy remaining to be established in randomized controlled trials.


Nargiza ESHANKULOVA, Gulnora RAKHIMBAEVA, Nodira TUYCHIBAEVA (Tashkent, Uzbekistan)
11:00 - 18:00 #7735 - Emergency 2D and CEUS ultrasound exam, a tool for triage the patients with acute severe pancreatitis.
Emergency 2D and CEUS ultrasound exam, a tool for triage the patients with acute severe pancreatitis.

Ultrasonography is a quick diagnosis method in the emergency department, allowing for the triage of patients. The management strategy in pancreatic emergencies requires a gradual assessment and an immediate and a subsequent management depending on the severity of the disease discovered during the emergency evaluation. The study group consisted of 95 patients with clinical picture of acute pancreatitis, admitted in ED between May 2010 – June 2015, with average age of 50.55 ± 14.20 years old.  The severity analyze of acute pancreatitis were made using severity scores, ultrasound findings and the biochemical parameters. Highly statistically significant parameters were demonstrated (Fischer Test, p=0.0000): the presence of more than 2 fluid collections found on the ultrasound exam, more than 20 breaths/min, fever higher than 38̊C, SIRS – positive, pleural effusion found on the ultrasound exam, leukocytosis > 16000/mm3, ASAT > 250U/l. Contrast enhanced ultrasonography identified new collection in 20 % of the cases. The correlations between the percentage evaluation of necrotic area determined using CEUS exam and the number of collections showed a positive correlation, moderately statistically significant (S, p=0.0009). It was also noticed on CEUS exam that there is positive correlation between evolution severity, the total number of fluid collections (p=0.00001), the effusion aspect (p=0.00001) and the presence on pleural collections (p=0.00001) that is highly statistically significant. The assessment of the CEUS technique in diagnosing acute pancreatic necrosis found a sensitivity of 76%, a specificity of 100% and an accuracy of 100%. A clinical-biochemical–ultrasonographic score was proposed for the emergency triage of severe acute pancreatitis (STCBUSC): Clinical parameters: 1. breaths/min > 20 – 1 point; 2. fever > 38ºC - 1 point; 3.positive for SIRS – 1 point; Ultrasound 2D parameters: 4. the presence of 2 or more fluid collection found on US exam – 1 point; 5. ultrasound pleural fluid collection found on US exam - 1 point; Ultrasound parameters – CEUS exam: 6. pancreatic necrosis – 1-3 points (CT analogy: <30% - 1point.; 30-50% - 2 points.; >50% - 3points.); 7. peripancreatic and distance effusions – 1 point; Biochemical parameters: 6. leukocytosis > 16000/mm3 - 1 point; 7. ASAT > 250 UI/l - 1 point. For an accurate triage of severe cases of acute pancreatitis that require referral to a specialized centre on gastroenterology intensive care it is necessary to specify the presence of pancreatic necrosis visualized through contrast enhanced ultrasonography along other three parameters, with al least one biological parameter and one clinical parameter that proves the acute pancreatic changes. The lowest score mandatory for a patient’s referral to intensive care gastroenterology is 4. This score has to be validated and the perhaps the “cut-off” values have to be optimized on a larger number of patients.


Adela GOLEA (Cluj Napoca, Romania), Lacan SORIN, Ilea CATALIN, Eugenia MURESAN
11:00 - 18:00 #7498 - Emergency Airway Management in an Emergency Department of a University Hospital in Germany - almost solely performed by ED-staffed physicians with a high success rate.
Emergency Airway Management in an Emergency Department of a University Hospital in Germany - almost solely performed by ED-staffed physicians with a high success rate.

Introduction:

Securing the airway can be a life-saving procedure under emergency conditions. Techniques, indications, complications and adverse events vary widely in different settings and countries. In Germany, no data exist about emergency airway management in emergency departments. The aim of the study is to implement an Emergency Airway Registry in Germany starting with a pilot study collecting data about emergency airway management in our facility.

Methods:

We set up an internet based website with login options for emergency departments as well as emergency medical services in Germany (www.intubationsregister.de). We recorded data made on every airway management attempts in the ED between September 2015 and April 2016. We evaluated indications, methods, intubator characteristics as well as success rates and adverse events.

Results:

 During the 6-month period we had a total of 49 emergency intubations, in 26 (53,0%) cases/encounters for neurological emergencies, in 18 (36,7%) for medical emergencies and in 5 (10,2%) for trauma. ED-staffed physicians managed 65,3% of encounters, anesthesiologists in rotation 16,3% and internists in rotation 18,4%. Rapid sequence intubation was the initial method chosen in 40 (81,6%) patients. Tracheal intubation was successful in all patients with ≤ 3 attempts. First time success rate was 81,6% and 93,8% of patients were successfully intubated with 2 or less attempts. Adverse events occurred in 17 (34,7%) patients, mainly due to hypotension with the necessity of catecholamines in 9 (18,4%) patients and significant hypoxia in 6 (12,2%) patients.

The updated numbers will be presented at the conference.

Conclusion:

The vast majority of emergency intubations in our university hospital ED is not performed by anasthesiologists, but by ED-staffed physicians. Up to now, the success rate of our emergency intubations is with 100% in ≤3 attempts very high compared to other registries. The complication rate is comparable to other registries and seems to be passable given the fact, that most patients are in a critical and unstable situation. It appears to be crucial to get more data from other hospitals about emergency airway management in emergency departments and emergency medical services, since this pilot study does not confirm the notion that a) airway management is mainly performed by physicians of the department of anaesthesiology and b) airway management by ED-staff is correlated with a high failure and low success rate.


Christina LAUE, Steffen HERDTLE, Christian HOHENSTEIN (BAD BERKA, Germany)
11:00 - 18:00 #7203 - Emergency and Acute Medicine Network for Health Care Research (EMANet) Berlin.
Emergency and Acute Medicine Network for Health Care Research (EMANet) Berlin.

Background: In recent years, utilisation of EDs and length of stay in EDs have increased steadily. EDs are a low-threshold gate to 24h per day/7 days per week available, multi-disciplinary emergency and acute care and are frequently used by patients without “classic” emergency conditions, who do not require hospitalisation. Societal and demographic changes have been leading to a growing number of older, socially deprived and multimorbid patients and therefore to a dramatic increase of the medical and psychosocial complexity of patients seen in the ED. The result is crowding of EDs which is symptomatic for supply gaps beyond EDs across the primary, secondary and tertiary care institutions, including nursing homes.

EMANet structure: EMANet is a regional health care research network in the large city centre district of Berlin-Mitte, funded by the German Federal Ministry for Education and Research (BMBF). EMANet will be set up to develop and sustain high quality, trans-sectoral, multi-disciplinary health care research in and across all 8 EDs of Berlin-Mitte. EMANet is a collaboration of institutions with expertise in public health research at the Charité – Universitätsmedizin Berlin and provision of emergency and acute care across the inner-city centre of Berlin as well as the largest statutory health insurance fund. The Network will be coordinated by the Division of Emergency and Acute Medicine and the Institute of Medical Sociology and Rehabilitation Science both at the Charité Berlin. The scientific partners reflect the integral, trans-sectoral network structure combining health care research, methodological and clinical expertise as well as health economic assessments in all EMANet research projects. The consortium will gradually be extended by integrating primary care physicians, nursing sciences and nursing homes, social services, specialist hospital departments, rehabilitation institutions and further regional health care researchers.

EMANet-aims: The scientific aims in the first funding period are to assess patient characteristics, trans-sectoral supply treatment trajectories and gaps in health care for multimorbid patients admitted to all of Berlin’s inner-city EDs. For the second phase, EMANet will aim develop and implement improved and cost-efficient health care provision for multimorbid patients with acute conditions. EMANet focuses on health care research in an area that has greatly been neglected in Germany but is key to identifying supply gaps in and across all sectors of the German health care system. It aims to develop relevant interventions for multimorbid patients who are currently not sufficiently supported or integrated in our health care system.


Julia SEARLE, Anna SLAGMAN, Johann FRICK, Liane SCHENK, Adelheid KUHLMEY, Pr Martin MÖCKEL (Berlin, Germany)
11:00 - 18:00 #6402 - Emergency Department Management of NSTEMI.
Emergency Department Management of NSTEMI.

Emergency Department Management of NSTEMI

Austin K1, Chaudhry U1, Ghiurluc D2

 

1 – FY2 doctor in Emergency Medicine, Northwick Park Hospital

2 – Consultant Physician in Emergency Medicine, Northwick Park Hospital

 

Introduction

Non-ST Elevation Myocardial Infarction (NSTEMI) is a common and serious acute medical presentation. Diagnostic difficulties and frequent changes to guidelines mean patients presenting to the Emergency Department (ED) are vulnerable to mismanagement. There are clear guidelines at Northwick Park Hospital (NICE and Trust) outlining optimal management of NSTEMI, but we noticed these were not being followed, to the likely detriment of patient care. We aimed to evaluate our ED practice against predetermined standards, teach the department regarding protocols, and subsequently reassess quality of care. 

 

Methods

The electronic ED database demonstrated whether: 1) patients with a ‘provisional diagnosis’ of NSTEMI in April had been appropriately risk-stratified; 2) appropriate analgesia was given; 3) dual anti-platelets were prescribed; 4) the choice of the second agent was appropriate to their degree of risk. We then used multiple methods to educate the department on NSTEMI management, and then recollected data to assess for a change in practice. 

 

Results

All aspects of management improved, most notably the prescription of aspirin (71% patients in the first round, 100% in the second) and a second antiplatelet (65% patients in the first round, 95% in the second). The frequency of correct choice of second agent improved, as did risk stratification and analgesia prescription. 

 

Conclusions

Important acute problems such as NSTEMI, which initially present to ED doctors, require not only thorough guidelines from specialty departments, but full awareness and understanding by front-line staff responsible for initial management. In this case, simple education via multiple media and raising awareness has significantly improved patient outcomes.

 

 


Austin KEZIAH, Dan Lucian GHIURLUC (London, United Kingdom), Umar CHAUDHRY
11:00 - 18:00 #8264 - Emergency department performance indicator based on 48 hr admit mortality rate!
Emergency department performance indicator based on 48 hr admit mortality rate!

Aim: To establish if mortality rate with in 48hrs of admission categorised by cause of death can be used as performance indicator for Emergency departments and be used to guide quality improvement work.

 

Method: The study was done at Leeds Teaching hospitals with two ED departments with combined emergency attendance of 1,84,000 patients per annum.

The data was obtained by simple enquiry of the existing IT systems (patient activity system & symphony).  A spread-sheet of all patients who died with in 48 hours of admission from ED was created between 1st April 2015 to 1st April 2016.

In depth case notes review of time of arrival, time to see clinician, age, sex and time to treatment based on working diagnosis was collected.

The information was grouped based on ED clinician diagnosis prior to analysis.

 

Results: The death rate with in 48hrs of admission to hospital from ED was 2.25/1000.  The diagnosis on admission was sepsis (32%), COPD, (22%), Cardiac (20%), Gastro (9%)and cerebral event((9%).

There was significant variation in time to see clinician and time to treatment between the groups.  100% of patients with initial diagnosis of COPD, gastro, cardiac problems were seen and treatment was commenced with in 120 minute’s of arrival to ED. Only 45% patients with Sepsis were seen and treated within the same time.

Over all the time to management is quicker for all causes in one department compared to the other.

 

Conclusion: The 48 hours mortality data is easy to gather from the exiting IT systems in the hospital. Our study highlighted the need to review our internal process in management of septic patients. The mortality rate can be used as performance indicator to analyse trends within the same hospital. It will be of little value to compare against different ED’s as this is dependent on populations they cater to.

Categorising this data based on diagnosis can help in reviewing internal ED process and form a basis for future quality improvement work.

 

Discussion:

The mortality data is easy to gather, the task of review and analysis of individual case notes is time consuming. The variation of case mix between the two departments is reflected in the results of the 48hr post admission mortality rate and the management of these patients.

The mortality rate is an objective indicator and its trend, can be used to inform on effects of change in internal process. 


Sundararaj MANOU (Leeds, UK, United Kingdom), Mohit ARORA
11:00 - 18:00 #7976 - Emergency department sedation for reduction of hip dislocations by emergency physicians versus non emergency physicians.
Emergency department sedation for reduction of hip dislocations by emergency physicians versus non emergency physicians.

Introduction

The Bronovo Hospital did not employ emergency physicians (EP’s) before 2015. Prior to 2015 emergency department (ED) sedations were supervised by the surgical specialties (non-EP’s). With the arrival of EP’s, sedation in accordance with the CBO-guideline was introduced. We analysed the difference in outcome and occurrence of adverse events during sedation for reduction of dislocated hips by EP’s and non-EP’s.

 

Methods

Retrospective review of 45 hip dislocations reduced in the ED in 2015. Twenty-five were supervised by EP’s.

 

Results

Patients in both groups had similar baseline characteristics, except for a difference in ASA classification (ASA 3-4: non-EP’s 40% versus EP’s 16%). EP’s documented fasting status and informed consent in all cases versus respectively 20% and 5% documented by the non-EP’s. Analgesia used by EP’s was mainly fentanyl (88%), while non-EP’s frequently did not document this (80%). EP’s preferred propofol (84%) above midazolam (16%) for sedation. Propofol gave a successful reduction in 95% of the patients causing one bradycardia and one case of hypotension. Midazolam gave a successful reduction in 75% with one case of hypotension with desaturation. Non-EP’s mainly used diazepam (45%) or midazolam (45%). Diazepam gave a successful reduction in 100% causing one apnoea. Midazolam gave a successful reduction in 55% with two apnoea’s. Flumazenil was used twice by non EP’s.

 

Conclusion

Sedation in the ED by EP’s and implementation of the CBO guidelines resulted in better documented sedations and avoidance of high risk patients. Non-EP’s used diazepam for sedation, which is not recommended for this purpose, although few adverse events occurred. We found preference for the use of propofol, midazolam had a lower overall success rate and higher occurrence of adverse events. This data shows the need for education in procedural sedation and analgesia amongst non-EP’s to improve better adherence to the national guideline.


Crispijn VAN DEN BRAND (den haag, The Netherlands), Petra VAN DER LELIE, Mischa VEEN
11:00 - 18:00 #7414 - Emergency fasciotomy as treatment for upper limb compartimental syndrome of the new born. Case report.
Emergency fasciotomy as treatment for upper limb compartimental syndrome of the new born. Case report.

Introduction: The compartment syndrome in the newborn is a rare disease. It is often initially misdiagnosed due to the low incidence of this disease and because lesions suggest other conditions of the newborn. The initial presentation varies from a local skin lesion to gangrene of the forearm. Early diagnosis and intervention are critical to achieve the best results and to avoid the consequences of prolonged ischemia, such as the development of sensorimotor disorders or Volkmann contracture.

Objectives: Describe the treatment and management done in a newborn compartment syndrome, by exposing a case.

Methods: We present a case of a 48-hour newborn fruit of the fifth pregnancy of young woman with two healthy children. We explain clinical symptoms and diagnostic tests that led to the diagnosis of compartment syndrome. Upper limb emergency fasciotomy was performed including dorsal and volar forearm, carpal tunnel, elbow flexure and distal volar arm. The operation was detailed by photographs taken from the surgical area. We describe the subsequent evolution and outcome.

Results: Periodic fasciotomies cures and artificial skin closure were performed. The patient today (one month after the intervention) has improved forearm mobility without becoming full, no pain, and injuries have evolved toward healing.

Conclusions: Congenital ischemic necrosis of the forearm has previously been reported to occur with compound presentation (when an extremity, hand, arm, or foot of the baby
prolapses together with the vertex in a woman in labor). In our case, this was spontaneously removed by breaking the amniotic sac and there was a vaginal delivery. The newborn should be carefully examined for clinical signs of circulatory compromise, the earliest of which are the skin lesions. Early
diagnosis and intervention must be performed.


Baguena ALICIA, Escriche ROCIO, Pardo TERESA, Hamam SAMI, Teresa DE FERNANDO GROS (ZARAGOZA, Spain), Bonez PATRICIA
11:00 - 18:00 #7922 - Emergency Management And The Relationship Between Serum Lactate Level in Sepsis.
Emergency Management And The Relationship Between Serum Lactate Level in Sepsis.

Aim: In this study; we aimed to evaluate of the varying lactate levels in the process of changing metabolism due to sepsis and determine effectiveness on emergency diagnosis and treatment in patients admitted to the emergency department.

Materials and Methods: This study was performed with 107 patients followed by sepsis between dates of 31.10.2014 - 16.02.2016. Age, sex, symptoms, vital and physical examination findings, SIRS criteria, general changes, inflammatory changes, hemodynamic changes and organ dysfunction changes, tissue perfusion changes, infection localization, treatment status, mortality rates were evaluated in terms of relations with lactate level. Data were analyzed using SPSS version of Windows 18. The distribution of variables was checked with the Kolmogorov-Smirnov test. In analyzing the data, Mann Whitney U, Kruskal Wallis and Pearson correlation tests were used. p<0,05 was considered statistically significant.

Results: In our study, the median age of patients was 63 years, 60,7% were male. The most common physical finding detected in patients was fever. The most common infection focus was the respiratory system. The median lactate level of the patients was detected 2,4 mmol / L. Lactate levels had no relationship with comorbid diseases, the number of SIRS criteria, the focus of infection, positive culture, emergency follow-up period and duration of hospitalization (p> 0,05). Lactate levels were significantly higher in patients with lower mean arterial pressure and systolic blood pressure levels (p <0,05). Lactate levels were significantly higher in patients with bronchospasm, acute lung injury, ARDS, blood coagulation disorders, decreased capillary refill / spotting and unexplained metabolic acidosis (p <0,05). A negative correlation was observed between hypoglycemia and lactate levels (p <0,05). Increased lactate levels were detected when clinical of patients got worse (p <0,05). The mortality rate of the patients was 15%, lactate levels were significantly higher in patients with mortal prognosis (p <0,05).

Conclusions: The height of the lactate level of patients with sepsis admitted to the emergency clinic is a sign of bad clinic and high mortality rate.


Selen Ada SÜRER, Ufuk AKDAY (ADANA TURKIYE, Turkey)
11:00 - 18:00 #7787 - Emergency Medical Services Triage based on Manchester Triage System: Is it feasible and reliable?
Emergency Medical Services Triage based on Manchester Triage System: Is it feasible and reliable?

Introduction: Established triage methods in hospitals for systemic prioritizing of patients also in the prehospital setting may improve patient transfer from emergency medical services (EMS) to emergency departments (EDs) by efficient communication between EMS and EDs. Therefore we evaluated the feasibility and reliability of EMS triage based on Manchester Triage System (MTS).

Methods: This prospective, observational study evaluated the feasibility and reliability of EMS triage based on MTS. EMS providers were trained to use MTS with 11 out of the original 52 flowcharts based on patient complaints. Discriminators indicative of severity of complaints were maintained. EMS personnel assigned triage scores to patients independent of ED assignments by registered nurses. All EMS and ED assignments were audited regarding correct triage category. Feasibility, differences of EMS versus ED triage assignments and reliability were evaluated.

Results: Overall 208 blinded triages assignments were available for evaluation. Audition revealed no significant difference in triage assignments, with 31/208 (15%) incorrect EMS and 29/208 (14%) incorrect ED triage assignments (Chi-square test p=0.896). All incorrect assignments were errors of application, in majority with 41/59 (69%) wrong discriminators were chosen.

Conclusions: Prehospital triage based on MTS is feasible and reliable with good concordance between EMS and ED triage based on MTS. Most incorrect assignments were due to application errors. Additional research to validate our results are warranted.


Bernd A. LEIDEL (Berlin, Germany), Angela ALE ABAEI, André BAUMANN, Jaqueline D. LEE, Birgit LIEHR, Stefan POLOCZEK, Lan Houng TIMM, Rajan SOMASUNDARAM
11:00 - 18:00 #7535 - Emergency medical system and emergency department: role of protocols in critical patient emergency treatment.
Emergency medical system and emergency department: role of protocols in critical patient emergency treatment.

Background: Emergency medical services (EMS) transport is expensive, and resource consuming. On the other hand a close collaboration between EMS dispatch center and receiving hospital in paramount to not collapse the receiving hospital. On the other hand in-hospital emergency response vary significantly among medical centres influencing patients outcome. The Medical Emergency Team (MET) was developed in order to rapidly manage critical ill patients at risk of cardiac arrest or high-risk conditions.

OBJECTIVES: The aim was to characterize the EMS and hospital response system for critical patient in the Emergency Department of Verona (Italy), hub centre of the county. In our Emergency Department Shock room and MET system activation is based on established clinical anatomical criteria or situational dynamic criteria of the event as described by the EMS Dispatch Center.

METHODS: This was a retrospective analysis of critical patients who were transported by EMS to the level II Emergency Department in Verona from January 2015 to December 2015. We included all trauma and no traumatic critical patients treated in the Shock Room accordingly the activation criteria. Patient, clinical characteristics and acute outcome are reported.

RESULTS: During the study period 1,054 critical patients, full filling the activation criteria, were admitted to the Emergency Department and managed by the MET in the Shock Room. Mean age was 65. years (SD 22.1), gender distribution was 41,7% male; 58,3% female and trauma patients accounted of 248 (23.5%). Mean treatment time was 300' (SD 395.9'). Outcomes analysis pointed out 39 fatalities (3.7%), 135 (12,8%) discharged home and 880 (83.5%) admitted. Only 196 (44.6%) of these patients needed admission to Intensive Care Unit.

CONCLUSIONS: Better recognizing which patients with falls and penetrating trauma have serious injuries that could benefit from being flown may lead to the more cost-effective use of helicopter EMS. More research is needed to determine why patients without insurance, who are most at risk for high out-of-pocket expenses from helicopter EMS, are at higher risk for being flown when only having minor injuries.

Results: The study shows two critical points in the management of critical patients: the high rate of patients discharged home and the reduced rate of Intensive Care Unit admission. A reading key could be the activation criteria based mostly on EMS Dispatch Center information and a scoop and run working system on the site. Such criteria have to be reviewed in order to better target those patients who will need advanced resources. This has a pivotal relevance in a medical emergency system overwhelmed but with reduced resources. This suggests that interventions to optimize cost-effectiveness resources utilization will likely require an evaluation of EMS-ED shared protocols in the context of provincial and patient needs.


Massimo ZANNONI (VERONA, Italy), Gianni TURCATO, Alberto RIGATELLI, Valentina SIVERO, Domenico VERALDI, Mariano BELLONI, Francesco BUONOCORE
11:00 - 18:00 #7082 - Emergency physician knowledge of anaphylaxis in US.
Emergency physician knowledge of anaphylaxis in US.

Anaphylaxis requires immediate treatment with epinephrine to prevent death. All physicians, but especially emergency physicians, should be able to recognize and treat patients with anaphylaxis. While guidelines suggest that all patients be discharged with self administered epinephrine, prior studies suggest that this practice is not universal in the emergency department. However these studies did not adjust for the potential that patients already had epinephrine at home.  We sought to survey emergency physicians, using a representative sample of members of the American College of Emergency Physicians (ACEP), regarding their knowledge of anaphylaxis and its treatment.

Objective: to determine if emergency physicians know to discharge patients with self-administered epinephrine. In addition we assessed the specific triggers of anaphylaxis, and follow established guidelines for care of these patients.

Methods: An on-line survey was distributed to the Emergency Medicine Practice Research Network (EMPRN), a group of ACEP members who have agreed to complete surveys on a quarterly basis. EMPRN membership is representative of ACEP members by geographic area, sex and age. The survey invitation and 2 followup reminders were sent out during the survey period of 11/15-2/16. Simple descriptive statistics were used. Guidelines published by the American Academy of Allergy Asthma and Immunology  (AAAAI) were used as the gold standard. These guidelines are very similar to those produced by the United Kingdom, Australia and the World Allergy Organization

Results: A total of 367 responses were received from the 1434 members. 77% were male, median age 51 years. All respondents would prescribe self-administered epinephrine at discharge, 86% glucocorticoids, 13% Beta agonists, 67% H2 blockers. All respondents recognized insects and peanuts could cause anaphylaxis, however fewer respondents correctly identified other triggers. Exercise was correctly identified by 57%, garlic by 56%, menses by 30% and spontaneous anaphylaxis by 66%. However 45% of respondents indicated steak could cause anaphylaxis. Acute anaphylaxis has not been reported (a delayed allergic type reaction has been reported in a few case studies).  Only 28%% of respondents correctly identified the length of time a stable patient should be observed after treatment (4-8 hours), and 39% correctly identified the correct observation time for an initially hypotensive, unstable patient (>8 hours).

Conclusion: This study demonstrates that emergency physicians do understand the need to prescribe self-administered epinephrine on discharge. Prior studies which suggested that emergency physicians did not prescribe epinephrine may be flawed or, over time, practice has improved. However there are still important knowledge gaps for physicians who treat anaphylaxis.

 


Sandra SCHNEIDER (Irving, tx, USA), David SKLAR, Ester CHOO, Lynne RICHARDSON
11:00 - 18:00 #7342 - Emergency Physician’s perception on the introduction of Video-Laryngoscope as a training tool for direct laryngoscopy.
Emergency Physician’s perception on the introduction of Video-Laryngoscope as a training tool for direct laryngoscopy.

Emergency Physician’s perception on the introduction of Video-Laryngoscope as a training tool for direct laryngoscopy.

An educational initiative to improve patient safety and trainee supervision

Abstract

Background

Conventional endotracheal intubation (ETI) is challenging and requires high level of individual skills and experience.  At the same time we are also committed to provide ETI training for Emergency Medicine Residents (EMR).  Video laryngoscope (VDL) like the C-MAC is designed to have a similar blade to the normal Macintosh blades (size 3 and 4).  It has a bright light source and blade thickness that allow direct laryngoscopy (DL) and hence ETI under direct vision.  We organised several sessions of ETI training using an intubating manikin. We found that the view from the C-MAC screen captured by the C-MAC video camera is the same view described by the operator doing the DL.

There were enough consistencies reported during several training sessions that we decided to use the C-MAC for DL in real cases of ETI in the resuscitation room. We have done several ‘live’ cases and all intubations successfully as DL, with the added benefit of ‘video supervision’ and ‘video confirmation’ of the tube positioning. We also used the video recording and playback functions to give feedback to the EMR at the end of the procedure. After 6 months of introduction in our Emergency Department (ED), we conducted a “physician survey” to broadly assess their opinion in using VDL as a training tool for DL.

Method

In this educational poster, we describe a step-by-step laryngoscopic picture guide and ETI view seen on the C-MAC screen during one of our airway training sessions with the manikin. We also include several views of possible poor techniques in laryngoscopy that may result in a failed intubation attempt.  We conducted our survey via an online survey tool.  The respondents of our survey were from all groups of Emergency Physicians:  14% residents, 20% Fellows, 41% specialists, 24% consultants.

Survey Results

These are the subjective perception of Emergency Physicians regarding the introduction of C-MAC VDL in our clinical practice

1-    Feasibility, usefulness & improving performance: 34% of respondents agreed for Excellent, 45% good, 16% Average, 4% Fair.

2-    Improvement of quality and safety to intubation by trainee: 47% strongly agreed, 43% agreed, 3% disagreed, and 6% strongly disagreed.

3-    Added value of using VDL in training:

(a)   reassurance to supervisor 67%

(b)   reassurance to operator 60%

(c)   ability to save/review/live pictures 78%            

 

 

Discussion

We discuss the potential patient safety and quality benefits in conventional ETI using C-MAC VDL, as well as its utilization in training program of Emergency Medicine.

 

Conclusion

We conclude that promoting the use of this technique in ED, especially for ETI undertaken by a trainee clearly gives the physician perception of improved patient safety and trainee direct supervision.


Zenab ABDEL RAHMAN (Doha, Qatar), Alhady YUSOF
11:00 - 18:00 #7183 - Emergency Procedures in Isolated, Highly Contagious Patients: A randomized controlled study comparing advanced airway management in different settings in manikins.
Emergency Procedures in Isolated, Highly Contagious Patients: A randomized controlled study comparing advanced airway management in different settings in manikins.

Background:
Incidence rates of highly infectious diseases are rising and treatment for patients suffering from diseases, such as Ebola or Tuberculosis, is challenging for emergency personnel worldwide. In these cases, patient isolation is a key component. However, wearing personal protective equipment is both cumbersome for health care personnel and negatively affects medical performance. Alternatively, portable isolation units may be used, but their influence on emergency skill performance such as airway management is unknown. For that reason we compared six airway skills on manikins in three different isolation settings.

Materials/ Methods:
With IRB approval, 20 anaesthetists working in emergency services performed advanced airway management procedures on manikins in three settings:
1) standard setting (gloves and face mask only)
2) participants wearing personal protective equipment (PPE) (Jupiter™, Versaflo™S-605-10,3M™; Tychem C™,DuPont™)
3) manikin isolated in a portable isolation unit (PIU) (VenIONPIU,TB-Safety)
Six devices / skills were used in each setting to secure ventilation:
-Macintosh blade for direct laryngoscopy
-AirtraqSP™ video-laryngoscope
-i-gel™
-ILMA Fastrach™
-Ambu fibreoptic aScope™
-Cricothyrotomy (Cook Melker Catheter Set™)
Order of settings and devices was randomized. Time was measured in seconds. Participants additionally rated the subjective level of difficulty on a 100mm visual analogue scale (VAS) for each device in each setting; “0” representing very easy and “100” extremely difficult.
Results:
In 85% of attempts, regardless of setting or device, participants were able to secure the airway in under 60s. The time-until-ventilation was shorter than 60s in 94% of attempts in standard setting, 90% whilst wearing personal protective equipment and 73% whilst the manikin was isolated in the portable isolation unit. Taking each individual device into consideration, the time-until-ventilation differed significantly in each setting (p<0.01). In the standard setting mean time-until-ventilation was 31±26seconds (95%CI: 26-36seconds), although time varied considerably between the devices: from fastest (i-gel, 8±2seconds (95%CI: 7-9seconds)) to longest (Cricothyrotomy 62±20seconds (95%CI: 53-72seconds)). Longer times-until-ventilation were observed in the PIU-Setting: 65±63seconds (95%CI: 54-76seconds). In the PPE-Setting it was 35±30seconds (95%CI: 29-40seconds). The overall level of difficulty (VAS-Score) was significantly different between each setting (p<0.01). It was highest for the PIU (74±13) compared with standard-setting (9±7) and PPE-Setting (42±18).

Discussion and Conclusion(s):
Wearing personal protective equipment only slightly prolongs time until ventilation, when compared to the standard setting. However, handling of the protection equipment is difficult, and contamination possible. The PIU is a safe alternative, while it considerably affects medical tasks. Cricothyrotomy and the use of a fibreoptic scope within a PIU-Setting are very difficult and excluding it from the analysis increased success-rates for ventilation under 60s to 91%. This shows, that though challenging for healthcare professionals, airway management in a PIU setting is feasible within a clinically tolerable time frame. With overall average times until ventilation of around 10s, supraglottic airway devices remain highly recommendable tools, even in this challenging setting. At the congress, tables with detailed results will be shown.


Eike PLAZIKOWSKI (Bern, Switzerland), Dominic KÄSER, Roland ALBRECHT, Robert GREIF, Lorenz THEILER
11:00 - 18:00 #7433 - Emergency Ultrasound Survey. Results from a national Survey in Germany.
Emergency Ultrasound Survey. Results from a national Survey in Germany.

Purpose: 
To evaluate the current state of ultrasound US) use in German emergency departments (ED). 
Methods: 
ED-Experts, DGINA and DEGUM Members were asked to complete the questionaire online by Surveymonkey®. Responses were collected and anonymized. 
Results: 
135 valid answers from different hospitals were received. 85% of the hospitals have 2 or more ultrasound machines in the ED. 1/3 of the examinations are done by residents without supervision from an expert sonographer. Among the most frequent US-examinations are „abdomen“, „FAST“, “lower-extremity duplex”, “echo/FEEL” and “chest-US”. The participants claim that basic examinations should be mastered by every doctor. Special ultrasound examinations including gut sonography and contrast enhanced ultrasound are applied in some EDs, but the respective use differs widely. 
Conclusion: 
To ensure US quality in the ED, levels of competence and training programs need to be established. Contrast enhanced US is so rarely used in EDs even though 50% have the technical possibility. Further research is required with respect to most needed examination types and focus on education.


Johannes BÖER, Tobias LINDNER (Berlin, Germany), Alexander HEINZMANN, Tobias KUNZMANN, Lars LOMBERG, Wolfgang BLANK, Martin MÖCKEL
11:00 - 18:00 #7901 - Emergency Upper Gastrointestinal Endoscopy in the Emergency Department of Izzet Baysal Hospital: Analysis of 269 Patients.
Emergency Upper Gastrointestinal Endoscopy in the Emergency Department of Izzet Baysal Hospital: Analysis of 269 Patients.

AIM: To document various endoscopic findings in patients undergoing an emergency upper gastrointestinal endoscopy (EUGIE) in the Izzet Baysal Hospital emergency department (ED).
MATERIALS-METHODS: The data of 269 patients who underwent an emergency upper gastrointestinal endoscopy in the Emergency Endoscopy Unit of Izzet Baysal Hospital from June, 2008 to March, 2009 were analyzed. Demographic features, reasons for referral, and endoscopic diagnoses were noted.
RESULTS: The mean age of male patients was 52.2±2 years as compared to 50.4±1.9 years for female patients. Abdominal pain was the most common clinical indication in 90 (33.5%) of the patients admitted for a EUGIE. The clinical reasons for emergency admission were significantly related to endoscopic diagnostic yield. Non-erosive gastritis was the most common diagnosis in 76 (28.3%) of EUGIE patients. Erosive duodenitis and gastric ulcer were found to be the other most common clinical indications in 69(25.7%) and 31(11.5%) of EUGIE patients, respectively. Abdominal pain was the most common complaint in women. The majority of patients who presented with abdominal pain and loss of appetite were between the age of 41 and 60 years, while a significant number of patients presenting with the same symptoms did so during the winter season. Non-erosive gastritis was found to be more common in females. We also found a significant relationship between erosive gastritis and erosive duodenitis with admittance during the winter season.
CONCLUSION: An emergency endoscopy is the procedure of choice for the investigation of upper gastrointestinal complaints. An emergency endoscopy is not only a diagnostic tool but also a therapeutic modality.


Arif DURAN, Tarık OCAK (Bolu, Turkey)
11:00 - 18:00 #8139 - Emotional experience of families in the aftermath of an admission in the emergency department.
Emotional experience of families in the aftermath of an admission in the emergency department.

Introduction:

Emergency departments’ hospitalizations are no planned and unexpected. Patients and families are exposed to a major overlooked emotional stress.

The objective of this study was to identify the emotional impact of hospital emergency department hospitalizations in the families and its variability based on demographic and medical characteristics of each.

Method: prospective cross-sectional study based on an evaluative hetero Questionnaire (Scale of differential emotions by Izard et al) given to families of patients hospitalized in emergency observational unit.

Results:

Our survey was conducted among 105 parents’ patients. We retained 100 records. 61% of cases were women. The average age was 45 years, 69% were aged between 20 and 60 years. 15% of patients had no medical past history. 31% of patients had been previously hospitalized in an emergency department.

92% of parents expressed negative emotions, 83% were sad, 88% had depression’s feelings. 70% of the attendants were afraid, the fear was described as very serious, 40% cited anger as the main reaction reported as extreme in 25%. 90% of accompanying persons whose parents had heart disease expressed a strong sense of fear. 82% of patients hospitalized for the first time had reported concern. The lack of information was considered the basis of 93% of emotions.

Conclusions:

According to the survey, the lack of information was the cause of emotions. We need more interest in communication with families and patients hospitalized in the emergency department, the emotional stress would be better managed. 


Ajala LOBNA, Maghraoui HAMIDA (Tunis, Tunisia), Kilani MOHAMED, Kallel MOHAMED AMINE, Achouri ABDERRAHIM, Mghirbi ABDELWAHEB, Majed KAMEL, Zaouche KHEDIJA, Hamouda CHOKRI, Borsali Falfoul NEBIHA
11:00 - 18:00 #7286 - EMS Prague – in the heart of Europe.
EMS Prague – in the heart of Europe.

Prague Emergency Medical Service was founded almost 160 years ago in the year 1857, which makes it one of the oldest emergency services in Europe. Currently, Prague Emergency Medical Service is a contribution-based organization established by the city of Prague in the very heart of Europe.

Its main purpose is to provide highly qualified urgent medical care. Emergency calls from the whole area of the capital city are being processed through a 155 line free of charge. This line is serviced by Medical Operation Centre which accepts and evaluates emergency calls and consequently sends various rescue services to help the citizens and visitors of the capital.

Emergency Medical Service vehicles (with the driver and a paramedic on board) and Rapid Response Vehicles (with the doctor on board) are the very core of emergency services. These vehicles operate within the so called Randez-vous system.

Apart from these, Prague Emergency Medical Service also operates several special and unique vehicles such as GOLEM vehicle for the purposes of safety insurance during extraordinary events or disasters and the XXL medical vehicle specifically designed to transport significantly obese patients.

Rescue teams are being dispatched by the Medical Operation Centre from 18 stations strategically dispersed across the whole Prague agglomeration, so the urgent care would always be secured for the patients in matter of minutes.

The Emergency Service also operates a special station of HEMS crew provided in cooperation with the Police of the Czech Republic. This station is based on Václav Havel International Airport in Prague.

The HEMS crew provides its services in the capital as well as in the region of Central Bohemia or anywhere else in the Czech Republic if the situation requires so.

The main focus of this lecture is to introduce Prague Emergency Medical Service and its history as well as to give a complex insight into the issue of providing urgent medical care in the very heart of Europe, in Prague, the capital city of Czech Republic.

 


Katarina VESELA (Prague, Czech Republic), Petr KOLOUCH, Jiří DANDA
11:00 - 18:00 #7571 - End-of-life Decisions in Patients Admitted through the Emergency Department.
End-of-life Decisions in Patients Admitted through the Emergency Department.

Background/Objective:


End-of-life decisions (EOLD) grew more important in recent years due to an increase in elderly and multi-morbid patients. Although life can be prolonged, the main questions from the patients’ perspective tend to focus on quality of life. Previous studies, e.g. in oncological settings, found that several factors may influence EOLD. Little is known about the prevalence of EOLD and underlying factors in patients presenting to the Emergency Department (ED). Therefore, we conducted a study on EOLD in patients admitted through the ED of the University Hospital of Basel (UHBS), Switzerland.

 

Method:

A retrospective analysis of data from all admitted patients presenting to the ED between 2012 and 2016 was performed. Patients opposing research consent, less than 18 years of age, without electronic health records (EHR), and direct boarding to another department were excluded. EOLD were categorised stepwise: preference for / against resuscitation (RES), and preference for / against Intensive Care (IC). Three preferences were identified: (i) RES yes / IC yes; (ii) RES no / IC yes; (iii) RES no / IC no. We used an ordered logit model with the 10 most suitable variables including age, sex and measures of disease. Using this regression model, we computed significance and odds ratios (OR) of the variables.

 

Results:

A total of 48'219 patients were admitted through the ED. After excluding all patients meeting the exclusion criteria, 14'816 patients were analysed. EHR contained EOLD in 64.8%. Patients’ choices were: 78.6% (i) RES yes / IC yes; (ii) 6.8% RES no / IC yes; and (iii) 14.6% RES no / ICU no. Older age, "non-surgical" patients, a lower triage level (ESI 4-5), a higher number of diagnoses, and a higher number of previous hospitalisations were significant for (ii) and (iii), i.e. forgoing life-prolonging interventions. The most important factors to forgo life-prolonging interventions were age (OR=3.7), and “non-surgical” (OR=2.7). Cancer, depression, dementia, sex and the Charlson Comorbidity Index (CCI) did not have a significant influence on forgoing life-prolonging interventions.

 

Conclusion:

The most important factor to forgo life-prolonging interventions is age. The influence of “non-surgical” increased the odds. This may be explained by the patients’ decision to undergo surgery, obviously being a predictor for other life-prolonging interventions. Interestingly, diseases, such as cancer, depression, or dementia did not have an impact on EOLD. Further research is needed to understand reasons to forgo life-prolonging interventions.


Victoria SIEGRIST (Zeiningen, Switzerland), Rui MATA, Ralph HERTWIG, Roland BINGISSER
11:00 - 18:00 #7315 - Epidemiologic characteristics of carbon monoxide poisoning in Korea : Emergency Department based Injury In-depth Surveillance.
Epidemiologic characteristics of carbon monoxide poisoning in Korea : Emergency Department based Injury In-depth Surveillance.

Purpose

The aim of this study is to describe the characteristics of patients with carbon monoxide (CO) poisoning.

Methods

We surveyed the data of Emergency Department based Injury In-depth Surveillance, (2011-2014), Korea Centers for Disease Control and Prevention, retrospectively. We included the patients that mechanism of injury is acute CO poisoning. We surveyed the annual and monthly incidence, gender, age, the result of emergency treatment, the rate of intensive care unit (ICU) admission, the result of admission, association with alcohol, and place of accident. We also surveyed the cause and experience of past suicide attempt of intentional poisoning.

Results

Total 3,405 patients were included, male and female was 2,015(59.2%) and 1,390(40.8%), mean age was 39.83±18.51 year old. The annual number of CO poisoning had been increased. The incidence of unintentional CO poisoning was higher than intentional CO poisoning at January, February and December. The mean age of unintentional CO poisoning was younger than unintentional CO poisoning (38.41 ± 13.03 vs 40.95 ± 21.83). The rates of discharge against medical advice (DAMA), ICU care and alcohol association of intentional CO poisoning were higher than unintentional CO poisoning (36.4% vs 14.0%, 17.8% vs 4.7%, 45.2% vs 5.6%). The most common place of CO poisoning was residence area

Conclusion

The annual incidence rate of CO poisoning had been increased with seasonal variation. DAMA, ICU care, and alcohol association of intentional CO poisoning were higher than unintentional CO poisoning.


Sohyun BAE (Koyang, Korea), Woochan JEON, Kyunghwan KIM, Junseok PARK, Dongwun SHIN, Joonmin PARK, Hyunjong KIM, Hoon KIM
11:00 - 18:00 #7724 - Epidemiological analysis of elderly patients with trauma and detected fracture in Emergency Department.
Epidemiological analysis of elderly patients with trauma and detected fracture in Emergency Department.

AIM: In this study, elderly patients over 65 years with the diagnosis of trauma and detected fracture in radiological imaging who admitted to emergency medicine clinic of Istanbul Medeniyet University,Göztepe Training and Research Hospital in 1-year period will be scanned and evaluated retrospectively. Etiological factors of obtained results and preventable causes will be researched and data based on evidence will be obtained.

METHODS: The patients were evaluated according to age group, comorbid diseases, gender, resume, radiological images, history of fracture, additional organ injuries of fracture, chronic diseases, drugs used, number of drugs used, hours of arrival to the emergency room, trauma scoring of NACA, AIS and ISS. Patients whose file notes were inaccessible, who have been resuscitated in the emergency room and patients who admitted exincorporation were excluded from this study.

RESULTS: 300 patients over 65 years who had fracture on radiological imaging were evaluated. Most of them were female (75.7%). The most common cause of injuries in the elderly population was 95% falling(simple fall, fall from heights) while motor vehicle collision was 4,7%. 88%(n=264)of patients had chronic illnesses and were using drugs and 22%(n=36) of them have no chronic illnesses and using drugs.. Patients in were divided into age group as 45%(n=135) 65-75, 35%(n=105) 76-85 and 20% (n=60) over 86 years. The ratio of female, hospitalization, ISS and the rate of additional organ injury with increasing age was meaningfull higher(p<0.05). The distribution of fracture femur and humerus was higher meaningfully (p<0.05) and the rate of fracture on hand and foot was lower meaningfully (p<0.05). The application hour, the mechanism of injury and the rate of extremity BT according to age had no significiant difference (p<0.05). 188 patients (62%) were discharged and 122 patients (37.3%) were hospitalized in the clinics.

CONCLUSION: In our study the most common cause of trauma depended on falling. We found out that the most common extremity trauma was fracture of femur and humerus. Because of the reduction of self protection of the elderly population while falling, fracture of humerus and femur has significantly increased but fracture of hands and wrists and feet has significantly decreased. However, the scores of ISS and NACA were not meaningfull in hospitalization. In geriatric population family members should be informed for protective measures as preventing the usage of multiple drugs, life comfort of patients after trauma care and preventing possible new cases.

 


Mehmet UNALDI (ISTANBUL, Turkey), Fırat ARSLAN, Onur INCEALTIN, Kurtulus ACIKSARI, Didem AY, Soner ISIK, Hatice ERYIGIT
11:00 - 18:00 #7599 - Epidemiology of Clinically Significant Playground Injuries To Children In Korea.
Epidemiology of Clinically Significant Playground Injuries To Children In Korea.

Backgrounds : Most of epidemiologic study of playground equipment-related injuries are primarily conducted with data from the United States and Canada. This study used local data rather than from the United States or Canada to evaluate injuries within the playground.

Aim : This study used the Korean Center for Disease Control(KCDC) data set investigates the factors of clinically important playground injuries that required inpatient treatment.

Methods : We identified and retrospectively reviewed patients aged 0-18 years old with playground injury, as evaluated in the emergency room of 6 hospitals participated in KCDC injury surveillance system in 2011. We conducted descriptive statistics and the Pearson's chi-squared test, and multinomial logistic regressions with several injury factors.

Results : There were 1,458 cases that presented in the emergency room of study hospitals with injuries in playground and injuries unrelated to playground equipment are 842 cases (57.8%). The most common injury mechanism was impact (37.0%), followed by fall (29.8%). The most common injury was laceration of the head/face/neck (24.4%), followed by contusion of the head/face/neck (14.8%) and upper extremity fracture (14.3%). Among 119 hospitalized patients (8.2%), the leading mechanism of injuries was fall (63.0%), impact (16.8%), and trip (14.3%) and the majority of the injuries affected upper extremities as the primary site of injury (70.6%). The injury that required the most number of hospitalizations was upper extremity fractures (68.1%), followed by lower extremity fracture (5.9%). Among upper extremity fractures which comprised the majority of chief complaints for hospitalization, ages 6-11 (OR 5.7; CI 1.3-25.0) and playgrounds situated in public places (OR 2.4; CI 1.1-5.3) were identified as significant risk factors.

Conclusion : The playground safety education should be emphasized for ages 6-11 group and a policy change is necessary to decrease the number of accidents within public playgrounds in South Korea.


Suh DONGBUM (Seongnam, Korea), Kwak YOUNG HO, Kim DO KYUN
11:00 - 18:00 #7781 - Epidemiology of infection in elderly patients admitted to the emergency.
Epidemiology of infection in elderly patients admitted to the emergency.

Objective  

The study aim was to describe clinical features of severe infection in old patients admitted in the emergency department.

Patients and methods

Descriptive retrospective study including old patients, admitted in the emergency department with severe infection presenting with an infection associated with systemic inflammatory response syndrome and an organ dysfunction.   

Results

Sixty one patients were enrolled. The average age was 77 ± 8 years,37 patients  were males. Most patients had a past history of diabetes (52%), stroke (31%), chronic pulmonary disease (18%), pulmonary neoplasm (13%) and chronic renal failure (8%). The most frequent complaint was dyspnea (40%). Fever was found in 34% of cases, cough in 25% and sputum in 20%. Coma and confusion were found respectively in 21% and 7% of cases. Sepsis was found in 77% of cases and septic shock in 15%. Pneumonia was the first infection (53%), urinary tract infections was diagnosed in 31%, gastrointestinal infection in 10% and skin infection in 5%. The consultation reason was correlated with the diagnosis in 44% of cases. In cases of pneumonia, respiratory signs were found in only 36% of cases, urinary symptoms were found in 10.5% of urinary tract infections.

In hospital mortality was 36%. The causes of death were a refractory shock in 62% of cases and acute respiratory failure in 38% of cases.

Conclusion

Sepsis related mortality is high in elderly in emergencies, about 36%.  It’s partially explained by the atypical infectious symptoms reaching 56% with a significant treatment. 


 


Kamel MAJED, Boubaker RADHIA (tunis, Tunisia), Neila MGHAIETH, Baccouche RAMLA, Khelil MOHAMED HASSEN, Khedija ZAOUCHE, Hamida MAGHRAOUI, Mohamed MODHAFFER, Chokri HAMOUDA, Nebiha BORSALI FALFOUL
11:00 - 18:00 #7409 - Epidemiology of patients admitted with chest pain and the care they received at Emergency Trauma Centre, Teaching Hospital Karapitiya, Galle, Sri Lanka.
Epidemiology of patients admitted with chest pain and the care they received at Emergency Trauma Centre, Teaching Hospital Karapitiya, Galle, Sri Lanka.

Introduction: Teaching Hospital Karapitiya (THK) is located within the city limits of Galle, the capital of southern Sri Lanka. THK is the second largest hospital in the country, with over 1800 inpatient beds and serves as the referral hospital for southern Sri Lanka.

The Emergency Trauma Center (ETC) was established in THK in year 2011.Over 15,000 patients are evaluated annually. This preliminary study was conducted to evaluate the outcome of patients presenting with non-traumatic chest pain to ETC.

Methods: Cross sectional study was carried out among the all patients admitted to the ETC with the complaint of non-traumatic chest pain. All the eligible patients admitted to ETC during the three months starting from January 2016 were recruited to the study. Data was collected by two trained doctors using an interviewer administered questionnaire after obtaining the informed consent. Final part of the questionnaire on admission parameters were completed using the patients notes. Data analysis was carried out using SPSS.

Results: Two hundred eligible patients were recruited to the study. Out of them over two thirds (68%) were males. Mean age of the patients was 57.5 years with a SD of 13.6 and a range of 24 to 86 years. Large majority (91%) of patients were from the Galle district and other 9% were from Matara and Hambanthota districts. Over 75% of people are living in rural areas of above 3 districts. 80% of the patients directly got admitted by themselves to the ETC due to their symptoms. Another 15% were transferred by the peripheral hospitals to the ETC and other 5% were referred by the outpatient department of THK and by general practitioners. Out of the patients 43.5% had past history of ischemic heart disease, 27.5% had hypertension and 17.0% had diabetes mellitus. At the ETC 17.0% of patients were diagnosed to have STEMI, 14.5% with NSTEMI and 28.0% with Unstable Angina. 40.5% of patents were diagnosed as having chest pain of non-cardiac origin. Only 6% of the patients got their cardiac enzymes checked during the stay in ETC and out of them only 25% got a positive result. Only 3% had primary PCI with 100% success rate and 12.5% had thrombolysis (Streptokinase) at the ETC. ACS protocol for NSTEMI was followed in the treatment of 96.5% patients of NSTEMI and ACS protocol for Unstable Angina was followed in the treatment of 94.6% patients with Unstable Angina. Out of the 200 patients, nobody died during the ETC stay and 77.5% were transferred to wards and 22.5% were transferred to the cardiac intensive care units for further management.

Conclusions: Majority of patients who presented with chest pain had ischemic heart disease and most of them had one or more vascular risk factors. Primary PCI is not freely available yet in our hospital and Streptokinase is the choice of thrombolytic due to the low cost.


Arosha ABEYWICKRAMA (GALLE, Sri Lanka), Roshel WIJENAYAKA, Malsha NETHMINI, Hemajith THARINDRA, Shelton PERERA, Vijitha DE SILVA
11:00 - 18:00 #7660 - Epidemiology of systemic inflammatory response syndrome in acute strokepatients admitted in the emergency department short stay unit.
Epidemiology of systemic inflammatory response syndrome in acute strokepatients admitted in the emergency department short stay unit.

Introduction:

The systemic inflammatory response syndrome (SIRS) is the body’s response to a multitude of chemical mediators. Conditions inciting the release of these mediators include bacterial sepsis, viremia, pancreatitis, trauma, neoplasia, heat stroke, and many others. The relation between SIRS and acute strokes remains poorly described, no study to date has investigated epidemiology of SIRS in acute stroke patients.

The aim of this study was to evaluate the frequency of SIRSin acute stroke patients admitted in the emergency department short stay unit (EDSSU), to list its main causes and compare the epidemiological characteristics and evolution

Methods:

A retrospective study including patients who were admitted during more than 24 hours for acute stroke into the EDSSU starting from January 1st, 2015to December 31, 2015.

We collected data regarding age, gender, past medical history, length of stay, intra-hospital mortality andreferralat the end of hospital stay to study the epidemiological and clinical features of this population.

SIRS was defined as the presence of 2 or more of the following criteria: body temperature less than 36°C or greater than 38°C, heart rate greater than 90, respiratory rate greater than 20, or white blood cell count less than 4000/mm3or greater than 12,000/mm3 or more than 10% bands.

Results:

Among 27980 of all emergency department visits during 2015, 696 patients were admittedfor more than 24 hours into the EDSSU from whom 192admitted for acute stroke and169 patients were selected

Patients were separated into two groups: positive SIRS (n = 38;22.5%) and negativeSIRS (n=131; 77.5%).

The two groups were comparable in age, sex ratio and past medical history.

Mortality was 31.6% (n = 12) in the positive SIRS group and 10.7% (n = 14) in the negative SIRS group with a significant difference between the two groups (p = 0.002).

The sensitivity was 46.15% and the specificity was 81.82% (OR = 4.19 [1.74 to 10.09]).

Conclusions:

SIRS has a high incidence in acute stroke patients admitted inEDSSU. In our series these patients have a mortality of 31.6%. These SIRS criteria are easily accessible in emergency department and can be collected on arrival of patient. A study on a larger scale would be needed to verify its prognostic value.


Mohamed MEZGHENI, Mohamed Ali CHERIF, Farah RIAHI (Belfort), Najeh HAJJEM, Malek HSOUNA, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7204 - Epigastric pain caused from spontaneous isolated left gastric artery dissection.
Epigastric pain caused from spontaneous isolated left gastric artery dissection.

Background

Spontaneous visceral artery dissection without concomitant aortic dissection is a rare but fatal disease. It is difficult to diagnose by contrast enhanced computed tomography(CECT), because affected artery is small especially when the lesion is in celiac artery. We think it is important to report this case because visceral artery have to be ascertained from its origin to distal branches.

 

Case presentation

A 46-year-old female had sudden, severe epigastric pain at rest. The pain was stabbing quality, radiating to the back, not intermittent and was associated with sweating. She was taken to the emergency department by ambulance after four hours. She had Basedow disease and untreated hypertension. Her current medication was methimazole. She was a non-smoker and non-drinker. Her mother had aortic dissection.

 

On physical examination her blood pressure was 189/102 mmHg and pulse 81 beats per minute. She had tenderness to palpation over her upper abdomen, especially in the epigastrium without associated guarding. The chest, lung, and cardiac exams wer reported as normal.

 

Lab results were all within normal limits. Her electrocardiogram showed normal sinus rhythm but no acute ischemic changes. Transthoracic echocardiogram and abdominal ultrasonography showed both normal results. Our impression was that the pain was most likely attributable to aortic dissection and CECT was performed.

 

The CECT revealed a focal left gastric artery dissection. The dissection began approximately 0.5cm distal to the origin of the left gastric artery, and its false lumen was completely thrombosed. There was no disruption of blood flow in its true lumen and other branches including celiac artery were intact. Our therapeutic strategy was noninvasive conservative medical treatment and she was started on intravenous Nicardipine to lower her blood pressure. Another CECT was performed after two days and there was no progression of dissection. She was discharged home with close follow up arranged.

 

Conclusion

There has been reported fewer than 100 cases of isolated celiac artery dissection in the literature, but not been reported any cases of spontaneous isolated left gastric artery dissection. When we suppose aortic dissection, we need to consider not only celiac or superior mesenteric artery dissection, but also left gastric artery dissection.


Shotaro KAWAMURA (Nagoya, Japan), Hidetoshi WATANABE
11:00 - 18:00 #7548 - ETView SL video tube for prehospital intubation by inexperienced novice physicians.
ETView SL video tube for prehospital intubation by inexperienced novice physicians.

Background. Endotracheal intubation is a gold standard for airway management during cardiopulmonary resuscitation (CPR). Endotracheal intubation enables asynchronous resuscitation, which, owing to minimal interruption in chest compressions (CC), improves CPR effectiveness. In the case of direct laryngoscopy, vocal cords visualization during CC may be difficult to achieve. An alternative may be the usage of a videolaryngoscope or an ETView SL, constituting a kind of a video tube.

Participants and methods. This was a randomized crossover manikin trial. Twenty-six novice physicians with limited experience in the videolaryngoscopy technique participated in the study. The time to intubation (TTI) using 2 methods of laryngoscopy (Macintosh and ETView) during and without CC were compared.

Results. The median TTI with the Macintosh laryngoscope in the scenario with uninterrupted CC was 42 (interquartile range [IQR], 38–47) seconds, which turned out significantly longer than the TTI in the scenario with interrupted CC (35 [IQR, 31–39] seconds, p < 0.001). The TTI with the ETView was similar in both scenarios: 32 (IQR, 26–34) seconds vs 26 (IQR, 21–31) seconds, respectively (p = 0.002). A statistically significant difference between ETView and Macintosh was observed in the TTI both in the scenario during CC (p < 0.001) and without CC (p < 0.001).

Conclusion. The ETView video tube helps novice physicians intubate a manikin in a CPR scenario in a shorter time and with fewer attempts than the classical Macintosh, both in the case of ongoing and stopped CC. Applying ETView in real clinical situations could improve the quality of CPR performed by physicians.


Szarpak LUKASZ (Warsaw, Poland), Smereka JACEK, Truszewski ZENON, Czyzewski LUKASZ
11:00 - 18:00 #7288 - Evaluate the feasibility of a smartphone-based app in the mass casualty incident to simplify the injuries and their dispositions.
Evaluate the feasibility of a smartphone-based app in the mass casualty incident to simplify the injuries and their dispositions.

Background: Due to the limited information in the early phase of rescue operation, the government, emergency medicine service (EMS) systems and the population in Taiwan usually get the ambiguous information of damage. Utilization of the medical electronics with well-established infrastructure of information communication technology to manage affected population in such scenario is thought to be practical and useful. Currently in Taiwan, paperwork-based documentation remained the major method for the first responders. Due to poorly adapted tools and strategies, responders are increasingly ill-prepared to produce useful knowledge from the flow of information. The aim of the project is managing the dataflow of the patients with mobile devices.

Methods: The information platform as an independent smartphone app was coded by Dr. Cheng with Android Studio 2.0. Instant and editable information will be provided to the clients including the medical responders in the scene, the staffs in the hospitals and the command center. All data in transit will be encrypted because of the security concerns. Subsequently, a table-drill was held to evaluate the efficacy and efficiency. Three voluntary medical students were recruited. A 30-minutes mini-lecture about simple triage and rapid treatment (START) was provided in advance. Two different groups of scenario card were given to these three medical student. In the first group, they were asked to complete triage by using the smartphone. In the second group, they would complete other 25 triage by using traditional paperwork alone. Finally, they must calculate and report the total injuries and their dispositions. The time and accuracy was recorded by comparison.

Results: There was no difference in the total triage time between the smartphone group (1172 seconds) and the paperwork group. (1262 seconds) (p=.643) However, it was significant difference in sorting the information between the smartphone group (29 seconds) and the paperwork group. (184 seconds) (p=0.003) It is time consuming to find out which destination and the transfer time. The accuracy was no significant difference between the smartphone group (25/25, 100%) and the paperwork group (24/25, 96%).

Conclusion: It is feasible to use the mobile phone app to clarify the injuries and their dispositions in the early phase of a mass casualty incident. The limitation in this brief study are the small convenient samples and scenarios.

Reference:

  1. Bellini P et al. Mobile emergency, an emergency support system for hospitals in mobile devices: pilot study. JMIR Res Protoc. 2013 May 23;2(1):e19.
  2. Bachmann DJ et al. Emergency Preparedness and Disaster Response: There's An App for That. Prehosp Disaster Med. 2015 Oct;30(5):486-90.

Acknowledgements: There was currently no funding or conflict of interest in this study.


Po-Liang CHENG (Tainan City, Taiwan), Yung-Cheng SU, Yi-Kung LEE, Po-Lun CHANG
11:00 - 18:00 #7343 - Evaluation of a diagnosis protocol in elderly patients with acute respiratory failure using cardiac and lung ultrasound : prospective non interventionist study.
Evaluation of a diagnosis protocol in elderly patients with acute respiratory failure using cardiac and lung ultrasound : prospective non interventionist study.

Introduction

Acute respiratory failure (ARF) in elderly patients is a common situation in Emergency Medicine. Usual diagnosis procedure (UDP) with clinical exam, chest X ray and biological samples is frequently inconclusive. Vital prognosis is worsened in case of bad initial diagnosis. The goal of this study was to investigate the performances of a echographic diagnosis procedure (EDP) including cardiac views and lung ultrasound performed by an emergency physician (EP).

Patients and methods

Inclusion criteria

age > 75 years

ARF defined by respiratory rate > 25/min and SpO2 < 90% in room air

Exclusion criteria

indication to immediate tracheal intubation

documented end of life

more than one reference diagnosis

Method

EDP included the four usual cardiac views, mitral and tissular Doppler and lung ultrasound. Possible diagnosis were acute cardiogenic pulmonary edema (ACPE), community acquired pneumonia (CAP), chronic obstructive pulmonary disease (COPD), cardiac tamponnade (CT), right ventricle overload (RV), other (O) and unknown (UN).

This non interventionist study was approved by the Ethics committee. After informed consent and UDP, the EP stated the diagnosis hypothesis (H1). The EDP was then performed in a blind fashion by the investigator and the new diagnosis hypothesis (H2) was stated. H2 was applied to the patient’s care. Reference diagnosis (H3) was the final one stated in the patient’s file.

Primary objective: concordance between H1-H3 and H2-H3

Secondary objectives : hospital mortality, frequency of diagnosis

The required number of subjects for a concordance of 0.7 between H1 and H3 and 0,9 between H2 and H3 with alpha risk 0.05 and beta 0.10 was 42.

Statistical method

Values stored in Microsoft Access were analyzed with PASW. Numerical data expressed as mean + SD were compared by a Student t test. Categorical data by a Khi2 test. Concordances were analyzed using Kappa coefficient. P< 0.05 was considered significant.

Results

82 patients were included, 11 secondary excluded because of more than 2 diagnosis. Included patients were 84+5 years old, 45 women and 26 men. H3 were mainly ACPE 33 (46.5%), CAP 16 (22.5%), COPD 9 (12.7%), RV 8 (11.3%), CT 2 (3%). Overall sensitivity and specificity for H1 were 0.56 [CI95% 0.45-0.67] and 0.94 [CI95% 0.90-0.96] respectively and 0.93 [CI95% 0.83-0.97] and 0.99 [CI95% 0.97-0.99] for H2 (p <10-3 for sensibility). Kappa coefficient was 0.41 [CI95% 0.34-0.48] for H1-H3 and 0.90 [CI95% 0.86-0.94] for H2-H3 respectively (p<10-3). Overall mortality was 35%. After regrouping, mortality were PAC 66%, ACPE 28%, COPD 25%, others 23%, respectively (p 0.03)

Discussion

Final diagnosis were conformed to published studies. Concordance was poor for the UDP while it was excellent for the EDP. Face to an ARF in elderly patients, EDP with simple cardiac and lung ultrasound enhances the diagnosis procedure and allows to determine the appropriate treatment.


Philippe LE CONTE (Nantes), François JAVAUDIN, Emmanuel MONTASSIER, Idriss ARNAUDET, Philippe PES, Laure DE DECKER
11:00 - 18:00 #7085 - Evaluation of age related d-dimers in determining the presence of Pulmonary Embolism and rationalising the use of CT Pulmonary Angiograms in a Brisbane Hospital.
Evaluation of age related d-dimers in determining the presence of Pulmonary Embolism and rationalising the use of CT Pulmonary Angiograms in a Brisbane Hospital.

Purpose:

 

The d-dimer is a breakdown product of crosslinked fibrin and occurs coincident with activation of the coagulation cascade. The d-dimer level may be elevated in the presence of a clot that embolises to the lungs causing a pulmonary embolism (PE). The d-dimer level is used in patients with a low to moderate pretest probability for PE. 1

 

There is increasing evidence that in patients over 50 years of age; the steady state level of the d-dimer increases. 2 This study investigates the possibility of increasing the standard cutoff for patients over 50 years without losing the sensitivity of the d-dimer test. 3 This will reduce the need for a CT Pulmonary Angiogram (CTPA) with a resultant cost saving to the hospital; reduced exposure to ionizing radiation and the risk of contrast reactions.

 

Methods and Materials:

 

A retrospective audit of CTPAs over an eight month period was undertaken. All patients who had a CTPA to exclude a pulmonary embolism had their d-dimers reviewed. Patients who did not have a d-dimer were excluded from the review.

 

Age stratified D-Dimer cut offs were:

 

Age 0 - 49         0.243

Age 50 - 64       0.4

Age 65+            0.45

 

Values were compared to the new age adjusted cut offs and CTPA results to determine if increasing the standard cut off value in patients over 50 may be possible without missing the presence of PE.

 

Results:

 

A total of eight months of data (1/1/2015 - 31/8/15) was acquired, in which 900 CTPAs were performed. 106 examinations had a d-dimer requested and these examinations were analyzed.

 

68 (63.6%) of the patients were over the age of 50. 8 (11.8%) patients above the age of 50 had a CTPA positive for PE.

 

Implementing the age-adjusted d-dimer cut-off resulted in no missed pulmonary embolisms. Of the 68 patients over 50; 35 (52.5%) patients age adjusted d-dimers would have been negative. 22 (55%) of the 65+ age group could have also avoided radiation with the new cut-offs.

 

Conclusion:

 

This study demonstrated that one in two patients over 50 could be spared a CTPA using the age adjusted d-dimer levels. The number of scans avoided could have saved $17850 in just eight months. 4 The radiation burden in this study that could have been avoided combined to a 105 years of background radiation (245msV). 5 In view of these results, a prospective multicenter study has been commenced to validate these findings.


Amit CHACKO (Brisbane, Australia), Tim HAINA
11:00 - 18:00 #7402 - Evaluation of blood cultures profitability performed in 2014 in a emergency department.
Evaluation of blood cultures profitability performed in 2014 in a emergency department.

Introduction : Sepsis represents 11.2% of emergency room visits. Blood cultures sampling is one mean for microbiological documentation of sepsis. We questionned the profitability of this exam in an emergency department, the state of local practices and we research predictive positive blood cultures factors.

Material and method : Descriptive retrospective single-center study. Data were collected from the hospital bacteriology laboratory without exclusion criteria from January 1st 2014 to December 31th 2014.The search for positive predictive criteria was carried out from January 1st  2014 to 1 February 1st 2014.

Résults : Among 57,430 patients who had consulted in the emergency department concerned over the study period, 2401 samples were performed of which 226 were positive for 9.4% profitability. These samples corresponded to 1939 patients included representing 170 patients who had at least one positive blood culture. The profitability per patient was 8.8%.The average number of samples per patient was 1.24. The predictive positive blood cultures criteria found were: central catheter sampling (OR 3.73 95% CI [2.29; 5.92], p <0.001), the presence of central catheters (OR 4.17 95% CI [2 43; 6.98], p <0.0001), the sampling of more than one blood cultures per patient (versus 1 blood culture: OR 2.77 95% CI [1.88; 4.04] p <0.001 for 2 blood cultures , oR 7.36 95% CI [3.98; 13.29] p <0.001 for 3 blood cultures and more), age ≥65 years (OR 1.89 95% CI [1.41; 2.54 ] p <0.0001), the notion of immunosuppression (OR 2.86 95% CI [1.00; 8.18] p = 0.03), the notion of fever (OR 3.45 95% CI [1, 13; 12,61] p = 0.02), fever at admission  (OR 3.8 95% CI [1.31, 11.55] p = 0.007), hospitalization (OR 8 45 95% CI [1.28; 358.74] p = 0.02), practice of urinary screening (OR 2.91 95% CI [1.02; 9.02] p = 0.03)

Discussion : Our study was underpowered for the search criteria predictive of positive blood cultures, a study on a larger sample would be appropriate to adapt our practices.

Conclusion : The profitability of blood cultures in the study site was comparable to literature data (from 5 to 15%). Highlighting positive predictive criteria is a way to improve our practices but requires further studies, prospective in particular.


Sofiane YEFSAH (Paris), Christelle HERMAND, Alessandra PUIG, Jessica ROUCHE, Félicité GEFFRIER, Ines LEUNG, Barbara SAKAROVITCH, Dominique PATERON
11:00 - 18:00 #8234 - EVALUATION OF CHEST PAIN.
EVALUATION OF CHEST PAIN.

University of Yıldırım Beyazıt Yenimahalle Educational Research Hospital Emergency Department

Sahin Havva K, Koptur P, Yılmaz H, Sezer Ahmet A, Akman C, Karakuş M

 

OBJECTİVE: Uncertainties in the measurement of troponin is a nuisance. Final diagnostic level of troponin is still unknown. Troponin in many cases can be positive. The aim of this study is to be a short presentation about the monitoring and evaluation of troponin-positive patients arriving with chest pain.

MATERİAL-METHODS: The records of mergency department  in February, March, and April 2016 were retrospectively reviewed. The 92 patients presenting with chest pain and cardiac troponin-positive detection of the 92 patients were examined.  Patient's age, sex, cardiac troponin, biochemistry and complete blood count test results, whether electrocardiographic changes, additional diseases were recorded. The records were classified  by using the Thrombolysis In Myocardial Infarction scoring(TIMI).

RESULTS: 29 women 63 male patient was admitted because of chest pain. verage age was calculated to be 70. Average systolic blood pressure of 145 mm / hg diastolic blood pressure 93mm / kg, 93% O2 saturation, pulse rate 88 / min were measured. The average value of urea in the blood values of 58 mg / dL, creatinine of 1.93 mg / dL, AST 60 U / L, ALT 56 U / L, white blood cell 10.53, first viewed cardiac troponin 0.894 , after 1 hour troponin value 1.93, third hour of troponin value was 2.44. Twenty-one patients had elevated levels of creatinine. It was TIMI scoring,8 patients 4 , 44 patients 5. 2  patients6, 8 patients 4, 20 patients 3,  2 patients had 2 points. Eight patients were referred to as ST elevation myocardial infarction, four patients was not considered an acute coronary syndrome. Eighty patients were followed as acute coronary syndrome.

CONCLUSSİON: Troponin can be positive in many diseases and conditions. The acute and chronic kidney failure, chronic heart failure, pulmonary embolism, acute myocarditis, pericarditis,, blunt chest trauma, sepsis-septic shock, hirertansif crisis, tachyarrhythmia, bradycardia, hypothyroidism, infiltrative diseases (hemochromatosis, amyloidosis) drug toxicity, snakes bites, respiratory insufficiency, carbon monoxide poisoning are some of these conditions. Due to all these factors, the increase in troponin levels should be evaluated . Etiologic diagnosis can be detected correctly by the other laboratory tests. In addition, the patient's age, additional diseases, changes in cardiac troponin follow-up, electrocardiographic findings, including risk classification and type of chest pain that certain factors should be used. Nevertheless, whatever the underlying pathology,the elevatin of troponin usually carries prognostic value of myocardial damage is shown. Primarily in the presence of a disease in the acute phase with high morbidity and mortality, to diagnosis of ACS and guide treatment by elevated cardiac troponins may not be an appropriate clinical approach. İt is more accurate to be guided by the patient's primary disease or monitoring in the existing clinic in such conditios. Regulation of cardiac treatment should be compared with the cardiology department.


Pınar KOPTUR, Hıdır YILMAZ, Havva ŞAHIN KAVAKLI (ANKARA, Turkey)
11:00 - 18:00 #6453 - Evaluation of different adenosine dose in junctional tachycardia.
Evaluation of different adenosine dose in junctional tachycardia.

Background: Junctional tachycardias (JT) occur in 36/100 000 persons per year. In France symptomatic episodes mostly benefit of out-of-hospital care. Since the year 2000, adenosine is the first-line treatment of JT. Although international guidelines advocate the use of a 6mg dose to reduce JT, French guidelines recommend to start with 3mg. The aim of the study was to evaluate the efficacy of different adenosine dosages in order to reduce JT. Further, to evaluate the efficacy of other interventions to reduce JT and the benefit of troponin testing after JT.

Methods: We present here a monocentric and retrospective study using data collected by the Emergency Medical Service (EMS). All adult patients from January 2011 to July 2015 were included. Patients were excluded if JT was not recorded during management on a hardcopy ECG.

Results: 110 patients were included for statistical analysis. 63 benefitted of at least one dose of adenosine and cessation of JT was achieved in 86% (95% CI (80-92%)). Considering all the dosages administrated, adenosine boli of respectively 3, 6 and 12 mg stopped 7%, 20% and 70% of JT. 70% of patients responded to a second 6mg adenosine dose after an unsuccessful first one. 56% of patients were given a 12mg dose when the 6mg dose failed. JT reduced spontaneously in 6 patients (5.5%). Vagal maneuvers were used in 71% (95% CI : (63-80%)) of patients and were successful in only 14%. 72% of all patients were conducted to the ER and 14% to the Cardiac Intensive Care Unit. Of these patients 51% (95% CI : (42-60%)) had at least one serum-troponin assay, and at least one troponin assay was elevated in 48% of these patients. Average troponin was 0,12ng/ml (N<0,04ng/ml). There was no relation between troponin-elevation and chest pain during JT (p=0.81) or ST-segment elevation (p=0.98). After hospital care, a daily treatment was initiated for only 5 patients.

Conclusion: Adenosine response is affected by an important inter- and intra-individual variability and considering the potential side-effects, low doses should be given first. Guidelines recommend first vagal maneuvers before pharmacological reduction. Efficiency of a 3mg dose among patients with JT remains low. Recent US recommendations advocate to begin with a 6mg bolus, and to follow with a 12mg bolus (to be repeated once). Our study also suggests the use of an initial 6mg adenosine bolus and an alternative to the second step of the guidelines repeating the 6mg dose.


Sarah UGÉ (Strasbourg), Mickael FORATO, Pierrick LE BORGNE, Céline RENFER, Laura BEJINARIU, Elena Laura LEMAITRE, Charles-Eric LAVOIGNET, Laurent TRITSCH
11:00 - 18:00 #8188 - Evaluation of high-fidelity simulation for effective teaching in emergency medicine.
Evaluation of high-fidelity simulation for effective teaching in emergency medicine.

Introduction: Simulation is a novel and effective teaching technique for medical education. It has been integrated in medical education for some years now. The literature suggests a clear benefit for initial learning for technical and non-technical skills. The objective of our work was to show the efficacy of high-fidelity simulation in effective teaching of technical and non technical skills in a specific population of already trained and working emergency physicians.

Material and Methods: We conducted an observational and analytical study on a cohort of emergency physicians participating in a university degree of high fidelity human simulator (METI) training, from January to May 2015. Surveys evaluated pre and post-test theoretical knowledge for each of the three weeks of the degree. We also analyzed the first and the last training session on the simulator for each participant using a validated score evaluating management skills: the NOTECH. A final survey of subjective satisfaction was submitted on the last day of training in order to gather more subjective parameters on the interest in this type of medical teaching. Results are expressed as mean, standard deviation and percentage; the Chi2 test was used for comparisons.

Results: 25 emergency physicians (40.9 years) were enrolled. The majority had worked in the public sector (84.6%) for at least 5 years (60%). Only 20% of them had used simulation before in their initial medical study. A statistically significant improvement was shown in the evolution of the average score between the pre-test and post-test of the first and second week of training (from 8.08 to 11.07 on 20 with p <0.001 for the first and from 9.57 to 12.45 of 20 with p <0.01 for the second). These results were confirmed by the analysis of management skills (NOTECH), which showed a significant improvement of 43.33% of the average score between the first and final training on the simulator (13.34 / 25 to 19.12 / 25 so a gain of 5.78 points with p <0.01). All participants (100%) felt that the use of simulation improved their emergency medicine knowledge and skills.

Discussion: Our results show that simulation training is a useful teaching tool in the continuous emergency medicine education but also that it completes the initial medical education of already qualified doctors. The limits of our work are the low number of participants (n = 25) although we found statistically significant results and the lack of a control group which could have given more power to our study. Another limit is the use of NOTECH which is a non-specifically validated tool for emergency medicine.

Conclusion:  This study confirms the need to integrate simulation in medical training for both initial but also continuous education. More research is needed in this field, among those, the creation of an evaluation tool for management skills in emergency medicine would be essential.


Sébastien LADYGA (PARIS), Jennifer TRUCHOT, Maxime GAUTIER, Ghanima AL DANDACHI, Johana MALKA, Patrick PLAISANCE
11:00 - 18:00 #7191 - Evaluation of knowledge of pre-hospital physicians on the diagnosis and management of purpura fulminans.
Evaluation of knowledge of pre-hospital physicians on the diagnosis and management of purpura fulminans.

Introduction: Purpura fulminans (PF) is a rare disease but any delay in diagnosis and/or therapy increases the risk of morbidity and mortality. Early diagnosis from first contact in the medical chain is essential to establish appropriate treatment as early as possible. The purpose of this study was to assess the knowledge of pre-hospital emergency doctors in urban areas on the diagnosis and management of PF.

Materials and methods: An initial practice survey was based on an online questionnaire sent to all pre-hospital physicians in our Emergency Department. The questions were multiple choice with 7 questions with 5 items and 1 question with 6 items. The questionnaire included 4 parts, evaluating the knowledge of epidemiology, clinical signs, treatment and prevention/prophylaxis. All responses of doctors who have completed and returned the questionnaire were included. The endpoint was the rate of correct answers.

Results: From November 12 to December 1st, 2015, 49/75 doctors answered the questionnaire, or a rate of completion of 65%. Out of all the answers (n= 2009) (100%), 1433 (71%) were correct. Among the 490 epidemiological answers, 310 (63%) were accurate, including 17/49 (35%) correct answers on PF mortality. 980 answers about PF clinics were correct in 729 (74%) cases with 4/49 (8%) correct answers about "the absence of meningeal syndrome" being perceived as a severity factor. The 294 answers about therapy were correct in 228 (78%) cases with 25/49 (51%) for the item concerning early administration of catecholamines. The 245 answers on prevention/prophylaxis were correct in 166 (68%) cases with 26/49 (53%) for the item concerning the usefulness of the introduction of the antibiotic prophylaxis beyond 48 hours of initial care.

Discussion: The theoretical knowledge of emergency physicians were good for most items. There is room for improvement, particularly on the concept of severity associated with the absence of clinical signs and modalities of therapeutic intensification.

Conclusion: An illustrated instruction card was then made to overcome the misunderstandings and harmonize the therapeutic and prophylactic practices in the studied service.


Jennifer CULOMA (paris), Sabine LEMOINE, Vincent LANOE, Christian LE NGOC HUE, Florian LOGARIDES, Frank PEDUZZI, Daniel JOST, Michel BIGNAND, Jean Pierre TOURTIER
11:00 - 18:00 #7702 - Evaluation of patients with maxillofacial trauma in the emergency department.
Evaluation of patients with maxillofacial trauma in the emergency department.

Background: In this study, we aimed to analyze the general features, maxillofacial fracture regions, concomitant injuries, and factors affecting clinical outcome of patients with maxillofacial trauma in the Emergency Department (ED).

Methods: Hospital records of the patients who applied to our ED due to maxillofacial trauma were analyzed retrospectively in a five year period. Patients whose maxillofacial fractures had been detected in maxillofacial tomography scans were included in the study. General features of patients, maxillofacial fracture regions, concomitant injuries, initial Glasgow coma score (GCS), facial injury severity score (FISS), injury severity score (ISS), the trauma and injury severity score (TRISS) and in-hospital mortality have been evaluated.

Results: A total of 282 patients were included in this study. Male/female ratio was 3.6/1, the mean age was 42.0±16.9 years. Most frequent cause of injury was falling (25.9%).The most frequent broken maxillofacial region was maxillary sinus (45%). 43.3% of the patients had at least one concomitant injury. The most frequent concomitant injury was head trauma (22.3%). There were 692 maxillofacial fractures. Maxillary sinus fractures were the most common in both sexes. The frontal bone, nasoorbitoethmoid complex and maxillary sinus fractures were related with head trauma. Mean duration of hospitalization was 7.9±15.6 days. It has been determined that the presence of concomitant injuries caused the duration of hospital stay to increase. In this study, the number of patients died was 11 (3.9%). The mortality was related with the frontal bone fractures and LeFort fractures. There was a positive correlation between FISS and ISS. There were negative correlation between FISS and GCS and between FISS and TRISS. There was a positive correlation between FISS and duration of hospitalization. The cut-off value determined for predicting in-hospital mortality of FISS was ≥5. Sensitivity of this cut-off value was 72.7% and its specificity was 70.5%.

Conclusions: The injury mechanisms, maxillofacial fracture regions and concomitant injuries are related with in-hospital mortality in maxillofacial trauma. FISS may be a useful parameter in the evaluation of clinical severity and prediction of mortality in maxillofacial trauma in the ED. 


Metin SAH, Turker YARDAN (Samsun, Turkey), Celal KATI, Naci MURAT
11:00 - 18:00 #7919 - Evaluation of point-of- care INR results in the Emergency Department. 'Is a hasty decision always the best?'.
Evaluation of point-of- care INR results in the Emergency Department. 'Is a hasty decision always the best?'.

Introduction

In the emergency department (ED) it is possible to check the INR of patients with a point of care device (POCT).

There has been some discussion about the use of POCT results in decision making for acute situations. Many

factors can influence the POCT result and its reliability. We aimed to evaluate the differences in POCT and lab

tested 'conventional' INR results and their impact on treatment decisions.

Method

Data was retrospectively collected from the laboratory system and the electronic patient record. The POCT

measurements (Coaguchek XS Pro, Roche®) recorded in the ED were compared to a conventional INR result

(Sysmex CS2100®). Patients with a difference of >15% between measurements, and patients who did not have

a conventional INR result, were analyzed separately by chart review on treatment decisions.

Results

Over six months, 187 POCT measurements were taken. 61.5% of patients were admitted to ED with suspected

CVA.147 of POCT measurements were confirmed with a conventional INR. 18 of these had >15 % difference in

INR. Evaluation of lipid spectrum and hematocrit revealed a possible reason for these differences in only 1

patient. 70.5% of these differences in measurements had a POCT-INR >2.7. There was no clear change in

decision making for this group, despite the sometimes substantial difference in INR result (e.g. 3.8 vs 1.7). No

patients with an INR ≤1.0 used coumarins. Of 40 patients with only POCT-INR, 7 received a hemostatic

intervention (e.g. Vitamin k, Cofact®, Merocel® or LMWH) 3 patients received thrombolysis.

Conclusion

The differences in measurements have no clear effect on decision making in the ED. In high POCT values (POCT

>1.5) it is advised to confirm by conventional INR. With a POCT-INR of ≤1.0, it is safe to start treatment without

waiting for lab results, saving time and costs.


Crispijn VAN DEN BRAND (den haag, The Netherlands), Maartje VERNOOIJ, Mischa VEEN, Rolf VERHEUL
11:00 - 18:00 #7373 - Evaluation of pre-hospital triage of trauma patients.
Evaluation of pre-hospital triage of trauma patients.

Introduction: Pre-hospital triage is a key element in a trauma system that aims to admit patients to the most suitable trauma center, and may decrease intra-hospital mortality.

the aim of this study was to evaluate the performance of a pre-hospital procedure and the efficacy of a triage protocol

Methods: This was a prospective study using the mobile emergency care unit (MECU)-database for all severe trauma patient's management from January to December 2015. Each patient was graded A (instable dispite resuscitation), B (stabilized after prehospital resuscitation or anatomic criteria) or C (stable with high-kinetic circumstances or medical history) by an emergency physician, according to the seriousness of their injuries at presentation on scene. The assessement of severity was based on Vittel criteria.

Results: There were 87 calls for severely trauma patients. They were evaluated and cared by MECU teams then transported living to the emergency department. The mean age was 36.7 +ou- 17 years and the sex ratio was 3.8. Of these patients, 80% were ejected and 10% were fallen from more than 6 meters. MECU teams evaluated 34.5% of patients grade A, 26% grade B and 35.5% grade C. These patients were re-evaluated in emergency department: grade A (18%), grade B (19%) and grade C (60%). 

Conclusion: Using Vittel criteria in prehospital managment of trauma patients induces an over-triage rate. These data highlight the imperative need to evaluate the effect on outcome of such organization.


Dorra CHTOUROU (Tunis, Tunisia), Saida ZELFANI, Amina JEBALI, Samia ARFAOUI, Hela MANAI, Slim BEN DLALA, Mounir DAGHFOUS
11:00 - 18:00 #7519 - Evaluation of professional practices in a emergency department for patients suffering from mild head injury.
Evaluation of professional practices in a emergency department for patients suffering from mild head injury.

Introduction : Since 2011, the French Society of Emergency Medicine (SFMU) recommends performing, for mild head injuries (MHI), a brain scanner if neurological signs, amnesia facts than 30 minutes, Glasgow coma scale <15 two hours after the traumatism, sign of fracture of the basis of the skull, anticoagulant or antiplatelet agent treatment… Hospitalization is recommended, among others if abnormal brain scanner, Glasgow coma scale <15 after brain scanner, persistent vomiting and/or severe headaches… Primary outcome : check if the guidelines are followed correctly within the emergency department of a regional university hospital in France, about performing a brain scanner, keeping secondarily in the hospital and giving the supervision instructions.

Methods : A prospective and monocentric before and after study of the practices taking (before and after specific information sessions) conducted in the reception of the emergency department of a regional university hospital in France. Inclusion criteria : patient >15 years, seen in the emergency room for MHI. The primary outcome was the performance of a brain scan and/or hospitalization for monitoring.

Results : From January to June 2013 “Before” period : 120 patients were included and from January to June 2014 “After” period : 162 patients. The concordance rate of good use of brain scanner was 93,3% (n=112) for « Before » and 90,1% (n=146) for « After » (p=0,34). The concordance rate of deciding an hospitalization was 80,8% (n=97) for “Before” and 84,6% (n=137) for “After” (p=0,41). The issuance of supervision instructions to patients going back to their home was significantly different between « Before » : 43,8% (n = 39 instructions/89 going back home) and « After » : 60,4% (n = 61 instructions/101 going back home) (p=0,029).

Discussion :  It is important to reassess professional practices within hospitals. Medical support of a patient suffering from mild head injury was mostly respectful of the guidelines, regarding the use of brain scanner and hospitalization without being significantly improved by continuing education. However, instructions were significantly more delivered after the continuing education, but still insufficient. Since then, regular continuing education sessions have been established within the emergency department, which results will be evaluated.


Alexandre ALLONNEAU (Paris), Pierre DARS, Hugues LEFORT, Delphine PAPEIX, Daniel JOST, Daniel BAUGNON, Jean-Pierre TOURTIER, Erick DURET
11:00 - 18:00 #7895 - Evaluation of QT Dispersion in emergency medicine patients with pulmonary embolism.
Evaluation of QT Dispersion in emergency medicine patients with pulmonary embolism.

AIM: Patients with pulmonary embolism take an important place in emergency service. Prolongation of QT interval may cause ventricular arrhythmias (especially torsades de pointes) and sudden cardiac death. QT interval shortens when heart rate increases and elongates when heart rate decreases. QT interval was investigated in pulmonary embolism patients.
MATERIAL-METHOD: Patients, who applied with dyspnea and were diagnosed as having pulmonary embolism in the emergency medicine of Abant Izzet Baysal University Training and Research Hospital, were included to the study after local ethics committee approval. A few complete beats, the longest ones in leads DII and V5-6, were measured, for calculating QT interval. Moreover, corrected QT interval was registered by calculating QT interval at a heart rate of 60 bpm. Bazzett formula: QTc = QT / was used for calculation. Durations of QT > 440 ms and > 460 ms were assumed as prolonged for men and women, respectively.
RESULTS: There was no a significant difference between the group with patients diagnosed as having pulmonary embolism and the group without pulmonary embolism, in terms of age and gender. For the group of the patients with pulmonary embolism, QT interval duration was 377.10±44.63 ms and QTc interval duration was 464.03±59.00 ms. For the group of patients without diagnosis of pulmonary embolism, QT interval duration was 364.41±46.25 ms, where QTc interval duration was 421.81±55.70 ms. There was a statistically significant difference between the groups, for both QT interval (p: 0.046) and QTc interval (p:0,0001) values. Furthermore, when clinical significance of QT interval duration was considered, it was found that there was a statistically significant difference (p: 0,004) between the groups according to QTc interval. There was also a statistically significant difference between two groups for heart rates (p: 0.002).
CONCLUSION: Patients diagnosed as having pulmonary embolism must be evaluated more carefully for mortal arrhythmias such as ventricular tachycardia, ventricular fibrillation and sudden cardiac death associated with shorter QT interval durations.


Arif DURAN, Serkan ÖZTÜRK (Bolu, Turkey), Mansur Kürşad ERKURAN, Tarık OCAK, Musa KAYA
11:00 - 18:00 #7956 - Evaluation of the emergency Echocardiography services in a middle east tertiary hospital, review of an audit.
Evaluation of the emergency Echocardiography services in a middle east tertiary hospital, review of an audit.

Background:

In HGH, the non-invasive cardiology department present an emergency echocardiography service which is available 24 hours a day. The aim of this service is to early diagnose and manage any cardiac emergency within the trauma, emergency, ICUs and inpatient departments. Our study aims were to evaluate demand for the service, participation, indications, echocardiography outcomes, and its effect on patient management. (1)

Aim of the study

Evaluate number of echocardiography studies requested by each department and their indication.

Assess the findings and impact of the Echocardiography study done on patient management.

Adherence to American society of echocardiography protocol. (2)

Methods:

Data from request forms, echocardiography reports and patient’s files were retrospectively analyzed on management of 262 consecutive patients (1-26 October 2015) for indication, findings, final diagnosis and ejection fraction in addition to impact on management. (3)

Results

Two hundred and sexty two files have been reviewed with 190 males (73%) compared to 72 females (27%).age group between 45 and 75 represented more than 50% of the cases. Of the 36 nationalities included in the study ,25% of cases were Qatari followed by 16% Indians.47% were inpatient where 36% of patients were Critical care and ICU cases while the rest are ED cases.

The indication in 71% of the cases was Left Ventricular assessment, where 59% of the scanning studies were normal and the ejection fraction of 199 patients (75%) was between 50-55% i.e. Normal ejection fraction. The echocardiography scanning done affected the management in 56% of patients.

Conclusion:

More than 50% of the echocardiography study done were normal and affected the management of 56% of patients only, so decreasing unnecessary requests will decrease time of request and burn out of echocardiographers.

This can be done through training of ED and ICU doctors on the bed side echo machines I addition to having guidelines on indications of echocardiography which is the second part of our project.

Refrences:

1- van Heur et al. Evaluation of an open access echocardiography service in the Netherlands: a mixed methods study of indications, outcomes, patient management and trends BMC Health Services Research 2010, 10:37

2-Pamela S. Douglas et al., Appropriateness Criteria for Transthoracic and Transesophageal Echocardiography, J Am Coll Cardiol. 2007;50(2):187-204

3-Jeyaseelan S, Goudie B, Pringle S, Donnan T, Sullivan F, Struthers A: A critical re-appraisal of different ways of selecting ambulatory patients with suspected heart failure for echocardiography. Eur J Heart Fail 2007, 9:55-61


Ramy ABDELKADER (Cairo, Egypt), Sherif HELMY
11:00 - 18:00 #8147 - Evaluation of the learning process among emergency nurses for the placement of peripheral intravenous catheter using simulated ultrasound guidance with an ultra-portable device.
Evaluation of the learning process among emergency nurses for the placement of peripheral intravenous catheter using simulated ultrasound guidance with an ultra-portable device.

Introduction:  patients with difficult venous access are frequent and can be a real emergency department (ED) problematic. The use of an ultrasound guidance puncture instrument for the peripheral veins can be an alternative to the placement of central veins catheter (VVC) or intraosseous catheter and can reduce the number of medical interventions. The objective of this study was to analyze the learning curve for the Emergency state-graduated nurses following a standard learning program. This analysis was conducted on simulation equipment

Equipment and Methodology: this study is descriptive, experimental and longitudinal and was conducted in 2015 among Emergency state-graduated nurses. After a first 1.30-hour theoretical and practical training session, nurses’ skills were assessed according to 5 criteria on 2 vessels of different size (V1 and V2) with the use of a phantom-type simulation equipment. Sterile protection probe kits were available for the ultra-portable ultrasound instruments. The state-graduated nurses answered a satisfaction survey about the training session. The studied parameters were the success rate and the time needed for the placement of the catheter.

Results: Among the 26 state-graduated nurses trained, 14 (54%) followed the entire training session. The assessment analysis showed success saturation between attempt 8 and 9 for V1 and after attempt 14 for V2, with a success rate of 92.9%. We observed a significant success rate difference between V1 (p=0.04) and V2 (p=0.001). The difference in the correct placement of catheter time was significant for V1 (p=0.03) but not for V2 (p=0.99). The participants appreciated the 1.30-hour theory/practice combination teaching method (satisfaction rate: 73% (55; 90)).

Discussion:  The assimilation of the ultra-portable ultrasound instrument among nurses was quick  (4th training) and its use remained stable in time, suggesting that the use of this new instrument will have an impact on  future research in our ED. It is probable that a more adapted and manageable sterile protection probe could help to improve this technique. The fact that vessel V2 was smaller and deeper explain why the diminution of the catheter placement time was not significant. The 41.7% success rate for V1 at the 1st attempt shows that the teaching method is effective

Conclusion: A 1.30-hour theoretical and practical training session followed by 9-to-15 attempts session on simulation equipment, with different level of difficulties in the vessels access, allows obtaining persistant technical skills. The assessment of the same state-graduated nurses on patients will allow the demonstration of  a more pertinent analysis of the training-session’s quality. This was the first step of a larger study protocol, which aims at generalizing the use of ultrasound guidance for difficult catheter placement


Benjamin OHANA (PARIS), Anthony CHAUVIN, Maxime GAUTIER, Jennifer TRUCHOT
11:00 - 18:00 #7311 - Evaluation of the management of elderly by the mobile emergency care unit.
Evaluation of the management of elderly by the mobile emergency care unit.

Introduction: Taking care of the elderly is a problem that is growing due to the aging population and advances in treatment. 

The purpose of this study was to evaluate the management of elderly by the mobile emergency care unit (MECU) 

Methods: This was a prospective, observatioenal study over 2 months (July and August 2015), using the MECU-database for all out of hospital elderly patients care, included patients age greater than or equal to 65 years. We studied the demographic characteristics of patients, their care and their outcome. The results were expressed as mean +ou - SD and pourcentage

Results: During the period of study, 100 elderly patients were management by the MECU teams. There were 52 males and 48 females. The median age was 86+ou- 5 years. The calls were received in the morning in 44% of cases; they coming in 89% of cases from the patients home. They were dominated by neurological disorders in 37.5% of cases. The MECU was mobilized in 80% of cases. The most frequent pathologies were dominated by stroke (33%) and respiratory diseases (25%). Ninety percent of patients were admitted to the emergency services and 5% were admitted directly into a cardiac intensive care unit. Overall mortality at 3 months was 31.4%

Conclusion: The survival rate of the elderly managed by the MECU teams was encouraging. This suggests a successful integration into the emergency system.


Rafika BEN CHIHAOUI (TUNIS), Saida ZELFANI, Afef CHAKROUN, Slim BEN DLALA, Chedly GHANEM, Samir ABDELMOUMEN, Mounir DAGHFOUS
11:00 - 18:00 #7665 - Evaluation of the management of severe sepsis in the emergency : insights from ReSSUS Registry.
Evaluation of the management of severe sepsis in the emergency : insights from ReSSUS Registry.

Introduction: sepsis are associated with high mortality worldwide. It is now accepted that support the precocity is a prognostic factor. The role of the emergency physician is essential in the recognition of severe sepsis and treatment initiation. Few data exist regarding the evaluation of our daily practice in the emergencies.

Methods: This is a prospective study of 77 cases of severe sepsis and septic shock among 153 cases recorded in a register of sepsis: ReSSUS. It database observational on the management of all sepsis in our service began on 03/01/14. The general data, clinical, biological, microbiological, and the final diagnosis and characteristics of support were collected. management of deadlines were particularly mentioned. The definition used in the severe sepsis is like that adopted by surviving sepsis compaign 2013.

Results: The percentage of severe sepsis is 50.32%. The mean age = 64 ±7 years. 50.6% are women and third have diabetes. Hemodynamic failure was marked in 22.07% of cases. An altered state of consciousness is found in 16.8% of cases. The hemostase disorder noted in 28.57% of cases. Renal failure in 85.71% of cases. The origin of infection is in 36,40% of pulmonary origin, in 23.40% of urinary origin. The average time of administration of antibiotics is 3h 40 mn (0 mn - 18h). Fluid replacement is immediately administered in most cases 70.10%. The catecholamines (norepinephrine) is used in 12.98% of cases. The evolution was marked by clinical improvement in 42.90% of cases, death in 14.30% of cases. The state of septic shock is the most frequented complication in 9.1% of cases.

Conclusion: The management of severe sepsis remains insufficient. Including the period recommended antibiotic treatment delivery are not respected in the majority of cases. Recognition of risk factors for severe sepsis from the sorting is essential.


Cherifa BECHIKH, Chawki JEBALI (Kairouan, Tunisia), Hajer YACOUBI, Asma ZORGATI, Lotfi BOUKADIDA, Riadh BOUKEF
11:00 - 18:00 #7982 - Evaluation of the patients who admitted to the trakya university health research center emergency service with syncope.
Evaluation of the patients who admitted to the trakya university health research center emergency service with syncope.

Syncope is accounting for 1%–3% of emergency department (ED) visits in a year. The rate of hospitilization of patients with syncope is % l-6. Syncope may indicate a serious disease, especially in the elderly population. 12-48% of healthy young adults lives once syncope atack among their lives. The annual incidence of syncope is 6% in people over 75 years  Sudden death is around 25% with underlying heart disease.

In our study, it is aimed to evaluate the clinical symptoms; laboratory and imaging findings, the diagnosis they receive in the emergency room and duration of stay, improving mortality status of within 3 months, the international scoring system (Short-Term Prognosis of Syncope Study, San Francisco Syncope Rule, Evaluation of Guidelines in Syncope Study, Observatorio Epidemiologico sulla Sincope nel Lazio , Martin et all., Boston Syncope Score) of patients with syncope who have admitted to our emergency department for two years.

When we compact to syncope score in terms of survival; San Francisco Syncope Rule, Martin et al. , Observatorio Epidemiologico sulla Sincope nel Lazio score, Evaluation of Guidelines in Syncope Study and Short-Term Prognosis of Syncope Study values were found to be higher in patients who died, Boston is no difference

p<0,05 was accepted statistically significant. Variables are evaluated with logistic regreccion and the results were evaluated in terms of mortality factors. As a result it has been seen that age, supin position and precence of cancer increase the mortality rates 1,3, 8,014, 7,336 times respectively

In patients with syncope, especially for high-risk patients the right to determine and early mortality and more comprehensive in terms of taking measures that could reduce morbidity, multicenter, prospective studies can be done.

In concluccion; it is needed to perform multicenter prospective and more comprehensive studys to determent the patients with high risk factor and to prevent morbidity and mortality.


Volkan MUMCU, Omer SALT (EDIRNE, Turkey), Mustafa Burak SAYHAN
11:00 - 18:00 #7825 - Evaluation of the rate of acute coronary syndromes with ST segment (STEMI) patients initial handling by a prehospital medical team.
Evaluation of the rate of acute coronary syndromes with ST segment (STEMI) patients initial handling by a prehospital medical team.

Introduction. Upon receiving a 112 call for chest pain, the assumption is that it is an acute coronary syndrome (ACS) and the immediate dispatch of an MICU constitutes the 1st phase of optimal STEMI handling.

Objective: To evaluate sending an medical intensive care units (MICU) as first intervention in the handling of ACS.

Method: Prospective data from a regional pre-hospital STEMI register involving 39 MICU and 8 departmental prehospital Emergency Medical Services. Included: patients with STEMI from 2008 to 2014 treated with primary intervention patient handling. Factors studied: age, gender, cardiovascular risk factors, pain characteristics, type of caller. Evaluation criteria: response rate of the MICU from the time of the initial call and factors associated with this early response.

Results. Out of 11 295 STEMI, the MICU response rate from the time of the initial call was 83%. In univariate analysis, heredity, smoking, diabetes and obesity were not significantly linked to MICU response. In multivariate analysis, a doctor's 112 call and a history of coronary heart disease were factors independent of instant MICU response, unlike an age over 75, female gender, a paramedic's 112 call and unusual pain.

Conclusion. Primary response by the MICU on an assumed ASC was found in 83% of cases. Among these cases, women, people aged over 75 and cases with unusual pain seemed insufficiently taken into account, and were associated with a delayed MICU response.


François-Xavier LABORNE, Amandine ABRIAT, Alexandre ALLONNEAU (Paris), Sophie BATAILLE, Aurélie LOYEAU, Gaelle LE BAIL, Lionel LAMHAUT, Virginie PIRÈS, Jean-Michel JULIARD, Yves LAMBERT, Hugues LEFORT, Frédéric LAPOSTOLLE
11:00 - 18:00 #7137 - Evaluation of the safety of an accelerated discharge protocol for low risk chest pain in the Emergency Department.
Evaluation of the safety of an accelerated discharge protocol for low risk chest pain in the Emergency Department.

Chest pain is one of the commonest reasons for presentation to Emergency Departments (EDs).Current estimates suggest that up to 6% of all attendances to UK EDs are due to a primary complaint of chest pain. In our ED this equates to approximately 6000 patients a year.

Whilst the vast majority of these patients do not have a myocardial infarction, there is good evidence to show that relying on the history and ECG of patients in isolation will lead to clinicians missing these conditions. Myocardial infarction (MI) is a potentially fatal condition, and the mortality for patients with MI who are wrongly discharged is much higher than those who are admitted to hospital.

In order to improve our diagnostic accuracy, in accordance with national guidelines from the National Institute of Clinical Excellence (NICE), our previous practice was to risk stratify patients with potential MI into low, moderate or high risk of having an MI.This was done using an evidence based clinical risk stratification tool (TIMI score), and the ECG. Intermediate and high risk patients were admitted  for further assessment, and low risk patients were managed in the ED through our short stay ward. 

The previous pathway for low risk patients involved performing a serum troponin at 10 hours after the patient’s worst symptoms. 

There has been an increasing evidence base around the usage of high sensitivity troponin tests in the last few years. These differ from the troponin assays that we were previously using as they can detect much smaller levels of troponin in a patients blood than previously.

There has been research conducted into whether the time interval for testing in low risk patients using the high sensitivity assays can be shortened. The conclusion from several well-conducted studies is that in low risk patients, high sensitivity assays can be used to safely discharge patients at 3 hours after their arrival in the ED.

We introduced an accelerated discharge pathway using a high sensitivity troponin assay in June 2014.

Results

From the 18/6/14 to 29/6/15, a total of 1327 patients went through the low risk chest pain pathway, with a median of 25 a week.

What was the rate of major adverse cardiac events at 30 days after discharge?

New pathway= 0 patients (0%)

Old pathway based on 10 months data= 0.16%

What was the total length of stay for low risk patients in the ED?

New pathway=6 hours 46 minutes (median LoS from arrival to discharge)

Old pathway=8 hours 24 minutes (median Los from arrival to discharge)

Reduction in median length of stay by 1 hour 38 minutes.

Conclusions

On the basis of over a years’  data for 1327 patients, the new pathway has resulted in a reduction in length of stay by  approximately 100 minutes per patient, with no significant compromise in patient safety. There have so far been no adverse cardiac events at 30 days pre-discharge.

This represents a total reduction in length of stay over the year of approximately 92 bed days, or 2212 hours.

 


Cheryl DAVIES, Sanjay RAMAMOORTHY (Southampton, )
11:00 - 18:00 #7560 - Evaluations of Occupational Injuries Presented to the Emergency Department. Mechanisms, Causes, Features of Accidents and Solutions Suggestions of Injured Employees.
Evaluations of Occupational Injuries Presented to the Emergency Department. Mechanisms, Causes, Features of Accidents and Solutions Suggestions of Injured Employees.

Objectives: The aim of this study was to evaluate the sociodemographic features, safety of the work environment and characteristics of work-related accidents and solution offers of injured patients who presented to the emergency department after occupational accident.

Material and Method: A cross-sectional study was conducted from 26 September 2014 to 26 December 2014 in Dokuz Eylul Univesity Hospital, Department of Emergency Medicine. The study was carried out with sequential patients presented to the emergency department results from occupational injuries whose age is 18 and above. Face-to-face interviews with survey were conducted. The survey has 4 main sections. The first section is about patients’ demographics, the second section is about occupational safety of the work environment, the third section includes the features of occupational injury and the fourth section includes the questions about occupational injury solution offers of workers.

Results: 40,185 patients presented to department of emergency medicine in the study period. There were 287 occupational injuries of them (0,71 % of all presentation). 170 (%59,2) of 287 were included to the study. The average age of the patients is 31, 1. The youngest patient was 18 and the oldest patient was 64.

Injured patients who presented to the emergency department after occupational accident (n=156, % 91, 8) were low-medium educated workers. The %90 of injured patients had SSK as a social insurance. 34 % of the patients (n=57) are presented within the first three hours after the accident. Most of their presentation (n= 95, % 55, 8) to the emergency department were in afternoon (between 13.00 am to 15:00 am). Only half (n=85, % 50) of the injured workers had occupational safety training. The %68,4 of the study group (n=118) had an opinion  that physical environment of the working places were suitable in terms of occupational safety. The most common cause of injuries were sharp and penetrating tools (%29,4 , n=50). Eleven patients (%6, 4) admitted to the hospital, and the majority of the patients (%92,9, n=158) were treated ambulatory and discharged from the emergency department. Three patients (1,7 %) had severe injury and one patient was dead (%0,58). Most of the workers (n = 113, 66.5%) were in favor regulation of the lack of protective equipment can not be corrected prevent the accident. The injured workers (n= 111 % 65.2) stated that if the necessary precoutions had taken the injury would not had happened.

Conclusions: Frequency of occupational injuries to the Dokuz Eylul University, department of Emergency medicine is low. Patients who presented to the emergency department after occupational accident were low-medium educated young workers. Although they stated that they did not receive adequate occupational safety training and they work in inadequate workplace safety environment that if the necessary precautions had taken the injury would not have happened.


Ahmet Çagdaş ACARA, Sedat YANTURALI (Izmir, Turkey), Omer CANACIK, Ramazan SABIRLI
11:00 - 18:00 #4511 - EVIDENCE OF MEDICAL STAFF EXPOSURE TO PROFESSIONAL RISKS AT THE AMBULANT CENTRE OF VLORE DURING THE PERIOD 2014 - 2015.
EVIDENCE OF MEDICAL STAFF EXPOSURE TO PROFESSIONAL RISKS AT THE AMBULANT CENTRE OF VLORE DURING THE PERIOD 2014 - 2015.

EVIDENCE OF MEDICAL STAFF EXPOSURE TO PROFESSIONAL RISKS AT THE AMBULANT CENTRE OF VLORE DURING THE PERIOD 2014 - 2015.

                     Denada Selfo1, Skender Skenderi2,Christos Chatzis3, Majlinda Zahaj4
                          University of Vlora1,University of Tirana2,University of Crecce3, University of Vlora4

                                                        Abstract

 Aim:A study for extending the knowledge and information about evidencing of professional risks, use of  biosecurity measures, hospital (or ambulant) waste management and the professional treatments from the medical staff in a country of Vlora. Material and Methods:There was a questionnaire used for information gathering at this study. The questionnaire was self-administrated for the medical staff, Medical Centre “Shushice” of  Vlora.The data was evaluated,structured and tabled with the SPSS method version 17.00 Results:About 43% belonged to the age of 20-30 years,79% were females. About73% were with high education.54% of them share the ambulant wastes, 67% of the nurses are not happy with the hygienic and sanity conditions and 86% of them think that their centre needs reconstruction. About 92% of the nurses were vaccinated for prophylaxis before job acceptance. About 80% of the nurses admitted the absence of the needed materials for the safety preservation at work and for job performance. About 52% of the nurses applied the safety measures in the working environment. Most of them about 96% were informed about the professional risks.There was 61% of nurses who were drilled with needles during the injections.  Conclusion:The use of protective elements especially the handles was applied by more than half of the nurses. This ascertains an increase of their use comparing to another study in 2013-2014 where only 40.5% of nurses had declared that they always use the personal protection elements.Shows an increase in the informing level comparing to year 2013-2014.

Key words: biosecurity measures,hospital waste management, professional risks 


Denada SELFO (Vlore, Albania), Skender SKENDERI, Christos CHATZIS, Majlinda ZAHAJ
11:00 - 18:00 #4512 - EVIDENCE OF MEDICAL STAFF EXPOSURE TO PROFESSIONAL RISKS AT THE AMBULANT CENTRE OF VLORE DURING THE PERIOD 2014 - 2015.
EVIDENCE OF MEDICAL STAFF EXPOSURE TO PROFESSIONAL RISKS AT THE AMBULANT CENTRE OF VLORE DURING THE PERIOD 2014 - 2015.

EVIDENCE OF MEDICAL STAFF EXPOSURE TO PROFESSIONAL RISKS AT THE AMBULANT CENTRE OF VLORE DURING THE PERIOD 2014 - 2015.

                     Denada Selfo1, Skender Skenderi2,Christos Chatzis3, Majlinda Zahaj4
                          University of Vlora1,University of Tirana2,University of Crecce3, University of Vlora4

                                                        Abstract

 Aim:A study for extending the knowledge and information about evidencing of professional risks, use of  biosecurity measures, hospital (or ambulant) waste management and the professional treatments from the medical staff in a country of Vlora. Material and Methods:There was a questionnaire used for information gathering at this study. The questionnaire was self-administrated for the medical staff, Medical Centre “Shushice” of  Vlora.The data was evaluated,structured and tabled with the SPSS method version 17.00 Results:About 43% belonged to the age of 20-30 years,79% were females. About73% were with high education.54% of them share the ambulant wastes, 67% of the nurses are not happy with the hygienic and sanity conditions and 86% of them think that their centre needs reconstruction. About 92% of the nurses were vaccinated for prophylaxis before job acceptance. About 80% of the nurses admitted the absence of the needed materials for the safety preservation at work and for job performance. About 52% of the nurses applied the safety measures in the working environment. Most of them about 96% were informed about the professional risks.There was 61% of nurses who were drilled with needles during the injections.  Conclusion:The use of protective elements especially the handles was applied by more than half of the nurses. This ascertains an increase of their use comparing to another study in 2013-2014 where only 40.5% of nurses had declared that they always use the personal protection elements.Shows an increase in the informing level comparing to year 2013-2014.

Key words: biosecurity measures,hospital waste management, professional risks 


Denada SELFO (Vlore, Albania), Skender SKENDERI, Christos CHATZIS, Majlinda ZAHAJ
11:00 - 18:00 #8081 - Evolution of claims in a Hospital Emergency Unit.
Evolution of claims in a Hospital Emergency Unit.

OBJECTIVES:

In order to improve the quality of care we performed the analysis of users' claims. In this analysis we have explored possible changes in its characteristics and assess improvements made during a time period of two years.

METHODOLOGY:

It was made a descriptive retrospective study of the claims made in observation emergency department, excluding claims directed to other units. Years of study: 2000 and 2015. Variables analyzed: reason, characteristics, justification or cause of the claim. The statistical program SPSS was applied to analyse the results and make inferences through the chi-square technique.

RESULTS:

Total number of emergencies: 79,200 (year 2000) 77,816 (year 2015) Total Claims: 39 (0.05%) (year 2000) 64 (0.08%) (year 2015). Cause of the claim: delay of care: 15 (38%) (year 2000) and 20 (31% ) (year 2015); inappropriate manner: 4 (10%) (year 2000) and 19 (30%) (year 2015); lack of information 1 (3%) and 2 (3%) (year 2015), technical or architectural problems and lack of privacy: 2 (5%) (year 2000) and 1 (2%) (year 2015) Restrict the access of more than one companion: 11 (28%) (year 2000) 0 (year 2015); Disagreement in care 7 (18%) (year 2000) and 16 (25%) (year 2015): lack of health personnel 0 (year 2000) and 1 (2%) (year 2015); Computer errors: 0 (year 2000) and 2 (3%) (year 2015); Administrative process 0 (year 2000) and 1 (2%) (year 2015) Diagnostic errors 1 (3%) (year 2000) and 1 (2%) (year 2015) Other 1 (3%) (year 2000) and 3 (5%) (year 2015). Unjustified claims. 88% (year 2000) and 91% (year 2015), Proper claims 12 % (year 2000) and 9% (year 2015). Avoidable claims: correcting architectural defects 30% (year 2000) (it includes not allowing companions and inadequate facilities) and 0% (currently solved). Increased health personnel (currently increasing): 32% and 15 % (it includes delay of care, lack of information and inadequate treatment)

CONCLUSIONS:

1.The most common cause for claim is the delay of care. This comparison shows that this indicator decreased over time (38% and 31%)

2. Patients reported and increased of the lack of information, inadequate manner and disagreement in care. probably for persisting the lack of personnel, as well as avoidable claims

3. There were not reported justified claims caused by medical errors.

4. The number of claims increased by 64% in the years compared.

5. Only 12% and 9% of claims were appropriate.


Pilar CONDE (SEVILLA, Spain), Jesus MORENO, Alberto MORENO, Vanesa GIL, Eduardo CHICHILLA, Jose Maria ROJAS-MARCOS
11:00 - 18:00 #7780 - Experience and representation of interactions with Emergency Medical Service: A qualitative study among general practitioners.
Experience and representation of interactions with Emergency Medical Service: A qualitative study among general practitioners.

 

Introduction:General practitioners (GP) are sometimes confronted to medical emergencies in their office. There have been few evaluations of the interactions between GPs and Emergency Medical Dispatcher when a call is made from the office. Our aim was to investigate GPs representations of Emergency Medical Dispatcher (EMD) and Emergency Medical Service (EMS) through their experience of joined management of emergencies.  

 

Method:We conducted a qualitative study through semi-structured interviews by maximum variation sampling from july 2015 to april 2016 in our region. We developed themes concerning GPs medical experience and training, personal histories of patients needing emergency care, experience of calls with EMD and interactions with EMS.

 

Results:We conducted 13 interviews with GPs. Analysis showed different GPs reactions and experiences while calling EMD and in front of EMS while in the office:

-       Collaboration: based on trust, confidence and acknowledgement of each other skills

-       Cooperation: based on the acceptance of GPs own needs of specialized help and skills and respect of practical standards.

-       Negation: based on the lack of relationship and interactions and sometimes competitive feelings.

-       Distrust: based on avoidance strategies

Cooperation is the model mainly developed. GPs are keen to apprehend and better understand EMS and EMD specialty and would like to see deeper links and interactions between general practice and hospital.

 Conclusion:This qualitative study shows the heterogeneity of GPs experiences while taking care in their office of urgent patients. Inter-professional interactions between GPs and EMD/EMS should be emphasized in order to increase the quality and efficiency of emergency care in general practice.   


Julie MAYER (CRETEIL), Anne-Laure FERAL-PIERSSENS, Philippe JUVIN
11:00 - 18:00 #8017 - Exploring the antibacterial effect of “chitosan lineer polymer” (celox™) in a experimental infected rat model.
Exploring the antibacterial effect of “chitosan lineer polymer” (celox™) in a experimental infected rat model.

Background and Purpose:

Wound infections are stil a serioous problems of emergency departments since its rate is around 8-10%. We aimed to discuss if “Chitosan Lineer Polymer” (CLP) (a local hemostatic agent) has antibacterial effect of in a experimental infected rat model.

Methods:

Following ether anesthesia, dorsal site of 11 rat was shaved and a 2 cm long paravertbral incision was done. Later, the wound edges were clamped for 2 minutes to increase occurance rate of wound infection. In order to contaminate the cut area a suspension of Staphylococcus Aureus (108 CFU/ml) is poured onto it. Later, the rats are randomly divided into: CLP (n=6) (2 gr CLP poured into the cut area) and control, (n=5) groups (no treatment). The rats were observed for 6 days. Everyday, the cut areas, were observed by “wound evaluation scale” (WES) for: redness, odema, discaharge. Following sacrification tissue samples were taken and investigated for bacteriological analysis.

Results:

In CLP group 1 rat died. There was no significant difference for WES value of control group, however there was significant difference for the 1. and 5. days WES of CLP group (p=0.032) was (CLP group: 3+0.83 (3,0-5,0), Control Group: 6+1.73 (2,0-6,0)). On behalf of mean bacterial count of groups, there was no significant difference between groups (CLP group: 1x105+354881, Control Group: 1x105 +472154) (p<0.05). When WES is compared between groups on 1. and 5 days, we percieved that wound infection was more evident in CLP group since p=0.034.

Conclusions:

Here in this experimental infected rat model study, application of CLP into the wound area didn’t decrease the occurance rate of infection.


Ebru TONAY, Gurkan ERSOY (Izmir, Turkey), Basak BAYRAM, Osman YILMAZ, Aydan OZKUTUK, Ipek DUYGU, Selcuk TURKEL
11:00 - 18:00 #8003 - Extradural haematoma in children still represents a big challenge for diagnosis and treatment in emergency department.
Extradural haematoma in children still represents a big challenge for diagnosis and treatment in emergency department.

Introduction

Extradural haematoma in children as in adults, represents a big challenge for diagnosis and treatment in emergency department(ED), being still a cause for high mortality.

Emergency Department presentation

A male child of 6 years old presented to Children ED at 7:30 pm on Saturday with Head injury after he fell from a bicycle and hit the forehead from concrete.

Patient-fit and healthy.

Initial assessment in triage room: History- fell from the bicycle, hit the concrete with the forehead with secondary haematoma on the left side of the forehead and loss of consciousness for a few seconds.

Vital signs in triage: AVPU-A(GCS=E4V5M6=15/15), no focal neurology, pupils equal and reactive sizes 2 bilateral, BM-normal,HR= 90bpm sinus rhythm , BP=90/55mmHg, CRT<2 sec, T=36.8 degrees, pain score=0.

Initial management in Children ED- the patient is to be waiting in the waiting room(WR) with his father.

After 2 hours the patient is reviewed by a doctor in children’s Majors ( at apx 9:30 pm), when it was noticed that the GCS of the patient dropped.

On  examination: the patient was confused, with GCS=E3V2M4=9/15, anizocoria  with left pupil (5mm)>right pupil(3mm), BM-normal, haematoma left side forehead,2  episodes of vomiting in the WR, but able to protect his airway, HR- 90bpm, BP=90/55mmHg, CRT <2 sec, T=36.8degrees.

ED management: urgent CT brain , neurology  monitoring every 15 minutes, continuous vital signs monitoring, afterwards the patient being transferred to Resuscitation Room, ED Consultant being informed also.

CT brain was reported after 30 minutes after the patient was examined as Large Left Extradural Haematoma with midline shift.

The Anaesthetics, Children ITU and  Neurosurgical  team was contacted urgently. The patient was immediately accepted in Neurosurgical Hospital in QMC Hospital Nottingham , UK.

Further resuscitation Room management: the patient received Rapid sequence Intubation, sedation and ventilation for airway protection, with continuous Propofol infusion, CXR, Arterial line, peripheral line , urinary catheter . He was transferred by ambulance with Paediatrics ITU Consultant to Neurosurgey QMC Hospital.

Evolution- the second morning after the above event, the doctor on duty at that night called the Neurosurgery team from the other hospital to ask about this patient- the patient had a successful surgical intervention with drainage of the haematoma- he was eating breakfast at the moment of the call.

Discussion

Despite the fact that it is followed the head Injury protocol in Children ED very thoroughly, it is always a possibility to miss a very difficult case as an extradural haematoma in children, when the patient is talking and die.

Conclusion

The management of this patient lasted apx 3 hours, with 45 minutes –examination, CT , Resuscitation room transfer and airway management , less than 1 hour as per our Transfer protocol, taking longer to  transfer  him to the other hospital. This problem was addressed with a conjunction meeting between Anaesthetics, ITU and ED Consultants.

Dr Nicoleta Cretu, ACCS ST1 Emergency  Medicine trainee

Dr Ben Teasdale, Emergency Department  Consultant.

Leicester Royal Infirmary Hospital, UK.

 

 

 


Dr Nicoleta CRETU (Leicester, United Kingdom), Ben TEASDALE
11:00 - 18:00 #7348 - Extrapyrimidal Symptoms (EPS); A rare side effect of Lignocaine!
Extrapyrimidal Symptoms (EPS); A rare side effect of Lignocaine!

Introduction:

Extrapyramidal symptoms (EPS) area well recognized group of side effects of antipsychotic medications, most commonly seen with drugs such as chlorpromazine, haloperidol etc. Side effects include Dystonia, Akesthesia, Tradive Dyskinesia and Parkinsonism (1). Other drugs such as Metoclopramide (2) has been also reported to cause EPS. EPS after the use of Lidocaine has seldom been reported (3). Here we present a case with EPS after the use of small dose of 1% Lidocaine.

Case Report:

18 years old male came in to Emergency Department with a wound on the left hand. He was given 3 mls of Lidocaine as local anesthetic around the wound, subcutaneously, for exploration and repair. Soon after the Lidocaine patient started rocking movements to and fro in the trolley. There were no signs to suggest an allergic reaction. Also patient was vitally stable, fully conscious with GCS 15/15. The movement subsided after 10 mg of Procycldine. Laboratory investigations showed a CK of 704, confirming EPS.

Discussion:

Mechanism by which Lidocaine can cause an EPS cannot be explained but the rocking movement after subcutaneous administration of lidocaine, improvement after Procyclidine and increased CK of 704 suggest EPS.

Conclusion:

Although the benefits of Lidocaine clearly outweigh the rare side of Lidocaine but all Emergency Physicians should keep in mind the rare side effect of Lidocaine

References

Divac N, Prostran M, Jakovcevsk I, Cerovac N. Second-generationantipsychotic and extrapyramidal advere effects. BioMed Research International.  2014;2014:656370.doi: 10.1155/2014/656370.

Moos DD, Hansen DJ, Metoclopramide and extrapyramidal symptoms: a case repot. Journal of Perianesthesia Nursing. 2008 23(5):292-9. doi: 10.1016/j.jopan.2008.07

Lesser D, McGough E, Case Report: Extrapyramidal CNS Toxicity from a Lidocaine

 

Epidural. American Family Physician. Retrieved from

 

http://aafp.org/afp/2005/1215/ol1.html


Mustafa MEHMOOD (Dublin, Ireland), Orla SMITHWICK, Zahid KHAN
11:00 - 18:00 #7563 - Eye complications of patients with head injuries. Cranio-facial trauma emergencies.
Eye complications of patients with head injuries. Cranio-facial trauma emergencies.

BACKGROUND

Eye trauma is recorded to be a main cause of blindness or partial loss of vision worldwide. The figures are even more dramatic in the countries that lack head trauma injury protocols that prioritize the first medical measures taken in the first stages to avoid losing the therapeutic time frame required in such cases so the eye surgery measures are not to be delayed.

About 25% of head injuries are associated with ocular and visual defects. The role of ocular injuries secondary to head trauma in the causation of blindness has become a subject of importance.

As a result of head trauma multiple systemic complications the damage to the visual system is most likely to be ignored in many cases and late assessment is futile.

As there are a series of possible mechanisms underlining ocular manifestations of head trauma that are not fully understood, many untested hypotheses have been advanced to explain these defects. As an example eye movement disorders are thought to be due from direct trauma to orbital contents, cranial nerves, and other brain areas.

The aim of this study is to evaluate the clinical profile of visual complications in patients hospitalized and managed for head injury in Sibiu.

METHODS

Source data for this retrospective study is Sibiu Emergency Hospital database, for a period of 2 years.  A selection of all head injuries cases is done to analyze the impact on visual system.

RESULTS

Ocular and visual complications occurred in many cases (almost 20%) with a number close to double  in favor of males against females. Main causes of visual  complications are road accidents, fights and other types of trauma. In road accidents pedestrians are more affected than drivers with more complications.

CONCLUSIONS:

Eye injuries remain one of the most common cause of different types of vision reduction, a life-long disability. An important number of them can be prevented or reduced implementing a prioritized trauma guide for all head injury patients addressing ocular and vision injures in the first stages of advanced medical care. Our study highlights the need of such a protocol to be designed and implemented in Sibiu to reduce these unfortunate situations.


Marius SMARANDOIU (Sibiu, Romania), Adriana STANILA, Alin CANCIU, Dan Mircea STANILA, Alina Adriana PANGA
11:00 - 18:00 #7803 - Facial cellulitis and diabetic ketoacidosis.
Facial cellulitis and diabetic ketoacidosis.

History:

34years old male who came to present box nausea and uncontrollable vomiting evolution of 48hours, accompanied by general malaise. 10days ago had acccidente traffic with nasal hematoma, treatment with analgesia and amoxicillin.

AP: DM-1 treated with Humalog.

Physical exploration:

TA 90 / 50mmHg, Fc 110lpm. Tachypneic. Regular state general. Dry skin and mucous membranes. ACP: taquirrítmicos and audible tones. No murmurs. MVC. Neurologic without source. Inability to eye opening nasal and periocular edema.

Investigations:

Blood tests: blood count: Leukocyte 26700, neutrophilia 92%. Hb 14.2, platelets 293000. Coagulation: PT activity 78.6%. venous blood gases: pH 7.11. Biochemistry: 379 glucose, urea 52, creatinine 1.74, normal ion 360 PCR.

TAC skull and sinuses: mucosal thickening of the left maxillary sinus, sphenoid sinus, ethmoid cells and some of the right frontal sinus. Increased extracranial soft tissue to frontal, periorbital and perinasal level. Diastasis left esfenocigomática joint with slight angulation of fragments.

Final diagnosis:

Facial cellulitis (periorbital and nasal) Staphylococcus Aureus by posttraumatic bacteremic.

Evolution:

Admission is decided in observation area for management of diabetic ketoacidosis box of infectious origin with facial door entrance.

Blood cultures are extracted and empirical antibiotic therapy with ceftazidime, cloxacillin, ampicillin and amphotericin B and supportive treatment (fluid therapy, insulin and analgesia) starts.

Once stabilized and ketoacidosis and renal failure having been corrected, enters plant, where the same antibiotic therapy is maintained until the fourth day of treatment Staphylococcus Aureus is isolated Methicillin Resistant both blood and facial exudate.

After completing intravenous antiboterapia for 14days he was discharged from hospital.

Conclusions:

However minimal possible entry must take special caution in patients with Diabetes Mellitus being immunosuppressed patients and complications that might entail.


Enrique CARO (MALAGA, Spain), Marina BUFORN, Carmen Adela YAGO CALDERON, Juan Antonio RIVERO GUERRERO, Eduardo ROSELL VERGARA, Eva María FRAGERO BLESA
11:00 - 18:00 #7754 - Facial Eritema, a diagnosis of a systemic pathology from Primary Care to Emergency department.
Facial Eritema, a diagnosis of a systemic pathology from Primary Care to Emergency department.

Clinic History:

19 year old patient with a history of urinary infections in infancy cause of vesicoureteral reflux.

He came to the Emergency Primary Care department because of a facial rash. The diagnosis was an Urticarial Reaction, treated symptomatically with antihistamines.

 

He came a 3rd time, having such facial and abdominal rush but it was accompanied by abdominal pain.

We study the patient with a blood analyse, and it presented neutrophilic leukocytosis, normal renal function with proteinuria and hematuria in urine.

The patient was admitted in Nephrology Service for the study of nephrotic syndrome. Finally he was diagnosed in hospital with lupus glomerulonephritis.

 

CONCLUSION:

Although urticarial reactions are a common pathology in our emergency services (Primary Care or Hospital), we have to discuss differential diagnoses with more complex medical conditions, such is the case of our patient. The reason for consultation were the injuries that produce a systemic disease like lupus.


Veronica PARENT MATHIAS (MALAGA, Spain), Maria Del Mar BECERRA MAYOR, Lorea DE UNAMUNO LUMBRERAS, Maria Isabel CORREA ROSALES
11:00 - 18:00 #4514 - Factors affecting difficulty in extubation after initial successful resuscitation in cardiopulmonary arrest patients.
Factors affecting difficulty in extubation after initial successful resuscitation in cardiopulmonary arrest patients.

Purpose: We retrospectively investigated the factors affecting the difficulty of extubation after an initial successful resuscitation.

Methods: From October 2013 to July 2015, a medical chart review was retrospectively performed for all patients with cardiopulmonary arrest (CPA).  The exclusion criteria included patients who experienced CPA in the hospital, patients with traumatic CPA, and those who died within a week and who did not undergo tracheal intubation in the course of the resuscitation. The subjects were divided into two groups: the difficulty in extubation (DE) group, which included patients who remained tracheally intubated for two weeks after their collapse; and the Control group, which included patients who could undergo extubation and who were free of tracheal intubation within two weeks after their collapse. 

Results: There were 8 patients in the DE group and 12 patients in the control group.  The rates of female patients, underlying pulmonary disease, flail chest and the average age in the DE group were significantly higher in comparison to the Control group.  In contrast, the rate of patients who returned to consciousness and the survival rate were significantly lower in the DE group than in the Control group.

Conclusion: This study demonstrated that among the patients with OH-CPA who obtained spontaneous circulation and survived for more than one week, female, advanced age, underlying pulmonary disease, the complication of flail chest and persistent unconsciousness, were risk factors for difficult extubation.


Youichi YANAGAWA (Izunokuni, Japan)
11:00 - 18:00 #7156 - Factors associated with acute bacterial prostatitis reconsultation in the emergency department.
Factors associated with acute bacterial prostatitis reconsultation in the emergency department.

Aim of the study:

To analyze the factors associated with reconsultation in the Emergency Department (ED) of patients with acute bacterial prostatitis (ABP).

Methods:

Design: Descriptive and retrospective study. Setting and period: ED of a 650-bed tertiary-care teaching hospital in the metropolitan area of Barcelona, Catalonia, Spain, during 1 year. Patients: All patients with ABP. Data were collected for demographic variables, comorbidities, previous episodes of ABP, signs and symptoms, microbiological findings, antibiotic treatment, admission to the hospital, outcome and return to the ED in the 30 days following discharge.  Statistical analysis: a univariate analysis was undertaken to evaluate the factors associated with reconsultation in the ED. Chi square test was used for qualitative variables (or Fisher's exact test when the expected values were less than 5) and a t Student test for quantitative variables. Statistically significant differences were considered for p value < 0,05. The statistical program used was SPSS 19.0.

Results:

During the study period 241 episodes of ABP were included for analysis. Mean age was 62,9 ± 16 years, a history of prostate adenoma was reported in 54 cases (22,5%), prior manipulation of the lower urinary tract in 40 (17%) and diabetes mellitus in 47 patients (19,5%). Mean symptoms duration was 3.38 ± 4.04 days, voiding symptoms were present in 176 cases (73%) and fever in 154 (64%). From 216 urine cultures, 128 were positive (59%) and 24 (17,6%) out of 136 blood cultures. Escherichia coli was the main pathogen (58.6% of urine cultures and 64% of blood cultures) with resistant strains to fluorquinolones, cotrimoxazole and amoxicillin/clavulanic in 27.7%, 22.9% and 27.7% of cases respectively. Other pathogens isolated were Enterococcus faecalis (10 episodes), Klebsiella spp (8, 4 with bacteremia), Proteus spp (5, 1 with bacteremia) and Pseudomonas aeruginosa (4). Seventy patients (29%) were admitted to the hospital and 3 died. At 30-day follow-up, 29 patients (12%) returned to the ED. In the univariate analysis, reconsultation to the ED was significantly associated only to prostate palpation (p=0,045) and bacteremia (p=0.037). Revisits appeared to be more frequent in patients with diabetes mellitus (p=0,052) and prior immunosuppressive therapy (p=0,050) although not reaching statistical significance.

Conclusions:

  1. In our series, prostate palpation and bacteremia were the only variables found to be related to reconsultation in the ED among patients with ABP.
  2. Patients with ABP discharged from the ED need clinical follow-up and monitoring of microbiological findings in order to assure an adequate antibiotic treatment.

Ferran LLOPIS (Barcelona, Spain), Carles FERRE, Javier JACOB, Elena FUENTES, Concepcion MARTINEZ, Ignasi BARDES
11:00 - 18:00 #8070 - Falls prevention: starting at the beginning (QIP).
Falls prevention: starting at the beginning (QIP).

Falls prevention: starting at the beginning (QIP)

Dr T Pervez1, Dr R McNamara1

Department of Emergency Medicine, St Marys Hospital, Imperial College Healthcare NHS Trust, London, UK

INTRODUCTION:

In-hospital patient falls is a burning issue with, nearly 240,000 falls reported from acute and community hospitals in England and Wales every year. Of these, nearly 1400 result in hip and other fractures. The financial burden of this on the NHS is over £15 million per year, albeit precise figures of the overall costs are much likely to be higher due to associated invisible costs

RATIONALE:

The Emergency department (ED) patient cohort and ergonomics profoundly increases the risk of falls in patients in the department. Furthermore, a significant number of the inpatients begin their hospital journey at the ED.

AIM:

To reduce the number, and subsequent consequences, of in-hospital falls at the front door by increasing awareness and vigilance; carrying out early assessment and introducing early fruitful interventions.

METHOD:

A pragmatic quality improvement project (QIP) carried out by the introduction of simple and cost-effective measures in ED.  The initiative consisted of 2 phases: phase 1 – focused on increasing awareness and phase 2 - focused on falls prevention. PDSA approach was used for project development, progression and assessment. Careful processing mapping led to clear identification of primary and secondary drivers, which were then used to identify aims and objectives.   

RESULTS:

Delivered outcomes recorded in the form of stakeholder satisfaction, reduction in the number of falls and reduction in the severity of injuries sustained secondary to the number o falls. Prospective database, questionnaires and structured interviews were conducted to achieve this.

CONCLUSION: 

Increasing awareness and taking measures preventive measures helped to reduce the number, and impact, of falls in the ED. The QIP also formed an integral part of the current frailty-friendly ED project in the Trust. It encouraged awareness and vigilance across the wider multidisciplinary team, having a holistic impact on the hospitalised patients. The project also received a positive reaction on the social media and won second prize at the RSM meeting (presented in the early stages of the project).


Tamkeen PERVEZ (London, United Kingdom), Rosa MCNAMARA
11:00 - 18:00 #7347 - Fascia iliaca block: training and teaching emergency medicine residents in Lithuania.
Fascia iliaca block: training and teaching emergency medicine residents in Lithuania.

Background & Objectives

Hip fractures, commonly in older patients, follows moderate or high level of pain. Systemic analgesics, often prescribed to relieve pain after hip fractures, have huge side effects, can delay surgery and may worsen the outcomes of the surgery. We analyze the role and efficacy of alternative forms of analgesia like fascia iliaca blocks (FIB) and assess the feasibility of a service delivered by emergency medicine residents, after given a short course about this block.

 

Methods

All emergency medicine residents were trained on administering FIB through a teaching presentation from a senior emergency medicine resident, followed by supervised training in theatre by a senior anesthesiologist. Once after the training, residents were permitted to administer a FIB for a patient with suspected or diagnosed hip fracture. The short video file, containing summary of the training course, was created, in order to give the resident a “time off” and ability quickly flick through the most important points according to this procedure. Video file is always available in emergency department. The questionnaire for the residents was given to know how confidence they feel performing this procedure. The questionnaire was given 1, 3, 6 months after the course. The course was repeated 3 months after training, especially for those residents, who did not perform the procedure in 3 months period time. The pain was measured 30 minutes and 2 hours after procedure, if needed additional analgesics were prescribed.

 

Results

The short video about this block and a “time off” before a procedure helps to memorize the most important things. Residents who performed this procedure more than 10 times feel confident to perform this procedure alone. Residents, who performed it less than 10 times, need a back up help while performing a procedure and exposed the wish to repeat the course, in order to build their confidence, and better understand this block. 

 

Conclusion

Different training techniques have been evaluated in literature. We suggest that repeated courses in short time and quick “time offs” before a procedure, is a valuable thing and could help achieve the best performance, quicker and more sustainable skills retention.

 


Simona SABULYTE (KAUNAS, Lithuania), Dinas VAITKAITIS, Justinas STUCINSKAS, Sarunas TARASEVICIUS
11:00 - 18:00 #7806 - Febrile syndrome in young patient. Boutonneuse Mediterranean fever.
Febrile syndrome in young patient. Boutonneuse Mediterranean fever.

History:

34years male goes to hospital emergency departments for fever of up to 40 ° C, malaise, nausea, vomiting and hyporexia about 3 days of evolution. No semiotics respiratory, gastrointestinal or genitourinary.

Refers live in pine forest where usually walk your dog.

Physical exploration:

REG. TA 120 / 80mmHg. Fc 100lpm.

ACP: taquirrítmicos and audible tones. No murmurs. MVC.

Abdomen soft and palpable. No palpo mass or organ enlargement. Not painful on palpation.

pápula type skin lesions disappear Acupressure generalized lesion localization frontal region blackish and reddish halo center

Investigations:

Blood tests: Leukocyte 16700, Hb 14.2, platelets 393000. Coagulation: PT-Act 68%. Biochemistry: Urea 42. Glucose 82. Creatinine 1'23. PCR 109.

Rx thorax: Normal.

Final diagnosis:

Boutonneuse Mediterranean fever. Rickettsia conorii infection.

Evolution:

Before the injury front, serology is requested and empirically starts treatment with Doxycycline.

Conclusions:

A thorough physical examination is necessary to reach a definitive diagnosis, being important to make a good history with the patient's history.


Enrique CARO, Carmen Adela YAGO CALDERON (Malaga, Spain), Marina BUFORN, Juan Antonio RIVERO GUERRERO, Eduardo ROSELL VERGARA
11:00 - 18:00 #4541 - Femoral nerve palsy, a rare presentation of Wunderlich syndrome.
Femoral nerve palsy, a rare presentation of Wunderlich syndrome.

Introduction

This is a case report of a 59 year old gentleman who presented after becoming acutely unwell whilst receiving dialysis. Presenting symptoms were left abdominal pain, with left hip and knee weakness and paraesthesia. The patient recieved dialysis three times a weak for renovascular disease secondary to hypertension. Other past medical history included a failed renal transplant, splenectomy, cerebrovascular accident and atrial fibrillation for which he takes warfarin. The patient was tender in the left lumbar region but was not peritonitic. Neurological examination of the lower limbs revealed some paraesthesia to light touch over the left thigh and markedly reduced power. Power in the left hip and knee was reduced to 2/5 using the Medical Research Council scale and 4/5 in the ankle. On initial venous blood gas (VBG) the lactate was 6.2 despite a haemoglobin of 119 and an INR 1.6. The patient was haemodynamically unstable and repeat VBG showed an acute drop in haemoglobin to 102. Initial differential diagnoses included a leaking abdominal aortic aneurysm, ischaemic bowel and discitis. Contrast computed tomography (please see images) revealed Wunderlich syndrome with spontaneous left perirenal haemorrhage. The haemorrhage had extended to the left iliopsoas region, causing compression of the femoral nerve and this was the reason for his neurology. The patient underwent left renal artery embolisation with transfusion and improved on the high dependency unit. His neurology fully resolved following his procedure. 

What is Wunderlich syndrome?

Wunderlich syndrome (WS) is a clinical condition defined as a spontaneous renal bleeding of non traumatic origin, contained within the subcapsular and perirenal spaces. The most common underlying cause is renal tumor (angiomyolipoma, angiosarcoma, renal cell carcinoma, oncocytoma), others include vascular causes, renal infection or calculus and secondary systemic diseases. The main risk factors are haemodialysis and anticoagulant therapy. Hemorrhagic tendency in hemodialysis patients is related to bleeding diathesis due to end stage renal disease and the use of heparin for the dialysis circuit. Classically it presents with acute flank pain, tender palpable mass and clinical hemodynamic deterioration (hypovolemic shock). These symptoms are defined as the Lenk's classic triad. However, the clinical manifestations can be varied and nonspecific.

Clincal significance

As mentioned above, spontaneous renal haemorrhage is often a difficult clinical diagnosis. This case represents an atypical presentation with quite pronounced neurology. Physicians should ensure that they do not become too distracted by these findings and concentrate their attention on the more pressing matters, in this case the development of shock. Renal haemorrhage should be considered in all patients on chronic haemodialysis receiving anticoagulation who present haemodynamically unstable or with a progressive anaemia. These patients require an abdominal CT and renal angiography to establish the method of treatment. 

Management

Management options include a conservative approach (bed rest, transfusion and withdrawal of anticoagulation therapy), interventional radiology or surgery. This case illustrates the safe and successful application of interventional radiology renal artery embolisation in the management of nontraumatic renal hemorrhage in a hemodialysed patient.


James BARROWMAN (Bristol, United Kingdom), Nirmal JAMES
11:00 - 18:00 #7482 - Fibrinogen use in trauma patients to control major haemorrhage: a literature review.
Fibrinogen use in trauma patients to control major haemorrhage: a literature review.

Introduction

A balanced transfusion of red blood cells, fresh frozen plasma (FFP) and platelets are recommended for massively bleeding trauma patients. The 2013 updated European guideline for the management of bleeding and coagulopathy following major trauma also recommends the treatment with fibrinogen concentrate (FC) or cryoprecipitate in the continuing management of the patient if significant bleeding is accompanied by thromboelastometric signs of a functional fibrinogen deficit or a reduced plasma fibrinogen level. The evidence supporting this practice is limited and largely derived from elective surgery and postpartum haemorrhage.

 

Search and Results

Does any evidence support the use of fibrinogen in trauma patients to control major haemorrhage?

A literature search of multiple databases was conducted via NHS Evidence and only 6 papers answered our query. These papers were based on small studies (4 retrospective and 2 prospective) which showed therapy with FC can decrease the exposure to allogenic blood products transfusions as well as morbidity.

 

 

Discussion

Current literature demonstrates that uncontrolled bleeding and coagulopathy are the main preventable causes of death in trauma patients. Although current use of platelets and FFP does produce favourable outcomes they do have their limitations. Fibrinogen has been identified as the most vulnerable coagulation protein, being the first to reach critically low levels and is required for both platelet aggregation and fibrin formation. Low plasma fibrinogen concentration is common amongst major trauma patients and is associated with poor clinical outcomes, suggesting replacement may assist early haemorrhage control. Fibrinogen supplementation may also compensate for dilutional coagulopathy or impaired haemostasis due to thrombocytopenia.

Several sources of fibrinogen are available; however, FC is not routinely used in current trauma settings. FC contains a well-defined concentration of fibrinogen, has a good safety profile and is immediately available for use. However, there are no adequately powered, well-designed, prospective, randomized controlled trials yet available to show the risk-benefit analysis of using FC in the management of the bleeding trauma patient, and such studies are urgently needed.

The Fibrinogen in Trauma-Induced Coagulopathy (FlinTIC) study is the first double-blind, placebo-controlled, multicentre, randomized clinical trial to assess the effect of early treatment with FC in trauma patients and recruitment is due to finish in 2016.

 

Conclusion

Retrospective research suggests that FC may improve haemostasis in the trauma patient and could potentially reduce or even replace the need for blood products. However, at present, there are no randomized control trials analysing its use in trauma patients.


Tom BARKER, Abdo SATTOUT (Liverpool, UK, United Kingdom)
11:00 - 18:00 #7494 - First experience with Lifeline ARM – a new chest compression machine.
First experience with Lifeline ARM – a new chest compression machine.

Background. The European Resuscitation Council Guidelines for Resuscitation 2015 highlight the significance of cardiopulmonary resuscitation (CPR) effectiveness and of reducing chest compression (CC) interruptions. As has been shown in many publications, the effectiveness of manual CC is very often low. The aim of the study was to compare the quality of CC with and without the Lifeline ARM (Defibtech, Guilford, CT, USA) CC machine during CPR performed by novice physicians.

Participants and methods. Participants were recruited during an emergency medicine workshop for physicians run by the Department of Emergency Medicine, Medical University of Warsaw, Warsaw, Poland. Thirty-eight novice physicians participated in this randomized cross-over study. Each participant performed 2-minute-long CC on a manikin with and without the ARM machine. The physicians were randomized into two groups to perform 2-minute-long CPR with ARM or using the manual (standard) technique in a random order. Data concerning the CC quality were recorded by the manikin software. Additionally, the participants’ subjective fatigue score values were collected.

Results. All subjects completed 2-minute-long CPR using both methods. The usage of the ARM machine during resuscitation resulted in a higher percentage of effective CCs (100 [IQR, 99–101]) as compared with standard basic life support (42 [IQR, 37–45], p < 0.001). When the ARM machine was applied, the number of effective CCs decreased less over time (p < 0.001), the required depth of 5 cm was reached more often (98 vs. 58%, p < 0.001), and the recommended CC rate was obtained more frequently (p < 0.001). The median hands-off time was lower when using ARM. Also, the fatigue score values turned out lower when ARM was applied.

Conclusion. The Lifeline ARM device reduces the rescuer fatigue during continuous chest compression CPR, with better CC quality during CPR in a simulation setting.


Szarpak LUKASZ (Warsaw, Poland), Truszewski ZENON, Smereka JACEK, Czyzewski LUKASZ
11:00 - 18:00 #8210 - First experiences of the Finnish resident Emergency Physicians.
First experiences of the Finnish resident Emergency Physicians.

Background

Emergency Medicine became its own specialty in Finland in January 2013. From its early beginning it has been a popular choice for junior doctors graduating from Med School. The number of residents has reach 140.

 

While developing the new specialty there has been a quite wide discussion about the role of Emergency Physicians in the Emergency Departments in forthcoming years? Will they work 24 hour shifts till the retirement? What will they learn during residency and who will teach them? Pros and cons of the new situation has been presented across the national professional journals, mainly by the senior doctors while juniors are wondering how to struggle in the developing field of EM.

 

The aim of this survey is to find out what residents really think about their specialty. Here we present selected results.

 

Methods

First annual national conference of resident EPs was held in May 2015. We organized a survey which was supposed to reflect the actual feelings of the residents after a few years working as a resident EP. The participants were asked for example about the working preferences in near future and about the current working conditions, about the supervision of the economic interests and about the actual collaboration between different specialties across the EDs. The questions were presented as claims and the answers were asked to present at the modified Likert scale 1 (perfectly false) to 7 (absolutely true). The link of the survey was send to all participants via email about two weeks before the meeting. There was seven-day deadline to answer the survey.

 

Results

Forty-three out of sixty-one participants (70%) answered to the survey. Of them 30 were residents in EM. The rest represented internists, GPs, surgeons and anaesthetists. There were 22 females and 21 males. Of them, 74 % were satisfied to their choice when claimed “right now I’m satisfied with my choice of specialty”. The same percentage said YES (answers at the scale 5-7) when asked “Right now I’m doing suitable job for me”. Only 65 % answered YES to this same question regarding period 5-10 years to the future. 58 % said that the collaboration between different specialties in their ED is working properly; 21 % said that is not working and the rest 21 % could not answer how it was. 88 % thought that it is necessary to have a public debate of the new specialty but only 53 % said that the discussion has been truthful. 77 % said that they will work both office-hours and out-of-office hours as a specialist.  91 % thought that the maximum length of the busy shift in the ED is 16 hours.

 

Conclusions

Preliminary findings indicate that residents view positively their specialty. Some work has to be done to get all sides work together for a common goal. 


Iiro HEIKKILÄ (Hämeenlinna, Finland), Ari PALOMÄKI
11:00 - 18:00 #7947 - First Manifestation of Diabetes Mellitus Diabetic Ketoacidosis accompanied by Pulmonary Embolism.
First Manifestation of Diabetes Mellitus Diabetic Ketoacidosis accompanied by Pulmonary Embolism.

DKA is a life thearetening manifestation of diabetus mellitus as a hypercoagolable state. venous and arterial thromboambolism are complications of DKA treatment .pulmonary thromboembolism  (PTE) is the most seriouse   manifestation of venous thromboembolic desease .this article reportsthe case of 52 years old woman with massive  thromboambolism presented with DKA.

case report:A 52 years old woman was broughte to emergency departeman at tehran 'haftetir hospital with a chife complain of acute dyspnea .She stated that after a few minuetes running in a short distance ,she had exprienced a shortnnes of breath,sweating,dizzenes,and drop attack.No significant sicknes was found in her past medical history .She no had history of recent of long-distance travel ,obecity and smoking .However she was ill,pail,prispring ,cyanotic and anxious with cold extermites .her heart rate was 124beats/min and BP WAS 70/30mmHg.Puls oximetry was shoud o2 saturation 75% in room air she had tachypnea of 32 breat /min.her lung sound was normal


Hassan AMIRI, Seyed Mohammad HOSSEINI KASNAVIEH (tehran, Islamic Republic of Iran), Hossein SAIDI, Nader TVAKOLI, Gholamreza MASOUMI, Samana NABI, Mohammad BAGHAEI, Samane REZAEI
11:00 - 18:00 #7468 - First seizure: an uncommon Influenza A debut.
First seizure: an uncommon Influenza A debut.

Encephalitis by virus influenza A, is a rare disease in Western countries, furthermore, it has a difficult diagnosis, because it usually presents a normal results in the examination of cerebrospinal fluid (CSF) and neuroimaging tests.

 In 1998, the amplification was achieved by polymerase chain reaction (PCR) RNA influenza virus serotype A in CSF, which facilitated the etiologic diagnosis of the disease, however this test is not available in many hospitals.

I present, the case of a 16 years old patient, with not known drug allergies or cardiovascular risk factors . She denies drugs use.

The patient came to A&E (Emergency department) with low GCS (Glasgow coma scale) and sudden onset dysartrhia. In previous days, she had had a headache, watery rhinorrhea and high temperature up to 39 ° C, and she was diagnosed with common cold. During our interview, the patient underwent an episode of tonic clonic movements, with vomiting and faecal and urinary incontinence.

 The initial physical examination revealed normal coloration of skin and mucous, blood pressure of 105/ 63mmHg, heart rate of 80 bpm, breathing rate  21bpm, temperature 37.4 ° C; oxygen saturation , 97%.. On pulmonary auscultation she had left basal lung crankles and neurologically, Glasgow 9, no neck stifness, miotic and reactive pupils. The rest of the physical exam was normal.

In initial tests: Biochemistry was normal except transaminases, ABG with lactate, blood cell count , clotting and glucose without any alterations; Chest X-Ray and computed tomography (CT) cranial was normal. The rapid detection of toxic substances in urine was negative. Cerebrospinal fluid: proteins, 0,83g / l; glucose 83 mg / dl; leukocytes: 0. Nasopharyngeal Flu PCR determination was positive. Serology was negative for other viruses.

Treatment with antibiotics and intravenous antiviral was started. After admission in A&E,  she had sudden general deterioration, with seizures, so was given 10 mg of Diazepam, and she was intubated.

The Electroencephalogram showed nonspecific encephalopathy moderate degree, influenced partially by drug component and associated post-critical component. and no status epilepticus associated. After 24 hours of sedation and improved EEG, she was extubated and she continued improving, and she was discharged home 1 week later.

In Europe, virus influenza is a rare cause of encephalitis, however, is important for A&E physician to recognice the encephalitis sympthoms, and think in the most common viruses, but also thinking in influenza virus, especially in the middle of  seasonal flu epidemic.


Fernando Constantino BRIONES MONTEAGUDO (ALMANSA, Spain), Francisco Javier LUCAS GALÁN, Mónica LÓPEZ GARCÍA, Nuria SÁNCHEZ GARRIDO-LESTACHE, Rafael SÁNCHEZ INIESTA
11:00 - 18:00 #7846 - Five-year experience of intraosseous access in prehospital stage.
Five-year experience of intraosseous access in prehospital stage.

Introduction: Establishment of State Emergency Medical Service (SEMS) in Latvia (2009) was the general precondition for implementation of unified equipment and new methods in prehospital emergency medical care provision. In January, 2011 devices for intraosseous (hereinafter - IO) access were introduced in all EMC crews throughout the state.  Regular and continuing training for IO establishment was provided for SEMS medical staff. According to the training IO has to be established in proximal tibial plateau in case when intravenous access is not available or feasible.

 Objective: To summarize the results of the IO access in 5-year period in prehospital stage in Latvia with a purpose to evaluate the effectiveness of training.

 Materials & Methods: Medical records of patients to whom IO access was established in prehospital stage in Latvia from 2011 to 2015 were analyzed.

 Results:

488 IO line placement attempts were performed to 468 patients from January 1, 2011 to December 31, 2015 - 457 times with Bone Injection Gun, B.I.G. (Waismed Ltd.) and 31 times with EZ-IO (Vidacare).

Age of patients varied from 19 days to 97 years (average 54.0 years, SD 25.3). In 47 cases IO was established to children, including 19 infants.

In most cases (41%, n=192) the patients had cardiac arrest, while 28.6% (n=134) of patients had hemodynamic instability and 30.3% (n=142) had other condition requiring vascular access during transportation to hospital. 25.2% (n=118) of patients had trauma, while 74.8% (n=350) of patients had non-trauma related condition.

Most IO insertions were performed by physicians - 67% (n=327), while in 33% (n=161) of cases IO access was performed by doctor’s assistant.

Successful insertion on the first attempt was achieved in 87.5% (n=427) cases. In 12.5 % (n=61) cases IO access was not established due to different reasons - bone but not marrow entered, failure to remove the trocar needle after insertion, inability to identify the insertion site correctly and improper needle length in obese patients.    12 unsuccessful IO line insertions were observed in children, including 7 infants. Needle dislodgment was observed in 14 cases after initially successful IO access, thus diminishing overall IO line success rate to 84,6%.

Conclusions:

  1. Regular training improves success rate in establishment of IO access. Our results showed substantial increase of success rate of IO insertion on the 1st attempt from 78.9% to 87.5%.
  2. First attempt success rate for B.I.G. device was 87,1%, including 88% for adults and 80% for children.
  3. There was no statistical difference in success of IO line placement performed by physicians or doctor’s assistants (OR=0.99; p=0.42). Overall 84.4% success rate was achieved by physicians and 85.0% - by doctor’s assistants.
  4. Vast majority of unsuccessful attempts were performed with B.I.G. device. There was only 2 unsuccessful IO insertion reported with EZ-IO, but the number of EZ-IO insertions is too small to make statistical analysis.

Dmitrijs SERGEJEVS (Riga, Latvia), Sarmite VILLERE
11:00 - 18:00 #7403 - Five-year trends in computed tomography of pulmonary angiogram (CTPA) for suspected pulmonary embolism: a retrospective review.
Five-year trends in computed tomography of pulmonary angiogram (CTPA) for suspected pulmonary embolism: a retrospective review.

Background

CTPA is considered the gold standard for diagnosing pulmonary embolism (PE), and evidence of right heart strain suggests sub-massive PE. 

 

Method

A retrospective review of 5 years CTPA scans was performed at a tertiary teaching hospital, University Hospital of Wales (UHW) from August 2010 to July 2015.  The objective of this study is firstly to assess changing trends in the incidence of emergency department (ED) diagnosed acute PE and submassive PE, secondly to evaluate the pick up rate against Royal College of Radiologist (UK) recommendations.

 

Result

Of the total 1507 CTPA scans requested in the ED, 270 (17.9%) were positive for PE, and at least 80/270 (29.6%) could have been categorized as submassive PE. Just over half (54%) of the positive CTPA scans reporting did not mention any radiographic evidence of right heart strain. There was a four-fold rise requested CTPA scans from 2010 to 2015. The positive yield over the years however decreases from 20.1% to 16.4%.

 

Conclusion.

There is a trend in increased requests in CTPA, and a higher absolute rate in pick up in PE which is within the acceptable range proposed by the Royal College of Radiologist UK.


Ngua CHEN WEN (CARDIFF, United Kingdom), Timothy RAINER
11:00 - 18:00 #7952 - Flail chest, a rare complication of cardiopulmonary resuscitation.
Flail chest, a rare complication of cardiopulmonary resuscitation.

Introduction: Flail chest is an injury that often follows blunt chest trauma. It results when each of three or more ribs is broken at two separate sites and moves in a floating manner, independent of other chest regions. It can also occur when the ribs are broken proximally and there is simultaneous disarticulation of the costochondral cartilages distally. Flail chest is diagnosed by observing the paradoxical motion of the affected region on physical examination. Flail chest is more common after high-energy traffic accidents and blunt trauma, such as falls from a height. Flail chest complicates 5~6% of patients surviving cardiopulmonary resuscitation (CPR), although the duration of hospital stay is not significantly affected by flail chest complicating CPR.

Here, we report a male patient suffering from flail chest following the return of spontaneous circulation after CPR.

Case report: A 50-year-old man had been admitted to a secondary healthcare centre with fainting, cold sweats, and chest pain. He subsequently developed cardiopulmonary arrest and regained spontaneous circulation after CPR, defibrillation, and tracheal intubation. He was then transferred to our institution. During transport, he suffered another cardiac arrest, but spontaneous circulation was successfully re-established. On admission he had a blood pressure of 100/60 mmHg, peak heart rate of 122/min, and body temperature of 36°C.  An ECG taken in the emergency department revealed ST segment elevation in leads V2, V3, and aVF. Based on these findings, the patient was diagnosed with an acute inferior myocardial infarction and preparations were made for urgent coronary angiography. At this time, paradoxical chest wall movements were noted and a video recording of them was made. CT of the chest showed multiple rib fractures in the left hemithorax. Based on the physical examination and radiological studies, the patient was considered to have a left-sided unilateral flail chest, probably secondary to blunt chest trauma during CPR.

Conclusion: In this case, repeat CPR was performed while travelling on ambulance. During transport, it can be difficult to perform CPR with chest compressions directed to the correct anatomic site, and chest compressions may be applied more deeply than needed. Therefore, we attributed the flail chest to the performance of ambulance CPR. In such situations, it may be useful to use mechanical CPR devices to apply chest compressions to the correct, fixed anatomic site. We believe that using mechanical CPR devices for ambulatory CPR procedures may prevent the rare complication of CPR-induced flail chest.


Adnan YAMANOGLU, Ozan SAHIN, Dr Sumeyye CAKMAK (İSTANBUL, Turkey), Neslihan SACLI BOZKURT, Ozgur SOGUT
11:00 - 18:00 #7168 - Flutter ic case of proarrhythmia.
Flutter ic case of proarrhythmia.

Clinic history:

73 years retired plumber man with active life medical history of hypertension, dyslipidemia, paroxysmal atrial fibrillation and neoplasia treated with radiotherapy prostate. His flecainide 100 mgr medication every 12 hours, bisoprolol 5 mgr, enalapril 5 mgr, acenocumarol and tamsulosin.

Before to receive radiotherapy, suffers box with sweating dizziness, general malaise which leads him to the emergency contact. He had breakfasted and taken his dose of bisoprolol and flecainide morning. electrocardiogram objectifying wide QRS regular tachycardia at 195 bpm, why it passes critical area is performed. He showed no chest pain or palpitations or dyspnea.

Physical examination on admission: conscious and oriented, hipotenso TA 80/40, taquicárdico190 lpm, pale skin with sweating and feeling sick.

No jugular venous distension

rhythmic cardiac auscultation tones to 190pm no murmurs, no pathological lung sounds.

nondescript abdomen, lower extremities without edema or signs of venous thrombosis.

 

Due to hemodynamic instability and evidence of wide QRS regular tachycardia proceeds to synchronized electrical cardioversion after sedation with a single download reverting to sinus rhythm 100 joules.

 

 

After cardioversion, ECG RS 65 pm shaft 45 Gº Signs Hypertrophy

Left ventricular. all antiarrhythmic medication was discontinued.

 

Complementary tests: analytical INR 3. Chest radiography: cardiomegaly discreet, parenchymas without findings. Echocardiography moderate and LVH prevalence of basal aortic stenosis.

 

Differential diagnoses:

- Ventricular tachyarrhythmia wide QRS

- Acute Coronary Syndrome

- QRS tachyarrhythmia secondary IC antiarrhythmic width (flecainide, propafenone)

 

Final diagnosis: Flutter wide QRS tachyarrhythmia IC.

 

Evolution: The patient remained stable for 20 h under observation entering cardiology study, where catheterization were performed which showed normal coronary arteries, Holter with frequent premature ventricular contractions and ventricular tachycardia episode Non-Hold (4 beats). electrophysiological study without induction of ventricular tachycardia and ventricular pacing after showing aberrant after atrial stimulation suggestive of supraventricular paroxysmal tachycardia aberrated.

 

Discussion: the first case of pro-arrhythmia (ie induction antiarrhythmic drugs or change worsening arrhythmia treated well with the development of a new bradyarrhythmia or tachyarrhythmia) dates from 1922.

 There was a before and after in terms of proarrhythmias following the publication in 1991 of the study CAST (The Cardiac Arrhrythmia Suppression Trial) showing an increase in mortality with the use of flecainide and encainide versus placebo in patients with previous myocardial infarction. In our case was a patient with paroxysmal atrial fibrillation treated with flecainide (pocket pill) he developed atrial flutter. Flecainide is an antiarrhythmic 1C group that acts by blocking the channel sodio.La flecainide or propafenone management, atrial fibrillation can transform into flutter (flutter called 1C). The result will be lent flutter with 1: 1 conduction to ventricles and wide QRS.

It is useful to prevent co-administration of beta-blockers.

The incidence of this type of IC Flutter is low, about 3%.


Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #7940 - Focused ultrasound in the real world – should we really learn FAST?
Focused ultrasound in the real world – should we really learn FAST?

Aim: Point-of-care ultrasound is a game-changer in the evaluation and treatment of acute ill and injured patients and is becoming more and more popular especially in emergency medicine. Traditional ultrasound programs typically start by learning FAST (focused assessment with sonography for trauma), which value has been challenged (1).  This study has been conducted to identify the most used protocols in our ED.

 

Methods: prospective registration of all point-of-care ultrasound activities of a single user (consultant emergency and internal medicine) at a rural ED in Denmark  (about 43.000 admissions/year) over a 3-month-period January to April 2016.  The user is trained in abdominal ultrasound, echocardiography, F-LUS (focused lungultrasound), MUS (musculoskeletal ultrasound), FAST, e-FAST, focused heart ultrasound, LCU (limited compression ultrasound for deep vein thrombosis), ultrasound-guided interventions (pleuracentesis, ascitesdrainage, vascular access). A General Electrics S8 ultrasound scanner was used most of the times, some intervention were done using a General Electrics V-scan. Ultrasound pictures and clips were stored on a hard-disc anonymous with a study-number.

 

Results: I the study period 178 patients were examined with ultrasound. As there were used more than one protocol in some patients, a total of 224 examinations or interventions were registered. FAS (focused abdominal sonography) was used 60 times, F-LUS (focused lung ultrasound) 48 times, FATE (focused assessed transthoracic echocardiography) 38 times, LCU 25, MUS 13, FAST 6, e-FAST 4, 1 scanning was not specified in the records. 29 ultrasound-guided interventions, mostly venous and arterial access, were registered. 14 patients underwent a F-LUS and focused echocardiography as part of a randomized controlled trial (RCT 1.4 ultralyd i akutmodtagelsen).

 

In 71 patients a significant pathology was noted, all from abdominal aortic aneurism, pleural- and pericardial effusions, appendicitis, ileus, ovary masses, ectopic pregnancies, ruptured tendons, cholecystitis and – lithiasis, low EF, acute dilated right heart, spleen haematomas, free peritoneal fluid, a lot of DVTs and Baker-cysts, lung consolidations. All but one interventions (venous catheter, arterial puncture and catheter, pig-tail drain in pleura and peritoneal cavity) were successful.

 

Discussion: Most often, a focused abdominal ultrasound was performed, followed by focused lung-ultrasound, FATE  and LCU. Only very few FAST, e-FAST or MUS were done in the study period. It was possible to identify significant pathologies with point-of-care ultrasound. Limitations for  single centre and singe user must be take into account.

As a result of this study, it seem more reasonable to focus ultrasound-training on abdominal and lung ultrasound, followed by focused echocardiography and LCU . Also ultrasound-guided vascular access seems to be a very useful tool in the ED. FAST and e-FAST may have a role in special settings, but not in our ED. Research in point-of-care ultrasound should be encouraged.

 

1) Stengel D, Rademacher G, Ekkernkamp A, Güthoff C, Mutze S.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma.

Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446


Gerhard TIWALD (Kastrup, Denmark)
11:00 - 18:00 #7791 - Follicular debris in the diagnosis of ovarian torsion.
Follicular debris in the diagnosis of ovarian torsion.

Objective

 

This study set out to examine the presence of fluid debris in patients diagnosed with ovarian torsion.  A secondary aim is to identify and correlate FFD to the presence of cysts, ovary size, and arterial resistive index (RI).

 

Methods

 

A retrospective chart review was done of all patients that presented to the emergency department (ED) at NY Methodist Hospital with the confirmed diagnosis of ovarian torsion from January 1, 2011 to July 1, 2015, who had an ultrasound available for review. RIs were obtained directly from the point of care ultrasound (POCUS) or comprehensive ultrasound (CUS).

 

Results

 

56 had ovarian torsion and 48 ultrasounds reviewed for the presence of FFD in the torsed ovary.  Of those 48, 21 had POCUS. all others had CUS.  63.8% (30) had FFD present in the affected ovary.  Of those with FFD, 83.3% (25) had ovarian cysts. Also 53.3% (16) had an RI calculated and 23.3% (7) of those had an elevated RI; 9 had no RI due to lack of arterial flow or poor image quality.

 

Conclusion

 

The majority of the torsion patients demonstrated FFD, however the value of this is not yet clear. A larger study combining other findings of torsion with the presence of fluid debris should be conducted.  Lastly, a larger retrospective or prospective study is required to evaluate the utility of the presence of FFD in POCUS. 


Gerardo CHIRICOLO, Christopher RAIO (Dix Hills, USA)
11:00 - 18:00 #7550 - follow we the recommendations of the CHA2DS2Vasc Score diagnosed atrial fibrillation in our emergency department?
follow we the recommendations of the CHA2DS2Vasc Score diagnosed atrial fibrillation in our emergency department?

Objective: Assess whether the discharge of our emergency department conducted a proper thromboprophylaxis in atrial fibrillation is not known following the score CHA2DS2-VASc

Material and methods
Observational, longitudinal, retrospective review of medical records. All patients diagnosed with Atrial fibrillation selected discharge not known in 2014 and 2015. Variables studied: sex, age, time of evolution, if frequency control is attempted or cardiovierte. EKG at discharge, calculation CHA2DS2-VASc score, HAS-BLED score of if discharge is not due pautar anything, whether to antiplatelet therapy or anticoagulation and with that drug. If they are reviewed in outpatient cardiology, ECG in consultation and change is made to the drug for prophylaxis.

Results: Of the 237 patients discharged with a diagnosis of the FA; 91 were not known Middle Ages 69.81%. 51.6% were women. Time evolution of the clinic was> 48 hours 53.8% and 2:  anything 20%, 66.1% anticoagulated and 13.9% t antiplatelet agents.  Were reviewed 87.9% in outpatient cardilogy in less than 1 month.
When they reach cardiology clinics,  taked nothing  36.6 %%, anticoagulated 45.1%, 18.3% antiplatelet agents. Remain the same 82.9. 17.1% change them

Conclusion: In our service we tend not to make a correct cardioembolic CHADSvASC prophylaxis following two criteria so that those who should be anticoagulated we do in 6 out of 10, leaving 40% without prophilaxys.. In the case of scrore 1 half left without prophylaxis and those who are tone only are you antiplatelet therapy. In all cases it is used acenocumarol. Given the results has started a cycle of improvement to try to perform better this prophylaxis


Daniela ROSILLO CASTRO (Murcia, Spain), Amalia CASTAÑO VILLAR, Carmen HERNÁNDEZ MARTÍNEZ, Maria Dolores PASCUAL MUÑOZ, Rocío LÓPEZ VALCARCEL, Estefanía CARREÑO AROCA
11:00 - 18:00 #7966 - Fournier Gangrene.
Fournier Gangrene.

Flournier gangrene.

Introduction. Fournier’s gangrene disease is a rare but potentially lethal, if not done quikly diagnose and urgent treatment. This is an necrotizing subcutaneous infection by aerobic and anaerobic germs. 

Usually originate in the urogenital or anorectal area, depending no de trigger factors, and can spread to the genital area, perineum and previous abdominal wall. 

Clinical case. The case of a 40 years old patient who come to emergency room for pain and inflamation in perineal area. In the exploration presents swelling and erythema perianal, no fluctuating. After nine hours of evolution the patient presents septic situation whith extension to scrotal area. It was necesary to make an urgent debridement in a skin and subcutaneous area in scrotal and sacral area and intravenous  antibiotic treatment.

Results. We observed that the patient presents the basic pathology as a hypertension, ischemic heart disease and perianal abscess. The patient presenting leukocytosis, hemostasis alteration and high fever. 

Conclusions. Fournier gangrene, is a rare disease but has a high morbility and mortalily. Specially in patients whith predisposing factors, so it is very important to make an early diagnosis and an urgent treatment. 


Elisa RUIZ OLIVARES, Sonia BALLESTÍN SOROLLA., Ana Belén MARÍN FLORÍA, Carola MEDINA SAINZ, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Silvia GANGUTIA, Pilar SARASA CLAVER
11:00 - 18:00 #8225 - Fracture of cervical spine from minor trauma leading to diagnosis of multiple myeloma.
Fracture of cervical spine from minor trauma leading to diagnosis of multiple myeloma.

 Introduction

Multiple myeloma (MM) is a neoplastic condition characterised by proliferation of plasma cells in the bone marrow. Approximately 60% of patients have bone pain at the time of presentation and focal lytic lesions are found in nearly 60% of those undergoing skeletal surveys1.

We discuss a case of a 46-year-old male who obtained a pathological fracture of the C2-vertebra following minor trauma as an initial presentation of MM.

Case report

A 46 year old gentleman presented to our Emergency Department with neck pain after having reversed his car into a lamppost at a low speed. He had had neck pain in the previous 3 weeks, however this accident severely exacerbated the symptoms. On initial assessment lower cervical spine (c-spine) tenderness, prominent over the paraspinal muscles, was elicited. He remained neurologically intact.

The patient had a plain x-ray of the c-spine which revealed a lucent lesion on C2-vertebra. He was subsequently triple immobilised, and a CT and MRI scans confirmed the presence of a lytic lesion through the base of the odontoid peg with a pathological fracture but no spinal cord compression.

Further CT imaging revealed no signs of any primary malignancy or metastatic disease within the chest, abdomen or pelvis. Subsequent bone marrow investigations confirmed the presence of monoclonal gammopathy and features consistent with the diagnosis of MM with plasmacytoma affecting the C2-vertebra.

The fracture was managed with external stabilisation, which resolved the neck pain. In view of his age and good performance status, combination chemotherapy was commenced with planned autologous stem cell transplantation.

Discussion

C-spine fractures occurring in the elderly following minor trauma is a common presentation, owing to higher prevalence of chronic rheumatologic and malignant conditions making them more susceptible to neck injury2,3. It often means clinicians have a low threshold for imaging of the c-spine in this group of patients.

Applying the NEXUS (National Emergency X-Radiography Utilisation Study) guidelines for imaging of the c-spine following trauma, our patient did not fulfil the criteria for any radiological imaging.

This case highlights the importance of considering imaging also in the younger population with atypical presentations, in this case neck pain out of proportion to the injury, despite clinical guidelines. The clinical judgement in managing our patient lead to an earlier diagnosis and treatment of MM, potentially extending the patient’s life expectancy.

Conclusion

Trivial trauma to the neck should be taken seriously as it can lead to fractures of the c-spine that is already compromised by underlying pathology. We discuss a case of a middle aged male who presented with severe neck pain following a low impact injury, and obtained a pathological fracture.

References

  1. Kyle RA et al. Review of 1027 patients with newly diagnosed multiple myeloma. Division of Hematology and Internal Medicine. Mayo Clin Proc. 2003;78:21.
  2. Goode T et al. Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? Am Surg. 2014;80:182-4.
  3. Chan L et al. Cervical fracture as the initial presentation of multiple myeloma. Ann Emerg Med. 1994;24:1192-1194.

Eva KERSNA (Norwich, United Kingdom), Sounder PERUMAL
11:00 - 18:00 #8259 - Frequency of acute respiratory infections in emergency medical services in the north of Montenegro for 2015 year.
Frequency of acute respiratory infections in emergency medical services in the north of Montenegro for 2015 year.

     

        Frequency of acute respiratory infections  in emergency medical services in the north of Montenegro for 2015 year

 

Tijana Rovcanin1 ,Vlado Dragas2 , Stevana Dragas3

Keywords: infection,medical treatment,emergency clinics,children.

INTRODUCTION: Respiratory infections in infants and young children include about 20% of the medical examinations in emergency clinics.Epiglottitis ,laryngitis( croup ) and laringotraheobronhiolitis are diseases that are mainly present in children younger than 5 years and are often urgent situation with which we meet in emergency clinics in the north of Montenegro.They are characterized by the most common triad of symptoms: inspiratory stridor  or dyspnea , hoarseness and coughing ( barking dog ) .An important predisposing factor for the inflammation may be  viruses ( Parainfluenza , Influenza A and B , RSV ) , the bacteria( Haemoflus inf . ) , allergic causes , as well as psychological factor.This disease have special characteristics because of the anatomical structure of the respiratory tract children , because the airways are narrower and shorter , easy to actively develop greater muscle constriction in infections , mucous membranes is better vascularised , due to the underdeveloped immunity kids are more vulnerable and susceptible pathogens respiratory infections.  TARGET: Testing the performance of urgent therapeutic care and the prevalence of these diseases in relation to the total morbidity as  and the mutual relationship of male and female population the incidence . METHODS AND MATERIALS : During the writing of this paper , we used a retrospective analysis of  medical protocols in emergency Units  Berane and Andrijevica for period January - December 2015 . RESULTS : During 2015 in units of  Berane and Andrijevica  was examined by a doctor on duty 12 434  patients , which is quite a big number .On  addition a total of   3 720 had symptoms of what makes (30 % ) of the total number of hits .Of this number, 3236 patients ( 87 % ) are male and  484 (13 % ) were female children.We  first started therapeutic treatment of the patient by the following combination of agents ( dexamethasone 0.6 ml / kg) , inhalationsteroids ( Pulmicort , Becotide ) , hidratation.In  74 % of the cases we have had a great success, while about 26 % was sent tofurther therapeutic treatment pediatrician . CONCLUSION: The male population is predominant in morbidity 87 %.This infection in children are quite difficult and life threatening condition.The presence of a mild clinical symptoms should be prevented occurrence of severe symptoms , as well as to educate parents about the importance of regular immunoprophylaxis in children. Particular attention should be paid when meeting with such patients , not to open mouth and do not try to examine the throat  as it may be due to sudden stimulation  to complete obstructions and cardiorespiratory  arrest.   1  Tijana Rovcanin, physician, Emergency Unit Berane2 Vlado Dragas, physician, Emergency Unit Plav3 Stevana Dragas,physician, Emergency Unit Andrijevica

 1  Tijana Rovcanin, physician, Emergency Unit Berane2 Vlado Dragas, physician, Emergency Unit Plav3 Stevana Dragas,physician, Emergency Unit Andrijevica

 


Tijana ROVCANIN, Tijana ROVCANIN (Kragujevac, Serbia)
11:00 - 18:00 #7902 - Frequency of MEFV mutation and genotype–phenotype correlation in cases with dysmenorrhea.
Frequency of MEFV mutation and genotype–phenotype correlation in cases with dysmenorrhea.

AIM: We aimed to investigate the relation between mutations and polymorphisms playing roles in the onset of clinical findings of Familial Mediterranean Fever (FMF) and clinical phenotypic reflections manifesting with painful episodes, such as dysmenorrhea.
MATERIAL-METHODS: A total of 1000 female patients who had not responded well to non-steroidal antiinflammatory drugs in the menstrual period, and who had presented to the emergency room with the complaint of recurrent pain episodes were included in the study. All the patients were Turkish women living in Istanbul. In this study, the mutations most frequently seen in the Mediterranean Fever Gene (MEFV), namely M694V, E148Q, M680I(G/C), V726A, P369S, R761H, A744S, M694I, K695R, F479L, M680I(G/A), and I692del were examined using the DNA sequence analysis following DNA isolation.
RESULTS: The number of individuals who had a mutation in at least one allele for FMF was 511 out of 1000 patients. Of these 511 patients, homozygous mutations were found in 21% (n = 109), compound heterozygous mutations were found in 27% (n = 136), and heterozygous mutations were found in 52% (n = 266). The most frequent homozygous genotype seen in our study population was M694V/M694V. The most common compound heterozygote genotypes were M694V/M680I, M694V/V726A, M694V/E148Q, and M680I/V726A; and 11.7% (n = 60) of the families in whom mutations were found had consanguinity.
CONCLUSION: Women who present to the emergency room with the complaint of dysmenorrhea that is irresponsive to non-steroidal anti-inflammatory drugs may have several types of MEFV mutations that are responsible for FMF.


Zeynep OCAK, Tarık OCAK (Bolu, Turkey), Arif DURAN, Tülay ÖZLÜ, Ertuğrul Mevlüt KOCAMAN
11:00 - 18:00 #7542 - FROM GALLSTONE TO BILIARY ILEUS.
FROM GALLSTONE TO BILIARY ILEUS.

Medical history:

Woman 71 years old without RAM, with AP HTA, DLP, type 2 diabetes mellitus. Possible asymptomatic cholelithiasis diagnosed 10 years ago and untreated. Current treatment with metformin, furosemide and simvastatin. She went to hospital emergency rooms due to recurrent vomiting, chills and malaise. In clinical analysis highlights leukocytosis 16000 / mm3 and Cr 1.85 mg / dl. After hydration, omeprazole and antispasmodic, improved and is discharged the next day diagnosed with gastroenteritis, type 2 renal failure to dehydration and diabetic ketoacidosis. She came back 4 hours later by intense malaise and vomiting fecaloid appearance. Blood pressure 155/95, heart rate 120 lpm, SaO2 95%, Tª 36.2ºC. Preliminary examinations indicate a distended abdomen, not painful on palpation, soft and depressible, tympanic, without other signs of peritoneal irritation, no masses and organ enlargment noted. Rectal examination without findings. In the AS highlights: Glucose 323, Cr 1.65, 17.80 and PCR Leukocyte 16800 / mm3. Abdominal radiography: intestinal pneumatisation. Abdominal CT: Mass gastric dilatation, SNG well placed. Severe intestinal dilatation with abrupt change of gauge in right flank region (at that level, impacted gallstone, probably vesicular origin). Normal colon structure. Collapsed bladder. Aerobilia in left hepatic lobe. Absence of free liquid or extraluminal air. Summary: intestinal obstruction, likely gallstone ileus. Surgical emergency was performed under general anesthesia (longitudinal enterotomy and stone removal). The patient had a poor postoperative course, having to be operated on again due to the sutures dehiscence and evisceration, during which carries an aspiration of gastrointestinal contents. Admitted to the intensive care unit where severe type 2 respiratory failure evolves to aspiration, septic shock and irreversible multiple organ failure.


Conclusion:

Gallstone ileus is a digestive disease that often goes unnoticed, sometimes interpreted as biliary colic or cholecystitis, making its diagnosis difficult. Complications and mortality are related to the time of evolution and the patient's condition, because of its high percentage we must be alert to the warning signs that can make us suspicious in the box and act in the shortest possible time.


María Teresa FERNANDO GROS (ZARAGOZA, Spain), María Pilar POVEDA SERRANO, Patricia BONED BLAS, Alicia BAGUENA GARCÍA, Rocío ESCRICHE ROS
11:00 - 18:00 #7171 - GALL BLADDER VOLVULUS.
GALL BLADDER VOLVULUS.

Abstract

Case report: GALL BLADDER VOLVULUS

Authors:

Dr Zeinab Abdel Rahman Senior Clinical Fellow

Dr Razana Mohammed PGY3

Emergency department/ HGH

Introduction:

Gall bladder volvulus is a rare entity, with a predilection for elderly women in their 7th or 8th decades of life. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Presence of redundant mesentery is a prerequisite. The disease is a frequent mimicker of acute Cholecystitis, often difficult to diagnose preoperatively .Till date only about 300 cases have been reported in the literature, with children and adolescent presentations being exceedingly rare.

 

Case Description:

We report a case of an 18 year old female who presented to Emergency with right upper Quadrant pain for a day associated with repeated vomiting. The patient was stable, had tenderness in right hypochondrium.

Patient was evaluated as a potential case of acute cholecystitis.

Laboratory investigations have shown normal White cell count, Double normal Liver function tests.

Ultrasound showed the gall bladder was out of the fossa with significant edema and wall thickness suggestive of “Gall bladder torsion”.

Further workup with MRCP was done, which have shown “retrohepatic Gall Bladder, with partial volvulus and hemorrhagic acalcular Cholecystitis. The patient underwent laparoscopic detorsion and cholecystectomy and had an intraoperative evidence of gall bladder volvulus with gangrene with an uneventful course of hospital stay.

Conclusion:

We believe that this may be the first documented case of this rare condition from Qatar.

Gall Bladder volvulus mostly occurs in Elderly, but it might occur in young patients as well and should be included in differential diagnosis of abdominal pain.

Ultrasound is safe, feasible diagnostic tool, as sensitive as MRI in diagnosis of Gall Bladder Volvulus.                          


Zenab ABDEL RAHMAN (Doha, Qatar)
11:00 - 18:00 #7682 - Gelejinse questionnaire is useful as a method of triage of chest pain?
Gelejinse questionnaire is useful as a method of triage of chest pain?

 

Introduction
Chest pain is a frequent complaint in the emergency department. Geleijnse questionnaire is used to classify suspicious chest pain of heart disease by obtaining a score of 6 or more points

objective
Evaluate those patients discharged from the emergency department with our discharge diagnosis of ischemic chest pain of low probability, if they had completed the questionnaire Gelejinse had submitted a suspected heart disease. As a secondary objective evaluate what high profile presents a cardiac event within 3 months following

Material and methods
Study: descriptive, observational review of medical records. Age, sex, if they had a high suspicion of heart disease according to the Gelejinse questionnaire: patients with a discharge diagnosis of our emergency department chest pain of atypical features in the first quarter of 2015. The study variables were selected. If they had had any previous episode of ischemic heart disease. If presented alterations in the electrocardiogram (ECG), cardiac enzyme test if they were made and whether they were serialized. If chest radiography was performed if were reviewed in outpatient cardiology. If they had structural heart disease. 

Results
152 patients with a discharge diagnosis of atypical chest pain or low probability for IHD were collected. The average age of our patients was 50.27 + - 19.05. 50.7% were men. They had presented an episode of previous ischemic heart disease 9.9%. They showed some alteration in the EKG 17.8% and 82.2% no. They made a determination of cardiac enzymes to 84.9% and 10.5% a second. They were asked chest X-ray to 82.2%. They presented an equal or greater rating of 6 on the scale Gelejinse 10.5% and therefore could have been suspected of heart disease. . They were reviewed in outpatient cardiology 15.8%. They presented structural cardiac pathology 2%. They suffered an event of ischemic heart disease in the next 3 months 0.7% (only one patient) patients, which prsentaba a value greater than 6 on the Gelejinse questionnaire. Of those who were not suggestive none suffered cardiac pathology in the next 3 months. Among patients with the highest score of 6 they had suffered an episode of ischemic heart disease by 25%, not suggestive of 8%.

Conclusions
Only 1 in 10 patients had suspected high risk of heart disease. The questionnaire Gelijense in our series presents a sensitivity of 100% and a specificity of 90%. So we can say that it could be useful as a method of screening in these patients for further studies from the emergency and / or referral to outpatient cardiology to complete the study. None of the low-risk patients having a cardiac event in the next three months


Carmen HERNÁNDEZ MARTÍNEZ, Maria Del Mar DE LA TORRE OLIVARES, Daniela ROSILLO CASTRO (Murcia, Spain), Rocío LÓPEZ VALCARCEL, María De La Paz EGEA CAMPOY, Alessandro GUASCHI CAGLIERI, Amalia CASTAÑO VILLAR
11:00 - 18:00 #7912 - GEMCON16: The first Geriatric Emergency Medicine conference in Europe.
GEMCON16: The first Geriatric Emergency Medicine conference in Europe.

Introduction

“Geriatric Emergency Medicine” (GEM) is an area of growing interest within geriatric and emergency medicine circles across Europe, Australia and North America. There are increasingly formal collaborations between societies within emergency medicine and societies within geriatric medicine. The topics addressed by such collaborations address both the development of improved systems of care for frail older people in urgent settings, and improving the education and training of clinical staff working with frail older people in emergency care settings.

We report here on the conceptualisation, design and delivery of the first European Geriatric Emergency Medicine conference in Europe.

The aims of the conference were:

1. Raise the profile of GEM
2. Enhance clinical knowledge
3. Provide a platform for networking and inter-professional discussions

Methods

A stakeholder meeting was held to determine the key objectives, the target demographic, and the timescale for delivery. A review of the educational content of existing North American GEM fellowships, and the recently published European GEM curriculum was performed to devise a balanced conference agenda. The conference was supported by a website and twitter account. Professional societies were used to disseminate information. A learning needs assessment was built into the booking process to direct future events.

Results

Places booked steadily over five months to “fully booked”; demand was such that additional places were added and a waiting list was created. The number of twitter followers and website views steadily increased over this time period. 57% of delegates are doctors and 43% are nurses or allied health professionals. There is a wide range of delegates from across the UK and Europe.

Key conclusions

As an initial feasibility test, the booking pattern and delegate distribution for this conference support the observation that there is significant interest in the field of GEM from across a range of healthcare professionals working within a range of healthcare systems. Future efforts should be made to sustain inter-professional networks and national forums to share good practice and innovation within the field of GEM.  


Sarah TURPIN (London, United Kingdom), Simon CONROY
11:00 - 18:00 #7973 - General practice and emergencies room.
General practice and emergencies room.

 

OBJECTIVE:
 Diverse studies make reference to the use of the hospital services of urgencies (HSU), based on the users who go to such service without being evaluated previously by a doctor. The objective of the study is to  value the accurateness level and the agreement of the derivations to urgencies by other facultative personal.
MATERIAL AND METHODS:
A data collection card for every patient sent to urgencies with its corresponding report of derivation from Primary Attention (PA), specialized attention (SA), Continued Attention Point (CAP), 061, Medical Unit of Emergencies (MUE) and geriatrical residences is elaborated.
In each card the following questions are collected:
1st. Personal antecedents of the patient in the derivation report are indicated.
2nd. Is the medication that the patient takes indicated?
3rd. Is the symptomatology that the patient presents indicated?
4th. Is his/her physical exploration indicated?
5th. Is the diagnosis direction that motivates the derivation of the patient indicated?
And in the same card, once made the clinical history of the patient in urgencies, the criterion of the urgencies facultative is written down, it is valued if the patient could be treated in his/her center of origin and if he/she has needed hospitable entrance.
RESULTS:
- Less of 10% of the patients who go to urgencies do it with report of derivation.
- 66% of the patients did it through the family doctor.
- 14% through the 061.
- 11% were derived by the doctor of geriatrical residence.
- 6% were derived from the CAP.
- 3% were sent by the UME.
Conclusions related to accomplishment of the derivation report:
- 19% do not indicate who is the doctor that derives the patient.
- In 34% of them the information of the symptomatology that the patient shows is not indicated.
- In 44% of the reports the personal antecedents of the patient are not mentioned.
- In 42% of the reports any diagnosis direction is not specified.
- In 50% of them the medication that the patient takes is not mentioned.
- Only in a 41% of the cases the diagnosis direction is concordant with the diagnosis in urgencies.
-Almost the 100% of the patients sent by the MUE require hospitable entrance in relation to the 24% of who that were sent from primary attention.
- CONCLUSIONS:
The unnecessary visits to HSU constitute an important problem for the National Health System, with implications in the quality and costs of the attendance.
The use of HSU as substitute of the primary attention and  the inadequate derivation made by the professionals becomes in an overload to the hospitable set in damage of the resources for the attention of patients in risk vital situations.
The creation of a Protocol of Adjustment of Hospitable Urgencies agreed with the rest of the health areas can be an effective element in the identification of the hospitable urgencies.
 

Sonia BALLESTÍN SOROLLA., Elisa RUIZ OLIVARES, Teresa DE FERNANDO GROS (ZARAGOZA, Spain), Inmaculada CALLEJAS GIL, Patricia BONED BLAS, Carola MEDINA SAINZ, Ana Belén MARÍN FLORÍA, Pilar SARASA CLAVER, Silvia GANGUTIA
11:00 - 18:00 #8143 - GHB/GBL/1,4BD overdose: a case series and implementation of a new management protocol.
GHB/GBL/1,4BD overdose: a case series and implementation of a new management protocol.

Introduction

Gamma-hydroxybutyrate (GHB), gamma-butyrolactone (GBL) & 1,4-butanediol (1,4BD) are recreational drugs which in toxicity can cause sedation and a reduced conscious level. There is a high incidence of GHB/GBL/1,4BD use within the catchment area of St Thomas’ Hospital, London (approximately 250 cases/year). Most patients recover completely and spontaneously within 2 to 4 hours without significant intervention and are suitable for discharge direct from the Emergency Department (ED). While a small number of patients may require endotracheal intubation to prevent pulmonary aspiration and maintain adequate ventilation, previous case series have demonstrated very low rates of complications in patients with acute toxicity who are managed conservatively alone (without definitive airway protection).

There are currently no national or international guidelines for the management of patients presenting with acute GHB/GBL/1,4BD toxicity and there is the possibility that these patients may undergo unnecessary interventions and investigations. We conducted a retrospective review of a cohort of patients attending our Emergency Department with acute GHB/GBL/1,4BD toxicity to assess the variation in management of these patients with particular reference to the documented indications for intubation and CT brain.

Methods

Consecutive patients presenting to the ED at St Thomas’ Hospital, London, with acute GHB, GBL or 1,4BD toxicity from May-July 2015 were identified from admission records. Patients were included if they self-reported or there was a collateral history of GHB/GBL/1,4BD use.  A retrospective case note review was then conducted and documented indications for intubation and/or CT brain were recorded. No analytical confirmation of GHB/GBL/1,4BD use was carried out.

We proposed that acceptable indications for endotracheal intubation were GCS ≤8 and any of: vomiting or signs of aspiration, severe respiratory acidosis (pCO2 ≥7.5), recurrent seizures (≥2) requiring use of benzodiazepines, in order to facilitate safe transfer or no improvement in GCS after 2hrs observation. Acceptable indications for CT brain were reduced GCS and any of: concomitant head injury, signs of focal neurology/posturing or one or more seizures.

Results

60 patients attended with GHB/GBL/1,4BD toxicity during the study period. 23 patients (38.3%) had an initial GCS≤8. Thirteen patients (21.7%) underwent intubation and sixteen (26.7%) had a CT brain; twelve patients (20%) had both. The documented indications were deemed sufficient in five patients (38.5%) who underwent intubation and in four (25.0%) who underwent a CT brain. All patients who met the criteria for intubation or CT brain were treated appropriately. Intubated patients were extubated after a mean time of 7hrs 9mins (range 45mins to 14hrs 12mins; standard deviation 3hrs 53mins). Two intubated patients (15.4%), who had both vomited prior to intubation, were treated for aspiration and none of the patients who had conservative airway management had any complications. No patients had an abnormal CT brain.

Conclusions

A high proportion of patients in our cohort underwent intubation and/or CT brain and it is possible that some of these may have been avoidable. A new trust guideline and decision-making algorithm for the management of patients with overdose of GHB/GBL/1,4BD was implemented based on the indications for intubation and CT brain listed above.


Mark HADEN (London, United Kingdom), Paul DARGAN, John ARCHER, David WOOD
11:00 - 18:00 #7232 - Giant splenic artery aneurysm presented with sudden epigastric cramping pain.
Giant splenic artery aneurysm presented with sudden epigastric cramping pain.

Introduction:
Splenic artery aneurysms (SAA) are the third most common true aneurysm occurring in the abdomen after aortic and iliac artery aneurysms. SAAs are more common in women (female: male = 4:1) and in the sixth decade of life, with as many as 80 percent occurring in patients >50 years of age. Patients with symptomatic SAA present with nausea and vague abdominal discomfort in the midepigastric or left upper quadrant. They are clinically important because of the possibility of rupture, which is associated with a high mortality rate, especially during pregnancy and/or in patients with portal hypertension. This time, we presented a case of giant SAA (15 x 8 x 8 cm) with initially manifestation of sudden epigastric cramping pain.

Case report:
A 91-year-old male with a past medical history of hypertension presented with sudden epigastric cramping pain eight hours prior to admission. Initial vital signs were T 36.5℃, pulse rate 145/min, respiratory rate 18/min, BP 122/86 mmHg, room air SpO2 97%. Physical examination revealed epigastric tenderness without peritoneal signs and one abdominal pulsatile mass.

Chest X-ray revealed no obvious subphrenic free air or widening mediastinum. ECG revealed sinus tachycardia. Laboratory data revealed WBC 5380/μL, Seg: 68.2%, creatinine: 1.54 mg/dl, total bilirubin: 0.5 mg/dL, lipase: 135 IU/L. We initially suspected abdominal aortic aneurysm and arranged abdominal CT with/without contrast for further survey. The abdominal CT result revealed giant SAA. Endovascular stenting was performed by radiologist. His epigastric pain was relieved well after stenting.

Discussion:
Previous studies have shown a high risk for SAA rupture when the aneurysm measures >2 cm. Patients treated with conservative treatment showed a higher late mortality rate. Endovascular repair of the SAA has better short-term results compared with open surgical repair, including significantly lower perioperative mortality; however, open surgical repair is associated with fewer late complications and reinterventions during follow-up. Endovascular repair has the best outcomes and should be the treatment of choice if the splenic artery has a suitable anatomy for endovascular repair.


Jiun-Jia CHEN (Taichung City, Taiwan)
11:00 - 18:00 #7448 - Glasgow Blatchord Score (GBS): Raising The Bar.
Glasgow Blatchord Score (GBS): Raising The Bar.

Introduction: Upper GI bleed (UGB) is a common presentation to the emergency department (ED). It accounts for three percent of all hospital admission. The GBS has been found to be superior to both the Rockall and AIM65 score for risk stratification of UGB. A GBS score of ≤0 has been shown to have a sensitivity of >99% for stratifying low risk bleeds, however recent studies show a GBS of ≤1 is equally sensitive and therefore could be considered as an appropriate cut-off for stratifying patients as low risk.

Aims: The aim of this study was to a) determine the frequency of use of the GBS score in the ED and b) to assess the relationship between GBS and esophagogastroduodenoscopy (OGDs) findings and need for intervention.

Method: Retrospectively, data was obtained from both ED and endoscopy unit from the 1st January to 31st of July 2015 of all patients presenting to University Hospital Galway with UGB. Patient’s demographics, GBS, OGD findings and intervention were recorded.

Results: A total of 109 patients were identified but data was available for 86 patients who fulfilled our criteria. In this study 47(55%) were males and 39(45%) were females, mean age 59 and 65 respectively. Only 12(14%) had their GBS documented on admission. Sixty four patients had normal (non-active bleeding) OGD’s, six had active bleeding on OGD, while sixteen patients had no data available. Of the seventy patients who underwent OGD’s, nine patients required intervention.

Seventeen patients(20%) had a GBS ≤1 who underwent OGD's, none had active bleeding or required intervention. A GBS≤1 had a sensitivity and specificity of 100% and 30% respectively. It also had a NPV of close to 100% in predicting active bleeding and need for intervention.

Conclusions: Using a GBS of ≤1 was shown to be sensitive for identifying low risk UGB which could therefore be offered OGD as out-patients, there by reducing admission for UGB by 20%. Education of first responders and appropriate referral system for outpatient management of patients presenting with a GBS of ≤1 should be facilitated.


Etimbuk UMANA (Belfast, Ireland), Olayiwola AMORAN, Carol GOULDING
11:00 - 18:00 #7768 - Glasgow Coma Score in trauma cases.
Glasgow Coma Score in trauma cases.

Background: Glasgow Coma Score are different patterns in each type of trauma. The aim of this study is to define certain patterns of GCS in some type of trauma: fire incidents, road accidents, falls, work accidents, drawing and electrocution.

Methods: Retrospective medical study based on statistical analysis of SMURD national database on a period of 4 years (2010-2013).

Results: Although the frequency of car accidents and falls from height is higher than other types of trauma, the incidence of seriously altered GCS caused by electrocution and drowning is 4 times higher.


Smarandoiu MARIUS, Canciu ALIN (Sibiu, Romania)
11:00 - 18:00 #7819 - Global State of Emergency Medicine.
Global State of Emergency Medicine.

Study Objectives The specialty of Emergency Medicine (EM) is at different stages of development around the world. Some important milestones in the development of EM include recognition as a specialty, the presence of residencies programs, board certification, professional societies, recognized fellowships, and a specialty journal. ACEP International Ambassadors are selected to represent ACEP and create a report on current state of EM in a particular country. Our objective was to describe the state of emergency medicine globally based on the ACEP International Ambassador Yearly Country Reports.

Methods All ACEP International Ambassador Country Reports published in the ACEP website as of April 2015 were analyzed. Variables available for most countries included whether EM is recognized as a specialty, existence of an EM residencies, presence of an emergency medicine professional society, availability of an EM Fellowships, and circulation of an EM professional journal. Descriptive data was tabulated and reported as frequencies.

Results Ambassador Country Reports were available for a total of 83 countries (Figure1). Of the countries represented, 6 were from North American and the Caribbean; 17 were from South American and Central America; 18 were from Europe; 15 were from Africa; 16 were from Asia and Australia; and 11 were from the Middle East. EM was recognized as a specialty in 58 countries (70%). EM residencies existed in 58 countries (63%). An EM professional society was present in 60 countries (72%). EM Fellowships were available in 52 countries (63%), and EM professional journals circulated in 31 countries (37%).

Conclusion ACEP International Ambassadors have produced Country Reports for approximately 50% of the world’s countries. Emergency medicine is present in a large part of the world, albeit mostly in early stages of development. More detailed information on the current state of EM in every country would inform efforts to further develop EM as a specialty globally and improve emergency care provided around the world.


Nirma BUSTAMANTE, Andres PATINO (Cambridge, USA), Christian ARBELAEZ
11:00 - 18:00 #8062 - Granulomatosis with polyangiitis (GPA) revealed by alveolar hemorrhage, ARDS and renalfailure: case report.
Granulomatosis with polyangiitis (GPA) revealed by alveolar hemorrhage, ARDS and renalfailure: case report.

 

Introduction:

Alveolar hemorrhage is a rare but usauallydivastating complication in systematic vasculitis. Early diagnosis and treatment of GPA may lead to a full recovery.

Case report:

A 38-year-old male patient presented to the emergency department (ER) for hemoptysis, arthralgia, asthenia and emaciation. He had a history of nosebleed, tinnitus and dizziness.

His vital signs were as follow: respiratory rate of 30 breaths/min, oxygen saturation with pulse oximetry as 96% with 5 litre/min of oxygen,crackles by lung auscultation, pulse rate of 110 beats/min, angiomas in both elbows and legs and hematuria.

The laboratory tests were creatinine clearance at 23 ml/min, hemoglobin level at 5,8 gr/dl, white blood cells count 13260/ml and platelets count 126000/ml.

Thoracic computed tomography (CT): massive alveolar hemorrhage

GPA has been confirmed with a positive level of antineutrophil cytoplasmic antibodies (ANCAs).

He became increasingly dyspneic due to acute respiratory distress syndrome. He has been intubated. A PiCCOᴿ has been performed. The extravascular lung water index was 24ml/kg. Many hemodialysis sessions have been performed. He received prednisolone and  a bolus of cyclophosphamide. He was transfused. The patient presented clinical and biological improvement. However, after the second bolus of cyclophosphamide, he presented a septic shock with pancytopenia. He died 27 days after.

Conclusion:

The patient in this case died due from iatrogenisis due to the side effect of immunosupressor, despite an early diagnosis and treatement. Management of therapeutics in GPA needs to be reviewed in intensive care units.


Houcem OUNI (tunis, Tunisia), Mohamed Ali CHERIF, Ons ANDOLSI, Khaled SAIDI, Najeh HAJJEM, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7165 - Gripal syndrome in January will not always be Gripe.
Gripal syndrome in January will not always be Gripe.

A 15 years old man student with no medical history.  He consultation in February with 3 days of  evolution in artromialgias, weakness in the lower limbs, 38C fever, decreased appetite and altered behavior.

Physical examination: agitation and nervousness, feeling of illness, fever, hypotensive and tachycardic , Saturation 98%, tachypneic.

Oropharynx normal, no lymphadenopathy. Cardiopulmonary auscultation without findings. Abdomen: soft and depressible with no signs of peritoneal irritation, discreet hepatosplenomegaly. Neurologic: moderate nuchal rigidity and lower limbs decreased sensitivity. A skin level, maculopapular rash on the legs and trunk with erythematous ulcerated lesion in the right edge of inner side knee. The patient tells us that since it appeared to three weeks skin lesions attributed to flea bites from your hamster.

           Tests: leukocytosis neutrophilia 33,320, TP 48.9%, Creat 3.66, PCR 354. Thorax Radiography: without findings. Given these results he entered expand analytical observation with suspected septic process (Ph 7.29 Lactate 4.5) and TAC prior skull puncture (high pressure liquid crystalline) was performed. Blood cultures were extracted throat swab H1N1 (seasonal influenza peak A), urine, and CSF culture Serology (Rickettsia, Coxiella, Borrelia, Brucella).

We begin empirical treatment: ceftriaxone, clarithromycin, doxycycline and acyclovir. Tras10 hours under observation, began with tachypnea, hypoxemia, alveolar infiltrates ray Thorax where bilateral interstitial were observed repeated.

 Serology negative H1N1. Due to respiratory distress proceed to orotracheal intubation: Septic Shock Distributive associating renal failure, coagulopathy consumption, lactic acidosis.

After 72 h in ICU serological result was received: Rickettsia agglutination conorii positive Ig M 1/700 confirming Fever boutonneuse. He evolved well remain high at 6 days.

Discussion:

 We have presented this case because full social alarm influenza must be alert to febrile almost all associated artromialgias, malaise, headache and fever, reasons for consultation very common in emergencies, thus highlighting the history and physical examination are very valuable tools in this case, where almost unnoticed boutonneuse the skin lesion spot on leg and February is not exactly the time where the vector, the tick, has increased activity, it usually happens in summer.

Rickettsiae usually live insects such as mites, ticks, fleas or lice. Human infection occurs by the bite of these insects that act as a reservoir. The clinical case corresponds to an infectious disease (boutonneuse fever) caused by Rickettsia conorii and transmitted by the hamster tick with skin sting from this location over the blood occurs, causing a vasculitis widespread. Today it is known that endothelial injury break endothelium-platelet unit, platelet activation, increased thromboxane A2 and endothelin release.

Spotted fever usually has a benign clinical course, but a small percentage of cases (2-3%) has a severe course with significant visceral involvement, resulting in renal failure, disseminated intravascular coagulation with purpuric rash, severe hepatic impairment, infiltrators lung and altered consciousness. Rickettsiae proliferate in the endothelium of small arteries, veins and capillaries causing increased vascular permeability, microthrombi formation, vascular occlusion and microinfarcts. Injuries can affect various organs such as the liver, spleen, lung, kidney, myocardium, muscle, meninges and brain.


Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #7860 - Hamate Body Fracture: A Rare Entity.
Hamate Body Fracture: A Rare Entity.

Background: The hamate bone is an irregularly shaped carpal bone found within the hand. Fractures of hamate bone are rare and often difficult to diagnose, hamate fracture constitute about 2 % of all carpal fractures. Hook of hamate fractures have the potential to cause significant injury to the ulnar nerve and artery. Herein, we present a rare case of isolated hamate body fracture in a young male following blunt trauma during a motor vehicle accident.

Case: A 23 year-old previously healthy man was involved in a motor vehicle accident and presented to our emergency department with a complaint of left wrist and hand pain on the ulnar side of the wrist. On arrival, the young male was alert and oriented, and his vital signs were stable. On physical examination, he complained about pain in his left hand and wrist since 1 hour. His pain relieved with grip strength. He had tenderness on the ulnar side of the wrist. Anteroposterior and oblique x-ray showed no fracture but, Computed tomography (CT) scan of the wrist revealed a displaced hamate body fracture. The patient was finally diagnosed as having hamate body fracture and he underwent operation for displaced hamate body fracture.

Conclusion: On conventional x-ray, 60% of wrist fractures are misdiagnosed as simple wrist sprains. Carpal bone fractures can be difficult to detect radiographically, hence CT of the wrist should be considered where fracture is still suspected. When hamate body fracture is detected early, appropriate treatment can improve a patient's quality of life and reduce disability,


Onur KAPLAN, Demet TAS (İstanbul, Turkey), Mehmet YIGIT, Tugba EVRAN
11:00 - 18:00 #8250 - headache and neurological deficit.
headache and neurological deficit.


Male 41 years without medical history that begins in the afternoon a picture of headache deaf features and occipital predominant location and right parietotemporal refractory to analgesia , to which is added from nausea morning and vomiting along with general malaise and loss left side of the body force, denies infectious symptoms or feeling in previous days dysthermia.

On arrival at the emergency presents Tª : 36º , FC. 45lpm , TA 128 / 65mmHg , Sat : 99 drowsy but conscious and oriented , reactive isochoric pupils, deviation left corner of the mouth , left-sided hemiparesis , rhythmic cardiac auscultation without murmurs and lung auscultation and abdominal preserved , Whit 25800 leukocytes / ul , 91.80 % neutrophils , lymphocytes 2.62 % 456000 platelets / ul Coagulation : standard without alterations in biochemical laboratory tests are performed where blood count presents.


It was decided to perform Neuroimaging : Brain CT hyperdensity upper , right sagittal sinus , sigmoid and right jugular vein filling defect after contrast administration regarding venous sinus thrombosis . Engorgement of veins. hypoplastic transverse sinus and sigmoid left . Cortico -subcortical hypodense occipital right in relation to cerebral edema cerebral congestion , effacement of sulci and fissures . partially obliterated Cisternas. ventricular system size and normal morphology centered midline


After result is oriented as ischemic acute cerebrovascular disease : cerebral infarction secondary to right parietal rare cause (cerebral venous thrombosis of superior sagittal sinus , rectum, sigmoid and right jugular vein) .  admission is decided in Stroke Unit for clinical monitoring , anticoagulation treatment begins with enoxaparin and cerebral resonance is requested Magnita resulting in venous thrombosis level superior sagittal sinus


Neurology patient admitted for cerebral venous thrombosis. He has presented severe headache that initially required treatment with analgesia and mannitol , improvement in recent days after admission , good control with oral analgesia. During admission he has presented progressive improvement of the initial neurological deficit


In the general population, 98% experience a headache in his life , 75 % men and 95 % women, which tension between the origin 42 % , 12% and chronic migraine headache daily 3%

The headaches cerebral venous thrombosis according to a study of a number of hospital-based nationwide in Portugal which included all patients admitted to the neurology in the country identified 91 new cases of CVT , corresponding to an incidence of 0.22 / 100,000 per year ( 95% CI : 0 to 0.47 ), although this low incidence etiology should be in the differential diagnosis of headaches with neurological deficits.


Sandra GUIU MARTI, German Jose FERMIN GAMERO (PALMA DE MALLORCAQ, Spain), Pedro RULL BERTRAN, Julio OLSEN, Claudina REVOL, Bernardino COMAS DIAZ
11:00 - 18:00 #7747 - Headache unresponsive analgesics:Cerebral abscess.
Headache unresponsive analgesics:Cerebral abscess.

INTRODUCTION: A brain abcess is a focal pyogenic infection. It is a pathologic response typical of a relatively compotent immune system against a bacterial invader. Presenting features of brain abcess are nonspesific. In this case, we present to the patient with still ongoing headache despite having taken analgesics.

CASE: 34-year-old female patient admitted ER with headache unresponsived the analgesics. She had complaints of nausea, vomiting. In history, she had migraine and had taken analgesics because of lasting headache. The radyologic imaging demonstrated a focal abcess about 17 milimeter in diameter with peripheral hyperdense, central hipodense and around edematous areas, forming mild pressure to third ventricule in the right lateral talamus. The patient was interned to neurosurgery clinic.

CONCLUSION: These patients rarely appear acutely ill, and the classic triad of headache, fever, and focal neurologic deficit is present in less than one third of all patients. As a result the diagnosis is often delayed. The most common symptom is headache,which is a complaint in almost all cases. It is diagnosed by imaging studies. The differential diagnosis of headche must be done even in patients with migraine as in the case we presented.


Mehmet UNALDI (ISTANBUL, Turkey), Ersen GUNDUZ, Cihan BUYUKSUTCU, Unsal KARAHALILOGLU, Meltem COLLU, Onur INCEALTIN, Kurtulus ACIKSARI, Hatice ERYIGIT
11:00 - 18:00 #7349 - Heart at the time of impact; A new mystery!
Heart at the time of impact; A new mystery!

Introduction Heart rate is an important indicator of injury after trauma. Tachycardia is associated with blood loss, pain, physiological and psychological stress (1). However what happens to heart rate at the time of impact in a crash is unknown and has never been recorded. The advent of heart rate monitors allows constant real time recording of heart rate and speed while exercising. 

Case ReportA competitive 45 year old triathlete was on kilometre 8 of a  40 km journey  at a speed of 30km/hr  ( recorded by his GPS tracker), when he skidded on ice and fell on his left side, skidding five  metres along the road. He got up immediately and went to the side of the road to recover. He rested for five minutes and then proceeded to visit a local doctor.  He was diagnosed with bruising of the left hip and acromioclavicular joint. 

At the time of impact his Heart Rate Monitor showed rapid deceleration over a period of 30 seconds. During these 30 seconds pulse dropped from a high of 130/min to 50/min and then within 8 seconds returned to normal.

On another event, he was cycling at a slower speed when he hit the corner of a footpath & stopped abruptly. His pulse again showed a rapid drop from 130/min to 70/min immediately after the crash which then went up to 120 over the next few seconds before normalising to 88/min.

In this exercising athlete the heart rate drops and quickly returns to normal after crashing despite the associated pain and stress.

DISCUSSION

There are no other recorded episodes of heart rates at the time of impact in the literature. Tachycardia is a normal physiological response to exercise with heart rates up to 220 beats per minute being recorded in elite athletes. Such heart rates usually return to normal rapidly during recovery (2). Tachycardia is also a response to stress while racing cars with rates averaging 168 being recorded while rally driving (3). While tachycardia is a sign of blood loss after trauma, it is unlikely to be present at the time of injury- as the blood loss has only begun.

In this case we can see that exercise related tachycardia returns to normal rapidly after a cycling crash. We can also ascertain that physiological stress such as exercise and impact do not cause persistent tachycardia in athletes after a crash.

If tachycardia persists after a crash an alternative should be sought and a major injury with haemorrhage or an arrhythmia needs to be excluded.  

Real time heart rate monitoring and GPS tracking have opened a new chapter of research. This will lead to unfolding of many cardiovascular mysteries previously unknown to man, just like the case mentioned above.

References

References

1. Hall,J; Guyton,A Textbook of medical physiology;2000.

2. The Heart of Trained Athletes, Cardiac Remodeling and the Risks of Sports, Including Sudden Death; Circulation. B.J, Marron etal. 2006, Vols. 114: 1633-1644.

3. Stress Markers During a Rally Car Competition; TJSCR  Del-Rosso etat 2015, Vols. 30(3):605-614.

 

 


Mustafa MEHMOOD (Dublin, Ireland), Brian MCNICHOLL
11:00 - 18:00 #7672 - Heart attack of origin nonatherosclerotic.
Heart attack of origin nonatherosclerotic.

Female 43 years without medical history being at home have chest pain radiating to left arm central opresive accompanied by intense vegetative courtship. In principle it attributed to recent treatment with benzodiapecines due to secondary Whiplash suffered a car accident 4 days before rollover of its tourism and trauma to chest with the steering wheel. Because of the duration of the emergency alerts box, on arrival home objective is electrocardiogram ST underside rise to normal after administration of nitroglycerin and giving pain.

It is he transferred to our hospital, normotensive remains in critical area has Idioventricular pace with normal initial troponin self-limiting. It is entered under observation with suspected coronary vasospasm as electrocardiogram was normal. At 6 hours troponins and CK-MB 18.5 32.3 remained asymptomatic. At 8 hours of admission presents new box typical chest pain with ST elevation in anterior territory. Given the traumatic history is requested Thorax CT angiography without significant findings. are contacted hemodynamics cardiologist and cardiac catheterization proceed to that objective compatible amputated anterior descending distal dissection, deciding conservative treatment. With the diagnosis of chest pain secondary to traumatic dissection of the left anterior descending coronary artery enters for 48 hours in intensive care unit remained asymptomatic and was discharged to ground where he remained admitted for 3 days.

At discharge he was treated with nitroglycerin, beta-bloquentes and dual antiplatelet therapy.

DISCUSSION

Within nonatherosclerotic etiologies of acute myocardial infarction secondary to blunt chest trauma is a rare entity. The difficulty in making the diagnosis is masked by the traumatic context, it is confused with the trauma clinic. Suspicion of this disease is the basis of successful management since early diagnosis allows to start the correct treatment.

There are also cases of spontaneous dissections in patients with: fibromuscular dysplasia, Marfan disease, Ehler-Dahnlos disease, pregnant or intake of contraceptives, cocaine intoxication or iatrogenic (angioplasty, catheterization). At present conservative treatment is recommended as most dissections heal spontaneously.

CABG is suggested in multivessel dissections, dissections extensive ongoing ischemia or commitment of left main coronary artery


Justino PACHECO (Malaga, Spain), Maria Isabel CORREA
11:00 - 18:00 #7562 - Heart Failure in an Irish ED: Presentation patterns, clinical trajectories and European guidelines.
Heart Failure in an Irish ED: Presentation patterns, clinical trajectories and European guidelines.

BACKGROUND

Noting that chronic disease (CD) accounts for 2/3 of emergency medical admissions and approximately 80% of all healthcare costs, the Irish Health Service has an initiative to improve CD quality of care. Presently, ‘integrated care’ of CD generally refers to care by GP punctuated by specialist input and does not explicitly involve the emergency department (ED). However, while CD’s do account for 2/3 of ED admissions, less than 1/4 of ED presentations are admitted. This study is part of a larger project that has previously shown (1) there is a nearly 3-fold larger cohort of CD-related ED presentations that are discharged, (2) ED acute management of CD is often inconsistent with evidence-based guidelines used by specialists, (3) inconsistencies in care for CD patients can be improved, and in so doing the ED can make a meaningful contribution to integrated care of CD.

This study aims to: (1) Characterize heart failure (HF) related presentations to the ED; (2) Compare discharged and admitted cohorts; (3) Assess the applicability of European Society of Cardiology (ESC) guidelines in the assessment and treatment of HF-related presentations.

METHODS

During a 1-year period, ED physicians were asked to complete a questionnaire in cases when HF was a contributing factor to presentation. Questions related to: establishment of HF diagnosis, presenting complaint, availability of HF baseline data, admission, and clinical concerns of the ED physician. ESC guidelines were examined as to their applicability in these presentations.

RESULTS:

Surveys from 65 HF-related presentations were received: In 63% of cases, patients were admitted. A diagnosis of HF was known in 70% of cases and 30% were likely de-novo diagnoses. Of established HF cases, 70% were receiving care in our hospita andl 40% of these were discharged. Of the de-novo presentations, 37% were discharged. In these, 88% had a dyspnoeic component to their complaint, but only 39% in the established HF patients.

ESC guidelines for HF is a 50-page document containing 29 tables. While comprehensive, at a practical level this document is not used in ED. Interestingly, section 7.1 states 'Reductions in mortality and hospital admission rates both reflect the ability of effective treatments to slow or prevent progressive worsening of HF'.

DISCUSSION

This project has shown previously that 3% of ED presenters have HF of which 30% are admitted. ED physicians in this study reported only completing the survey for HF related presentations they found challenging. Challenges most reported were (1) the lack of explicit admission criteria (2) lack of guidance in therapy for discharges, particularly in the context of renal failure. No one interviewed had used the ESC guidelines, though all were aware of them. Many cited the COPD care bundle used in our hospital as an effective ED tool.

CONCLUSION

(1)There is a significant cohort of HF-related presentations who are discharged directly from ED. (2) ESC-HF guidelines lack practical functionality for application in ED, particularly admission criteria and discharge advice. (3) Distilling the ESC guidelines in to a functional ED care bundle should be explored. 


Dr Kelly JANSSENS (Dublin, Ireland), Nigel SALTER, Rory O'HANLON
11:00 - 18:00 #8099 - Helping the doctor to being a doctor - The future Role of Physician Assistants in central emergency departments.
Helping the doctor to being a doctor - The future Role of Physician Assistants in central emergency departments.

Background

In consideration of rising patient’s figures, demographic change and multimorbidity, the emergency care is an important field in healthcare systems [1]. Actually, ensuring supply of emergency care is a great challenge [2]. The emergency department (ED) belongs to the high risk area of a hospital [3]. The patient’s amount can´t be planned and the different certified employees lead to different assessments of the urgency of treatment [4]. The clinical emergency care has made a development into the professionalization, standardization and adjustment to international relations during the past years [5].

Aim

To show the characteristics of a central emergency department and the professional opportunities or possibilities of a Physician Assistant in emergency care units.

Methods

A structured literature research by PubMed in Medline and EMbase was conducted. Additional, experts were interviewed to different subjects of the clinical emergency care and the job profile of the Physician Assistant. These results were compared to the evidence-based knowledge.

Results

Characteristics of the future emergency care are centrality, cooperation and independence [6, 7]. The centralization can contribute to professionalization of structures and working procedures [7]. In the last 10 years more and more central provisional ED´s were established [8]. So far, the technical qualifications of the employees in ED´s is not regulated, indeed, the DGINA recommends an education of specialists for emergency medicine [6, 8].

Discussion

Emergency care is currently highly influenced by the sector separation and technical interests. But actually, the patient should be on focus of the economy and medicine [1]. Besides, the takeover of the emergency patients is delayed by the specialised emergency departments. This often results in conflicts between different specialised divisions to the detriment of the emergency patients [9]. From medical point of view the optimum medical treatment has priority [10]. Nevertheless resource shortage and the use of scarce resources with regard to public welfare should not be neglected [1].

In this dilemma Physician Assistant's offer the possibility to implement physician-relieving structures and thus lead to a reduction of resource shortage.

 

Conclusion

The future emergency department should be organised centrally, guarantee evidence- based medical care and transfer the initial symptoms into a reasonable diagnosis. The exclusion of life-menacing differential diagnosis is a key task [11].The legal basic conditions to the organisation and financing of the emergency care must be adapted to the high-class standards of an evidence- based medicine [12]. The central emergency department should guarantee the quick certified first care and contribute to the efficiency increase in the hospital [13]. The centralisation of the available resources to a central emergency department is recommended in general, but the necessary personnel qualification must still be regulated. Above all, certified staff is the condition for an optimum patients care [14]. The implementation of PA´s in central emergency departments would help doctors to being doctors.


Christina ISFORT, Julia GRATOPP, Manuel GEUEN (Rheine, Germany), Michael WESSELS
11:00 - 18:00 #7341 - Hemodynamic evaluation in patients with undifferentiated shock in the Emergency Department : validation of a simple goal-directed ultrasound based protocol.
Hemodynamic evaluation in patients with undifferentiated shock in the Emergency Department : validation of a simple goal-directed ultrasound based protocol.

Introduction

Shock state (SS) is a life-threatening condition which frequently occurs in Emergency Medicine. It requires a prompt treatment based on an accurate diagnosis. Usual strategy including clinical exam, biological and radiology exams is frequently conclusiveness. A treatment as a fluid loading can be life-saving in a case and deleterious in another.

The goal of this study was to validate a protocol based on B-mode echocardiographic views and lung ultrasound (EPU).

Patients and methods

Inclusion criteria

Age > 18 years

Shock defined by systolic arterial pressure < 100 mm Hg

exclusion criteria

clinically evident hemorrhagic or anaphylactic shock

Acute coronary syndrome

Documented end of life

Methods

EPU included the four usual cardiac views and lung ultrasound. Possible treatments were : fluid loading (FL), inotropic agents (IA), thrombolysis (TH), pericardiocentesis (PE) and unknown. Associated diagnosis were: hypovolemic (including early severe sepsis) (HV), cardiogenic(CA), cardiac tamponnade (CT), right ventricle overload (RV) and unknown (UN).

This non interventionist study was approved by the Ethics committee. After informed consent and clinical exam, the EP stated the diagnosis hypothesis (H1), the treatment (T1) without applying it and the certainty (C1). He realized the EPU and stated again the diagnosis hypothesis (H2), treatment (T2) and certainty (C2). Duration of realization and difficulty evaluated on a scale from 1 (very difficult) to 10 (very easy) were recorded. T2 was applied to the patient’s care. Reference diagnosis (H3) and treatment (T3) were determined by a 3 experts panel with the whole patient’s file.

Primary objective: concordance between T1, T2 and T3

Secondary objectives :

Concordance between H1, H2 and H3

Analyze of duration, difficulty and certainty

The required number of subjects for a concordance of 0.6 between T1 and T3 and 0.8 between T2 and T3 with alpha risk 0.05 and beta 0.10 was 44.

Statistical method

Values stored in Microsoft Access were analyzed with PASW. Numerical data expressed as mean + SD were compared by a Student t test. Categorical data by a Khi2 test. Concordances were analyzed using Kappa coefficient. P< 0.05 was considered significant.

Results

50 patients were included, 22 women and 28 men, aged 73+12 years. Final treatments were 37 FL (74%), 5 TH (10%), 4 IN (8%), 3 PE (6%) and 1 UN. Corresponding diagnosis were 37 HV, 5 RV, 4 CA, 3 CT and 1 UN. T1- T3 and T2-T3 Kappa were 0,17 [0.05-0.28] and 0.95 [0.90-0.99] respectively, p < 10-4. H1-H3 and H2-H3 were 0.35 [0.25-0.44] and 0.95 [0.90-0.99] respectively, p <10-4. C1 and C2 were 3.6+2.3 and 9.2+1.1 respectively, p <10-4. Duration was 14+5 min and difficulty 6.4+1.9. Appropriate treatments were 62% before EPU and 96% after, p = 8 10-5.

Discussion

Concordances were bad (T1-T3) and poor (H1-H3) for the usual approach while they were excellent for the EPU (T2-T3) and (H2-H3). Almost 40% of intentions of treatment were inappropriate after the usual approach. Face to a shock, a simple visual ultrasound exam enhances the diagnosis procedure and allows to determine the right treatment in a very short delay.


Philippe LE CONTE (Nantes), Pierre LEROUX, Idriss ARNAUDET, Philippe PES, Frédéric VIGNAUD, Emmanuel MONTASSIER
11:00 - 18:00 #7377 - Hepatic venous gas: A case report.
Hepatic venous gas: A case report.

Introduction : Hepatic portal venous gas is an ominous and late radiological sign indicating severe intra-abdominal pathology, with the most common cause being mesenteric infarction. The mechanism inducing this gas in the portal vein is not well understood. The prognosis is more influenced by the severity of underlying disease rather than hepatic portal venous gas itself. 

Case report: A 75-years-old female with medical history of anemia and thrombocytopenia. She presented to the emergency department, nine days after surgery, for generalized abdominal pain and fever. She was operated for caecal adenocarcinoma associated with multiple adenomatous polyps in the left colon. A total colectomy with primary anastomosis performed. She was discharged at home six days post-operative. Physical examination revealed a body temperature 39 C, blood pressure 11/6, a pulse rate 130 beats/mn, a respiratory rate 40 cycles/mn. The abdomen was distended with no bowl sounds, generalized tenderness with rebound. Laboratory studies revealed a hemoglobin level at 10g/dl, a white blood cells count of 22900 cells/ul and a prothrombin time of 43.1%. His creatinine level was 54 umol/l and his c-reactive protein level 186 mg/l. A contrast enhanced abdominal CT showed a multiple branching radiolucencis in the periphery of the liver, large amount of gas in the portal and superior mesenteric vein. It showed also an important pneumoperitoneum, ascites and small bowel distension. These finding strongly suggested post-operative peritonitis.  Emergency surgery followed. Laparotomy showed a generalized purulent peritonitis with anastomotic leak. Peritoneal wash and closure of rectal stump were performed and ileal stoma constructed. The patient died twenty fours hours after surgery by septic shock.

Conclusion : Porto mesenteric venous gas is a nonspecific radiological sign. Its causes are various but mesenteric infarction and intra-abdominal sepsis were the most common. Abdominal CT allows the diagnosis with high degree of sensitivity and sensibility and identifies the underlying cause. Urgent laparotomy is mandatory without delay to improve the prognosis. The mortality rate remains high and is related mainly to the etiology.


Jihene AOUAM (Tunis, Tunisia), Mehdi CHARFI, Saloua HOUIMLI, Mouna TITEY, Dorsaf BELLASFAR, Rim HASSINE, Abdelmajid BEN ROMDHANE
11:00 - 18:00 #7757 - Hepatotoxicity caused Cassia angustofolia (Senna).
Hepatotoxicity caused Cassia angustofolia (Senna).

Cassia angustifolia (Senna), used as a laxative, is a plant from the Fabaceae family. It includes hydroxyanthracene glycosides, also known as Senna Sennoside. These glycosides stimulate the peristalsis of the colon and alter colonic absorption and secretion resulting in fluid accumulation and expulsion.We report in this case that hepatotoxicity related to drinking tea contained Cassia angustofolia only once ( as a cup of tea).

A 72-year-old man was admitted to the ED with six hours history of worsening abdominal pain. He not reported nausea and vomiting.In history,he sufferred from biliary pancreatitis eight months ago.Blood samples revealed AST:364 U/L, ALT:274 U/L, LDH:540 U/L. Hepatobiliary ultrasonografic scanning detected multibl milimeter calculs and minimal sludge in gall bladder.We implemented fluid replacement initially. He was interned to general surgery clinic.

The cause of senna-related hepatotoxicity is unclear but could be explained by the exposure of the liver to unusual amounts of toxic metabolites of anthraquinone glycosides. In the literature, there are reports illustrating the hepatotoxic effects of Cassia angustifolia with long-term usage but hepatotoxicity caused use Senna only once is rare.

 


Mehmet UNALDI (ISTANBUL, Turkey), Ersen GUNDUZ, Ismet DOGAN, Tuce DUZKEL, Onur INCEALTIN, Kurtulus ACIKSARI, Hatice ERYIGIT
11:00 - 18:00 #7739 - Herpes simplex encephalitis: report of a case.
Herpes simplex encephalitis: report of a case.

Male patient, 24 years. No medical history. Presents with headache, fever, vomiting and diarrhea since 5 days. His family doctors diagnosed him stomach flu and prescribed him antypiretics (paracetamol) and antibiotic (ciprofloxacin); patient continued with fever, headache and disturbance of consciousness so he decided to come to our emergency.

Physical exam: Regular condition, conscious and disoriented, febrile,eupneic. BP 115/70, HR 85 bpm Tª38,1. Cardiopulmonary auscultation: Rhythmic no murmurs, preserved vesicular murmur; Abdomen: globular, blando, no masses or organ enlargement, blumberg - Murphy -; MMII:, no signs of DVT. NRL: PICNR, no findings cranial pairs, bradipsiquia language, motor dysphasia. Glasgow 14. 

Additional tests on admission: Blood test: Leukocytes 10600, Hb 15,9% Platelets 320.000 TP 80 g, 109 glucose. EKG: sinus rhythm at 90 bpm without alterations of repolarization.Chest and abdomen x-ray: no findings of interes. Cranial CT showing hypodense area that affects white matter of the temporal lobe , insular area and left external capsule , with discrete mass effect and midline deviation (2.5 mm). 

The patient was admitted to the observation area where a lumbar puncture was performed. Cerebrospinal fluid analysis showed: Leukocytes 460 (polymorphonuclears: 5%; monocytes 95%), glucose 57, proteíns 139,6; xanthochromia negative. To these results , the diagnosis of herpetic meningitis is made and treatment is initiated with acyclovir.

Evolution:  Patient was transferred to the neurology care unit. During admission the neurology area a nuclear magnetic resonance was performed: hypointense signal on T1 images convolutions translating edema , and hyperintensity on T2 signal , DP , Flair. It affects the insular cortex including cortical and white matter, respecting the putamen.

CNS infections and meninges in recent years have increased their prevalence and have changed their appearance due to various factors such as increased immigration occurrence of infections that until recently were unknown in our environment, the development of resistance to treatment the existence of more patients with immunosuppression (HIV , transplant immunosuppressant drugs ... ). All this means greater diagnostic difficulty for both the clinician and the radiologist.The herpes simplex encephalitis is the most common viral encephalitis and produces a hemorrhagic necrotizing meningoencephalitis and withering. The HSV type 1 affects infants, children and adults (in the latter is the result of reactivation of latent infection in the trigeminal ganglion nerve). The changes affect the limbic system (temporal lobes, insular cortex, subfrontal circonvoluciones area and cingulate). CT is frequently normal in early stages, later may show hypodensities in temporal lobe with mild mass effect, hemorrhage at the beginning is rare but very suggestive. Contrast administration can show poorly defined giriforme patched or enhancement. MRI shows changes in the first 48 hours: hypointense signal on T1 images convolutions translating edema, and hyperintensity on T2 signal, DP, Flair. It affects the insular cortex including cortical and white matter, respecting the putamen. Bilateralism is sequential feature: the involvement is usually initially unilateral but is typically followed by a less severe contralateral disease. Treatment is intravenous Acyclovir.


Carmen Adela YAGO (Malaga, Spain), Enrique CARO, Marina BUFORN
11:00 - 18:00 #7930 - HHOSPITAL ADMISSION OF PATIENTS WITH COPD EXACERBATIONS IN AN EMERGENCY ACCORDING TO THE CRITERIA OF SEVERITY.
HHOSPITAL ADMISSION OF PATIENTS WITH COPD EXACERBATIONS IN AN EMERGENCY ACCORDING TO THE CRITERIA OF SEVERITY.

Introduction
Exacerbations of COPD (COPD exacerbations) represent today the main reason for consultation in the emergency of these patients. The use of antibiotics have precise indications but no longer in dispute.

Objetive:
Rate hospitalization of patients visiting an emergency ward for exacerbation of COPD taking into account the severity criteria both clinical and analytical.

Material and methods:
Observational, retrospective study in a General Hospital with an area of 200,000 inhabitants and 275 urg / day. The medical records of patients with a previous diagnosis of COPD exacerbation had consulted January 2012 to July 2015. clinical severity criteria (cyanosis, impaired consciousness, respiratory arrest, tachypnea and use thoracic accessory muscles) and analytical (pO2 <50, pCO2> 70, pH> 7.30, high HCO3)

Results:
1021 included patients with exacerbation of COPD of which 823 (80.6%) had severity criteria for attention in the emergency department and 198 (19.4%) had no severity criteria. Of those with severity criteria; 482 (73.6%) required hospitalization and 341 (41.4%) were discharged home. Of those without severity criteria; 173 (87.4%) required hospitalization and 25 (12.6%) were discharged home.

Conclusions:

As the literature suggests most of our patients with exacerbation of COPD they showed clinical and laboratory criteria where a percentage of them than seventy percent required hospitalization. The severity of our patients that consistent with published hospitalization needs most the same as the blibliografia point.


Nuria RODRIGUEZ GARCIA, Maria Consuelo QUESADA MARTINEZ, Maria CORCOLES VERGARA, Danae FERNANDEZ-CAMACHO, Blanca DE LA VILLA ZAMORA, Pascual PIÑERA SALMERÓN (montepinar, Spain), Maria Carmen MOLINA MORAZO, Cesar CINESI GOMEZ
11:00 - 18:00 #7606 - High paracetamol intoxication in a young boy: the role of a toxicological approach.
High paracetamol intoxication in a young boy: the role of a toxicological approach.

Paracetamol, belonging to the OTC group (over the counter drugs) is easily available and widely used as analgesics and antipyretic. It is used in children for its well known safety profile. On the other hand overdose and poisoning with this drug always brings about the risk of progressive hepatic necrosis and acute hepatic failure. Antidotal treatment with N-acetylcysteine (NAC), restoring intracellular glutathione, is effective in preventing hepatic injury. A previously healthy 12 years old boy, weight 65.5 Kg, was conducted to our Emergency Department (ED) for an intentional ingestion of 25.5 gr of paracetamol one hour before admission. In the ED gastric lavage followed by activated charcoal was performed at first. Antidotal treatment with N-acetylcysteine was then started at 150 mg/kg body weight followed by 50 mg/kg every 4 hours; supportive therapy was associated too. Paracetamol level was 291.6 mg/l at 4 hours from ingestion with concentration decreasing during antiodotal treatment (180.2 at 12 hours, 18.2 at 24 hours, negative after 36 hours). Laboratory tests showed coagolopathy: PT 1.31 at admission, 1.58 after 12 hours; aPTT: 0.88 (admission), 1.43 (12 hours). No other laboratory test alterations were noted. The boy was discharged home after72 hours without clinical and laboratory sequelae: PT 1.17; aPTT: 1.01.

Paracetamol overdose of 7.5-10 g leads to hepatic necrosis in adults and doses of 25 g are considered lethal to the patient. Paracetamol levels from 150/Kg body weight are tagged as potentially hepatotoxic in children. We describe a case of intentional ingestion of paracetamol at lethal dose in a young boy treated with decontamination and antidotal therapy that rapidly recovered without hepatic or renal damage. Literacy data report that paracetamol levels over 300 mg/L at 4 hours from ingestion cause severe hepatic damage in 90% of patients. Liver damage is present with parecatmol concentration of 120 mg/l, too. An early adoption of the appropriate of toxicological treatment (decontamination, reduce adsorption, supportive therapy and antidotes) avoids damages from the toxic substance. Antidote therapy is not always available for poisoning: NAC has been demonstrated to be a specific therapy and is highly effective in paracetamol intoxication. Without the antidote this young boy would not have the favourable course he had but the risk of a liver transplantation.


Massimo ZANNONI (VERONA, Italy), Gianni TURCATO, Alberto RIGATELLI, Giorgio RICCI, Valentina SIVERO, Francesco BUONOCORE
11:00 - 18:00 #8171 - High resolution consultation tool for the optimization of hospital admissions and monitoring of patients from the emergency department.
High resolution consultation tool for the optimization of hospital admissions and monitoring of patients from the emergency department.

Bakground : 

A preferential consultation is proposed for the referal of patients from the emergency room (ER ) , The purpose of this consultation is to avoid the hospital admission of patients with pathologies that need further studies , by streamlining the circuits for monitoring and study of patientes on an outpatient setting , as well as to improve patient satisfaction. 

There is currently a preferential external consultation are for dermatology , interna medicine , digestive medicine an orthopaedics. 

Objetive :

1-.Welfere activity generated by these consultations.

2-.impact on the percentage of hospital admissions from the ER .

3-.Final destination of the patiente and readmissions to the emergency room . 

Methods:

A descriptive , cross-sectional , obervational study was performed by the collection of data contained in the medical history of patients initially seen in the emergency room during 2015.

Results:

130.650 patients attended the emergency department in 2015 , 925 of those were referred to high-resolution consultation.10,5 % were referred to dermatology , 40.8 % orthopaedics , 12.2% to digestive medicine and 30.3 % to internal medicine . The percentage of hospital admissions from the ER was 12.3 % lower tha the previous years figures. 58.6 % of referred patients werw asked for furthure examinations . 30 % of the patients eres referred to primary care and 60.4 % were followed-up in outpatiente care . Only 9.6 % of the patients were admitted to hospital . 

Conclusions:

High -resolution consultations provide an alternative to conventional hospital admission from the emergency room . In addition to allowing monitoring of patients, it shortens time to diagnosis. As a result, it reduces patient attendance to the emergency services 


German Jose FERMIN GAMERO (PALMA DE MALLORCAQ, Spain), Sandra GUIU MARTI, Bernardino COMAS DIAZ, Pedro RULL BERTRAN, Julio OLSEN
11:00 - 18:00 #7689 - Hodgkin lymphoma Mixed cellularity in patients with multiple emergency room visits for knee pain.
Hodgkin lymphoma Mixed cellularity in patients with multiple emergency room visits for knee pain.

42 year old patient with no known drug allergies and a history of multiple sclerosis, diagnosed 6 years ago by optic neuritis and tracking neurology; Iron deficiency anemia in tracking microcítica digestive additional tests without pathological findings; anxious and depressive syndrome hiatal hernia.

Current treatment: trazodone 100mg / 24hrs, ferrous sulfate, bupropion 150 mg / 12 hours, Vitamin B1-B6-B12 / 8 h, Betaferon three days a week.

Current disease: Patient has consulted several times in emergencies in the past two months by box of pain in the right lower limb at the level of tibial region, go for intensity of pain that wakes you up during sleep did not improve with analgesia and paresthesias that level. During the interview highlights anorexia 30 kg weight in the last year accompanied by asthenia. In previous consultations they had been conducted additional tests without findings except microcytic anemia known,

After further tests the patient is admitted to the Internal Medicine,

Additional tests on admission

Blood test: Hemoglobin 6.9, VCM 69, 18,100 leukocytes (neutrophils 84%) Platelets 551,000, 113% prothrombin time, glucose 84 mg / DCL, Creatinine 0.58, 9.74 calcium corrected. GOT 11 19 GPT, GGT 360, FA 176, total bilirubin 0.25, C-reactive protein. 192

Chest x-ray line broadening suggestive of right paratracheal lymphadenopathy. Increase bilateral hilar lymphadenopathy suggest. Mild bilateral pleural effusion.

Radiography of right knee injury lytic bone epiphyseal-metaphyseal external proximal right tibia with ill-defined borders consistent with aggressive bone injury.

Evolution. During admission expansion of additional tests (venous ultrasound doppler and bilateral arterial, CT thorax and abdomen, bone scan, colonoscopy and PET) is performed objectifying aggressive litca lesion in the right tibial region, multiple bilateral pulmonary nodules predominantly in the right lower lobe, occupying lesions liver and spleen space. After liver biopsy diagnosis of lymphoma Mixed cellularity classical Hodgkin confirmed, starting chemotherapy treatment.

Conclusion: The reasons for repeated consultation frequent attenders emergency patients often hide serious diseases. It is important to make a correct medical history on each visit and let us not be carried away by previous episodes.


Rafael INFANTES RAMOS, Maria Eugenia REYES GARCIA (Málaga, Spain), Cristina FERNANDEZ- FIGARES MONTES, Jose Ignacio VALERO ROLDAN, Ivan VILLAR MENA, Maria Victoria ALARCON MORALES
11:00 - 18:00 #7926 - HOSPITAL ADMISSION IN PATIENTS WITH EXACERBATION OF COPD ACCORDING TO TRIAGE LEVEL AND AGE.
HOSPITAL ADMISSION IN PATIENTS WITH EXACERBATION OF COPD ACCORDING TO TRIAGE LEVEL AND AGE.

Introduction

Chronic obstructive pulmonary disease (COPD) is a progressive and irreversible disease characterized by chronic airflow obstruction. The development of exacerbations and comorbidities may increase its severity.

Objective

Assess the classification of triage patients presenting with exacerbation of COPD (COPD exacerbations) to the emergency room and analyze the relationship with the patient's age and subsequent hospitalization.

Material and methods

Observational, retrospective at the Reina Sofia Hospital Emergency Department. We included patients diagnosed with COPD attended by heightening between January 2012 and June-2015.

We analyze the classification of triage model used is Manchester (Nivel1 - Resuscitation -Red: immediate attention; Level 2 - Emergency - Yellow: wait until 10-15 minutes; Level 3 - Urgency - Orange: wait until 60 minutes Level 4 - less urgent - Green: waiting up to 2 hours) and its relationship with age (> 75 years and <75 years) and hospitalization.

Results

A total of 1021 patients consulted for COPD exacerbations. They were classified according triage: Level 1; 52 (5.1%), Level 2; 116 (11.4%), Level 3; 839 (82.2%) and Level 4; 14 (1.4%). By age <75 years (503 patients): Level 1; 28 (5.6%), Level 2; 56 (11.1%), Level 3; 412 (81.9%) and Level 4; 7 (1.4%). Those of> 75 years (518) were classified as Level 1; 24 (4.6%), Level 2; 60 (11.6%), Level 3; 427 (82.4%) and Level 4; 14 (1.4%).

In relation to admission: Level 1; 95.7%, Level 2; 64.3%, Level 3; 55.2% and Level 4; 50% They were admitted

Conclusions

There are no significant differences in levels of triage by age. There is a correlation between the results and income level triage patients being classified as Level 1 at the greatest percentage of income (95.7%) and Level 4 the lowest percentage (50%). It is noteworthy that up to 50% of patients entering Level 4 which can reveal a problem in the standings with certain patients. Therefore we can say that the rating level on arrival to the ER is in line with the seriousness if we exclude patients with Level 4.


Danae FERNANDEZ-CAMACHO, Maria CORCOLES VERGARA, Maria Consuelo QUESADA MARTINEZ, Nuria RODRIGUEZ GARCIA, Blanca DE LA VILLA ZAMORA, Pascual PIÑERA SALMERÓN (montepinar, Spain), Cesar CINESI GOMEZ
11:00 - 18:00 #7746 - HOSPITAL DEATHS DUE TO ACUTE POISONING DURING A DECADE.
HOSPITAL DEATHS DUE TO ACUTE POISONING DURING A DECADE.

Introduction:
Acute poisoning is a frequent complaint in Emergency Services but studies on deaths from acute poisonings are limited.  The aim of this study is to analyze the epidemiological characteristics of patient deaths due to acute poisoning.
Method:
Retrospective descriptive study of patients treated for suspected clinical exposure to a toxic substance in Emergency Service and in the UCI of the Hospital Clinico Universitario of Zaragoza between the years of 2004-2013, and who died as a consequence of said poisoning.  The data was obtained from the files of our clinical toxicology unit for the ten years being evaluated.
Results
Out of a total of 11764 patients admitted for acute poisoning during those 10 years, including pediatric emergencies, 17 (0,14%) of deaths recorded were selected for the study. Their mean age was 63 (SD ±16) and 12 (70,6%) were male. The means of transportation most commonly used was an ambulance in 13 cases (75,4%).  Oral was the most common route of exposure with 13 cases (76,5%). 7 (41,2%) cases involved a suicide attempt, followed by drug overdose with 4 (23,5%).  8  (47,1%)  cases had previous psychiatric disease, and for 15 (88,2%) of cases it was their first poisoning. The involved agents were caustics in 6 cases (36,5%), a combination of  alcohol and  drugs of abuse in 3 (17,6%) cases, a combination of  alcohol and  benzodiacepines in 2 (11,8%) cases,  solvents in 2 (11,8%) of cases, and  CO , pesticides , antiarrhythmics drugs  and  opiates 1 case each  (5,9%). The relationship between the poisoning and the cause of death was undoubted in 14 (82,35%) cases.
CONCLUSION
Death by acute poisoning is a rare event despite the drama of the situation. In our study they are most frequently first oral poisoings in males due to a suicide by means of a caustic substance, arriving to the emergency room by ambulance.

Pilar MIRANDA ARTO, Patricia BONED BLAS (zuera, Spain), Ana FERRER DUFOL, Francisco Jose RUIZ RUIZ, Teresa DE FERNANDO GROS, Teresa PARDO VINTANEL
11:00 - 18:00 #7142 - Hospital preparedness in respect of terrorist attacks: a comparison between Italy and Finland.
Hospital preparedness in respect of terrorist attacks: a comparison between Italy and Finland.

Background: Hospitals are included in health critical infrastructures, which must continue daily function in the case of terrorist attacks. The objective of the study was to evaluate and compare the security and preparedness condition of eight hospitals in Italy and in Finland, in respect of terrorist attacks.

Material and methods: This cross-sectional observational study was conducted from November 2014 to November 2015. A convenience sampling method was applied to perform this study. A questionnaire, consisted of 74 questions, was validated through the experts' consensus. The questionnaire was categorized into three main topics: 1) Information about the hospital structures, 2) Information about the emergency/crisis management plan and 3) Information about resources. For general results dichotomous questions were applied. One point was given to positive answers, zero points to negative ones.

Results: The study showed that, up to 88 possible points, Finnish hospitals got 53 points, while Italian hospitals got 23 points. In addition we found lack of communication between the governments and the hospitals regarding terrorist attacks. Furthermore, the study demonstrated that the hospitals had low availability of funding to improve the level of preparation and the shortage of the hospital managers, whose responsibility is to prepare against terrorist threats.

Conclusions: The level of preparedness in respect of terrorist attacks is higher among the Finnish hospitals than the Italian hospitals. Moreover, the governments and the hospitals had shortage in the communication regarding terrorist attacks. Furthermore, the hospitals had minor funding for improvement of the preparation.


Francesco FILIPPONE (Kotka, Finland), Maaret CASTRÉN, Pierluigi INGRASSIA, Marta CAVIGLIA, Ahmadreza DJALALI
11:00 - 18:00 #8223 - HOSPITAL WASTE MANAGEMENT AND IMPACT OF PROFESSIONAL RISKS IN WELFARE.
HOSPITAL WASTE MANAGEMENT AND IMPACT OF PROFESSIONAL RISKS IN WELFARE.

Bacground:

Health institution frequented by many people, regardless their age, religion, gender or nationality.. Wastes produced in such institution have a higher potential for causing significant damage to human health and the environment around us, compared to waste, produced at other institutions. The knowledge that nursing staff has for the appropriately management of hospital waste and the use of protective measures have an important role in administation of these residues.
Purpose: Inspection of management of hospital waste and the use of bio-safety measures e, in order to establish and implement adequate health education programs, for nursing staff to optimize the management of hospital waste and prevent the accidents at work                     .
Material and methods: This study is transversal, descriptive-analytic, quantitative and applied. The data were processed by means of SPSS v 17.0                                                                      .
Results:In general the nursing staff had knowledge about hospital waste management and the protection to the risks at work. Even though they had knowledge, the protection measures were not applied by all of  them and that because there were not enough necessary materials. I emphasize that the study lasts in fact till 2014-2015, that enables me to make a comparison between the years. There was also noticed that the bio-security measures during work were used more, as a result of the different trainings made in 2014-2015.  There were less accidents than in 2013 because there was much more security at hospital wastes separation, making the risk of accidents during work decrease
Recommendations: Nursing staff of Vlora Regional Hospital need continuous training on the way of management of hospital waste. Also this health care institution must provide nursing personnel the necessary conditions and means that during the realization of nursing procedures, nurses must be protected against  infections                                                             .
Key words:biological risk, drilling with age, biosecurity measures, hospital infections, nursing staff, administration, hospital waste




Denada SELFO (Vlore, Albania), Majlinda ZAHAJ
11:00 - 18:00 #8089 - How heart and kidney work together; the cardiorenal syndrome.
How heart and kidney work together; the cardiorenal syndrome.

Introduction:

Acute kidney injury and cardiac pathology are daily seen problems at the Emergency Department. We present a case that shows the close relation between cardiovascular disease and kidney dysfunction. The presented patient was found to have a rare cardiac complication.

Case description:

A 77 year old, previously healthy woman was brought to our Emergency Department by ambulance after referral by her family doctor with the suspicion of dehydration. The previous week she was treated with amoxicillin/clavulan acid for a suspected pulmonary infection; dyspnoeic and ill, without coughing or fever. One day after starting treatment the patient got diarrhoea. Because of weakness she was lying in bed for a week.

On physical examination the patient was slightly confused with a Glasgow Coma Scale of E4M6V4. Patients heart rate was 62/min, her blood pressure 124/68 mmHg, and she had a respiratory rate of 13-17/min and oxygen saturation 97% with three litres oxygen. She was hypothermic (34.7 degree Celsius) with cold acra. Auscultation revealed  a loud murmur of the heart, grade III-IV/VI. Crepitation was heard over the lungs. Pitting oedema of her ankles was visible.

The chest x-ray showed an enlarged heart and fluid in the fissure without other signs of heart failure. Pathological Q’s in V2-V3 and ST-elevation in V2-V6 were visible on the electrocardiogram. Blood results revealed disturbances of renal- (creatinine 207, urea  52.3, sodium 122, potassium 5.3) and hepatic function (bilirubin 49, GGT 63, AF 89, ASAT 305, ALAT 179, LDH 697). Arterial blood gas analysis was normal. The cardiac markers were also elevated (troponin I 5.34 and CK 241). An additional echocardiography showed, besides akinesia of the apex and apical septum, a rupture of the apical septum and a dilated right ventricle.

Patient was transferred to an academic hospital because of the possible need for cardiothoracic surgical intervention. Three days later the patient died.

Discussion:

In this case the diagnosis initially seemed easy because of the history of diarrhoea and low oral intake after recently prescribed antibiotics: dehydration. Taking a closer look at all the  preformed examinations another diagnosis was more plausible; a semi recent anteroseptal myocardial infarction complicated by septum rupture, followed by renal and hepatic impairment as a result of forward failure.

Ventricular septal rupture is a rare complication of myocardial ischemia that normally presents within three to four days after the infarct. A majority of patients with acute myocardial infarction develop acute kidney injury within 72 hours. Cardiorenal syndrome implicates the coexistence of cardiovascular and renal disease. Clinical outcome is poor.

Conclusion:

There is a close association between cardiac and renal function (cardiorenal syndrome). A cardiac cause of acute kidney injury should be taken into consideration especially when the history and clinical presentation do not match. In addition, women with a myocardial infarction may present with atypical symptoms, leading to an increased complication risk.  


Sabine BEKS (Rotterdam, The Netherlands), Emma RÖTTGER, Eva SLAG
11:00 - 18:00 #7201 - How is the clinical impacts of blood cultures ? Analysis of patient presenting with sepsis due to pneumonia at the emergency department in Japan.
How is the clinical impacts of blood cultures ? Analysis of patient presenting with sepsis due to pneumonia at the emergency department in Japan.

Background

Blood cultures are routinely used to investigate suspected sepsis with pneumonia in the emergency department. However, recent studies have reported the low impact of these cultures on therapy of pneumonia.

Objective

To assess the clinical utility of blood cultures for patient presenting with sepsis due to pneumonia.

Methods

This is two-years retrospective study. The patients (age ≧15 years) who were transported to our hospital by ambulance and hospitalized with sepsis due to pneumonia from Janualy 1, 2013 to December 31, 2014, were enrolled. The diagnosis of pneumonia was made by clinical and radiographic evidence. Clinical evidence of pneumonia included findings from the medical history, vital signs, physical examination, laboratory findings, and gram stained sputum.

The blood culture results, treatment for pneumonia, and severity were investigated. Blood cultures were classified as negative, true positive, or contaminant. A contaminant culture is defined when common contaminants isolated only 1 set of blood cultures.

Results

The study involved 194 of the total of 17674 cases transported by ambulance. 26 cases were septic shock. Two sets of blood cultures were collected in all of cases with the exception of one case. Of all cases of pneumonia, 11 (6.5%) had positive blood cultures and 3 (2.0%) resulted in changed in management. Those with septic shock were higher positive blood culture ratio than those with not, but we found no significant difference (11.5% vs 6.5%, OR 1.85, P=0.40).

Discussion

Recently, the low positive blood culture rates of pneumonia have been reported in Japan. They reported it was 3.7%. This study shows even the patients were septic state, positive blood culture rates were low and blood cultures have low clinical impacts for sepsis due to pneumonia. It may not be necessary to obtain blood cultures for patients with sepsis due to pneumonia.

Conclusion

Even the patients were septic shock state, positive blood culture rates were low in pneumonia cases and had low clinical impacts. It may not be necessary to obtain blood cultures for patients with sepsis due to pneumonia


Yakushiji HIROMASA (izumi, Japan)
11:00 - 18:00 #7706 - HOW MANY CHILDREN SURVIVE TO AN OUT-OF-HOSPITAL CARDIORESPIRATORY ARREST?
HOW MANY CHILDREN SURVIVE TO AN OUT-OF-HOSPITAL CARDIORESPIRATORY ARREST?

Introduction: Paediatric out-of-hospital cardiorrspiaratory arrest (OHCA) is an uncommon condition, and since the staff of the emergencies medical system don´t face daily with it it suposes a big challenge for them. We describe the paeditric OHCA registered in Spain along one year.

Material and methods: A prospective, observational database including all the out-of-hospital cardiorespiratory arrests (OHCA) registered by the 19 regional Emergency Medical Systems (EMS) of Spain, with data collected according to Utstein style was designed. The paediatric sample (patients aged 0–18 years) corresponding to the period between October 2013–September 2014 is described.

Result: 160 patients aged between 0 to 18 year were included, 60.6% males. Median age was 6 years (range 0–18). The event occurred at home in 46.3% and was witnessed in 61.9% of cases (by a bystander in 61.6%). Basic life support was provided in 75% of cases (by a bystander in 41.7%, and first provider in 58.3%). The first detected rhythm was non-shockable in 89.9% and shockable in 10.1%. The arrest’s aetiology was car- diac in 47.2%, respiratory in 14.5%, traumatic in 18.9%, drowning in 13.2%, neurological in 2.5%, and other in 3.8%. ROSC was achieved in 36.3% patients and 6.3% were admitted to hospital in on-going CPR. Survival at hospital discharge was 13.75%, and 10.6% had good neurologic condition at that time.

Conclusions: Paediatric OHCA is an uncommon condition. Only 10% ofvictims have an initial shockable rhythm.In Spain the current rate of bystander CPR is relatively low. ROSC, survival to hospital discharge and specially the neurological outcome in these patients need to be improved by means of multifaceted resuscitation strategies. 


Antonio IGLESIAS VAZQUEZ, Luis SANCHEZ SANTOS (Santiago de Compostela (A Coruña), Spain), Manuel BERNARDEZ OTERO, Ortiz ROSELL
11:00 - 18:00 #7206 - How medical students use the web to conduct everyday clinical research?
How medical students use the web to conduct everyday clinical research?

Introduction:

Given the field of medicine is increasingly broad, a physician may sometimes use Internet in order to improve his knowledge. As a result, we examined how medical students look for an answer to a clinical question using Internet within a limited time.

Methods:

The study was divided into two parts. Part 1: each student has to solve a clinical case, within a limited time, using Internet if necessary. Part 2: each student has to complete a survey detailing his documentary research on the Internet. The students were divided into two groups. The first group answered to the clinical question then did a self-assessment and vice-versa for the second group. We examined their browsing histories (how many websites were visited, the frequency of consultation for each website, the number of copy & paste, the search time...). Each student has also to assess the relevance of websites as well as his level of training for documentary research and his knowledge of the certified websites.

Results:

In this study, 90 students were evaluated. 41 websites were consulted. The most visited websites were: google.fr with 90% of consultations in the 1st group versus 100% of consultations in the 2nd (p=0.04). HAS-sante.fr (French National Authority for Health): 7% of consultations for group 1 versus 23% of consultations for group 2 (p=0.046). It was noted that the WHO websites were less frequently consulted by students (21% versus 35% (p=0,17)). By contrast, Wikipedia.fr and doctissimo.fr (French medical popularization website) were more consulted in the first group (81% versus 67% and 31% versus 19% respectively). The students who use the Internet were more highly rated than others (p=0.017).

Conclusion:

The students consult websites such as Wikipedia.fr and doctissimo.fr, but they don’t check information with other websites. A study on the relevant of the websites helps to improve their searches (as has-sante.fr or doctissimo.fr) and receive high ratings. Internet offers additional knowledge, however the students don’t use correctly this tool. For example, they consult the same Internet page and they don’t have the same answer. They don’t consider wikipedia.fr as a reference site but they keep consulting this website. To sum it up, the medical student should be trained on the Internet search in order to know the assets and the limits.


Carine ZUMSTEIN, Claire KAM, Pierrick LE BORGNE (Strasbourg), Sophie HATSCH, Caroline WITT, Arnaud PERRIGUEY, Charles-Eric LAVOIGNET, Pierre VIDAILHET
11:00 - 18:00 #8182 - How to Assess Chest Compression Quality In Emergency Medicine Team.
How to Assess Chest Compression Quality In Emergency Medicine Team.

HOW TO ASSESS CHEST COMPRESSION QUALITY IN EMERGENCY MEDICINE  TEAM

 

INTRODUCTION: Emergency medical service in Croatia is two-tier system – in Split it consists of three Team 1 ( T1 - physician, emergency medicine technician -EMT, driver with no former medical  education) and Team 2 ( T2 - two EMT) in 24 hours,  taking care of  178000 inhabitants. All team members working  in Institute for Emergency Medicine   Split-Dalmatian County have passed structured education in basic skills and procedures according to recent guidelines and competencies. We tried to make an objective assessment of their chest compression skills after more than one year of any training.

METHODS: We made a prospective investigation of chest compressions skills at our physicians, EMT and drivers working daily 12 hour shift in four consecutive days so that all teams in Split could participate. They were asked to make  chest compressions on manikin Resusci Anne QCPR-D with  sensor  and software that provides real time feedback ( Resusci Anne Wireless Skillreporter) . From data of  rate, depth and recoil it calculates total cpr score (limited to chest- compression-only,2 minutes, depth 5-6cm, rate 100-120/min). No demonstration was provided formerly. There were 19 physicians (13 women, 6 men - daily shift in T1 as well as daily shift in Medical Dispatch Unit because they are also T1 members), 23 emergency medicine technician ( T 1 and 2) and 12 drivers. 1 physician was excluded because of active rheumatologic illness as well as 1 driver who had intensive training less than 6 months ago.

RESULTS: Average CPR score for physicians was 79,16% ( SD= 18,92). EMT had 92,57% (SD=8,74) and drivers had 96,27% (SD= 3,26) score of successful chest compressions. They were all in group „advanced CPR provider“. Physicians achieved in  72,32% ( SD= 33,29), EMT 60,09% ( SD= 30,1) and drivers in 80,45% (SD=14,97)   successful chest recoil. Physicians achieved 45,53% ( SD= 34,60) satisfying depth , EMT 77,26% ( SD = 17,49)and drivers 77,27% ( 20,16). Adequate compression rate  was achieved by physicians in 72,42% ( SD=26,48), by EMT 78,39% (SD= 20,90) and by drivers in 83,82% ( SD =17,87).

CONCLUSION: The physician group  had most variable results concerning both total cpr-chest compression-score and all three components participating in total score - recoil, depth and rate. That is probably due to significant difference in working experience ( from 1 till more than 20 years) which means less and more opportunity in performing CPR, taking into account participation of 13 women - only physicians. Drivers had the best  score  both total and  in all three components. It is probably due to the fact  that they most frequently  perform chest compressions during CPR that enables them to preserve the skill. Short training after 3-6 month, as reccommended by guidelines, should be performed to see if this score would improve at all team members, not only observing chest compression, but ventilation and  cpr combining both compression and ventilation since most studies show that CPR skills decay within three to six months after initial training.

 


Radmila MAJHEN UJEVIC (yes, Croatia), Zoran VIDOVIC, Leo LUETIC
11:00 - 18:00 #7326 - How to perform the care of the acute ophthalmological case coming in A and E ?
How to perform the care of the acute ophthalmological case coming in A and E ?

 Introduction

Ophthalmology is a small part of the job in emergency but as emergency physicians we shouldn`t miss a reversible disease with a potentially catastrophic consequence on the vision of the patient, we have to recognize early an acute ophthalmological problem and try to treat it and or to transfer the patient if needed asap to the specialist.

Which is the population coming with an acute oftalmological problem to ED? When are they coming to ED ? How are they managed by the ED physician? How many are then referred? How to perform this acute care from the emergency point of view for a better collaboration with the oftalmologist?

Materiel,methods and results

We proceeded to a prospective study in a general hospital where the oftalmologist is not on call locally. We registreted all the patients with a problem with his eye from the 3/04 until the 30/04/16. An inform consent is signed by the patient. We recensed 51 patients. An excel tabel recenses the following data: 29% were referred by de GP, only 29% of the patients come to the ED during the working-hours (from 8 am untill 17 pm) , 29% of the pathologies were non-traumatic and 71% were traumatic disease (corneale erosion in majority) , an anamnesis is performed in 94% but in 88% relevant questions about the vision of the patient are lacking, examination with fluorescine is done in 94% . 52% are in a second time referred to the oftalmologist.

Discussion

We notice a high percentage (70,5%) of out-of hours patients.That means that on this moment the ED is the only solution for this patients and we decide if this problem could be postponed. This important role makes us responsible for not missing any reverseable pathology.

The emergency physician doesn't encounter to care with traumatic eye problem ( 95% of corneale erosion) but have more difficult to manage a non-traumatic eye disease
and this patient is quickly referred but without right anamnesis to estimate a real risk as glaucoma, retinal detachment, thrombosis or arteritis.

88% of the doctors performed a minimal anamnesis without enquiring about the basic questions about the vision, the factors to estimate the risk of a reverseable dangerous pathology.

Conclusion:

Even acute oftalmology is a small part of hour job, 7/10 patients with this problem wil come to us because of the hours, and we will the firt and potental doctor to see this.

This reason is enough to encourage the emergency physician to increase his knowledge in this area and perhaps to create in collaboration with the ophthalmological ward a flow chart to
summarize the relevant questions to estimate the risk of reverseable pathologies.

We see the patient but how well can the patient see? Good question indeed !


Elke THIJS (Bellem, Belgium), Adeline HIGUET, Saartje THIJS
11:00 - 18:00 #7454 - How we handle new-onset atrial fibrillation in our emergency department.
How we handle new-onset atrial fibrillation in our emergency department.

Introduction: Atrial fibrillation is the most common arrhythmia seen in the emergency services.

Objective: Assess if we make a proper handling of recent onset atrial fibrillation in our emergency department

Material and method: observational, longitudinal , retrospective review of medical records. All patients diagnosed with AF selected discharge not known . Variables studied : sex , age , reason for consultation , evolution time , if frequency control is attempted or method used and used drugs cardiovierten . EKG at discharge. If they were reviewed in outpatient in less than 1 month and ECG in consultation

Results: Between 2014-2015 we had 237 patients with a discharge diagnosis of atrial fibrillation, of which 91 patients were not known . mean age 69.81 %. 51.6 % were women. Complaint: Palpitations 46.1 % , 17.6 % Chest pain ,Disnea16.5 %, casual 11.7 %, other 13.2 % Time evolution > 48 hours 53.8 % and < 48 46.2 %.  In 54.9 % is made control heart rate fc and  cardioversion 45.1 %. At 31.9 % they remained high in FA and 68.1 % were in sinus . Was used : 2.2 % electric,  pharmacological 61.5 , 36.3 spontaneous . In cardioversion: spontaneus was 32.6 % , 14 % used amiodarone , flecainide 39.5 %, the rest with drugs for frequency control . In the frequency control was spontaneus 37.5% , 22.9 % was used digoxin , diltiazem 10.4 % ,  Amiodarone 6..3%, bisoprolol 6.3 % , 4.2 % propanolol , verapamil was used  6.3 % and  2.1 % carvedilol. They were revised 87.9 % in outpatient cardilogia in less than 1 month. In sinus 48.8 % , 47.6 % Atrial Fibrillation 42.9 % , 3.3 % flutter

Conclusions: Overall we make a correct handling of recent onset atrial fibrillation , as a function of time of evolution almost 100 % , cardioversion or frequency control is performed as indicated. It is noteworthy that in 1 in 3 patients this objective is achieved spontaneously . For cardioversion is the most used drug flecainide and frequency control digoxin and diltiazem


Daniela ROSILLO CASTRO, Maria Dolores PASCUAL MUÑOZ (Murcia, Spain), Carmen HERNÁNDEZ MARTÍNEZ, Amalia CASTAÑO VILLAR, Rocío LÓPEZ VALCARCEL, Vivianne Andrea JÍMENEZ GARZÓN, Paula RODRIGUEZ LAVADO
11:00 - 18:00 #7574 - Howlong We Must Follow Paroxysmal Atrial Dysrhythmia due to Electrical İnjury?
Howlong We Must Follow Paroxysmal Atrial Dysrhythmia due to Electrical İnjury?

Background: Electrical injury should cause a wide spectrum of cardiac complications ranging from myocardial necrosis with ventricular fibrillation to less common atrial fibrillation. Atrial fibrillation is not a common arrhythmias. Recommendations on cardiac monitoring were published for certain risk factors, but indications for hospital observation are less clear especially for length of observation time. According to current guidelines, the risk of late arrhythmias is not known. We present a case of paroxysmal atrial fibrillation with rapid ventricular response resulting from a low voltage electrical injury. 

Case Presentation: A 35 years old construction worker with no prior history of cardiovascular disease presented to the emergency department after an electrical shock from accidentally touch of his truck haulage to the electrical conduit. He experienced severe pain in both hands and foot. He denied to loss of his consciousness. He experienced to fall backwards and hit her  back and head to the floor. On initial assessment he was found to be in atrial fibrillation with a moderate to rapid ventricular rate.  Transient rise in markers of muscle damage were noted. After analgesia and wound care, monitorization was continued. Troponin T and renal function tests normal. His transthoracic echocardiography revealed no structural abnormality. After cardiology consultation with patient stable conditions 300 mg amiodarone infusion made with in 1 hour. And then 900 mg amiodarone was performed within 24 hours after anticoagulation was made for protect from embolization. As consideration of follow up as 24 hours, his dysrhythmia was resolved nearby foolowing 14 hours. After resolution of atrial arrhythmias his cutaneous wounds were bandaged and the patient was discharged with cardiology follow up. 

Conclusion: Atrial fibrillation in the setting of electrical injury is rarely reported previously.The path of electrical conduction involving heart may herald cardiac dysrhythmia involving atrial and ventricular structures. In patients without loss of consciousness, cardiac arrest, rhabdomyolysis and history of cardiac structural abnormalities, medical cardioversion is a potential option for restoration of normal sinus rhythm and resolution of other symptoms after electrical cardiac injury like atrial fibrillation with rapid ventricular response within 24 hours.


Volkan ÜLKER (ISTANBUL, Turkey), Hilal HOCAGİL, Abdullah Cüneyt HOCAGİL
11:00 - 18:00 #8194 - Human accidental poisoning in rural and fishing occupational setting in Italy: a 5 years case series.
Human accidental poisoning in rural and fishing occupational setting in Italy: a 5 years case series.

OBJECTIVES: To describe clinical aspects and medical management of human poisoning in rural and fishing occupational setting, in order to identify preventive measures.

METHODS: A five years (2010-2014) retrospective study concerning the Pavia Poison Centre (PPC) in poisoning data from all over Italy was performed. Cases were evaluated for: circumstances of poisoning, clinical manifestations, management, risks factors, outcome.

RESULTS: Farmers, veterinarians, herpetologists, fishers and aquarists were identified as professionals at risk for accidental poisoning in rural setting. In details, 581 occupational poisoning involved: (i) farmers (494;87%)  [pesticides/herbicides/rodenticides (439; 89%), insect/spider bites (9; 1.6%), vipera envenomation (22; 4%) and lethal incident in confined spaces (8; 2%)]; (ii) veterinarians (64;11.3%) [accidental self-administration of drugs/vaccine/antibiotics/sedatives (63; 98%), wound management for potential rabies disease n=1 (2%); (iii) herpetologists (4; 0.7%), Agkistrodon bilineatus, Crotalus atrox, Bitis parviocula, Botriechis schegeli envenomation; (iv) Fishers/Aquarist (19;3.4%) [stings, algal toxins intoxications (ciguatoxin ingestion, palitoxin inhalation)]. The inappropriate and/or incorrect use of protective equipment is associate to toxic pesticide exposures. Envenomation by exotic snakes is rare and may regard particular risk categories (e.g. herpetologists/veterinarians) but may require antivenom administration not always promptly available: in these cases specific antidote has been supplied abroad after activation of extraordinary procedures. All cases fully recovered except one (Crotalus bite) that presented a mild permanent dysfunction at the hand. Among veterinarians, occupational exposure are mainly characterized by accidental self-injection of veterinary medicines (vaccines, antibiotics, anesthetics/sedatives): no cases of systemic toxic effects were registered. Veterinarian managed for potentially rabid fox bite required only active immunization. In PPC experience fishermen may be exposed to the risk of venomous marine organisms stings (Trachinidae 50%, Dasyatidae 25%, Muray 13%, Sea Anemone/Sea Coral 12%). Aquarists has been involved in palitoxin inhalation after boiling a pot of water containing a piece of rock polluted by the cnidarian zoanthids Palythoa spp, taken out of a 300-liter-aquarium. Patients (father 36 years-old and daughter 18 months) manifested gastrointestinal manifestations, fever (39°C), sore throat, cough and dyspnea. The clinical manifestation resolved after 48 hours and a 6 months follow-up was negative for late respiratory consequences. CONLUSIONS: Besides playing a fundamental role in the diagnosis of intoxication, PPC provides also a specialized advice to evaluate correct indications for antidote administration and to supply antidote in adequate amount. In occupational setting, a correct preventive information program may be essential and continuous training of physicians and workers is required.


Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy), Davide LONATI, Azzurra SCHICCHI, Marta CREVANI, Giulia SCARAVAGGI, Eleonora BUSCAGLIA, Sarah VECCHIO, Valeria Margherita PETROLINI
11:00 - 18:00 #7239 - Humanitarian emergencies: training residents in anaesthesia for deployment with Médecins Sans Frontières.
Humanitarian emergencies: training residents in anaesthesia for deployment with Médecins Sans Frontières.

BACKGROUND

Over the last few years, international concerns have been risen regarding the need of professionalization in humanitarian assistance. Aside from the escalation of violence, the disparity between medical needs and the quality of care provided is fueled by the insufficient workforce capacity and poor performance of inexperienced humanitarian health staff. The nuances of humanitarian settings demand professionals able to display specific competencies and adapt their abilities to complex contexts regardless of the skills gained during medical residencies. The Research Center in Emergency and Disaster Medicine (CRIMEDIM) alongside with MSF-Italian section developed an evidence-based training program aimed to promote the professionalization of young doctors in the field of disaster medicine and humanitarian health. This is a descriptive analysis of the program innovation.

METHODS

Upon acceptance of the project proposal by the MSF-Italian section directional branch, the course didactic structure and learning objectives as well as the eligibility criteria for participants were defined through a meticulous literature review, expert opinion and round tables with MSF recruiters. The course curriculum covered the following topics: disaster medicine, public health, safety and security, infectious diseases, psychological support, communication, anaesthesia in underserved areas, leadership, decision-making, problem-solving, teamworking, and human resource management. Senior residents (4th or 5th year) were defined as target audience. Candidates  were jointly selected on the basis of their motivation, flexibility, professional competence and language proficiency. Upon acceptance, participants completed a competency-based course. The actual novelty was the course format which intended to expose participants to an innovative blended-learning experience consisting of three months of distance learning, one-week traditional instructor-led teaching with state-of-the-art simulation technologies and workshops and apprenticeship in the field in a project run by MSF. Upon completion of the apprenticeship, the residents’ performance was evaluated by the Medical Focal Point (MFP) of their projects through the MSF standard evaluation module.

RESULTS

Two editions of the course took place between 2013 and 2015. Eight residents were admitted; of these, 3 were female and 5 were male with a median age of 31 y.o. One resident was deployed in Pakistan, 2 in Afghanistan, 1 in Democratic Republic of Congo, 1 in South Sudan, 1 in Central African Republic and 1 in the Philippines. One was sequentially deployed in Nepal and Yemen. Six candidates held a position as anesthetists while 2 functioned as emergency physicians. The mean time of deployment was 2.5 months with 4 MSF operational centers involved. Evaluators highlighted the following participants’ strengths: leadership, problem solving, communication, team working, cultural awareness and compliance with humanitarian principles. Their professional competence was never questioned. All residents were recommended for future MSF missions and two were again deployed by the end of 2015.

CONCLUSION

This course intends to contribute to the development of young doctors’ professional skills when working in emergency settings and limited-resource environments. Moreover, this project demonstrates how academia can successfully partner with humanitarian aid organizations to promote the professionalization of future humanitarian health workers.

 

 

 

 

 

 

 

 


Alba RIPOLL GALLARDO (Milan, Italy), Luca RAGAZZONI, Ettore MAZZANTI, Stella EGIDI, Pier Luigi INGRASSIA, Francesco DELLA CORTE
11:00 - 18:00 #6978 - Hyperglycemic crisis episodes may be associated with higher risk of pancreatic cancer: a population-based cohort study.
Hyperglycemic crisis episodes may be associated with higher risk of pancreatic cancer: a population-based cohort study.

Introduction: The relationship between diabetes and pancreatic cancer has been discussed. However, the effects of glycemic control on pancreatic cancer have never been evaluated. We address the strength of association for relationship between glycemic control and pancreatic cancer.

Methods: The sampled data from one million National Health Insurance beneficiaries were utilized. The study cohort consisted of 46,973 diabetic patients and 652,142 unexposed subjects. Among patients with diabetes, 1114 who had been admitted for hyperglycemic crisis episodes were defined as diabetes with poor control. All adult beneficiaries were followed from 1 January 2005 to 31 December 2013 to evaluate if pancreatic cancer was diagnosed. Cox regression models were applied to compare the hazards adjusted for potential confounders.

Results: After controlling for age, gender, urbanization level, socioeconomic status, chronic liver disease, hypertension, coronary artery disease, hyperlipidemia, malignancies, smoking, chronic obstructive pulmonary disease, obesity, history of alcohol intoxication, chronic renal insufficiency, biliary tract disease, chronic pancreatitis, Charlson Comorbidity Index score and high-dimensional propensity score, the adjusted hazard ratio of pancreatic cancer was 2.53 (95% confidence interval, 1.96—3.26) in patients with diabetes. In diabetic patients with poor control, the hazard ratio of pancreatic cancer was significant higher. (hazard ratio, 3.61; 95% confidence interval, 1.34—9.78)

 

Conclusions: This cohort study reveals a possible relationship between diabetes and pancreatic cancer. Moreover, poorly-controlled diabetes may be associated with a higher risk of pancreatic cancer.


Yung-Cheng SU, Yung-Cheng SU (Chiayi County, Taiwan)
11:00 - 18:00 #7708 - Hyperthermia: heatwave or urinary tract infection: Which differential dignosis?
Hyperthermia: heatwave or urinary tract infection: Which differential dignosis?

Backround

The increase in seasonal temperatures has a potential influence on the health of the population, especially elderly and polimorbid persons. There are specific disorders linked to hot summer, for exemple heatwave. In south of Switzerland the second half of July 2015 was particularly hot and the differents media gave great and continuos accent to this condition.

 

Aim

Helped to a case report we want focus attention on the importance of a large spectrum evaluation of a problem that present with carachteristics of heatwave but required also investigation for a urinary tract infection.

 

Method

During the period from 20 to 27 July 2015, a total of 241 consultation where registred at the Emergency Department. In 12 (5,0%) cases clinical manifestation related with the high temperature where noted as the reason for the consultation. Between the 87 patients that where hospitalized, 5 (5,7%) were affectet by problems related with high temperatures. One was admitted in the Intensive Care Unit.

 

The Case

A male of 72 years with hystory of pulmonary embolism for witch he takes oral anticoagulation, arterial hypertension (treated with a calcium channel blocker, beta-blocker and hydrochlorothiazide) and previous cerebral ischemic attack, come at the emergency department with ambulance after he was found on the floor of his kitchen unconsciuos by his daughter. The Glasgow Coma Score was 9/15, his blood pressure 180/100, SpO2 100%, HF 102 bpm. The timpanic temperature was 41°C. The management was initially performed in the intensive care unit because of the severe deshydratation and for the emodynamic observation. After administration of aboundant intravenous hydratation and paracetamol for management of the temperature, he become contactable and he reports suffering for the high temperatures in the last days. No symptoms of urinary tract or other infection was present. A blood sample show no electrolytes disturbance, a serum creatinine of 110 umol/l, a PCR of 6 mg/l, Leucocytes where 14,2 G/l with 10,6 Neutrophils. The urine examination showed 10 – 20 leucocytes/cluster, positive nitrites and the presence of number of bacteria. The coltures of urines show a growth of E. Coli multisensitive. A sonografy of the abdomen rouled out any echografic sign of pyelonefritis. A antibiotic therapy was started with prompt recovery.

 

Conclusion

For polymorbid and elderly patients the consequencese of a head stroke can be live treathening. It is not simply to determine if the infection of the urinary tract is the cause of the hyperthermia (which is rarely the case in lower urinary tract infection) or if the deshydratation with consequent stasis of urine in the bladder is the cause of the infection. It is important to have a large diagnostic approach to pose the correct diagnosis.


Zamprogno EMANUELA, Salmina DAMIANO (Locarno, Switzerland)
11:00 - 18:00 #7370 - Hypoglycaemia in the emergency room of béja's regional hospital (tunisia).
Hypoglycaemia in the emergency room of béja's regional hospital (tunisia).

Background : Although educational practices and prevention have been expanded, hypoglycaemia was the most common complication, potentially the greatest and most feared threat. This is due to its possible but rare consequences (coma, sudden death, irreversible neurological damage, traumatic accident).
Objectives : The objective of this study was the description of hypoglycaemia’s clinical and biological features, patient’s education and of everyone in his social circle on clinical manifestations and circumstances of hypoglycaemia, encourage them manage themselves particularly self-monitoring the blood sugar, and emphasize the higher frequency and potential severity of hypoglycaemia in elderly diabetic patient due to the co-existence of contributing factors.
Methods : That cross-sectional study was done from 30th of december 2010 to 21st of may 2011 in the emergency room of Béja’s Regional hospital. It covered 49 patients (21 women and 28 men). The threshold chosen to support hypoglycaemia’s diagnosis was 3.3 mmol/l (0.6 gr/l) for diabetic patients treated, and 2.8 mmol/l (0.5 gr/l) for non-diabetic patients. A questionnaire was completed.
Results : The mean age of patients was 63.1 years. 82.6 per cent of patients had personal history of diabetes. In 17.4 per cent of the cases, hypoglycaemia occured in the absence of personal history of diabetes. 76 per cent of diabetics questioned of our sample were taking insulin. 24 per cent were taking oral antidiabetic drugs only. 70.8 per cent of questioned patients did not perform self-monitoring of blood sugar. Five patients had impaired renal function without personal history of diabetes, of whom one on hemodialysis. The average blood glucose of all patients was 2.22 mmol/l. 87.7 per cent of patients had greatly evolved after administration of glucose. It had been noted some residual neurological damage aphasia type in a single female patient. Five patients (10.2 per cent) died, including 3 non-diabetics, within hours or after a couple of days. The mean age of patients who died was 77.3 years. The average blood glucose level in deceased patients was 1.34 mmol/l. In 66.6 per cent of patients, the cause of hypoglycaemia was non-compliance with diet. An error while filling the insulin syringe was involved in 25 per cent of patients. It was the first hypoglycaemic incident in 24 per cent of all patients.
Conclusion : Hypoglycaemia is more common in elderly diabetic patient due to the frequently found co-existence of many contributing factors. The risk of hypoglycaemia is greater in insulin-treated patients. Severe hypoglycaemic attacks may have serious consequences in elderly patients. Education of the patient and his entourage, along with self-monitoring the blood sugar and respect of dietary laws, are crucial to the prevention.


Jobrane MANSOURI (TUNIS, Tunisia)
11:00 - 18:00 #8226 - Hyponatremia Treatment Et Emergency Service.
Hyponatremia Treatment Et Emergency Service.

OBJECTİVE: Hyponatremia is the electrolyte abnormality that is encauntered mostly. İt can happen in variable clinic symptoms in accordance with the reason and inception shape. Hyponatremia in acute inception can cause brain oedema; that's why it needs treatment urgently. İf chronic hyponatremia is treated hardly, it can cause a very serious neurologic chart called 'osmotik demilition'.Here is the presentation  about  treatment of patients with hyponatremia.

material-methods: The records of february, march, april in 2016 are observed. The age ,gender, additional health problems and biochemical analysis results in accordance with study  retrospectivly.

RESULTS: Twentythree patie nts are found with hyponatremia in study that is completed retrospectivly. They are treated at emergency. Eighteen patients are female,8 ones are male. The age average of patients is 74,43. Twenty patients have hypertension, diabetes, and coroner heart problem; 3 patients have renal insufficiency but they don't get hemodiafiltration. The ure average rate of patients is 58,96 mmol/l, sodium 116,8 mmol/l, creatinin 1,42 mmol/l, control sodium 123,47 mmol/l is confirmed. Fifteen patiants % 3 nacl infusion is treated, 8 patients is treated with %0,9 nacl.

DİSCUSS: When sodium levels decrease 135 mmol/l, it is called hyponatremia. The precaution is to give sodium or limited water to repair the serum sodium level of patient with hyponatremia. The two factors are very important in the determination of tretament: the existence of symptoms and  teh development of hyponatremia . While nausea whitout vomiting, confusion and headache are accepted as serious symptoms moderately, vomiting, respiration circulatory disorder, convulsions and coma  are considered as seriously symptoms. İf a patiant comes with these serious symptoms in 20 minutes, 150 ml %3 nacl intraveneous infusion is advised; at the end of 20 minutes, taken blood for sodium level; moreover it is advised that the same treatment can be doing again.The process must be continued till serum sodium level increases 5 mmol/l. İf hyponatremia happens more than 48-72 hours, it is described as chronic hyponatremia. Till the symptoms disappear, serum sodium level process is continued, not more 12 mmol/l in a day. The treatment of the main reason is important for patients with cheonic hyponatremia. We organized our patients to evaluate treatment in this way


Havva ŞAHIN KAVAKLI (ANKARA, Turkey), Pınar KOPTUR, Hıdır YILMAZ
11:00 - 18:00 #8049 - Hyponatremia, what is it hiding? : Case report.
Hyponatremia, what is it hiding? : Case report.

Introduction:

For psychiatric patients,potomania and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) are the most causes of hyponatremia. We report here the case of patient with hyponatremia.

Case report:

A 53-year-old female patient presented to the emergency department (ER) for tonic-clonics seizures without recovering consciousness. She had a 100 pack-year history of cigarette smoking, with a history of schizophrenia.

Her sugar blood pressure was 1,2 gr/litre. Her GCS was 12. She was hemodynamically stable. There was no other neurological sign nor meningism. She was bedridden with multiple lymphadenopathy. Her laboratory tests were natremia at 100mEq/l and kaliemia at 3 mEq/l. the urea and creatinine level were normals. The electrocardiogram had no abnormality.

A Convulsive Status Epilepticus due to hyponatremia was diagnosed.

She received 1 mg of clonazepam associated to 15mg/kg of phenobarbital and she was suplzmented in sodium and potassium.

The etiology of hyponatremia was associated to SIADH due to a metastatic small-cell lung carcinoma (SCLC).

Conclusion:

Hyponatremia is usually iatrogenic for psychiatric patients. However, an exploration for other etiology should be performed.


Houcem OUNI (tunis, Tunisia), Mohamed Ali CHERIF, Ons ANDOLSI, Khaled SAIDI, Youssef Zied EL HECHMI, Mohamed MEZGHENI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #5793 - Hypothermia inhibits the propagation of acute ischemic injury by inhibiting HMGB1.
Hypothermia inhibits the propagation of acute ischemic injury by inhibiting HMGB1.

Aims: Acute ischemic stroke causes significant chronic disability worldwide. We designed this study to clarify the mechanism by which hypothermia helps alleviate acute ischemic stroke.

Methods: Beginning 15 min after inducing a middle cerebral artery occlusion (MCAO), we kept groups of rats under either hypothermic (33°C) or normothermic (37°C) conditions. We then harvested brains and sera 4 h after the onset of MCAO. Thirty min prior to MCAO onset, we inhibited high mobility group box 1 (HMGB1) in two ways: intraperitoneal administration of glycyrrhizin (100 mg/kg) and intracerebroventricular injection of an anti-HMGB1 neutralizing antibody.

Results: Hypothermia effectively reduces mean infarct volume. Hypothermia also prevents neurons in the infarct area from releasing HMGB1. By preventing its release, hypothermia also prevents the MCAO-induced increase in serum HMGB1. We also found that both glycyrrhizin-mediated inhibition of HMGB1 and intracerebroventricular neutralizing antibody treatments diminish infarct volume. We next used RT-PCR to measure the levels of pro-inflammatory cytokines in peri-infarct regions. Although MCAO increases the expression of interleukin-1β (IL-1β) and tissue necrosis factor-α (TNF-α), this elevation is suppressed by both hypothermia and glycyrrhizin treatment.

Conclusion: We show that hypothermia reduces the production of inflammatory cytokines and helps salvage peri-infarct regions from the propagation of ischemic injury via HMGB1 blockade. In addition to suggesting a potential mechanism for hypothermia’s therapeutic effects, our results suggest HMGB1 modulation may lengthen the therapeutic window for stroke treatments.


Je Sung YOU (Seoul, Korea), Jung Ho LEE, Chul Hoon KIM, Sung Phil CHUNG
11:00 - 18:00 #7566 - Hypothermic trauma patients: rewarming before trauma therapy?
Hypothermic trauma patients: rewarming before trauma therapy?

Background: Accidental hypothermia is a typical low incidence – high impact disease in emergency medicine. The combination of hypothermia and multiple trauma is a dreaded situation mainly due to the impaired coagulation resulting in increased blood loss and intensified hemorrhagic shock, well-known under as the lethal triad of hypothermia, acidosis and coagulopathy.

Results: We present three hypothermic trauma patients who arrived under CPR and underwent invasive active rewarming with extracorporeal life support ECLS before detailed trauma assessment and interventions. All three patients survived with excellent outcome.

Discussion: Since 2010, the University Hospital in Bern works with an algorithm for assessment and therapy of patients suffering from accidental hypothermia and arriving under CPR. This Bernese Hypothermia Algorithm was developed by an interdisciplinary group of anesthesiologists, cardiovascular surgeons and intensivists under the lead of an emergency physician. Severely hypothermic patients in cardiac arrest undergo a very limited trauma assessment concurrent with preparations for an active invasive rewarming. Only after rewarming, regular trauma assessment takes place.  With growing experience and bearing in mind international developments (avalanche checklist and updated ERC guidelines), the group adjusted the standard to the newest version which will be presented. With the help of this algorithm, which is known to all members of the trauma teams, it was possible to save the lives of three polytraumatized, severely hypothermic patients who reached our emergency department under CPR.

Future trends in clinical research will be discussed, and the need of a register in this low incidence – high impact disease is highlighted.


Dr Monika BRODMANN MAEDER (Bern, Switzerland), Balthasar EBERLE, Alexander KADNER, Andreas BLOCH, Aristomenis EXADAKTYLOS
11:00 - 18:00 #4562 - Hypovolemic shock in a patient with spontaneous kidney haemathoma.
Hypovolemic shock in a patient with spontaneous kidney haemathoma.

I present here the a case of a 72-year-old patient with acute onset hypovolemic shock secondary to spontaneous haemathoma in the right kidney. It is a particular one, because the patient's complain were two presyncopal episodes in the context of fever up to 39ºC, cough and sputum for the last 3 days, so the initial management was to rule out pneumonia.

After anamnesis, physical exploration and initial blood sample were performed, he suffered a sudden onset of tachypnea and reduction in conciousness level. Remarkably, in the exploration his limbs were cold and in gasometry he had a fall of 2 g/dL in haemoglobin level in 30 minutes. In order to prevent cardiac arrest, intubation was performed and vascular resuscitation both with fluids and norepinephrine through a central vein access. Bedside ultrasound revealed no significant findings, so a computed tomography scan was performed, giving the diagnosis and the cause of the shock. At laboratory results was remarkable an INR of 16 (the patient was on regular acenocumarol).

After being transferred to the ICU, embolisation of the source was made. 2 weeks later he is still recovering in the ICU.

There are some key points I find interesting about this case:

-Differential diagnosis of shock.

-Intubation to avoid cardiac arrest.

-Central vein puncture as a skill for Emergency Physicians.


Luis Ángel MATEOS VEGA (Valencia, Spain)
11:00 - 18:00 #8007 - I am still learning ( Michelangelo)- A young case of atrial fibrillation leading to cardiac arrest.
I am still learning ( Michelangelo)- A young case of atrial fibrillation leading to cardiac arrest.

Atrial fibrillation is one of the most common causes of abnormal heart rhythm and a major causes of stroke. The causes of atrial fibrillation are widespread , from Hypertension, valvular heart disease, thyrotoxicosis, excess alcohol consumption, diabetes mellitus and coronary heart disease .However majority of times no cause has been identified and this is still a concern. 

 Recent NHS England Statistics show that Prevalance for atrial fibrillation is 1.2% with increasing numbers every year. Although it affects adults of any age but incidence is more in elderly  with a ratio of about seven (7) in hundred (100) people and more prevalant in males than females ( source NHS England UK).

We present an extraordinary case of a thirty seven (37) years old female patient who recently presented to our emergency medicine departmet at east surrey hospital with onset of palpitaions from lunchtime onwards at a social gathering. She had a presyncopal episode for thirty (30) seconds but recovered immediately. She had no chest pain or Shortness of breath throughout and no associated symptoms otherwise. She was on oral contraception and had two small children. Her medical background was depression and anxiety for which she was on low dose citalopram.

On arrival she was in fast atrial fibrillation, heart rate of 150-160per minute and was shifted immediately to resusitation and managed accordingly. The rest of her vitals were stable . She was started on maintainance intravenous fluids and was on continuous cardiac monitoring.Her Arterial blood gas was normal. Her chest xry was normal.She was discussed with the cardiologist and it was decided to electrically cardiovert her. However she reverted back to sinus rhythm on her own within twenty minutes (20) of arrival in resus. She was monitored for the next four hours and remained stable with no furthur episodes .

Her laboratory tests were normal and expert cardiology advice was sought again.It was decided not to antocoagulate her  as she scored low on CHA2 DS2-VASc score and a referral to arrythmia clinic was done.

She was discharged home with follow up advice . 

Later on in the evening she went into cardiac arrest at home.She was intubated and shocked eight (8) times till return of spontaneous circulation( ROSC) by paramedics.She was taken to a speciality centre in London where she stayed in intensive cardiac unit for the next week. On extubation she had full recovery and an ICD was fitted. The interesting thing was that her inflammatory markers were persistantly high thereafter during her inpatient stay and she was treated with intravenous antibiotics as a precautionary measure.However no clinical sign of sepsis was noted .She also had an echocardiogram and CT scan of her coronaries which were normal. She was discharged home and has remained stable.

This was an interesting learning case and had opened discussions amongst physicians whether patients who present with new onset atrial fibrillation need inpatient twenty four (24) hours monitoring and specialist cardiac investigations before discaharge.


Akhtar MUNAZAH (Redhill, United Kingdom), Julian WEBB, Inigo RUBIO
11:00 - 18:00 #8206 - Iatrogenic insulin intoxication.
Iatrogenic insulin intoxication.

A 75-year-old woman was admitted to the hospital because of dog bite. She didn’t have a significant medical history other than metformin use for diabetes mellitus. The physical examination revealed teeth marks on dorsal side of her right wrist. Wound care was performed. The patient was consulted with Infectious diseases for rabies post-exposure prophylaxis (PEP). Because of lack of a 10-day observation and confinement period of the straggler dog without any known vaccination, the rabies PEP regimen (administration of immune globulin (Ig), given only once, and a series of five dose rabies vaccinations) was planned. Ig (calculated totally as 3000 UI; 40 IU/kg, body weight:75 kg) and the first vaccine were given on the first day of treatment (designated day 0). Half of the dose was injected into and around the wound and the remaining half dose was administered intramuscularly in deltoid muscle by a truly hardworking intern and a junior resident doctor who had taken out the Ig vials from the vaccine refrigerator. It was noticed during the standard control procedure of matching vial labels to the patients file that planned Ig injection had been performed with crystallized insulin (Humulin R) instead of rabies Ig accidentally.

A lightning strike must be something like that!

The patient was monitored closely and taken to the resuscitation room immediately. Her finger stick blood glucose was 116 mg/dl. A central venous catheter was placed and 10% dextrose infusion with a rate of 250 cc/h was started. Baseline blood samples and ECG were obtained. All tests were in normal range. First measured blood glucose and potassium in blood samples were 207 mg/dl and 4.2 mEq/L respectively. Her GCS was 15.

The patient was consulted with Endocrine Department for hospitalization and admitted to ICU. Close monitoring of blood glucose and potassium was started. A special oral diet programme was planned hourly containing high levels of glucose, potassium, magnesium and phosphate.

Figure 1: The patient's blood glocose levels by time

During the follow-up, 10-30% dextrose infusion rate was set due to blood glucose checks and replacement of potassium was administrated due to potassium levels (max. 40 mEq/h required). Because of the drop of blood glucose to 79 mg/dl after 4 hours and 20 minutes later from the accidental injection of crystallized insülin instead of rabies Ig, 1 mg glucagon was applied subcutaneously and 30% dextrose infusion rate was increased. During the 7. minute of glucagon injection, the patient vomited but her blood glucose started to increase within 15 minutes. No pathology was detected in her cardiac monitoring. No recurrent glucagon administration was needed until blood glucose was measured as 70 mg/dl at the 7. hour after the first injection of glucagon. This second 1 mg dose of subcutaneous glucagon was supported by 30% dextrose again without any following side effects. Following fluid therapy was arranged due to instant blood glucose levels of the patient.

The patient was hospitalized 2 days in ICU and 3 days in the ward. She was discharged with healing at the end of 5. day with normal range cardiac and renal function levels. All along the first three days of the hospital stay of the patient; the attending specialist of the emergency department, concerning junior resident and intern doctor accompanied the patient with care, monitored her therapy with endocrine department and assisted the treatment.     

Our literature search showed examples of the publications regarding the management of high-dose insülin cases however none of them couldn’t state such a high dose circumstance. We aimed multiple purposes with presenting this case; firstly to discuss the potential new errors due to the control of critical drugs, the stress management (among relatives of patients and emergency personnel) and also drug name similarity problems in emergency departments. Secondly our case is an extreme example of its similars. And lastly this case is significant that it includes peak hours of insulin effects and extensions of glucagon administrations with explained conductions. 


Ertan CÖMERTPAY, Figen COŞKUN (ISTANBUL, Turkey), Aşkın GÜNGÜNEŞ, Şenay ARIKAN DURMAZ
11:00 - 18:00 #7515 - Icatibant treatment for non-histaminergic angioedema acute attacks in two emergency hospital departments.
Icatibant treatment for non-histaminergic angioedema acute attacks in two emergency hospital departments.

BACKGROUND

Angioedema is a relatively common reason of emergency department visits. Angioedema is due to different pathogenetic mechanisms with the same clinical manifestations. Around 80% of angioedemas are result of histamine release and in a lower percentage of cases bradykinin is the main mediator. Bradykinin- mediated angioedemas are generally unresponsive to corticosteroids and H1 antagonists. Icatibant is a selective bradykinin-2 receptor antagonist that blocks the vascular effects of bradykinin. ACE-induced angioedema and acquired angioedema are bradykinin- mediated angioedemas where Icatibant is not indicated and its use is off-label and requires signed informed consent for its administration.

OBJECTIVE

Description of use of Icatibant in bradykinin-mediated angioedemas without previous diagnosis

 in two hospital emergency departments

METHODS

We retrospectively  analyzed  angioedemas treated with Icatibant following our protocol in Bellvitge hospital and Universitary La Paz hospital emergency departments during Two years Epidemiological data, safety data and Icatibant label and off-label use are analyzed

RESULTS

Thirty five episodes of angioedema were treated with Icatibant in 28 patients (median age: 65+/-2 years; 62% males); 85% of episodes were oro-facial attacks, 5.7% in extremities and 2.8% abdominal attacks. 62.8% had previous attacks of angioedema. All attacks were treated with corticosteroids and H1 antagonist without response and Icatibant following emergency protocol for angioedema at the two hospitals. Second dose were needed in 7 patients. Non adverse events were observed

Diagnosis of Icatibant treated angioedemas was: 22.85% idiopathic angioedema, 14.28% acquired angioedema and 37.14% ACE-induced angioedema.

CONCLUSION

Icatibant for non-histaminergic angioedema in emergency department were effective and well tolerated. Orofacial location was the most common location. The first frequent cause of Icatibant treated angioedema was ACE-induced angioedema and the second one was idiopathic angioedema


Manuel QUINTANA DIAZ, Ana Maria MARTINEZ VIRTO (MADRID, Spain), M Angelica RIVERA NÚÑEZ, Javier JACOB, Rosario TORRES SANTOS OLMO
11:00 - 18:00 #7681 - Iceberg: what lies beneath the water. Accurate diagnosis are crucial in emergency and that implies a careful examination of the patient and ordering the correct exams.
Iceberg: what lies beneath the water. Accurate diagnosis are crucial in emergency and that implies a careful examination of the patient and ordering the correct exams.

Case report

A 75 years-old female patient presented at our Emergency Department (ED) with complaints of fever and right lumbar pain for 10 days. At the beginning of symptoms, she went to her local hospital where a diagnosis of pyelonephritis was made. She was discharged on cefuroxime 500 mg bid for 8 days. After finishing treatment without any improvement, she decided to go again to an ED.

On arrival to our ED, her major complaints were right lumbar pain and fever. She also had mild dysuria and shortness of breath. She had no significant medical history and she wasn´t on any medication.

Her temperature was 37.7 ºC, she had a normal blood pressure, normal heart and pulmonary sounds. Abdomen had no relevant findings, and both Murphy signs were absent.

Blood tests revealed leukocytosis, neutrophilia and high C-reactive protein. Chest X -ray film showed a right pulmonary base infiltrate.

We were considering a patient whose condition didn´t improve under a course of cefuroxime and whose X-ray finds didn´t seem to be related with the previous diagnosis of pyelonephritis.  A renal abscess with contiguous spread, a sub-phrenic abscess or a pulmonary infection were considered.

Abdominal CT scan was normal but thoracic CT scan revealed a pulmonary abscess contiguous with lower third of the esophagus and a linear density strongly suggesting a foreign body.

The patient denied any previous episode of dysphagia, sialorrhea, thoracic pain, cough and sputum.

A diagnosis of mediastinitis and pulmonary abscess due to esophagic perforation was made, and she was proposed for surgery.

She was referred to her local hospital, where she was submitted to surgery. Removal of a chicken bone and drainage of the abscess were performed. The patient was totally recovered.

Discussion: Back pain is a conundrum. It is crucial to carefully evaluate this symptom to have a more accurate scope in the differential diagnosis. In our case, pain was a lower thoracic pleuritic pain instead of a lumbar pain. The key findings in the workout of this patient were the absence of a renal Murphy sign and the presence of dyspnea. Chest X-ray also pointed to a thoracic infectious condition, which was also supported by blood work.

This case draws our attention towards the importance of a diagnosis-oriented management in emergency, as well as the potential danger of multiple urgency episodes with the same complaints. A serious diagnosis may be concealed by an innocent presentation and we must not be misled by a former diagnosis.


Andrea BARCA (Lisboa, Portugal), Svetlana RITA, Nadia KORCHEVNYUK, Gabriel OLIVEIRA, Cristina RODRIGUES, Luís CUÑA
11:00 - 18:00 #7693 - Identification of acute poisoning in emergency department.
Identification of acute poisoning in emergency department.

INTRODUCTION: Poisoning, alcohol over-consumption or drug overdose constitute a significant source of morbidity and mortality. According to Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS)" in 2014 there were almost 2.2 million toxic exposures in humans in the United States of America, of which 79.4% were unintentional and 16.4% were Intentional exposures, being mainly involved sedative/hypnotics/antipsychotics, cardiovascular drugs, opioids, stimulants and street drugs1. In Spain, a multicentre study in 2000 showed that drugs remain as leading cause of acute poisoning, especially in adults and in patients with psychiatric history. It is followed by alcohol intoxication, illegal drugs of abuse, and miscellaneous group including industrial products, spoiled food, plants and animals poisoning. OBJECTIVE: The aim of this study is to describe the clinical and epidemiological characteristics of the patients visiting the emergency department for acute poisoning. MATERIALS AND METHODS: All patients presenting with acute poisoning in the emergency department during January and February 2014 were included. Demographic, clinical and laboratory variables are collected. RESULTS: 156 patients presenting with acute poisoning in the study period were included. 51.3% were women. The mean age was 42 years. 21.8% had a history of alcohol abuse, 6.4% alcohol, tobacco and cocaine, 3.8% chronic smoking, 64% had no history of substance abuse. Regarding psychiatric history, 72% of patients had no history of psychiatric disorders, 20% had depression, 3.6% anxiety disorder, 3% schizophrenia, 2.4% eating disorder. 15.4% of patients had a history of self-harm/suicide attempts. According to the cause of admission to the emergency 45.5% of patients were admitted to the emergency department for alcohol poisoning, 44.2% for benzodiazepine intoxication, 5.1% cocaine overdose, 3.2% food poisoning, 1.3% CO2 poisoning 1.3% cannabis, 1.8% Hashish or MDMA. 42.3% of patients had suicidal ideation or autolytic intention. 52.6% of patients required psychiatric assessment during their admission in the emergency department. 85.9% of patients were discharged, 10.35% were hospitalized at the department of psychiatry and 3.2% at the internal medicine department. CONCLUSIONS: Patients who present with poisonings are mostly women. Alcohol poisoning is the most common cause of attendance. Mostly they have no history of substance abuse or psychiatric disease. Less than half refer intention or suicidal ideation and over 80% are discharged from the emergency department.


Maria Angelica RIVERA NÚÑEZ, Rosario TORRES SANTOS-OLMOS (MADRID, Spain), Ana MARTÍNEZ VIRTO, Charbel MAROUN-EID
11:00 - 18:00 #7280 - Identification of severe sepsis at triage, a simple screening tool.
Identification of severe sepsis at triage, a simple screening tool.

Sepsis is one of the leading causes of death in hospital patients worldwide. It causes more deaths than prostate cancer, breast cancer and HIV/AIDS combined. It is a medical emergency just like a heart attack or stroke but it can be subtle and difficult to diagnose. Early recognition and prompt treatment is essential to improve survival. Patients with sepsis are high risk and may deteriorate rapidly. It extremely important to identify septic patient at triage and to detect signs of possible unfavourable evolution.

Triage to the emergency department (ED) is the most critical time in the identification of evolving severe sepsis and is the first part of a differential diagnosis. Therefore, it is essential to have simple tools or scales to assist rapid and reliable identification.

A clinically based system of triaging ensures that patients needing priority medical care get it.

The identification of severe sepsis is based on clinical signs but also on laboratory findings.

An early warning indicator is necessary for early identification of patients at high risk of evolution.

Shock Index (Heart Rate/Systolic blood pressure) is a valuable and non-costly tool, that could help identify  patients at high risk of evolution at triage as it’s elevation is correlated to an increase in lactates. The prognostic value of isolated lactate measurements and serial measurements has been

investigated in various settings. Shapiro et al. found that lactate levels could correctly stratify patients according to mortality. Lactate levels of 0–2.4, 2.5–3.9 and ≥4 mmol/L were associated with mortalities of 4.9% respectively.

In our Emergency department  we started a multicentric observational study  using SI at triage in patients presenting to our Emergency Department with suspicion of infection. With a  Shock Index >7  lactates are measured immediately and if the value is >4 mmol/l the patient is immediately monitored and seen by an expert Emergency Physician. If lactates are >2 mmol/l the patient is seen within 15-30’ by an expert team.

Preliminary results show that implementation of triage algorythm with SI and immediate lactate measurement in adult ED patients with suspected sepsis reduces time to Emergency physician care  and to i.v. fluids and antibiotics. We expect also a decrease in mortality and ICU admission.

 


Germana RUGGIANO, Monica GALLI (Florence, Italy), Monica GIUSTI, Patrizia SIGNORONI
11:00 - 18:00 #7120 - Idiopathic thrombocytopenic purpura after onset of skin lesions in young patient.
Idiopathic thrombocytopenic purpura after onset of skin lesions in young patient.

MEDICAL HISTORY:

25 years old male patient without drug or interest personal medical history presented to the emergency with skin lesions on both legs of 3 days of evolution allergies. He regards the possibility of an allergic reaction.

Feeling feverish not have measurable in the last 15 days.

Subsequently the patient indicates have mild blood remains in nasal and gingival graves from the onset of symptoms. No box or catarrhal infection associated.

It has not taken any medical treatment or risk behavior lately. 

Browse: Vascular punctate, pruritic lesions with negative diascopy (no pressure disappearance of lesions) affecting back and legs as well as palms and soles.

Complementary tests:

Blood analysis in the presence of platelets: 4000 IU / microliter. (Normal range: 150,000 to 450,000 IU / microliter). Rest analysis unaltered.

Blood smears without observing dysplasias or immature cells and erythroid confirms thrombocytopenia without pathology. 

Evolution and Treatment:

The case is discussed with Hematology and transfer of patient referral hospital for evaluation in turn is decided.

The specialist in hematology informs the patient of hemorrhagic risk in your case (1-2%) and the patient decides to start home treatment and remain at rest relative slope house preferential appointment to continue study.

In consultation bone marrow biopsy, myelogram, cranial abdominal Ultrasound and CT are scheduled for resistance to treatment, with no evidence of changes in the results.

Analytical protein electrophoresis were performed, autoimmune markers, thyroid hormones and complete serology (HIV, HBV, HCV, CMV, EBV, ...) with negative results

We conclude with a diagnosis of idiopathic thrombocytopenic purpura

 Clinical Trial: idiopathic thrombocytopenic purpura


María Victoria ALARCÓN MORALES, María Eugenia REYES GARCÍA (Málaga, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7704 - Impact of Climatic Factors on the non-urgent visits to three Emergency Rooms in 2014.
Impact of Climatic Factors on the non-urgent visits to three Emergency Rooms in 2014.

Purpose. Conducted in 2016, the study seeks to find correlations between the non-urgent visits to emergency rooms and climatic factors.

Design: A multicenter retrospective study of registered medical records.

Participants: Three Emergency departments.

Tasks were: 1) Seeking to find correlations between climatic factors of the environment and the non-urgent medical examinations in emergency rooms. 2)Application of different models for evaluation of trends and evaluation of their validity

Methodology. Two methods have been applied. The first one employed a factorial analysis in order to reduce the included in the study climatic data. In the second one all data were included in a linear multifactorial regression model. The effect of each component on the demographic indicators was included and evaluated. The effect of the climate on leading classes of registered morbidity was also studied. The validity of the models was tested. Using a non-linear regression analysis, the role of the weather – fog, rain, and snow, was evaluated.

Results. The study has encompassed 32071 medical entries. Correlation dependencies were established between climatic components, age demographic indicators, and morbidity. There are present moderate statistically significant correlations between climatic factors, against the patient flow in childhood age (k=-0.416; p=0.001); morbidity in asthma (k=-0.416; p=0.001), and as to acute respiratory diseases (k=-0.579; p=0.001).

In the first model, the climatic factors were reduced to three groups: factor 1 – temperature and dew point; factor 2 – barometric, and factor 3 – humidity. The regression model indicated a predictive value of the first two factors of the non-urgent visits to the wards. Due to the marginal values of the confidence interval, the validity with regards to the general flow of patients not hospitalized (non-urgent patients) was dismissed (Ljung-Box Q statistics 24.428; Sig=0.041). The model indicated applicability with asthmatic patients (Ljung-Box Q statistics 27,152; Sig=0.076). The predictive value of the model is 5, 4%.

The carried out nonlinear regression analysis proved that fog is a factor when people seek medical help in emergency wards.  There was a proved effect on the average number of patients seeking help in wards (AUC=0.571 Sig. =0.041) as well as the fact that fog is a factor for the increased number of medical examinations of children and of patients with acute respiratory diseases. There was established a linear regression model of climatic factors which revealed nearly the same summarized effect of predictability as to climatic factors - 5, 4%.

Conclusion. The study has proved the impact of separate climatic factors on the registered medical examinations. There is no evidence as to the role of sex in the studied group. The non-urgent visits of children as well as of patients with acute respiratory diseases and asthma are significant. The conclusion that there is a high risk of unjustified visits among these groups has been made.

The study has not established a substantial significance and validity of the application of the two methodologies – factorial analysis and reduction of climate components against.


Nikolay HUBANOV (Sofia, Bulgaria), Petko STEFANOVSKI
11:00 - 18:00 #7151 - Impact of Early Coronary Angiography on the Survival to Discharge after Out-of-Hospital Cardiac Arrest.
Impact of Early Coronary Angiography on the Survival to Discharge after Out-of-Hospital Cardiac Arrest.

Background      Acute myocardial infarction is a major cause of out-of-cardiac arrest (OHCA). Coronary angiography (CAG) would enable diagnostic confirmation of coronary artery disease subsequent revascularization, which might improve the prognosis of OHCA. However data showing the impact of CAG on the clinical outcome or the optimal timing of CAG are limited.

Methods           Clinical outcome of 607 OHCA patients who were registered in Cardiac Arrest Pursuit Trial with Unique Registration and Epidemiologic Surveillance (CAPTURES), a nationwide multicenter registry consisting 27 hospitals, were analyzed. Early CAG was defined by within 24 hours of arrival to emergency department (ED). Primary outcome was survival to discharge with neurologically favorable status defined by cerebral performance categories ≤2.

Results              Compared to patients without CAG (N=469), patients who underwent early CAG (N=138) were younger, more likely to be male to underwent bystander cardiopulmonary resuscitation (CPR), prehospital defibrillation, and revascularization (p<0.01, all). Analysis of 115 propensity score - matched pairs showed that early CAG is associated with 2.3-fold increased survival to discharge with neurologically favorable status (p<0.001, all). Survival to discharge increased consistently according to the interval between ED visit to CAG (p<0.05).

Conclusions      Early CAG of OHCA patients was associated with better survival and favorable neurologic outcome at discharge. There was no clear threshold of CAG time associated with survival to discharge.


Jikyoung SHIN (Seoul, Korea), Eunsil KO, Won Chul CHA, Tea Gun SHIN, Min Seob SIM, Ik Joon JO, Jin-Ho CHOI
11:00 - 18:00 #4530 - Impact of prehospital critical physician team on time on scene and transport time following major trauma: analysis of a national trauma registry.
Impact of prehospital critical physician team on time on scene and transport time following major trauma: analysis of a national trauma registry.

INTRODUCTION

Studies in several countries suggest there may be a benefit to patients who receive physician-led prehospital critical care, especially more seriously injured patients. Data about the effect of physician-led prehospital care on on-scene time and time to hospital arrival is mixed with some studies showing a longer scene and transport time for physician led teams. Scotland has three prehospital critical care teams; we wished to investigate whether treatment by such a team was associated with an increased on-scene time.

METHODS

We performed a retrospective cohort study of patient data from the Scottish Trauma Audit Group, covering all trauma patients admitted to hospitals in Scotland, for the four calendar years 2011-14. We compared those who were seen by a physician-led prehospital critical care team to those who received standard ambulance care. We excluded patients seen by other physicians, most of whom cannot provide critical care. The primary outcome measure was time from first ambulance resource arrival to departure of patient from scene.

EXCLUSIONS

Patients seen by non critical care physicians (e.g GP)

Patients pronounced life extinct at scene

RESULTS

A total of 13,135 patients were included in initial dataset. Of these 13,135 eligible patients, 603 patients were seen by a non-critical care doctor and in 2280 cases, it was not recorded whether care was from ambulance service or other staff, leaving a total of 10,252 patients available for analysis. Of these patients, 503 (4.9%) were seen by a prehospital critical care team and 9749 (95.1%) received standard ambulance care. Complete time series data was available for 74.4% (7627 / 10252) of eligible cases. 

Analysis showed the mean time spent on scene for the group of patients where a prehospital critical care team attended was 53.7 minutes versus 32.3 minutes where no prehospital critical care team was in attendance. The difference was 21.4 minutes (95%CI 19.0 to 23.8,p<0.001).

There were significant other differences between those patients attended by a versus those receiving standard ambulance care. Those attended by a prehospital critical care team were likely to be younger (44.5 v 54.8 years, p<0.001), were more severely injured (median ISS 17 v 9, p<0.001) and were more likely to receive intubation at the scene of the incident (30.0% v 0.9%, p<0.001). They were also more likely to be transported by air (30.0 v 2.8%, p<0.001)

DISCUSSION

Our data shows attendance of a physician led prehospital critical care team in associated with a longer on scene time. However the group attended by prehospital critical care physicians are more seriously injured and have a larger number of invasive procedures done. Geographical location was not recorded in this study. More air transports suggests more remote location and possibly longer waiting on scene for resources to arrive.

Our data is based on the time of initial ambulance resource arrival (which may not be the prehospital critical care team) until patient leaves scene. Some of the on-scene time may reflect wait for a prehospital critical care team to arrive due to dispatch issues.

 

 


Alistair MADDOCK, Alasdair CORFIELD (Glasgow, ), Michael DONALD, Hearns STEPHEN, David FITZPATRICK
11:00 - 18:00 #7720 - Impact of traffic conditions on time management of acute coronary syndrome with ST elevation myocardial infarction.
Impact of traffic conditions on time management of acute coronary syndrome with ST elevation myocardial infarction.

Introduction: Dealys for taking over  are the key determinants of the prognosis of acute coronary syndrome with ST elevation myocardial infarction (STEMI). Diverse criteria that can influence these deadlines were studied including the day of the week or the on-call period. The impact of the traffic conditions was not specifically studied. However, in highly-urbanized cities, such as a European capital, it could lengthen the response time.

Objective: To assess the impact of the traffic conditions over the delay for STEMI management. The regional traffic data analysis identified two critical periods: from 8 to 9am and from 6 to 7pm (average speed < 60 km.h-1) and calm periods from 1 to 2pm (average speed > 80 km.h-1). Inclusion: primary care of patients with incoming call during one of these periods. The primary endpoint: delay between 112 call and first medical contact was considered as directly connected to traffic conditions. Statistics: data obtained were analyzed using Kruskal-Wallis test.

Results: 19.658 delays were analyzed from 2003 to 2014. The traffic conditions did not impact the delays.

Conclusion: the traffic conditions had no impacts on traffic delays. Obviously, the “urgent” traffic modalities  allow overcoming traffic difficulties.


Frédéric LAPOSTOLLE, Jimmy ROBERT, Alexandre ALLONNEAU (Paris), Sophie BATAILLE, Aurélie LOYEAU, Thévy BOCHE, Mireille MAPOUATA, Virginie PIRÈS, Jonathan GONZVA, Gaelle LE BAIL, François DUPAS, Yves LAMBERT
11:00 - 18:00 #7322 - Impact of using point of care creatinine device prior to contrast enhanced computed tomography in emergency department.
Impact of using point of care creatinine device prior to contrast enhanced computed tomography in emergency department.

Background

Contrast-enhanced computed tomography (CECT) is essential to diagnose some fatal emergent diseases. However, lack of the kidney function data may often delay CECT in emergency department and as a result, patients have to receive plain CT prior to the CECT thus time and cost may double in some patients. StatSensor® Creatinine Xpress Meter, which is one of the point-of-care (POC) creatinine devices, can provide quantitative data on a patient’s kidney function within 30 sec. We introduced this device from Jan 2015 in our emergency department and have used it routinely since then. The purpose of this study is to assess how POC creatinine device have affected the number of CECT or “double CT” in emergency department.

Material and methods

Between Jan 2014 and Dec 2015, the data of thoracic and abdominal CT ordered from emergency department was collected retrospectively. CT that was taken between Jan 2014 and Dec 2014 were grouped as “before POC” and CT taken between Jan 2015 and Dec 2015 were grouped as “after POC”. The rate of CECT, rate of patients who had plain CT prior to the CECT, and rate of diagnoses that were corrected or confirmed after added CECT were compared between these two groups. The chi-square test was used for statistical analysis, and the values of P<0.05 were considered significant.

Results

The total number of CT in “before POC” and “after POC” were 1373 and 1358, respectively. The rate of CECT were 150/1373 (10.9%) for “before POC” and 232/1358 (17.1%) for “after POC” showing significant increase after the introduction of POC (P<0.001). The rate of CECT added after plain CT in “before POC” and “after POC” were 21/1223 (1.7%) and 20/1126 (1.9%), respectively (n.s.). The rate of cases that diagnoses were corrected or confirmed after added CECT were 11/21 (52.3%) in “before POC”, and 7/20 (35%) in “after POC” (n.s.).

Conclusion

The use of POC creatinine device significantly increased the rate of CECT in emergency department. This may have assisted an accurate diagnosis of fatal diseases within limited time. However, in contrast, diagnosis made after added CECT have not been decreased and this may have added unnecessary CECT as well. Further investigation is essential to analyze the efficacy of additional CECT to assess the real usefulness of POC creatinine device in emergency department.


Shotaro KAWAMURA (Nagoya, Japan), Hidetoshi WATANABE
11:00 - 18:00 #7472 - Impact of WBCT in early diagnosis and management of Major Trauma.
Impact of WBCT in early diagnosis and management of Major Trauma.

Background

 

Major trauma describes serious and often multiple injuries that may require lifesaving interventions. It is the biggest killer of people aged below 45 years in the UK. The National Audit Office (2010) report estimated that there are 20,000 cases of major trauma per 
year in England; 5,400 people die of their injuries with many others sustaining permanent disability. 


In poly trauma patients every second counts. Time is of the essence. Earlier WBCT is just like doing a primary survey to get earlier diagnosis for critically ill patients. Hence, direct scanning can expedite patient care; improve survival and a reduction in emergency department stay.

 

Objective:

 

To find out the incidence and Impact of positive WBCTs in suspected polytrauma patients.

 

Methodology:

 

We did the retrospective analysis of case notes from June 2014 to June 2015 for patients presenting at university hospital Birmingham. All adult major trauma patients who triggered TTT were included.

 

Results:

 

We had a total 489 patients over this period that had WBCT. They were predominantly male (88%) and 12% were females. The mean age was 53 years. The mean ISS score was 39 among these patients. The commonest cause was road traffic accident 37% followed by falls 20% and then assault in 6% of the cases.

 

We had 69% patients who had positive WBCT as multiple regions were involved. The commonest region involved was thorax followed by head 36% then pelvis 20% and then abdomen in 17% of the patients. The mean time to CT was 29 minutes.

 

Conclusion:

 

Major trauma patients require more time and resources to manage as traditionally the whole trauma team rather than 1 ED physician receives the patients. All these patients in the study had a diagnosis within 45 mins of their arrival and that lead to earlier treatment (Bloods, Theater, IR) and will improve the survival out come.


M Azam MAJEED (Birmingham, United Kingdom), Heren WIJESINGHE, Jessica HIN, Bethan JONES, Lara PILBEAM, Zoe MCMILLAN, Asif NAVEED, M Saif REHMAN
11:00 - 18:00 #4570 - Implementation of a pre-hospital intubation register. Data collection of indications, methods, success rates, and complications of pre-hospital intubations.
Implementation of a pre-hospital intubation register. Data collection of indications, methods, success rates, and complications of pre-hospital intubations.

Background:

In pre-hospital settings there exist some data of indications, methods, success rates, and complications of pre-hospital intubations. But there exist no standard data collection in the german speaking countries. Aim is to get standard data to give evidence about pre-hospital intubations.

Methods:

A standardized web-based questionaire has been created. There is asked eg. for qualification of performer, success rate, method, indication, complication and other options in case of no success.

Results:

The data collection homepage can be found under www.intubationsregister.de. All data can be analysed by master admin. Individual logins for each emergency service base allow local admins to check there own data. Both, analysis of general and local data is anonymous.

Conclusions:

The implementaion of a pre-hospital intubation register is an easy and quick possibility  to collect standardized data. This data can be used for eg quality management.


Steffen HERDTLE (Jena, Germany), Sebastian LANG, Jens REICHEL, Wilhelm BEHRINGER, Christian HOHENSTEIN
11:00 - 18:00 #7998 - Implementation of an animal model for toxic smoke inhalation and resuscitation.
Implementation of an animal model for toxic smoke inhalation and resuscitation.

Objective

Resuscitation of fire victims may be different from resuscitation in sudden cardiac death, because death by fire mainly is caused by toxic smoke inhalation and therefore may need specific antidote treatment[1,2]. To investigate the effects of combined inhalation of the important toxic gases carbonmonoxide (CO) and hydrogen cyanide (HCN) we designed a realistic animal intoxication model. The goal of this study was the feasibility and safety of this model and the effects of Advanced Life Support on Return of Spontaneous Circulation (ROSC).

Materials and methods

After approval by local authorities and in accordance with German animal protection law a smoke inhalation model for pigs (25-35kg) was developed based on a closed ventilation circuit. Gas cylinders with oxygen, compressed air, compressed air with CO=1500 parts per million (ppm) and compressed air with HCN=1000ppm were connected together with valves allowing multiple mix of gas concentrations to supply a Siemens Servo300 ventilator. The expiratory outlet lead to a gas suction unit. Room-air concentrations were monitored with gas detection devices for CO and HCN.  24 pigs (mean 31kg) underwent anaesthesia, intubation and instrumentation. Inhalational intoxication was simulated by controlled ventilation with: air with CO=1500ppm (5min), followed by air with CO=750ppm and HCN=500ppm (5min), followed by HCN=1000ppm until cardiac arrest occurred. Resuscitation was started with 100%oxygen and chest compressions (10 minutes), followed by ALS according to guidelines. Additionally 5g hydroxycobalamin or placebo were given. Time to cardiac arrest and time to ROSC were measured. Results as median (25/75%percentiles).

Results

No increase in room air concentration of CO/HCN could be observed. Cardiac arrest occurred in all pigs in a median time of 38min(25.5/48.5). ROSC was achieved in 14/24 pigs (7 hydroxycobalamin, 7 placebo), median time to ROSC 14(13/15.8)min.

Conclusions

This smoke inhalation model was safe and lead to cardiac arrest in all cases. The time to cardiac arrest hereby was much longer than in literature data described for inhalation of HCN 1000ppm[3]. Additional investigations are needed to reevaluate both the toxic effects of combined CO/HCN inhalation and resuscitation outcome.

References

[1]Postgrad Med. 1987;82(1):63-8, [2]Eur J Emerg Med 2013;20(1):2-9, [3]Fire Technology 1972;8(2):120-30


Jost BEELITZ, Wolfgang DERSCH, Clemens KILL (Essen, Germany), Nina VOGT, Florian VEIT, Hinnerk WULF, Carsten FELDMANN
11:00 - 18:00 #7529 - Implementation of one Patient Safety Practice in two emergency service in Bogota - Colombia.
Implementation of one Patient Safety Practice in two emergency service in Bogota - Colombia.

Use of real-time ultrasound for central line placement is a Patient Safety Practice according the Agency for Healthcare Research and Quality. Despite this, in our country and in similar countries in Latin America this practice has not been widely implemented, additionally had been published the limited development of point-of-care ultrasound in the Emergency Departments in Colombia. However, our working group implements this Patient Safety Practice in two highly complexity hospitals in Bogota Colombia. To our knowledge, being the first Emergency Services to establish this Practice. In our work we describe the experience during de first year of implementation.

Objective
To describe the outcomes of implementing a Patient Safety Practice in two hospitals in Colombia

Methodology
Since January 2014 all central venous lines were placement guided by ultrasound, this Practice was implemented in the Emergency Department of Hospital Universitario Mayor - Mederi and Fundación Cardioinfantil in Bogotá Colombia. The Emergency Physician performed these procedures to critical patients admitted in the Shock and Trauma rooms. The following aspects were analyzed for each Procedures: reasons for venous central line placement, access site, number of attempts and complications.

Results

762 procedures were analyzed. The main reasons for the implantation of a central venous line were the presence of shock (56.3%), respiratory failure (12.5%), monitoring of critically ill patients (21.2%) and other causes in 10 % of the cases. Approximately 22% of patients were enrolled with INR greater than 3.0. The access sites were distributed as follows: right internal jugular: 73.5%, left internal jugular: 18.5%, right subclavian: 4%, left subclavian 0.8% and femoral veins 3.2%. Success rates according to the number of attempts were: at the first attempt; 88%, at the second attempt 9.3% and need for more than 2 attempts 2.7%. The complication rate was 1.4%: arterial punctures (5 patients), visible hematoma (6 patients), pneumothorax (7 patients), infections (3 patients).

Conclusion
Despite the limited use of point-of- care ultrasound in emergency departments in Colombia, our working group has succeeded implementing this Patient Safety Practice and the complications rate were lower than those reported in the literature. Our data support the benefits of implementation of this medical technology in other Emergency Departments in Colombia and in other countries with similar populations.


Luis Arcadio CORTES-PUENTES (BOGOTA, Colombia), German DEVIA, Gerardo LINARES-MENDOZA, Carlos Hernan CAMARGO MILA, Jenny TORRES, Monica BUITRAGO
11:00 - 18:00 #7602 - Implementation of principles of palliative care in Emergency Medicine in Croatia.
Implementation of principles of palliative care in Emergency Medicine in Croatia.

Patients with end stage disease or at the end-of life stage (palliative patient) often present to the emergency department or ask for prehospital emergency medical service intervention because they need pain or symptoms relief. providers of emergency medical care in booth hospital and prehospital settings need to be familiarized with specific approaches to palliative patients.

Following the Strategy for development of palliative care in Croatia 2014 -2016, Croatian Ministry of Health stressed the importance of improvement of care for palliative patients in prehospital and hospital emergency medicine settings. For this purpose Croatian Institute of Emergency Medicine together with national experts for palliative care organized four regional workshops and initiated devolpment of Prehospital and hospital emergency medical service guidelines for care of palliative patients. Workshops were orginezed for prehospital and hospital emergency workers and county policy makers with aim to exchange expierence, collect suggestions and personal perspectives of their roles in the delivery of palliative care in emergency medical settings. Topics of the workshops covered improvement of palliative care knowledge, awereness of available hospital and prehospital resources and of in-house palliative care teams and their hours of availability in their local surroundings. Guidelines provide the initial information about paliative care in emergency medical settings, including symptom and pain recognition and management;describe how to conduct discussion with families and how to make critical decisions.

Next step in improvement of palliative care in emergency medicine settings is to prepare and organize training courses for emergency medical workers dealing with acute palliative patients, based on framework defined in guidelines.


Maja GRBA-BUJEVIC, Milena CAR, Branka TOMLJANOVIC (ZAGREB, Croatia)
11:00 - 18:00 #7130 - Implementation of the emergency department model improves justified hospitalizations and hosptial efficiency in St. Petersburg, Russia.
Implementation of the emergency department model improves justified hospitalizations and hosptial efficiency in St. Petersburg, Russia.

Relevance:  Today, effective utilization of healthcare resources is crucial anywhere. In Russia, introduction of the emergency department (ED) model is an important step towards improving in-hospital emergency care. Goal: To analyze outcomes of a pilot ED at a multi-specialty hospital. Methods: We analyzed ED performance at the Dzhanelidze Institute of Emergency Care (St. Petersburg) for the period 2002-2012. Results: The need to improve the metric of justified hospitalizations expanded the use of diagnostics by the ED by 62.7% compared with the prior “Receiving Department”: from 316.7 (2004) to 515.4 (2012) studies per 100 patients. EKG use increased by 123.3%, US by 203%, XR by 137.9%, blood chemistry by 2629.8%, urine analysis by 103.9%. CT use increased from 0 cases to 13 per 100 patients. The overall rate of medical interventions increased by 316.5%, including a 2265.2% increase of syndrome-based treatments. The latter led to a five-fold increase in the proportion of patients considered “ambulatory”: from 8.6% (2004) to 45.4% (2012), or 53.4% if counting ED-observation beds. Total percentage of incorrect or discrepant diagnoses fell from 37.6% to 15.4%. There was a 23.8% decrease in length of stay for short-stay patients (< 3 days). Above outcomes improved percent of justified hospitalizations to specialized departments, e.g. shifting the relative weight of stays of over 14 days from 10.9% to 16.9%. Overall hospital mortality decreased from 3.8% to 3.7%, in parallel with a 24.9% increase in the annual patient volume (45,389 to 56,691). Conclusion: The ED model improved justified hospitalizations by aligning inpatient resources with sicker patients, preserved overall quality of care and allowed to accommodate yearly rise in hospital throughput.


Sergey BAGNENKO (Saint Petersburg, Russia), Alexandr MIROSHNICHENKO, Ruslan ALIMOV, Anthony RODIGIN, Dmitry KORBUT
11:00 - 18:00 #7607 - Implementing coded presenting complaints to be used for symptom-based analyses of emergency department data.
Implementing coded presenting complaints to be used for symptom-based analyses of emergency department data.

Background:

Generally speaking, in health care research the coded diagnosis according to ICD serves as the main classification variable. However, a diagnosis is the result of anamnesis, examination and diagnostic; but the way of a patient in an acute care setting begins with a symptom or a symptom complex. For symptom-based analyses the collection of standardized presenting complaints is essential. Since there wasn’t a German classification system available, the presenting complaint list of the Canadian Emergency Department Information System (CEDIS) [1] was translated into German and included into the dataset “emergency department”. This dataset is the basis for data collection in the joint research project for establishing a German emergency department data registry (AKTIN) [2]. We evaluate the implementation of presenting complaints in one pilot hospital and report first results.

 

Methods:

All 171 presenting complaints were integrated in the electronic medical record system of a tertiary care hospital’s emergency department serving 36,000 patients per annum. Additional to recording a narrative reason for visit, one coded presenting complaint was assigned during administrative admission. The medical administrative staff didn’t receive specific training regarding coding of ambiguous cases. After three months, an explorative analysis was performed. Descriptive analysis comprised the calculation of frequencies and association with triage category (Manchester Triage System, MTS) and hospitalization of the patients.

 

Results:

8,755 patients treated in the given time period were included in the analysis. After excluding those cases coded as “unknown” the top 5 presenting complaints were: upper extremity pain (11.5%), lower extremity pain (11.5%), abdominal pain (7.6%), upper extremity injury (6.3%) and chest pain-cardiac features (5.6%). Extremity pain and injuries were mainly triaged as standard or non-urgent (89.1% in MTS acuity scale green or blue). Extremity weakness/symptoms of CVA or TIA, chest pain-cardiac features and palpitations/irregular heart beat predominated as cardiologic and neurologic complaints. They tended to be triaged as very urgent or urgent (>65% MTS category orange or yellow) and were associated with a high hospitalization rate in critical care units. Shortness of breath was assigned to diverse triage categories and led in 17.4% to ICU-hospitalization. The ratio of cases coded as “unknown” decreased from initial 22.0% to 13.8% in the third month.

 

Discussion:

The adaptation of the CEDIS presenting complaint list enables symptom-based analysis of health care provided in German emergency departments. Once integrated into the electronic medical record system, the assignment of a coded presenting complaint during patient admission requires little extra effort. So far, for grouping and further analyses a narrative reason for visit had to be coded ex post manually. Containing 171 presenting complaints, this classification system could be implemented without providing extensive training for the staff. However, e.g. due to overlapping categories, basic instruction for use should be offered to reduce the rate of cases coded as unknown. Additional to quality management, benchmarking and science, a coded presenting complaint may be used for standardization of care processes, such as clinical pathways.

 

References:

1. http://caep.ca/resources/ctas/cedis#presentingcomplaintlist

2. http://www.aktin.org/

 

Acknowledgements: AKTIN, funded by Federal Ministry of Education and Research: 01KX1319A


Felix GREINER, Dominik BRAMMEN, Martin KULLA, Felix WALCHER, Bernadett ERDMANN (Wolfsburg, Germany)
11:00 - 18:00 #6484 - Improved compliance with a bundle of care for chronic obstructive pulmonary disease.
Improved compliance with a bundle of care for chronic obstructive pulmonary disease.

Background:  Chronic obstructive pulmonary disease (COPD) is a common reason for attending emergency departments (ED).  Evidence and published guidelines recommend the use of a bundle of care including controlled oxygen therapy, inhaled bronchodilators and systemic corticosteroids along with antibiotics, blood gases and non-invasive ventilation (NIV) when indicated. The Emergency Care Clinical Network (ECCN, Victoria, Australia) works with ED across the state to improve clinical care by uptake of evidence-based practice and reduction in variation in practice.  Member EDs vary in size, staffing and supporting specialist services; approximately half are based in rural and regional areas. 

Participants and methods: The aim of this project was to improve compliance with bundle of care elements for the management of acute exacerbations of COPD in ED.  This was a quality improvement project measured by collection of before and after data.  Participation was by expression of interest. ECCN uses a modified knowledge transfer methodology. The network management team develops the project parameters, conducts awareness raising activities, provides resources (including published papers, data collection tools), provides project management training for project leads, analyzes data and mentors project leads throughout the project.  Local clinical leads and supporting teams develop a local implementation plan, implement changes and collect before and after data.  Outcome of interest for this project were administration of controlled oxygen therapy, inhaled bronchodilators, systemic steroids and taking of a chest xray and, for qualifying cases, administration of antibiotics, blood gas analysis and use of NIV.    

Results: Seven ED completed the project, most from rural or regional areas.  There were 180 patients in the pre-data and 203 in the post data set.  The proportion of patients receiving controlled oxygen increased from 74% to 80% (p=ns), the proportion treated with bronchodilators increased from 81% to 90% (p=0.004) and the proportion treated with systemic corticosteroids increased from 76% to 88% (p=0.003). The proportion of patients with signs of infection receiving antibiotics increased from 85% to 99% (p<0.001), the proportion of non-mild cases having blood gas analysis increased from 82% to 91% (p<0.05) and the proportion of patients with pH <7.3 receiving NIV increased from 53% to 81% (p<0.02). The proportion having a chest xray was unchanged (98% vs 98%).

Conclusion: A locally managed, clinical network supported quality improvement project resulted in significant improvements in compliance with COPD bundle of care elements.  This methodology is transferable to other clinical issues and across disciple boundaries.

Sources of funding: This project was supported by direct grants to ED from ECCN.


Anne-Maree KELLY (Melbourne, Australia), Pannifex JAN
11:00 - 18:00 #6482 - Improved compliance with key quality and safety process measures during emergency intubation.
Improved compliance with key quality and safety process measures during emergency intubation.

Background:  Emergency intubation is a high risk procedure in emergency departments (ED). Recently published evidence strongly suggests that compliance with key process measures improves the safety of this procedure and avoids adverse events.  The Emergency Care Clinical Network (ECCN, Victoria, Australia) works with ED across the state to improve clinical care by uptake of evidence-based practice and reduction in variation in practice.  Member EDs vary in size, staffing and supporting specialist services; approximately half are based in rural and regional areas. 

Participants and methods: The aim of this project was to improve compliance with key quality and safety process measures during emergency intubation in emergency departments.  This was a quality improvement project measured by collection of before and after data.  Participation was by expression of interest. ECCN uses a modified knowledge transfer methodology. The network management team develops the project parameters, conducts awareness raising activities, provides resources (including published papers, data collection tools), provides project management training for project leads, analyzes data and mentors project leads throughout the project.  Local clinical leads and supporting teams develop a local implementation plan, implement changes and collect before and after data.  Outcome of interest for this project were, at the ED level, routine use of intubation checklists and audit of emergency intubations. Patient level outcomes were documented structured risk assessment of the airway, use of apnoeic oxygenation, confirmation of correct tube placement by capnography, low tidal volume ventilation, post intubation chest xray and nasogastric tube placement. 

Results: Fourteen ED completed the project.  There were 272 patients in the pre-data and 242 in the post data set.  Use of checklists and audits each increased from 14% to 93% (p=0.0002). The proportion of patients undergoing risk assessment increased from 43% to 69% (p<0.0001), the proportion having apnoeic oxygenation increased from 31% to 65% (p<0.0001), the proportion having capnographic confirmation of tube placement increased from 82% to 97% (p<0.0001) and the proportion having low tidal volume ventilation increased from 29% to 67% (p<0.0001).  The proportion having CXR confirmation of ET tube increased from 88% to 94% (p=0.04) and the proportion having nasogastric tube insertion increased from 76% to 87% (p=0.003).

Conclusion: A locally managed, clinical network sponsored quality improvement project resulted in significant improvements to key quality and safety process measures for emergency intubation.  This methodology is transferable to other clinical issues and across disciple boundaries.

Sources of funding: This project was supported by direct grants to ED from ECCN.


Anne-Maree KELLY (Melbourne, Australia), Pannifex JAN
11:00 - 18:00 #7951 - Improving multidisciplinary team meetings in Geriatric Emergency Medicine.
Improving multidisciplinary team meetings in Geriatric Emergency Medicine.

Introduction

Multidisciplinary team (MDT) communication is key to providing comprehensive geriatric assessment. Frail older people attend emergency departments with increased frequency and have higher conversion rates than younger people. Effective MDT working within the ED area as part of a collaborative apporach with ED physicians and nursing staff, "The Emergency Frailty Unit" has been shown to reduce conversion rates and reduce readmission/reattendance rates in patients aged over 80.  Leicester’s Emergency Frailty Unit (EFU) aims to deliver two brief MDT meetings per day to aid communication and efficient patient assessment and management. Historical meeting attendance rates were variable, which negatively impacted on the efficiency of communication between team members and was felt to slow down patient flow through the unit and main department . A QI project was designed to optimise the frequency and attendance at meetings, aiming to improve communication and reduce variability.

Methods
Quality improvement methodology was used (PDSA cycles). Baseline data collection was continuous; during this period including the number of handovers per day, attendance of MDT members and length of meeting. Two planned interventions occurred:

    1.    MDT meeting rates and attendance was then published, alongside an email explaining the rationale for the project (intervention 1).

    2.    All team members were all encouraged to take shared ownership and initiation of the MDT meetings (Intervention 2).

Results

Both interventions resulted in a measurable improvement in the frequency and attendance of MDT meetings.

·         Occurrence of an MDT on any given day improved from 25% to 100%.

·         Proportion of MDT present during a meeting improved from 25% to 70%

·         Length of meetings decreased from 88.7 seconds to 79.1 seconds per patient

Key Conclusions
Using established QI methodology, this project has identified that the frequency and attendance of rapid MDT meetings in an emergency medicine setting can be improved with no adverse impact on the duration of the meeting.

 

 


Sonal KUMAR, Thomas MORRIS, Amina KAVAL, Salsabila MADI, Abdul MATIN, Mary REN, Sarah TURPIN (London, United Kingdom)
11:00 - 18:00 #8009 - Improving psychiatric risk assessment for patients presenting in crisis to the emergency department at a London hospital.
Improving psychiatric risk assessment for patients presenting in crisis to the emergency department at a London hospital.

Background:  The Royal College of Emergency Medicine recommends that risk assessment by Emergency Department (ED) staff is integral to the optimal management of psychiatric presentations to the ED.  The ED in question had an existing risk assessment tool which was poorly understood and underused. Referrals to psychiatry lacked consistency and patient safety was potentially at risk.

Method:  A retrospective note review was carried out on ED referrals to Psychiatry in July 2015 (n = 41) and found that only 7% of the sample had a risk assessment by ED clinicians, with 0% use of the existing risk assessment tool.  As a result, an intervention was planned.  A new mental health risk assessment proforma (MHRAP) was designed with input from Liaison Psychiatry and ED staff.  The proforma was abbreviated, focused on key factors relevant to decision-making, and risk categories were simplified to correlate with clear actions by ED staff.  The MHRAP was introduced alongside multidisciplinary team teaching on the tool.

Results:  On re-audit (n = 40), 48% of patients had a completed MHRAP, and 55% had either an MHRAP or a risk assessment documented in the notes.  A significant proportion of referrals (18%) were by nursing staff at triage, and the MHRAP was only used for one of these referrals.

Discussion:  Risk assessment recording for mental health patients was significantly improved by the introduction of a new streamlined MHRAP.  Factors leading to this improvement were (i) successful collaboration between interested parties in designing and implementing the new tool; (ii) establishment of a rolling training programme to support use of the tool; and (iii) aiming not only to improve ED standards but also provide a user-friendly tool for staff.  Feedback has already been obtained and the MHRAP amended to make the tool more workable for use at triage.  One of the key next steps is to expand tailored training to triage nurses as this will maintain safety of vulnerable patients and speed flow through the ED. 


Frances DEBELL (London, United Kingdom), Barbara CLEAVER, Sachin PATEL
11:00 - 18:00 #7421 - Improving quantity of ultrasounds in the ed via standardized and simplified documentation.
Improving quantity of ultrasounds in the ed via standardized and simplified documentation.

Background: 

In recent years emergency ultrasound has been a rapid developing subspecialty in Emergency medicine. A lot of new standardized Exams like FAST, FEEL or RUSH for detecting free fluids or the genesis of shock have emerged. Besides the well known exams like Echocardiography or abdominal Ultrasound, procedures like Lung ultrasound or Ultrasound of bones and muscles are increasingly performed. The way of documentation often seems as variable as the diversitiy of the exams. We hypothesize that a standardized Ultrasound procedure individualised for each entitiy combined with an easy to use documentation system will substantially increase the number of documented procedures. 

 

Methods: 

Following a baseline survey with identifying correctly documented Exams during 6 Months in the first half of 2015, we implemented our documentation system and evaluated the results after a short run in-phase. We compared the numbers of documented ultrasound in the 2 time periods. 

 

Results: 

In the first half year 56 correctly documented Ultrasound exams could be identified. After implementing our simplified documentation system, 500 relevant exams were performed within the first three months (p < 0,001).

 

Conclusion: 

Implementing an easy and approachable way to document the exams will significantly increase the correctly documented ultrasound exams. Furthermore, the quality of performed ultrasound is probably increased as well, as other studies suggest.

 


Felix LORANG (Erfurt, Germany), Tudor PÖRNER
11:00 - 18:00 #7993 - In situ simulation in pre-hospital emergency medicine: a comparison between high-fidelity and low-tech approach.
In situ simulation in pre-hospital emergency medicine: a comparison between high-fidelity and low-tech approach.

In the field of simulation, in-situ-simulation is the new trend: inspired from the idea of training as one works, i.e. in the normal surrounding, with the original equipment and the „real“ team, more and more applications where described on conferences, in blogs and in case-studies. As simulation-training is meanwhile regarded as effective for enhancing as well psychomotor- and team-skills, in-situ-training aims to add experience with the normal equipment and to reduce the artifacts of simulation.
It is undeniable, that frequent training in working environment increases the confidence, provides an opportunity to train skills and to train effective teamwork.  Simulation creates riskfree setting to master the challenges of the life-threatening events and of caring for critical ill patients.
Beginning in 2012, we conducted several in-situ-trainings for medical emergencies in several different units of our hospital, a 500-bed-teaching hospital of the University of Rostock in a pretty rural area at the baltic coast. Using that experience, we startet 2014 to use the technique for the skills- and team-training of EMS-crews in the handling of critical situations, namely the induction and pre-hospital intubation in case of a) traumatic brain injury, b) polytraumatised patient and c) cardiogenic lung edema, refaractory to non-invasive ventilation.
We started 2014 with low–tech/low-cost concept.  A usual ambulance, which was only for the day of training out off duty, was staffed with a portable camera, a simple manikin and an iPad-based simulation-system. Later on, the whole video-debriefing-system was made portable and the training was again conducted and in 2016, one of the ambulances of the local rescue service was fix equipped with simulation-equipment and audio-video-debriefing system.
After working with several possibilities, we could not find great benefit from one or another simulator-set-up, either on the site of the trainers, nor on the students. It seems, the acceptance of the setting and the learning effect are mainly based on the quality of briefing and debriefing. A well-known surrounding might be the base for a quicker familiarization.
In the following, we precisely describe the set-up in a “how-to” way and compare all the components to each other in order to help other projects to get started.
 

Daria WIESE (Proseken, Germany), Martin FANDLER, Thomas PLAPPERT
11:00 - 18:00 #7283 - INADEQUACY IN CHANNELING PERIPHERAL VENOUS CATHERIZATION AND ITS RELATIONSHIP WITH THE PRIORITY OF PATIENT CARE IN AN EMERGENCING DEPARTMENT.
INADEQUACY IN CHANNELING PERIPHERAL VENOUS CATHERIZATION AND ITS RELATIONSHIP WITH THE PRIORITY OF PATIENT CARE IN AN EMERGENCING DEPARTMENT.

INTRODUCTION:

One of the techniques realized by nursing staff presents great incidence in emergency departments in the peripheral venous catherization. However, there are a significant number of non-indicated venous catherizations that imply an iatrogenic risk for the patient, an unnecessary use of material and an increase of the nursing staff´s workload.

AIM:

The main goal of this study was to describe the use of peripheral venous catheterizations registered in the Emergency Department of the Hospital Universitario de LA Ribera and analize its indications depending on the priority of the patients.

METHODOLOGY:

For this purpose, a retrospective observational, descriptive and transversal research has been carried out during January 2015.

A range of the patients’ factors were studied such as sociodemographic characteristics, attention priority following Manchester triage system,  venous catheterization  indication and the destiny of patients after discharge from emergency care.

RESULTS:

1844 patients were included in the study, with a slight preference in female gender (53’5%), with a mean age of 37 years.

In relation with priority, most of the patients were classified following Manchester’s triage system with green priority (standard priority).

Peripheral venous catheterization was indicated in 87% of patients, with the main function of this device being drug administration.  

The majority of peripheral venous catheterization was registered in patients with low priority (69’1%). Patients with high urgent priority obtained the highest percentage of peripheral venous catheterizations indicated( 95 % ), while patients with little urgent priority had lower percentages of peripheral venous catheterizations not indicated (14.6% )

 

CONCLUSION:

There is an excessive use of venous peripheral catheterization in non-indicated situations, being those catheterizations in urgent priority the most indicated, whilst those which have low priority, the least. 


Maria CUENCA TORRES (VALENCIA, Spain), Laura CORTIJO MONTEAGUDO, Ana REVERT COGOLLOS, Marisa ROMANY CASAÑ, M Jose ESQUER PERIS, Jose Luis RUIZ LÓPEZ, Luis MANCLÚS MONTOYA, Pablo GARMILLA EZQUERRA
11:00 - 18:00 #7277 - INADEQUACY OF THE PRESCRIPTION OF CERVICAL COLLAR TO PATIENTS WITH A WHIPLASH IN AN EMERGENCY DEPARTMENT.
INADEQUACY OF THE PRESCRIPTION OF CERVICAL COLLAR TO PATIENTS WITH A WHIPLASH IN AN EMERGENCY DEPARTMENT.

INTRODUCTION

Despite the extensive bibliography and information about SLC provided by associations and study groups where the attention way to patients with a whiplash are described, the attention in the emergency department to these patients are standardized to the point that almost always a radiography of the patients’ cervical spine is taken and they are treated in the same way (muscle relaxant, analgesics and cervical immobilization with a collar, regardless of the severity/exent of the injury.

OBJECTIVE

To know the prescription of cervical collar to patients treated in a hospital emergency department and to analyze if this prescription is adjusted to a clinical practice guide.

MATERIALS AND METHODOLOGY

The study was conducted at Hospital Universitario de La Ribera (Alzira-Valencia-Spain). All the patients diagnosed with a whiplash that were treated between 1st January and 31st December 2015 were included.

The variables selected were: age and sex of the patients, mechanism and severity of  the injury and prescription of a cervical collar.

RESULTS:

373 patients were included. A little bit more of a half were females. The age average was 36.84 ±13.76 years old.

The registration of the type of accident was done in the 90.60 % of the cases. The most frequent type of accident was the traffic accident that was suffered by 314 patients.

27.10 % of the patients had a grade 1 injury, 49.60 grade IIa, 23.10 % grade IIb and only one patient with grade III.

61.70 % of the patients were prescribed a cervical collar. This prescription was wrong in the 60.40 % of the patients with grade I, 55.10 with grade IIa and 22.10 with grade IIb.

CONCLUSIONS:

In spite of the recommendations of the Quebec Task Force, the attention to the patient with a whiplash has been standardized in the emergency department to the point that most of the patients are treated in the same way and immobilization with a cervical collar is almost always prescribed without considering the injury grade.


Luis MANCLÚS MONTOYA (Valencia, Spain), María CUENCA TORRES, María Teresa GALMES RAMIREZ, Joana GUILLEM GONZALES, Almudena LLUCH SASTRIQUES, José María TENIAS BURILLO
11:00 - 18:00 #4522 - Inappropriate interpretation of high-sensitive troponin-I values is associated to non-occlusive coronary angiographies.
Inappropriate interpretation of high-sensitive troponin-I values is associated to non-occlusive coronary angiographies.

High-sensitive troponin assays, designed for the earlier myocardial infarction detection, have increased the false-positive rate for this disorders; so it is necessary an accurate selection of the individuals with high values that will benefit from coronary angiography. Objective: To evaluate the rate of angiographies without severe coronary occlusion between a conventional troponin-I (TnI) method and a high-sensitive troponin-I (hs-TnI) assay. Methods: A total of 128 patients from the emergency department with suspicion of non-ST segment elevation myocardial infarction, were retrospectively analyzed.  In 64 patients were evaluated the initial values of conventional TnI, while in other 64 patients, hs-TnI was investigated. Following TnI measures were review, and decisions of angiography were categorized by the basal values and TnI elevations. Results: Conventional TnI method showed 42% of angiographies without severe coronary occlusion; hs-TnI assay had a higher sensibility, and 31% of angiographies wasn’t associated to severe occlusions. However, while the area under the ROC curve was examine for both methodologies, conventional TnI, due to its specificity, tended to higher results. When elevation criteria (absolute delta, and relative delta) were approached for hs-TnI, all the angiographies demonstrated severe coronary occlusions. Conclusions: A single hs-TnI measurement wasn’t more accurate than conventional TnI method in terms of the area under the ROC curve, so elevation criteria must be considered when hs-TnI is used, in order to decreased the angiographies without coronary occlusion.  


Arturo J. FUENTES-GÓMEZ (Ciudad de Mexico, Mexico), David GONZÁLEZ-KLADIANO, Celso MONTOYA-GONZÁLEZ
11:00 - 18:00 #8006 - Inappropriate Ipratropium ?
Inappropriate Ipratropium ?

Title: Inappropriate Ipratropium ?

Introduction: Acute exacerbations of COPD and asthma are common presentations to the Emergency Department. Many will have received bronchodilator therapy prior to their attendance. Salbutamol is recommended as the inhaled bronchodilator of choice in all cases. The addition of a anticholinergic muscarinic antagonist ( ipratropium) is not recommended in all cases. This was a questionnaire of ED doctors prescribing habits based on 4 common scenarios.

Methods: We gave clinical scenarios in a verbal questionnaire to doctors working in the Emergency Department. All grades were asked to give their choice of nebuliser drugs for each scenario. The scenarios were for adult patients and were designed around the British Thoracic Society guideline for COPD & the SIGN guideline for Asthma. 

Scenarios were:

1: Moderate Exacerbation of asthma with no prior Rx.

2: Severe Exacerbation of asthma with no prior Rx.

3: COPD Exacerbation with no prior Rx.

4: Moderate Exacerbation of asthma with prior Rx with both salbutamol & Ipratropium

Results:  

18 doctors completed the questionnaire comprising 12 juniors & 6 Consultants. The overall correct prescribing rate based on guidelines was 53 / 72 cases ( 74%) . Junior doctors had better adherence to guidelines ( 77 %) compared with their senior colleagues (67 %).

The two scenarios where salbutamol alone would be acceptable ( scenarios 1 & 4) had  64% correct prescribing compared with the scenarios where combined nebulisers are recommended ( 2 & 3) 83%,  suggestive of an tendency towards over prescribing of ipratropium.

Discussion: This study suggests that doctors working in Emergency Medicine often prescribe nebulised brochodilators outwith current guidelines. The most frequent error appears to be the addition of ipratropium to salbutamol despite guidelines supporting its use less frequently. Some of these combinations may be inappropriate. Side effects of muscarinc antagonists are well described and include dry mouth, allergic reactions and rarely paradoxical bronchospasm therefore they should be used within current guidance. Further prospective audit of actual prescribing is planned with feedback to staff in the ED to improve compliance with current guidance.


Gordon MCNAUGHTON (Glasgow, ), Christine MURPHY, Emel BARBIROU, Simon HOBSON
11:00 - 18:00 #7089 - Increased Risk of Ischemic Stroke in Patients with Venous Thromboembolism: A Nationwide Cohort Study.
Increased Risk of Ischemic Stroke in Patients with Venous Thromboembolism: A Nationwide Cohort Study.

Background: Conflicting results have been obtained by studies attempting to assess the risks of ischemic stroke in patients with venous thromboembolism, while the long-term risk of stroke in survivors of venous thromboembolism remains unexplored.

Objective: We evaluated whether the risk of ischemic stroke in patients hospitalized with venous thromboembolism is higher when compared to the general population.

Methods: One million patients from National Health Insurance beneficiaries in Taiwan were sampled. There were 2,145 patients who had been hospitalized with diagnosis of venous thromboembolism and 727,607 unexposed subjects. All adult patients were followed from 1 January 2005 to 31 December 2013 to evaluate if ischemic stroke was diagnosed. Cox regression models were applied to compare the hazards adjusted for potential confounders.

Results: After controlling for age, gender, urbanization level, socioeconomic status, diabetes, hypertension, coronary artery disease, hyperlipidemia, history of alcohol intoxication, malignancies, congestive heart failure, atrial fibrillation, smoking, peripheral artery disease and Charlson Comorbidity Index, the adjusted hazard ratio of ischemic stroke was significantly increased in patients with venous thromboembolism (2.47; 95% CI, 2.16–2.83). A subgroup analysis based on patients who survived longer than 12 months in the cohort also revealed higher hazard ratio in the patients with venous thromboembolism. (1.32; 95% CI, 1.05–1.66).

Conclusion: The possible risk of ischemic stroke is significantly higher in patients hospitalized with venous thromboembolism than in the general population.

 


Shih-Kai LAN (Chiayi County, Taiwan)
11:00 - 18:00 #7090 - Increased risk of psychiatric diseases in patients with mild traumatic brain injury: a nationwide cohort study.
Increased risk of psychiatric diseases in patients with mild traumatic brain injury: a nationwide cohort study.

Background: It is known that psychiatric disorders after traumatic brain injury are frequent. However, the relationship between mild traumatic brain injury and psychiatric diseases has never been established. We conducted a study of patients with mild traumatic brain injury to evaluate if they had a higher risk of psychiatric diseases compared with the general population.

Methods: We utilized a sampled National Health Insurance claims database containing one million beneficiaries. We followed all beneficiaries from January 1, 2005 to December 31, 2013 to determine if they were diagnosed with psychiatric diseases. The definitions of psychiatric diseases in our study are schizophrenia, bipolar disorders and major depression. We further identified patients with mild traumatic brain injury and compared their risk of psychiatric diseases with the general population.

Results: We identified 76,991 patients with mild traumatic brain injury and 881,511 patients without mild traumatic brain injury. After controlling for age, gender, urbanization level, socioeconomic status, liver cirrhosis, chronic obstructive pulmonary disease, diabetes, hypertension, coronary artery disease, hyperlipidemia, history of alcohol intoxication, malignancies, smoking, obesity, chronic renal insufficiency and Charlson Comorbidity Index score, the adjusted hazard ratio for psychiatric diseases was 1.46 (95% confidence interval, 1.29—1.64).

Conclusion: Mild traumatic brain injury may be associated with diagnoses of psychiatric diseases.


Yung-Cheng SU (Chiayi County, Taiwan)
11:00 - 18:00 #7093 - Increased risk of pyogenic liver abscess among patients who receive upper gastrointestinal endoscopies within 90 days: a nationwide cohort study.
Increased risk of pyogenic liver abscess among patients who receive upper gastrointestinal endoscopies within 90 days: a nationwide cohort study.

Background: Pyogenic liver abscess (PLA) is a potential lethal disease with known pathogeneses including ascending biliary tract infection (BTI) and hematologic bacterial spreading from portal systems or systemic circulation. Gastrointestinal (GI) endoscopies are commonly performed procedures with complications of mucosa trauma, local infection and even bacteremia. There has been no population-based large-scale study on the relationship between gastrointestinal (GI) endoscopies and subsequent pyogenic liver abscess (PLA).

Objective: The aim of this study was to investigate the risk of PLA following recent GI endoscopies.

Methods: Using Taiwan National Health Insurance Research Database, 2,135 patients with first diagnosis of PLA were identified from 1998 to 2011 (International Classification of Disease, 9th Revision, Clinical Modification, code 572.0). 10,675 patients without PLA matched by age and sex were selected from the same database as reference controls using incidence density sampling method. We identified and compared the known or possible risk factors for PLA and GI endoscopies performed during the recent 90 days before the index date (the diagnosis date of PLA) between the two cohorts.

Results: Patients with history of diabetes [adjusted odds ratio (aOR), 2.65; 95% confidence interval (CI), 2.09-3.36], end-stage renal disease (aOR, 2.35; 95%CI, 1.50-3.68), BTI (aOR, 7.03; 95%CI, 5.30-9.31), liver cirrhosis (aOR, 3.20; 95%CI, 2.30-4.44), appendicitis (aOR, 5.01; 95%CI, 1.80-13.95) and diverticulitis (aOR, 3.95; 95%CI, 1.44-10.79) were significantly associated with the risk of PLA. After adjusting the above risk factors, and the frequency of outpatient department visits and abdominal ultrasound during the recent 90 days before the index date, upper GI endoscopy (aOR, 2.89; 95%CI, 2.16-3.85) but not lower GI endoscopy (aOR, 1.05; 95%CI, 0.61-1.81) was significantly associated with PLA.

Conclusion: Patients who received upper GI endoscopy during the recent 90 days were associated with an increased risk of PLA compared to patients without receiving upper GI endoscopy.


Ming-Jen TSAI (Chiayi city, Taiwan), Chin-Li LU, Ying C. HUANG, Solomon Chih-Cheng CHEN
11:00 - 18:00 #8181 - Incresed appropriateness in laboratory requests in the ED through revision of software automated routine lists: our experience.
Incresed appropriateness in laboratory requests in the ED through revision of software automated routine lists: our experience.

Background

Appropriateness in laboratory requests in the Emergency Department (ED) can lead to costs reduction and better use of the economic resources. In our ED, a level I in northern Italy with about 40.000 visits/year, the laboratory requests can be done through fixed routines or by choosing exams one by one. Fixed routines are easier and faster to request but still allow physicians to add single exams, not included in the routines.

Methods

In November 2015 we modified the fixed routines, removing some exams and adding others after an internal informal discussion among senior emergency physicians. We also reviewed the  routines (Table 1)

Table : Full description of the new laboratory routines adopted in our ED

Mini-routine:  Blood count and formula, creatinine, sodium, potassium, glycaemia, Alanine Aminotransferase (ALT)

Medical general: Mini-routine + calcium, prothrombin time (PT), lactic dehydrogenase (LDH), fibrinogen

Abdominal routine: Medical general + lipase,  aPTT

Pre-surgery – trauma – bleeding: Mini-routine + PT, activated partial prothrombin time (aPTT), fibrinogen

Septic patient: Pre-surgery + C reactive protein (CRP), urine analysis

Cardiologic: Mini-routine + high sensitivity (HS) troponin I

_______________________________________________________________________________________________________

 We calculated the laboratory requests in the first 4 months of 2015 and 2016 and their costs, we also verified differences in the number of patients in our ED in the same period.

Results

 In the first 4 months of 2015 12.324 patients were visited in our ED, compared to 12.490 of the same months of 2016 ( + 1,30%). The results of the requested exams in the same months are summarized in Table 2. Variations lower than 2% were not reported. 

Table 2 : Detail of results

Test                                           Number in 2015       Number in 2016     % reduction/ increase      Unitary cost          Total cost variation

__________________________________________________________________________________________________________

Alanine Aminotranferase (ALT)            5343                        5225                             -2.20%                         1,00 €                    -118,00 €

Aspartate Aminotranferase (AST)        5121                          260                            -95.00%                        1,00 €                      -4861 €

Bilirubin                                            4259                        3861                            -10.00%                        1,40 €                      -557  €

Glucose                                             5329                        5191                              -2.60%                       1,20 €                      -165  €

Lipase                                               1659                        1351                            -19.60%                        2,60 €                      -800  €

Potassium                                          5497                        5391                             -2.00%                        1,00 €                      -106  €

Sodium                                              5487                        5382                             -2.00%                        1,00 €                      -105  €

Urea                                                   227                          302                            +25.00%                       1,10 €                       +82 €

Urine Analysis                                     459                          667                             +31.00%                      2,20 €                      +457 €

D-dimer                                              502                         323                              -26.00%                     10,30 €                     -1843 €

Fibrinogen                                         4162                       3914                               -6.00%                        2,70 €                      -248 €

CRP                                                  3136                       3319                              +5.60%                        3,90 €                     +713 €

aPTT                                                 4302                       1355                             -69.00%                         2,90 €                    -8546 €

PT                                                    4347                       4055                               -6.70%                         2,90 €                      -846 €

LDH                                                  4491                       4046                             -10.00%                         1,10 €                      -489 €

Creatine Phosphokinase (CPK)            4063                        2852                             -30.00%                        1,40 €                     -1695 €

Chloride                                            3154                         235                             -92.50%                         1,00 €                    -2919 €

Calcium                                            3206                        3029                              -5.50%                          1,10 €                     -194 €

Blood Colture                                     173                          269                              +35.00%                       26,40 €                 +2534 €

________________________________________________________________________________________________________________

Total requests                             64917                     51027                              -21.40%                                                  -19706 €

 

Our data suggest that an enhanced appropriateness in laboratory requests in the ED lead to general cost reduction and allow  to better utilization of the economic resources. The increased request of blood cultures is an example of better distribution of resources. 


Roberta MARINO (Vercelli, Italy), Aldo TUA, Marianna TAGLIABUE, Francesco Saverio MOSCHELLA, Chiara PIZZORNO
11:00 - 18:00 #5392 - Indicators of clinical deterioration during early hosptial admission present during emergency department to ward transfer.
Indicators of clinical deterioration during early hosptial admission present during emergency department to ward transfer.

Introduction: The relationship between abnormal physiological states during ED care and subsequent adverse events on the ward raises questions about the patient’s clinical status during the transition from ED to the ward. The aim of this study was to examine the relationship between physiological status during transition from the emergency department to the ward and emergency calls for clinical deterioration during the first 72 hours of hospital admission.

 

Methods: A descriptive, exploratory design was used. The study involved 1980 patients at three hospitals in Melbourne Australia: i) 660 randomly selected adults admitted via the ED to medical or surgical wards during 2012, and who had an emergency call for clinical deterioration during the first 72 hours of admission and ii) 1320 adults without emergency calls matched for gender, triage category, usual residence, admitting unit and age.

 

Results: The median patient age was 78 years and 48.8% were males. The median time to the first emergency call was 18.8 hours. One or more abnormal physiological parameters were documented in 34.9% of patients during the last hour of ED care and 47.1% of patients during first hour of ward care. Emergency calls were more common in patients with heart rate (46.0% vs 31.3%, p<0.001) and conscious state (49.6% vs 31.2%, p=0.002) abnormalities during the last hour of emergency care and abnormal oxygen saturation (41.8% vs 31.6%, p<0.001), heart rate (45.6% vs 31.3%, p<0.001) or respiratory rate (43.1% vs 32.2%, p=0.002) during the first hour of ward care.

 

Discussion: Abnormal physiological parameters at the ED-ward interface were common and predicted subsequent emergency calls. The utility of physiological status at the transition between the ED and inpatient wards to guide care planning, particularly frequency of nursing and medical assessments warrants further analysis.

 

Acknowledgements: This study was generously funded by the Nurses Board of Victoria Legacy Limited Mona Menzies Postdoctoral Research Grant and an Eastern Health Research Grant.

 

References

Considine J, Jones D, Pilcher D, Currey J. (in press). Patient physiological status during emergency care and rapid response team or cardiac arrest team activation during early hospital admission. Eur J Emerg Med. Accepted 06/01/2016. Available on line 06/02/2016 http://journals.lww.com/euro-emergencymed/toc/publishahead

Considine J, Jones D, Pilcher D & Currey J (in press): Patient physiological status at the emergency department -ward interface and emergency calls for clinical deterioration during early hospital admission. J Adv Nurs, accepted 06/01/2016. Available online 18/02/2016 from http://onlinelibrary.wiley.com/doi/2010.1111/jan.12922/abstract


Julie CONSIDINE (Burwood, Australia), Daryl JONES, David PILCHER, Judy CURREY
11:00 - 18:00 #7110 - Infectious spondylitis as a differential diagnosis in acute low back pain.
Infectious spondylitis as a differential diagnosis in acute low back pain.

Case Report:

Patient 70 years old who has back pain with several days of evolution accompanied by deterioration of general condition in the last few hours.
He has consulted in his health centre and emergency unit for this reason where he has been diagnosed with low back pain and prescribed usual analgesic treatment and benzodiazepines. Given the persistence of the symptoms finally it is decided to treat him with short course of corticosteroids.
Despite the different treatments, the patient complained of an increase of the pain and in the last hours a further deterioration of general condition and cognitive level.. They deny the presence of another clinic condition.

Personal history:
No known alergies to drugs. Morbid obesity. Limited mobility. Bronchial asthma. Hashimoto's thyroiditis. Anxious-depressive syndrome. Fecal and urinary incontinence. 


Physical examination:


Generally poor condition. Poorly perfused. Dry skin and mucous membranes. Morbid obesity. Unresponsive to stimulation. Glasgow 3. 
ACR: weak but rhythmic tones, no murmurs or extrasistoles appreciated. Breathing sounds conserved without pathologic sound except mild hypoventilation in bases. 
Abdomen globular, not tender to palpation without peritoneal irritation Preserved peristalsis. Distal neurovascular unchanged.

Investigations:

In analytical highlights platelet 75000, 23700 leukocytosis with neutrophilia, PCR 456, 3.34 creatinine, altered liver profile.

Rx thorax and abdomen without obvious alterations so they decided to perform an abdominal CT which shows degenerative changes in dorsal-lumbar spine with decreased height and irregularity of D12 disc with an increased soft tissue and associated gas bubbles inside, diagnosis of spondylitis.

Patient is admitted to the ICU. Antibiotic therapy and resuscitative measures despite which the patient has just presented multiorgan failure and died.

Conclusions: Although the osteoarticular pathology is common in the elderly, we must be cautious in situations that do not show good performance and influence possible differential diagnoses.


David NÚÑEZ CASTILLO, María Eugenia REYES GARCÍA (Málaga, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7180 - Influence of social insurance statuts on emergency department visits.
Influence of social insurance statuts on emergency department visits.

Introduction

frequentation of emergency departments (ED) is continuously rising. There are several proposals to convince the patients to contact first their general practioner (GP) and even to forbid access to an ED without prior GP consultation.some argue ED are a safety net guarantying access to medical care to everybody.If recent reseach's show that frequentation of ED is rarely due to financial conditions, other studies have shown a limited access to medical care of precarious people.despite a lack of universal definition, lack of social insurance ( LSI) is most often an admitted criteria of possible precarity. A recent study of a social insurance compagny have shown that uninsured patients have a six fold higher frequentation rate of ED compared to their insured affiliates.We investigated more deeply the influence of the social insurance status on ED visits.

Material and method

We conducted a retrospective analyse of all the medical records of patients attending our ED in 2013. Data collected were the demographic characteristics ( age and sex), social insurance status, time and reason of presentation, length of stay, admission mode, type of investigations and destination at the exit of ED.

Results

After exclusion of 3063 uncompleted or inconsistent rerecords, 32171 visits were analyzed, among witch 2136 LSI ( 6.64%)

LSI was significantly ( p<0.001) more prevalent in male 55.4% vs 49.5%) and in younger patients  ( age 0-14: 33.5%  vs 25.8% age 15-65 65.8% vs 64% age >65 :0.7% vs 10.2%). LSI patients were less likely admitted by ambualce ( 6.9% vs 13.4%, p< 0.001), had a shorter length of stay ( 01:25 vs 0:45 , p < 0.05) and a very lower rate of hospitalization ( 1.7% vs 15.7%, p< 0.001). Among LSI patients , we also observed a lower rate of those who left without being seen( 1.4% vs 2.4%, p< 0.001).Significantly( p< 0.001) less investigation exams were perfomed in LSI patients ( no exam: 63.9% vs 52.9% , 1 exam 17.9% vs 18.1% > 1 exams 18.2 vs 29% ).

Discusion and conclusion

Emergency department patients with a lack of social insurance are more likely to be young and male.Spontaneous presentation for consultation, a lower need of investigation exams, a shorte length of stay, a very lower rate of hospital admission and a lower rate of leaving without being seen are all indicators that the emergency departement is effectively the safety net allowing access to medical care of these precarious population before deterioration of their medical conditions.


Jacques Désiré NKENG METOUKÉ (Charleroi, Belgium), Marc VRANCKX
11:00 - 18:00 #8146 - Informatics in ED – A DGH Experience of Clinical Librarian.
Informatics in ED – A DGH Experience of Clinical Librarian.

Background:

Role of clinical librarian (CL) has been established for some time and their valuable input at ward rounds is well recognised, which has expanded into more acute settings recently. Even ED has been advocated to gain benefit from this prosperous resource in high pressure and time constrained environment at larger/academic units.

Objectives:

We looked at our experience of having CL at our ED with annual census of over 85,000 (approx.) patients a medium sized DGH. We had a pilot one year project of informatics ED in-reach for up to 3 day per week targeting consultant led mid-day board rounds on shop floor.  

Aims of the intervention were identified:

  1. Acquisition of up to date evidence based information for clinical dilemmas posed by ED team, recognising time constraints.
  2. Embedding Informatics in clinical team to bridge the gaps in utilisation of available resources in an era of information overload in acute settings, efficiently and accurately.
  3. Giving CL insight and development into requesting patterns of clinicians and translation of information into practice.
  4. Add value to the teaching experience of board rounds for juniors and inculcate some academic interest.

 

Methods & results:

We reviewed the kind of information being asked and who was asking and how. How much literature review was being done and the time it was consuming? What information and how was it coalesced by CL and presented to clinicians? We also explored how this information was used subsequently and if translated into change of practice etc. i.e. impact. Any trends or themes?

 

About 40 literature reviews were conducted. 16 came out of board round directly while reaming were requested by email. Majority (24) were from consultants but ANPs and middle grades requested some (12 and 3 each). Each search took from somewhere as little as 5 minutes up to 4 hours with an average of 2.85 hr consuming over 85 hours just for running these searches. Mostly treatment options (medications and devices mainly) and diagnostics were in question (blood tests & scans) with age being the variable most commonly associated with them.

The information was crude to begin with but over time was filtered more accurately and tailored specific to the clinical dilemma.

Review of some existing guidelines was done while development of new policies was undertaken as direct outcome of the evidence gained through this pilot. Some of the valuable information was incorporated by trainees into their work as dissertation/CTR and also presented at local/regional and national level.

Conclusion:

Having a CL in ED and even at DGH has shown us to be a productive and valuable to our team materialising this work practically. Based at our experience, CL in-reach has been already extended at our department and we would like to recommend this positively.


Imran ZAKRIA (Manchester, ), Peta JONES, Muhammad QURESHI, Nasreen CONTRACTOR
11:00 - 18:00 #7316 - Inhaled furosemide effectiveness for acute asthma exacerbations: A meta-analysis.
Inhaled furosemide effectiveness for acute asthma exacerbations: A meta-analysis.

Background: Although inhaled furosemide is expected to be effective for treating asthma exacerbations, previous studies have yielded inconsistent results.

Methods: To test the hypothesis that inhaled furosemide is effective during asthma attack, we performed a comprehensive literature search of MEDLINE, EMBASE, Web of Science, and Cochrane Library databases to identify studies that examined inhaled furosemide effectiveness for asthma attacks by adding it to conventional therapy using a double-blinded randomized clinical trial design. A meta-analysis was conducted by calculating a standardized mean difference from each study and integrating them using a random effects model. Sub-analyses were made for studies that evaluated peak expiratory flow rate (PEFR) and forced expiratory volume in 1 second (FEV1.0). Jackknife sensitivity analysis was also conducted.

Results: Six studies involving 78 patients who received inhaled furosemide and 79 who received placebo were eligible for inclusion in our meta-analysis. This analysis found a significant effect of inhaled furosemide during asthma attacks (Z = 2.70; P = 0.007). Sub-analyses of studies that reported PEFR (Z = 2.23; P = 0.026; n = 68/70, inhaled furosemid/placebo) and FEV1.0 (Z = 1.84; P = 0.066; n = 49/46, inhaled furosemide/ placebo) values preserved the significance of inhaled furosemide effectiveness for asthma attacks. Jackknife sensitivity analyses confirmed the replicability of these findings (P < 0.028). No adverse events with furosemide inhalation were reported.

Conclusion: Adding inhaled furosemide to conventional therapy for asthma attacks may improve respiratory function without apparent adverse effects.


Ryota INOKUCHI (Bunkyo-ku, Japan), Yuta AOKI, Ai AOKI, Hiromu MAEHARA, Yoko YAMAGUCHI, Kent DOI, Susumu NAKAJIMA, Naoto MORIMURA
11:00 - 18:00 #7676 - Initial mechanical ventilation settings in pre-hospital and hospital emergency medicine : retrospective study with emphasis on lung protective ventilation.
Initial mechanical ventilation settings in pre-hospital and hospital emergency medicine : retrospective study with emphasis on lung protective ventilation.

Introduction

Mechanical ventilation (MV) is usual in Emergency Medicine (EM). Utilization of protective ventilation (PV) has been shown to improve outcomes for patients both with or without acute respiratory distress syndrome (ARDS). It associates a low tidal volume (6-8 ml/kg), a positive expiratory pressure (PEP) and an adapted inspiratory fraction of oxygen (fiO2) to SpO2 95%. Benefits have been shown in intensive care units patients and in anesthesiology. Furthermore, animal models have proven than a 20 minutes inappropriate ventilation cause histologic and pathophysiologic changes. Though emergency physicians (EP) are skilled in definitive airway management, their management of mechanical ventilation is not well described.

We undertook a retrospective survey to explore MV settings.

Patients and methods

Patients

All patients intubated and mechanically ventilated in pre-hospital and hospital settings during a nine months period were included via a dedicated register. The lonely non inclusion criteria was a cardiac arrest (CA) without return to a spontaneous rhythm.

Methods

After anonymisation, ventilation settings were compared to protective ventilation.

Primary objective

Number of patients with PV

Secondary objectives

indication of intubation and MV

duration of MV

Mortality

Statistical methods

Data stored in Microsoft Excel were analyzed with PASW Statistics. Numerical data expressed as mean + SD were compared by a Student t test. Categorical data by a Khi2 test. P< 0.05 was considered significant.

Ethic

As it was a retrospective study, according to the French legislation, approval of the ethics committee was not needed to use data for epidemiologic study.

Results

201 patients were included, 63 women and 138 men, mean age 51+17 years old. A protective ventilation was observed in 19% of patients. Indications of ventilation were neurological 127 (64%), CA 42 (21%), 21 multiple trauma (10%) and 11 acute respiratory failure (5%). Duration of MV was 71+65 min (mean + SD). 57 patients (28,4%) died in the hospital.

Discussion

Few patients were ventilated with PV settings. Mortality was high in our population. Duration of ventilation was probably sufficient to influence outcome. Formation of our EP is warranted to improve their ventilation skills in order to increase survival.


Anne MÉLÉARD (Chateaubriant), Philippe PES, François JAVAUDIN, Philippe LE CONTE
11:00 - 18:00 #7160 - Internal Management as a key lever to retain experienced nurses in the ED.
Internal Management as a key lever to retain experienced nurses in the ED.

Introduction:

Building up nurses’ loyalty to their work place is a strategic stake in the Emergency Department (ED). However, in our teaching hospital, the turnover remains over 20% each year. The nurses are key actors in the effective and smooth running of the department. The quality of care they deliver is affected by the work environment. They often feel conflicted between their roles as an ED nurse and the internal organization of the department (i.e. between quality of care and performance requirements). Our aim was to analyze staff satisfaction in the ED in order to identify the best actions suitable for their needs. This approach is known as internal marketing. Concepts such as Magnet hospitals have been recently developed and a significant literature is there to demonstrate their effectiveness [1].

Methods:

All nurses were invited to fill in a questionnaire in order to assess their satisfaction, their autonomy, their beliefs and their training needs.

Results:

A total of 43 nurses returned the questionnaire (73% response rate). Our nurses get along well together and are happy to help each other. They would like to be more involved in the Emergency Department. They have various learning needs and ask for appropriate training. However, there are several negative points; firstly a lack of strategic vision for the department. They also feel that their teamwork is not valued. Sometimes the relationship between physicians and nurses is troubled leading to an inefficient organization. The nurses with more than 3 years of experience are paradoxically the least satisfied. They feel that their value and qualifications are not recognized and that they cannot express their concerns, this in turn generating frustration.

Conclusion:

From this analysis a strategic plan has been developed with 3 priorities:

-       Maintain a sense of belonging.

-       Set up a training program for staff.

-       Improve the relationship between physicians and nurses.

We have initiated a short track plan for patients, which was requested by 42% of nurses, leading to improved and faster emergency care. Internal marketing is a powerful lever creating a meaningful work environment as well as a more unified and well-trained team. Our aim is to become a great place to work with a focus on quality of care, in other words to become a hospital with magnet status. It has been proven that this kind of department attracts and retains the most qualified nurses while also being preferred by patients, as well as having the highest quality of care.

[1]Aiken L, Havens D, Sloane D. The Magnet nursing services recognition program: a comparison of two groups of Magnet hospitals. J Nurs Adm. 2000;39 suppl 7/8:S5–S14


Claire KAM (STRASBOURG), Pierrick LE BORGNE, Claude GERONIMUS, Charles-Eric LAVOIGNET, Sarah UGÉ, Sophie HATSCH, Pascal BILBAULT, Pierre VIDAILHET
11:00 - 18:00 #6329 - International smuggling of cocaine by body concealment.
International smuggling of cocaine by body concealment.

Background: Drug smuggling by internal bodily concealment, called ‘body packing’, is a widespread method of transporting narcotics. People using this method are known as ‘body packers’, ‘mules’, ‘internal carriers’, or ‘couriers’. The three main drugs smuggled in this manner are cocaine, heroin, and cannabis products. Cocaine is the drug most commonly smuggled by body concealment, followed by heroin. We present a case report of a healthy man who ingested a large number of well-manufactured cocaine packages to smuggle them across international borders.

Case: A 36-year-old man ingested cocaine packages worth approximately US $900,000 to transport it from Dubai to Madrid. He was arrested by police at Istanbul Ataturk Airport for suspected body packing of drugs. He confessed that he had attempted to smuggle 76 packages of cocaine in his gastrointestinal tract. The patient had nausea, but no abdominal pain. He appeared well and was conscious and oriented. Cardiopulmonary, abdominal, and rectal examinations were normal, and there were no signs of drug overdose or intoxication. A plain abdominal radiograph revealed multiple opaque foreign bodies in the gastrointestinal tract . Non-contrast-enhanced three-dimensional (3D) abdominal and pelvic computed tomography (CT) showed multiple spherical capsules in the small intestine, colon, and rectum. After detecting the capsules radiologically, he confessed to carrying about 1.35 kg of cocaine, pressed and wrapped into packages weighing 18 g each. He had swallowed the packages of cocaine in Dubai two days before admission to our hospital.

The patient was managed successfully with conservative measures, including enemas and laxatives. All of the ingested packages were evacuated spontaneously and the police secured and collected 76 intact swallowed packages of cocaine. CT 4 hours later showed that the abdomen was clear of cocaine packages. The patient was observed in the ED for six hours post-arrest. No symptoms of cocaine toxidrome or other complications such as obstruction or ileus were observed. He was discharged into police custody. Analysis subsequently indicated that the cocaine was 75% pure and type III packages had been used.

Conclusion: Abdominal radiography and CT are useful tools for screening patients suspected of body packing cocaine. Although our patient had swallowed a large number of cocaine capsules, he was managed conservatively and all of the capsules were evacuated uneventfully. This may be because of the sophisticated capsule material and packing technique, and the health of our patient. 


Onur KAPLAN, Ozgur SOGUT (Istanbul, Turkey), Mehmet YIGIT
11:00 - 18:00 #8022 - Intestinal tuberculosis mimicking colon cancer; a case report.
Intestinal tuberculosis mimicking colon cancer; a case report.

Introduction

Tuberculosis is an important health problem all over the world. Intestinal tuberculosis constitutes 1% of the whole tuberculosis cases although it is extremely rare. The prevalence of colon tuberculosis is a lot fewer.

The Case

Fifty-eight-year-old female patient applied to the Emergency Service with the complaints of stomachache, abdominal swelling and inability to defecate. In her history, it was detected that she had weakness, lack of appetite and loss of weight that continued for the past 1 year. In the physical examination, it was detected that she had sensitivity especially in lower-right quadrant, m. defense and doubtful rebound. Her laboratory tests revealed that the white blood cell count was 13200/mm3. The standing empty abdominal radiograph revealed that there were air-fluid levels. Urgent abdominal tomography revealed that there was increase in the thickness of the colon proximal, which was partly out in the localization where terminal ileum was connected to cecum. Intestinal obstruction was considered for the patient and urgent surgery was planned.

There was mass lesion observed in the stomach radiography in the cecum-out coming colon localization in the exploration. This mass lesion was invasive to the retroperitoneum, which included the right ureter. Resection was not considered, and ileotransverse by-pass was applied. Biopsy material was taken from the lymph nodules existing in the meso.

The patient, who did not have any problems, was discharged from hospital on 6th post-operational day. In the pathological examination of these lymph nodules, granulomatous changes that included caseification necrosis were observed; and therefore, it was decided that this was colon tuberculosis, which had caused intestinal obstruction. This diagnosis was confirmed with the laboratory tests that were applied later.

Conclusion

Although tuberculosis most frequently holds the lungs, it is also possible that it may hold any organ in the gastrointestinal system from the mouth to the rectum. The tuberculosis that holds the colon may be confused with the inflammatory diseases of the intestines, intestinal malignity, and non-specific infectious diseases of the intestines. Colonoscopic examination must be conducted especially in endemic areas for the patients for whom colon tuberculosis is doubted. In patients who arrive with intestinal obstruction, which was also the case in our patient, resection must be applied to the lesion if it is suitable for this; and if not, by-pass must be conducted in surgeries conducted in urgent conditions.


Sukru ARSLAN, Erdem KARADENIZ, Bünyami OZOGUL (Erzurum, Turkey), Esra DISCI, Mesut YUR, Atıf BAYRAMOGLU, Sabri Selcuk ATAMANALP
11:00 - 18:00 #7799 - Intraabdominal a-lines as a new sign of pneumoperitoneum.
Intraabdominal a-lines as a new sign of pneumoperitoneum.

INTRODUCTION:

Acute abdominal pain is one of the most common chief complaints encountered in emergency medicine and bowel perforation is one life-threatening etiology of such a presentation.  Timely detection of intraperitoneal free air is critical.   Imaging is frequently performed to better elucidate the cause of pain.  Upright plain film x-ray and the gold standard of CT are commonly utilized for the detection of intraperitoneal free air.  Although frequently employed during the work-up of abdominal pain, ultrasound is not considered the imaging study of choice for the detection of pneumoperitoneum.  We describe a case of a patient presenting with acute abdominal pain and distension after colonoscopy that was ultimately diagnosed as rectal perforation.  Massive pneumoperitoneum was first detected via emergency physician performed bedside ultrasonography.  We discuss the sonographic features and accuracy of ultrasound in the diagnosis of pneumoperitoneum as described in recent literature, and also define “intraabdominal A-lines” as pathognomonic for pneumoperitoneum.             

CASE REPORT:

An 82 year-old female presented to the emergency department after experiencing severe abdominal pain and distension immediately following colonoscopy for rectal prolapse.  She denied chest pain, dyspnea, fevers, chills, nausea, or vomiting.  Surgical history was significant for hysterectomy 30 years ago.  Vital signs were normal.  Physical examination was remarkable for an elderly woman in moderate distress with diaphoresis, and a severely distended, tympanic abdomen with diffuse moderate tenderness to palpation.   There was no rigidity, guarding or rebound tenderness.

A focused abdominal ultrasound using the curvilinear probe was performed by the emergency medicine physician and revealed diffuse abdominal “A-lines" consistent with intraperitoneal free air.  Suprahepatic reverberation artifact was also clearly visualized.  Exploratory laparotomy revealed rectal perforation and repair with anterior segmental resection of the rectosigmoid as well as proximal and distal colonic donuts was performed successfully.  The patient was discharged on post-operative day six.        

DISCUSSION:

Although not well-investigated, studies have attempted to define the sonographic features of pneumoperitoneum.  The diagnosis is based on the detection of intra-abdominal air outside its physiologic location within the bowel lumen.   Hyperechoic enhancement of the anterior peritoneal line is the earliest pathognomonic sonographic sign of intraperitoneal free air.  Reports have concluded that this finding may be evident in extraluminal collections as small as 2-5ml of air.  Additionally, Muradli et al. described a horizontal posterior reverberation pattern that is more evident with larger accumulations of intraperitoneal free air, akin to intrathoracic A-lines.

It has been reported that even under ideal conditions and technique, plain film chest x-rays may miss up to 49% of patients with pneumoperitoneum.  In addition, upright positioning of patients for xrays may cause discomfort or may not be possible in emergent situations. While CT possesses greater sensitivity than plain radiography, it is a more time-consuming study requiring the transport of patients away from the emergency department.  Furthermore, CT exposes patients to ionizing radiation.Ultrasonography can provide a rapid bedside evaluation of the acute abdomen. Patients can be scanned in supine position, and reported results demonstrate promise for this technology.

CONCLUSION:Ultrasonography represents a potentially useful bedisde option for the evaluation of free air.


Christopher RAIO, Gerardo CHIRICOLO (Holmdel, USA)
11:00 - 18:00 #4508 - Intravenous Caffeine for the Treatment of Acute Migraine: a Pilot Study.
Intravenous Caffeine for the Treatment of Acute Migraine: a Pilot Study.

Background: Caffeine has a long profile of use as an adjuvant therapy for headache and migraine. This study evaluates the safety and efficacy of intravenous Caffeine Citrate for patients with acute migraine headache.

Methods: In this single arm study, we enrolled 61 patients who were diagnosed with migraine according to International Headache Society Criteria. Patients received 60 mg caffeine citrate intravenously as a drip in about 10 minute. VAS pain scores were measured on baseline and one hour and two hours after caffeine infusion. Statistical analysis was performed by SPSS version 22. Wilcoxon and Mann-Whitney tests were employed to test differences in VAS pain score.

Results: The improvement in VAS pain score was >3 point change from baseline to one hour after IV infusion (P<0.001) and >5 point change from baseline to two hours after IV infusion (P<0.001). Patients, who received other medications before caffeine IV infusion, did not show better improvement after one hour (P=0.304) or two hours (P=0.926) than other patients.

Conclusions: IV infusion of 60 mg Caffeine citrate is safe and well tolerated. It achieved therapeutic success for patients with acute migraine headache after one and two hours. Further controlled studies are recommended.


Alireza BARATLOO (Tehran, Islamic Republic of Iran), Alaleh ROUHIPOUR, Nazanin BEHNAZ, Ahmed NEGIDA
11:00 - 18:00 #7539 - Introduction Of A New Terminology: Acute Life Threatening Pulmonary Embolism (ALTPE).
Introduction Of A New Terminology: Acute Life Threatening Pulmonary Embolism (ALTPE).

Introduction:

Pulmonary Embolism (PE) is an important cause of morbidity and mortality. Currently, Thrombolytic Therapy is reserved for cases of Massive PE when patients are hypotensive.1 The definition, diagnosis and management of Sub-massive PE is debatable. It relies on clinical characteristics, cardiac imaging, cardiac bio-markers, and possibly assessment of clot burden by CT scan.2 Patients may present with a variety of symptoms (chest pain, dyspnoea, dizziness, collapse, syncope, palpitation, seizure, cardiac arrest, etc). Low Molecular Weight Heparin (LMWH) administered and Computed Tomography Pulmonary Angiogram (CTPA) is requested based on clinician’s index of suspicion. There is still a debate whether Sub-massive PE cases should be thrombolysed. 2

Methods:

1.To introduce the new term “Acute Life Threatening Pulmonary Embolism(ALTPE)

2. To report cases of ALTPE presented to Hamad General Hospital (HGH) Emergency Department (ED), who were thrombolysed despite of being normo-tensive.

3.To propose a Policy/Protocol for early management of possible ALTPE presenting to Emergency Department (ED)

 

Results: 

We present here the clinical findings that we propose, should trigger the consideration for thrombolysis, in cases of proven PE on Computed Tomography Pulmonary Angiogram (CTPA).  We define patients with any one of these criteria as having ALTPE:

1. Hypotension (on presentation or ongoing), defined as systolic blood pressure (SBP) < 90mmHg or ≥40mmHg drop from baseline SBP and not caused by sepsis, hypovolemia or anaphylaxis 1

2. Need for inotropes or vaso-pressors1,3

3. Respiratory distress/Oxygen dependence 2

4.Persistent tachycardia/ Arrhythmias/ Right Ventricular (RV) strain pattern on Electrocardiogram ECG 4

4. Signs of Right Ventricular (RV) Dysfunction on Echocardiogram5

6. Signs of end-organ hypo-perfusion (decrease level of consciousness, oligurea,increased lactate..)5

7. Syncope (on presentation or ongoing symptoms)6

8.Symptoms that are provoked or worsen with minimal exertion

Conclusion: 

We propose that all PE patients that are considered for thrombolysis, to be re-categorized in one subgroup called ALTPE (in correspondence to the above mentioned criteria). This group of patients, should have a standardized rapid work-up plan & a pre-planned management strategy in case of rapid deterioration. We recommend the establishment of Emergency/Critical Care protocol for the management of ALTPE.  Further research studies & audits are needed to determine the safety, effectiveness, and outcome of this strategy.

Acknowledgment:

The authors declare no conflict of interest.

References:

1.Dong B, Jirong Y, Liu G, et al. Thrombolytic therapy for pulmonary embolism. Cochrane Database Syst Rev 2006

2.Vishal Sekhri, NimeshKumar Mehta, etal . Management of massive and nonmassive pulmonary embolism. AMS 2012 Dec 20; 8(6): 957–969. PMCID: PMC3542486

 3. Lankeit M, Konstantinides S. Thrombolytic therapy for submassive pulmonary embolism. Best Pract Res Clin Haematol. 2012 Sep;25(3):379-89

4..Abecasis J, Monge J, Alberca D, Grenho MF, Arroja I, Aleixo AMElectrocardiographic presentation of massive and submassive pulmonary embolism. Rev Port Cardiol. 2008; 27: 591–610

5.Sanchez O, Trinquart L, Colombet I, Durieux P, Huisman MV, Chatellier G, Meyer G. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J 2008;29(12):1569-1577

6.Thames MD, Alpert JS, Dalen JE. Syncope in patients with pulmonary embolism. JAMA 1977; 238(23):2509–2511

 

 

 


Lubna Ghali Amin ANDRAOUS (Doha, Qatar), Alhady Alfian YUSOF
11:00 - 18:00 #7734 - Iron bar injury to the groin.
Iron bar injury to the groin.

INTRODUCTION: High-velocity penetrating pelvic injury is one of the most difficult challenges to emergency physicians and trauma surgeons. The injury sites frequently include soft tissue, pelvis, genitourinary tract, vascular structures and intraabdominal viscera. We present an unusual case of a male patient suffering a collision with an iron bar penetrating into his left groin.
CASE: A 20-year-old male worker presented to the emergency department after suffering an accidental, self-inflicted iron bar injury to the left side of his groin. The vital signs of his were stable and general situation was good. A computed tomography (CT) of the pelvis with contrast noted the iron bar to be located within pelvic zone. The patient was taken to the operating room for removal of the iron bar under general anesthesia and exploration of the wound. The foreign body was located superficially and he had no damage to any organ.
CONCLUSION: Careful planning of the surgical approach is important before extracting the foreign body. It is possible multiorgan damage to intrapelvic structures such as colon, urinary bladder, vessels and nerves in such injury and frequently necessitates a multidisciplinary involvement and systematic approach. It was the chance for the patient with remained superficial intrapelvic foreign body in this case.


Mehmet UNALDI (ISTANBUL, Turkey), Onur INCEALTIN, Kurtulus ACIKSARI, Didem AY, Soner ISIK, Hatice ERYIGIT, Cihan BUYUKSUTCU
11:00 - 18:00 #7915 - Is bedside point-of-care testing by emergency department nurses as accurate as central lab testing by lab technologists?
Is bedside point-of-care testing by emergency department nurses as accurate as central lab testing by lab technologists?

BACKGROUND

Point-of-care bedside testing (POCT) reduces lab turn around and has the potential to improve process of care and timely diagnosis and management in the emergency department.  However, concerns remain regarding the accuracy of POCT relative to traditional central laboratory testing.  We compared the accuracy of nurse performed POCT for a panel of electrolyte versus central lab testing by trained laboratory technologists.

METHODS

Study design—prospective, observational study.  Setting—academic, tertiary care, level 1 trauma center with over 100,000 annual ED visits and a dedicated 15 bed critical care unit.  Subjects—50 critical care ED patients in whom a POCT for a basic electrolyte panel was ordered by the ED physician.  Interventions—in all study patients a 5-10 ml blood sample was collected in one lithium containing vacutainer and one EDTA vacutainer, using standard technique.  The sample was tested for Na, K, Cl, TCO2, glucose, creatinine, BUN, and hematocrit.  Each sample was tested twice by the treating nurse at the bedside using the Chem8+ cartridge and the iStat testing device (Abbott Point of Care).  Duplicate additional samples were tested by trained laboratory staff in the central lab using the COBAS 6000 (Roche) and Sysmex analyzers.  Data Analysis—paired comparisons of test results were performed using Pearson’s correlation coefficients and Bland Altman analyses.  We hypothesized that values measured by the iStat would have excellent correlations with levels measured by the central lab and that the differences between paired iStat-central lab measurements would not be significantly greater than the paired differences between the duplicate central laboratory testings.

RESULTS

 Samples from 50 ED critical care patients were analyzed.  Values for each of the 9 analytes measured were not significantly different between bedside and central lab testing.  Correlation coefficients were excellent (0.88-1.00) and did not differ for all pairwise comparisons.  Bland-Altman plots for the ED and central lab measurements showed similar results.  Mean (range) paired differences between iStat and central lab were Na 0.3 (-6 to 4) mEq/L, K -0.1 (-0.40 to 0.15) mEq/L, Cl 2.1 (-3 to 10.3) mEq/L, TCO2 -1.7 (-4 to 2) mEq/L, Glucose 2.5 (-9 to 9) mg/dL, BUN, 1.7 (-4 to 9) mg/dl, Creatinine 0.13 (-0.10 to 0.87), and hematocrit -0.4 (-7.2 to 4.2)%.  

CONCLUSIONS

 Bedside point-of-care testing using the iStat platform is as reliable and accurate as central lab testing.   


Adam SINGER (New York, USA), Braden MCINTOSH, Jay BOCK, Jirina VASEK, Henry C Jr THODE
11:00 - 18:00 #7977 - Is female gender associated with a delayed diagnosis of acute appendicitis in emergency department?
Is female gender associated with a delayed diagnosis of acute appendicitis in emergency department?

Background & Objectives

We hypothesized that sexually active female patients of fertile age, presenting to ED with lower abdominal pain might undergo more additional testing and examination. This potentially could be associated with a delayed diagnosis of acute appendicitis and subsequent surgery, placing these patients at higher risk of perforation, increased morbidity and/or mortality. The aim of the study is to analyze the clinical pathways for female and male patients presenting with acute appendicitis and to explore the examination modalities used in emergency department before surgery. 

Methods

We performed a retrospective chart review study at emergency department in tertiary, university-affiliated hospital. Two hundred and seventeen consecutive retrospective records of subjects with the diagnosis of appendicitis as per surgical pathology were reviewed. Patients were divided into two groups, female (study population) and male (control). Inclusion criteria included patients presenting to the ED and positive post-surgical pathological specimen showing appendicitis. We collected the following data: sex, age, time to OR from ED triage, whether CT was done and whether an abdominal and/or pelvic ultrasound was performed, obs-gyno was consulted. Length of hospital stay, whether patient were admitted to the ICU and duration of symptoms before ED presentation were also noted.

Results

Data are obtained. Results under evaluation.

Conclusion

Results could help to discover bottlenecks of diagnostic approach to the diagnosis of appendicitis in female patients with abdominal pain in emergency department and let us create more sufficient clinical diagnostic protocol.


Laimonas MISEIKIS (VILNIUS, Lithuania), Zilvinas DAMBRAUSKAS
11:00 - 18:00 #7836 - Is substance abuse a trigger for psychiatric disorder in patients presenting to the Emergency Department?
Is substance abuse a trigger for psychiatric disorder in patients presenting to the Emergency Department?

Introduction

 

Patients with psychiatric disorders frequently present to the Emergency Department with acute illness.  It is extremely important to understand the factors that trigger this decompensation in order to best manage these patients as well as to establish recommendations and subsequent preventative treatments.

 

Methodology

 

It is a descriptive retrospective observational study analyzing data from patients with the ED discharge diagnosis of psychiatric disorders during the period of January 1 – December 31 of 2015.   The data used includes the chief complaint, reason for psychiatric consultation, drug consumption, treatment and evaluation by specialists.

 

Results

 

Anxiety was the most frequent diagnosis in patients in this sample (77 out of 359 patients).   Many of the patients were being treated for psychiatric disorders.  21.73% were taking anti-psychotics, 11.98% were taking anti-depressives and 11.14% were being treated with anxiolytics.  We note that 51.81% of the patients had no history of psychiatric disorders. 

 

Of the reasons for presenting to the ED, 47.63% presented with altered behavior, 36.77% for physical complaints and 15.60% for attempted suicide.

 

Regarding drug consumption, only 19.5% used toxic substances of which sedatives were the most common at 5.6% and cannabis, 3.6%.   80.5% of the patients did not ingest any toxic substance.

 

After discharge, 47.1% of the patients had no complications after the resolution of the initial presenting complaint.

 

Conclusion

 

We found that the consumption of toxic substances was not an important factor or trigger for the decompensation of the majority of patients presenting to the Emergency Department with psychiatric disorders.

 

The abuse of sedatives and cannabis may contribute to the decompensation of underlying disease requiring urgent medical attention.


Luisa TARRASO GOMEZ, Pedro GARCIA BERMEJO, Luis MANCLUS MONTOYA, Asif MUHAMMAD, Maria CUENCA TORRES, Jose Luis RUIZ LOPEZ (VALENCIA, Spain)
11:00 - 18:00 #7177 - Is the emergency department a good place to die?
Is the emergency department a good place to die?

INTRODUCTION: The mortality rate in the Emergencies Departments is considered an index of hospital quality, their analysis can be derived specific actions aimed at improving certain aspects of the hospital assitance. In recent years it has noticed an increase of  patients dying in emergency departments in connection with increasing terminal and chronic patients and  with lack of beds in hospital services increasing organizational pressure on emergencies departments. Determinate which patients should not die in the emergency room is difficult because in addiction to clinical factors must be taken sociocultural changes over should deliver the care of dying patients. All this makes essential to establish the necessary measures for these patients

OBJETIVES: To describe clinical and demographic charactersitics of patients who dyed in our emergency department and anylize what points could improve heathcare attention to this group of patients . University Hospital of Móstoles in Madrid with a population of 155.000 habitants

METHOD: Retrospective descriptive study of patients who died en the emergency department between 1st of January and 31st of December of the years 2013, 2014 and 2015, excluding patients who dies in the areas of paediatrics and gynecology. Data were collected: age and sex, death cause, pre-exitus, terminal patients, cardiopulmonary resuscitation initiated, palliative cared were aplied, necropsy was requested, hours spent in the emergency department , medical discharged report and information to relatives of the patient´s current condition.

RESULTS: A total of 54 patients were analyzed. The most frecuent was an elderly patient whose death was expected (80%) with a mean age of 83.7 years, 52% womwn, 40% were terminal patients and 59% were dependant for daily activities.

No relationship was evident the day of the week or the time of  death. January was the month with the highest number of deaths. 

The average spent in emergency deparment was 8 hours, with 40% pre-exitus patient died in less than 3 hours. 35%  received palliative care. 

Cardiopulmonar resuscitation were realised in 33%. The cause of death was established in 53% , and no autopsy was requested in any case

In 60% was given information to relatives of the current situation of the patient , in half cases wre registared as no reanimables patients.

CONCLUSIONS: The patients with terminal illnes who die in emrgency services are a significant number of deaths in emergencies. Mostly of the emergency departments are not prepared for these patients making consider devoloping specific protocols for this group of patients.

It is important to deepen the measures necesary in terminal patients covering clinical as non clinical condicions. The majority of deaths were expected (terminal or not) , it would be advisable to have a place with more privacy where they coul be accompanied by their relatives, as well guidelines for sedation in order to facilitate a dignified death. 

In conclusion, there is a considerable percentage of patients who die in the emergency department and whose death is expected. Should be improved palliatives care units and home support trying to ease the last moments of life.


Alicia RODRÍGUEZ (MADRID, Spain), Virginia LOZANO, Maria VILLA, Ramón MARÍN, Guillén IRENE, Fátima FERNADEZ SALGADO
11:00 - 18:00 #7340 - Is there a correlation between qSOFA criteria positive patients and microbiology-positive sepsis?
Is there a correlation between qSOFA criteria positive patients and microbiology-positive sepsis?

Background & objectives

Early sepsis diagnostics is still challenging in emergency department due to variety of symptoms presented. What is more, sepsis rates are still increasing and mortality rates remain significant despite optimal care. Many sepsis scores were created to evaluate risk for sepsis mortality, but recently qSOFA score was released for evaluating risk for mortality due to sepsis without laboratory findings. This study aim was to retrospectively evaluate correlation between microbiologically positive sepsis patients and their qSOFA validity on arrival to emergency department.

Methods

A retrospective observational study was performed in adult emergency department in tertiary, university-affiliated hospital. Patients were included in study if microbiological test and first antibiotic dose were initiated in emergency department for suspected sepsis and quick SOFA score was calculated. Exclusion criteria was trauma patients and departure to other hospitals.

Results

Much more patients were suspected for having a sepsis by qSOFA criteria based protocol. Further study results will be presented.

Conclusions

qSOFA is much promising score with ability not only recognising high risk mortality sepsis patients in hospital but also in emergency department or even pre-hospitaly without using laboratory tests. This study was created for accepting or refusing qSOFA criteria in emergency department, especially in poorly finansed emergency deprtments.


Linas DARGINAVICIUS (Kaunas, Lithuania), Kestutis STASAITIS, Aida MANKUTE, Nedas JASINSKAS
11:00 - 18:00 #7231 - Is this another case of vasovagal syncope?
Is this another case of vasovagal syncope?

Syncope is a common presentation to the Emergency Department with at least 1/3 of the population having experienced it at least once during their lifetime. The top 2 causes of syncope are vasovagal (21.2%) and cardiac (9.5%), and the cause is unknown in 36.6%. We present a case of a 28 year old Chinese gentleman with an unusual cause of syncope due to a mediastinal mass. He presented with a first onset of syncope lasting 1 min following a visit to the local general practitioner for 1 week of cough. A CXR was performed in view of the cough which revealed prominence of the left hilar shadow which suggested a possible hilar mass, which upon further evaluation with CT, turned out to be a 6.8*4.8cm heterogeneous lobulated anterior mediastinal mass. We will also review the pertinent points in the evaluation of a patient who presents with syncope.


Ivan CHUA (Singapore, Singapore)
11:00 - 18:00 #8136 - Ischemic heart failure associated with severe anemia.
Ischemic heart failure associated with severe anemia.

INTRODUCTION

Severe anemia is associated with high risk cardiovascular mortality. Through the sympathetic response to the decrease of oxygen delivery, the heart structure will change and an inflammatory myocardial damage will occur if the anemia is not treated enough early. Megaloblastic anemia due to thiamin or folate deficiency had specific pathophysiology and so specific therapy which we will elucidate through this case report.

THE CASE

A 63 three year-old women was admitted in the emergency department because of a severe respiratory distress associated with chest pain. The initial finding confirmed a congestive decompensated heart failure with evidence of myocardial necrosis as attested by an elevated troponines amount. Furthermore, there was a severe megaloblastic anemia with a hemoglobin amount of 2.1 g/l and a mean cell volume of 120 fl. The situation was improved after a transfusion and diuretic therapy with ventilatory support. The patient was admitted to cardiology ward and further tests were performed in order to investigate the etiology of the anemia and the heart failure.

CONCLUSION

Anemia must be treated and explored without delay especially when is associated with heart disease.

 


Majed KAMEL, Abderrahim ACHOURI (tunis, Tunisia), Khedija ZAOUCHE, Hamida MAGHRAOUI, Jobrane MANSOURI, Chokri HAMMOUDA, Nebiha FALFOUL BORSALI
11:00 - 18:00 #8056 - ISEE Hospital: a 2D hospital incident management training simulator.
ISEE Hospital: a 2D hospital incident management training simulator.

Introduction

Training is a vital part, if not the most important part of the preparation process of a good emergency plan. The lessons that are learned are needed to make adaptions to new and unexpected problems. Training can be from real-life exercises to table-top or paper scenario’s. Multiple software programs are available. ISEE Hospital is a 2D simulation platform that is developed as private public project and has the advantages of an academic background and a commercial objective.

Debriefing is in general the weakest link of every exercise and is in general subjective. Recording key performance indicators and time stamps is difficult and interpretation takes time. Debriefing your trainees in depth on the spot isn’t feasible with big exercises. Getting everybody again together afterwardsi s difficult so in general a paper report is the result. It is be better to have the data available on the spot and therefore have time for discussion when everybody is available.

 

Methods

As the concept for the simulator already was created in the beginning of the new millennium as an European research project, the result was commercialized but was only used in academic circles and some  hospitals in the Netherlands. A think-tank that consisted of IT developers and academic disaster researchers redesigned the program from scratch with the double-sided objective: a tool that could be used in an academic environment and that was easy to learn and use for a first time user.

Results

ISEE Hospital was launched in 2015 and replaced the old simulator. All the commercial users were excited with the new possibilities: easy to use for trainer and trainee, designing your own department, adaptable resources, time reduction of scenario creation, web-based program, low IT requirements, sharing of victim profiles and scenario’s, registration of key performance indicators and build-in statistical analysis.

The program is already used for different research and master projects. The flexibility of the program makes it possible to use from one-on-one training to big multi-center training. In November 2015 ISEE Hospital was used in the Netherlands to support an online exercise between 10 hospitals with the objective to test the regional disaster plan. Every department vital in the chain of management was involved: the dispatch and ambulances of the EMS, the emergency and intensive care departments, the operating theaters, the wards and the administration of the hospital. Everything ran in an artificial environment that kept logs of every move that was made.

Conclusions

ISEE Hospital has proven that commercial and academic objectives can work together. The cost of a real life exercise or the time it takes to set up table top scenarios is too big for small non university hospitals that want to prepare. Those centers need a tool that is quick, easy to use and can be used on the spot without the need for extra materials or working space. ISEE Hospital is capable of fullfilling all those requierements.


Tom SCHMITZ (Humbeek, Belgium), Nima HOSSEINPOUR TABRIZI, Michel DE BACKER, Ives HUBLOUE
11:00 - 18:00 #7440 - It would be useful STONE questionnaire in hospital emergency rooms for suspected nephrolithiasis?
It would be useful STONE questionnaire in hospital emergency rooms for suspected nephrolithiasis?

Introduction

The questionnaire STONE predicts the probability of presence of ureteral calculi uncomplicated and can be used for the diagnosis of renal colic in Primary Care Emergency

 

Objetive

Compare the probability of renal colic according to the questionnaire STONE with the presence of abnormalities in imaging tests ( ultrasound and computed tomography (CT ) ) in a hospital emergency department

Material and Methods

Observational, longitudinal , retrospective review of medical records , patients were selected patient with renal colic  diagnosis in 2015 that underwent ultrasound or CT in the period up to 1 week of diagnosis.  The probability of nephrolithiasis according STONE questionnaire was calculated.  Collected variables: gender , age , location, duration of clinical (less than 6 hours, between 6-24h and more than 24 hours), if I have nausea or vomiting, presence of hematuria , impaired creatinine, if he had lithiasis and / or hydronephrosis

Results

Of the 532 patients with a discharge diagnosis of renal colic emergency patients underwent imaging test 159 patients (29.87%). The mean age was 47.8, 56% men. 56% were left location. 44.7% went to the emergency in the first 6 hours of evolution, 28,3 6-24 hours and 27% with more than 1 day evolution .. There were hematuria in 89.3%. 25.2% had nausea, vomiting 12.6% and 58.5% did not mean any of them. In 20.8% of patients was impaired creatinine STONE According to the questionnaire the likelihood of renal colic was low at 8.2%, moderate in 45.3% and high in 46.5%. Ultrasonography was performed CT 67.3% and 32.7%. 69.8% in the presence of calculi was confirmed, and there ureterohydronephrosis 28.3% grade 1, grade 2: 32.1% and grade 3: 1.3% Any alteration in 89.3 % of tests target image . They had litiasis 83.8 % and one of the two 97 % of patients with high probability , 68% stones and some 90 % of the average and 0% lithiasis and 38 % ureterohydronephrosis I grade of low . In 100% of patients with medium probability and impaired creatinine calculi visualized

Conclusion

Any alteration in our series aim at a high probability in the questionnaire STONE predicts in 8 of 10 patients the presence of calculi and almost 100 % the presence of some alteration . In 100% of patients with low probability is not objective stones. In all patients with average probability with impaired renal function calculi visualized , what makes us think about the possibility that it could create a questionnaire STONE extended for hospital use including this value.


Daniela ROSILLO CASTRO (Murcia, Spain), Carmen HERNÁNDEZ MARTÍNEZ, Maria Dolores PASCUAL MUÑOZ, Rocío LÓPEZ VALCARCEL, María De La Paz EGEA CAMPOY, Maria Del Mar DE LA TORRE OLIVARES
11:00 - 18:00 #7404 - It´s not always a child´s play.
It´s not always a child´s play.

            Female patient 44 years old without important antecedents. She came  to the emergency room for facial and  lower extremities edemas  accompanied by dyspnea and asthenia important with amenorrhea three months and  not altered bowel habits.

            On examination: Important pale skin and mucous membranes, rest  nondescript except  edemas.  Additional tests: blood count Hb 7.1, Hct 21, VCM 147, 139000 platelets . Abdominal ultrasound  hepatomegaly with increased echogenicity its suggestive of steatosis. Study prior to transfusion anemia is requested and entered in Internal Medicine.

 

            During admission other tests are performed .  Normal gastroscopy,  blood. folic ac> 20 ng / ml, negative antiendomysial AC,  AC antitranglutaminasa 10 (positive)

Intestinal transit thickening compatible with jejunal loops with celiac box, small bowel biopsy: chronic duodenitis with marked villus atrophy.

 

             It is diagnosed by folic acid deficiency and celiac disease and treated with folate supplements and gluten-free diet. During follow-up  in outpatients presents elevation of transaminase, GGT 788 and hepatomegaly, paresthesia persistent in lower extremities accompanied by loss of strength, enter again to conclude study being realized EMG compatible with sensory polyneuropathy of axonal predominance in moderate degree, and liver biopsy  with steatohepatitis and pericellular fibrosis

           

            During admission hypertransaminasemia normalizes, we can not be attributed to nutritional deficiencies polyneuropathy or increased ferritin and MCV, but due to existing alterations as well as the presence of teleangectasias and hypertrophy of parotid makes us think of a harmful drinking , so that rehabilitation begins during admission

 

            Conclusion:

            Celiac disease is an autoimmune disorder that can occur in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine.  It is estimated to affect 1 in 100 people worldwide. When people with celiac disease eat gluten (a protein found in wheat, rye and barley), their body mounts an immune response that attacks the small intestine. These attacks lead to damage on the villi, small fingerlike projections that line the small intestine, that promote nutrient absorption. When the villi get damaged, nutrients cannot be absorbed properly into the body.
 The most common form is classical with esteatorreica diarrhea, malnutrition, abdominal distention and growth arrest. Left untreated, celiac disease can lead to additional serious health problems. These include the development of other autoimmune disorders like Type I diabetes and multiple sclerosis (MS), dermatitis herpetiformis (an itchy skin rash), anemia, osteoporosis, infertility and miscarriage, neurological conditions like epilepsy and migraines, short stature, and intestinal cancers as in our case. All these variants can induce diagnosis delay.  Intestinal biopsy remains the gold standard


Patricia BONED BLAS, Teresa FERNANDO GROS (ZARAGOZA, Spain), Rocio ESCRICHE ROS, Alicia BAGUENA GARCIA, Alba GALLEGO ROYO
11:00 - 18:00 #7617 - JAUNDAICE AND DISCOMFORT: A CASE-REPORT.
JAUNDAICE AND DISCOMFORT: A CASE-REPORT.

Jaundice often is a reason for consulting in an Emergencies Department (ED). Jaundice may be due to an excess of direct bilirubin (DB) or indirect. A correct anamnesis and physical examination with complementary tests are important for reaching the etiologic diagnosis.

We present the case of a 35-year-old male without a medical history of interest that goes to the emergency room by dark urine, headache, general discomfort and dysthermia 24 hours ago.

Physical examination

Blood Pressure 123/94 mmHg, 88 bpm, oxygen saturation 97%, temperature 36.6°C, dryness of mucous membranes, icteric dye, jaundice subconjunctival. Normal cardiopulmonary auscultation, soft abdomen, it had no masses or organomegaly.

Complementary tests

Blood Test:  hematies 3.610.000, hemoglobin 11.5 g/dl, hematocrit 34.3%, 11200 leukocytes, platelets 238,000. Total bilirubin 7.2 mg/dl (DB: 0.5 mg/dl), ALT 12 u/l, AST 22 u/l, GGT 17 u/l, FAL 61 u/l, LDH 376u/l,

Urine Test: 1043 density, pH 6, negative glucose, negative bilirubin, urobilinogen 2 EU/L, erythrocytes, leukocytes and nitrite are negative.

After observing the analytics results where there was a hyperbilirubinaemia by increase in indirect bilirubin and elevated LDH that suggest hemolysis. We returned to question the patient about the possibility of having consumption of medicines or foods the days before, and he reported have consumed broad beans two days earlier.

Direct Coombs Test was negative direct and this ruled out active hemolysis in that time. The study of peripheral blood under the microscope showed the presence of spurs cells and isolated Heinz bodies (they were suggesting glucose 6 fosfatodeshidrogenasa (G6PD) deficiency). We sent the patient at home with high suspicion of favism and the next day he returned to emergency because he presented general deterioration with fever (38.8ºC) and then in blood test presented hematies 2.020.000, hemoglobin 6.6 gr/dl, LDH 407 u/l, total bilirubin 2 mg/dl (bilirubin direct 0.7). In the new study of Blood smear showed polychromatophilia, spurs cells, spherocytes and a few schistocytes. Admission to the service of Hematology is decided. During their income remains stable disappearing data from hemolysis at 48 hours.

Discussion

G6PD is a eritroenzimopatia, linked to the X chromosome, more common worldwide, affecting more than 400 million people, distributed in Africa, Mediterranean regions, Middle East and China. The enzyme deficiency causes irreversible oxidative damage of erythrocyte causing his death. We have identified more than 400 variants of G6PD, among the best known are the G6PDH-A and G6PDH Mediterranean. This last variant is the most common found in the Caucasian race, particularly in the Mediterranean area. In Spain, it is especially prevalent in the South of the Peninsula and Balearic Islands. The majority of people who have this deficit remain asymptomatic until they come into contact with drugs or foods such as broad beans, then this disease named favism occurs.  It comes with an intense hemolysis to 24-48 hours after ingestion. There is not specific treatment being the best treatment the prevention. 


María Jose JIMENEZ, Mercedes FERNÁNDEZ-ESCRIBANO, Sergio SANCHEZ (Guadalajara, Spain), Eduardo FERNANDEZ, Pilar LOZANO, Félix Manuel DOMINGO, Sergio AZNAR
11:00 - 18:00 #7439 - kearns-Sayre's a-v complete block: An uncommon cause of collapse.
kearns-Sayre's a-v complete block: An uncommon cause of collapse.

Kearns-Sayre syndrome is a rare disease, discovered in the 1950s by Thomas Kearns and George Sayre, caused by mutations in the mitochondrial DNA. It is important to know that this syndrome is developed due to  an isolated mutation, not a hereditary alteration. Patients may have reduced visual ability, hearing loss, dysphagia, ophthalmoplegia, neurological and cardiac disorders, and ptosis along with proximal symmetrical muscle weakness. There is no cure and the treatment is purely symptomatic with regular assessment for its main manifestations, especially of those symptons with vital risk for the patient.  Disturbances in cardiac conduction are common, although most patients have A-V blocks of first and second degree but, infrequently, they can develop  a complete A-V block. That's the main reason why most patients with Kearn-Sayre's diagnosis need a pacemaker along their lives.

 In December 2015 we recived a 29 year old patient, diagnosed with Kearns-Sayre syndrome, brought to the Emergency Service of General Hospital of Albacete by recurrent syncope with spontaneous recovery. She had been previously attended two times for the same reason, and the test performed yielded normal results (blood test and EKG). She told us that Neurology and Cardiology experts were studying her due to frequent dizziness in the past6 months. PMH (pass medical history) she was diagnosed of type 1 diabetes and myopathy (right ptosis and paresis ophthalmoparesis members (proximal 3/5, 4/5 distal). On examination, the patient was asymptomatic , observations (BP, HR BR) were normal, and cardiac auscultation: rhythmic without murmurs. No other symptoms were done in exploration.. The electrocardiogram showed a complete AV block, and a temporary pacemaker was placed and the patient was transferred to the Intensive Care Unit of Coronary where a cardiology expert implanted a permanent pacemaker DDDR MEDTRONIC resulting in complete recovery of the patient.

Mitochondrial disorders, like Kearns-Sayre syndrome, are a heterogenic group of disease with a variety of manifestations. Heart damage is common, especially cardiac conduction (like A-V complete block). Since this is a vital emergency in these patients, we have to detect it as soon as possible. It is important to note that there is no cure for these diseases, so the treatment is pure symptomatic and preventive.


Francisco Javier LUCAS GALÁN (Albacete, Spain), Nuria SÁNCHEZ GARRIDO-LESTACHE, Fernando Constantino BRIONES MONTEAGUDO, María OLMOS ALEMÁN, Francisco Javier LUCAS IMBERNÓN
11:00 - 18:00 #7217 - Ketamine and Morphine in prehospital care: an effective tool for paramedics in routine practice. A before-after study.
Ketamine and Morphine in prehospital care: an effective tool for paramedics in routine practice. A before-after study.

ABSTRACT

Background. Although there are several papers which have assessed the effectiveness of the association of morphine sulphate with Ketamine in prehospital trauma care, until now we don`t know any study to examine the effectiveness and safety of the morphine-Ketamine (M/K) combination administered by paramedics in everyday practice.

Methods. Data before and after the implementation of a new pain protocol were collected in 4 Ticino Ambulance Services. Previously, a bolus of i.v. morphine 0.1mg/kg, up to 10 mg, was administered to patients older than 18 years, with medical or trauma pain more than 6 (scale 1-10); if the pain remained  more than 3, subsequent doses of  2.5 mg were administered every five minutes, up to 20 mg; if the initial pain score was 3-5, then i.v. morphine 2.5 mg initially and 2.5 mg every five minutes up to 10 mg was administered.  In the new protocol, the same dosage of i.v. Ketamine (0.1 mg/kg or 2.5 mg, respectively) was associated with morphine. At baseline, after 5 and 10 minutes, and until arrival at the emergency department, the following data were collected: state of consciousness, vital signs, heart rate, blood pressure, 3-lead ECG; pain, agitation, hallucinations, nausea and vomiting.

Results. On the whole, 398 patients were included in the study (208 treated with morphine and 190 with M/K); pain was significantly reduced in both groups but more in the M/K group (morphine vs M/K: 5 min mean score 6.00 (SD2.29) vs 4.54 (2.66); 10 min 4.65 (2.33) vs 3.28 (2.46); ED arrival 3.35 (2.20) vs 2.20 (1.93); P< 0.0001 for all comparisons).

No differences were observed at any time for nausea and vomiting. Patients treated with M/K had more episodes of hallucinations (5 cases vs none, P 0,02) which regressed rapidly and didn’t need administration of benzodiazepines. The mean dosage of morphine was not significantly different (morphine 8.5+3.76 mg; M/K 7.8 +4.06 mg p=0.06)

Conclusions. The association of M/K is an effective and well tolerated treatment which can be administered by paramedics in everyday practice.


Stefano DELLAGIACOMA, Micaela HOCHSTRASSER, Paola DI GIULIO, Fulvio RICCERI, Michael ZURRU, Christiane BERTA (Brissago, Switzerland), Bruno CONTI ROSSINI, Luciano ANSELMI
11:00 - 18:00 #7432 - ketoprofen versus diclofenac in treatment of renal colic: double-blind randomized forward-looking comparative Study.
ketoprofen versus diclofenac in treatment of renal colic: double-blind randomized forward-looking comparative Study.

Introduction: The renal colic of the adult is a frequent lombo-abdominal painful syndrome in emergencies. Treatment is based on nonsteroidal anti-inflammatory drug (NSAID) but the choice between different NSAIDs remains a subject of controversy. Our aim was to compare the efficiency and the tolerance of two intramuscularly NSAIDs in renal colic.

Materials and methods: A randomized controlled clinical trial, single-center double-blind realized in emergencies service over an 8 month period. was included: Age > 16 years with a visual analogue scale (VAS) ≥ 5 . Exclusion criteria: Pregnant , renal failure or known hepatic, known or suspected allergy to NSAIDs, known peptic ulcer, hemorrhagic. All patients was randomized in to 2 groups: GK (Ketoprofen): a 5 ml syringe with an ampoule 100 mg / 2 ml + 1 ml of serum. GD (diclofenac): a 5 mL syringe containing a bulb of 75 mg / 3 ml. The route of injection was intramuscularly. If VAS > 3 after 40 mn, 1 g of paracetamol slow intravenous was administered to the patient. Primary outcomes were successful treatment, time to resolution of pain and VAS drop percentage. Secondary outcomes were the occurrence of side effects.

Results: We have included 80 patients. Indeed, the average age was 39 ± 13 years for GK versus 43 ± 14 years for GD. The mean VAS on admission was also similar in both arms. We objectified a therapeutic success rate of 92% in both groups. This success was similar in both arms with a slight tendency for the ketoprofen group. The use of rescue medication was 32.5% in the GK versus 47.5% in the GD  (P=0.17). We have observed in 46% (n = 37) of the study population side effects. These effects were only minor and no major intolerance expression was registered.

Conclusion: The effect of anti-inflammatory drugs on the efficacy and tolerance in the treatment of renal colic was the same for diclofenac and ketoprofen. Other factors such cost, side effect profile, and personal preference may be taken into consideration in the choice of treatment.


Nesrine IBN HASSINE, Chawki JEBALI (Kairouan, Tunisia), Achref HAJ ALI, Lotfi BOUKADIDA, Asma ZORGATI, Riadh BOUKEF
11:00 - 18:00 #7394 - Kicking off a retropharyngeal abscess.
Kicking off a retropharyngeal abscess.

Introduction

Retropharyngeal abscesses (RPA) are deep neck space infections that can pose an immediate life-threatening emergency, such as airway obstruction. The potential space can become infected by bacteria spreading from a contiguous area or direct inoculation from penetrating trauma. Infection is often polymicrobial and the source is usually oropharyngeal flora (most commonly group A beta-hemolytic streptococci). The incidence of RPA is declining due to the widespread use of antibiotics for upper respiratory tract infections (URTI).

Methods

We describe an atypical presentation of RPA in a three year old girl who attended with a history of post-traumatic neck pain.

Case History

MB presented to the Emergency Department with neck pain and reduced range of motion following a kick to the neck by a sibling. Her mother witnessed the accident and felt that it was a mild trauma, with disproportionate pain afterwards. Of note, MB had an ongoing URTI for which she had been treated with antibiotics one week previously. On examination, MB was irritable and held her head in slight flexion, resisting any neck movements. Her pain was severe, requiring opiate analgesia. She was constitutionally well; eating and drinking, haemodynamically stable and apyrexic. Her tonsils were not inflamed and she had no signs of inflammation of the posterior pharyngeal wall. Blood tests revealed a normal white cell count with a raised CRP (50) and ESR (99). Given the history of trauma, a cervical spine x-ray was performed which showed psuedosubluxation of C2/C3 with a concern regarding facet joint injury, which was further characterized by CT. As physicians were focused on the boney structures, pre-vertebral soft tissue swelling (which was visible on both x-ray and CT) was overlooked. Ultimately, MRI revealed a RPA without any traumatic bone injury. The RPA was incised and drained. Cultures grew Haemophilus influenzae for which she was treated with antibiotics. She recovered well without any negative sequellae.

Discussion

In this case the presenting history of mild trauma did not explain the clinical picture of our patient, however there were no clinical signs of an infective cause of neck pain.

Influenced by the history of trauma, physicians both arranged and interpreted imaging with a view to identifying boney injury. Although psuedosubluxation at C2/C3 is a recognized finding in children, the history of trauma was concerning. Therefore a non-contrast CT was performed to visualize the vertebrae and facet joints, albeit sacrificing soft tissue detail to reduce radiation dose. MRI ultimately defined the RPA however in retrospect, swelling of the prevertebral soft tissues was visible on both the x-ray and CT.

MB did not have classic symptoms and signs of RPA. She did have a URTI which may have triggered her RPA but this is not a certainty. It is also possible that the recent course of antibiotics masked her symptoms.

Conclusion

This case highlights an unusual presentation of a common disease and reminds us that trauma can often be a red herring in a patient’s presentation.

 


Laura HEFFERNAN (Tipperary, Ireland), Abdullah BIN RAUF, James BINCHY
11:00 - 18:00 #7141 - Knowledge and preparedness of the emergency department nursing staff for a mass casualty radiation event.
Knowledge and preparedness of the emergency department nursing staff for a mass casualty radiation event.

Background:

The medical response to radiation remains one of the least taught among all disciplines within medical education(1).Recent world events have increased concern that hospitals must be prepared for radiological emergencies, Especially Emergency departments(2).

objective:

The main purpose of this study is to examine the level of knowledge of registered nurses who work in emergency departments, regarding a mass casualty radiation event, by comparing the level of knowledge between nursing staff at a medical center which is designated to receive victims of radiation and the nursing staff at a medical center which does not receive radiation victims. Other objectives are to examine the relationship between the level of knowledge and the level of staff fear of treating the victims of a radiological incident and to examine the relationship between the staff's fear and its preparedness to report to work in a radiological format.

Methods:

This cross-sectional study included 83 registered nurses, male and female, in emergency departments at three medical centers in Israel, where one of the centers is designated for intake of radiation victims. The sampling method used was cluster sampling.

Results:

The findings revealed a low score (46.25%) on the questionnaire about knowledge, with no significant difference between the medical centers, including the one designated for the intake of victims of radiological injury. Fear of a high probability that this scenario will become a reality ranges from 10% to 29%. Fear of the four scenarios which were presented to respondents was high, ranging from 55.4% to 83%. The rate of preparedness to report for work ranged from 48.2% in an oral poisoning scenario to 54.2% in the event of the explosion of a "dirty bomb".

Conclusions:

The present study demonstrated that the level of knowledge among the nursing staffs in emergency departments is low. This is regardless of whether the medical center is one designated to treat radiation victims or one that is not. The study demonstrated a link between the level of knowledge and the sense of risk, fear, and willingness to report for work. In other words, increasing the level of knowledge of the staff regarding a mass casualty radiation event will have a significantly positively impact on all the factors mentioned above. We recommend the institution of programs at all the medical centers to increase knowledge, by incorporating contents based on the 'all hazard' approach and including the unique features of a mass casualty radiation event through lectures at staff meetings, executive team-building games, the creation of courseware, and the like. In addition these subjects should be added to professional in-service training.

Bibliography:

  1. McFee, R. B., & Leikin, J. B. (2009, February). Death by polonium-210: lessons learned from the murder of former Soviet spy Alexander Litvinenko. InSeminars in diagnostic pathology (Vol. 26, No. 1, pp. 61-67). WB Saunders.‏
  2. Bushberg, J. T., Kroger, L. A., Hartman, M. B., Leidholdt, E. M., Miller, K. L., Derlet, R., & Wraa, C. (2007). Nuclear/radiological terrorism: emergency department management of radiation casualties. The Journal of emergency medicine, 32(1), 71-85.‏

Uri AIZIK (tel aviv, Israel), Yaniv PERETZ
11:00 - 18:00 #7727 - Kounis syndrome: allergic induced coronary artery spasm 2 cases report.
Kounis syndrome: allergic induced coronary artery spasm 2 cases report.

Introduction:

Kounis syndrome, also known as allergic angina syndrome, was described in 1991 by Kounis and Zafras as “the coincidental occurrence of chest pain and allergic reactions. Vasospasm of the coronary arteries has been suggested to be the main pathophysiologic mechanism.

We report here two cases of patients diagnosed with kounis syndrome.

Case 1:

A 53 year old man came to our emergency department (ED) with a cutaneous rash which occurs soon after he ate a tuna sandwich.

He was a heavy smoker, with a history of hypertension, diabetes mellitus, coronary artery disease but without previous history of allergy.

On arrival, he had a generalized erythematous rash over the face, neck and thorax accompanied by itching. His blood pressure (BP) was 100/60mm Hg and the pulse 100 beats/min. Examination of the heart, lungs, abdomen and central nervous system revealed no abnormalities. An electrocardiogram (ECG) performed initially was normal. An antihistamine and steroid therapy were given to the patient. During admission in the ED, he felt unwell, started sweating, became pale and complained of severe retrosternal pain radiating to both arms associated with nausea and vomiting. His BP fell to 70/40 mmHg and his pulse increased to 120 beats/min.

An ECG performed immediately revealed elevation of ST segment of 1 mm in leads I and aVL, with a specular reflection on leads II, III and aVF.

The diagnosis of ST-segment elevation acute myocardial infraction (STEMI) was made and the patient received a dual anti-platelet (aspirin and clopidogrel) and anti-caogulant medications. After administration of isotonic saline infusion (1000 ml) without epinephrine use, the patient became hemodynamically stable.

A coronary angiography was done immediately and showed a tight thrombotic stenosis of the anterior interventricular artery with a TIMI flow at 3. An intracoronary stent was implanted with good outcome.

Case 2:

A 40 years old female presented to the EDt with acute dyspnea after she inhaled a chlorinated product. She was a heavy smoker, with no history of allergy.  

She was sweating and agitated but conscious, she had a cutaneous rush her respiratory rhythm was equal to 40 cycles per min, with the use of accessory muscle. Her blood pressure was 220/100, and the pulse 120 beats/min without signs or right cardiac impairment.

Arterial blood gas: PH=7.25, pCO2=54 mmHg, pO2=62 mmHg, lactate=1.9, HCO3=23.7, SaO2=87%. An electrocardiogram was performed, it showed a complete left bundle branch block.

The diagnoses of anaphylaxis stage was established. She received several nebulizations of Terbutaline and Ipratropium Bromure, in addition to antihistamin and corticosteroids with a good clinical outcome.

Another electrocardiogram was performed, it showed: an incomplete left bundle branch block with ST segment deviation.

Troponin was equal to 0.16 in admission and 0.20 after 6 hours.

She received and antiischemic and antithromboltic treatment and was transferred to a cardiology department. A coronagraphy was performed and it showed normal coronary artery.

 

Conclusion:

Kounis syndrome should be borne in mind when diagnosing patients with or without cardiovascular risk factors who experience acute coronary syndrome accompanied by symptoms of anaphylaxis.


Rym KADDOUR, Hanen GHAZALI (Ben Arous, Tunisia), Anware YAHMADI, Mouna GAMMOUDI, Farah RIAHI, Ahmed SOUYAH, Noura NGHACH, Sami SOUISSI
11:00 - 18:00 #7135 - Lactate and CRP levels in unselected emergency department patients: Association with hospital admission, intensive care unit admission and hospital length of stay.
Lactate and CRP levels in unselected emergency department patients: Association with hospital admission, intensive care unit admission and hospital length of stay.

Introduction

Increasing interest has been given to lactate levels in acute ill patients. Especially septic patients are described to have elevated lactate levels, although it is unclear whether high lactate in emergency department patients helps to distinguish those with high risk from low risk patients. Furthermore, neither the prognostic nor the diagnostic value of lactate levels is clear in unselected patients of the emergency department. There is growing evidence that lactate levels in the emergency department might serve as a screening method for patients at higher risk for mortality, but it is still unclear under which circumstances and which symptoms or diagnoses they are really useful for. The aim of our study was to analyze the lactate levels of unselected patients in the emergency department and look for possible correlations of certain patient characteristics as well as their possible prognostic value in different diagnosis groups.

Methods                                                                 

We retrospectively analyzed all patient data, were blood samples were drawn during a 2-week period (March 2014), excluding patients <18years, no lactate levels available, no documentation. Analyzed patient characteristics were age, sex, type of allocation (walk in, family physician, EMS with and without physician, other), symptoms, diagnosis, hospital admission, ICU-admission, 30-day mortality, vital signs, blood samples (CRP, leukozytes, thrombozytes, creatinine, hemoglobin, lactate).

Results

1157 visited the emergency department during the study period, of which 587 were included into the study. The mean age was 60,4 years (sd 20,8), 313 patients were admitted to hospital with an average length of stay of 11,9 days (sd 11,9). 80 patients were admitted to the ICU (25,6%) with a mortality rate of 2,6%. The main diagnostic groups were cardiovascular (24,5%), infections/sepsis (21,5%), orthopedic/trauma (18,6%) and other (35,4%) with some differences in distribution between hospital admissions and ambulatory management. Average lactate levels were 2,08mmol/l (sd 1,51, p<0,001 Kolmogorov-Smirnov). Univariate regression analysis showed a significant (p<0,05) influence on hospital admission of the variables age, HR, saturation, type of allocation, lactate, CRP, leukozytes, hemoglobin and creatinine. Multivariate regression analysis showed a significant (p<0,05) influence on hospital admission of the variables HR, allocation, lactate and CRP. Multivariate regression analysis disconfirmed lactate as a factor for ICU-admission (OR,1,154, p=0,117). The multivariate regression analysis also showed no influence of lactate for length of hospital stay (regression coefficient B 0,273; p=0,471) whereas only CRP levels show an influence (regression coefficient B 0,045; p=0,003).

Discussion

Lactate levels in unselected patients in the emergency department on average are low. Increased lactate levels mean higher risk for hospital admission, although it does not influence admission rate to the ICU or length of hospital stay. The prognostic value of lactate levels in unselected patients of the emergency department without a pretest-probability seems to be low.


Maria BERNHARDT, Christian HOHENSTEIN (BAD BERKA, Germany)
11:00 - 18:00 #7136 - Lactate levels in different diagnostic groups of unselected patients in the emergency department.
Lactate levels in different diagnostic groups of unselected patients in the emergency department.

Introduction

Increasing interest has been given to lactate levels in acute ill patients. Especially septic patients are described to have elevated lactate levels, although it is unclear whether high lactate in emergency department patients helps to distinguish those with high risk from low risk patients. Furthermore, neither the prognostic nor the diagnostic value of lactate levels is clear in unselected patients of the emergency department. There is growing evidence that lactate levels in the emergency department might serve as a screening method for patients at higher risk for mortality, but it is still unclear under which circumstances and which symptoms or diagnoses they are really useful for. The aim of our study was to analyze the lactate levels of unselected patients in the emergency department and look for possible correlations of certain patient characteristics as well as their possible prognostic value in different diagnosis groups.

Methods                                                                 

We retrospectively analyzed all patient data, were blood samples were drawn during a 2-week period (March 2014) as described in an earlier abstract.

The classification of symptoms and diagnoses was based on similar studies and included a systemic category (infection, trauma, intoxication, shock, hypovolemia, allergic, neoplasm) or involvement of an organ system (cardiovascular, orthopedic, neurologic, gastrointestinal, pulmonary, ENT, eye, skin, urogenital, gynecological, psychiatric/psychological, hematological, other). Statistical analysis was done with SPSS, multivariate regression analysis, determination of Kolmogorov-Smirnov-Test, Kruskal-Wallis-Test and Mann-Whithney-U-Test in order to determine the influence of lactate in different diagnostic or systematic groups and the comparison between admitted versus ambulatory patients.

Results

Only in the orthopedic/trauma group lactate levels show a normal distribution (Kolmogorov-Smirnov-Test 0,111). The lactate levels within the different diagnostic groups do not differ significantly (Kruskal-Wallis-Test p=0,111). Within the ambulatory patient group, lactate levels show a normal distribution in the neurologic as well as cardiovascular group (Kolmogorov-Smirnov-Test 0,2 and 0,063, resp.). No difference of lactate levels is observed among the diagnostic groups (Kruskal-Wallis-Test p=0,678). Within the patient group admitted to hospital, lactate levels are not normally distributed in any diagnostic group (Kolmogorov-Smirnov-Test always <0,05). No difference of lactate levels is observed among the diagnostic groups (Kruskal-Wallis-Test p=0,033). The Mann-Withney-U-Test showed significant lower lactate levels in patient with neurological disease (p<0,05).

Within the group infection/sepsis the Mann-Whithney-U-Test showed no difference of lactate levels in comparison with the overall patient population, in contrast to HR, temperature, CRP, leukozytes, creatinine (all higher), arterial pressure, saturation and hemoglobin (all lower).

Discussion

It seems to be unclear, which patient population would benefit from lactate sampling. This study does not confirm the notion, that high lactate might be more frequent in certain diagnostic groups like infection/sepsis than in other but is equally distributed regardless of symptoms or diagnosis. The value of lactate levels in risk stratification and diagnostic and prognostic clinical support has yet to be determined.


Maria BERNHARDT, Christian HOHENSTEIN (BAD BERKA, Germany)
11:00 - 18:00 #8178 - Lactic acidosis caused by Metformin.
Lactic acidosis caused by Metformin.

Introduction: This case report include a brief review of the literature about the lactic acidosis, and specifically the lactic acidosis caused by Metformin. Case report: We describe a 83-year-old patient, with type 2 diabetes who was found unconsciousness by his neighbour. He was tachypnoeic. He also had hypertension, atrial fibrillation and Chronic kidney disease. His medications were Vildagliptin/ Metformin 50/1000 mg every 12 hours and Insulin Humulina NPH KwikPen 18 Units Once daily, Acenocoumarol 3 mg Once daily, Barnidipine 20 mg Once dailys, Carvedilol 6,25 mg Once daily and, Valsartán/Hydrochlorothiazide 80/12.5 mg Once daily.. Relatives of the patient reported that he has been unwell for 5 days prior to the event. He was hyporexia and repeated hypoglycemias. On arrival the patient was tachypneic, pale and clammy, and was unresponsive. He was oliguric. Tests on admission showed urea 165 mg/dl, creatinine 9.44 mg/dl, pH 6.645, bicarbonate 2.1 mmol/l, and lactate 24 mg/dl, Leukocytes 17400. A computed tomography of brain was done and it was normal. The patient was managed with aggressive fluid therapy and inotropic support and was admitted Intensive Care Unit. Metabolic acidosis are caused by various disturbances of acid-base balance. The causes may be due to loss of bicarbonate, alterations in renal excretion of acids, the exogenous contribution acid hydrogen or an increase in endogenous acid production., Lactic acidosis deserves special attention because of their frequency, morbidity and potential mortality. Lactic acidosis, usually the result of the accumulation of the isomer L-lactate, can be congenital or acquired, Acquired lactic acidosis may be secondary to tissue hypoxia (type A) or impairment of liver and or kidney, seizures or exposure to toxins (type B). A common adverse effect acute or chronic biguanide (Metformin) use in treating diabetes is lactic acidosis. The incidence of lactic acidosis is 5.1 cases per 100,000 patients years. A physician have to pay attention if a patient on Metformin presents with metabolic acidosis. The common triggers in such patients are dehydration, administration of iodinated contrast, surgery, treatment with NSAIDs and starting new medications like w diuretics or antihypertensives, acute infection or hepatic insufficiency Metformin is eliminated rapidly and actively by the kidney and any decrease in renal perfusion accumulates the drug in the body and cause lactic acidosis. References: 1. Boucaud-Maitre D et al. Lactic acidosis: relationship between metformin levels, lactate concentration and mortality. Diabetic Medicina (2016) 1:18 DOI: 10.1111/dme.13098 2. Doenyas-Barak et al. Lactic acidosis and severe septic shock in metformin users: a cohort study. Crit Care. 2016 Jan 15;20(1):10. doi: 10.1186/ s13054-015-1180-6. PMID: 26775158 3. Petersen C. D-lactic acidosis. Nutr Clin Pract. 2005;20: 634-45. 4. Herrero et al. Alteraciones del metabolismo ácido base: acidosis. Medicine. 2015;11(79):4748-58 5. Salpeter S, Greyber E, Pasternak G, Salpeter E. Risk of fatal and nonfatal lactic acidosis with metformin use in type 2 diabetes mellitus. Cochrane Database Syst Rev 2006.


Lupe Del Rocio CORONEL CHUMBI (MURCIA, Spain), Juan Antonio HIDALGO RAMOS, Ashid KODUMAYIL, Monica Asuncion ALEIXOS ZURIAGA, Maria Fernanda FALCON REIBAN, Paul ESPINOZA MOSQUERA, Juan Orlando LOPEZ OJEDA, Meulry CAPELINI
11:00 - 18:00 #7578 - LAT gel efficacy in children’s procedural pain-related fear: an Italian observational study.
LAT gel efficacy in children’s procedural pain-related fear: an Italian observational study.

LAT gel efficacy in children’s procedural pain-related fear: an Italian observational study

Background:

Pain influences the structural development of  brain, thus its treatment is fundamental in pediatric patients. Sedation and analgesia are widely applied strategies to manage acute procedural pain and anxiety in the emergency departments (EDs) but a standardized management’s protocol has been not still approved in children. Application of  LAT (lidocaina 4%, adrenalina 0,05%, tetracaina 0,5%) gel, a topical anesthetic, on lacerations before painful procedures seems to be as effective as intradermal anesthetic infiltrations to reduce the procedural pain but a few studies were conducted on children in Italy. The aim of this study is to test the effectiveness on procedural pain and anxiety of LAT in a Italian pediatric population.

 Materials and methods:

34 children (0 -14), who presented a superficial laceration to the ED of  Pavullo’s Hospital (MO; Italy), have been assessed by the pain’s Numeric Rating Scale (NRS) at the Triage. Then LAT has been applied on the clean lacerations and covered by a plaster about 30-45 minutes before suturing. During the suture, the children’s pain has been revalued by different scales based on age (FLACC in patients <3 years old; Wong-Baker in patients 4-7 years old; VAS in patients >8 years old). We analyzed the localization of lacerations, the need of further analgesia, and side effects probably associated to LAC treatment. Mucosal laceration localized on nose and ears were excluded from the LAT’s treatment.

Results:

The superficial lacerations were localized on head (85%), on upper limbs (6%) and on inferior limbs (9%). Only two children needed further analgesia: one is treated with intranasal Midazolam, and the other one  with subcutaneous injection of Lidocaine. Children didn’t present side effects to the drug.

 Conclusions: 

This study demonstrates that LAT treatment before suturing is useful to minimize pain-ralated fear during suture, to simplify the management of pediatric patients in ED and  to improve the children’s compliance to therapeutic practices. These Italian findings are consistent with international literature about this topic, leading the way to extend the use of this drug in adults and elderly people.

 


Brugioni LUCIO, Francesca MORI (MODENA, Italy), Marcello BARALDI, Daria TOSATTI, Andrea RIGHETTI, Chiara PIGNATTI
11:00 - 18:00 #7716 - Learning Outcomes of Basic Life Support in Schoolchildren (RAMAkids club).
Learning Outcomes of Basic Life Support in Schoolchildren (RAMAkids club).

Background : Out-of-hospital cardiac arrest (OHCA) is a leading cause of death among adults in worldwide. Rapid initiation of basic life support (BLS) significantly associate with return of spontaneous circulation (ROSC).  Thailand, layperson BLS is performed in 15.8%. Most of Thai people unknown about basic life support and fear to do. BLS training in primary-school could be establish because children are keen to learn, accept new things and not afraid to making mistakes.

Objective : To study learning outcome in basic life support of primary school children.

Method : A observational study using data from the teaching of basic life support (RAMA kids club) in summer. Participants are primary-school children of hospital personnel. Using a pretest then an instructional video clip and trial practice. Posttest and skill are quizzed after learning. Descriptive and analytic statistics were used to analyze abilities in learning and performance in BLS.

Result : All 63 students who have completed all the steps. 26 boys. Mostly students are studying in grade 1-4 and normal weight by age. Tests before and after learning students can correctly only 61.6% and 89.9%, respectively. From the practice students keen to help and to see the response of 98.4% and make compressions immediately 88.9%. They can call emergency numbers correctly 87.3% and use an AED 81%. The effectiveness of chest compressions can have average in depth and speed of 3.3 cm. and 106.9 time/minute, respectively.

Conclusion : Children can learn step of BLS as check response, call for help, call for AED and quick start chest compression. The depth can’t reach gold in quality of chest compression may be the weight of children and power are’t the same adult. The study reveals that primary-school children are able to learn about the basic life support. The earlier in the course of learning BLS instruction begins can increase amount of rescuer.


Kasamon ARAMVANITCH (Bangkok, Thailand), Yuwares SITTICHANBUNCHA, Patcharaporn KLONGKLAEW, Krisana NILSAI
11:00 - 18:00 #8217 - Life threatening arrhythmia in the emergency department.
Life threatening arrhythmia in the emergency department.

Introduction: Severe hypokalemia (SH) can cause a variety of tachyarrhythmias, including ventricular tachycardia/fibrillation and rarely atrioventricular block. It can be a diagnostic dilemma for the practicing emergency physician. We report a case of a patient with severe hypokaliemia and life threatening arrhythmia.

Case report: A 65-year-old woman with hypertension and type II insulin treated diabetes experienced a sudden loss of consciousness followed by generalized body stiffening and violent jerking, revulsion of the eyeballs, with gradual awakening after 10 minutes, which prompted her family  to bring her to the emergency department. She reported having dizziness and vomiting for a month. Physical examination revealed a poor general condition. Her blood pressure was 240/10 mmHg with a pulse of 43 beats/min. She was breathing 26 times/min with an oxygen saturation of 95% on air room. Physical examination revealed no signs of acute heart failure or neurological deficiency.  The electrocardiogram (ECG) showed sinus rhythm of 42 beats/ min with complete right bundle branch block (RBBB), complete atrio-ventricular block and giant, asymmetrical T waves. The QT interval was markedly prolonged at 602 ms.

Based on the medical history and the electrical signs, severe hypokalemia (SH) was suspected. The blood gas analysis showed: K+ at 2.9 meq/L, than confirmed by the laboratory tests. The patient received the conventional medical treatment for SH.

The ECG monitoring showed polymorphic ventricular tachycardia (VT) with a change in the amplitude and twisting of the QRS complexes around the isoelectric line. It was Preceded by an R-on-T phenomenon. The diagnosis of Torsade de pointe was made based on these electrical finding. An infusion of magnesium sulfate was given, with the supply of potassium deficiency. The patient was transferred to the cardiology department where further investigations were made.

Conclusion:

Torsade de pointe is a specific type of arrhythmia that can lead to sudden cardiac death. The etiology and management of torsade de pointe are, in general, quite different from those of garden-variety VT. Differentiating between these entities, therefore, is critically important. It remains a diagnostic challenge for the practicing emergency physician and holds important implication.

 


Rania JEBRI (Lyon), Hana HEDHLI, Syrine KESKES, Mouna GAMMOUDI, Faten AMIRA, Bechir BOUHAJJA
11:00 - 18:00 #7336 - Life threatening slow and fast heart rate disturbances in prehospital environment.
Life threatening slow and fast heart rate disturbances in prehospital environment.

Life threatening slow and fast heart rate disturbances in prehospital environment

 

Author: Andreescu Gabriel (Paramedic, Medical Student)

Co-Author: Wandschneider Josef Alexander (Paramedic, Medical Student)

Coordinator: Dr. Taran Ana Daniela (Specialist Emergency Medicine)

 

Key words: heart rate, arrhythmias, tachycardia, bradycardia

 

Background:

Rhythm disturbances represented by paroxistic tachycardia and extreme bradycardia, are amongst top causes of circulatory shock and subsequently leading to sudden cardiac death, thereby taking an enormous role in the cases of emergency medicine. Our study tries to collect and analyse data from actual cases encountered by the organisation SMURD-TIM Sibiu (Mobile Emergency Service for Resuscitation and Extraction Intensive Care Unit). With this data in mind we try to optimise current treatment and assessment of these potential lethal rhythms.

 

Material and Method:

This is a retrospective observational study conducted on a group of 366 patients located on Sibiu county area,  who needed emergency assistance at various locations, for treatment of slow and fast arrhythmias during the time interval of 01.01.2013 – 31.12.2015.

 

Results:

From a total  of 366 patients assisted by SMURD-TIM  Sibiu 174 were men (48%) and 192 women (52%).

Based on living environment, patient are distributed: 284 (77%) in urban areas and 82 (23%) in rural areas.

Depending on fast or slow heart rhythm, there were 152 cases (41%) of extreme bradycardias with heart rate under 40 beats per minute and 214 cases (59%) of paroxistic tachycardia with heart rate above 140 beats per minute.

Classified on age interval we obtained the following results: 48 (13%) patients were between the age 13 to 20 years, 16 (5%) between 21 to 40 years, 80 (22%) between 41 to 60 years and 222 (60%) above 60 years.

The main  rhythm disturbances encountered by our specialists were paroxistic supraventricular tachycardia and atrial fibrillation with high ventricular response amongst other  rapid rate arrhythmias.

For bradycardic rhythm disturbances, the top pathologies were third-degree atrioventricular block and atrial fibrillation with slow ventricular response alongside other slow rate arrhythmias.

 

Conclusions:

We observe that  women are more susceptible to heart arrhythmias then men.

People from urban areas tend to solicit medical assistance more then those from rural areas.

We have a predominance of fast heart rate arrhythmias than slow heart rate arrhythmias.

Rapid and slow heart rate arrhythmias tend to appear at very young or old adults, with only a few cases of young adults between 21 an 40 years.

From our results we infer that a better patient screening of patients with potential hearth risks  conducted by general practitioner and referring them to a cardiology consult, alongside with use of heart rate monitoring gadgets (bracelets)  would result in decreased risk of developing life threatening situation represented by  sudden cardiac death and also a increase in patients reassurance. 


Andreescu GABRIEL (, Romania), Wandschneider ALEXANDER JOSEF, Taran ANA DANIELA
11:00 - 18:00 #7375 - Life-threatening complication of warfarin: lingual hematoma.
Life-threatening complication of warfarin: lingual hematoma.

Introduction: Warfarin sodium is an anticoagulant drug. It disrupts the usual production and destruction of vitamin K. By the existence of warfarin, coagulation factors are producing but their transforming for functional shapes are inhibited so it acts as an anticoagulant. Warfarin is being used for prophylaxis at cardiovascular and thromboembolic diseases. The most frequent complication of warfarin usage is hemorrhage. The hemorrhage is often seen at genitourinary system, gastrointestinal system and central nervous system. Lingual hematoma is a rare complication and it threats the life. In this case, we aim to present intubation caused by lingual hematoma.

Case: 87 years old female patient had presented to a health institution with swelling of her tongue and alteration of mental status which had been started 8 hours ago. When she admitted to our emergency department we learned that she was using warfarin for 5 years. In her physical examination, arterial blood pressure was 160/95 mmHg, pulse rate was 108/min, temperature was 37.2°C, oxygen saturation was 91%, Glasgow coma score was 11, there was neurological deficit on her left upper and lower extremities. Her tongue was edematous and ecchymotic. In laboratory tests, WBC was 18,000/uL, hemoglobin was 12.0 g/dL, platelet was 203,000/uL, INR was 11.41 and APTT was 50.7 seconds. Brain computed tomography scan revealed intracerebral hemorrhage. The patient was intubated to ensure the airway security. 2 units of fresh frozen plasma and 10 mg intravenous vitamin K were administered. The patient was consulted with neurosurgery and admitted to intensive care unit. The patient was followed up till the regression of lingual hematoma and intracerebral hemorrhage.

Conclusion: Skipping warfarin doses, releasing the drug, oral or intravenous vitamin K, fresh frozen plasma, concentrated prothrombin complex administration are therapeutic modalities used in patients with chronic intoxications of warfarin. In the literature, there are case reports of patients with lingual hematoma due to warfarin. But most of the patients’ intubations may be challenging because of the large tongue. Early provided intubation is lifesaving in cases with large lingual hematoma. Alternative surgical airway methods like cricothyroidotomy and tracheostomy should be considered. 


Zerrin Defne DUNDAR (Konya, Turkey), Mehmet ERGIN, Mustafa Kursat AYRANCI, Abdullah Sadik GIRISGIN
11:00 - 18:00 #8120 - Lifting the Boundaries of the EDs in Helsinki.
Lifting the Boundaries of the EDs in Helsinki.

Who gets whom?

 

Lifting the Boundaries of the EDs in Helsinki

 

 

Emergency Medicine is the 50th and the newest specialty in Finland, founded in 2013. Currently training in emergency medicine is in all five University hospitals in Finland and tens of emergency departments work as a training facility to new enthusiastic residents.

 

Resident who have chosen this new specialty are particularly tough, and they need to be. Challenges to change antiquated systems are huge, in the administrative level and especially in the middle of the night when resident are facing patients who everyone wants to treat or nobody wants to treat.

 

Therefore we need to lay some interfaces, lines, that’ll move as the knowledge and experience of the residents grows. Eventually, in Finland, Emergency Medicine specialists will be in charge of the EDs. But right now we need to set where we are and where we are heading. And this is something that we need to do together, in the administrative level and among residents.

 

Due to the rotation placements, residents get to know and trust each others knowledge and skills. This itself lays a level of trust towards the EM. However, we found it to be extremely important to go around different specialties emergency clinics and ‘introduce ourselves’. What can we do now, what are our expectations from you, what do they expects from us and of course how can we get there, together? Without residents fighting in the ED at 3 am.

 

We started these face-to-face introductions in the spring of 2015. Under a careful supervision of our Professor, the residents went thru different clinics, having multiple meetings of the bilateral expectations when working together in the ED.

 

The reaction was positive, every time. Clinic after clinic reacted with enthusiasm and cooperation to work together to make the EDs of Helsinki more focused, patient oriented and efficient. Based on these meetings we were able to design distribution of the basic patient cases between specialties, collaboration between clinics, short trainings in the clinics own facilities and possible future research topics.

 

When discussing directly to the EM residents the chiefs of different department could understand more clearly what do we need to learn in terms of treating patients from their specialty better. 

 

Emergency Medicine being such a new specialty in Finland we don’t have our own seniors or supervisors yet. We must gain our knowledge and experience from the rotations, short trainings and under the supervision of the other specialists.

 

And we are truly fortunate to say that they agreed to do so.

 

 


Eeva TUUNAINEN (Kajaani, Finland), Veli-Pekka HARJOLA, Johanna KAARTINEN, Maaret CASTREN
11:00 - 18:00 #7227 - Lingual Abscess In A Heavy Smoker.
Lingual Abscess In A Heavy Smoker.

Lingual abscess is an extremely rare disease that misdiagnose may lead to sepsis and/or airway obstruction. Only 24 cases were reported during the last century in the United States of America.  Here, we present a case with lingual abscess with no identifiable etiological cause. We suggest that the reason may be mucosal damage related to smoking. 

A 50-year-old male patient was admitted to our emergency service with complaints of swelling of his tongue, pain and dysphagia. The swelling and pain had started 4 days ago and had been increasing gradually. Additionally, over the last 24 hours, dysphagia and difficulty in speaking developed. He was a heavy smoker (2 packets/day for 35 years). His medical history revealed neither a predisposing factor such as a chronic disorder including immunosuppression nor recent history of oral trauma. His physical examination revealed poor oral hygiene and a red, swollen tongue. There were two painful, protuberant lesions with purulent discharge: one located over the tongue, 2x3 cm in dimension and the other located sublingually, 1x2 cm in dimension . He had hoarse voice and saliva was discharging from his mouth. Maxillofacial and cervical tomographic examinations with contrast were performed. Tomographic examination revealed a lesion with peripheral contrast uptake, located at the mid-portion of the tongue and consistent with an abscess . The patient was consulted with an otorhinolaryngologist and then hospitalized. Here, fine needle aspiration was performed for diagnostic and therapeutic purposes and pus was drained from the lesion; then, ceftriaxone 2 gr/day IV and ornidazole 1gr/day were started empirically. The culture result revealed gram-positive cocci and anaerobes. The empirical antibiotic treatment was continued with the same protocol. The patient was discharged from the hospital at his 8th day of admission, following regression of his symptoms.

Although the tongue is in contact with numerous pathogens, it is highly resistant to infections. Smoking increases the sensitivity to oral mucosal infections. It reduces the immunological response of the host by altering the immune system in the oral, nasal and airway mucosa. The development of infection is more evident in cases who have poor oral hygiene or diabetes mellitus and immunocompromised status accompanying heavy smoking. We consider that smoking caused impairment in the mucosa leading to be infected by elements of oral flora in our case. Immunocompromised status, poor oral hygiene, chemotherapeutic agents and diabetes mellitus are among predisposing factors for development of lingual abscess. It is essential to evaluate underlying medical problems and trauma. However, no specific cause can be identified in some cases. No history of trauma, no history of a chronic disorder, foreign body or bite was present in our case. In conclusion, this case leads us to suggest that smoking may be an etiological factor in the development of lingual abscess in patients with no other identifiable etiological factors. Although clinical explanations related to lingual abscess are not generally mentioned in the majority of classical essential textbooks, emergency service physicians and head-neck surgeons should be aware of this situation which may lead to fatal consequences. 


Mustafa UZKESER, Ilker AKBAS (Erzurum, Turkey), Abdullah Osman KOCAK, Fatma CAKMAK, Mucahit EMET
11:00 - 18:00 #8068 - Liquitab Detergent Capsules; cleaning up paediatric emergencies. The introduciton of a new practice guideline to OLCHC.
Liquitab Detergent Capsules; cleaning up paediatric emergencies. The introduciton of a new practice guideline to OLCHC.

INTRODUCTION

Exposure to the contents of Liquid detergent capsules is a common presentation to the emergency department in OLCHC. The adverse effects of  liquitabs can vary, and depend on the route and significance of exposure. Their understandable attraction pose a significant risk to the pediatric population, and with little public knowledge of these dangers, the continued danger of exposure necessitates the requirement for enhancing clinician knowledge and improving management  of these patients. A practice guideline was introduced to the emergency to provide an evidence based guideline on the management of patients presenting to the ED with exposure (splash and ingestion) to liquid detergent capsules

METHODS

A rigorous literature search was conducted, investigating for studies related to Liquitab exposure and for the existance of any previous guidelines. Information was sought from the National Poisons information service and toxbase.  Departmental teaching delivering updates on the development of the guideline steered the direction of the guideline in its inital phases. Practice guidelines were drafted and underwent assessment/ revision by a guidelinees committee in Our Ladys Childrens Hospital Crumlin. The inclusion of speciality review was pivotal. Approvment was sought from Opthamology, Plastics, General Surgeons and Gastroentrology prior to the introduction of the guideline into the Emergency Department.

 

CONCLUSION 

The introduction of this guideline will allow for the safe assessment of patients presenting with any degreee of exposure to liquid detergent capsules.  The enhancment of clinician knowledge  facilitates a safe discharge and the involvmemt of various specialties caters for coperative enviornment in managing patients requiring further managment.  A  parent information leaflet, administered on discharge, also aims at improving public knowledge and recommends safety tips, reducing the liklihood of further presentations.


Eanna MAC SUIBHNE (Co Mnaghan, Ireland)
11:00 - 18:00 #8191 - Long-acting antipsychotics injection: adverse toxic effects related to two different formulations.
Long-acting antipsychotics injection: adverse toxic effects related to two different formulations.

Objective: Long-acting injection (LAI) of antipsychotic drugs are used in psychiatric practice for treating patients with non-adherence/partial adherence to oral pharmacotherapy. Most of these drugs are conjugated to fatty acids or other components that confer slow release properties when administered by intramuscular (depot) injection. However, direct entry into the bloodstream can occur during administration. We describe a case series of adverse events during administration of LAI antipsychotics in order to identify differences in severity and risks with olanzapine and haloperidol LAI. Case series: Olanzapine-LAI: We describe four cases of PIDS (post-injection delirium/sedation syndrome) after intramuscular administration of olanzapine-LAI. These effects are probably due to entry of the drug into a blood vessel during injection. Case 1: Thirty minutes after injection of 300 mg a49-year-old man was lethargic (Glasgow Coma Scale 8-9) with sinus tachycardia (150-160 beats/min) requiring beta-blockade. He improved 12 hours later and was completely recovered after 24 hours. Case 2: A 50-year-old woman in therapy with OLA/LAI for one year, developed paresthesia, confusion, disorientation and mood swings (aggressiveness and depression) after the 13th dose, She recovered with symptomatic treatment. Case 3: During the first OLA-LAI dose (405 mg) a 38-year-old man developed drowsiness which persisted for 12 hours. Case 4: Ninety minutes after OLA-LAI 300 mg rapid intramuscular administration, a 63-year-old woman had agitation, akathisia and QT prolongation (492 ms) which resolved with symptomatic treatment. Haloperidol-LAI: Case 1:A 55-year-old man erroneously received a 50 mg vial of haloperidol decanoate in a 1 hour infusion. Serum haloperidol was undetectable 8 hours later. Patient was asymptomatic and returned to the psychiatric ward the day after. Case 2:A 89-year-old woman received 50 mg haloperidol decanoate by intravenous instead of intramuscular injection. Serum concentration was 1.1 ng/mL one hour after administration and was undetectable 24 hours later. She was monitored for two days but had no neurological impairment or rhythm disturbances were observed. Haloperidol serum concentrations were assayed using high performance liquid chromatography (limit of detection 0.5 ng/mL). Conclusion: PIDS is related to the rapid dissolution of the olanzapine pamoate salt in blood vessels, while haloperidol decanoate requires an esterase enzyme to act. Consistent with these findings, adverse events can occur even after correct administration of olanzapine LAI, but even if haloperidol decanoate is intravenously administered, neither clinical effects nor elevation in serum concentrations are expected.


Valeria Margherita PETROLINI (Travacò Siccomario, Italy), Giulia SCARAVAGGI, Marta CREVANI, Davide LONATI, Azzurra SCHICCHI, Mara GARBI, Eleonora BUSCAGLIA, Sarah VECCHIO, Carlo Alessandro LOCATELLI
11:00 - 18:00 #7488 - Low Back Pain - A Red Herring.
Low Back Pain - A Red Herring.

Introduction:

Low back pain is the most common musculoskeletal complaint that results in a visit to the emergency department (ED). The common diagnoses in low back pain are lumbar strain, lumbosacral radiculopathy, osteoarthritis, degenerative disc disease, spinal stenosis, etc. This report describes a patient who presented with symptoms suggestive of musculoskeletal back pain but was diagnosed with a Penetrating Atherosclerotic Ulcer (PAU) of the abdominal aorta.

Case Report:

A 63-old hypertensive male came to ED with a one-day history of progressively worsening low back pain which started after carrying heavy weight. The pain was radiating to the left flank and left iliac fossa. There was no numbness of lower limbs and no bowel or bladder disturbances. His examination revealed stable vital signs with severe back pain. Abdomen was soft with minimal tenderness over the left Iliac fossa but there was no pulsatile mass over the abdomen and no abdominal bruit. His peripheral pulsations were normal. X-ray of lumbosacral spine was normal. The patient was observed after analgesia but his symptoms persisted and he developed guarding over the left lower quadrant. Bedside ultrasound revealed the abdominal aorta measuring 1.54 cm with an intimal flap. He was diagnosed to have aortic dissection and given further analgesia and intravenous labetalol infusion. Bloods tests and chest-xray were reported normal. CT aortogram showed atheromatous plaque in the posterior aspect of infrarenal abdominal aorta with focal ulceration (22mm length). The patient was admitted to High dependency under vascular team and he underwent endovascular repair of abdominal aortic ulcer. He was later discharged in a stable condition.

Discussion:

PAU is defined as an atherosclerotic lesion with ulceration penetrating the internal elastic lamina and the media of the aortic wall and it representing a different aortopathy from that of classical aortic dissection.  It typically affects elderly patients with a history of hypertension, coronary disease or other cardiac risk factors, and carotid or peripheral arterial occlusive disease.

The most common sites of PAU are the distal thoracic aorta and the abdominal aorta, The exact incidence of PAU is yet unknown. Thoracic and abdominal PAU have been considered responsible for 2–7% and 1–5% of all aortic ruptures, respectively

The natural history of PAU is not yet fully understood. PAU may be complicated by aortic intramural hematoma, subadventitial pseudoaneurysm (SAP) formation in cases of hematoma extension along the media and subsequent stretching of the weakened aortic adventitia, as well as aortic rupture.

A high degree of clinical suspicion is crucial for its diagnosis. An aggressive management approach is needed because of their tendency to rupture. Contrast-enhanced CT angiography of the aorta is the most common imaging modality to diagnose PAU. Because of its lower morbidity and mortality, endovascular repair is preferred over surgical repair to prevent further potential complications.

Conclusion:

This case re-emphasizes to the physicians the need to consider the uncommon presentations in the differential diagnosis of patients presenting with low back pain.

 


Faizur Rahman MOHAMED MADEENA (singapore, Singapore), Sohil POTHIAWALA
11:00 - 18:00 #8251 - Low Back pain common cause of unusual illnesses.
Low Back pain common cause of unusual illnesses.

Low back pain is a common symptom referred at the Emergency Department(ED). A  Vas majority of patients seen there have non specific low back pain.

Amng patients who present low back pain less than one per cent will have a  serious systemic etiology ( cauda equina syndrome, metastatic cancer and  sponal infection). Almonst all patients  with theses  conditions will have risk factors or other symptoms.

We present a report  of two cases of known low back  previous conditons.

First case, 70 years old female  went into surgery in the past  20 days due to L4.L5 radiculopathy: left L4.L5 laminectomy and left L5 facetectomy were done. Last  24h acute low back pain developed., no fever  , no other symptoms.No neurologic disorder  was found neither swelling  signs  at surgery location.Conservative  NSAID´s( non steroidal antiinflamtory drugs ) and major opioids drugs were not effective. White blood count swowed mild leucocytosis amb elevated C reactive prtein. Arterial  blood gases ranger normal.

Patient presented decreased conscious level and confusional  stete front  7 to 9 Glasgow Coma Scale modified. No reverted  with  Naloxone, the orotracheal intubation  was  mandatory.

CT head  scan was  the done, showed   left parietal lobe subcortical injury due to acute brain ischaemia.CT  scan of lumbar area also located   subcutaneous  ascesss at laminectomy  surgery.

Spinal fluid examination  revealed elevated whiteand red cell count and porteins. Gram  Staining and  bacterial antigens tested negative.No grown at blood  culture at  day 5th.

Bacterial meningitis and spinal  fluid fistula   were suspected thus  empirical antibioitic scheme started at  ED: aciclovir, ampicilin, cefotaxime.Patient  was referred  to an Intensive Care Unit ( ICU), once  stabilized went  to surgical reparing  of  spinal fistula.Spinal fuid and  flid cultures both tested negative.

Seconda case, a 61  years  old obese  female  with no known previous medical conditions. Low back pain in past  20 days in ED. Conventional X  ray  study revealed L4.L5 spondylolisthesis thus followed NSAID´s corticosteroids and major  dermai opioids.Pain no controlled so far and then irradiated to  right lower limb and promoting transient inmobility in past  days.

In lumbar  area  a skin ulcer  appeared  as  well as lower  limb  edema. No  neurologic  dysfunction nor fever  were observed. Blood  test   revealed  high blood  sugar levels while white and red cell bllod count were  normal. 

Diabetic onset  and right  heart  failure  were  oriented thus empiric  antibiotic treatment  was    done  plus   iv  furosemide  and insulin.

CT  lumbar scan was   indicated: severe  width  reduction of foramens and lumbar  spinal  stenosis  were  shown.

Clinical condicion  of patient  worsened next  12 hours, palpable  purupura  appeared in abdomen  anb lower limbs. Blood testes   revealed  reduced  platelet count, elevated   C reactive protein and Procalcitonin up to 17 ng/dl suggeting  sepsis. Extended  expectrum antibioitic  scheme  was  initiated.

Chest and abdomen  CT scan   showed necrotizing lumbar  fascia.

Haemodinamically  unstable  , required inotropic  drugs until  cardiac arrest  in ED.

Cardiopulmonary  ressucitation was  successfully  done   and patient was  refered to  ICU  were  finally  died  at second  day


Madalina Gabriela GRECU, Josep MONTESINOS COTS (EL VENDRELL, Spain), Jordi PÉREZ TORRES, Carles GREOLES ROYO, Claudia ROMERO RAMÍREZ, Salvador SARRÀ MORETÓ
11:00 - 18:00 #7188 - Low back pain in Emergency Room.
Low back pain in Emergency Room.

Acute low back pain in an extremely common condition in the emergency care for their intensity and sudden onset. Low back pain annually generates large amount of sick leave and multiple consultations in different specialties representing a huge health and employment, economic and social spending. It is the job of the entire medical team try to reach the same differential diagnosis of early identification and those specific low back pain for the specific treatment as soon as possible.

In this paper is described and analyzed the assessment of low back pain in the ED, focusing on the specific back pain. Analyzing the information gathered in the emergency department (triage sheet and sheet discharge) to see if there are specific prognostic factors for back pain in the ED.

Methods: observational, descriptive, analytical and retrospective study was conducted in 2014 in the emergency department of the University Hospital de la Ribera. Data collection in Excel® format for the treatment and organization of variables, which are then analyzed in the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL) version 15 was performed.

Results: The study was conform with 346 patients of both sexes with an average age of 52 years and a standard deviation of 19,095. Low back pain predominated in females. Of all diagnoses at discharge, the majority was low back pain, and back pain diagnoses considered as specific vertebral fracture.

Conclusions: According to our study could be defined as prognostic factors specific low back pain in the ED: The EVA in the diagnosis of vertebral fracture and the priority given in triage only for the diagnosis of vertebral fracture. Doctors helped diagnostic tests, specifically the RX to issue a clinical diagnosis right. Those patients who came repeatedly to HUS with back pain and were sent to CCEE for that reason, were eventually diagnosed with specific low back pain.


Raquel PEREZ CASTILLO (GANDIA, Spain), Jose Luis RUIZ LOPEZ, Maria CUENCA TORRES
11:00 - 18:00 #7774 - Low level of consciousness in a psychiatric patient.
Low level of consciousness in a psychiatric patient.

This is a case about a 35- year- old woman, under treatment because of a Bipolar Disorder, with two previous admissions because of trying to commit suicide.
She is admitted to the Emergency Department because that morning her mother could not waking her up from bed.

When she arrives to the Emergency Room, she is in a bad condition, with a Glasgow Score (GSC) of 12, no fever or tachycardia, normal blood pressure and blood sugar. She kept her eyes closed only opening them after vigorous stimulation and complained  about  headache and assured not having taken pills or any other type of drug.

Just after ten minutes, her level of consciousness falls quickly to a GSC of 9 so she is taking quickly to the Computerized Tomography (CT) room. Meanwhile the Intensive Care Unit (ICU) is under advise just to be prepare.

The CT scan showed right frontal hematoma extending throughout the ventricular system.

She went under Neurosurgery, an intraventricular drain device is placed and after performing a new one CT that showed no complications after the surgery, an Arteriography was performed that showed and arteriovenous malformation in the right  lenticular artery. Embolize procedure was performed with excellent result.


In the ICU they were able to remove the tube just 48 hours after  with satisfactory evolution and leaving the Unit just four days after that.

During the rest of admission, she was recovering well and finally leaved hospital four weeks after admission, with no neurological sequels.

Two months later, she was feeling good and living normally and independetly.

A decreament in the level of consciousness is a common a potentially serious condition in the Emergency Department. We must act quickly in order to begin the treatment as soon as possible. And above all we do not have to assume previous diagnosis nor stigmatize our patients, especially those with a history of psychiatric condition. There are many other causes of low level of consciousness, as we have just seen in this case.


Luz Tamara VÁZQUEZ (Madrid, Spain), María CUADRADO, Santiago BERMEJO, Luis PÉREZ, Francisco JIMÉNEZ, Manuel GIL, Luis YUBERO, Ana SÁNCHEZ
11:00 - 18:00 #7969 - Lumbar fracture after delirium by cocaine.
Lumbar fracture after delirium by cocaine.

 

33-year-old male who comes to the Emergency Department after cocaine use. The patient has suffered a delirium and has believed Superman jumping from the window of the first floor.

The patient referred pain right calcaneum and gait difficulty level.

Exploration is located espinosa of L2 and deformity palpation pain in right heel. Not affecting neurological strength, sensitivity of EEII correctyas without sphincter incontinence.

He is a blood clotting which does not show any alteration and radiological study with LUMBAR RX showing a flattening of the L2 vertebral body fracture of lamina. RX CALCANEOUS: Fracture of calcaneus. With these tests is performed LUMBAR CT: fractured pop of the L2 vertebral body with hundimient of the top cymbal, decrease and displacement of the posterior wall causing a decrease in the spinal canal of 60%. Affects the three pillars with one right lamina fracture line that passes through.

The patient receives treatment analgesic iv and moved to Hospital of higher level for entry into service of neurosurgery. There make you Noms that is reported as fracture outbreak of L2 vertebral body, with major oedema on body vertyebral and invasion of 55% of the spinal canal.

The patient received surgical treatment and is Kyphoplasty L2. Fixation percutaneous in L1 and L3. Placed splint suro-pedial later. Given high is uneventful


Sonia Sofía BALLESTIN SOROLLA, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Elisa RUIZ OLIVARES, Ana Belén MARÍN FLORÍA, Carola MEDINA SAINZ, Pilar SARASA CLAVER, Silvia GANGUTIA
11:00 - 18:00 #7547 - Machine learning with acute coronary syndrome.
Machine learning with acute coronary syndrome.

Introduction: Acute coronary syndrome (ACS) is a serious condition arising from an imbalance of supply and demand to meet myocardium’s metabolic needs. Patients typically present with retrosternal chest pain radiating to neck and left arm. Electrocardiography (ECG) and laboratory tests are used indiagnosis. However in emergency departments, there are some difficulties for physicians to decide whether hospitalizing, following up or discharging the patient. The aim of the study is to diagnose ACS and helping the physician with his decisionto discharge or to hospitalizevia machine learning techniques such as support vector machine (SVM) by using patient data including age, sex, risk factors, and cardiac enzymes (CK-MB, Troponin I) of patients presenting to emergency department with chest pain.

Materials and Methods: Clinical, laboratory, and imaging data of 228 patients presenting to emergency department with chest pain were reviewedand the performance of support vector machine. Four different methods (Support vector machine (SVM), Artificial neural network (ANN), Naïve Bayes and Logistic Regression) were tested and the results of SVM which has the highest accuracy is reported.

Results: Among 228 patients aged 19 to 91 years who were included in the study, 99 (43.4 %) were qualified as ACS, while 129 (56.5 %) had no ACS. The classification model using SVM attained a 99.13 % classification success. The present study showed a 99.13 % classification success for ACS diagnosis attained by Support Vector Machine.

Conclusion: This study showed that machine learning techniques may help emergency department staff make decisions by rapidly producing relevant data.

References: 1.Nichols, M., Townsend, N., Scarborough, P., and Rayner, M., Cardiovascular Disease İn Europe: Epidemiological Update. Eur. Heart J.34(39):3028–3034, 2013

2.Conforti, D., and Guido, R., Kernel-Based Support Vector Machine Classifiers For Early Detection Of Myocardial İnfarction. Optimization Methods And Software 20(2-3):401–413, 2005

Acknowledgments: There is no conflict of interest in this study.


Goksu BOZDERELI BERIKOL (Istanbul, Turkey), Gurkan BERIKOL, Oktay YILDIZ, Ismail Turkay OZCAN
11:00 - 18:00 #8207 - MAD COW DISEASE.
MAD COW DISEASE.

Introduction : 

Over the period of 2 weeks in july 2015 we receved a number of 10 patients severly injured after getting in contact with cows or bulls. 

Matherial and Methods :

We retrospectively studied the charts of 10 patients who arrived in our Emergency Department (ED) after farming injuries over a period of 2 weeks. We looked at mechanism of injury, age distribution,  injury severity scores (ISS) and injury sustained  and outcomes. The trauma team was acitvated in all cases and massive blood loss protocol was also in place.

Results :

6 males and 4 females, 2 deaths, age distribution group was between 23-82 with a dominant over 55, ISS was between 19-62 with most comon injuryr identifined rib fractures and pneumothorax. Animals involved where cows and bulls

Conclusions :

Farming injuries in Ireland has become a major ED presentation during the acting growing season or planting season because of the growing age of population and migration of farming youngest members. The position of our hospital is near an area of large farming zones with no fast access to medical attention. Department of Agriculture and Health in ireland is involved closely to education and injury prevention in this comunities.


Cristiu OCTAV (drogheda, Ireland), Kelly MR CONOR
11:00 - 18:00 #5027 - Management of a difficult airway in ED - A case study of Treacher Collins syndrome.
Management of a difficult airway in ED - A case study of Treacher Collins syndrome.

Introduction -

Treacher Collins syndrome is a genetic condition which effects the development of the development of bones and the soft tissue of the face.

Mutations in the TCOF1POLR1C, or POLR1D gene can cause Treacher Collins syndrome.

The condition causes hypoplasis of certain facial structures, including the cheekbones, jaw (micrognathia) and other zygomatic structures.

Patient often are born with cleft palates leading to further risks of respiratory compromise.   

Aim -

Poster Aim is to highlight learning points of what happened when our team had to intubate a patient with Treacher Collins syndrome.

Case study -

43 year old male patient was bought in by ambulance, at 3am,  following status epilepticus  and treated for this. Patient has a background of Treacher Collins syndrome. Patient was post ictal after treatment and was unable to maintain his airway. Patient was ok to ventilated, however after multiple attempts were not able to intubate patient.

Following this ITU Consultant was called from home whilst patient was manually ventilated.

After multiple attempts  ITU consultant was unable to intubate and ENT Consultant was called to do surgical cicoidectomy. However before this could happen patient was

 

Learning points

  1. Treacher Collins syndrome and anatomy abnormalities
  2. Anticipation of difficult airway  and readiness for difficult intubation
  3. Difficult airway society guidelines
  4. Working with ITU/ Anaesthetist early.

Irfan ULLAH (London, United Kingdom), Fredrica FRANCO, Chi NG
11:00 - 18:00 #8247 - Management of anterior segment ocular trauma emergency.
Management of anterior segment ocular trauma emergency.

Aim of the study

The aim is to show emergency management in anterior segment trauma that occurred  in the department of Ophthalmology at the County Hospital Sibiu.

Material and method

The study is based on a total of 92 cases (from January 2010 to January 2016), with these types of injuries:

Traumatic anterior pole concussion:

• With scleral rupture: 13 cases

• With no scleral rupture: 3 cases

- Penetrating anterior pole injuries:

• With the presence of intraocular foreign body: 25 cases

• Without the presence of intraocular foreign body: 48 cases

- By the location of the injury:

• Corneal: 33 cases

• Corneo-scleral: 24 cases

• sclera: 22 cases

Traumas with partially eviscerated eyeball: 11 cases

The conduct that was applied in the case of trauma was to evaluate the local emergency situation and mandatory radiography to detect intraocular foreign body.

 Urgent wound suture was performed with separate wires 10.0  for the re-positioning of the herniated intraocular membranes.

In trauma cases older than 3-4 days was tried reinstatement intraocular membranes, and if not managed, it has resorted to resection and suture the wound membranes.

In trauma cases older than 3-4 days an attempt was made for the re-positioning of the intraocular membranes, and if not managed, the resection of the membranes was performed followed by the  suturing of the wound.

In all cases presented with ocular anterior segment trauma, prophylaxis was made for tetanus and infections.

Results and discussions

The main therapeutic aim was the anatomic restoration of the eye.  

The evisceration of the eyeball in emergency condition was not practiced without the written consent  of two doctors and the patient.

The extraction of the foreign body was performed after three – dimensional location and after the suturing of the wound.

In most cases the functional recovery was partially because of the following affections: corneal leukoma, traumatic cataract, uveitis and secondary posttraumatic glaucoma.

Conclusions

Of the 92 cases that occurred in the emergency department of Ophthalmology at the County Hospital Sibiu, distribution by type of injury and course of treatment was the following:

- 14.72%  anterior segment concussion with or without scleral rupture

- 85.86% penetrating trauma

- 27.17% trauma with intraocular foreign body

- 52.17% trauma without the presence of intraocular foreign body

- 4.37% cases with evisceration of the eyeball

The therapeutic emergency conduct in the case of anterior segment traumas was the suture of the wound and the extraction of the foreign body ( where it was the case) as soon as possible.

Eyeball evisceration  was not performed in emergency  


Alina Adriana PANGA, Adriana STANILA, Dan Mircea STANILA, Marius SMARANDOIU (Sibiu, Romania)
11:00 - 18:00 #7079 - Management of children presenting with Deliberate Self-Harm in a medium-sized District General Hospital.
Management of children presenting with Deliberate Self-Harm in a medium-sized District General Hospital.

Introduction

Deliberate self-harm (DSH) is reaching epidemic proportions in the UK adolescent population with an estimated 10-20% of young people self-harming and Childline estimating a 41% increase in deliberate self-harm in children which ties in with Public Health England figures giving a 68% rise in ten years. This equates to about 21,000 attendances per annum in England for under 19s.

People who deliberately self-harm have a 30 times greater risk of completing suicide than the general population.

Managing patients presenting with Deliberate Self-Harm is an area that many healthcare professionals feel uncomfortable with.

Method

We established how children and young people under the age of 19 presenting with Deliberate Self-Harm to a medium-sized District General Hospital were managed with regard to local and National Institute of Clinical Excellence (NICE) guidelines through a retrospective audit of case notes.

In addition to this we conducted a survey of 80 clinical staff working in the Paediatric Department, the Emergency Department, the Medical Assessment Unit and other clinical support teams to identify training received and how competent and comfortable staff felt dealing with children who presented with DSH.

Results

A total of 127 episodes of DSH in 18s and under were identified in a fifteen month period.

Compliance with the local guidleines and NICE guidance ranged between 9% and 100% for various items. Looked after Children and Multiple attenders made up the majority of attendances.

Five children were responsible for 48% of all Deliberate Self-Harm presentations to this Emergency Department (ED).

Fifteen children had 3 or more presentations. One had 11 attendances.

24% of DSH attendances were by children known to social services. 20% of presentations to the ED were by psychiatric inpatients at the time of the episode. 11% of attendances were for overdose with prescribed antidepressants. One patient overdosed whilst admitted and awaiting treatment for another overdose.

Two-thirds of presentations were for potentially fatal overdoses.

Paracetamol as well as antidepressant and NSAID overdose were by far the most common presenting complaints followed by lacerations.

40% of staff respondents who deal with children have received no training in how to manage DSH in children, two thirds felt they had received inadequate training. A third were were not confident in handling children presenting with DSH.

100% of staff surveyed agreed or strongly agreed they would benefit from further training.

Conclusions

There were large variances in how front-line staff assessed children medically and psychosocially. Staff feel their training could be better. There may be a link.

A formal, structured pathway needs to be considered for children presenting with DSH.

Staff training needs to be improved throughout the trust including areas where adolescents may be admitted and treated as adults.

Social Services involvement should be considered for multiple attenders.

It is essential General Practitioners prescribing anti-depressants to young people consider the risk of Deliberate Self-Harm.


Colin WONG (Chester, United Kingdom), Howie ISAAC
11:00 - 18:00 #7625 - Management of dizzy patients in Emergency Departement: a retrospective study.
Management of dizzy patients in Emergency Departement: a retrospective study.

Introduction: The number of patients consulting in the ED  for dizziness has increased of 37 % in 10 years. The concept of vertebrobasilar insufficiency challenges the conventional peripheral and central vestibular disorders. The interest of neuroimaging in the diagnostic process of dizzy patient is controversial. Our emergency department (ED)  welcomes the Ear Nose Throat (ENT) physicians during the night shift. No studies have compared the differences in management of ENT practitioners, emergency physicians and neurologists. For this reason, the management of dizzy patients was evaluated in our structure.

Methods:A mono-centric, retrospective, descriptive and observational study was conducted from January to June 2013. Every patient presenting for dizziness to the ED during night shifts and weekends were included. The data included pre-hospital care, the patient's personal data, anamnestic and clinical data of dizziness, and patient’s outcome. Quantitative data are expressed as mean and extreme values. Categorical data are expressed in number or percentage. The independence of our series of qualitative data was assessed by the chi 2 test and the Pearson Fischer test. Quantitative data were compared using a Student T-test. A p-value <0.05 was considered statistically significant

Results: 197 patients were enrolled, 126 were examined by an ENT physician and 71 by an emergency physician. Being managed by an emergency physician multiplied by 3.5 the probability of having neuroimaging compared to an ENT physician (p <0.01). The mean length of stay was  significantly higher when the patient was seen by an ED physician (p<0.01). Nystagmus was 2 times more frequently sought by the ENT physician than by the emergency physician (p <0.01). Patients examined by an ENT physician had more ENT diagnoses, as they had more alternative diagnoses if they were evaluated by emergency physicians. An exploration of the vestibular-ocular reflex and eye movement was performed for none of the patients.

Discussion: The difference in management of vertigo between emergency physician  and ENT physician reflects the lack of consensus guidelines. The bedside examination with the HINTS (horinzontal-Head-Impulse-Nystagmus Test of Skew) test could be a key element of the diagnosis of dizzy patient and question the necessity of imaging. The HINTS test  appears to be more sensitive than brain MRI in the diagnosis of vascular injuries of the posterior circulation and should be integrated with the clinical examination of the dizzy patient.

Conclusion: The implementation of exploring the h-HINTS test in the ED could improve the management of vertigo.A prospective study with the use of this bedside examination (h-HINTS test) is needed to confirm these results. The implementation of exploring the h-HINTS test in the ED could improve the management of vertigo.


Pauline DESWARTE (Paris), Jennifer TRUCHOT, Anthony CHAUVIN, Rafaelle CARDI, Anne-Sophie VOARICK, Patrick PLAISANCE
11:00 - 18:00 #6430 - Management of epistaxis in the Emergency Department: a retrospective study.
Management of epistaxis in the Emergency Department: a retrospective study.

Introduction: Epistaxis has been reported to occur in up to 60% in the general population and accounts for 1% in the Emergency Departments (ED). Sometimes it can be quite a severe  condition necessitating a medical intervention, but it is mostly benign. Nowadays, there are no existing guidelines for management of epistaxis and the practices are highly variable among physicians. The aim of the study was to evaluate the management of epistaxis in an urban ED.

Methods: We present here a retrospective and monocentric study. We included all adult patients with an epistaxis who presented to the ED of an urban teaching hospital in 2014. 41 parameters were analyzed in the following categories: epidemiology, hemodynamics, biology, treatments.

Results: 264 patients were included for statistical analysis. This represents 0.4% of annual admissions in the ED. The sex-ratio was 0.6. The median age was 71 years (IQ : [56-82]). 34% of the patients presenting to the ED had an hypertension (systolic blood pressure ≥ 140 mmHg) at admission but only 6% of them were on antihypertensive medication. A blood tests were conducted in 62 % (95% CI: [56-68]) of patients and showed: 6% of thrombopenia, 9% of anemia and 8% of patients had an international normalized ratio (INR) outside their disease specific range. Almost three quarters of epistaxis had not been directly treated by the ER physician (stopped spontaneously / ENT specialist first called). The ENT specialist was contacted in 61% (95% CI : 48-73) of the cases, but came to the ED only for half of them. Prophylactic systemic antibiotics in spontaneous epistaxis were prescribed for 11% of the patients. A control visit was organized only for 19% of the patients. More than half of the population had anticoagulant or antiplatelet medication, however there was no link between these treatments and the probability to be admitted to the hospital (p=0.24). There was no significant association between anticoagulant medication and the risk of rebleeding 7 days later (p=0.66). 16% of patients were hospitalized (mean duration of stay: 3 days).

Conclusion: Our study shows that ER physicians manage epistaxis in a low percentage of cases in our ED. The use of antihypertensive medications, prophylactic antibiotics and blood tests is highly variable among practioners. Some guidelines and complementary training may be appropriate in order to optimaze management of this frequent condition.


Carmen HAMMANN, Pierrick LE BORGNE (Strasbourg), Fanny SCHWEITZER, Charles-Eric LAVOIGNET, Claire KAM, François LEFEBVRE, Christian DEBRY, Pascal BILBAULT
11:00 - 18:00 #7471 - Management Of Hypertension In Intracerebral Heamorrhage (ICH): Auditing current practice.
Management Of Hypertension In Intracerebral Heamorrhage (ICH): Auditing current practice.

Introduction: Intracerebral Haemorrhage is the 2nd most common form of stroke, accounting for 27% of stroke cases globally. Hypertension (elevated Mean Arterial Pressure (MAP)) is often present in these patients. Severe hypertension (HTN) can worsen ICH resulting in continued bleeding and hematoma expansion leading to poor out comes. The European Stroke Organization recommend that intensive blood pressure management below systolic blood pressure of 140mmHg or a MAP of 106mmHg within 6 hours of onset is safe and could improve functional outcome. It also reports that patients managed in acute stroke units had better outcomes for mortality and morbidity compared to general wards.

Aim: To assess and review the monitoring, treatment of patients with HTN presenting after ICH and note where their care was provided after transfer from the emergency Department (ED). 

Method: Data was obtained from case files retrospectively for all patients presenting to University Hospital Galway (UHG) ED; who had ICH in 2015. Patient’s demographics, monitoring, treatment, ward care and mortality were recorded. Those not seen in ED were excluded from the study.  

Results: 39 patients were identified to have ICH in 2015; 28 were included within the study. There was a female predominance of 64%(18). The mean ages for males and females were , 73.6 and 66.8 respectively. Twenty patients presented with focal neurology (FAST+) the remaining 8 patients reported headaches and vague symptoms. Only 6 patients presented within 6 hours of symptoms. The modified Rankin and NIHSS scores were only recorded in 5 case files. Blood Glucose was not recorded in 13 cases. Initial CT-Brain results showed ICH in 25 patients, normal scan in 2 and an infarct. ICH was confirmed in the latter 3 cases on repeat CT and MRI.  

The mean MAP was 123.5mmHg with the lowest value of 83mmHg and the highest value of 158mmHg. Over 50% of the patients had a MAP > 110mmHg. About 21 patients had their MAP monitored regularly and according to guidelines. Eight patients were treated with labetalol, another 8 with other medications such as GTN Patch, Nimodipne, Amlodipine and Hydralazine. The remaining 12 patients had no treatment for acute HTN. Nine patients were managed in intensive care unit, 2 in high dependency units, 6 in stroke unit while the rest were managed in general wards. A patient’s MAP did not affect admission to high dependency units as there was substantial variation of patients managed across units. 24 patients had co morbidities. There was a 53.5% mortality recorded in this cohort within a 3 month period.

Conclusion: There was adequate monitoring of MAP in this cohort however there was a lack of documentation of Blood Glucose, Modified Rankin and NIHSS scores despite stroke pathway charts being available. Hesitancy in initiating anti-hypertensive treatment and transferring patients to general wards was notable. Interestingly comorbidities or transfer to ICU or ward did not affect mortality. Reinforcing knowledge and continuous education will facilitate compliance with guidelines and help achieve favorable outcomes for patients.


Etimbuk UMANA (Belfast, Ireland), Kiren GOVENDER
11:00 - 18:00 #7387 - Management of patients admitted to the emergency department due to acute atrial fibrillation episode in North Estonia Medical Centre.
Management of patients admitted to the emergency department due to acute atrial fibrillation episode in North Estonia Medical Centre.

 Introduction 

Atrial fibrillation (AF) is a frequent arrhythmia affecting up to 1% of population and is a major contributor of stroke and thrombembolism. AF management involves assessments, rhythm conversion if decided and  thromboprophylaxis. Several risk and symptoms scores are used - CHA2DS2VASc (C- congestive heart failure, H-hypertension, A- age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65- 74, Sex (female)), HAS-BLED (Hypertension, Abormal liver/kidney function, Stroke, Bleeding history or predisposition, Labile INR, Elderly >65, Drugs concomitantly/alcohol abuse), EHRA- European Heart Rhythm Association score. 

The aim of this study was to describe the management of acute AF episode in emergency department (ED). 

Methods 

The study was retrospective. List of patients admitted to ED during the period Oct 01 to Nov 30 2014 due to AF (ICD-10, code I48) was obtained from hospital database. Patients with onset of AF ≤48 h and discharged home from ED were included. Patients, hospitalized or considered not to be subjects for rhythm conversion (electrical, EC or medical, MC), also patients with onset of AF >48 hours, were excluded. 

Data about sex, age, outpatient treatment (use of anticoagulants, antiagregants, antiarrhythmics), time of onset of AF,reporting of scores (CHA2DS2VASc, HAS-BLED, EHRA), mode of rhythm conversion in the ED (EC or MC), the use of anticoagulants and antiarrhythmics in ED was collected from patient cards.

Patients were contacted by telephone 6 months after admission and data about anticoagulation, thrombotic episodes and bleeding were collected.  

Results 

794 patients admitted to the ED, 676 were excluded according to prespecified criteria,118 were included into the final analyses.

There were 50 men and 68 women. 68% of patients were seen in ED during the first 12 hours of onset of AF. In 97 patients (82%) AF was recurrent. 53 patients (45% ) used anticoagulants, including 31 patients (58%) warfarin. Metoprolol was used by 37 (31%), propafenon by 24 (20%) and amiodarone by 4 patients (3%). 13 patients (11%) used metoprolol and propafenon concomitantly. 

CHA2DS2VASc score was reported in ED for 7 patients(6%), other scores were not reported. 

113 patients (96%) were treated with antiarrhythmics in ED (82 (72%) metoprolol, 80  (71%) propafenon, 32 (28%) amiodaron). 

From 65 patients, not using anticoagulants before admission, 38 were treated by enoxaparin. 27 patients didn’t get any anticoagulation. 

Electrical cardioversion was performed in 34 patients (29%), 30 of them were anticoagulated. Sinus rhythm was restored in all of them. Medical cardioversion was done in 79 patients. Sinus rhythm restored spontaneously in 5 patients. Further anticoagulation was advised to 65 patients (55%). 

All patients were attempted to contact by telephone 6 months after admission, 59 were reached – 42 were currently using some anticoagulant/antiagregant, 18 reported bleeding (11 haematomas, 2 gastrointestinal haemorrhage). Thrombotic event was reported once- ischaemic stroke in a patient taking warfarin and 5 patients died. 

Conclusion 

Our analysis revealed wide variability in management of patients with AF in our ED. Thus, local treatment guidelines should be updated, use of scores recommended (CHA2DS2VASc, HAS-BLED, EHRA) and education courses planned as a part of implementation programs.


Kaisa JOARAND (Tallinn, Estonia), Helena NESTOR, Toomas MARANDI
11:00 - 18:00 #7662 - Management of ST-elevated myocardial infarction : insights from ReSCUS Registry.
Management of ST-elevated myocardial infarction : insights from ReSCUS Registry.

Introduction : During the last decades, the prognosis of myocardial infarction has not stopped improving. Several years of considerable therapeutic progress in ST-elevated myocardial infarction towards a reduction in morbidity and mortality has been achieved. The management of this emergency cardiology must be in the shortest time to permit early reperfusion and prompt management of complications.

Our aim was to assess the quality of care  and management acute coronary syndromes.

Material and methods : We collected data on ST-elevated myocardial infarction (STEMI) patients as part of the ReSCUS Registry, in a prospective study (between February 2014 and December 2015). We included 142 patients admitted to emergency department.

Results : we collected 142 patients. We noted a male predominance (sex ratio = 4.68) and a mean age of 62 ± 12 years. Only 12% of our patients were admitted to our emergency through medical transport. Tobacco, hypertension and diabetes were the 3 risk factors predominant in our patients with respective rates of 51.4%, 33, 8% and 33.4%. Six patients (7.9%) have peripheral signs of shock at initial presentation. Eleven patients (7.75%) present with acute Heart failure. Patient delay was 450 min (with extremes ranging from 24 mn to 48 hours). The average time first medical contact to realize an EKG was 28 minutes with a median of 15 minutes. The average time for thrombolysis was 122 mn, with extremes ranging from 2 to 225 mn. The anterior localization was the most frequent (51%) followed by the inferior STEMI (41%). The thrombolysis rate was 14.1% (n = 20) with a success rate of 62%. The primary  angioplasty rate was 85.9%. Only four cases of cardiac arrest was noted, one of them  was recovered.

Conclusion: The management of acute coronary syndrome is appropriate for the time of implementation of the EKG and initial management but still insufficient for the late angiographic exploration. It is a real challenge for the emergency physician. An improvement in the overall management first requires a better practice  to identify, assess risk and treat  patients in the shortest time possible.


Achref HAJ ALI, Chawki JEBALI (Kairouan, Tunisia), Wael CHAABENE, Lotfi BOUKADIDA, Asma ZORGATI, Fethi GRAA, Riadh BOUKEF
11:00 - 18:00 #5055 - Management of trauma patients on an observation ward in an Emergency Department: improving patient pathways and patient safety.
Management of trauma patients on an observation ward in an Emergency Department: improving patient pathways and patient safety.

Background & Objectives

Analysis of major trauma admissions in to the Clinical Decision Unit over the period of one year and effect of implementing exclusion criteria with the aim of improving patient pathways and patient safety. Initial data collected compared to data collected post implementation of guidelines and departmental teaching.

Methodology

Initial data was collected by reviewing case notes of all patients admitted to the CDU for a one-year period from 1st August 2012- 31stJuly2013.

Patients triggering the major trauma pre-alert followed by a preliminarily assessment by a consultant led trauma team in the emergency department with relevant imaging who then required inpatient admission in to the CDU were included in the study.

These were patient whom did not have life threatening injuries however required a short period of observation prior to their discharge and thus the CDU was deemed the most appropriate ward.  Patients with significant injuries or those involving multiple limbs and high Injury Severity Scores (ISS) and thus admitted directly to the Major Trauma Ward (MTW) were not included in this study along with those that were discharged home directly from the emergency department.

Following these results, from 1st August 2012 – 31st July 2013, exclusion criteria were devised and implemented via formal teaching and changes to the pre-existing proforma. During a six month period following the recommended changes patients presenting as major trauma had their case notes analysed with a particular focus once again on number of admissions, length of stay, discharge destination and late-identified injuries.

Results and Conclusion

Admission to St. Marys hospital remained at a high level when compared to the intital data collection period.  64.3%-(n=717) required admission in the period of December to June 2014 is in comparison to 57.9%-(n=1281), between 1st August 2012-31st July 2013. The percentage of trauma patients however transferred to the clinical decision unit however decreased and is suggestive of improvement in patient safety with patients requiring specialist admission transferred directly to the relevant team and fewer late identified injuries.

With the implementation of strict exclusion criteria and formal teaching we are able to demonstrate management of patients with low ISS can be achieved in a safe and timely manner. Due to results gathered and analysis of the data from 2012-2013 we were able to highlight 3 key sets of patients which were not safe to be managed in CDU.

  1. Stab Victims
  2. Pelvic Injuries
  3. Medical Causes

With the above exclusion criteria in place along with a sign off by the trauma team leader a significant reduction in the number of missed injuries was noted from 8% to 0%. Thus, out of 142 trauma patients admitted to CDU none were taken to theatre, major trauma ward or referred to the surgical teams for management of undiagnosed/missed injuries.

In our experience having guidelines and procedures to facilitate this has led to a decrease in the length of stay of patients from an average of 1.28 days to 0.83, which is what is expected from the observation units across the United Kingdom. 


Ali NAQVI (Slough, United Kingdom), Sergio SAWH, Nicola BATRICK
11:00 - 18:00 #8176 - Managing emergency ambulance calls in São Paulo, Brazil.
Managing emergency ambulance calls in São Paulo, Brazil.

Background: In São Paulo lack of resources and high demand means it is not possible to dispatch an ambulance for all emergency calls. Calls are triaged using AMPDS then re-triaged by physicians who choose which cases are prioritized. This study aimed to identify which criteria other than AMPDS codes influence physician decision on ambulance dispatch.

Methods:  We used one month call data for October 2012.  For each emergency incident assigned an AMPDS response we calculated the number of incidents in each of the 34 chief complaints allocated to each response level (Delta through Alpha) and selected those with frequencies ≥ 10%. For this subgroup the proportion of calls allocated a response in less than 10 minutes was calculated and, chief complaint type compared for each level.  

Results: Out of 202,186 telephone calls, 37,457 (18.5%) were eligible for ambulance service assessment. Of these 23,736 (63.4%) were allocated an ambulance, 13,339 (35.6%) within 10 minutes.  13,721 (36.6%) had no ambulance dispatched. Chief complaints with the highest proportion of calls allocated within 10 minutes were Third party request for Delta calls, (99%; p<0.0 01); Unconscious/Fainting (Near) for Charlie (44%; p=0.0142); and Falls for both Bravo and Alpha  (43% and 37%; both p<0.001).

 Conclusion: Allocation within 10 minutes was used to infer prioritization. In addition to the AMPDS the physicians prioritized patients who were unconscious or fell. Calls from other services (e.g police, fire, health professionals) are coded as Delta and are prioritized over other chief complaints.

 


Flavia FERNANDES (Sheffield, United Kingdom), Oswaldo TANAKA, Janette TURNER
11:00 - 18:00 #7669 - Massive intentional intoxication digoxin.
Massive intentional intoxication digoxin.

Female 57 years history of recurrent from 32 years depressive disorder treated with amitriptyline and Bromazepan with 4 previous suicide attempts, the patient denies. He lives with his daughter in marriage separation process, aggravating his depressed state.

Go to our urgent transferred in medicalized ambulance, due to massive intake of 225 tablets of digoxin (56mgr) with autolytic ends 1 hour before .Gag reflex, normotensive, sinus rhythm 75 bpm, conscious collaborator not recognizing intake (his daughter confirms ) .In analytical high levels of digoxinaemia (usual range 0.8-1.9ng / ml, had> 5 ng / ml, can not specified exact digoxinaemia technical problems) .Procedemos to orogastric washing tablets abundant extraction and subsequent administration of activated charcoal . Immediately we ask digoxin immune pharmacy and administer 9 40 mgr vials (each vial neutralizes 0.59 mg of digoxin), the number of vials is equal to digoxinaemia by weight divided by 100. If the amount ingested or digoxinaemia is unknown, administered at 10 vials in adults, children 5.

Blood count and biochemistry and X-ray Thorax without findings.

During admission he presented gusting not self-limiting sustained ventricular tachycardia rhythm of sinoatrial block based on Grade 1 more PR than 260 msec, occasionally sinus bradycardia to 35 bpm and marked digitalis bucket. He entered the 72 hours Cardiology in sinus rhythm at 55 bpm PR less than 200 msec being evaluated and treated by psychiatry.

DISCUSSION

Digitalis toxicity associated with chronic treatment, is a recurring complaint in emergency, aggravated if associated with hyperkalemia or renal failure. Acute poisoning is exceptional, associated with high mortality, due to the variability of rhythm disorders that occur. Bradyarrhythmias treated with atropine and ventricular arrhythmias with phenytoin or lidocaine. Life-threatening situations require use of anti-digital anti antibodies and although there are only seven case studies series having a low scientific evidence, many authors consider that the anti-digital anti antibodies are a first-line treatment in severe digitalis intoxication. availability of antibodies anti-digital anti reference hospitals is recommended.


Justino PACHECO (Malaga, Spain), Maria Isabel CORREA
11:00 - 18:00 #8078 - MASSIVE PROTOCOL RECEPTION IN THE EMERGENCY DEPARTMENT.
MASSIVE PROTOCOL RECEPTION IN THE EMERGENCY DEPARTMENT.

No country, people or person is exempt from being involved in an emergency or disaster involving resource mobilization. In the next 3 decades, 70% of the population will be affected by some type of disaster or emergency, caused by climate change and many other derivatives of social violence, the developing countries will be hit hardest.

Patient care in the emergency room requires strategic response efforts with pre-established policies and training of physicians in the emergency department and they, in turn, lead and guide the activity of other areas, medical and administration body.

Our Centre has a specific training program to all medical and non-medical members to know what measures of prevention, mitigation, preparedness and alert in an emergency or disaster specific communication internal and external risks are. Associated with this, training is provided on massive programs referred patients receiving code yellow or red or epidemiological traumatic origin. |

During the event response is has a control unit that determines its impact generating activities support and assistance to those affected with a strategy of triage color input and subsequent zoned income.

Post-event analysis for improvement plans and continuity in education are made, it is attempted rehabilitation activities impact the population.

Policies are within the Crisis Plan, Risk and Epidemics of the institution, which includes the Program Emergency Management Response to Epidemiological and Biological Hazards Program Contingencies. Emergencies are led by a Strategic Crisis Committee, with the essential activities: Internal and External Communication, Coordination Emergency Committee (Operating Crisis), Human Resource Management, Evaluation and Financial Support, Health Care and Triage, Evaluation and support for Nursing, Operations Control Emergency Supply, Logistics rehabilitation of affected areas, legal support, which are held together in the same physical space and time.

There have been multiple events Emergency in our hospital, one of them was secondary to an explosion Maternal and Child Hospital in Cuajimalpa in which affected patients, newborns, mothers and medical personnel, traumatic injuries and burns, same as they were transferred to our unit for proximity. They were served simultaneously 37 patients, 8 patients by triage category were in red, 5 yellow and green policontundidos other category.

Pediatric patients mostly had no identification by name or characteristics, so that their post-DNA identification parents gave.

the local response to the emergency services are coordinated, in turn, was made immediate transfer of two adult patients Specialized Center in Burns and days to a pediatric patient to the Burn Unit at Hospital Galveston.


Cruz SALEME (Mexico, Mexico), Karla HERNANDEZ, Hector MONTIEL
11:00 - 18:00 #8044 - Mean platelet volume as a diagnostic tool on acute mesenteric ischaemia.
Mean platelet volume as a diagnostic tool on acute mesenteric ischaemia.

INTRODUCTION: Mesenteric ischaemia is a vascular emergency that includes life-threatening with high mortalities. It is revealed that mean platelet volume (MPV) and platelet activation are closely related. We researched whether MPV can be used as a diagnostic reagent on acute mesenteric ischaemia (AMI) diagnosis, and its relation to disease prognosis.

MATERIAL-METHOD: 112 people treated by AMI diagnosis in our clinic between February 2010 and March 2015 are taken as a patient group, and 122 people applied to our polyclinic for routine control in this period, and who does not have any diseases are taken as control group. Patient files are examined retrospectively. In this study, the differences between the groups are compared by using Independent T-Test. Statistical analysis of this study is made by using Statistical Package for Social Sciences version 21.0 Software for Windows (SPSS 21.0, Inc.,Chicago, IL).

FINDINGS: 53 of the patient group were female, and 59 were male. Average of age was 69,9 (30-94). 55 of the control group were female, 57 were male.   Average of age was 66,5 (28-75). On patient group, MPV, neutrophil/lymphocyte rate (N/L) and platelet distribution width (PDW) values are found higher than the control group and this difference was statistically significant. (p<0.01) Mortality developed in 55 (49%) patients in the patient group. Between the groups mortality developed and not developed, age, white blood cell, MPV, N/L rate and PDW values were not statistically significant (p>0.05)

RESULT: As well as more studies are required in this case, MPV, N/L rate, PDW values promise hope on AMI disease as a diagnostic reagent. However, these parameters do not have importance on specifying the disease prognosis.


Erdem KARADENIZ, Sukru ARSLAN, Bünyami OZOGUL (Erzurum, Turkey), Sabri Selcuk ATAMANALP
11:00 - 18:00 #7103 - Medical history of adult septic patients in the prehospital setting: what do septic patients say?
Medical history of adult septic patients in the prehospital setting: what do septic patients say?

OBJECTIVE: To diagnose sepsis is often difficult due to non-specific presentations. Existing screening tools rely on vital parameters, which are however normal in one third of patients with serious infections. There is a need to include variables other than vital parameters to identify sepsis. Our primary aim was to explore the documented presentations of septic patients in the prehospital setting, and to identify and quantify keywords related to the patients´ medical history. A secondary aim was to compare the prevalence of keywords between subgroups of septic patients.                                                           METHODS: Mixed methods analysis of a sequential exploratory design, starting with a content analysis of presentations of septic patients as documented in Emergency Medical Services (EMS) records (n=80) during 2012, to identify keywords related to sepsis presentation. Second, the identified keywords were quantified among 359 septic patients during 2013. All patients were adults, admitted to Södersjukhuset and discharged with an ICD-10-code compatible with sepsis.                                                                                                                                                                              RESULTS: The most common keywords related to the patients’ medical history were: abnormal, or suspected abnormal temperature (64.1.%), pain (38.4%), acute altered mental status (38.2%), weakness of the legs (35.1%), risk factors for sepsis (30.6%), breathing difficulties (30.4%), loss of energy (26.2%) and gastrointestinal symptoms (24.0%). Presentations differed between age categories, survivors and deceased and between patients with severe and non-severe sepsis.                                                                                                                                                                                      CONCLUSIONS: Keywords related to the patients’ medical history recur in EMS records of septic patients in the prehospital setting. This information is not included in current sepsis screening tools but may be used to increase the identification of sepsis.


Ulrika M WALLGREN (Saltsjö-Boo, Sweden), Katarina BOHM, Lisa KURLAND
11:00 - 18:00 #7657 - Medium- and long-term health effects of earthquakes in high-income countries: a systematic review of research methods.
Medium- and long-term health effects of earthquakes in high-income countries: a systematic review of research methods.

BACKGROUND

Over the last decades, the negative effects of earthquakes have increased sharply. In high-income countries, the immediate health outcomes resulting from these events (e.g., crush injuries, infections) are usually monitored and managed using standardized procedures. Conversely, the health effects arising during the chronic phase appear to be scarcely and heterogeneously monitored even in countries with well-established healthcare systems. This study aims to highlight the methodological strengths and weaknesses of present surveillance practices in high-income countries to prompt the development of future contingency plans.

METHODS

Medline, Scopus, and 6 international and national sources of grey literature including the websites of the World Health Organization, Centers for Disease Control and Prevention and the European Centre for Disease Control and Prevention were systematically searched. Keywords included a combination of the most common synonyms of “earthquake” with all high-income countries according to the World Bank list. Review papers retrieved with the above searches were manually screened for relevant references. Inclusion criteria comprised: measurement of health outcomes at least one month after the earthquake, investigation of earthquakes occurred in high-income countries and use of an observational study design including at least one control group with subjects unexposed to the earthquake. Only studies on human species and written in English, Italian, Spanish, French, Portuguese or German were included. No time restrictions were set.

RESULTS

The search yielded a total of 2,976 titles and 64 articles were included. The studies referred to 14 different earthquakes occurred in 8 countries between 1981 and 2015. The Kobe/Hanshin-Awaji (Japan, 1995) and L'Aquila (Italy, 2009) seisms were the most investigated earthquakes. The studies had a median sample size of 454 subjects, used most frequently a cross sectional (21/64) or time series design (21/64), and included predominantly temporal control groups (42/64). The highest number of measurements (median 12) and largest samples sizes (median 103,788) were found in studies with a time series design (median 12). Most studies focused on patients with specific diagnoses (25/64) rather than on the general population (17/64) and (43/64) used routine data collection. The 116 outcomes reported were evaluated for a median follow-up time of 16 months and articles focused on a wide range of physical and mental health outcomes including: all-cause mortality, cardiovascular diseases, intentional self-injury and problems related to lifestyle. Evidence of an increase was reported for 66 outcomes (56%) while 40 (34%) did not vary and 12 (10%) decreased.

CONCLUSION

A more intensive and coordinated use of routine data could benefit future epidemiological surveillance in the aftermath of earthquakes. Whenever possible, a cohort design should be preferred and both geographical and temporal control groups should be used. Future epidemiological surveillance systems should consider capturing the impact of earthquakes on the access to health services and its utilization.


Alba RIPOLL GALLARDO (Milan, Italy), Barbara PACELLI, Marta ALESINA, Dario SERRONE, Giovanni LACUTONE, Fabrizio FAGGIANO, Francesco DELLA CORTE, Elias ALLARA
11:00 - 18:00 #7086 - Metformin and Risk of Pancreatic Cancer in Diabetic Patients: A Population-based Cohort Study.
Metformin and Risk of Pancreatic Cancer in Diabetic Patients: A Population-based Cohort Study.

Background: It is known that metformin has been found to have survival benefits on patients with pancreatic cancer. However, the reports regarding risk of pancreatic cancer in metformin users are conflicting.

Objectives: We investigated the incidences of pancreatic cancer among patients with diabetes prescribed with metformin to evaluate if there is lower risk.

Methods: We utilized a sampled National Health Insurance (NHI) claims data containing one million beneficiaries. We followed all adults with diabetes from January 1, 2005 till December 31, 2013 to see if they had diagnosed with pancreatic cancer. We further identify patients prescribed with metformin and compared their risk of pancreatic cancer with those who had never taken metformin. Metformin use was treated as a time-dependent variable. The Cox regression model was applied to compare the adjusted hazards for potential confounders.

Results: There are 46973 diabetic patients without pancreatic cancer before January 1, 2005. We identified 32024 (68.2%) patients prescribed with metformin and 14949 (31.8%) without. After controlling for age, gender, urbanization level, socioeconomic status, chronic liver disease, hypertension, coronary artery disease, hyperlipidemia, malignancies, smoking, chronic obstructive pulmonary disease, obesity, history of alcohol intoxication, chronic renal insufficiency, biliary tract disease, chronic pancreatitis and Charlson Comorbidity Index score, the adjusted hazard ratio of pancreatic cancer was 1.003 (95% confidence interval, 0.57—1.78) in patients with metformin use.

Conclusions: Metformin prescription did not seem to be associated with lower risk of pancreatic cancer in patients with diabetes.

 

 


Shu Ping CHOU (Chiayi, Taiwan)
11:00 - 18:00 #7927 - Microbiological isolations, focal infection, and empiric therapy : patients admitted to the emergency department for sepsis.
Microbiological isolations, focal infection, and empiric therapy : patients admitted to the emergency department for sepsis.

Objective: to perform a descriptive study of focal infection, microbiology isolates and empiric treatments admitted as sepsis in the emergency deparment. The objective is to determine the septic patient characteristics and stablish which measures implement to enhance patient atention and health outcomes.

Metodology: patients admitted with sepsis in the emergency department during the period January 2014 to November 2015 were enrolled. Following data were collected: 

- Socio-demographic (sex, age).

- Sepsis type (sepsis, severe sepsis and septic shock)

- Focal infection

- Take blood culture (Yes, No)

- Microbiological isolates of blood culture and microbiological isolates of other culture.

- Empiric antibiotic therapy.

- Exitus (Yes;No)

A descriptive study of these variables was performed using SPSS v.10 stadistic package.

Results: 32 of them were men, the average age of all patients was 75.69 years (SD 14.63). 13.5% had sepsis, almost 52% were severe sepsis and septic shock were 34.6%. In more than 50% (29 patients) the focus was urinary, respiratory focus followed by 21.2%. The blood culture was taken at 84.6%, there were 8 patients who were not taken, in 3 cases were septic shock with death within hours in the emergency department. urine cultures were taken in 33 patients (63.4%), others cultures were taken as ulcer exudates, sputum, septic abscesses, oriented by focal infection. The 61.33% of the blood cultures were negative, among the most frequent microorganisms isolated bacteria were Enterobacteriaceae (E. coli [6], Proteus [2], Klebsiella [1]), there were 2 blood cultures insulated 2 bacteria, one of them   abdominal focus (E.Coli and S.gallolyticus subsp pasteurianus), the other one urinary focus (E.Coli and Enterococcus faecalis). There were only two isolates of S. aureus, one of them by a central catheter.Only in 4 cases, the same microorganism was isolated in blood and urine cultures or culture of exudate. As for antibiotic therapy, in 6 patients empirical antibiotic therapy was not recorded in the medical record digital . In patients with urinary focus, the antibiotic combination more used was Tobramycin + Ceftriaxone IV (9 patients) , followed by Imipenem IV (7 patients) and Ceftriaxone IV monotherapy (7 patients) . In patients with respiratory focus the most common empirical antibiotic was Ceftriaxone IV monotherapy (4 patients) , with high variability of antibiotic treatment in other cases . As for the combinations of antibiotics used , 2 of which is a highlight , Ceftriaxone + Imipenem + Vancomycin in respiratory focus and Piperacillin / Tazobactam + Metronidazole in soft tissue infection .23 Patients Were finally exitus , 9 of them died within the first 48 hours . 

Conclusions:Sepsis is a syndrome that requires a high organization in the emergency services to get the best health outcomes. Taking blood cultures must be established structurally in all cases of sepsis before administration of the antibiotic . Regarding antibiotic therapy is essential to establish guidelines empirical antibiotic therapy according comorbidities and septic foci to standardize clinical practice, improve the approach of infection and reduce the risk of selection of resistant microorganisms.


Maria GIL LOPEZ (OSUNA, Spain), Elena PRADO MEL, Antonio Bernabé ROJAS RAMIREZ
11:00 - 18:00 #6058 - Middle East Respiratory Syndrome trends influence emergency department utilization patterns.
Middle East Respiratory Syndrome trends influence emergency department utilization patterns.

An outbreak of Middle East Respiratory Syndrome (MERS) occurred in May of 2015 in South Korea. All cases were associated with healthcare facilities. Since emergency departments(ED) were suggested as the primary way that the virus spreads, the change of visits patterns to the ED were observed. The purpose of this study was to analyze the patterns of adult and pediatric patients visiting the emergency department (ED) during the MERS period. This study was carried out from June 1, 2015 to July 31, 2015 during the MERS epidemic in South Korea. We performed a retrospective study on all ED patients at Seoul National University Hospital. We compared and analyzed the characteristics of patients, emergency severity index (ESI) level at visits, cause of visit, diagnosis, emergency room treatment results, injury/non-injury, length of ED stay (EDLOS) and hospitalization rate. A total of 9,107 patients visited the ED during this period, 2,571 pediatric patients (28.2%) and 6,536 adult patients (71.8%). The most common cause of ED visit was fever (adults 21.62%, pediatric 56.2%). The proportion non-urgent visits of ESI 4-5, non-injury patient rate, and the EDLOS all decreased significantly in pediatric patients. During the MERS period, pediatric ED visits for non-urgent cases decreased compared to the previous two years while the rate of injured patients increased compared to the previous two years. There were more pronounced differences in emergency department utilization patterns for adult patients than in pediatric patients.


Paek SO HYUN (SEOUL, Korea), Kim DO KYUN, Jung JIN HEE, Lee JIN HEE, Kwon HYUKSOOL, Chang IK WAN, Park JUNGWAN
11:00 - 18:00 #7520 - Mild head injuries under antiplatelet agents or anticoagulants : compliance guidelines before and after formation.
Mild head injuries under antiplatelet agents or anticoagulants : compliance guidelines before and after formation.

Introduction : Before 2011, no consensus existed concerning the management of mild head injuries (MHI) with antiplatelet agents or anticoagulants. Masters and al. classification (NEJM 1987: 316;84-91) was less accurate because there is no precision about patients under  antiplatelet agents. Since 2011, the French Society of Emergency Medicine (SFMU) recommends performing a brain scanner and hospitalization under surveillance for every MHI under antiplatelet agent (AP) or anticoagulant (AC). Aim : checking is the guidelines are followed before and after specific information sessions.

Methods : A prospective and monocentric before and after study of the practices taking (before and after specific information sessions) conducted in the reception of the emergency department of a regional university hospital in France. Inclusion criteria : patient >15 years, seen in the emergency room for MHI and taking his usual treatment of antiplatelet agents or anticoagulant. The primary outcome was the performance of a brain scan and/or hospitalization for monitoring.

Results : From January to June 2013 : “Before” period : 26 patients under AP and 6 under AC were included. From January to June 2014 : “After” period : 38 patients under AP and 20 under AC were included. For patients under AP, performance of a brain scanner was 92% (n=26) Before and 95% (n=36) After (p=0,54). About hospitalization for monitoring : 35% (n=9) : Before and 66% (n=25) After (p=0,0014). All patients under AC had a brain scan (Before n=6 and After n=20) and hospitalization for monitoring was 50% (n=3) Before and 70% (n=14) After (p=0,33).

Discussion : It has been observed that the 2 groups did follow correctly the guidelines about mild head injuries and brain scanner, whether it was before or after specific information sessions. The rate of hospitalization for surveillance was low, mainly for AP. Better after specific information sessions but insufficient. Since, differents actions were established in the emergency department for increase the accordance with the guidelines.


Alexandre ALLONNEAU (Paris), Pierre DARS, Hugues LEFORT, Delphine PAPEIX, Daniel JOST, Daniel BAUGNON, Jean-Pierre TOURTIER, Erick DURET
11:00 - 18:00 #8177 - Mind the Syncope.
Mind the Syncope.

72 year old woman with a history of hypertension, COPD , no known drug allergies diagnosed in the emergency room 10 days before pericarditis acute days (box chest pain center retroesternal at rest progressive establishment, radiating to the neck and drop PR ECG. Discharged in treatment of NSAIDs and colchicine), go back to the emergency room episode of dyspnea woke him at night, and when going to the bathroom presents transfixing chest pain and syncope. In the last 48 hours it has presented another episode of similar characteristics.

On arrival at the emergency room the patient has dyspnea at rest with inability to speak, sinus tachycardia to 120x ', sweaty and general nervousness. Presents heart rate (HR) 125 bpm, TA within normal limits, eupneic with SatO2 96% and 37 Tª.

A physical examination is pale and sweaty, with tachycardia cardiac auscultation, no murmurs or pericardial rub. paradoxical radial pulse and light edemas in lower limbs. No jugular venous distension. Auscultation normal respiratory and abdominal exploration.

In additional tests to 100bpm sinus rhythm with narrow PR and decreased voltages, aortic elongation of the aortic button prominence in CXR is objective; in analytical leukocytosis are 13,700 (78.4% neutrophils) and D Dimer 2509, with troponin and normal hemoglobin. arterial blood gas analysis in p02 71mmHg, pCO2 29 mmHg and pH 7.53

CT angiography was requested by suspected pulmonary tromboembolisto, which is reported as Dilation of the pulmonary artery, pericardial effusion Severo study it seems restricted venous return, Moderate Mild hepatomegaly and pleural effusion.

 

interconsultation is done performing cardiology echocardiography moderate pericardial effusion without cardiac tamponade data so that guide clinical case as torpid pericarditis with pericardial effusion.

It is entered by putting in place internal medicine treatment with ibuprofen, colchicine and doxycycline. After slow clinical improvement is discharged with outpatient control by cardiology.

Acute Pericarditis represents 0.1 % of all hospital revenue and 5% of revenues from the emergency room with chest pain etiology of idiopathic 80-90 % , 5-10 % and 2-7 % neoplastic tuberculosis, the percentage of complications ages between 17-90 years is 16.8% . We conducted a literature search regarding the increase in D dimer pericarditis and found no conclusive studies on the subject .


German Jose FERMIN GAMERO, Claudina REVOL (Palma de Mallorca, Spain), Carmen RODRIGUEZ OCEJO, Pedro RULL BERTRAN, Sandra GUIU MARTI, Bernardino COMAS DIAZ, Alejandro ADROVER, Julio OLSEN
11:00 - 18:00 #7759 - Minor traumatic brain injury revealing dermoïd cerebral cyst.
Minor traumatic brain injury revealing dermoïd cerebral cyst.

INTRODUCTION :   

Cerebral dermoid cysts are a rare congenital benign tumor formations of slow growth. They represent approximately 1% of all intracranial tumors, and occur equally in both sexes. The clinical presentation depends  on the tumor location. Headaches and epilepsy are the most common symptoms, they can also be discovered following a complication. Some of incidental findings have been described. Rupture of an intracranial dermoid cyst is a rare event wich may be associated to morbidity and potential mortality. 

OBSERVATION: 

We report a case of a 21-year-old man with no medical history who suffered a high-velocity traffic accident  resulting in minimal traumatic brain injury .The medical taking history noticed an  initial loss of consciousness during few minutes.  On examination: The patient was conscious with a Glasgow coma scale of 15 and no neurological signs of localization. No visible trauma above the clavicle was found. The blood pressure was = 140/70 mmHg with a regular pulse rate of 70 bpm. Biological tools was normal.  A computerized cranial tomography was conducted after six hours of observation based on guidelines of Traumatic brain injury and revealed an intraventricular multiloculed left lateral  expansive process, , with heterogeneous density exerting a mass effect with dilatation of the left lateral ventricle and controlateral deviation of the interventricular septum. It combines multiple fat density of punctate pictures localized at the base of the tank, left parietal cortical grooves and realizing a lipid supernatant at the frontal and temporal horn of the left lateral ventricle. There were no  traumatic bone injury associated. The Diagnosis of intraventricular dermoid cyst rupture was made with a spread Subarachnoid lipid droplets. The patient was admitted for observation in the emergency ward and neurosurgeons dit not indicate an urgent need of neurosurgical act. The patient remains asymptomatic after the observational period and was referred  to the neurosurgery ward for further explorations and decision making.

CONCLUSION: 

Dermoid cysts are benign formations of slow growth, which explains the late diagnosis, usually to 30 years in 66% of cases. Occasionally they are incidental findings discovered on brain computed tomography (CT) or magnetic resonance imaging (MRI).


Imen MEKKI (Tunis, Tunisia), Hamed RYM, Hana HEDHLI, Alaa ZAMMITI, Salwa MANSOURI, Saloua AMRI, Wided DEROUICHE, Bouhajja BÉCHIR
11:00 - 18:00 #7321 - Misdiagnosed cases of acute aortic dissection in the emergency department.
Misdiagnosed cases of acute aortic dissection in the emergency department.

【Background】

Acute aortic dissection (AAD) is a life-threatening disease and nearly 33% of patients die within the first 24 hours without treatment. We considered patients with AAD who were misdiagnosed at the first visit in Fukui Prefectural Hospital (FPH).

【Methods】

We retrospectively analyzed 68 patients with AAD who visited the emergency department of FPH between April 2010 and March 2015.  We identified patients diagnosed promptly at the first visit (Group A) and  those misdiagnosed (Group B). We compared the following items statistically using Fisher test and Mann-Whitney test; sex, age, mortality, Stanford type of dissection, presenting symptoms, use of emergency medical services and time to definite diagnosis with CT.

【Results】

Group A was 54 patients (81%) and Group B was 13 patients (19%). Median time to definite diagnosis with CT was 25 min (interquartile range, 16.25 to 35.75 min) in Group A and 100 min (60 to 120 min) in Group B (P<0.001). Group B was older (Group A: median 69.5 years, Group B: 77 years, P=0.03) and had more Stanford type A dissection patients (Group A : 46.3%, Group B : 84.6%,P=0.001). Stanford type A patients complained chest and/or back pain less compared with type B patients (P=0.004). Misdiagnosed patients were diagnosed at the first visit as gastrointestinal disease (four cases), acute myocardial infarction (three cases), musculoskeletal disease (two cases), cerebral infarction (one case) and others (three cases).

【Conclusion】

Older age and Stanford type A dissection was associated with misdiagnosed AAD in our study. Further our study indicates that we should not remove AAD from differential diagnosis even in the patients without chest or back pain, especially in the elderly.

 


Tomoko SHIGEKIYO (Fukui, Japan), Taizo NAKANISHI, Makoto SERA, Hideya NAGAI, Shinsuke TANIZAKI, Hideyuki MATANO, Shigenobu MAEDA, Hiroshi ISHIDA
11:00 - 18:00 #8208 - Misdiagnosis : Aortic dissection. A case report.
Misdiagnosis : Aortic dissection. A case report.

A 35-year-old female patient was admitted to our clinic due to a suddenly emerged mild characteristic chest pain simultaneously causing accompanying a near-syncope episode during travelling by car. When the pain was questioned, the patient decribed it as stabbing, radiating to her back and lasting only a few minutes. Her medical history showed no significant feature except oral contraceptive use but family history revealed that her mother’s unknown sudden death at a young age. On her physical examination, no pathology detected with normal vital signs (BP:105/37mmHg, pulse:59/min, RR:22 ve satO2: %95). Her ECGs (at the admission and the second one at 15. Min) were normal. She was taken to cardiac follow-up due to the sudden death of her mother. D-dimer level was added to standard blood tests to rule out of the possibility of pulmoner thrombo-embolism due to risk factors of the patient like travelling and oral contraceptive use. No symptom was occurred during her follow-up. Her cardiac markers and standard tests were normal but D-dimer level was measured as 4190. Torax angio CT imaging was planned with a prediagnosis of pulmoner thrombo-embolism. PACS images showed normal pulmoner vascularity with normal main pulmonary vessels but a flap noted in the normal diameter ascending aorta. Blood pressure was checked again, but bilaterally this time. The difference between two extremities was found to be more than 20 mmHg (right upper extremity BP:84/34 mmHg and on left upper extremity BP:117/46 mmHg). Interpreted CT reported that a dissection flap involving the arch-ascending-descending aorta, and extending through brachiocephalic trunk, left common carotid artery and the left renal artery was observed. The patient was firstly taken to the operation for supracoronary graft interposition by cardiovascular surgery immediately and then to ICU for post-operative care for 2 days. She was discharged a week later with medical treatment. During her post-operative period, she was investigated for rheumatic connective tissue and auto-immune diseases but no pathology was detected.

Consequently, an aortic dissection was determined incidentally while investigating pulmoner thrombo-embolism in a young woman with a normal aortic diameter on a contrast chest CT. This case reminds us that bilateral blood pressure measurement should be an absolute part of physical examination and aort dissection cannot be rule out with a normal aortic diameter. even mild and not prolonged pain presentations in emergency departments should be considered in differential diagnosis of aortic dissection.    

 


Figen COŞKUN, Barış YILMAZ (Kırıkkale, Turkey), Sevilay VURAL, Oğuz EROĞLU, Turgut DENIZ
11:00 - 18:00 #7083 - Mom, i hate the fish.
Mom, i hate the fish.

A 52-year-old woman with abdominal pain was admitted to the emergency room (ER). The abdominal pain started 8 hours ago, located in lower abdomen. She didn`t show nausea, vomiting or altered bowel rhythm. No fever was reported.

On physical examination, the patient has a distended abdomen without ascitic semiology, tenderness mainly in lower abdomen. No signs of peritonitis. No CVAT (Costo vertebral angle tenderness). Laboratory tests were normal except for C-reactive protein (CRP) 24.9 mg/L. Abdominal Xray was reported as normal.

Examined by Gynecology with vaginal ultrasound: annexes were normal and no free periotenal fluid was detected.  She was discharged from gynecology department and referred to our ER again.

Kept under observation for 6 hours without any changes. The analytical examination remains normal except for the CRP was increasing (60.5 mg/L). Ultrasonography revealed distended gallbladder, which several pictures of cholelithiasis. No free fluid in the abdomen and pelvis. Appendix not displayed, but not indirect ultrasound signs suggestive of acute appendicitis were identified.

24 hours after the arrival of the ER, patient was reevaluated without locating changes in physical examination but continuous increase in acute phase reactants (CRP 111 mg/L). Since the physical examination and the analytics findings were not correlated, abdominal CT scan was performed. The findings were: in left hemipelvis a loop of small intestine distended with discrete mural thickening circumferential identified, hyperdense linear image of approximately 4 cm in length through the right wall and goes to the fat path extra luminal mainly by contacting another segment of the small intestine and the posterior wall of the rectum, compatible with foreign body (FB), probably fishbone.

The patient was operated infraumbilical laparotomy: bowel resection with mechanical latero-lateral anastomosis. No postoperative complications are described, being discharged from hospital a week later.

DISCUSSION

FB ingestion is usually encountered in children. It`s rare in adults, (about 1%) and is usually caused by long, sharp objects, such as toothpicks, fish bones or needles. The most of the ingested FB move through gastrointestinal tract without causing complications, especially if they get through the esophagus. Perforations are more common in segments with a closed angulation, as the pylorus, the angle of Treitz, the distal ileum and recto sigmoid junction.

Clinical presentation is usually insidious and difficult to diagnose unless occurs a complication of drilling itself as abscess formation, colorectal fistulas, colovesical and enter vascular, pseudo tumor of omentum, bacteremia and endocarditis. Patients often do not remember the history of intake fish and may take months between intake and drilling.

The utility of abdominal radiography is limited, and depends on the density of the fish bone. CT is superior to radiography and it can identify the cause, detect pathological intestinal complications area and drilling itself. The fish bones are typically displayed as images linear density calcium inside an inflammatory area. Nevertheless, there are a significant number of cases diagnosed intraoperatively.

In summary, intestinal perforations by fish bones are rare, but should be kept in mind in an adult patient admitting with a longstanding, nonspecific abdominal pain.


Raul FALLOS MARTI (madrid, Spain), Carolina FERNÁNDEZ PALACIOS, Cecilia CARRASCO VIDOZ, Raquel CASERO GOMEZ, Patricia BAZAN DOMINGUEZ, Manuel Jesus RUIZ POLAINA
11:00 - 18:00 #7389 - More than a simple laceration: extremity vascular injury.
More than a simple laceration: extremity vascular injury.

Introduction

Lacerations and minor penetrating injuries commonly present to the Emergency Department (ED). It is still crucial to thoroughly assess for any associated neurovascular injury and/or injury to deeper structures in the management of such injuries. We present a case of a small laceration which had serious underlying vascular injury.

Case

A 41 year-old gentleman presented to the ED after having slipped and sustaining a stab injury by a metal file which he happened to be holding on his thigh. There were two small linear wounds (1.5cm and 2cm) over the right upper inner thigh, actively bleeding but controlled with compression. A toilet and suture was performed for the two wounds and the patient was discharged.

He re-presented to the ED 3 days later complaining of increasing pain over the wound with surrounding haematoma. Although he had been massaging the area at home, there was no obvious repeat trauma and no symptoms of anaemia. There was ecchymosis over the anterior aspect of the thigh up to the knee. Distal pulses were present. Hb was 10mg/dL. He was discharged to follow-up at primary care.

On his 3rd visit 3 days later for worsening bruising and pain, he was found to have extensive bruising involving his entire right lower limb and calf, tracking up to the perineum and right iliac fossa. Sutures were still in-situ over the wounds with no active bleeding. Distal pulses were present and there were no other signs of compartment syndrome. Hb dropped from 10 to 8.5mg/dL in 3 days. He was admitted and found to have a 7x3cm and 1.5x1.5cm pseudoaneurysm of the right profunda femoris which was embolised. The patient was then discharged well.

Discussion

This case highlights the importance of excluding neurovascular involvement deep tissue injury in any penetrating injury, no matter how innocuous the external wound may look. Signs of vascular compromise can be divided into hard and soft signs. Patients with hard signs such as absent pulses, bruit/thrills, active or pulsatile haemorrhage, pulsatile or expanding haematoma, signs of limb ischaemia or compartment syndrome warrant urgent surgical or interventional radiological intervention.

In the absence of hard signs, soft signs such as diminished pulses, mononeuropathy, non-expanding hematoma should be actively looked for. An arterial pressure index (API) should be measured if soft signs are present or if the injury is proximal to a main vessel, there was evidence of hypotension or moderate bleeding at scene, or if knee or elbow dislocations were sustained. A CT angiogram should be considered in an API of <0.9 with soft signs.i Patients with normal API still need close follow up on discharge as 1-4% of these patients with penetrating wounds eventually require operation for progression of an undetected injury.ii iii 


Ian HONG (Singapore, Singapore), Wei Lin Tallie CHUA
11:00 - 18:00 #7430 - Mortality in emergency department: myth or reality?
Mortality in emergency department: myth or reality?

Introduction: The study of mortality in emergencies is of high importance for emergency didactic. It is also a useful indicator for assessing the provision of care and support for patients. Our emergency department has not yet been the subject of such a study. Thus, it seemed appropriate to consider a prospective study whose objectives were to determine the characteristics of the patients died in the emergency specify the cause of death and to evaluate patients who died with the waning of the limitation or shutdown therapeutically active.

Materials and methods: This is a prospective observational study mono centric over a period of one year including all deaths in the emergency department during the period of study. Several parameters were collected from the medical records. Then, two seniors have investigated whether the death was reversible with the waning of a medical condition, there was a concept of preventable death in severe trauma and finally, if the limitation or cessation of active treatment was formalized conduct or implicitly. Exclusion criteria inclusions were: patients already arrived dead, age <15 years, patients without medical records and patients whose medical records are unusable due to lack of data.

Results: We included ninety-four deaths in emergencies. Thus, we have objectified male predominance. The majority of death affects a young population with an average age of 61 ± 5 years. Only 24.5% of our patients underwent a medical transport. More than half of patients have cardiovascular history. The cause of death was the most common stroke and in 29.8% of cases the etiology of death was unclear. The incidence of reversible medical death was 12.7%. We noted 17 premature deaths post-traumatic.

Conclusion: early deaths were frequent emergencies and are mainly the elderly, for which an "alternative" home maintenance decision could be taken. Active resuscitation measures have been taken in principle in most cases before deciding on a limitation or termination of active treatment.


Nesrine IBN HASSINE, Chawki JEBALI (Kairouan, Tunisia), Hajer KRAIEM, Nawfel CHBILI, Mejdi OMRI, Mohamed Nejib KAROUI
11:00 - 18:00 #4516 - Mortality rate in alterated state of consciousness patients ; comparison between mode of patient arrival.
Mortality rate in alterated state of consciousness patients ; comparison between mode of patient arrival.

Background: Emergency medical services (EMS) provide adequate pre-hospital treatment and transports patient to the appropriate hospital. Patient who has altered state of consciousness is emergent and need a proper management and transportation.

Objective: This study aims to determine mortality in altered state of consciousness patients with different mode of arrival.

Materials and Method: A retrospective chart review was performed for 200 consecutive alteration of consciousness patients presenting to Rajavithi hospital from January 2013 to December 2014.  Patients with cardiac arrest, pediatric, pregnant and trauma were excluded. The patients were divided in three groups by mode of transportation. One-way ANOVA was used to determine the strength of correlation between demographic variables, as well as the variation between individual transportation.

Result: No statistically significance differences in mortality rate existed when compared between ALS 40.7% ,BLS 66.7% and private car 38.8%. (p = 0.85). Sepsis (37.5%) and neurological cause (21.5%) which top etiology, lead to alteration of consciousness. However the mean of GCS in patients who transported by ALS is significantly less than the others (p = 0.001). Modified early warning score (MEWS) is significantly higher, in patients transport by ALS, between death in hospital and discharge alive (p = 0.047, 95%CI -2.67; -0.02). It is the same as MEWS in patients who transport by private car, death in hospital had significant greater score than discharge alive (p = 0.006, 95%CI -3.19; -0.55).

Conclusion : The study shown higher mortality rate in BLS group but there was no statistically significant. The study also shown significantly less GCS score in patients transport by ALS group. Appropriate pre-hospital treatment and evaluation should be promoted in order to help EMS development in the future.


Laddawan KIETTIKUNWONG (Bangkok, Thailand), Nathida SUMATCHOTIMAYTHA
11:00 - 18:00 #7262 - Most emergency department patients with epistaxis are treated without intervention and bounce backs are uncommon.
Most emergency department patients with epistaxis are treated without intervention and bounce backs are uncommon.

Epistaxis is a common disease encountered in the emergency departments (ED), which can be time, labor, and resource intensive.  Though rarely life-threatening its treatment can cause significant discomfort.  Also troubling are the rate of bounce backs.  Study Objective: To evaluate epistaxis ED returns visits and analyze based on procedural intervention.   Methods:  Design: A multi-center retrospective cohort study. Setting: 29 urban, suburban, and rural ED in the New York/New Jersey area. Participants: Consecutive patients with final ICD9 diagnosis of epistaxis from Jan. 1, 2010 to Sept. 30, 2015.  Exclusion: ≤ 17 yrs of age. Repeat visits were defined as an unplanned ED encounter < 72 hours from initial visit.  Seasonality was determined by equinoxes and solstices.  Procedure codes were extracted utilizing ICD-9 billing information.  Statistics: Chi-square and Mann Whitney were utilized with a P-value < 0.05 as significant.  Results:  A total of 2,954,800 patient encounters occurred during the study period.  The total of 19068 (.6%) were diagnosed with epistaxis.  Pediatric patients comprised 20% (N=4643), and were excluded.  The overall median age was 67.5 yrs (IQR 52.8-80.0).  Females comprised 48% (N=9325). Ninety-three percent were discharged, 7% were admitted, and 0.01% were transferred.  Mean age in years of those admitted versus those discharged was 68 and 64, respectively (p=<0.0001). The most common season for ED epistaxis visits was winter 30% followed by spring (27%), fall (22%) and summer (21%).   Unplanned return visits occurred in 10% of cases (N=1813).  Median age of  those who had repeat visits was 65 (95% CI 64.3-65.9) years  versus 64 (95% CI 64.1-64.7) years  for those who did not (p=0.83).  Procedure codes incidence: anterior simple 39%, posterior 2%, anterior complex 1% and none 58% (cautery and or packing would have been performed on all codes except for “none”).  Sixteen percent of those who underwent an anterior procedure had an unplanned return and 7% of epistaxis patients without a procedure had an unplanned return.  (p=<0.0001).  Conclusion:  Unplanned return emergency department visits for epistaxis are uncommon and occur more frequently following packing.  Physicians display good clinical judgement on those patients who do not require packing or cautery, which can be uncomfortable , time consuming, and costly. 


Renee RIGGS, Fred FIESSELER (Long Valley, USA), Dave SALO, Dave CUTHBERT, Jamie ALLEN
11:00 - 18:00 #7445 - MRI in the emergency department: why do emergency medicine doctors order MRIs.
MRI in the emergency department: why do emergency medicine doctors order MRIs.

Title: MRI in the emergency department: why do emergency medicine doctors order MRIs

Authors

A Casey, F Mustafa, P Gilligan

Introduction

We present an observational study that assesses the accuracy of clinical diagnosis made by EM physicians when correlated with MRI scan results.

Given concerns with radiation-induced malignancies from the excessive use of CT scans, intuitively an alternative method of evaluation that does not entail ionizing radiation is invaluable. MRI does not use ionizing radiation, and has not been shown to be harmful to humans but this test is not without its downsides, including cost, availability, some contraindications, and the time needed to perform the scan.

Methods

A retrospective study of MRI scans requested by EM physicians using a digital radiology system NIMIS (National Integrated Medical Imaging System) was performed. We looked at the clinical diagnoses suspected by the EM physicians when requesting the scans and compared them with the radiological reports. This is a pilot study and we aim to analyse the data for a period of 1 year with a total of 396 scans.

Results

A total of 37 MRI scans were requested by EM physicians in the study period of 3 months. 21 of those scans were of lumbosacral spine and 10 were of brain with or without contrast. There were 2 cervicothoracic, 1 hip, 1 knee, 1 ankle and 1 breast scan performed.

17 MRI scans of lumbosacral spine were performed for a suspected cauda equina syndrome out of which 6 were positive for cauda equina syndrome and another 7 showed advanced degenerative changes with nerve root impingement, thecal sac indentation and significant disc bulges.

Of the 10 brain scans, 4 were positive for the clinical suspicion of exacerbation of Multiple Sclerosis, increased size of meningioma, metastatic brain lesions and for progression of cavernous hemangioma.

The hip scan was performed for a suspected illiopsoas abscess which confirmed the clinical suspicion of the physician and the breast scan confirmed a suspected implant rupture. The cervicothoracic, knee and ankle scan results did not confirm the suspected clinical diagnosis.

In total, of the 37 MRI scans requested by EM physician, 18 (48.65%) were found positive for the suspected clinical diagnosis.

The study results indicate that EM physicians are increasingly using MRI in the evaluation of patients and their clinical concerns are often confirmed radiologically.

Conclusion

With the increasing availability of MRI Emergency Medicine specialists need to consider its potential applications in the evaluation of patients attending Emergency Departments. This study shows that though we use it infrequently we have a high pick up rate with regards to presumed diagnosis.


Farah MUSTAFA, Andrew CASEY (Dublin, Ireland), Peadar GILLIGAN
11:00 - 18:00 #7325 - Multiple casualty training for university hospital emergency department staff.
Multiple casualty training for university hospital emergency department staff.

Introduction

Multiple casualties can occur in different ways, and military conflicts are considered to be a special type of them. We present a disaster training model designed in collaboration with USA military forces located in Latvia. The aim of this exercise was to verify the emergency responce of civil university hospital  in case of three simultaneous explosions at military bases located across Latvia with all casualties converging onto the Riga East clinical university hospital emergency department.

Material and methods

Training for multiple casualties in emergency department.

Results

 The legend of training was unknown for emergency department personnel. The day of training was Monday with usual overcrowding during afternoon hours. All patients converging onto Riga East clinical university hospital Emergency Department to do the best training for both US and Latvian personnel. Totally 28 international casualties were transferred to the emergency department within 3 hours after notification of crisis situation. 21 of them were evacuated by US army helicopters, 2 - by Latvian borderguard helicopter and 5 - by ambulances of Latvian national armed forces. All patients were re-triaged upon arriving. 14 patients had red tags, 10 patiens - yellow tags, 2 patients - green tags and 2 patients - black tags ( dead upon arriving). It was important for emergency department personnel to continue working with or transfer current patients to other departments and increase emergency related staff to bolster capabilities. During exercise  14 casualties were transferred directly to the operation rooms ( time from triage to transfer 9 – 27 minutes), 12 casualties didn’t need immediate surgery and were referred from emergency department to intensive care unit ( 6) or to the surgical departments ( 6). All casualties underwent emergency diagnostic and life-threating procedures according to in-hospital trauma protocol. Per limitations of the exercise, the staff and systems maintained life for all living patients received.
Conclusion
The only way to check the emergency responce, capacity and resources of civil hospital in case of multiple casualty event is well organized and realistic training.  Collaboration between military and civilian medics, communications , pre-hospital care, time of transportation , emergency department readiness and resources play very important role and have to be improved during regular trainings.

 


Aleksejs VISNAKOVS (Riga, Latvia), Anita SLOKENBERGA, Solvita STABINA, Aleksandrs GARINS
11:00 - 18:00 #4523 - Multiple Cystic Lung Disease in an Adolescent Boy.
Multiple Cystic Lung Disease in an Adolescent Boy.

Background: Cystic lung disease is defined as intrapulmonary air-containing multiple cysts surrounded by sharply demarcated thin walls. Although cystic lung disease is rare, incidental detection has increased significantly in recent years by screening using computed tomography. We present a case report of a multiple cystic lung disease diagnosed with chest radiography and thoracic computed tomography.

Case: A 15-year-old previously healthy boy was involved in a traffic accident and presented to our emergency department (ED) with complaints of chest pain and mild shortness of breath. On physical examination, he had complained for the last 2 hours of the right hemithorax pain in the fifth intercostal space radiating to the right midaxillary line. He had no past medical or surgical history. Chest x-ray demonstrated  doubtful multiple thin-walled cystic lesions in the right lung. Computed tomography  (CT) scan of thorax revealed a well- defined thin-walled, and 9.97 x 8.78 cm in diameter giant air cyst occupying the right upper lobe parenchyma with multiple air-space cysts. The patient was finally diagnosed as a multiple cystic lung disease and he underwent  elective thoracic surgery for cyst removal.

Conclusion: Patients with cystic lung disease may be asymptomatic or present with nonspecific symptoms, such as chronic cough or shortness of breath, as it was in this case. They are at increased risk for spontaneous pneumothorax. Hence, surgical treatment of multiple cystic lung disease plays a crucial role in the prevention of pneumothorax. 


Ozgur SOGUT, Demet TAS (İstanbul, Turkey)
11:00 - 18:00 #7307 - MUST - Medical students Ultra Sound Training for 5th Year Medical students: User feedback.
MUST - Medical students Ultra Sound Training for 5th Year Medical students: User feedback.

MUST - Medical students Ultra Sound Training  for 5th Year Medical students: User feedback 

The Medical student Ultra Sound Training (MUST) for 5th Year medical students to obtain ultrasound guided vascular access and arterial blood gas sample.

This was the first ever procedural ultrasound training for medical students in the UK. The course has evolved since it was first started in 2013.

The training comprised of e-learning equivalent to 30 minutes teaching session via VLEψ platform, 30 minutes of didactic teaching (lecture with demonstration of procedure and lecture on ultrasound governance) and 120 minutes of supervised scanning. The face-to-face course which runs over one full day gives the students plenty of hands on experience in scanning. This is followed by an end of training formative assessment.

During the year 2015-16 the course was held on 5 days at two locations (Leeds and Dewsbury) and 250 medical students underwent training.

Learning outcomes of the course:

•Basic ultrasound physics & Knobology (VLE)
•How to operate the ultrasound machine and optimizing image
•Ultrasound guided peripheral vascular access
•Governance issues related to ultrasound guided procedures.

The candidates were asked to feedback on a scale from 1 (very disappointed) to 5 (very pleased). The response rate was 92.8%.

                                                               1      2       3       4       5

Ultrasound Physics and Knobology (VLE)            2%   10%   39%   49%

US Guided IV Access and ABG sampling Lecture                   18%   82%

Scanning hands-on-practice                                                11%   89%

Governance Lecture                                                  10%   34%   56%

Comments:

•Lots of opportunity to practice; learnt a skill which will be very useful in the future.
•Great to be taught this - I feel confident to be more useful as an Foundation Year 1 doctor.
•Very friendly staff, very supportive and enthusiastic.
•Excellent structure.  Briefing → practice → assessment → debrief → well sign-posted.
•We got plenty of practice and teaching from experienced and knowledgeable clinicians.  Also great to practice on each other and with different machines.
•Useful to learn a new skill, which is applicable to working as a junior doctor.
•I really enjoyed learning how to use the probe and practicing my needle technique.  The course should definitely be included for the curriculum in future years as it is a very useful skill to know.
•It was good to receive constant feedback.
•Best teaching I've ever had!!
•A refresher session later in the year if possible
•Some practice with sterile procedure while acquiring venous access
•Less rushed for time, a bit longer in each station.  Longer presentation of all techniques at the start.

Conclusion

The course has evolved and achieved success over the last few years. Overwhelming positive feedback from medical students has acted as a catalyst to pave the way into integrating ultrasound into the undergraduate curriculum at Leeds Medical School.


Mohit ARORA (Leeds, ), Asoka WEERASINGHE, Patrick TUNG, Dean OKEREKE
11:00 - 18:00 #7438 - Myocardial infarction and dextrocardia.
Myocardial infarction and dextrocardia.

Myocardial infarction and dextrocardia

Valdez F., Karina; Rodriguez O., Carmen 

Emergency Department, Hospital Son Espases, Spain

 

Background:

 

This case report describe the difficulties of emergency physicians to obtain an ecg in a patient with a known dextrocardia.

 

Case Report:

A 57 years old male was found in an internet café by the ambulance crew after he presented a syncope. No known allergies. He has history of Hypertension, Type-2 Diabetes and is a cigarette smoker. He also had a Killip II myocardial infarct 5 years ago, treated with primary angioplasty and 4 stents in the right coronary artery were placed. His last echocardiography found an ejection fraction of 29%. He was currently taking: Salycilic acid 100mg qd,Atorvastatin 40mg qd,Furosemide 40mg qd, Pantoprazole 40mg qd,Metformine 850mg bid,Insulin Glargin 18UI bid,Bisoprolol 5mg 1qd,Ezetimib 10mg qd,Ivabradin 7,5mg bid,Candesartan 4mg qd and Eplerenon 50mg qd. His vital signs were normal and physical examination showed signs of decompensated heart failure. 

He was admitted to the hospital for further investigation and monitoring. The physician and nurses in ED had low experience recording an ecg in a patient with dextrocardia. 

1st ecg standard: Negative P wave and QRS complex in I, Poor progression of R wave in precordial limbs. QRS negative V4-V6. 1 mm elevation ST in II and flattening ST in III, aVF and V4-V6. Negative T in II, III and aVF

2nd ecg: bipolar wires switched from left to right. P positive in I. Poor R wave progression in precordial leads. There is no longer ST elevation in DII. Negative T waves in II, III and aVF. 

3rd ecg: bipolar and precordial wires switched. P positive in I. Good progression of R in precordial leads. No changes in ST. T negative in II, III, aVF and V4-V6.

During the monitoring, he presented a polymorphic ventricular tachycardia followed by ventricular fibrillation. Advanced CPR was performed with further recovery of vital signs after 15 minutes. After CPR, the ecg showed an elevation of ST segment in inferior leads. Primary angioplasty was performed and confirmed the total occlusion of the left anterior descendant coronary artery, Septal and right coronary artery. 

Conclusions: The dextrocardia is the right sided position of the heart. It’s a unusual condition.  Negative P wave and QRS complex in I must let us be alert. The malposition of the electrodes of the right and left arm can also produce a negative P wave in I. The right way to do an ecg in presence of dextrocardia is switching the left and right arm lead electrodes and right-sided precordial leads.(1)

The Ecg lecture is an important skill to diagnose coronary artery disease and we must try to recognize the normal variations and avoid lead misplacement using guidelines or electrocardiograph alarms. 

 

1.        Kligfield P, et al. Recommendations for the standardization and interpretation of the electrocardiogram: part I: The electrocardiogram and its technology: a scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee.Circulation. 2007 Mar 13;115(10):1306–24. 


Karina VALDEZ FLORES, Maria Del Carmen RODRIGUEZ OCEJO (PALMA DE MALLORCA, Spain)
11:00 - 18:00 #8196 - Myocarditis related to African scorpion envenomation: cardiac magnetic resonance findings.
Myocarditis related to African scorpion envenomation: cardiac magnetic resonance findings.

Objective: Scorpion envenomation are worldwide reported, and it is considered a major public health problem in tropical, subtropical and sub-Saharan areas. Scorpion α-toxins inhibits the voltage-gated sodium channel inactivation resulting in prolonged depolarization and, finally, neuronal excitation with adrenergic and cholinergic excess. The main mechanisms of cardiac dysfunction and pulmonary edema related to scorpion envenomation are multifactorial: the vasoactive effect of catecholamine and biochemical mediators causes cardiac overload and contribute to acute cardiac failure or myocardial ischemia or myocarditis. We describe the evolution of a toxic myocarditis documented at four repeated cardiac magnetic resonance (CMR) during a 9 months follow-up.

Case report: A 25-year old woman was stung on a foot by Leirus Quinquestratius scorpion on a Red Sea beach (Egypt). At ED admission (2 hours later), the patient presented with normal blood pressure, local acute pain, fever (38°C), tachycardia (117 bpm) associated with dyspnea and diffuse pulmonary rales. Chest radiography evidenced severe pulmonary edema, and echocardiography assessment revealed significant deterioration of left ventricle (LV) systolic function, with global hypokinesia and left ventricle ejection fraction (LVEF) of 25%. Biochemistry showed an increase of troponin I (6.16 μg/L), CPK-MB (97 U/L), amylase (220 U/L) and LDH (558 IU/L) associated with leukocytosis and thrombocytopenia. Patient was treated with prazosin, dobutamine, furosemide, hydrocortisone, levofloxacin, PPI, acetaminophen, NSAIDS, clindamycin and enoxaparin. Purified Polyvalent Antiscorpion Serum was administered. Clinical condition progressively improved with normalization of myocardium necrosis indexes and LVEF (67%) within 9 days.

The patient was transferred to our hospital 11 days after the accident. Echocardiography was normal except for systolic pulmonary pressure at the upper limit level. Repeated CMR evaluations (11 days; 3, 9 and 16 months) were performed. ECG-gated cine images, assessed by a steady-state-free-precession sequences, showed normal LV volumes and LVEF at baseline, and mild worsening of LVEF during the follow-up (53 to 60%). Significant early uptake of gadolinium at T1-weighted-TSE sequence, suggesting myocardial inflammation, was revealed at base-line, and gradually reduced during the follow-up, particularly between the 6th and 9th months. Irreversible myocardial damage was assessed by late enhancement technique, which revealed mild intra-myocardial and sub-epicardial late enhancement that persisted in the follow-up. Conclusion: Our experience support the hypothesis that the excess of catecholamine is crucial in the pathophysiology of the cardiac dysfunction observed both in stress-induced cardiomyopathy and scorpion envenomation. CMR evaluations is useful in follow-up sub-clinical myocardial alterations also considering the possible evolution in dilated cardiomyopathy.


Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy), Davide LONATI, Oronzo CATALANO, Guido MORO, Francesca CHIARA, Sarah VECCHIO, Valeria Margherita PETROLINI
11:00 - 18:00 #7683 - Narrow QRS tachycardia in Down´s Syndrome patient with history of intervention for ventricular septal defect and hypotiroidism.
Narrow QRS tachycardia in Down´s Syndrome patient with history of intervention for ventricular septal defect and hypotiroidism.

Case report: we report a 33 years old female, who was admitted in emergency department with a Narrow QRS tachycardia. It is a patient with Down syndrome, hypothyroidism and congenital heart disease (ventral septal defect) underwent surgery 6 months after birth with good outcomes.

Patient was in the school in a physical education class and begins with vomiting, sweating with relaxation of sphincters and loss of consciousness self-limited (syncope) by what is taken suffering three episodies of syncope in the travel. The patient was admitted in observation area for monitoring: TA 96/60 mmHg, and Electrocardiogram (ECG) with narrow complex tachycardia to 200 bpm with retrogade P wave, suggestive of atrio ventricular nodal reentrant tachycardia.

After consultation the medical record, the last ecocardiography was done in 2002 (more than 15 years ago) with theses results: close patch well preserve, Ventricular size and eyecction fraction normal.

First, treatment is performed with Adenosine and verapamil unanswered. Subsequently, esmolol IV is given,  getting only reduce the frequency of tachycardia. As a third pharmacological line treatment, amiodarone perfusion was given during 12 hours, without getting sinusal rhythm.

For last, echocardiography is performed, with results within normality. After that, patient presents again an episodie of tachyarritmia and we decided underwent her to a electrical cardioversion. After midazolam administration for sedation, a discharge of 100 julies was done, being efective at the first time, with ECG in sinusal rhythm with right bundle branch block.

Discussion:

Atrioventricular nodal reentrant tachycardia represents a significant part of tachy-arriythmias seen by attending physicians in emergency departments.

The clinical practice guidelines , recommend synchronized electric cardioversion as the first therapeutic option for a patient with tachyarrhythmia and clinic instability situation.In our particular case ( patient with Down's Syndrome And congenital heart disease) it is decided as a first choice pharmacological cardioversion despite the situation of hemodynamic instability finally being ineffective


Maria GIL LOPEZ (OSUNA, Spain), Elena PRADO MEL, Maria Josefa MARTINEZ LOPEZ, Antonio Bernabé ROJAS RAMIREZ
11:00 - 18:00 #7585 - National pilot structured triage system: Experience in emergency department Hospital Carlos Van Buren.
National pilot structured triage system: Experience in emergency department Hospital Carlos Van Buren.

Emergency care in any health situation represents a permanent challenge in order to provide quality care within which the opportunity turns out to be decisive. From the health point of view the demand for emergency services depend directly of prevention and health promotion of the population and the response capacity of local health strategies devices.
Of the four stages that make up the process Emergency Care, the thread selection or Prioritization Demand Attention has been defined as the first clinical thread by which ensures the chance of patient care.
Adult Emergency Department of Hospital Carlos Van Buren has a triage system following the recommendations given by the Commission Report Urgent Care approved in 2013. The scale in our depertment categorizes patients into five levels and establishes waiting times for medical evaluation; It is performed by a professional (nurse) accompanied by a technician.
However, this system has been listed as subjective and currently poses implement a structured triage system. The goal of structured triage is to manage the influx of users, to be attended by urgency and not presented in order of arrival; a structured triage system has higher reliability and validity than the current system.
Currently there are several models of classification standard, universalized, structured and standardized 5 levels adapted to the emergency department: Australian Triage Scale (ATS); Canadian Emergency Department Triage and Acuity Scale (CTAS); Manchester Triage System (MTS); Emergency Severity Index (ESI) and Model Andorrà Triatge (MAT), which was adopted as the standard model for Spain with the name of Spanish Triage System (SET)

Since December the Chilean Ministry of Health starts programming a pilot for the implementation of a new triage tool nationwide where 16 hospital centers for evaluation 2 triage system: Manchester Triage System (MTS) and  Emergency Severity Index (ESI). In our emergency department training with structured triage system was completed in December 2015 and trial run began on 1 March.

The aim of the study is to present the experience of working with a structured system of triage as a preliminary result of the national pilot at local level in the emergency department of Hospital Carlos Van Buren; the variation observed in categorizing compared to the same period in the last year was assessed.


Valentina DUARTE (Viña del Mar, Chile), Karen SOTO, Gloria VALDES, Viviana AMPUERO, Jonathan BUSTOS, Fabian RODRIGUEZ, Jorge ZENTENO, Pedro GALLARDO, Veronica DEL FIERRO, Susana FUENTEALBA
11:00 - 18:00 #7812 - National trends in quantative descriptors of emergency departments in The Netherlands.
National trends in quantative descriptors of emergency departments in The Netherlands.

National trends in quantitative  descriptors of Emergency Departments in The Netherlands.

 

E. Gips

Emergency Physician, Fiona Stanley Hospital Emergency Department, Perth, Australia

 

C.L. van den Brand

Emergency Physician, Medisch Centrum Haaglanden, The Hague, The Netherlands

 

Dr. R. Veugelers

Emergency physician, clinical epidemiologist, Emergency Department, Admiraal De Ruyter Ziekenhuis, Goes, The Netherlands

 

M.I. Gaakeer

Emergency Physician, Admiraal De Ruyter Ziekenhuis, Goes, The Netherlands

 

 

Background

In 2012 the first nationwide inventory of attendances at Dutch emergency departments (EDs) and self-referrals was done.  We present the results of this survey repeated in 2013, 2014 and 2015 and compare them with the 2012 results.

Methods

All Dutch EDs providing 24/7 patient care were approached and the following data were collected: type of liaison between ED and on-call GP service,  total number of ED attendees, origin of patient (self-referral,  referred by GP, by ambulance or other) and the number of hospital admission via ED

 

Main findings

In 2012, out of all EDs, 89/93 (96%) responded; 83/89 (93%) in 2013; 85/88 (97%) in 2014 and 84/88 (95%) in 2015.

In 2012, total number of visits, extrapolated to all 93 EDs, was 2.079.172.

In 2013, 2.008.737 in all 89 EDs; in 2014, 2.003.411 in all 88 EDs and in 2015, 1.943.998 in all 88 EDs

The average percentage of ED patients brought in via ambulance was 13% in 2012; 14% in 2013; 16% in 2014 and 2015

The average percentage of GP referrals for all EDs was 43% in 2012; 47% in 2013 and 49% in 2014 and 2015

The average percentage of self-referrals for all EDs was 30% in 2012; 26% in 2013; 21% in 2014 and 17% in 2015

The percentage of close liaison types between ED and GP services was 49% in 2012; 64% in 2013; 70% in 2014 and 76% in 2015

The average percentage of hospital admissions via ED was 32% in 2012; 34% in 2013; 35% in 2014 and 37% in 2015

 

Conclusion

There remains a nationwide variation in the number of ED visits, rate of self-referrals and admission rate.

The total number of ED visits decreased little despite increasingly closer liaisons between EDs and GP services.

The number of self-referrals has decreased, whereas the number of patients presented via GPs or ambulance services has increased with the same percentage.

Further research is required to establish any causality between these last two phenomenons.

 

 

 

 


Evert GIPS (Fremantle, Australia), Crispijn VAN DEN BRAND, Rebekka VEUGELERS, Menno GAAKEER
11:00 - 18:00 #7291 - Necrotizing fasciitis: A case report.
Necrotizing fasciitis: A case report.

CASE HYSTORY:M.G.K. is a 59 yo lady with a prior medical history of type 2 diabetes, hypertension and IV stage chronic renal secondary to post-actinic  bilateral idroureteronephrosis.She presented to the ED after a 3hr plane flight complaining of right leg swelling, tenderness to the right hip and fever (38,5°C) since the last hours. A CBC showed leukocytosis with neutrophilia (WBC 17x10^3/mmc, Neu 91%).Routine labs pointed out elevated C-reactive proteine (60mg/dl), elevated D-Dimer and a slightly worsened renal function (creatinine 3,1mg/dl). A doppler ultrasound revealed femoro-popliteal deep venous thrombosis and the patient was referred to our Internal Medicine ward where was started on enoxaparin. Ciprofloxacin was also administered suspecting an UTI due to patient's complaint of typical urinary symptoms. The day after the patient was still febrile, complaining of worsening pain and paresthesias to the right limb. Her WBC count raised to 20x10^3/mmc, C-reactive protein was stable and procalcitonin was 19mg/dl. Moreover, her HbA1c revealed a poor glicemic control with a value of 73 mmol/mol. On clinical examination, except from leg oedema and marked hyperalgesia, nothing relevant was noted. A musculoskeletal US showed diffuse oedema of subcutaneous tissues to the right hip with a liquid layer of 3-4mm surrounding muscular fascia extended for 50mm in lenght. A subsequent TC scan showed thickening of subcutaneous fat and fascial layer next to the greater trochanter , medium and small gluteus and the anterior face of right thigh with contextual lymphadenopathy. Due to worsening clinical conditions the patient underwent emergent fasciotomy on the same day, 12hrs after clinical diagnosis of necrotizing fasciitis has been performed: fascial tissues in the area of clinical findings were greyish and easily detachable from muscular groups, confirming the diagnosis. The patient came back to the IM ward soon after surgery and was started on clindamycin and piperacillin/tazobactam. The day after she developed massive bleeding from fasciotomy and needed urgent transfusions and emergency suture of surgical wound. After an hospitalization of 3months M.G.K. survived and was sent home.

DISCUSSION: Necroting Fasciitis (NF), first described by Confederate Army Surgeon Joseph Jones, is the most lethal form of soft tissues infections, with reported mortality from 20 to 80%, according to different studies. Diabetes represents the most known risk factor, with 90% of prevalence in all cases on NF in literature, but other identified risk factors are EtOH abuse, renal disease,chirrosis and thrombocytopenia. NF is a tricky diagnosis since slight initial clinical findings may appear conflicting with patient's referred pain. Moreover, NF represents a surgical emergency and maximal debridement must be the goal of intervention. Some case-series showed a linear correlation between delay of surgery and mortality.Full spectrum early antibiotic therapy and fluid resuscitation are other cornerstones of treatment. LRINEC score can be helpful for early diagnosis in the ER, but it has been validated only for cervical NF. There is no evidence for recommending some kind of imaging over other, but a multi-technique approach seems to be the most effective to facilitate and support a diagnosis that remains primarily clinical.


Francesco BORRELLI (Venezia, Italy), Caterina ZANDOMENEGHI, Maurizio PONZ DE LEON
11:00 - 18:00 #8020 - Nephrolithiasis or renal artery thrombosis?
Nephrolithiasis or renal artery thrombosis?

Background: Renal artery thrombosis (RAT) is a rare condition, with a poor prognosis, which can lead to renal infarction (RI). The frequency of renal infarction is higher than reported: Clinical diagnosis of renal infarction is frequently missed or delayed because the patients present with abdominal or flank pain,  which mimic other, more common conditions, such as nephrolithiasis and pyelonephritis.

Case presentation: A 68-year-old male patient with diabetes and hypertension history, who had a primary percutaneous coronary intervention and stent placement 6 months ago because of an acute myocardial infarction, was admitted to our Emergency Department (ED) with flank pain on the left side. His blood pressure was 175/80 mmHg, his pulse 74/minute, oxygen saturation 99%, and fever 36.8 degrees Celsius.At his physical examination he only had costovertebral angle tenderness on the left side. Of his parameters, only his troponin level (0.22ng/mL)  and blood glucose (161mg/dL) were high. In his urinalysis he had glucose and erythrocytes.In the contrast enhanced abdominal CT there was a 20 mm thrombosis formation at the left proximal renal artery, which was reaching the abdominal aorta. The patient was interned in the Urology Department with a diagnosis of renal artery occlusion. The interventional radiologist applied a balloon expandable stent in the renal artery as well as thrombolytic therapy.

Conclusion: In a patient with flank pain who has a high risk of atheroembolism, the differential diagnosis of renal artery thrombosis should be considered.Computer tomography angiography could be used to prove the diagnosis in EDs. An early detection of renal artery thrombosis can save the kidney from injury, improving the quality of the patient’s life.

 


Incifer KANBUR, Behlul BAS, Sila SADILLIOGLU (istanbul, Turkey), Hakan TOPACOGLU
11:00 - 18:00 #7207 - Neurogenic pulmonary edema: case report.
Neurogenic pulmonary edema: case report.

Neurogenic pulmonary edema, firs described by Shanahan in 1908, is characterized by pulmonary edema that occurs shortly after serious injury of thr central nervous system. It is a common but underdiagnosed condition; its incidence varies from 20 to 50% among patients with serious neurological injuries and its mortality reache 7%. Differential diagnosis must be made with aspiration pneumonia, pulmonary edema from primary myocardial disfunction, pulmonary contusion and ventilator inducec lung (barotrauma).

The purpose of this case report communication is to review this entity and remind the importance of early diagnosis.

A 38 year old male, previously healthy, was transferred to the emergency room of our center in a medicalized ambulance after suffering abrupt syncope, collapse and maintained loss of consciousness while doing physical exercise.

Assessed in situ an emergency physician, the patient had a Glasgow Coma Scale of 3 with medium, non reactive pupils, blood pressure of 145/80 mmHg, 90 beats per minute and oxygen saturation of 97%. The patient was intubated before the tranfer.

When entering the emergency room blood pressure was 111/83 mmHg and heart rate 111 beats per minute. In spite of the invasive endotracheal intubation and mechanical ventilation, the patient´s oxygen saturation level was 55-60% and outlet of pink, foamy liquid from the tube was noticed. Sinus tachicardia with no repolarization alterations was observed on the electrocardiogram.

From pulmonary auscultation crackels were heard in both lung fields suggesting acute pulmonary edema. Urgent brain and thoracoabdominal CT scans were requested revealing the presence of extensive Fisher IV subarachnoid hemorrhage and a 7.0 x 6.5 x 7.2 mm ruptures aneurysm of the anterior communicating artery was confirmed by Supra-Aortic Trunks and Circle of Willis angiography. Also thoracic images suggestive of bilateral alveolar consolidation were appreciated.

The blood work, coagulation study and cardiac enzymes were within the normal range. The patient died 40 hours after admission in the Intensive Care Unit.

CONCLUSION

Neurogenic pulmonary edema should be suspected in patients with acute and severe injury to the central nervous system and rapid development of acute respiratory failure, hipoxemia and desaturation.

90% of patients with subarachnoid hemorrhage from ruptured aneurysm that die abruptly previously present neurogenic pulmonary edema. Its onset can be acute and sudden, as in our case, but usually it appears between the 2nd and 7th day of bleeding. Risk factors associated with the magnitude, severity of bleeding, diagnosis and early treatment are essential to reduce mortality and improve the prognosis.


Maria De La Peña LOPEZ-GALINDO (ZARAGOZA, Spain), Alba HERNANDEZ, Beatriz SIERRA, Alexander MAZA, Sara LAINEZ, Maria Jose GIMENO, Blanca MARADIAGA
11:00 - 18:00 #7972 - New anticoagulants as an alternative to the classical therapy with antivitamin K drugs in atrial fibrillation.
New anticoagulants as an alternative to the classical therapy with antivitamin K drugs in atrial fibrillation.

Atrial fibrillation is the most common sustained arrhytmia in adulthood , and the most commonly diagnosed in ambulatory and hospitalized patients. Its presence contributes the formation of thrombus in atrium which can be detached and cause serious thromboembolic complications.

The risk of a brain stroke increases specially in those patients who associate valvular heart disease and after medical , electric or spontaneous cardioversion.

This kind of brain stroke is more severe than others derivated from other pathology , and they are responsible of the majority of mortality and comorbidity associated to AF.

Prophylaxis of arterial thromboembolism  is one of the therapeutic goals in AF. Use of anticoagulant therapy reduces the risk of having a brain stroke . The emergence of new anticoagulants as an alternative to the classical therapy with antivitamin K drugs , that improve the quality of life of patients as the don´t need dose adjustment periodically , and decreases the need of frequent controls as well as close monitoring of coagulability rate , is the reason why we decided to start with this study in our Emergency Service ( Hospital Royo Villanova , Zaragoza) with the purpose of watching changes in atrial fibrillation management after the introduction of these direct action new anticoagulants .


Noelia ORTEGA JIMENEZ, Elisa ALDEA MOLINA (zaragoza, Spain), Irune ALBISTUR LESMES, Teresa PARDO VINTANEL, Pilar MIRANDA ARTO, Teresa FERNANDO GROS, Marco SARRAT TORRES
11:00 - 18:00 #7967 - New forms of hashis consumption.
New forms of hashis consumption.

 

INTRODUCTION:
The hashish is made by extracting the resin of marihuana leaves and flowers. It is more powerful than dry leaves since it contains 10 times more THC. More than 8 million Spaniards say they have consumed sometimes. In the last ten years the consumption in young people in our country has been doubled.
 
1.CLINICAL CASE:
woman of 15 years, occasional smoker of marijuana, refers palpitaciones and parestesias of 5 hours of evolution, after to have consumed a “Chinese” of marijuana dissolved in yogurt.    Physical exploration: Tª: 37.2º, TA: 140/80, pulso.111ppm. Pulmonary auscultation: without alterations.  Auscultation cardiac: rythmical noises cardiac to 110ppm.   Neurological exploration: reactive average pupils.   Complementary tests  - analytical sanguineous: CK: 118 (24-173)  - ECG to its arrival to urgencies: sinusal tachycardia to 111ppm., with hemibloqueo of right branch and reduction of the ST in the antero-septal face    Evolution: The patient receives treatment with diazepam 5mg.  After 2 hours the asintomática patient, with ECG of control: sinusal rate to 77ppm., with hemibloqueo of branch dcha and without alterations of repolarización.
2.CLINICAL CASE:
man of 25 years, who refers to have consumed, for 4 hours, hashish in infusion (approximately 5 gr.). For one hour he has been presenting/displaying palpitaciones, sensation of turn of objects, buccal and bad dryness to be general.    Physical exploration: Tª: 37.1º, TA: 150/80, pulse 100ppm.  Neurological exploration: horizonto-lateral nystagmus (izdo-decho).  Complementary tests:  - ECG: sinusal tachycardia to 101 ppm. Without alterations of the repolarización.    Evolution: The patient is dealt with 5 sueroterapia and Diazepan mg.
 
CONCLUSIONS:
 The hashish consumption is more and more prevalente in young people who experience new forms of administration in search of sensations, finally finish in the Services of Urgencies presenting/displaying more or less habitual symptoms.

Elisa RUIZ OLIVARES, Sonia Sofía BALLESTIN SOROLLA, Ana Belén MARÍN FLORÍA, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Carola MEDINA SAINZ, Silvia GANGUTIA, Pilar SARASA CLAVER
11:00 - 18:00 #7726 - New venous blood gas guidelines for the emergency department.
New venous blood gas guidelines for the emergency department.

Venous blood gases (VBGs) are an invaluable tool in the assessment of the adult patient presenting to the emergency department (ED). The sample can be taken with the patient’s admission bloods and its point of care capability means that results are ready within minutes. The information a VBG provides enables unwell patients to be identified, for tailored management to be commenced and assists decision making.

Within our district general hospital ED in the south east of England, we noticed that VBGs were performed inconsistently. In our department, the majority of adult patients have their bloods taken by a nurse or healthcare assistant (HCA) prior to being seen by a doctor. With no clear guideline of when this should include a VBG, we identified some problems: 1. VBG not performed but clinically indicated, 2. VBG performed but not clinically indicated, 3. Delay in VBG sampling.

We aimed to establish whether guidelines exist on this subject and, if not, to develop a set of clear evidence based guidelines for implementation in our ED.

We performed a comprehensive literature search using multiple databases and found that there are currently no published guidelines for when to perform VBGs in the emergency department.

Consequently, we formulated a list of patient groups to include in our new guideline based on literature searches and clinical experience. We identified the following groups: patients with high early warning score/in resus, abdominal pain, active bleeding/anaemia, diarrhoea & vomiting/dehydration, dialysis patient, overdose/poisoning, reduced GCS, sepsis, short of breath with normal oxygen saturations (including exacerbation of COPD), suspected diabetic ketoacidosis and trauma. The guidelines were produced in poster form with clear headings. A brief explanation of why a VBG is required for each patient group was included under each heading. We hoped that better understanding would aid adherence. The posters were displayed in triage, nurse assessment areas, resus and minors. They were also made available in the guidelines section on the ED intranet and were emailed to all ED staff.

We intend that if the guidelines are followed, VBGs will be taken when clinically necessary: unwell patients will be recognised sooner, clinical decisions can be made sooner and treatments can be tailored to the VBG results. The guidelines should also decrease the number of patients having a VBG taken on a separate occasion to the admission bloods thereby reducing patient discomfort. VBGs will not be taken unnecessarily which has time and cost implications. Lastly, they should decrease the time delay caused by nursing staff asking their seniors or doctors whether or not a VBG should be taken.

We intend to evaluate how well the guidelines are being adhered to, how they are affecting the workload of the nursing staff and whether they are decreasing the number of blood tests per patient. Most importantly, we will establish whether patient care is improved and whether significant efficiency improvements have been made by the implementation of the VBG guidelines.


Helen COLLYER-MERRITT (Brighton, United Kingdom), Chisom EMECHETA, Adam WOODMAN-BAILEY, Craig PRENTICE, Kamal VEERAMUTHU
11:00 - 18:00 #7149 - NO MORE ABGS, PLEASE!
NO MORE ABGS, PLEASE!

A 68-year-old man was seen in the Emergency room with a diagnosis of hand pain. 15 days previously, he had been hospitalized with a respiratory infection. The patient believes the simptoms started when he had an arterial blood gas analysis (ABG) just before he was admitted.  No fever. Nor  constitucional symptoms. Nor previous  history of arthritis.

We present the case of a patient with past medical history of severe COPD (chronic obstructive pulmonary diseases),  bronchiectasis, severe obstructive sleep apnea(OSA), solitary kidney with chronic kidney disease , diabetes mellitus,  hypertension, hypercholesterolemia, hyperuricemia and hypogammaglobulinemia. Allergies: Sulfonamides, pyrazolones.

Social history: He is totally independent in terms of activity of the daily living. Long-term supplemental oxygen therapy (LTOT)1.5l/16h per day. No dementia

Physical exploration: Vital signs stable. Blood pressure:  143/76 mmHg, heart rate: 80 bpm, SpO2 air room: 92%. Tª 36.9ºC

Erythema, warmth, severe pain and tenderness in wrist and hand. No other affected joints.

Laboratory test: Glucose 146 mg/dl, PCR 58 mg/L, Leukocyte 17.98  10E3/µL, Creat 2.04mg/dL

Ddímero 0.31mg/dL (<0.50)

Wrist Xray: no bone injury

Eco-doppler: No DVT

Echography : hematoma doubtful postpuncture

Traumatologist  discharged him and he was referred to our ER again. With the diagnosis of  infectious tenosynovitis  he was admitted in internal medicine department.

Wrist RM: significant effect/injury of common flexor digitorum

Final diagnosis : septic tenosynovitis

Antibiotics were administrated during 8 days, piperazilin-tazobactam + linezolid while he was at the ward. Surgery was not necessary. 

INFECTIOUS TENOSYNOVITIS

Tenosynovitis refers to inflammation of a tendon and its synovial sheath; It is most frequently in the hands and wrist but can occur in any joint.

Three mechanism:

-Trauma with direct inoculation (laceration, puncture or bite)

- Contiguous spread from infected adjacent soft tissues

- Hematogenous spread

The most common pathogens implicated in tenosynovitis due to trauma are skin flora: eg, gram- positive cocci such as Staphylococcus aureus and streptococci.

Clínical manifestations range from pain with passive extension to tenderness along the tendon sheath. Fever may or may not be present. Findings of advanced infection may include subcutaneous purulence, tissue necrosis, and/or compartment syndrome.

Risk factors associated with poor outcome included: age>43;  presence of diabetes mellitus, peripheral vascular disease or renal failure;  subcutaneous purulence; digital ischemia; polymicrobial infection

The diagnosis is confirmed by microbiological and histopathological evaluation. In most cases, aspiration and/or biopsy is required for diagnostic and therapeutic  purposes. Ultrasonography and magnetic resonance imaging may also be useful to confirm the presence of tendon sheath abnormalities.

The management includes surgical intervention and antibiotic therapy. A reasonable approach(tenosynovitis associated with trauma) is to combine vancomycin with ciprofloxacin or  third cephalosporin such as ceftriaxone. In general,  7 to 10 days of therapy is appropriate for uncomplicated bacterial infection.

CONCLUSION

ABG is a routine test in the emergency room but is not without complications. Septic tenosynovitis is a rare but serious complication.

 


Raquel CASERO GOMEZ (Madrid, Spain), Patricia BAZAN DOMINGUEZ, Virginia ÁLVAREZ RODRÍGUEZ, Marta MERLO LORANCA, Raul FALLOS MARTI, Manuel Jesus RUIZ POLAINA
11:00 - 18:00 #8014 - Non accidental injuries(NAI) in children represents a high emotional impact on the medical staff implicated in their management.
Non accidental injuries(NAI) in children represents a high emotional impact on the medical staff implicated in their management.

Introduction

The NAI in children represents a significant  Paediatrics Emergency Department(ED) presentations in UK, with 10% presentations in children under 2 years old.

Emergency Department presentation

A 7 months old male patient with head injury presented with his mother, after the GP advised her to present to the hospital.

History taken from the mother , having as chaperone one of our nurses, revealed that she left her baby  in the basket with the other 4 children of hers( 10 years, 6 years, 4 years and 2 years old) while she went to the toilet. When she arrived from the toilet, she found her baby on the sofa, with mark of head injury-left frontal haematoma. She couldn’t give an explanation for the injury.This event was happening in the early morning, the presentation in the hospital being in the afternoon apx 2pm, after she discussed with her GP.

On examination: AVPU-A, haematoma left side of forehead, pupils equal reactive size 2 bilateral, ENT- both thympany membranes normal, throat examination-normal, no other bruises on the body examination,CRT <2 sec, HR=110bp, BP=80/40mmHg,T=36.7degrees, BM –normal, normal weight for his age.

ED management

The patient’s mother was interviewed by Police crew and Social Workers team in the ED, before the patient was admitted on the Paediatrics Medical team.

Dipstick urine was normal. CT brain was organized and reported as Acute on Chronic subdural haematoma.

Paediatrics medical team management

x-ray scheletal survey showed multiple bones fractures, with different periods of healing.

The patient was referred to the Social Workers teams and it was started a Police investigation in the patient’s family.

Discussion

The medical staff that was dealing with this patient,  playing team , nurses or doctors, were very much impressed about this event. Even if they have years of experience, it is still difficult to deal with a NAI in such a small baby.

Conclusion

NAI in children, particular babies, represents a big challenge for the clinicians that are examining this type of patients.

The emotional implication for  the medical staff for this patient was significant, even in the next days my colleagues giving phones to Paediatrics Medical Ward asking about the evolution of events for this patient. Some of us went to the ward to review the patient.

It is difficult to quantify the emotional effect of such a tragic case on medical and nursing staff in Emergency Department, and the psychological toll it takes on carers.  More focus needs to be placed on debriefing of medical staff after such incidents.

Being non-judgemental and in the same time professional, we need to involve early  the Social Workers and the Police in order to protect this children.

Dr Nicoleta Cretu, ACCS ST1 Emergency Medicine trainee

Dr Ben Teasdale, ED Consultant

Leicester Royal Infirmary Hospital, UK.


Dr Nicoleta CRETU (Leicester, United Kingdom), Ben TEASDALE
11:00 - 18:00 #8058 - Non-invasive CPAP-ventilation support versus oxygen-therapy using a reservoir face mask for carbon monoxide poisoning: an observational study.
Non-invasive CPAP-ventilation support versus oxygen-therapy using a reservoir face mask for carbon monoxide poisoning: an observational study.

Background:
Carbon monoxide (CO) is a leading cause of morbidity and mortality. Treatment focuses on the rapid elimination of CO and management of hypoxia. Oxygen is the cornerstone of therapy, and usually applied via a reservoir face mask. Hyperbaric oxygen therapy (HBO) eliminates CO faster, but requires extensive equipment and its benefits are discussed controversially.

Non-invasive continuous positive airway pressure (CPAP) ventilation using a tight mask provides an inspired fraction of oxygen of 1.0 compared to 0.6 using a reservoir face mask, and increases gas exchange. As this modality is widely available, it might represent a supplemental approach to current treatment of CO poisoning.

Methods:
Prospective, observational trial at the critical care facility of a tertiary-care hospital's emergency department. Adult victims of CO poisoning were treated either by reservoir facemask (O2 flow 15l/min), or non-invasive CPAP ventilation-support (PEEP 5cm H20, 100% FiO2) until a carboxyhaemoglobin (COHb)-level of 3% was reached. COHb levels were continuously measured and half-life was calculated.

Results:
In total 56 patients were included, 14 were treated by CPAP, 42 by reservoir facemask. Median COHb-half time was 100 minutes (IQR 75-134) with inhalation therapy by reservoir face mask and 64 minutes (IQR 55-74) with treatment by CPAP (p<0.01).

Mean difference in half-times between groups adjusted for baseline-differences was 112 minutes (95% CI 9 to 215; p=0.04).

Conclusions:
Our findings suggest a potential benefit of non-invasive CPAP ventilation-support in the reduction of COHb half-life in intoxicated subjects. This seems to be justified to be further investigated in randomized controlled trials.


Dominik ROTH (Vienna, Austria), Lukas SCHEINOST, Wolfgang SCHREIBER, Harald HERKNER, Christof HAVEL
11:00 - 18:00 #7175 - Non-invasive ventilation in the emergency department: length of staying.
Non-invasive ventilation in the emergency department: length of staying.

Introduction:

In last decades Non-invasive Ventilation [NIV] (both Continuous Positive Airway Pressure [CPAP] and different modalities of Non-invasive Positive Pressure Ventilation [NIPPV]) has been increasingly applied in the Emergency Department (ED) to treat Acute Respiratory Failure [ARF].

 

Aims:

Prospective observational study to identify predictors of outcome in Patients with ARF treated with NIV in the ED, and factors related to the needed length of NIV before shifting to standard oxygen therapy (O2tp).

 

Methods:

We enrolled every Patients treated with NIV for ARF in the ED in a 3 months time.

Criteria to start and stop NIV referred to an institutional protocol.

Attention was focused on diagnostic hypothesis of ARF (Cardiogenic [C], broncho-pulmonary [BP], both or mixed [M], others [O]) and the time to resolution [tR] of the acute phase (min of NIV before shifting to O2tp for almost 48 h).

 

Results:

One-hundred and fourty-nine patients included (media 1.66/day).

tR significantly higher in case of chronic BP disease (media 1100 vs 377'; CI 95% 744–1453' vs 240–514'; p<0.01).

Cases with acidosis or hypercapnia had a slightly higher tR (p = 0.07 and 0.08, respectively).

NT-proBNP was not related with tR in any group.

Patients having M or O ARF significantly differed in tR when compared with C and BP groups (p<0.001).

tR in C patients was not different with or without chronic BP disease.

 

Conclusions:

Patients with chronic BP disease and an episode of ARF due to a BP cause should be admitted to a High Medical Dependency Unit capable to ensure a supposable longer NIPPV.

It's possible to consider carrying out in the ED the treatment of the shorter very acute phase of a C ARF, and then admit to a regular ward able to allow at least CPAP.


Dr Rodolfo FERRARI (Bologna, Italy), Roberto LAZZARI, Daniela AGOSTINELLI, Riccardo VOZA, Mario CAVAZZA
11:00 - 18:00 #7399 - Non-traumatic coma in the Emergency Department.
Non-traumatic coma in the Emergency Department.

A limited number of studies investigate patients admitted to the Emergency Department (ED) for non-traumatic coma (NTC). Aim of our study was to investigate aetiology and acute outcome of patients referring to the ED due to a NTC. All the adult patients admitted to the ED in Verona (Italy) from May 2011 to March 2016 with a Glasgow Coma Score below 10 were included in the analysis. Post-traumatic coma or subjects with a major trauma were excluded from the study. A brain computerized tomography scan was performed in all the patients and the cause of impaired consciousness was explored by instrumental and laboratory data available in the ED before patient to be discharge to the hospital ward or at home, if applicable. Acute outcome is reported too. During the study period 1,742 patients were admitted for NTC: 1,046 males, 696 females (mean age: 59,7 years; range: 18-101 years). Stroke caused NTC in 805 (46.2%) patients, heart failure in 304 (17,4%), metabolic disorders in 203 (11.7%), epilepsy in 188 (10.8%), respiratory insufficiency in 110 (6.3%), intoxication in 64 (3.7%), infection in 51 (2.9%) and malignancy in 17 (1%). Gender analysis showed males to have a higher prevalence of heart failure (20.2% vs 14.3%) NTC. On the other hand stroke (50% vs 43%) and malignancy (1.4% vs 0.7%) were higher in females. When dividing the study population by age, aged (over 65 years old) had higher prevalence of NTC due to respiratory insufficiency (7.9% vs 3.9%) and infection (4% vs 1.4%). Epilepsy (12.5% vs 9.9%), malignancy (1.6 vs 0.6%) and intoxications (6.8 vs 1.5%) were more frequent in patients below the age of 66 years. Diagnostics and patient stabilization in the ED accounted of 2 hours and 42 minutes (SD: 3 hrs 28 min) occupancy of the shock room. We had 29 fatalities in the Emergency Room, 21 patients were discharged home. The remaining patients were admitted mostly to intensive care units (1,262) or medical specialties (330) rather than ,medical wards (150). Diagnosis of non traumatic coma in the Emergency Department is a real challenging situation, requiring human and diagnostic resources for a significant amount of time. Intensive care units are often the final destination of most of these patients and diagnosis has a paramount importance in order to avoid hospital resources to be overwhelmed. On the other hand we have to consider NTC a serious condition requiring swift medical or surgical decision making upon arrival at the emergency department to give the best chances to the patient in terms of survival and long time clinical sequelae.


Massimo ZANNONI (VERONA, Italy), Gianni TURCATO, Alberto RIGATELLI, Valentina SIVERO, Francesco BUONOCORE
11:00 - 18:00 #7934 - Non-Traumatic Spontaneous Posterior Interosseous Neuropathy.
Non-Traumatic Spontaneous Posterior Interosseous Neuropathy.

Posterior interosseous nerve (PIN) neuropathy accounts for 0.7% of upper limb peripheral nerve compression syndrome with an annual incidence of 0.003% (1,2,3). We present a case of a 55 year old lady who presented with acute and progressive weakness of her left hand extensors. Examination revealed complete loss of extension of all the fingers of the left hand and mild weakness in wrist dorsiflexion(4). Tenderness was noted over the left radial head . Xray of the elbow showed no abnormalities. She was diagnosed with PIN neuropathy and discharged with oral vitamin B, analgesia and an early neurology appointment. PIN neuropathy is rare(1,2,3). It is thus important to understand the anatomical course of the radial nerve with its deep terminal branch , the PIN , including its clinical presentation to avoid misdiagnosis and to  initiate proper treatment for these patients.


Kenneth Boon Kiat TAN, Corinne Yee Lyn LAU (singapore, Singapore)
11:00 - 18:00 #7697 - Nonspecific abdominal pain in the Emergency Department: malignancy incidence in a nationwide Swedish cohort study.
Nonspecific abdominal pain in the Emergency Department: malignancy incidence in a nationwide Swedish cohort study.

Introduction The role of emergency physicians is to identify patients in need of immediate treatment, but also to identify symptoms indicative of serious, if not immediately life-threatening conditions. Aim To assess whether symptoms described as nonspecific abdominal pain (NSAP) could be the first indication of an abdominal malignancy. Materials and methods This was a nationwide registrybased cohort study of all patients discharged with NSAP from Swedish Emergency Departments (EDs) during the year 2011, based on Swedish patient registries of in-patient and out-patient care, and the cause of death registry, studying patients diagnosed with de novo cancer within a year after their NSAP discharge. Results Of 24801 patients discharged with NSAP in 2011, 2.2% were assigned a cancer diagnosis within 12 months. Almost 20% of patients diagnosed with a malignancy died within the year, and 16% of these deaths occurred within a monthaftertheEDvisit.Themajorityofpatientswithcancer were 60 years of age or older, and thus significantly older than the remaining NSAP patients. Patients with
malignancies also had a greater number of comorbidities than the remaining NSAP patients (P<0.01). Conclusion A small percentage of patients discharged with NSAP from Swedish EDs are diagnosed with a malignancy within a year. Patients aged 60 years or older and with comorbidities were over-represented in terms of developing malignancies after discharge. Emergency physicians should be aware of the fact that diffuse abdominal symptoms in elderly patients could be the first sign of an underlying malignancy and more liberally refer such patients for follow-up in primary care


Elfström CECILIA (Stockholm, Sweden), Goransson KATARINA, Therese DJARV
11:00 - 18:00 #7772 - Normal pressure in pseudotumor cerebri.
Normal pressure in pseudotumor cerebri.

Introduction

Pseudotumor cerebri (PTC), or Idiopathic intracranial hypertension (IIH), is a disorder defined by clinical criteria characterized by elevated intracranial pressure in the absence of a space-occupying lesion.

However, some cases have been described in which all diagnostic criteria are not met so far defined. We present a case report of a patient with clinical features suggestive of pseudotumor cerebri, whitout a document elevated measurement of intracranial pressure.

Case report

An 27-year-old woman, smoker, and with an mildly overweight body habitus, was admitted to our hospital with a history of headhache for one week. Also, her symptoms included nausea, pain eye, and diplopia binocular and horizontal. She denied traumatism, infections o drugs. On examination, pupils were normal, but exists sixth nerve palsy. Fundus examination revealed bilateral disc elevation. Study TC was normal. A lumbar puncture revealed an opening pressure CSF of 170 mmH2O, with a normal composition. She was admitted to Neurology, and she was begun acetazolamide (250mg / 8 h) and steroids (60mg prednison / 24 h). The patien’s visual fields and headache declined. In their reviews so far remained asymptomatic. 

Conclusions

PTC is the term use to describe a syndrome characterized by elevated intracranial pressure (ICP), without a space-occupying lesion. Generally has a self-limiting and benign course. Affects primarily obese women of childbearing age. The incidence is increasing as the obesity epidemic continues to expand worldwide. 

The pathogenesis is still uncertain. The most widely accepted theory postulates impaired CSF absorption at the level of the arachnoid granulations. 

It has been associated with various medical conditions, but recent weight gain and obesity are the only risk factors that have been demonstrated in case-control studies. Others associated conditions are: exogenous agents (vitamin A), obstructive sleep apnea, endocrine disorders, obstruction to venous drainage..

Headache is the most common symptom (present in over 90% of patients), and bilateral papilledema. Other symptoms include pulsatile tinnitus, transient visual obscurations, diplopia, and develop some degree of vision loss, that is severe and blinding in 10%.

The current criteria for diagnosis of PTC syndrome require:  elevated opening pressure (>250 mmH2O CSF in adults, normal neurological examination except sixth nerve palsy, papilledema bilateral, essentially normal neuroimaging, and normal CSF composition.

Some cases, if opening pressure is too low to meet definite criteria, but all the other criteria are met, the diagnosis of ‘probable’ PTC has been proposed, or has been called too ‘normal pressure PTC’. If this happens, we believe that a patient should undergo more agressive evaluation requiring extra vigilance to avoid misdiagnosis of other causes of optic nerve swelling. We believe that our patient represents this variation of PTC.

The goal is to treat the symptoms and the visual function. Treatments include treating the secondary cause, weight loss, medications (diuretics, particularly acetazolamide, corticosteroids) and occasionally repeated lumbar punctures. If vision is failing despite medical treatment, rapid surgical intervention is necessary.


Maria Del Carmen RODRIGUEZ CASIMIRO, Angelica CANAS BARRANCO (Malaga, Spain), Enrique CARO VAZQUEZ
11:00 - 18:00 #7838 - Nosocomial and Healthcare-Associated Pneumonia on a patient with chronic antibiotic treatment.
Nosocomial and Healthcare-Associated Pneumonia on a patient with chronic antibiotic treatment.

Introduction: 
Nosocomial viral pneumonia remains a common disease, associated with significant morbidity and mortality. It is the second most common nosocomial infection and accounts for 15–20% of the total patients in the intensive care unit. Patients with nosocomial pneumonia with influenza virus are older and more commonly have simultaneous health problems (such as previous stroke, heart failure and DIABETES).
Case report: 
A 60-year-old female patient, with a history of oxygen dependent chronic obstructive pulmonary disease, stage III hypertensive disease, type II insulin-dependent DIABETES, surgical treatment for mitral valve stenosis secondary to rheumatic fever, in her early life (for which she administers monthly antibiotic therapy, with amoxicillin/clavulanic acid), congestive heart failure, tricuspid and aortic valve disease, chronic kidney disease addressed the emergency department, presenting dyspnoea, anterior chest pain with posterior irradiance, and cough with expectoration for two days. The disease occurred after waiting for about 4 hours at the general practitioner for her antibiotic prescription and she went into progressive respiratory failure, because she could not administer herself oxygen. 
She was unstable in the emergency ward, where she presented severe dyspnoea, wheezing, diffuse sibilant rales, moderate hyperkalaemia (potassium level 5.88 mEq/L), peripheral oxygen saturation of 82%, arterial oxygen pressure was 68.4 mmHg (83‒106 mmHg), respiratory acidosis with arterial blood pH-7.26, and moderate leucocytosis with neutrophil predominance. In the emergency ward she received oxygen with a high volume, several administrations of inhalatory salbutamol (100 mcg/inhalation), intravenous hydrocortisone (two doses of 100 mg each), intravenous aminophylline (5.7 mg/kg body weight dose, as a bolus). She was eventually admitted to the internal medicine department as her status did not improved significantly. Her blood tests revealed chronic infection with hepatitis B virus.
After 8 days of hospitalization and antibiotic treatment with large spectrum penicillins, the patient contracted nosocomial pneumonia due to the airborne transmission. The patient's symptoms were: dry cough, chest pain, myalgia, wheezing. Both lungs presented crepitants in the lower halves of the lungs. This correlated with X-ray aspect which showed increased heart size, basal pulmonary stasis and increased opacity in the base.
The patient was treated with oxygen therapy, acenocumarol (for mitral valve vegetations prophylaxis), ceftriaxone, aminophylline, metamizole, ranitidine, furosemide, nifedipine, and her evolution was favourable, with the disappearance of the dyspnoea and the anterior chest pain.
Discussion:
Viral pneumonia, in patients with chronic pulmonary pathologies and other major comorbidities, constitutes a frequent cause of acute presentations. Although hospitalization is mandatory in their instances, their chronic use of prophylactic antibiotherapy makes them susceptible to overinfection with nosocomial bacterial pathogens, with resistance to regular antibiotics, therefore complicating their evolution. It is essential to monitor their evolution very closely. Also, it is very important for the emergency medicine specialist to correctly evaluate the potential hazards at which such a patient is exposed and to recommend for hospitalization, even if, in several cases, he might present a partial remission of the signs and symptoms that have determined the presentation to the emergency ward.


Chirea GABRIELA (Bucharest, Romania), Comsa MIHAI
11:00 - 18:00 #7526 - Not all massages are relaxing.
Not all massages are relaxing.

Our patient is a woman, 43 years old, with Fibromyalgia and anorexia, who is treated by Psychiatry, she hat secundary malnutrition. Her treatment is Trazodone, Aceclofenac, Pantoprazole, Venlafaxine, Clorazepate, Retinol, Lorazepam and topic Mometasone. She comes to Emergency Room because of a pain in her left shoulder with mechanic characteristics, which began several days before, and it persists in despite of NSAID that her doctor prescribed her in consultation, with the suspicion of an acute tendinitis. She suffers frequently back pains, that she treats with physiotherapy and osteopathy, and her last session happened 10 days ago.

She was hemodynamically stable, without fever, normal breath ratio, 100% O2 Saturation. There were no findings in chest and abdomen, but her left arm was clearly higher than the right one, from shoulder to the hand,, with collateral circulation. There was no pain in bones or ligaments, but the mobilization of the arm was painful.

In the blood tests, there were no alterations, except for Ddimer 0.77, so, with the suspicion of deep vein thrombosis (DVT), it´s made an ultrasonography exploration, and we found a DVT in left axillary and subclavian veins, so we began with anticoagulation and the patient was admitted in Internal Medicine to begin the study.

In Hospital, the collateral circulation and oedema were resuced with treatment. A TC was made, which showed an embolism in lower lung arteries of the right lung, without nodules or adenopathies. All the other tests were normal.

The upper extremities DVT is an uncommon entity (10% DVT). It could be primary, because of a compression of the subclavian vein or because of physical exercise (Paget Schroetter Syndrom), or secundary (catheters, pathmakers, cancer, hormonal cause, thrombofilic state, or direct injury). There are cases which happen after a physiotherapy or osteopathy session, as our patient. A pulmonary embolism must be searched (in despite that is more common in DVT of lower extremities).

In conclussion, we have to consider always a DVT diagnostic in a patient with pain and oedema in upper extremity, and knowing the Risk Factors for a sooner diagnostic.


Félix Manuel DOMINGO SERRANO, Sergio SÁNCHEZ RUIZ (Guadalajara, Spain), Eduardo FERNÁNDEZ VERSTEEG, Maria José. JIMÉNEZ MELÉNDEZ, Mercedes FERNÁNDEZ-ESCRIBANO HERNÁNDEZ, María Pilar LOZANO GARCÍA, Amor GIL DÍAZ, Jose Antonio LAPERAL MARTÍN, Eulalia LÓPEZ NAHARRO
11:00 - 18:00 #6290 - Not for the faint-hearted: towards better management of syncopal patients presenting to the emergency department.
Not for the faint-hearted: towards better management of syncopal patients presenting to the emergency department.

Background/Introduction:

Syncope is a common Emergency Department (ED) presentation, and often misdiagnosed (1). Initial assessment seeks to discern episodes with an underlying cardiac cause from those that are vasovagal/postural. The former are more dangerous, carrying greater mortality, and often require admission for early cardiac follow-up, monitoring, or other investigation/treatment (2). We audited the ED assessment of syncope against National Institute of Clinical Excellence (NICE) guidance to assess whether we were extracting the proper information that would raise the alarm for cardiac syncope (1). The eventual aim is to establish a guidance document that has some key points to remember when dealing with a syncopal patient.

 

Participants/Methods:

This was a retrospective study in patients presenting with syncope to the ED of Royal Preston Hospital in January 2016. The search terms from triage included: ‘fall, collapse, faint, transient loss of consciousness (TLoC), blackouts and vasovagal’. The age range was between 15 and 65. Of 178 sets of casenotes, 45 were included on closer review as they were truly syncopal. The documentation was searched for evidence of 11 key variables we deemed of key importance in the syncope assessment:

 

  1. Evidence of a coherent history
  2. Observations [pulse, respiratory rate, temperature, blood sugar (BM)]
  3. Lying/standing blood pressure (BP)
  4. Past medical history (PMH) of cardiac disease
  5. Drug history (DH)
  6. Electrocardiogram (ECG)
  7. Evidence of congestive cardiac failure (CCF)
  8. Exertional syncope
  9. Shortness of breath (SOB)
  10. Murmur
  11. Family history of sudden cardiac death (FHx)

 

 

Results:

No single variable had evidence of documentation/consideration in more than 80% of the sample. Of the 11 variables, the following had evidence of documentation/consideration in more than 50% of the 45-patient sample: ECG (80%), coherent history (78%), history of cardiac disease (76%), murmur (76%), observations including BM (69%), DH (58%). The remaining variables had been documented/considered in fewer than 50% of the sample: SOB (29%), lying/standing BP (18%), CCF (9%), exertional syncope (7%), FHx (4%).

 

Discussion/Conclusion:

The variables we audited represent either ‘red flags’ or essential data for the management of syncopal patients. Documentation of these were poor and inconsistent, perhaps representing: a lack of education among clinicians about best management of syncope; appropriate consideration of factors but incomplete documentation; illegible handwriting (noted in our data collection); or clinicians’ presumption (younger patients had less complete drug histories perhaps because they were presumed not to take any).

We have implemented a guidance document that will help consider all these variables when dealing with a syncopal patient, which we are re-auditing. The key benefit is improvement in patient safety by not missing key points that suggest a dangerous cause of the syncopal episode. Furthermore, ‘low-risk’ patients suffering a clear vasovagal can be safely discharged with advice after minimal investigation if all the red-flag issues are addressed.

 

References:

(1)    Nice.org.uk. Transient loss of consciousness ('blackouts') in over-16s|1-Guidance|Guidance and guidelines|NICE 2010

(2)    Moya A, Sutton R, Ammirati F et al. Guidelines for the diagnosis and management of syncope: The Task Force for the Diagnosis and Management of Syncope of the European Society of Cardiology. European Heart Journal. 2009;30(21):2631-2671.


Chieun HAN (Milton Keynes, United Kingdom), Sarah SHAW, Roshan SALEH
11:00 - 18:00 #8204 - Not just a sport injury.
Not just a sport injury.

Introduction

We present the case of a 29 years old male who was transferred by ambulance to the Emergency Department(ED) post tonico-clonic seizures and a bruise over right leg.

Methods and matherials: CASE REPORT

29 years old male transferred by ambulance to the ED post tonico-clonic seizures and a bruise over right leg. Bruise over right leg got worse for the last 4 days after an injury suffered while playing football. patients was unwell with vomitings and mild headache 1day prior to arrival. On inital assesment GCS(glasgow coma scale) 3   Blood pressure (BP) 120/67) HR 100 Oxigen saturation of 89%. Was intubated and ventilated iv access was obtained bleeding profunsly from venopucture site. On examination : bruise noticed over the body different stages from yellow colour to purble and green right calf swollen and sevrely brusie compare to left, Chest: normal exam, Abdomen : normal exam, Central Nervous System : GCS3  pupils size 6 reactive to light reflexes normal. Laboratory Results: white cell count of 37.000, Platlets : 7, Hb 9, Urea and creatinine where normal, c reactive proteine was normal, INR 1.8, , Fibrinogen 0.7 DD high >20 normal 0.5, gass performed showed hypoxia and mild metabolic acidosis with a lactete of 5. Working diagnoses was : severe sepsis with diseminated intravascular coagulation and seizures or massive pulmonary embolus with intracerebral extension. Patient was stabilized and transfered to Computer Tomgraphy (CT) of the brain.

Results: 

CT results: acute left parieto-occipital haemorrage with intraventricular extension, diffuse axonic brain injury with tonsilar, sub uncal and subfalcine herniation skull vault unremarkable

CT Pulmonary Angiogram Negative for pulmonary embolus.

Blod Film results : promyelocytes , atypical mononuclear cells with blasts presents neutrofil count normal, promyelocits contains auer rods, image conistent with acute promyecocytic leukemia

After stabilisation patient was transfered to the neurosurgical national refference centre in Beaumont Hospital Dublin where he died after 3 days of intensive care unit stabilisation.

Conclusions : 

Most patients with acute promyelocytic leukemia present with pancytopenia and coagulopaty our case is particular that was taken as a minor sport injury and did not attented medical advice until late with catastrofic consequences .


Cristiu OCTAV (drogheda, Ireland), Ahmad MR JAMAL
11:00 - 18:00 #7382 - NOT TO APLPLY THE CANADIAN SPINE RULE. ECONOMIC COST.
NOT TO APLPLY THE CANADIAN SPINE RULE. ECONOMIC COST.

INTRODUCTION

The Canadian Spine rule is an assassment tool used to rule out cervical spine injury in low-risk patients, obviating the need for radiography.

AIM:

Describe the application of simple radiology patients diagnosed with cervical whiplash in a hospital emergency department and analyze whether such requests in accordance with the proposed the Canadian C-Spine rule algorithm.

MATERIAL Y MÉTODOS:

The study was conducted at the Hospital Universitario de La Ribera (Alzira-Valencia-Spain). All the patients diagnosed with a whiplash that were treated between 1st January and 31st December 2015 were included.

The application of imaging tests (Simple radiology, CT, MRI, electromyography and myelography) in patients sample was studied.

For requests of plain radiographs examined whether these requests were made according to The Canadian C-Spine rule.

RESULTADOS:

373 patients were included. A little bit more of a half were females. The age average was 36.84 ±13.76 years old.

Imaging tests were applied to 86.3 % of patients : 82.3 % radiography and 4% ( TAC / RM)

In 67.56 % of cases, radiographs requests did not conform to the recommendations of The Canadian C - Spine rule.

This meant an economic impact of 7.350 €.  

CONCLUSIONES:

Clinicals of hospital emergency services requested radiography to almost all patients diagnosed with cervical sprain without following the proposed The Canadian C - Spine rule algorithm which results in a health system like the current unjustified cost human and economic resources.

REFERENCES:

1.- Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH et al. The Canadian C-Spine rule versus NEXUS low-risk criteria in patients with trauma. N Engl J Med.2003 Dec 25. 349 (26):2510-8.

2.- Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio et al. The Canadian C-Spine rule for radiopgraphy in alert and stable trauma patients. JAMA.2001 Oct 17.. 286 (15):1841-8.

3.- Stiell IG, Clement CM,O´Connor A, Davies B, Laclair C, Sheehan P et al. Multicentre prospective validation of the use of the Canadian C-Spine Rule by triage nurses in the emergency department. CMAJ.2010 Aug 10. 182 (11):1173-9


Luis MANCLÚS MONTOYA (Valencia, Spain), María CUENCA TORRES, Pedro GARCÍA BERMEJO, Sergio NAVARRO GUTIERREZ, Miguel Angel GINER ESPARZA, José María TENIAS BURILLO
11:00 - 18:00 #8148 - Novel team approach in trauma patient management: a single center’s experience.
Novel team approach in trauma patient management: a single center’s experience.

Purpose of the study: Worldwide, trauma claims more productive life years than any other disease. It is well known that almost 90% of fatalities develop within the week after major trauma, but more alarming is the fact that many preventable causes of death occur within the first few hours. Today, the most common identified problems during trauma patient management are: underestimation of the seriousness of injuries, misinterpretation of performed investigations, technical failures, as well as lack of experience of the trauma teams. The World Health Organization estimates that the mortality of major trauma in Europe could be decreased up to 30% by improving the chain of care for major trauma patients. Trauma 'chain of survival' refers to a series of actions that, when put into motion, reduce the mortality associated with trauma. Like any chain, the trauma 'chain of survival', commencing at the scene of injury, all the way through to the place of definitive treatment, is only as strong as its weakest link. Therefore, trauma care represents a major challenge for all medical professionals, especially the ones working in the Emergency Department (ED). The aim of our study was to demonstrate University Hospital Center Zagreb Emergency Department’s experience in trauma patient management after implementation of a novel model called ‘horizontal team approach’. Materials and methods: During 2015 we have implemented an innovative model of  ‘the horizontal team approach’ in our Department's trauma patient management. Senior instructors and educators of the European Trauma Course Organization trained all trauma teams dealing with trauma resuscitation on a daily basis. Results: Our concept of trauma teams installs physicians of different specialties, nurses and technicians, working seamlessly together in the acute care of major trauma patient. The essence of ‘horizontal team approach’ implementation is to provide trauma patient care where variable set of processes run simultaneously. These are adapted to the trauma patient's condition, which can change anytime. The response of critically injured patient to the trauma team’s interventions is dynamic and therefore resuscitation is continuous cycle of assessment, intervention and reassessment. Each member of the team understands their responsibilities (A, B, C person) and role within the team, synchronously working within their competencies. We put strong focus on team member’s leadership skills, cooperation between the team members, coupled with non-technical skills of teamwork and communication. Conclusions: Well-established ED trauma teams, offering state of the art trauma care, with a focus on the multi-specialty, multi-professional team approach, represent one of the paramount links in the trauma 'chain of survival', and should be implemented in every ED receiving traumatized patients.


Ileana LULIC, Dr Dinka LULIC (Zagreb, Croatia), Mirjana MIRIC, Mihaela MIHOVILCEVIC, Anita LUKIC, Nina CVJETICANIN, Ivan GORNIK
11:00 - 18:00 #8097 - Nurses' knowledge of cardiopulmonary arrest and resuscitation in hospital settings.
Nurses' knowledge of cardiopulmonary arrest and resuscitation in hospital settings.

BACKGROUND: ''Science of Resuscitation" is continuously advancing, and clinical guidelines have to be regularly updated in order to follow the development and offer the health care workers the best procedures for treatment. Early identification and effective therapy procedure for patients with deteriorating conditions can prevent the development of cardiopulmonary arrest. Besides the doctors, there is a need for constant professional training of nurses as well. According to the  the Croatian Nurses Council nurses have obligation for constant renew already acquired knowledge and adopt new knowledge in accordance with the latest achievements and findings in the field of nursing.

AIM: This research aimed to investigate levels of nurses knowledge in the field of resuscitation in the departments of emergency medicine.

METHODS: Cross sectional multi - centre study has been conducted. The target population were nurses that are employed in departments of emergency medicine. The quantitative approach has been applied in several University Hospitals in Croatia with questionnaire prepared for the purpose of the research.

RESULTS: Results of a research conducted on a sample of 91 nurses of the University Hospital Centre Zagreb, University Hospital Centre Rijeka and University Hospital Centre Osijek showed  that the level of theoretical knowledge is about 75%. Also, the analysis determined a positive correlation of additional education to the research results. A nurse with quality education represents an exceptionally valuable medical team member, and consequently, the quality of their education improves the patient's hospital care.

CONCLUSION: Health care professionals show a high degree of motivation for continued education (which is the foremost indicator of knowledge and skill acquisition at organized permanent education programs) and the willingness for saving human lives, which contributes to the advancement of the practice and efficiency of resuscitation in cases of pulmonary arrest.

 

 


Sandro VIDMANIC, Adriano FRIGANOVIC (Zagreb, Croatia)
11:00 - 18:00 #7205 - Obstructive Hydrocephalus Secondary To Third Ventricle Colloid Cyst: A Rare Cause Of Severe Acute Headache.
Obstructive Hydrocephalus Secondary To Third Ventricle Colloid Cyst: A Rare Cause Of Severe Acute Headache.

INTRODUCTION: Headache is a common presenting complaint to the Emergency Department, with a variety of etiologies ranging from benign primary headaches to catastrophic intracranial bleeding. We present a patient with severe, acute headache secondary to obstructive hydrocephalus from third ventricle colloid cyst.

 

CASE REPORT: A 34 year old male with no significant past medical history of note presents to the emergency department after landing from a four hour flight. He presented with acute onset of headache prior to his flight and the severity of headache worsened during the flight, associated with altered mental state during flight descent.

 

 His vital signs are as follows: temperature, 38.0OC; pulse rate, 82/min; respiratory rate, 16/min; blood pressure, 131/89mmHg; pulse oximetry, 100% on room air; GCS score of 14 (eye opening 3, verbal response 5, motor response 6). On physical examination, neck was supple and patient was still able to converse, but opens eyes only to calling. There were no focal neurological deficits. Laboratory investigations showed elevated total white blood cell count of 15.5 x 103/uL. Chest x-ray was unremarkable. CT head showed a hyperdense mass in the interpeduncular cistern causing mass effect on the floor of the third ventricle and probably on the foramen of Monro with resultant moderate hydrocephalus. Patient was admitted to the Neurosurgery department for further management.

 

 External ventricular drain (EVD) was inserted early to relieve acute hydrocephalus. Inpatient MRI of the brain showed a colloid cyst over inferior aspect of foramen of Monro and third ventricle, causing hydrocephalus with mild decompression of lateral ventricles post-EVD insertion.

 (If identified for poster presentation, additional relevant images of pertinent radiological investigations done would be included to provide further illustration and enhance learning value)

 

 Subsequently, the patient underwent craniotomy and excision of third ventricle colloid cyst and was noted to have deficits in attention span, working memory, speed of information processing, learning, and executive function. Inpatient septic work up was negative and fever was attributed to a central cause. The patient was discharged with outpatient follow up to neurosurgery and rehabilitation medicine.  

 

 DISCUSSION: Colloid cysts are rare intracranial lesions and are the most common tumor of the third ventricle. Patients with colloid cysts may remain asymptomatic or can be associated with morbidity when obstruction of the foramen of Monro occurs, leading to severe headache, hydrocephalus and even death.  CT head should be performed at the emergency department to identify causes of severe headache, and surgical intervention should be performed if there is evidence of acute hydrocephalus.

 

 CONCLUSION: A third ventricle colloid cyst is a rare cause of acute headache with significant morbidity and mortality in the setting of acute obstructive hydrocephalus. It requires a high index of suspicion, particularly if headache is severe and unremitting, with the presence of red flag signs and symptoms.


Yuzeng SHEN (SINGAPORE, Singapore), Yee Chien TAY
11:00 - 18:00 #8057 - Occupancy is not associated with a delay in treatment with antibiotics in patients with sepsis.
Occupancy is not associated with a delay in treatment with antibiotics in patients with sepsis.

Introduction: Emergency department (ED) overcrowding is important since it might decrease quality of care. The aim of our study was to examine if crowding measured by occupancy in an Emergency Department (ED) has any impact on the time of delivery of antibiotics in patients with sepsis.

Methods: A historical cohort study among prospectively registered sepsis patients admitted to the ED at Slagelse Hospital, Denmark, during the period 01.11.2013 to 30.09.14. The information about the time of admission to the ED, and time of delivery of antibiotics was obtained from the department’s sepsis registry form. Data about the number of patients who were admitted to the ED, and the occupancy rate throughout all hours of the study period were retrieved from the IT department at Slagelse Hospital.

Results: A total of 393 patients were included in the study. The median door-to-needle time was 1.49 hours. The median door-to-needle time was 1.31, 1.75, 1.47 and 1.60 hours within the ED occupancy rate intervals of  < 0.75, 0.75 to 0.99, 1.0 to 1.25  and > 1.25, respectively (p = 0.240). There was no association between delayed antibiotic treatment (>1 hour) after the sepsis diagnosis was recognized and the occupancy rate (p = 0.685). The door-to-needle time among women was longer compared to men (1.63 hours vs. 1.34 hours, p = 0.007).

Conclusion: Increasing occupancy rates did not have any negative impact on the time of antibiotic treatment.


Theo Sebasian TILTNES, Chris Andre HØYVIK, Finn Erland NIELSEN (Copenhagen, Denmark)
11:00 - 18:00 #8108 - Ocular manifestations as a guide of disease activity in systemic lupus erythematosus. A case report.
Ocular manifestations as a guide of disease activity in systemic lupus erythematosus. A case report.

Introduction

Systemic lupus erythematosus is a multisystem disease of unknown etiology characterized by numerous autoimmune phenomena with lesions in multiple organ systems. Ocular manifestations of systemic lupus erythematosus (SLE) include mucocutaneous involvement of the eyelids, secondary Sjogren’s syndrome, optic neuropathy. Retinal vasculitis and optic neuritis are two of the most vision-threatening complications that can be associated with the disease. Ocular manifestations are often associated with wide-spread systemic inflammation which can be fatal. Thus, immediate recognition and treatment is vital for a positive outcome.

Case report

A 47 year old female patient, with systemic lupus erythematosus, treated with hydroxychloroquine 400 mg/day, was admitted for third time during the last week because she referred repeatedly 20-minutes-long episodes of periphery photopsias in both two eyes and a temporal visual field defect above the horizontal. No other symptoms were associated.

At presentation in the emergency department on this occasion, she underwent a complete ophthalmological examination, which was normal, as well as the neurological one.

The general examination revealed no disorders.

The laboratory evaluation, neuro- radiological studies and cardiovascular evaluation showed no alterations.

Having the history of patient in mind and taking into account these features we suspected the clinical diagnosis of vasculitis due to SLE, therefore the patient was discharged and referred to rheumathology, from where more specific laboratory test were requested revealing abnormal titers of antinuclear antibodies and increased of erythrocyte sedimentation rate. The levels of antiphospholipid antibodies, complement levels and screening for thrombophilia were within normal range.

She was treated with oral prednisone (60mgr per day) and hydroxychloroquine successfully.

Discussion

The patient was admitted at the emergency department time and time again during the last week and discharged every time because of the absence of alterations at the examination and the complementary test.

Ocular manifestations is suggestive of high disease activity during the history of SLE and may reflect systemic vascular damage. Thus, immediate recognition and treatment is vital for a positive outcome (as in our case). Therefore close communication between the emergency department and rheumatology is critical in the effective management of these complex clinical situation


Teresa ESCOLAR, Miguel RIVAS, Jose Manuel ABASCAL, Peña LOPEZ (ZARAGOZA, Spain), Michelle SOLER
11:00 - 18:00 #7830 - Oculo-orogenital disease: an interesting rare case of Fuch’s syndrome in association with ibuprofen.
Oculo-orogenital disease: an interesting rare case of Fuch’s syndrome in association with ibuprofen.

Introduction: The aetiology of oculo-orogenital disease is vast and can include various causes including infections, drug-reactions, neoplasms, trauma or Behçet’s syndrome. Stevens-Johnson syndrome is a hypersensitivity reaction most commonly induced by drugs that often presents as a medical emergency with both skin lesions and mucosal involvement. A rare pure mucosal variant of Steven-Johnson syndrome or Fuch’s syndrome is reported in the literature which should be considered in the differential diagnosis. We present a case of this rare entity presenting in a patient with oculo-orogenital disease in absence of any cutaneous symptoms and a rare association with a commonly used drug ibuprofen.

Case: A 26-year old previously fit and well female presented to emergency department with one-week history of insidious-onset bilateral conjunctivitis, an oral-ulcer along with dysuria and dyspareunia. She became generally unwell over next 24 hours with worsening painful red-eyes, difficulty in swallowing and dysuria. On examination she had multiple buccal-mucosal erosions with vulvo-vaginal ulcers and bilateral conjunctivitis; rest of the systemic examination was unremarkable. Interestingly, there was complete absence of any cutaneous lesions. On direct questioning, no high-risk behaviour or sexual history was elicited; however, she reported using over the counter ibuprofen for last fortnight for intermittent headaches.

Investigations revealed raised C-reactive protein and erythrocyte-sedimentation-rate. Rest multitude investigations were negative including cultures for urine, blood, throat-swab, nasal, oral, uretheral, triple-swab, high-vaginal swab; serology for retrovirus, gonorrhoea, syphilis, Chlamydia and screening for human herpes virus type 1 and 2, varicella-zoster virus,cytomegalovirus and Mycoplasma pneumonia. Immunology screen was negative for auto-antibodies (antinuclear, extractable nuclear antigens, DNA, neutrophil-cytoplasmic, rheumatoid-factor) and HLAB-51/5 and had normal vitamin B12/B6 levels. Empirical treatment for possible herpes (started on admission) was discontinued once results were confirmed.

After excluding common differentials, a suggestive history of drug-exposure (ibuprofen) with gradually progressive oculo-orogenital non-cutaneous pure mucosal involvement supported the diagnosis of Fuch’s syndrome.

Her ibuprofen was discontinued. Supportive care with corticosteroids (systemic and topical) was provided including appropriate cleaning of eyelids and daily lubrication with preservative-free drops/ointments and topical corticosteroids for ocular care. Antiseptic solutions and gargles were administered for oral care. Intravagical topical corticosteroid ointments were used in conjunction with topical antifungal-creams to prevent vaginal-candidiasis followed by inserting soft-vaginal-moulds (to prevent adhesions). This led to a clinically-evident regression of her mucosal symptoms and within 14 days she made a significant recovery with ongoing high-dose oral-corticosteroids; and complete symptomatic resolution with no recurrence of her symptoms at one–month follow-up.

Discussion: “Fuch’s syndrome” or “Steven-Johnson syndrome without skin lesions” or “Atypical Steven-Johnson syndrome” is usually reported in literature in children and adolescents but rather rarely in adults; and mostly in association with Mycoplasma pneumonia infection.

As per our best knowledge this is the first ever reported case of ibuprofen associated Fuch’s syndrome in an adult worldwide.

Our case report emphasises the need to consider drug-induced Fuch’s syndrome as a differential diagnosis while evaluating non-cutaneous oculo-orogential presentations; where early identification and prompt withdrawal of the culprit drug with appropriate supportive care and steroids could lead to a remarkable recovery.


Deepwant SINGH (Bury St Edmunds, )
11:00 - 18:00 #7554 - Oncology patients profile attended at the emergency deparment.
Oncology patients profile attended at the emergency deparment.


Introduction: In recent times , there is an increase in oncology patients who come to emergency deparment due to improved diagnostic and therapeutic procedures, as well as an aging population.
Whenever possible, the emergency personal should consult the patient's medical record to know the clinical patient situation and the active treatment who the patient is receiving for the optimal therapeutic management.

Objetive:Describe the oncology patient profile attended in the emergency department, the reasons for consultation and clinical management.

Methods:There was realized a descriptive and retrospective study of the oncology patients attended in the emergency department of our hospital between January and December, 2015.
Data were extracted from the record of the digital medical history Diraya ®.
For the study of the profile and management of patients were collected as variables: sociodemographic characteristics (age and sex ) , reason for consultation, diagnosis at discharge, type and location of the tumor, tumor stage , final destination and mortality in emergency department.

Results: A total of 118 patients were attended from January to December 2015. 62% of patients were males.  The median age was 64 years (SD 9.8 years). The most common reasons for consultation were fever/infection in 46 cases ,  (38,9% , of which 11 % were febrile neutropenia), digestive complications in 24 cases (20.3 %, of which 54.1% were vomiting or diarrea) and thrombosis in 11 cases (9.35).
Both pain and the direct clinical reaction to chemotherapy were infrequent reasons consultation (4% in both cases). According to the location of the tumor, the most common neoplastic diseases included digestive tract (48%), lung ( 18%), breast (15%) and urologic tract locations (10%). Of the 118 patients , 94% were receiving chemotherapy. 66% of patients (78 cases) were diagnosed with stage IV advanced neoplasia compared to 3% (4 cases) in initial stage of disease. After evaluation in the emergency department, 49 patients (41,5%) required  hospital admission and 17 cases were exitus.

Conclusions: More than 60 % of oncology patients who come to the Emergency deparment have advanced disease . Most of Stage IV patients were being treated with chemotherapy , so the reason for consultation may be influenced by both the stage of the disease and chemotherapy treatment. The value of chemotherapy treatment, in certain stages can be questioned.


Maria GIL LOPEZ (OSUNA, Spain), Elena PRADO MEL, Almudena LOZANO VICENTE, Antonio Bernabé ROJAS RAMIREZ
11:00 - 18:00 #7893 - Ophthalmoplegic Migraine: A Case.
Ophthalmoplegic Migraine: A Case.

AIM: Migraine is a frequent neurologic disease which is presented with headache and some accompanied symptoms such as phonophobia, photophobia, nausea and vomiting(1). Sometimes, findings like diplopia, ptosis, pupillary abnormalities and limitation of eye movements can be determined as unusual. In such a case, it is called ophthalmoplegic migraine and it is seen rarely.
CASE: A forty nine year old male patient applied to our emergency service by complaining of headache and diplopia. Nausea was another coexistent complaint.The patient expressed that he used to have this type of headache episodes previously. He had no any medical history and medications. Vital signs were noted as normal. Blood pressure was 110/80 mmHg, heart beat was 76 bpm and body temperature was measured as 36. 7°C degrees. Limitation of abduction of the left eye was determined by examination (figure 1). There was no any abnormal result for laboratory test. Brain MR was assessed as normal (figure2). Besides, brain CT also didn’t reveal us any significant finding (figure3). 1000 mg of Paracytamol was supplied as intravenous to relieve headache. The patient was consulted to Neurology and Ophthalmology.
CONCLUSION: Consequently, we want to emphasize that ophthalmoplegia should be assessed in terms of OM if accompanies to migraine-like headache, nausea and vomiting.


Musa KAYA, Arif DURAN, Faruk KURT, Mansur Kürşad ERKURAN (Bolu, Turkey)
11:00 - 18:00 #7785 - Opioids and Emergency: is it an alternative?
Opioids and Emergency: is it an alternative?

INTRODUCTION

 

Up to 50 % of E&A visits are for pain, either acute or chronic exacerbations. Proper diagnosis , treatment and control significantly influences the care overload of these services.

 

OBJECTIVES

¥ To analyze the epidemiological characteristics and management in the emergency department of patients with severe acute or chronic pain, exacerbated or poorly controlled, noncancer (VAS> 8), which is administered therapy with inhaled quick-release fentanyl (IQF).

¥ To Check the discharge treatment and evolution in the next week.

 

METODS

Descriptive study, without intervention, retrospective of patients presenting to the emergency department of a tertiary hospital for pain of the features described, from 1 to 31 March 2015. The data obtained from clinical history program and we analyzed using SPSS program.

 

 

RESULTS


During the study period it was prescribed IQF to twelve patients presenting with acute or exacerbated pain, with mixed characteristics .

 

Women predominated (58%) with mean age 65 ± 13 years. The sample was characterized by high Charlson comorbidity index (75%). 17% consulted for acute pain less than a day of evolution and the rest (73%) by poor control of chronic or acute pain, the average time duration of symptoms was 22 ± 12 days.

 


Except for two patients , all taking analgesic treatment before his visit to the emergency room , the most used paracetamol and anti-inflammatory . None took strong opioids. The most frequent reason for consultation was musculoskeletal pain 67 % (8 ) followed by visceral pain. The average intensity according to the numerical visual scale (VAS ) was 9.


They were given IQF getting a good pain control in all cases within 30 minutes with VAS < 6. This value was maintained or decreased to thirty minutes in all patients . ( VAS average 2-60 minutes) .

 


All patients were discharged with analgesic treatment ( strong opioids 83%). Only one patient was admitted to complete inpatient study and two were assessed again at 48 hours : one for persistent pain (VAS 5-6) that was resolved by adjusting the dose of fentanyl without specifying income and another for a reason different it is having to do with an underlying disease.

 

 

 

 

CONCLUSIONS

IQF administration get good control of pain of moderate to severe intensity, helping to reduce the stay and revisits, and promoting quality of care in the E&A.


Marta MERLO (MADRID, Spain), Mercedes CUESTA, Francisco SALAS, César VERGARA
11:00 - 18:00 #7186 - Opportunities and difficulties for achieving an equal and timely access of patients to emergency care in Bulgaria.
Opportunities and difficulties for achieving an equal and timely access of patients to emergency care in Bulgaria.

Introduction: Emergency medicine is provided in deficit of time and information. Every emergency team must reach the patient on time and apply the appropriate lifesaving diagnostics and treatment. Bulgaria has long-standing traditions in emergency care, striving to ensure equal and timely access for all the population.

Material and methods: The organization and the legal framework of emergency medical care in Bulgaria in pre-hospital and hospital environment are analyzed. The results are presented from a study that was carried out in 2016 among 312 professionals in emergency aid regarding the reforms in the emergency system – information was obtained via a semi-structured questionnaire.

Results and discussion: The emergency medical care in Bulgaria is free of charge for the patients irrespective of their health insurance status or place of residence, and it is financed by the state budget. It was organized by the 1960s in structures belonging to hospitals and polyclinics. In the 1990s, 28 centers for pre-hospital emergency were established, and emergency wards were differentiated in 34 hospitals in 2007. Nowadays there are 366 mobile teams in the country, 197 emergency rooms with teams on duty, and 34 emergency departments in the biggest hospitals. The European Emergency Number 112 has been operating since 2007 in Bulgaria and is connected to 27 emergency medical telephone exchanges. Specialty of emergency medicine was introduced in 1996. The specialized hospital of emergency medicine “Pirogov” in Sofia is responsible for the continuing education of the physicians in emergency medicine. The main difficulties for timely and equal access of patients to emergency aid include the irregular distribution of emergency teams throughout the country; the shortage of personnel due to ageing, low remuneration and cases of aggression against them; as well as a lot of patients who are not urgent but do not possess a health insurance and use emergency structures every time they need medical care (thus, the service of urgent patients is delayed). A new medical standard in emergency medicine was adopted in 2015, based on the best world practices and particularly the European curriculum for emergency medicine of the European Society for Emergency Medicine (EuSEM). The new standard was intended to introduce the triage, algorithms of work, standardized architecture and equipment of all emergency structures. The training of paramedics and physician’s assistants who should enter in pre-hospital emergency was introduced. The results of the study among emergency personnel show that 67.9% of the respondents consider that the introduction of the triage will improve emergency services, 67.9% approve algorithms for work, 59.9% believe that the paramedics will solve the personnel shortage, 80% are motivated by reforms to continue to work in the system.

Conclusion: As a whole, the emergency care in Bulgaria is well structured but it experiences some organizational and personnel problems, which are expected to be solved through an introduction of the triage, improving the equipment, and the inclusion of paramedics and physician’s assistants in the emergency teams. 


Desislava KATELIEVA (SOFIA, Bulgaria), Lora GEORGIEVA
11:00 - 18:00 #8110 - OPTIMIZATION OF PATIENTS HOSPITAL TO AGE AND SEVERITY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE.
OPTIMIZATION OF PATIENTS HOSPITAL TO AGE AND SEVERITY OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE.

Introduction
Chronic obstructive pulmonary disease (COPD) is defined as obstruction usually progressive and irreversible airway. It involves large consumption of resources in health given the high frequency of Hospitalization

Objective
Assess whether there is an adaptation of hospitalization in response to gravity as FEV1 and / or age ( 75 years) with attention to the frail elderly.

Material and methods
observational, retrospective study in a General Hospital with an area of 200,000 inhabitants and 275 urg / día.Se included patients with previously diagnosed COPD by spirometric who presented to test from January 2012 to July 2015 due to worsening of their disease. It was analyzed was taken as basis baseline ill patients according to GOLD and age grouping sign> or

Results
They consulted by 1029 COPD exacerbation patients.
According GOLD, 273 (26.5%) patients had very severe stage. Of which 191 are admitted to hospital (70%) and are discharged 82 (30%).
severe patients 446 (43.35%), admitted to the hospital 277 (62.1%) and are discharged 169 (37.9%).
Moderates 290 (28.18%), admitted to the hospital 181 (62.4%) and are discharged 109 (37.6%)
Mild 20 (1.94%), admitted to the hospital 9 (45%) and are discharged 11 (55%)
By age, 564 (54.7%) are> or equal to 75 years. 365 (64.7%) admitted to the hospital. 199 (35.3%) they are are discharged home.
465 (45.3%) were patients aged

Conclusions
With respect to the baseline severity by FEV1 patients with severe or very severe baseline stage they enter more than mild or moderate as is normal.
In relation to age, there is a slightly higher percentage of patients of patients aged> or equal to 75 who earn more revenue although the percentages are similar in both age groups.
Overall an adaptation of hospitalization is performed based on the baseline stage with a tendency to objectify hospitalization without major differences according to age.
The healthcare professional should attempt a proper matching of income of patients with COPD exacerbations for proper optimization of health resources.


Maria CORCOLES VERGARA, Danae FERNANDEZ-CAMACHO, Blanca DE LA VILLA ZAMORA, Maria Consuelo QUESADA MARTINEZ, Nuria RODRIGUEZ GARCIA, Pascual PIÑERA SALMERÓN (montepinar, Spain), Cesar CINESI GOMEZ, Jose ALONSO AGUILERA
11:00 - 18:00 #7568 - Orbital emphysema which becomes apparent after blowing nose.
Orbital emphysema which becomes apparent after blowing nose.

Introduction: Orbital emphysema is generally seen secondary to paranasal sinus fractures within the first 24 hours after trauma. The orbital air is absorbed by body approximately in two weeks spontaneously and orbital emphysema usually heals without any complication. We are presenting two cases of orbital emphysema.

Case 1: A 25-year-old male presented to our emergency department with sudden orbital pain and swelling of the left eyelid after blowing his nose. He had head trauma a few hours before the swelling of eyelid. In his past medical history, there is no disease. His left eyelid was swelled. There was periorbital ecchymosis and crepitation on left eye in his physical examination. His sight was normal in both eyes. Orbital computed tomography imaging revealed intraorbital free air and ethmoid bone fracture. The patient was consulted with ophthalmology and otorhinolaryngology departments. He was discharged from emergency department with recommendations of medical treatment and control visit. 

Case 2: A 26-year-old female presented to emergency department with swelling of left eyelid after blowing her nose. She had no trauma history except blowing her nose. In physical examination, she had pain with palpation on her nasal bone and crepitation on her left eye in. Her sight was normal in both eyes. Orbital computed tomography imaging revealed intraorbital free air and ethmoid bone fracture. Orbital computed tomography imaging revealed intraorbital free air and ethmoid bone fracture. The patient was consulted with ophthalmology and plastic surgery departments. She was also discharged from emergency department with recommendations of medical treatment and control visit.

Conclusion: Orbital emphysema is very frightening for patients and ethmoid bone fractures may develop with blowing nose.  Fortunately, the clinical course of orbital emphysema is benign in nature. 


Zerrin Defne DUNDAR (Konya, Turkey), Hakan GUNER, Basar CANDER, Sedat KOCAK, Mehmet GUL
11:00 - 18:00 #7590 - Orderliness of chemical rescue service In Poland – example of Małopolska region.
Orderliness of chemical rescue service In Poland – example of Małopolska region.

Introduction: State Fire Department is responsible for chemical rescue operations in the Republic of Poland. Structure and functioning of chemical rescue has been presented using the example of Małopolska region.

Method: Analysis of current state of realizing legal requirements by Fire Department. Structure, equipment and procedures concerning chemical rescue in Małopolska. Analysis of interventions undertaken so far.

Results: Level of training, equipment and task assignment leads to the following division of chemical rescue:

Basic level – rescue actions undertaken by each Fire Department unit.

Specialist level – undertaken by specialist chemical and ecological rescue groups.

Two basic operation areas can be outlined:

Area of rescue action – ensuring rescuers’ and scene safety, removal of dangerous agent, etc.

Area of chemical recon – action utilizing specialist analytical techniques

Tasks of chemical rescue services on specialist level are divided into three levels:

Level A – actions such as recognizing and identifying hazard, verifying danger zone, evacuation, etc.

Level B – level A actions along with combined rescue/evacuation of casualties, animals and saving the environment and property, evaluating danger scale and limiting its development.

Level C – level A and B actions along with complex chemical action, including mass decontamination of people and rescue operation during situations of considerable size.

Conclusion: Chemical rescue in Małopolska region is highly developed and does not diverge from current international standards. In the area of operations undertaken, there are fewer interventions considering dangerous goods transportation, while the number of interventions concerning environmental hazards is at constant level.


Karol ŁYZIŃSKI (Krakow, Poland), Jacek NITECKI, Arkadiusz TRZOS, Katarzyna DŁUGOSZ
11:00 - 18:00 #7588 - Orderliness of rescue service in case of biological hazards realized by State Fire Department in Poland – example of Małopolska region.
Orderliness of rescue service in case of biological hazards realized by State Fire Department in Poland – example of Małopolska region.

Title: Orderliness of rescue service in case of biological hazards realized by State Fire Department in Poland – example of Małopolska region.

Introduction: In Republic of Poland several institutions are responsible for biological rescue. Chief Sanitary Inspectorate is the leading one. However most rescue operations are undertaken by State Fire Department.

Method. Analysis of current state of realizing legal requirements by Fire Department. Structure, equipment and procedures concerning biological rescue in Małopolska – taking into account current state and further development. Analysis of interventions undertaken so far.

Results: Development of biological rescue within State Fire Department was greatly stimulated by bioterrorism hazard after the year 2000 (Anthrax). Chief Sanitary Inspectorate is the leading institution in case of biological hazard. Fire Department units can be dispatched only after the Sanitary Inspectorate has assessed the situation as serious biological threat. State Fire Department acts under the supervision of Chief Sanitary Inspectorate and Ministry of Internal Affairs. Fire Service units are equipped mainly with gear to self-protect and decontaminate buildings, vehicles, etc. Decontamination of people, healthcare institutions and ambulances should be done by healthcare units. These are currently being equipped in order to be able to perform this task.

There are isolation rooms for patients presenting biological hazard in large airports.

Actions connected with biological hazard are realized by specialist chemical and ecological fire service rescue groups.

Conclusion: It is necessary to perfect procedures, so that it is clearly stated how particular services need to cooperate in case of biological hazard. Large number of such institutions makes it difficult to organize joint training.


Arkadiusz TRZOS, Katarzyna DŁUGOSZ, Jacek NITECKI, Karol ŁYZIŃSKI (Krakow, Poland)
11:00 - 18:00 #8045 - Our 5-year clinical experiences on acute mesenteric ischaemia.
Our 5-year clinical experiences on acute mesenteric ischaemia.

INTRODUCTION: Acute mesenteric ischaemia (AMI) is one of the general surgery emergencies requiring immediate diagnosis and treatment, associated with high morbidity and mortality.  Successful treatment of the disease depends on early diagnosis and early surgical operation on clinical suspicion. In this study, we aim to evaluate patients treated at our clinic with AMI diagnosis.

MATERIAL-METHOD: 112 patient files, treated with AMI diagnosis between February 2010 and March 2015 in our clinic, are analysed retrospectively.

FINDINGS: 53 of the patients were female, and 59 were male. Average of age was 69,9 (30-94). Most frequently complaints were stomach ache (100%) and nausea-vomiting (71%). The time between the release of the complaints and application to the hospital was longer than 24 hours on 80% of the patients. Most frequent co-morbid diseases were hypertension, coronary artery disease, atrial fibrillation and diabetes, respectively.  The aetiological cause was arterial occlusion on 107 (96%) patients and venous occlusion in 5 (4%) patients. 74 patients had small intestine gangrene, 23 patients had small and large intestine gangrene, 9 patients had total small intestine gangrene, and 6 patients had large intestine gangrene. To 9 patients having total small intestine, gangrene were implemented exploration and resection was applied for all other patients. 2 patients are implemented intra-operative superior mesenteric arteriotomy and embolectomy, a second look and re-resection are made on 2 patients. Mortality developed in 55 (49%) patients.  Small intestine syndrome developed in 2 patients who are implemented massive resection and no mortality is monitored on follow-up.

RESULT: Mesenteric ischaemia is a disease requiring early diagnosis and treatment, associated with high morbidity and mortality. The most important step for diagnosis is to be suspicious about the disease.


Erdem KARADENIZ, Sukru ARSLAN, Bünyami OZOGUL (Erzurum, Turkey), Sabri Selcuk ATAMANALP
11:00 - 18:00 #7381 - Out of hospital cardiac arrest: an observational study.
Out of hospital cardiac arrest: an observational study.

Introduction: SAMU teams were frequently called for out-of-hospital cardiac arrest. 

The purpose of this study was to evaluate the management and outcome of pre hospital cardiac arrest by the mobile emergency care unit (MECU).

Methods: This was a retrospective study using the MECU-database for all out of hospital cardiac arrest registred from January to December 2015. We studied the demographic charecteristics of patients, their management and their outcome.

Results: During the period of study, 114 prehospital cardiac arrest were management by the MECU teams. The median age was 63 +ou- 15 years, predominantly male (59.5%). The majority of events occured at home (80%) in the pesence of a family member, who did not initiate resuscitation attempt. The medical history was diabetes in 11.3% of cases and coronary disease in 9% of cases. The most frequent reason for calling MECU teams was neurological distress (38%). The average time for MECU sterting was 4+ ou - 3min and the average time to arrival on the scene was 17 + ou - 4 min. Cardiopulmonary resuscitation (CPR) was done for only 56% of ceses and return of spontaneous circulation was obtained for only 7 patients (6%) who were died 48 h after their admission to intensive care unit.

Conclusion: Unsuccessful resuscitations were longer and beyond guideline recommandations when cardiac arrest occured out of hospital 


Dorra CHTOUROU (Tunis, Tunisia), Saida ZELFANI, Samia ARFAOUI, Amina JEBALI, Mylène BEN HAMIDA, Abdelaziz ZOUARI, Mounir DAGHFOUS
11:00 - 18:00 #7668 - Out of Hospital cardiac arrest: prospective study.
Out of Hospital cardiac arrest: prospective study.

Introduction: In spite of much progress in medicine, out-of-hospital cardiac arrests (OHCA) still remain a large health, social, and economic problem. The epidemiologic data on the incidence, the survival and the prognostic factors of OHCA is often heterogeneous. We therefore conducted the present study to evaluate the managing of OHCA in our region.

Methods: Our study proceeded between October 2014 and December 2015. We conducted a prospective observational study for all OHCA managed by ours EMT. Thus we collected the epidemiologic data (age, sex, ground, the hour of stop, the place of stop…). The beginning of CPR and the decision of the regulating doctor. As well as the rhythm of the cardiac arrest, the initial rhythm and signs preceding the arrest. We carried out the analysis of the various results by using the SPSS software 13.0 .

Results: During the period of study we collected 230 cases. We noted a clear male prevalence with a sex-ratio of 2 and an average age of 55 years with extreme ages of H1 of life at 93 years. The hour of call was relatively more frequent between 16h and midnight: 57% versus 22% (between 8h and 16h) and 20% (between 1heure and 8 hours of the morning). The time between the call and the OHCA could be identified only in 104 cases only (45%) and was of 21± 18 minutes. 2 only cases of OHCA during transport was recorded. Alarm was given by a doctor in 43% of the cases and 37% of the OHCA by a citizen. The OHCA were more frequent in residency (47%) vs (38%) of the cases in a health establishment. In 59% of the cases the CPR was begun, the decision to limit the reanimation was taken in 41% of the cardiac arrest. The average duration of No flow noted was of 22±15 minutes, for a low flow estimated at 26±15minutes. An initial shockable rhythm was found among 41 (18%) patient against 189 patients (82%) in asystolia. Lastly, initial survival in our study is estimated at 16%. In the multivariable analysis, the following pre-arrest factors were significantly associated with survival: age, public location, chest pain, dyspnoea, dizziness, vomiting, ventricular tachycardia, and inotrope administration.

Conclusion: The prognosis of victims CA depends on the initial patient’s characteristics, the circumstances of the CA and the quality of the management. As a result, the subsequent outcome of these patients relies on the efficiency of the chain of survival: prompt alert, bys-tander cardiopulmonary resuscitation and early defibrillation, the advanced care life support provided by the emergency medical services and the integration of in-hospital care. Great efforts relating to the improvement of quality and the data processing, associated a collaboratif effort (transverse research, creation of registers, organization in consortium) must be carried out to allow a better apprehension of this phenomenon.


Achref HAJ ALI, Nesrine IBN HASSINE, Chawki JEBALI (Kairouan, Tunisia), Nawfel CHBILI, Aymen JAOUDI, Hajer KRAIEM, Mejdi OMRI, Mohamed Nejib KAROUI
11:00 - 18:00 #7673 - Out of Hospital Difficult Intubation Management: prospective study.
Out of Hospital Difficult Intubation Management: prospective study.

Background and objective:  Laryngeal tube (LT) airways are commonly used in the prehospital setting, but there are limited data on clinical success rates across emergency medical services (EMS) agencies. Prediction of intubation difficulty can save patients from major pre-operative morbidity or mortality. We aimed to determine factors associated with unsuccessful LT placement in the prehospital setting.

Methods: We conducted a prospective observational study on prehospital endotracheal intubation (ETI) performed by prehospital care providers, from January 2015, to January 2016. We quantified patient, provider, and system characteristics. Success rates and number of ETI attempts were calculated. Predicting difficult ETI and procedure complications were evaluated for the entire study.

Results: During the study period, we observed 112 attempts at laryngeal tube placement by Emergency Interns or Prehospital Emergency physicians. We noted a clear male prevalence with a sex ratio of 3 and an average age of 41 years with extreme ages of H1 of life at 71 years. Unsuccessful LT placement occurred in 14.2% of first attempts and 1.7% of cases overall. The majority of EIT occurred in patients with traumatic complaints (32.1%) and in cardiac arrest (30.3%). Guidelines consensus conferences on difficult intubation are only partly followed by the EMS. Only 60% of the EMS perform systematic rapid intubation sequence. Unexpected difficult ETI occurred in 5.0% of the ETIs suspected to have no difficulties. The incidence of difficult ETI was 14.2%. Only 1 case ETI was impossible, but no patient was unable to be ventilated sufficiently. Predicting conditions for difficult intubation were limited surrounding space on scene, short neck, obesity, face and neck injuries, mouth opening < 3 cm and Burn injuries, (p < 0.01). ETI on the floor or with C-spine immobilisation in situ were of no significant influence. Complications occurred in 26  (23,2%) patients. The incidence of complications was associated with the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p < 0.001). Severe desaturation and inhalation associated with ETI were noted in respectively 8 and 5 cases.

Conclusion: The laryngeal tube is an effective airway management tool for both advanced life support and critical care prehospital providers. Short neck, obesity, face and neck injuries, mouth opening < 3 cm and Burn injuries were associated with unsuccessful laryngeal tube placement by prehospital personnel.


Achref HAJ ALI, Nesrine IBN HASSINE, Chawki JEBALI (Kairouan, Tunisia), Nawfel CHBILI, Aymen JAOUDI, Mejdi OMRI, Hajer KRAIEM, Mohamed Nejib KAROUI
11:00 - 18:00 #7679 - Outcome of patients transported without medical assistance after mobile intensive care unit intervention : prospective study.
Outcome of patients transported without medical assistance after mobile intensive care unit intervention : prospective study.

Introduction :

To reveal short-term outcome and risk factors for patients transported with No medical assistance after mobile intensive care unit intervention.

Method :

We realized a prospective regional survey including consecutively 301 transported with no medical assistance patients. The following events occurring within 72 hours were registered: unexpected and expected death, mobile intensive care unit and hospital medical procedures, mobile intensive care unit and hospital diagnosis. Data were collected from mobile intensive care unit dispatching center computer, telephone follow-up on Day 3 and medical report for hospitalized patients. 

Results :

There were no lost to follow-up. Rate events and confidence intervals were: 2% [0-3%] for death, 20% for hospitalization among which 5% in intensive care unit and 9,2 % [10-15%] for diagnostic disagreement. Patients presenting with chest pain or dyspnea were at higher risk together for intensive care requirement and diagnostic disagreement (p < 0.01).

Conclusion :

Unexpected short term outcome is not uncommon for patients transported with no medical assistance after mobile intensive care unit intervention. As main risk factors seem to be chest pain and dyspnea, mobile intensive care unit transport should be encouraged whenever these symptoms are encountered.


Khaoula BEL HAJ ALI, Nesrine IBN HASSINE, Chawki JEBALI (Kairouan, Tunisia), Mejdi OMRI, Hajer KRAIEM, Aymen JAOUDI, Nawfel CHBILI, Mohamed Nejib KAROUI
11:00 - 18:00 #7623 - Outcomes in emergency department patients with multiple symptoms.
Outcomes in emergency department patients with multiple symptoms.

Background/Objective:

The nature and number of symptoms in emergency patients differ widely. E.g. women report more symptoms than men, but outcome may not differ. Furthermore, the number of symptoms has a linear relationship with the number of consultations, and multiple symptoms are associated with anxiety and depression. However, the outcome in patients presenting with multiple symptoms to EDs is unknown.

Methods:

The prospective observational study was run at the Emergency Department of Basel University Hospital over a period of 6 weeks, 24hours/7days. Every patient presenting to the ED was eligible. Exclusion criteria were: unable to answer questions, unwilling to participate. Systematic history taking (35 predefined symptoms) and registration of chief complaints was performed by a member of the study team, using a questionnaire.  The number of symptoms was recorded. Multiple symptoms were defined as more than 2 out of 35 symptoms. Demographics, triage categories (ESI 1-5), and the use of resources were also recorded. Physicians` first clinical impressions were recorded at presentation using a numeric rating scale of 0 (not looking ill) to 10 (looking severely ill) by the study team. Resources were defined as an investigation ordered by an emergency physician, such as x-ray, lab exam, or consultation by a specialist. Outcomes were categorised in terms of hospitalisation, serious outcome, and intensive care. Serious outcome was defined as an acute morbidity requiring early intervention (e.g. use of antibiotics) in order to avoid deterioration of health status, disability or death.

Results:

Of 5634 patients presenting to the ED, 4006 were included.  The mean number of the reported symptoms was 2.4 (range 0-25). 1392 patients had 3 or more symptoms. These patients showed a higher rate of hospitalisation (39.7% vs. 26.7% in all other patients), a higher rate of serious outcomes (38.1% vs. 36.5%), and a higher use of intensive care (6.3% vs.5.1%). Patients with 3 or more symptoms were older (median 53.5 years vs 49 years) and had a higher use of resources (2.38 vs. 2.10). They were judged to look sicker in terms of the first clinical impression (4.2 vs 3.5), and they had a longer length of stay in the ED (262 minutes vs. 212 minutes).

Conclusion:

Patients with multiple symptoms, i.e. 3 or more, may be a vulnerable group, as their outcomes are worse as compared to all other patients presenting to the ED. They used more resources and had slower throughput times as compared to patients with 2 or less symptoms. Further research is necessary in order to find the reasons for this finding.


Karin WEIGEL (Schwoerstadt, Germany), Christian NICKEL, Roland BINGISSER
11:00 - 18:00 #7497 - Outcomes of computerised tomography trauma series scanning in trauma alert patients to a major trauma centre.
Outcomes of computerised tomography trauma series scanning in trauma alert patients to a major trauma centre.

Rapid radiological investigation is a backbone of the UK Major Trauma Network, with Major Trauma Centres (MTCs) required to have immediate (

50 patients (44M, 6F; mean age 40) between March and June 2015 were transferred by the ambulance service as a ‘trauma alert’ to The Queen Elizabeth Hospital, Birmingham, UK.  One patient was excluded as they were transferred from another hospital.  Initial observations, injury mechanism, A-to-E assessment, CT scan and results were recorded.  Shock was calculated according to ATLS guidelines.  Qualification for WBCT on arrival was assessed according to local guidelines.  Body regions were divided as per CT reporting: Head, Thorax, Abdomen/Pelvis, Spine and Long Bones.  Primary survey findings were correlated to the CT report to calculate sensitivity and specificity for the body regions. 

47/49 patients survived to discharge, with an average stay of 17.3 days.  26.5% (13/49) of patients were in class IV shock on arrival.  44/49 patients qualified for WBCT on arrival; of the remaining 5, 3 underwent WBCT, and 2 had partial body CT scans due to clinical judgement.  38 patients underwent a WBCT, 7 had partial body CT scans and 4 were not scanned (1 burn patient, 1 CT abandoned and taken to theatre, 2 not specified). Primary survey to WBCT report statistics were: Head: Sensitivity 60.9%, Specificity 94.4%; Thorax: Sensitivity 40.9%, Specificity 94.7%; Abdomen/ Pelvis: Sensitivity 40%, Specificity 84.4%; Spine: Sensitivity 93.8%, Specificity 27.6%; Long Bones: Sensitivity 50%, Specificity 77.5%.  One patient underwent further imaging to include other body regions.

These results show a general trend of low sensitivity and high specificity of primary survey compared to CT report.  A low sensitivity may be explained by the nature of WBCT scanning in the trauma patient.  Rapid assessment is carried out, patient stabilised and then taken for scan if they qualify. Only spinal injuries showed a high sensitivity compared to specificity; which may be due to a low triple immobilisation threshold.  Overall there is a high specificity, except for the Spine. Of the 5 patients who did not qualify for WBCT on admission, all had imaging done based on clinical judgement; those who were not scanned qualified for a WBCT.  This study demonstrates the importance of WBCT scanning in the trauma patient given the low sensitivity of the primary survey, and would suggest all trauma patients should have a WBCT on admission.    We plan to expand the study numbers to maximise the statistical power.


Onn Shaun THEIN, Charn GILL (Birmingham, United Kingdom), Muhammad Azam MAJEED
11:00 - 18:00 #7197 - Outcomes of older patients attended by paramedics for falls in Perth, Western Australia.
Outcomes of older patients attended by paramedics for falls in Perth, Western Australia.

Background: Falls are a leading cause of injury-related hospitalisation, and one of the most common reasons for emergency ambulance calls among elderly patients in Australia [1].  Despite the high incidence, little is known about outcomes of falls among older patients.  We aimed to compare outcomes of falls attended by ambulance paramedics with those from other common reasons for emergency ambulance calls among older patients.

Participants and methods: We conducted a retrospective cohort study of falls attended by ambulance paramedics in Perth, Western Australia (WA) between 1 October 2013 and 31 December 2014. We selected patients who were 65 years or older from electronic patient care records (ePCR) from the St John Ambulance Western Australia (SJA-WA) , the sole provider of ground-based emergency ambulance services in Perth. We identified patients who had a fall based on dispatch codes. We linked the ePCR with the emergency department (ED) information system data and the WA death registry to identify patient outcomes. The primary outcome was patient disposition after assessment by paramedics at the scene, and secondary outcomes included patient disposition from ED as well as subsequent ambulance request, ED presentation, and death within 24 hours after the index event (the first attendance by paramedics). These outcomes were compared to outcomes of older patients with the next two most-common reasons for emergency ambulance response – undifferentiated “sickness” and chest pain.

Results: There were 11,806, 11,451 and 8,998 cases of falls, sickness and chest pain, respectively. Patients who had a fall were oldest among the three patient groups (median age 84 years old vs. 82 for sickness, 79 for chest pain). Patients who had a fall were most likely to be discharged at the scene (13% vs. 6% for sickness, 2% for chest pain, p<0.001), subsequently request an ambulance (8% vs. 5% for sickness, 4% for chest pain, p<0.001) and present at ED (4% vs. 3% for sickness, 2% for chest pain, p<0.001) within 24 hours after the index event. Among those who were transported to ED, patients who had a fall were most likely to be discharged from ED (38% vs. 33% for sickness, 29% for chest pain, p<0.001). Patients dispatched as sickness were most likely to die within 24 hours after the index event (1.0% vs 0.6% for falls and 0.6% for chest pain).

Discussion/conclusion: We found that patients who had a fall were most likely to be discharged at the scene and from ED among the three most frequent reasons for requesting emergency ambulance services in older patients. However, we also found that patients who had a fall were most likely to subsequently request ambulance services and present at ED within 24 hours after the index event. In WA currently there are no clinical decision rules to guide paramedics as to which patient could be managed at the scene. Decision rules to identify patients who had a fall and could be discharged at the scene are required.

References:

1.            Australian Institute of Health and Health (2016). Falls in older people. http://www.aihw.gov.au/injury/falls/.


Hideo TOHIRA (Perth, Australia), Stephen BALL, Teresa WILLIAMS, Paul BAILEY, Anthony CELENZA, Judith FINN
11:00 - 18:00 #4519 - Overcrowding. A task to solve.
Overcrowding. A task to solve.

In the spring of 2015 University Hospital Motol in Prague opened whole new, larger and modern Emergency Department (ED). Most of the acute outpatient clinics in the hospital were closed and ED was designated as one and only place, thrue which all of the emergency patients come. Number of visits at the ED rose dramatically. So the doctors, nurses and administrators of ED experienced fist hand real crisis, which lasted for weeks and months. Crisis was by the most defined as boarding of patients in the deparment and overcrowding of waiting area and departmental space. Communication troubles and conflicts between ED staff and consultants from other services was daily bussiness. Personell was overwhelmed by patients and tasks, health care people used to "emergencies" started to feel under more pressure than bearable. At he same time complaints from patients (mostly about long times and lack of communication) skyrocketted. We went quickly thru the literature and tried to use some of the recommendations and experiences from it. Author of this presentation shares knowledge from the recent publications. Definition of the overcrowding, its symptoms and consequences are presented. Possible solutions, tips and trics are discussed. Finally author shows results from his department, where number of visits rose by 100% interanually as the new department was opened. Changes in work organization, changes in communication with other departments and push to get the whole hospital to understand the specifics of how the ED operates, push to cooperate, created momentum towards improvement. Our time to treat in the ED changed from almost 200 minutes in July 2015 to 80 minutes in February 2016. At the worst times we used the comparison to the McDonnalds fastfood service. In case of doubling of number of customers you either work twice faster, or need to invest in another unit with the same number of beds and personell. In our case, we, together with other departments, managed to work faster. Overcrowding and boarding is no more common, people are sensitive for signs of looming problem and manage to prevent it in most cases. Author describes specific steps which were put in place to shorten time to treat, steps taken to comfort and inform the waiting "crowd" and steps to prevent overcrowding and its consequences. Author shows results of statistics of patient flow over the mentioned period (June 2015 - February 2016) and presents our own research of patient satisfaction with waiting and treatment time from period before and after the measures taken place. In conclusion, worldwide phenomenon of ED overcrowding occurres in the heart of Europe too and thank to the shared experience and own work we (so far) managed to solve it. It is, nevertheless the lasting problem which will probably occur in any new ED in other places and which is the canary of the level of cooperation within the whole hospital.


Jiri SOUPAL (PRAGUE, Czech Republic), Jan BYDZOVSKY, MD, PHD.,DOC., Jaroslav, Md KRATOCHVIL
11:00 - 18:00 #7556 - OXIDATIVE STATUS AND DNA DAMAGE FOLLOWING ANALGESIC TREATMENT IN PATIENTS WITH ACUTE PANCREATITIS.
OXIDATIVE STATUS AND DNA DAMAGE FOLLOWING ANALGESIC TREATMENT IN PATIENTS WITH ACUTE PANCREATITIS.

Background

This study is designed to investigate the effect of three different analgesics used to treat pain in AP on oxidative stress, DNA damage in mononuclear leukocytes and on oxidative status.

Methods

This parallel design randomized controlled trial is composed of three treatment arms, intravenous paracetamol, intravenous dexketoprofen and intravenous tramadol.

Results

A total of 107 patients were diagnosed with acute pancreatitis within the study period in the ED. Seventy-seven of them were included for the study; 26 patients for the paracetamol group, 24 patients for the dexketoprofen group and 27 patients for the tramadol group. The mean age of study subjects was 52.73 ± 15.38 and 66% (n = 51) of them were men. At the beginning of the study (before treatment) mean levels of DNA damage, TOS and OSI levels significantly higher and TAS was significantly lower in the acute pancreatitis groups than in the control group. DNA damage and OSI in HAPS-positive patients were found to be significantly greater than  HAPS-negative patients (p = 0.046). DNA damage and oxidative stress were compared between the three groups. There were no differences between the groups in terms of DNA damage (p = 0.42) and also for the oxidatif stress parameters (OSI,TAS,TOS respectively p = 0.26, p = 0.78, p = 0.35)

Conclusions

There is no difference between the effects of paracetamol, dexketoprofen and tramadol which are commonly used to manage acute pain in AP on DNA damage in human T-lymphocytes and on serine parameters of oxidative status.


Gulen BEDIA (İstanbul, Turkey), Abdurrahim KOCYIGIT, Cenker EKEN, Mustafa SERINKEN, Karcioglu OZGUR, Ali DUR, Elif KILIC
11:00 - 18:00 #7167 - Paget-Schrotter syndrome as a cause of pulmonary embolism.
Paget-Schrotter syndrome as a cause of pulmonary embolism.

Female 40 years nurse with a medical history of tonsillectomy and anemia in current study, being treated with iron. Practice usually quite sport, including spinning.

 

Emergency room because pain, paresthesia and right arm size increase progressively from seven days ago. He was treated with anti-inflammatories and benzodiazepine arm pain. Given the improvement not consult us .From made 24 hours shortness of deep inspiration air. No chest pain or palpitations.

Physical exploration. Afebrile, normotensive, 99% saturation eupneic. Right arm increase in diameter compared with contralateral arm smearing biceps and chest vascular redistribution. Pulses present. Normal cardiopulmonary auscultation. nondescript abdomen. normal legs.

Suspicion Diagnóstica: Muscle Injury hematoma, lymphoedema, venous thrombosis, cellulitis in the right arm.

Additional tests: Normal analytical except high D-dimer 2051.EKG: RS 75 pm shaft 60G. Chest radiograph without alterations. Doppler ultrasound arm thrombosis subclavian, axillary vein and right Basilica.

 

 

Because deep vein thrombosis right arm and mild dyspnea was referring the patient CT angiography Thorax showing defect segmental repletion level lobar artery lower left was requested lobar artery lower right and at the level of artery middle lobe, all compatible with thromboembolism pulmonary.

Final diagnosis: proximal deep venous thrombosis and in the right forelimb (Basilica veins, axillary and subclavian), Paget-Schrotter syndrome. Pulmonary embolism in segmental level.

Evolution: the patient was admitted in Internal Medicine with anticoagulant treatment and study of negative thrombophilia high .It was after 7 days in hospital, receiving treatment with warfarin.

 

Discussion:

 Deep vein thrombosis of the upper limb is rare, accounting for 10%, but should be taken into account by the emergency physician because of the risk of pulmonary embolism (6-9% of deep Thrombosis may be complicated by pulmonary thrombosis) .The upper limb thrombosis are divided into primary and secondary. The primary can be idiopathic, compression of subclavian vein with adjacent musculotendinous structures during exercise (Paget-Schrotter syndrome). Secondary relate to catheters (venous or pacemakers), cancer, thrombophilia, trauma, shoulder surgery or hormonal.

The Paget-Schrotter syndrome is an underdiagnosed disease, which mainly affects young individuals in their dominant limb. Its incidence is 2 per 100,000 inhabitants, average age 32 years being the male-female ratio 2: 1.A 80% of patients report significant previous physical activity, although the first rib and clavicle hardly move, the vein is located at the point of maximum compression on passing between the anterior scalene and subclavian muscle tendon.

There is no consensus regarding the treatment of this disease. Today, most of the authors seem to agree that anticoagulation alone offers poor results so it is recommended to associate to fibrinolysis and surgical treatment (first rib resection) or endovascular.


Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #7179 - Paint thinner ingestion - an uncommon cause of altered mental status and abdominal pain!
Paint thinner ingestion - an uncommon cause of altered mental status and abdominal pain!

Paint thinner ingestion - an uncommon cause of altered mental status and abdominal pain!

 

Case presentation

A 56 year old Malay man was seen at the ED for acute confusion and severe abdominal pain.

His symptoms started following an accidental ingestion of “Paint thinner”. He had hypertension, dyslipidemia and diabetes mellitus but no underlying psychiatric illnesses.

He was tachycardic and hypertensive but afebrile and saturating normally.

On physical examination, he was noted to be very combative and agitated. Examination of his heart, lungs and abdomen were unremarkable. No focal neurological deficits were noted.

No abnormalities were detected on a resting electrocardiogram. He had mild neutrophilia. His renal and liver function tests were normal.

Computed Tomographic scans of his brain, thorax and abdomen did not reveal any evidence of intracranial infarction, bleed, pneumonitis, pneumomediastinum or pneumoperitoneum. 

He was given intramuscular Haloperidol and intravenous fentanyl for sedation and pain relief.

His mental state normalised subsequently over time.

An oesophageal-gastro-duodenoscopy showed mild oesophagitis and pan-gastritis/oesophagitis.

He was treated symptomatically and discharged stable after two days.

 

Discussion

“Paint thinners” are solvents used in the cleaning of oil-based paints. They typically contain a combination of aliphatic and aromatic hydrocarbons, terpenes and oxygenated solvents. [1]

Patients present primarily with CNS symptoms and/or symptoms of pneumonitis after ingestion of aliphatic hydrocarbons. [2]

CNS symptoms include ataxia, confusion and CNS depression. The mechanism of CNS toxicity remains largely unknown but may be related to solvent effects on neuronal membranes or interactions with ligand-gated ion channels. They may also be the result of hypoxemia resulting from displacement of oxygen in the lungs by vapour from the aspirated hydrocarbon.

Pneumonitis may be due to associated aspiration of the hydrocarbon and is likely the result of direct toxicity to pulmonary tissue and lipid surfactant disruption. Patients may present with hypoxemia, haemoptysis or pulmonary oedema.

Following an ingestion, other organ systems that may be affected include the cardiovascular (cardiac arrest, arrhythmias), gastrointestinal (Abdominal pain, nausea, vomiting, haematemesis), haematologic (Leucocytosis, DIC, haemolysis) and hepatic systems (Transminitis)

Management of such patients should follow the steps of containment, decontamination and stabilisation. Forced emesis and use of activated charcoal are not recommended in such patients. Prophylactic administration of antibiotics and/or steroids are controversial but do not appear to be useful. [3] 

Patients with respiratory failure may require the use of mechanical ventilation. Extracorporeal membrane oxygenation may be considered for severe pneumonitis or pulmonary failure. [4]

Patients who remain asymptomatic after 4 to 6 hours of observation in the emergency department with a normal chest radiograph can be discharged with the advice to return if respiratory symptoms develop within the next 24 hours. Patients with CNS depression, fever, abnormal chest x-ray findings, or respiratory distress should be admitted for further inpatient management.

References

  1. Paints & Coatings – Solvents, http://www.sigmaaldrich.com/analytical-chromatography/air-monitoring/applications/paints-and-coatings/solvents.html
  2. Lexicomp Online®, Aliphatic Hydrocarbons (Lexi-Tox): Lexi-Comp, Inc.
  3. Gummin DD, Hryhorczuk DO. Hydrocarbons. Goldfrank's Toxicologic Emergencies. 7th ed.
  4. Scalzo AJ, Weber TR, Jaeger RW, Connors RH, Thompson MW. Extracorporeal membrane oxygenation for hydrocarbon aspiration. Am J Dis Child. 1990;144(8):867-871.

Shao Hui KOH (Singapore, Singapore)
11:00 - 18:00 #7225 - Paracetamol overdose may cause transudatic pleural effusion in adults.
Paracetamol overdose may cause transudatic pleural effusion in adults.

Since its first clinical introduction in the United States during the 1950s, acetaminophen (paracetamol) has been one the most widely used drug in the world. It is highly effective and safe in the recommended doses. Although it is a remarkably safe drug, it is the most common cause of poisoning and fatality due to its toxic administration worldwide. Liver and kidney damage after its toxic administration are well known; however, direct damage to other organs has rarely been reported. This case is the first report in the literature on the development of the pleural effusion after high-dose paracetamol intake.

A 34-year-old female patient applied to our ED with the complaint of swallowing 33 g of paracetamol with suicidal ideation. Her initial and follow-up vital and laboratory findings were within normal range. After routine toxicity treatment, a total of 200 mg/kg N-acetylcysteine IV therapy was given during 21 hours. On the third day of the hospitalization, dyspnea and pain on the right hemithorax and right flank occurred. Chest X-ray showed blunted right sinus which was not observed before. CT angiography revealed bilateral pleural effusion that was more prominent on the right. With thoracentesis, clear, colorless and odor-free fluid of about 500 cc was drained. Laboratory examination of the fluid confirmed it as transudate. Blood, sputum, urine, pleural fluid cultures and ARB staining were all negative. We believe pleural effusion occurred due to decrease in pleural permeability and the consequent decrease of the fluid absorption. The absence of any chronic disease in the medical history, occurrence of the event just after the drug intake, transudative character of the fluid and the exclusion of other disorders. 

Pleural effusion is defined as an abnormal fluid accumulation because of the penetration of excessive fluid in the pleural cavity or of the decrease of the absorption of the fluid or of both. Although pleural effusion can develop as a complication of various diseases, heart failure, pneumonia, tuberculosis, and pulmonary embolism are the most common underlying factors in adults. Pleural effusion due to drug intake is rare. We found no other reported case of paracetamol-induced pleural effusion. In a clinical study on IV paracetamol, it was reported that pleural effusion might occur as a rare adverse effect in the pediatric patient population. There were no reports on the risk in adults. Paracetamol and NSAIDs blocked the Na+ channels and the Na+/K+ pumps in normally functioning parietal pleura. Due to this blockage, the permeability of the pleural membrane decreases. Therefore, the absorption of the fluid from the pleural membrane is also decreased. In a recent in vivo study conducted on rats, paracetamol and NSAIDs delayed the pleural fluid absorption in the rats with postoperative hydro-thorax.We believe that the cause of the pleural effusion in our patient was the variability of the pleural permeability and the consequent decrease in fluid absorption caused by the high-dose intake of paracetamol. In summary, it should be kept in mind that high-dose intake of paracetamol may cause transudative pleural effusion as a complication.


Mucahit EMET, Abdullah Osman KOCAK, Ilker AKBAS (Erzurum, Turkey), Sibel GUCLU
11:00 - 18:00 #7943 - Paramedic airway management in paediatric traumatic brain injury: A 9-year observational study.
Paramedic airway management in paediatric traumatic brain injury: A 9-year observational study.

Introduction

Prehospital airway management of the paediatric patient with traumatic brain injury (TBI) is controversial. Endotracheal intubation of children in the field requires specific skills and has potential benefits but also implies potentially serious complications. We aimed to compare mortality and functional outcomes after six months between children with TBI who either underwent prehospital RSI by a paramedic or received no intubation.

Methods

We conducted a retrospective study of patients aged ≤14 years with suspected TBI. Patients were either transported via helicopter and received rapid sequence intubation (RSI) (2005-2013) or via road ambulance and received no intubation (2006-2013). Prehospital data was linked to hospital and 6 months follow up data to assess mortality and functional outcome.

Results

A total of 106 patients were included in the study of which 87 received RSI by paramedics and 19 did not receive intubation. Baseline characteristics were comparable between the groups. Overall intubation success rate was 98.9% with a first-pass success rate of 93.1%. Overall, there was no difference in mortality, ICU and hospital length of stay and functional outcome after six months between the two groups. Major trauma patients who received RSI were more likely to have favourable neurological outcome after six months compared to patients who were not intubated (66.1% vs. 16.7%, p=0.03). Prehospital RSI was also associated with a significant decrease in length of hospital stay in this group (523.0h vs. 1938.8h, p=0.03).

Discussion

Prehospital RSI in paediatric patients with TBI can safely be performed by paramedics. Overall, outcome was not significantly different between patients who receive prehospital intubation and those who did not, however our study is not powered to detect a significant difference. Intubation prior to transport might be beneficial for major trauma patients.

References

Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, et al. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA 2000;283:783–90.

Gerritse BM, Draaisma JMT, Schalkwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics perform paediatric tracheal intubation in the field? Resuscitation 2008;79:225–9.


Stefan HESCHL (Graz, Austria), Ben MEADLEY, Emily ANDREW, Warwick BUTT, Stephen BERNARD, Karen SMITH
11:00 - 18:00 #7271 - Parameters in Emergency Department related with increase of hospital mortality.
Parameters in Emergency Department related with increase of hospital mortality.

INTRODUCION: Healthcare in patients who are admitted in hospital tries to treat the cause that motivates the income and detect and treat other health problems. The expected impact is to reduce hospital stay, readmissions and finally, the hospital mortality as well. If we could identify the factors present on associated with increased hospital mortality, we could change them earlier and intensify monitoring of those patients.

OBJETIVES: Identify which characteristics of patients on of admission to the emergency department are associated with higher mortality during hospital stay.

PARTICIPANTS AND METHODS: Case-control study. We collected as cases all patients who died in hospital between 1 July and 31 December 2014. Controls were patients discharged during the same period with aged-matched 1:1 with a deviation of ± 5 years. The clinical endpoint was hospital mortality. They were collected prior to entering clinical (personal background, Charlson score, blood pressure (BP), temperature) and analytical variables (glucose, creatinine (glomerular filtration rate (GFR) with CKD-EPI), ions, hemogram and arterial blood gases). Differences with p <0.05 were considered significant.

RESULTS: 1297 patients (650 cases and 647 controls) were included. There were significant differences in cases vs controls at Charlson index (2.9 vs 1.5; p <0.0001), systolic BP (123 vs 135 mmHg, p <0.0001), glucose (155 vs 137 mg / dl; p <0.0001), GFR (54 vs 61 ml / min / 1.73 m2; p <0.0001), sodium (138 vs. 139 mEq / L; p = 0.009), O2 saturation (92.6 vs 94 , 3%; p <0.0001), hemoglobin (11.6 vs 12.8 g / dl; p <0.0001), leukocytes (12846 vs 10547 mm3; p <0.0001), pH (7, 37 vs 7.40; p <0.0001) and lactate (3.3 vs 1.9 mmol / L; p <0.0001).

DISCUSSION: There are features on admission (increased Charlson score, arterial hypotension, hyperglycemia, reduced GFR, anemia, hypoxemia, leukocytosis and increased lactate) that are associated with increased hospital mortality. Patients with these characteristics require more intensive monitoring from admission.


Marta JORDÁN DOMINGO, Daniel SÁENZ ABAD, Cristina BAQUER SAHÚN, Carmen LAHOZA PÉREZ, Inés MURILLO DÍAZ DE CERIO, Mercedes JIMÉNEZ CASADO, María MARTÍNEZ DÍEZ, Miguel RIVAS JIMÉNEZ (Zaragoza, Spain)
11:00 - 18:00 #7703 - Patient attitudes and barriers towards participation in the Manchester Acute Coronary Syndromes decision rule pilot trial.
Patient attitudes and barriers towards participation in the Manchester Acute Coronary Syndromes decision rule pilot trial.

Background

Observational studies have shown that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively rule in and rule out acute coronary syndromes (ACS) following a single blood test in the Emergency Department. A well-designed randomised controlled trial (RCT) would now provide important evidence of its effectiveness when used in practice. We recently completed recruitment to a pilot RCT comparing use of the MACS rule to standard care. Successful recruitment to a definitive, fully powered RCT requires participation to be acceptable to patients. We therefore aimed to explore patient attitudes and potential barriers to participation in an RCT of this nature.   

Methods

We conducted a qualitative study nested within a pilot RCT comparing use of the MACS rule to standard care. All trial participants were asked if they would be willing to participate in a follow-up interview discussing their experiences of trial participation. We then scheduled semi-structured interviews with consenting participants. We used purposive sampling, aiming to achieve a heterogeneous sample based on age, gender, ethnic origin and MACS rule risk group. Interviews were conducted with reference to a bespoke topic guide. They were audio-recorded, transcribed verbatim and analysed using the Framework method with an inductive approach. Identified themes were assessed on the individual participant and group level.

Results

Ten participants completed semi-structured interviews. Overall, interviewees felt that participation in the MACS trial was acceptable and all but one would recommend participation to others. They expressed few reservations concerning an early discharge according to the MACS rule when compared to usual care. Some participants expressed frustration at playing a “passive” role in their own healthcare. Trial participation allowed them to play a more active role, which they welcomed. They also welcomed the potential to reduce unnecessary waiting time so long as their medical care was appropriate with timely follow-up. In accordance with the trial protocol, patients were first approached to participate at the time of arrival in the ED. Some participants, who described being anxious or in pain at that time, felt this was undesirable. They were, however, welcoming of the approach once these matters had been attended to. Treatment by the MACS rule was perceived as largely non-invasive intervention and the process of randomisation seemed to hold little significance for participants. Although several participants described being generally sceptical of medical research, they were amenable to participation in this trial. This appears to be because they agreed with the need for research in this field. Personal qualities of the research staff (such as “friendliness”, “considerateness” and “competence”) also seem to have influenced the decision to participate.

Conclusions

Patients were positive about their participation in the MACS rule feasibility trial comparing the MACS rule to standard care.  They welcomed the opportunity the MACS rule offers in reducing unnecessary waiting in the hospital. A number of potential limitations to the trial design were identified and should be considered in the planning of a future larger trial.


Patricia VAN DEN BERG (Manchester, United Kingdom), Richard BODY, Sarah KENDAL
11:00 - 18:00 #7172 - Patient Perceptions of the Emergency Department.
Patient Perceptions of the Emergency Department.

Background:

From 1992 to 2014, the number of emergency department (ED) visits increased from approximately 91 million to 133 million.1 ED overcrowding is among the biggest problems in the United States healthcare system, to the extent that ED directors nationwide admit the quality of care of patients is negatively impacted as a direct result of it.2 While a variety of complex factors are responsible for overcrowding, inappropriate use of the ED is often targeted because it is considered expensive and wasteful. Other factors such as not having a primary care provider (PCP) or overestimating the severity of their condition may also influence their decision to present to the ED. By identifying factors that cause ED overcrowding, ED staff may be able to provide more timely care to the patients who need immediate care.

Purpose:

The purpose of this study was to examine the type of conditions patients are presenting with to the ED and their reasons for choosing to seek care in the ED.

Methods:

This cross-sectional study collected 500 surveys via convenience sampling from emergency department patients at a county hospital. Due to being on the US/Mexico border, surveys and consents were provided in English and Spanish.  The survey was used to collect data regarding urgency for the ED visit, triage rating by the ED staff, self reported condition, demographics, and PCP status. Data analysis was completed using IBM SPSS 22. 
Results:
Study results showed that 58% of patients reported not having a PCP. A total of 17% of the patients surveyed considered their condition to be life-threatening. Additionally, 9% of patients were rated as emergent and 81% as urgent by the ED triage rating suggesting that a large portion of the patients surveyed could have received care elsewhere. However, only 34% of the patients believed that they could be treated at a clinic. The main influences on seeking care in the ED was being “seen quickly and/or without an appointment” and “allowed them to work around their schedule“.
Conclusions:
These findings suggest that many patients are aware they are using the ED inappropriately or are considering themselves as more in need of urgent care than the ED staff evaluates them to be. Although many patients may not need immediate care, the ED may be their only option for healthcare.  The availability and convenience of the ED, along with a lack of access to other sources of care are highly influential factors that the healthcare system should focus on to reduce the overcrowding in EDs in the United States. Addressing these factors will allow EDs to provide appropriate, uncompromised, and timely care to the patients with true emergencies.
References:
1.American Hospital Association. Trendwatch Chartbook 2014: Trends Affecting Hospitals and Health Systems. Washington, DC: Avalere Health; 2014.
2.Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001;8(2):151-155.

Stormy MONKS, Igor KUSHNER, Alejandro VARGAS, Raymond RUIZ, Radosveta WELLS (El Paso, USA)
11:00 - 18:00 #4510 - Patient Satisfaction Before and After Executing Health Sector Evolution Plan.
Patient Satisfaction Before and After Executing Health Sector Evolution Plan.

Introduction: After long discussions, carrying out health sector evolution (HSE) plan began on May 5, 2014 throughout Iran. Shohadaye Tajrish Hospital, Tehran, was also included in this plan. This study aimed to evaluate the level of emergency department patient satisfaction, before and after running this plan.
Methods: This cross-sectional study analyzed the data extracted from a standard questionnaire filled out by the patients presented to the emergency department of Shohadaye Tajrish Hospital over 6-month periods before and after the beginning of HSE.

Results: 3665 patients were surveyed. After the execution of the plan, satisfaction decreased significantly regarding pre-discharge training (p = 0.03), hospitalization room condition (p = 0.0002), restroom sanitation (p = 0.007), waiting time to be visited by the physician (p = 0.04), accuracy and duration of physical examination (p = 0.007), feeling confident and desirable outcome (p = 0.03), commitment to religious and moral principles (p = 0.01), and handling financial affairs (p = 0.03).

Conclusion: Based on the results of the present study, after execution of HSE plan, patient satisfaction has decreased significantly regarding pre-discharge training, hospitalization room condition, restroom sanitation, timely visit of the physicians, accuracy and duration of physical examination, suggestions for wellbeing of the patient, handling financial affairs, and commitment to religious and moral principles.


Alireza BARATLOO (Tehran, Islamic Republic of Iran), Alaleh ROUHIPOUR, Behrouz HASHEMI, Saeed SAFARI, Mohammad Mehdi FOROUZANFAR
11:00 - 18:00 #7721 - Patient, emergency call and treatment characteristics of medical transportations by 112 Emergency Health Services of Çanakkale from islands of Gökçeada and Bozcaada O.
Patient, emergency call and treatment characteristics of medical transportations by 112 Emergency Health Services of Çanakkale from islands of Gökçeada and Bozcaada O.

Objective: The study was carried out in order to evaluate patient, emergency call and treatment characteristics of medical transportations by 112 Emergency Health Services (EHS) of Çanakkale from islands of Gökçeada and Bozcaada from 2009 to 2013.

Materials and Methods: The study is a descriptive-cross sectional epidemiological study. The universe of the study was consisted of all of the patient registration forms which were completed for the patients transferred in ambulances from Bozcaada and Gökçeada islands between the dates of 01.01.2009 and 31.12.2013. A total of 1,144 forms were analyzed. The data of the study were obtained from the electronic database of Çanakkale EHS which was based on these registration forms. SPSS 15.0 program was used to compute the descriptive statistics and the chi-square statistics. The variables were patient characteristics (gender, age, social insurance), call type, reasons to call, first medical examination findings, Glasgow Coma Score (GCS), receiving hospital, preliminary diagnosis and treatment procedures. Official permissions were obtained from the relevant institutions to conduct the study.

Results: Of the patients transferred from the islands, 62.7% of them (n=703) were male; 18.6% (n=199) were in the age group of 20-29. The average of age was 46.9 (S=24,363, min-max. 0-95, median: 46 years old). 44% of the transfers (n=458) were insured by social security authority. 83.9% of the transfer system (N=889) were activated by 112 emergency call system. Of the transfers, 64.1% (n= 676) were recorded as medical calls; 66.7% (n=748) were treated as inter-hospital transfers; 80.3% (n=892) were referred to as the transfer to the State Hospital of Çanakkale. In regard to the preliminary diagnosis of the medical cases transferred, trauma was the most common  by 33.5% (n=370), followed by cardiovascular system (CVS) problems (19.2%, n=212) and gastrointestinal (GIS) problems (11.4%, n=126). The most common types of trauma were fracture (29.7%, n=110), head trauma (27.8%, n=103) and general body trauma (14.6%, n=54). The most common causes of CVS problems were myocardial infarction (44.1%, n=94), angina pectoris (14.6%, n=31) and others (12.7%, n=27). The most common causes of GIS problems were acute abdomen (47.7%, n=61), bleeding (19.5%, n=25) and stomach ache (7.8%, n=10). The most common cases were trauma patients (65.3%, n=242) in the age group of 0-49 and CVS diseases (68.9%, n=146) in the age group of 50-79. Furthermore, in regard to the seasonal distribution of the preliminary diagnosis, 45.4% of the trauma cases (n=168) and 39.0% of the CVS diseases (n=83) were reported in summer. The four most common medical interventions were establishing vascular access, administering intravenous drugs, using a cervical collar and spinal board. Occupational accidents, traffic accidents and injuries were more common among the male patients compared to female patients (p<0,05).       

Conclusion: The male patients, patients aged between 20-29, trauma patients were mainly transferred from the islands. Medical treatment and stabilization of fractures prevailed during the transports. The findings on the transfers may be instrumental in the improvement of the entire system by initiating a transfer chain and allocating a separate telephone line.


Cüneyt CALISKAN (Çanakkale, Turkey), Hakan ALTINTAŞ
11:00 - 18:00 #8172 - Patients Suffering Cardiac Arrest from Right Coronary Artery Occlusion can Benefit from Mobile Extracorporeal Circulation.
Patients Suffering Cardiac Arrest from Right Coronary Artery Occlusion can Benefit from Mobile Extracorporeal Circulation.

Background: Although extracorporeal cardiopulmonary resuscitation (ECPR) has been shown to be beneficial in several cardiopulmonary diseases, its effect on survival after acute myocardial infarction (AMI) complicated by cardiac arrest is unknown.

Methods: We evaluated outcomes in 42 patients who received ECPR and coronary intervention for the treatment of in-hospital cardiac arrest due to AMI between January 1, 2003 and July 1, 2010.

Result: The overall survival rate was 40.47% for patients with cardiac arrest due to MI who received ECPR. After adjustment for age and gender, right coronary occlusion (95% CI[A1] , 0.147–0.951; p = 0.039) and ST-elevation MI (95% CI, 0.097–0.494; p = 0.000) were associated with better survival results. Furthermore, prolonged delay before coronary intervention was associated with worse survival (95% CI, 1.010–1.029; p = 0.000).

Conclusion: In addition to ST-elevation MI and timely coronary intervention, patients with cardiac arrest due to right coronary artery occlusion can benefit from ECPR


Chou TZUNG-HSIN, Siu YIU (Taipei, Taiwan)
11:00 - 18:00 #7540 - Patterns for pre-hospital emergencies in Romania.
Patterns for pre-hospital emergencies in Romania.

BACKGROUND

Current days, Emergency Medicine field is characterized by interdisciplinarity. Abstract sciences like Mathematics provide powerful tools to predict optimize and allocate sufficient resources to meet the needs in staff and equipment. The current staffing and resources allocation method for Romanian EMS and other countries in Europe is mostly static. Our goal is to find a tool that can be used approach to improve this process by finding a pattern and predict the needs.

Typical medical cases patterns are successfully identified in emergency medicine. Starting from the logical assumption that during special occasions like public holidays or religious fasting, the number of emergency incidents rises, and as a result an extra number of ambulances are required to meet the expectations.

The purpose of this study is to propose a functional mathematical model based on main events in time associated with the need for extra MICU resources. A correct prediction model could allow a more efficient way of ambulance distribution, based on necessity.

METHODS

Source data for this study is Romanian SMURD national database, comprising of 900.000 cases for a period of 4 years. The quantity of emergencies addressed by EMS is calculated for main types of emergencies correlated with important social events.

RESULTS

National holidays generate an increase of the number of all types of emergencies. Medical cases involving toxic increase by 40% (we speculate to be ethanol consumption), trauma by more than 10%, involving aggression and road accidents. False alarms multiply as well.

The pattern is during religious fasting. Toxics cases increase by a quarter followed by cardiovascular afflictions with 19% and other pathologies by  15%.  Neurological and trauma cases are significantly higher.

Amazing results are characterized by periods with school holidays when most incidents of all types significantly decrease.

CONCLUSIONS:

Using the right mathematical model  bring the possibility to predict a pattern change of medical incidents based on contextual events like holidays or special events etc.

Current planning approaches of medical resources based on assumptions or heuristics ways may not always meet all the needs and each  information about possible predictable behavior will bring an increase of efficiency. Everywhere in the world Emergency Medicine is expensive and a good allocation of resources based on needs will reduce the costs without affecting the quality.


Marius SMARANDOIU (Sibiu, Romania), Alin CANCIU, Denisa FALAMAS, Dania LUNCA, Daniela TARAN
11:00 - 18:00 #7447 - Patterns of child and adolescent mental health admissions to the emergency department.
Patterns of child and adolescent mental health admissions to the emergency department.

Objectives and Background

 

Appromixmately 1 in every 12  to 15 children and young people deliberately self-harm. Our aim was to identify all the paediatric mental health (MH) patients that presented to the Emergency Department (ED) and follow their journey to paediatric ward. By understanding the service needs we will be able to identify areas for improvement. The hospital has a Child and Adult Mental Health Service (CAMHS) service works Monday to Friday in daytime hours only (9am – 5pm).

 

Methods

 

This retrospective analysis looked at patients younger than 18 years who attended the ED in a District General Hospital with a primary MH issue between January and December 2014. Data collected included reason for admission, length of stay in the department, length of stay in ward and other epidemiological data. Final discharge destination and nursing provision needed was also looked at.

 

Results

 

103 paediatric patients presented to the ED with a primary MH problem, all of whom were admitted to await further psychiatric assessment. Most patients were female (9:1 ratio), with a mixed overdose as the common presentation. 4% of the total paediatric admissions over this period were MH related. 70% of patients presenting out of hours. Median length of admission was 31 hours and 40 minutes. Admission on a Friday night resulted in the longer stays, with a median stay of 52 hours. Nearly 20% of these patients required 1:1 nursing care on the ward, 87% were subsequently discharged home after psychiatric review. Since 2011 there has been a 30% increase in the numbers of admitted to the paediatric ward in our hospital.

 

Discussion

 

This rise in paediatric MH patients presenting to the ED is likely to be mirrored across all EDs in the United Kingdom. This has a significant impact both on the ED and the paediatric ward. A major concern is all these patients are being admitted to the ward, which is not the appropriate setting to be reviewed. If CAMHS was available in the ED, these patients could be discharged from here. Subsequently to this study, there has been a review of service provision and CAMHS is planning to introduce a 6-day week. Additionally, the ED now attempts to identify all children with MH problems at triage, and aims to get them seen as soon as possible by the paediatric team. Further work is needed to understand why there has been an increase in the number of children and young people with MH problems. 

 

 


Sarah EDWARDS (Leicester, United Kingdom), Elly LESSER, Leesa PARKINSON
11:00 - 18:00 #7070 - Pediatric case of Accidental Methotrexate Ingestion.
Pediatric case of Accidental Methotrexate Ingestion.

Paediatric overdoses and acute poisoning is a common phenomenon encountered in clinical practice. However, methotrexate over doses is a rare presentation despite the increasing use in practice.
Methotrexate is a cytotoxic antimetabolite and antifolate drug widely used  for chemotherapy,treatment of autoimmune diseases and seldomly as an abortifacient.It has both rapid and complete absorption from the gastrointestinal tract with primary renal excretion. Parenteral toxicity has been reported to be lethal, more frequently known to result in myelosupression, respiratory failure ,renal failure, hepatotoxicity, neurological dysfunction, abortion,sepsis and multi-organ failure.
Antidotes like Glucarparidase (Voraxaze) may be considered in severe toxicity and acute kidney injury.
Regular infusion of leucovorin (folinic acid) remains the recommended initial treatment in symptomatic and significant overdoses to reduce toxicity.Activated charcoal can be used within an hour of suspected toxicity. Urine alkalinisation may be beneficial in drug excretion.

We present a case of Paediatric Methotrexate acute ingestion with no previous therapy in a 2 years old boy, who presented to the emergency department  3 hours following a suspected accidental ingestion of his mother's medication.
History revealed suspected intake was greater than 3mg/kg as 60mg tablets was unaccounted for my parent. He had non-specific symptoms with a single vomiting episode and an hour of profound hyperactivity.He was treated with immediate leucovorin rescue therapy without waiting for methotrexate assay as recommend by Toxbase to avoid severe toxicity. Blood investigation (6h) result showed leucocytosis, with slightly raised Alkaline Phosphatase and elevated methotrexate level.
National poisoning centre (NPIC)  was contacted and patient was admitted by paediatric team with unremarkable clinical course also with no adverse sequelae 4 weeks after overdose.
In conclusion, early identification and calculation of estimated dosage is essential, including  prompt administration of folinic acid to decrease toxicity and prevent methotrexate overdose vast complication in patient management.Weekly assessment with blood investigation for 4weeks post-acute ingestion due to delayed complications is recommended.

Comfort ADEDOKUN (dublin, Ireland), Iomhar O'SULLIVAN, Adrian MURPHY, Rizwan MUHAMMED
11:00 - 18:00 #7756 - Pediatric Emergency in Sport. A case report.
Pediatric Emergency in Sport. A case report.

Background

12 years patient arrive at our health center for syncope while playing handball at 50m.

During the game he gets hit in the chest by the ball, after that he falls immediately unconscious. At his arrival cardiopulmonary arrest is diagnosed, and we start CPR ,we send someone to search Automated external defibrillator (AED) in the sports center. Resuscitation was initiated and the desfibrilator provides 2 desfibrillatons. He was transferred to the hospital. The electrocardiogram on admission shows Ventricular Fibrillation so he gets the tirad desfibrillation. It appears sinus rhythm.

He get hemodynamically stable without arrhythmias. Color echocardiogram shows no cardiac structural alterations and ECG-Holter 24 h was normal too.

Family and Community Focus: Study of family and community: Any patient with a history of sudden death should make a genetic family study.

Results

Sudden death due to cardiac shock is caused by a direct hit to the chest, in the absence of underlying cardiovascular disease, and it is an event known as commotio cordis , one of the most frequent causes of sudden death in young jóvenes. In USA most victims are men (95%) and ethnic "white" (78%). 50% of events take place in Sports in the high competition. It must be a hit in the chest by a blunt object, a ball or body contact with another player, directly on the heart, and it has to take place in the electrically vulnerable period of the  cardiac cycle (rising part of the T wave, just before its peak).

Treatment . The treatment was desfibrillation. There is no evidence that survivors of commotio cordis event present new high risk of arrhythmic events, so secondary prevention is not indicated.

CONCLUSIONS 

Family physicians and emergency doctors engaged in health care centres or other services near sports centres, and they must have a Automated external defibrillator. Now in our country, Spain, this kind of sport center must have. They can save lives and in our case.


Veronica PARENT MATHIAS (MALAGA, Spain), Lorea DE UNAMUNO LUMBRERAS, Juan Manuel GARCIA LOPEZ, Maria Del Mar BECERRA MAYOR, Maria Isabel CORREA ROSALES
11:00 - 18:00 #8165 - Pediatric pre-hospital care in Turkey; one year multicentric descriptive study.
Pediatric pre-hospital care in Turkey; one year multicentric descriptive study.

Background

Emergency medical services (EMS) systems in Turkey (also called 112) developed to care for adults. Pediatric patients comprise approximately 8-10 % of EMS requests for aid, but little is known about the clinical characteristics of pediatric EMS patients and the interventions they receive.

Objective

Our objective was to describe the pediatric prehospital or interhospital  patient cohort in our country.   We also tried to measure how often EMS providers  give a call before deliver the patients, and how often they do/not interventions.

Methods

All children (age <19 years) who required EMS transportation  from August 2013 to August 2014 were eligible for inclusion. This prospective study was conducted at 9 tertiary care hospitals where located in 4 city. Surveys  were completed by the person on shift of emergency department at each institution.  This survey was conducted after receiving approval from the ethics committee of Ege University Hospital.  Survey was including all informations on transported patients  such as; ambulance type, patient demographics, general appearing, clinical features with vital signs(before and after the transfer ), the reason for transfer,  received interventions/procedures and final outcome. 

Results:

There were 2094 pediatric transports, 6.7% of the total call volume. Most patients used (96%) land ambulances. Only 16%  ambulance staffed with physician and  2% with a nurse . Majority children (72.4%) delivered to the tertiary pediatric emergency departments (ED) without giving any  information. The median age of the whole cohort was 5,5 years and 54,9% was male. The most common reasons used for transfer calls were trauma (20%), neurologic disease (19,5%), intoxication(13,5%) and respiratory tract infections(10%). Fourty percent of transported children had no venous acces. Upon admission to the ED the most common life saving interventions were  endotracheal intubation and cardiopulmonary resuscitation(CPR), and they administered respectively for 25 and 9 patients. All patients who received CPR (n=9),  died in the ED. Overall, 41% of transfers  triaged as urgent resulted  in a hospital admission(669 children to ward, 218 to PICU).  Patients who tarnsported by ambulance staffed with paramedic were more likely to have lifesaving interventions and poor outcome (p<0.001).  

Conclusions:

Children made up a small  part of EMS providers’ clinical practice, so that prehospital providers infrequently perform pediatric interventions. Our observational data showed that Turkish EMS is not well specialized in pediatrics.  We believe that more physician staffed (pre-hospital emergency medicine specialists) ambulance is  essential to provide a high quality of care to critically ill children out of the hospital.  EMS teams should be better prepared to deal with sick children in the pre-hospital setting.

 


Eylem Ulaş SAZ, Caner TURAN (ISTANBUL, Turkey), Murat ANIL, Alkan BAL, Gazme GOKALP, Hayri Levent YILMAZ, Sinem SARI GOKAY, Tuğçe ÇELIK, Nilden TUYGUN, Halise AKÇA, Deniz TEKIN, Sinan OĞUZ, Tanju ÇELIK, Özlem TEKŞAM, Ayşe GÜLTEKINGIL KESER, Gülser Esen BESLI, Murat DUMAN, Ali YURTSEVEN
11:00 - 18:00 #7457 - Penetrating aortic ulceration: A predictable aort dissection.
Penetrating aortic ulceration: A predictable aort dissection.

Introduction: Aort dissection and aortic syndromes are rare but highly mortal conditions in emergency departments. In aorta lumen, ulcerated atherosclerotic plaques makes the intimal layer disrupt. Mostly tearing chest and interscapular pain occurs with aortic rupture.

Case report: Our case is 66 years old woman applying to emergency department with chest and interscapular pain. Tearing-like chest pain was started early in the morning and severity was not decreased. Vital signs are ta in left arm 160/80 and right arm 150/75, tachicardic, pale and sweating, normoglicemic, saturation 95 with O2. Her ECG is normal sinus rythm. Her laboratory findings are normal. D-dimer is 3600. Computer angiography is reported as acute penetran ulceration started between ascending and arcus aorta and continuous mural hematoma to iliac arteries with obliteration lumen. Patient was forwarded to university hospital. Multi-sliced BT has done but no change in the size of hematoma. After she was followed up for 2 days with antihypertensive and analgesics, she was discharged from hospital. On the fourth day she reapplied to our department with severe pain. After 72 hours her tomography reported as aort dissection of arcus aorta. She was forwarded to university hospital for operation.

Discussion: Penetrated aortic ulceration causes tear like pain in patients. Emergency physicians suspect aortic dissection as well as pulmonary embolism, acute coronary syndrome  as differential diagnosis but angiography also normal for dissection. Intramural hematomas and penetrating aortic ulcers are less urgent for operation than aort dissections. D-dimer can be a prognostic value for penetrating aortic ulcers. Symptomatic ones should be treated endovascular besides asymptomatic patients can be followed up. In emergency department, all suspected chest and interscapular tearing pain should be evaluated as progressive and mortal.

References: 1.Kilic, Arman, and Ahmet Kilic. "Penetrating Aortic Ulcers." Principles and Practice of Cardiothoracic Surgery. InTech (2013): 375-385.

2.Gifford, Shaun M., et al. "The natural history and outcomes for thoracic and abdominal penetrating aortic ulcers." Journal of vascular surgery 63.5 (2016): 1182-1188.

Acknowledgments: There is no conflict of interest in this study.


Goksu BOZDERELI BERIKOL (Istanbul, Turkey), Gurkan BERIKOL, Onur SAYDAM, Attila BESTEMIR, Mehmet Serkan YURDAKUL, Ismail EKINOZU
11:00 - 18:00 #7639 - Percutaneous coronary intervention with ongoing cardiopulmonary resuscitation in refractory out of hospital cardiac arrest.
Percutaneous coronary intervention with ongoing cardiopulmonary resuscitation in refractory out of hospital cardiac arrest.

Purpose of the study:

Acute Myocardial Infarction (AMI) is one of the most common causes of cardiac arrest (CA). Resuscitation after refractory in-hospital CA in the catheterization laboratory using mechanical chest compressions (MCC), during simultaneous percutaneous coronary intervention (PCI), have an 78.2% of PCI success rate, with a 46.9% of discharged from cath-lab with return of spontaneous circulation (ROSC) and 25% discharged hospital with optimal neurological outcome. We designed a study to evaluate a new treatment strategy for the patients with coronary suspicious origin refractory out of hospital cardiac arrest (OHCA), with no response to conventional advanced live support (ALS), that could be transferred to the cath-lab for PCI with ongoing cardiopulmonar resuscitation (CPR) with MCC.  

Material and methods:

Prospective and descriptive study from 26.12.2014 until 26.04.2016 of patients with OHCA transferred to Joan XXIII University Hospital in Tarragona (Spain), with 795.101 reference population. Inclusion criteria:  Age <70 years, quality of life without terminal illness, suspect of AMI, witnessed CA, immediate and good quality CPR (<3 minutes), shockable rhythm, absence of ROSC after 10 minutes of CPR, possibility of MCC, possibility of PCI, time CA-Hospital< 45 minutes.

Results:

23 patients were included. Average age: 59.69 years (13% <40 years; 8.7% 41-50; 17.4% 51-60; 43.5% 61-70; 17.4% >70). Gender: men 78.2%. Concomitant diseases: Smoking 34.7%, hypertension 52.2%, diabetes 4.3%, hyperlipidaemia 39.1%, chronic ischemic heart disease 13%, hypertrophic cardiomyopathy 4.3%. Time of CA: morning 8-15h 56.5%; evening 15-22h 21.7%; night 22-8h 21.7%. Witnessed CA:  yes in 95.6%, with no health professional witness in 65.2%. CA location:  home  52.2%; public  13%; ambulance 13%; work 8.7%; restaurant 8.7%; hotel 4.3%; sports facilities4.3%. Initial time chest compressions: <3 minutes 52.2%; 3-5 minutes; 30.4%; 5-8 minutes 8.7%; > 8 minutes; 4.3%; unknown 4.3%. CPR initiated by: health professional in 65.3%. Shockable rhythm in any time: 69.5%. First defibrillation (DF): ambulance 60’7%; public AED 13%; no DF 26%. Average time of first DF: 6.8 minutes (62.5 %< 8 minutes). Average time of arrival ambulance:  8.1 minutes. Use of MCC: 73.9%. Return of spontaneous circulation (ROSC): 78.2% (before start transport 47.8%; during transport 13%; in cath-lab 21.7%). Average time to arrive at the cath lab: 75.6 minutes. Angiography done: 86.3%. Primary PCI done: 36,3%. Cath lab discharge: 65.2%. Hospital discharge: 34.7%. Cerebral performance category (CPC) 1-2: 26%.

Conclusions:

1. - Coronary reperfusion therapy is a real possibility of treatment in patients with refractory OHCA.

2. - We must improve our use of public AED and bystanders CPR.

3. - The absence of shockable rhythm is a bad prognostic factor and a frequent inclusion error (30.5%).

4. - The average delay time of arrival at the hospital is 30 minutes. The main delay factor is caused by waiting for ROSC before starting the transport.

5. - The results of survive and CPC in our study encourage us to increase efforts in this new treatment strategy with diffusion and staff training.


Guillermo CAÑARDO (Alforja, Spain), Aitana PÉREZ, Mar SOLANO, Gil BONET, Alfredo BARDAJI, Alfonso LÓPEZ, Isaac LUCAS, Christer AXELSSON, María JIMÉNEZ
11:00 - 18:00 #5194 - Performance of manchester triage cystem for children with chronic cardiovascular diseases including vital parameter measurement.
Performance of manchester triage cystem for children with chronic cardiovascular diseases including vital parameter measurement.

Performance of Manchester Triage System (MTS) for children with chronic cardiovascular diseases (CVD) including vital parameter measurement.

PR Espina, T Wrba, S Greber-Platzer
Medical University Vienna, Austria

Background: In pediatric emergency care MTS has moderate sensitivity (63%) and a good specificity (78%) (van Veen et al 2012). Seiger et al. (2014) have shown that inclusion of vital parameters (VP) in MTS for pediatric emergency care did not improve triage classification. Performance of MTS for children with chronic diseases (CD), especially with CVD has barely been evaluated.

Objective: The aim of our study was to evaluate the MTS performance in children with CVD by measuring VP (HF, RR, Poxy).

Methods: Data derived from a registry of patients attending the pediatric emergency of the Dep. for Pediatrics and Adolescent Medicine from 01/2014-12/2014 were analyzed retrospectively. Inclusion criteria were children <18-y.o., children with CVD (congenital heart defect, arrhythmia, acquired heart disease and cardiomyopathy) and without known CD including data for MTS urgency level (UL), VP, therapy, diagnostic examination, diagnosis and outcome.

Results: In total 16715 patients, 8151 (49%) female, with an overall mean age of 5-y.o., were included. Of these 936 (5,6%) children presented with CVD and 15779 (94,4%) children without CD. VP were more often measured in children with CVD (59%) compared to children without known CD (41%). We further investigated the cohort of children with CVD and compared between those with measured VP and those without measured VP. In the group with VP more often acute treatment was given (28,2% vs.18,6%), diagnostic examination was performed (55,2%vs.40,8%) and lifesaving interventions were needed (0,7% vs.0%). A higher UL was more often selected in children with CVD and measured VP than without measured VP (UL-1 1,4%vs.1%, UL-2 17%vs.4,4%). Admission to an intensive care unit (0,5% with vs.0,8% no VP) did not depend on VP measurement, but a slight increased hospitalization rate (18,4% vs.15,5%) and decreased follow-up at outpatient clinic or by pediatrician (80,9% vs.83,5%) was found in children with VP measurement.
Comparing patients without CD and with or without VP measurement showed more often an acute treatment (23,2% vs.18,3%), diagnostic examination (28,1% vs.18,2%) and lifesaving interventions (0,14% vs.0%) with measured VP, also a more frequent and higher UL (UL 1 - 0,5% vs.0,2%, UL 2 - 8% vs. 3,3%) was chosen. Also admission to ICU (0,2% with VP vs.0,01% no VP) or hospitalization-rate (4,7% vs.3,5%) was slightly higher in patients with measured VP. Follow-up at outpatient clinic or by pediatrician  (95,1% vs.96,44%) did not depend on VP measurement.
The most frequent diagnoses in children with measured VP were infections of the respiratory-tract (RT) (46,1% both), viral-infection or fever (15,8% for children with CVD, 15,2% for children without CD) and gastrointestinal-infections (GI) (9,5% and 11,1%).  In the group of children without VP measurements GI (24% with CVD and 25% without CD) and RT (23,5% and 23%) infections were same frequent, followed by viral-infections or fever (18,3% and 18,4%).

Conclusions: Our study demonstrates that MTS performance could benefit by including VP measurement in children with CVD.


Pinky Rose ESPINA (Vienna, Austria), Thomas WRBA, Susanne GREBER-PLATZER
11:00 - 18:00 #7931 - Performing a blood gas analysis to patients who come for exacerbation of COPD in Emergency Service.
Performing a blood gas analysis to patients who come for exacerbation of COPD in Emergency Service.

Introduction

Chronic obstructive pulmonary disease is a pulmonary disorder that is characterized by being a blockage usually progressive and irreversible airway. The clinical practice guidelines (CPG) recommend assessing the severity of each episode, for which propose a classification that identifies the risk of death if the exacerbation is severe or very severe. Two of these criteria are hypercapnia (PaCO2> 45 mmHg) and respiratory acidosis (pH <7.30). Knowing this also influences the subsequent treatment. Thus, it is important to blood gases to patients presenting with this pathology.

 

Objetive

Gas analysis is performed to assess whether patients diagnosed with COPD who come to the emergency department with an exacerbation.

 

Material and methods

observational, retrospective study in a General Hospital with a population of 200,000 and 275 urg / day. COPD are classified according to GOLD Guide and according to their FEV in FEV> 80% very severe mild, moderate 50-80%, 30-50% severe and <30%. performing blood gas analyzes all serious and very serious patients who consult with exacerbation of COPD January 2012 to June 2015 and PaCO2 and pH values.

 

Results

Rated 1173 patients, 539 (45.95%) had FEV 30-50% and 282 (24.04%) had FEV <30%. Gas analysis was performed to 1058 (90.19%).

 

Of patients with FEV 30-50%, to 447 (82.93%) they were asked gases, having a PaCO2> 45 mmHg 39 of them (8.72%) and 29 of them (6.49%) of them pH <7.30.

 

Of patients with FEV <30% to 207 (73.4%) they were asked gases, having a PaCO2> 45 mmHg 25 of them (12.07%) and a pH <7.30 25 of them (12.07%).

 

Conclusions

Performing a blood gas analysis to patients who come for exacerbation of COPD is improved if we follow the recommendations of the Clinical Practice Guidelines (CPG), especially in severely ill patients.

The results provided by the gas analysis help determine the severity of the patient and influence subsequent treatment, it is important to make to COPD patients who come to the emergency room for a sharpening as recommended by the GPC


Nuria RODRIGUEZ GARCIA, Maria Consuelo QUESADA MARTINEZ, Blanca DE LA VILLA ZAMORA, Danae FERNANDEZ-CAMACHO, Maria CORCOLES VERGARA, Pascual PIÑERA SALMERÓN (montepinar, Spain), Antonio MARTINEZ-GARCIA, Cesar CINESI GOMEZ
11:00 - 18:00 #8002 - Pericardial tamponade as first manifestation of non-advanced lung adenocarcinoma.
Pericardial tamponade as first manifestation of non-advanced lung adenocarcinoma.

75 year old man patient, independent living, a nonsmoker, hypertension treated with enalapril. Go to emergency service for epigastric pain, dyspnea and asthenia 1 month of evolution; previously serviced by family doctor and treated with antibiotics, without improvement. Not fever, not refer other symptoms.

Physical exam: Normotensive, tachycardia (130 pm), increased jugular venous pressure basal. Sat 94%. Afebrile. Cardiopulmonary auscultation: Rhythmic tones without murmurs, decreased  vesicular murmur; Abdomen: globular, pitting blandoy, no masses or organ enlargement, blumberg - Murphy -; MMII; distal edema with fovea +, no signs of DVT. 

Complementary tests: Blood test showed no significant findings. ECG: electrocardiogram showed prominent low voltage QRS complexes in all derivations. Chest x-ray showed a markedly enlarged cardiac silhouette and a nodule in the right upper lung. Two-dimensional echocardiography showed a large pericardial effusion and marked diastolic collapse of the right auricular with significant respiratory variation in mitral flow velocity, there was no collapse of the right ventricule.

Emergency pericardiocentesis was performed via a subxiphoid approach. After the removal of 1800ml of non-coagulable bloody fluid, clinical symptoms rapidly improved. A post pericardiocentesis echocardiography showed a high pulmonary artery systolic pressure with pulmonary artery systolic pressure at 50 mmHg.

Discussion: Pericardial effusion is a well-known complication of many advanced malignancies such as lung cancer, breast cancer, lymphomas and leukemias. Although infrequent, symptomatic pericardial effusion with hemodynamic compromise can be the initial presentation of underlying malignancies. It can occur because of accumulated fluid amounts as low as 150 ml if the accumulation occurs rapidly. On the other hand, the slow accumulation of fluid, in some instances as much as two liters, may not cause tamponade. Echocardiography Doppler is a portable, non-invasive imaging modality that was ideally suited in this instance to rapidly confirm the clinical suspicion of tamponade and help guiding therapeutic management.  We believe that it is necessary to consider a possible diagnosis of pericardial tamponade of various causes, even advanced malignancies, in otherwise healthy patients admitted with the aforementioned symptoms. Cardiac tamponade and pulmonary embolism are a rare but potentially fatal cancer complication.


Carmen Adela YAGO, Enrique CARO (MALAGA, Spain), Daniel FERNANDEZ
11:00 - 18:00 #7652 - PERSISTENT BRONCHITIS IN A YOUNG MALE WITH SURPRISING FINAL DIAGNOSIS.
PERSISTENT BRONCHITIS IN A YOUNG MALE WITH SURPRISING FINAL DIAGNOSIS.

Anamnesis: 35 year old male with a history of acute myeloid leukemia twelve years prior to the current query reason, treated with chemotherapy: Anthracyclines (Idarubicin / Cytarabine) and twice Mitoxantrone plus autologous bone marrow transplantation in complete remission for three years and no standard treatments. He consulted for persistent dyspnea associated with moderate activity, coughing, lower limbs edema and a paroxysmal nocturnal dyspnea episode. Previously examined on several occasions in the health center and hospital for the same symptoms weeks earlier, it was labeled as a bronchitic process and anxiety without clinical improvement. Acute heart failure (AHF) was suspected probably secondary to previous treatment with Anthracyclines. Clinical examination: conscious, oriented, Blood pressure: 125/90 mmHg, basal oxygen saturation 99%, 100 per minute rhythmic heart beats with gallop rhythm and mitral systolic murmur. Bilateral basal lung hypoventilation and bilateral ankle edema. Rest of exploration within normality.
Given the clinical suspicion of AHF an electrocardiogram was made showing sinus rhythm with signs of left branch blockage. Chest radiograph showed cardiomegaly and interstitial edema. Blood work showed natriuretic peptide of 12.883 and the initial echocardiogram (VScan method) showed dilated left ventricle with estimated ejection fraction of 15-20% and moderate mitral and tricuspid regurgitation. During admission in the Cardiology Department more studies were made with new echocardiogram and cardiac MRI. The final diagnosis is dilated cardiomyopathy with severe ventricular dysfunction of nonischemic etiology. Medical treatment was established and an implantable defibrillator-resynchronization pacemaker was placed since recorded episodes of ventricular tachycardia were detected. The patient is currently pending for heart transplantation.

Discussion: Anthracyclines are cytotoxic drugs used in the treatment of different cancers. Cardiotoxicity is a characteristic and serious side effect of these drugs that occurs through different mechanisms lastly generating increased oxidative stress, myocyte apoptosis and fibrosis.
The overall incidence of symptomatic heart failure by these drugs is between 2.2 and 5.1%. Heart damage can occur immediately after treatment, subacute in the following months and finally chronically until 20 years after starting treatment; thus, it is recommended that long-term patients with Anthracycline follow up with echocardiography to detect their possible damage since Anthracycline-induced cardiomyopathy has been associated with a poor prognosis and a 2-year mortality of up to 60%.
This case shows the importance of early recognition of clinical syndromes such as heart failure and knowledge of the potential side effects associated with the patient’s previous treatment


Beatriz SIERRA BERGUA, Maria De La Peña LOPEZ GALINDO (ZARAGOZA, Spain), Alba HERNANDEZ MARCOS, Alexander MAZA GONZALEZ
11:00 - 18:00 #8199 - Pesticides intoxications in professional setting.
Pesticides intoxications in professional setting.

Introduction Pesticides and herbicide are professional products largely used by farmers and gardeners. The identification of risks and the modality of acute exposure may delineate a various range of clinical manifestations, from irritating symptoms to severe cases of systemic functional and lesional damages. Objectives To describe toxic professional acute exposures to pesticides and herbicides. Methods A five years (2010-2014) retrospective review of cases of professional acute exposures to pesticides and herbicides managed by the PPC was performed. Included cases were assessed for sex, age, agent involved, modality of exposure and PSS (Poisoning Severity Score) at first evaluation by specialist toxicologist. Attempted suicides were excluded. Results 439 cases were included (95% males; mean age 52.5 ± 16 years). Concerning the agents involved, insecticides account for the 42% of cases of intoxication (245/439) and, among these, organophosphates and pyrethroids are those more represented (45% and 30% of cases respectively). Also herbicides (19%; 110/439) are often involved (19%), with glyphosate that represent the 57% of these cases. Other agents involved are fungicides (18%), copper and sulphur (11%) and miscellaneous of other products in 4% of cases. In 6% of cases the agent involved is unknown. In general, only one product was involved in 74% of cases, 2 products simultaneously in 18%, 3 products in 6% and 4 products in 1% of cases. The exposure occurred during the use of the product in the 67% of cases, accidentally in 5%, during the preparation of the product in 3%. This data is unknown in the 26% of cases. Inhalation and dermal contact were the main routes of exposure (72% and 17% of cases respectively). Concerning the PSS at first evaluation by the PPC, patients were asymptomatic in the 10% of cases, presented mild symptoms in the 68% of cases, moderate symptoms in the 10% of cases and serious symptoms in the 1% of cases. This data was not evaluable in the remaining 10% of cases. Mortality resulted 0.1%.

Conclusions Main intoxication predisposing factors are the inappropriate use of pesticides, associated with the incorrect use of personal protective equipment. Besides playing a fundamental role in the diagnosis of intoxication, PPC provides also a specialized advice to evaluate correct indications for antidote administration and to supply antidote in adequate amount. To reduce potential risk of intoxication, especially in occupational setting, a correct preventive information program may be essential.


Sarah VECCHIO, Azzurra SCHICCHI, Marta CREVANI, Mara GARBI, Giulia SCARAVAGGI, Eleonora BUSCAGLIA, Valeria Margherita PETROLINI, Davide LONATI, Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy)
11:00 - 18:00 #7576 - Pilot implementation of structured triage system in emergencies: Qualitative assessment of perception of the health team to change.
Pilot implementation of structured triage system in emergencies: Qualitative assessment of perception of the health team to change.

The concept of triage is defined as the process of preliminary clinical assessment ordering patients according to their urgency / severity before diagnostic and therapeutic assessment complete. The triage system ensures the categorization of patients with the aim that the most urgent priority patients are visited when the situation arises eventual service expected.
Adult Emergency Department of Hospital Carlos Van Buren has a triage system following the recommendations given by the Commission Report Urgent Care approved in 2013. The scale in our unit categorizes patients into five levels and establishes waiting times for medical evaluation; It is performed by a professional (nurse) accompanied by a technician.

Since December the Chilean Ministry of Health starts programming a pilot for the implementation of a new triage tool nationwide where 16 hospital centers for evaluation 2 triage system: Manchester Triage System (MTS) and  Emergency Severity Index (ESI)

In our emergency department training with structured triage system was completed in December 2015 and trial run began on 1 March.
The specific initial and continuing training and professional experience triage in an emergency room is essential and unavoidable, inherent pillars staff must carry out this activity. Incorporating a triage system structured as a tool for prioritizing the demand for care in emergency units represents a change in the way they work on the selector Demand, as well as a change in the way users will attend.

The aim of the study was to evaluate the perception of the health team to the implementation of the pilot of a structured triage system in emergency department.


Valentina DUARTE (Viña del Mar, Chile), Karen SOTO, Gloria VALDES, Viviana AMPUERO, Jonathan BUSTOS, Jorge ZENTENO, Fabian RODRIGUEZ, Veronica DEL FIERRO, Pedro GALLARDO, Susana FUENTEALBA
11:00 - 18:00 #6228 - Pivotal role of revisiting personal social history: another case of dyspnoea.
Pivotal role of revisiting personal social history: another case of dyspnoea.

Introduction: Hypersensitivity pneumonitis (HP) represents a spectrum of respiratory disorders associated with type III and type IV immune responses. The non-specific and often insidious course of sub-acute forms of HP can lead to misclassification or misdiagnosis. We present a case of 57 year old man presenting with dyspnoea where on revisiting his personal/social history, further pivotal information was obtained which led to the correct diagnosis and appropriate management.

Case: A 57 year old male attended the emergency-department with sub-acute onset breathlessness on exertion with fatigue and flu-like symptoms. He was non-atopic, otherwise healthy and was not on taking any regular medications. He had no pets and there was no significant travel-history/occupational-exposure/high-risk behaviour. He denied any other systemic symptoms. He smokes 15grams of tobacco weekly and drinks under 10 units of alcohol weekly.

Respiratory examination revealed multiple rhonchi and high-frequency inspiratory crackles on auscultation of both lung-fields. The rest of the systemic examination was unremarkable. Laboratory-investigations revealed neutrophilic-leucocytosis with raised inflammatory-markers. His chest-radiograph revealed several ill-defined irregular foci of parenchymal opacification in both lungs. He was treated empirically for a chest infection and possible presumed underlying chronic-obstructive-pulmonary-disorder (COPD). Despite oral antibiotics, oxygen, nebulisers and low-dose steroids, his symptoms gradually progressed over the next 24 hours. His pulmonary function testing showed a normal pattern. In view of his smoking history and peculiar chest-radiographic-findings, the radiologist proceeded with a computerised-tomography (CT) scan of his chest with contrast which demonstrated numerous irregular centrilobular opacities < 5mm in diameter with areas of patchy oedema affecting both lungs, concentrated in the middle part and base of the lungs but predominantly on the right lung fields without any pulmonary-mass lesion or COPD changes; however, the possibility of allergic/hypersensitivity pneumonitis was suggested.

Subsequently on revisiting his personal/social history and on further direct-questioning; he recalled that just prior to the onset of his symptoms; he bought a new-brand of an aerosol-spray paint online for "modding" his motor-bike which he used without using any personal protective equipment on relatively warm metal-work (after a long-drive) on his bike in an indoor-garage setting. The aerosol spray paint was confirmed to contain isocyanayte.

He refused to have both broncho-alveolar-lavage (BAL) and further high-resolution CT scan.

HP was diagnosed in view of the clinical symptoms, the history suggestive of exposure to aerosol-spray paint with further possibility of haptenation with isocyanate-component and compatible radio-imaging findings. He received high-dose prednisolone (1 mg/kg) in a tapering regimen, which lead to remarkable improvement of his symptoms and he made a recovery within one week without any recurrence of symptoms at one month’s follow up.

Discussion: HP is a form of interstitial lung disease that is preventable and "curable" by early recognition of antigen-exposure and subsequent avoidance that could improve the overall prognosis and lead to a clinically favourable outcome. Our case report re-emphasizes the pivotal role of revisiting patient’s personal/social history while performing the crucial exceedingly thorough search for an obvious antigen-exposure in a case of HP which had consequences both for diagnosis, prevention and prognosis.


Nikhil PRASAD, Vanessa KING, Deepwant SINGH (Bury St Edmunds, )
11:00 - 18:00 #8192 - PMMA poisoning: clinical features in lethal and non-lethal cases.
PMMA poisoning: clinical features in lethal and non-lethal cases.

Objective: Paramethoxymethamphetamine (PMMA), and its metabolite PMA, cause central nervous system stimulation and hallucinogenic effects, like MDMA, and represented one of the recent relevant cause of death by new psychoactive substances of abuse (NPS). Outbreak of PMMA/PMA poisoning resulting in fatalities has been described (1). We report 5 cases of PMMA/PMA severe intoxication collected in 2 years. Case series: Five cases referred to Pavia Poison Control Centre (PPCC) were evaluated (age ranging from 16 to 32 years-old). PMMA/PMA consumption was never declared: 1 patient referred MDMA intake, 1 patients amphetamine and cannabis, 3 patients were unable to report the taken substance. Most common clinical manifestations were severe psychomotor agitation (100%), tachycardia (80%), mydriasis (60%), sweating (60%), hallucinations (40%) and hyperthermia (20%). Immunoenzymatic urinary tests resulted positive for amphetamine/methamphetamine, MDMA, cocaine and THC. Chromatographic second level laboratory investigations were performed in all cases: all patients were positive for PMMA/PMA but also to MDMA (4 cases), amphetamine (3), THC (3), cocaine (2), ketamine (1) and methoxetamine (1). Treatment consisted in benzodiazepines (5 cases), oro-tracheal intubation and respiratory support (2). Hospital stay ranged from 24 to 96 hours for the patients that need intensive care treatment. One fatal case was registered. Clinical picture worsened rapidly: metabolic acidosis, hypoglycemia, hyperkalemia, severe hyperthermia, multi-organ failure and severe disseminated intravascular coagulation. Although pharmacological treatments and intensive care support (including depurative techniques), patient died in 20 hours. The results of blood analysis were: PMMA 615 ng/ml, PMA 91 ng/ml, tramadol 88 ng/ml, MDMA 192 ng/ml, MDA<20 ng/ml, cocaine 28 ng/ml, benzoylecgonine 529 ng/ml. Analysis of a residual part of the tablet taken by the patient revealed PMMA 25 mg and MDMA 11 mg.

Conclusion: PMA/PMMA intoxication may be related to a rapid and fatal outcome. Among clinical manifestation, hyperthermia should be interpreted as potentially severe risk factor.  Nevertheless, the national epidemiological data of abuse of PMA/PMMA cannot be quantified, as the PPCC (with advanced toxicological analysis facilities) and the National Early Warning System detect only patients with acute and severe intoxication. Urine positivity for ecstasy and amphetamines should be considered as cross-positivity to PMA/PMMA (not easily detectable in common laboratories). All the cases are reported to the National Early Warning System.

References: Lurie Y, Gopher A, Lavon O et al. Severe paramethoxymethamphetamine (PMMA) and paramethoxyamphetamine (PMA) outbreak in Israel. Clin Toxicol. 2012;50:39-43. Acknowledgements: Study carried out with the support of DPA-Presidency of the Council of Ministers.


Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy), Eleonora BUSCAGLIA, Pietro PAPA, Marta CREVANI, Sarah VECCHIO, Carolina PREVALDI, Giulia SCARAVAGGI, Davide LONATI, Teresa COCCINI, Valeria Margherita PETROLINI
11:00 - 18:00 #7411 - Pneumomediastinum secondary to cocaine insufflation: an uncommon cause of central chest pain.
Pneumomediastinum secondary to cocaine insufflation: an uncommon cause of central chest pain.

Introduction

Mediastinal emphysema, or pneumomediastinum, is the abnormal presence of air within the mediastinum and can result in life-threatening complications. A proportion of pneumomediastinum cases have been attributed to cocaine smoking and insufflation.

 


Case

A 20-year-old man, normally fit and well, presented to the Emergency Department (ED) with an eight-hour history of central pleuritic chest tightness radiating to the back and associated with lower neck pain. He was a non-smoker but admitted to occasional cocaine use.

He stated to have consumed an unquantified amount of alcohol and cocaine (via insufflation) over the previous three days. He was haemodynamically stable and examination of the neck revealed right-sided palpable subcutaneous emphysema. Electrocardiogram (ECG) displayed normal sinus rhythm whilst a plain chest radiograph (CXR) showed a linear shadow outlining the left heart border with significant anterior subcutaneous emphysema. Urgent computed tomography (CT) of the chest confirmed mediastinal emphysema whilst contrast swallow studies ruled out a concomitant oesophageal perforation.

The patient was managed conservatively and discharged with an outpatient follow up.



Discussion

Pneumomediastinum and associated subcutaneous emphysema result from the proximal tracking of free air from ruptured alveoli along peri-bronchiolar sheaths towards the mediastinum and deep fascial tissues of the neck. Repeated forced deep inspiration and Valsalva manoeuvres associated with cocaine use cause local barotrauma as a consequence of the alternating pressure gradients across the alveolar wall which result in alveolar rupture and subsequent air dissection. This in turn leads to air-tracking and the development of mediastinal and subcutaneous emphysema. This phenomenon is well-documented in cocaine smoking, with recent cases also identifying cocaine insufflation as another aetiology.

A secondary causative mechanism has also been hypothesised; it suggests direct toxic damage to alveolar cells further precipitates alveoli rupture and hence the development of pneumomediastinum. However, this is more likely a consequence of prolonged exposure to cocaine rather than acute use.

Pneumomediastinum and associated subcutaneous emphysema are rare but significant complications of illicit drugs use, including nasal insufflation of cocaine, and can often be present with mild, nonspecific symptoms such as chest pain, dyspnoea, dysphagia, dysphonia and cough.

As demonstrated by our case, the condition is usually self-limiting and can be managed conservatively. However, it is essential to monitor potential respiratory complications and to undertake further investigations (CT scans and other contrast studies) to exclude other causes such as mediastinitis, tracheal and oesophageal rupture, pneumopericardium, pneumorrhachis and airway compression.



Conclusion

Patients frequently present to the ED complaining of chest pain following cocaine use. Although the majority will not experience any adverse effect, it is important to be vigilant for signs of pneumomediastinum and prudent to organise a plain CXR to confirm such occurrence.


Geraint PHILLIPS, Laura BIRKS, Abdo SATTOUT (Liverpool, UK, United Kingdom)
11:00 - 18:00 #7981 - Point of care ultrasound for infective endocarditis.
Point of care ultrasound for infective endocarditis.

Infective endocarditis (IE) is a deadly condition that carries a 20-30% mortality rate.  It is most often associated with valve repairs, endovascular devices, or intravenous drug use causing damage to native otherwise healthy valves.  The modified Duke Criteria has become the standard means of diagnosing this condition, however, the utility of the criteria is limited in the ER setting due to the necessity of blood cultures to improve its sensitivity. The diagnosis of IE is met if patients have 2 major, 1 major + 3 minor, or 5 minor criteria.  The 2 major criteria are positive blood cultures and evidence of endocardial involvement. Given that culture results are not available during ED evaluation, bedside ultrasound is instrumental in detecting IE in the ED.  Transthoracic echocardiogram is 65-75% sensitive for valve vegetations and 84% sensitive for vegetations >10mm.  Vegetation size has been shown to correlate with severity of illness, therefore a timely point of care ultrasound gives the emergency physician a tool to immediately detect those patients at greatest risk of morbidity and mortality.  Here, we present the case of patient DC who was transferred to our institution for “endocarditis.” DC met just 1/5 minor Duke Criteria and had no accompanying imaging.  Point of care ultrasound performed by the Emergency Department residents revealed a large aortic valve vegetation with severe aortic regurgitation, despite minimal appreciable murmur on exam.  With 1 major + 1 minor modified Duke Criteria, this patient fell into the category of “possible endocarditis.”  Despite the uncertainty reflected by this term, the patient’s diagnosis was clear.  He had signs of heart failure on exam and required timely intervention to avoid further morbidity or death. The impressive size of the vegetation and evidence of failure facilitated immediate transfer of care to the Internal Medicine and Cardiothoracic Surgery services.  DC was taken to the operating room the following day for aortic and mitral valve replacement and ultimately discharged in well condition.

 

1Seif D, Meeks A, Mailhot T, Perera P. (2013) Emergency department diagnosis of infective endocarditis using bedside emergency ultrasound. Critical Ultrasound Journal 5: 1-4.

2Haldar SM, O’Gara PT. (2006) Infective endocarditis: diagnosis and management. Nature Clinical Practice 3: 310-317.

3Westphal N, Plicht B, Naber C. (2009) Infective endocarditis—prophylaxis, diagnostic criteria, and treatment. Deutsches Ärzteblatt International 106: 481-490.

4Bruun NE, Habib G, Thuny F, Sogaard P. (2014) Cardiac imaging in infective endocarditis. European Heart Journal 35: 624-632.


Talia WALKER (New Orleans, USA), Julie SLICK
11:00 - 18:00 #7282 - Point of Care Ultrasound for Manipulation of Colles’ fracture in the Emergency Department.
Point of Care Ultrasound for Manipulation of Colles’ fracture in the Emergency Department.

Point of Care Ultrasound for Manipulation of Colles’ fracture in the Emergency Department

Background: Colles’ fracture (distal radial fracture) is a common presentation to the ED and their reduction comes under the scope and competency of Emergency Physicians.  It is estimated that 71,000 adults sustain a distal forearm fracture in Britain each year.1 Fractures of the distal radius are the most common fractures of upper limb, and represent 14% of all fractures treated each year.2

Currently reduction and manipulation of distal radial fractures is done with blind manual palpation, with post-reduction x-rays as a guide for adequacy. Pre-reduction the patient is either given a hematoma block, Bier’s block or conscious sedation in the Emergency Department. Those with unsatisfactory reduction; the outcome may be (1) a re-manipulation and x-rays, (2) admission under orthopaedic surgery for re-manipulation under general anaesthetic, or (3) accepting the suboptimal position in those where functional issue is less important.

A Medline search found two relevant papers, which suggested ultrasound might be a useful tool for distal radius manipulation. Both were single-centre prospective studies and involved small number of patients.3,4

Prospective observational study

8 patients with Colle’s fracture underwent manipulation and reduction of fracture in the usual way; but with real time two plane ultrasound guided observation during the procedure.

Method: A linear high frequency probe was used and the distal radius was viewed in long axis in two planes (from dorsal surface and radial surface). Ultrasound was repetitively used during manipulation until the operator was satisfied with position of distal radial fragment. Plaster cast and plain radiograph was performed in the usual way after reduction..

Results: ‘No need for further manipulation’ was considered as successful reduction. All reductions were satisfactory and none required re-manipulation.

Limitations: 1. Small numbers in the study. 2. No objective measurements (ultrasound or radiographic) used to define successful reduction. 3. No other factors taken into consideration eg. anaesthetic technique used, total time spend in the department, patient experience evaluation.

Conclusion: Ultrasound guided reduction and confirmation of satisfactory reduction prior to applying plaster cast seems a very novel and attractive concept. This might prove beneficial to patients by reducing second exposure to radiation if satisfactory position confirmed with ultrasound, improved patient experience and possible reduction in time spent in the emergency department. A larger multi-centric randomized control study in future would provide better evidence to support this novel concept.

References

1. O’Neill TW, Cooper C, Finn JD et al. Incidence of distal forearm fracture in British men and women. Osteoporos Int 2001; 12: 555–558.

2. Jupiter JB, Fernandez DL. Comparative classification for fractures of the distal end of the radius. J Hand Surg 1997;22:563-71.

3. Chern TC; Jou IM; Lai KA; Yang CY; Yeh SH; Cheng SC, et al Sonography for monitoring closed reduction of displaced extra-articular distal radial fractures Journal of Bone & Joint Surgery - American Volume February 2002, vol./is.84-A/2 (194-203), 0021-9355.

4. Ang S-H, Lee S-W, Lam K-Y. Ultrasound-guided reduction of distal radius fractures. Am J Emerg Med. 2010;28(9):1002–8.


Mohit ARORA (Leeds, )
11:00 - 18:00 #7470 - POINT-OF-CARE ULTRASOUND CHANGES THE AIRWAY MANAGEMENT DECISIONS IN THE EMERGENCY DEPARTMENT.
POINT-OF-CARE ULTRASOUND CHANGES THE AIRWAY MANAGEMENT DECISIONS IN THE EMERGENCY DEPARTMENT.

Very little is described in the literature regarding the utilization of ultrasound during the management of difficult airway in the Emergency Department (ED). Ultrasound-guided airway evaluation at the bedside has been described as an effective tool in identifying difficult airway in the perioperative setting. Additionally, point-of-care ultrasound has been used to identify the appropriate position of endotracheal tube, to guide procedures in the airway such as urgent cricothyroidotomy and to identify pathologies of the airway e.g. vocal cord malfunction, swallowing abnormalities, supraglottic hematomas or abscesses, respiratory papillomatosis, laryngeal stenosis, etc. Our work puts together a series of cases where the ultrasound-guided approach changed the initial airway management in patients admitted in the ED of Fundación Cardioinfantil in Bogotá Colombia.

 

Objective

To describe our clinical experience where airway ultrasound assessment has changed the initial approach for difficult airway management in the ED.

 

Methodology

We described 10 cases of patients admitted to the ED of Fundación Cardioinfantil who required airway management during the period of 1 January of 2015 to 30 March of 2016.  We only described patients in whom the initial decision for airway management changed after ultrasound assessment. The following aspects were analyzed for each patient: indication for airway management, initial approach for airway intubation, ultrasound examination findings, approach for airway management after ultrasound assessment and outcomes.

 

Results

The main indication for intubation was upper airway obstruction due to inflammatory process (Ludwig's angina and anaphylactic reaction) and tumors. In the anaphylactic airway obstruction, the glottis swelling was monitored by ultrasound during management and finally the tracheal intubation was not necessary. In 3 cases the decision to perform orotracheal intubation was switched to surgical tracheostomy as the initial approach due to ultrasound examination findings of severe supraglottic obstruction and tracheal tumor that made orotracheal intubation.  Ultrasound determined the need to change the size of the orotracheal tube due to the finding of unidentified subglottic stenosis. Additionally, in 2 patients with previous diagnosis of subglottic stenosis and apparent difficult airway, the ultrasound assessment concluded that it was a normal airway and rapid sequence intubation was performed without complications.  Four patients admitted for inflammatory submandibular process and tumors had initial clinical observation and conservative management, however in a patient a dynamic airway obstruction were identified by ultrasound and immediate intubation (performed by fiberoptic bronchoscope) and surgical management were performed.

 

Conclusions

Based on our experience, ultrasound approach could be a valuable tool for decision making during difficult airway management. Airway ultrasound assessment is not only useful for identifying true difficult airway, but also for monitoring the dynamic changes in the airway during initial treatment.


Luis Arcadio CORTES-PUENTES (BOGOTA, Colombia), Gustavo Andres CORTES-PUENTES, Gerardo LINARES-MENDOZA, Monica BUITRAGO
11:00 - 18:00 #7557 - Point-of-care ultrasound: training medical students.
Point-of-care ultrasound: training medical students.

Introduction

Use of ultrasound in clinical practice is a burgeoning field, not least in emergency medicine. However, the teaching of ultrasound scanning (USS) in most U.K. medical schools does not currently reflect its increasing clinical application. Cambridge University Emergency Medicine Society (CUEMS), a student-led society promoting the emergency medicine specialty, in collaboration with Dr. Richard Kendall, Consultant in Emergency Medicine at Addenbrooke’s Hospital, designed and delivered a course introducing USS to a group of Cambridge University medical students.

 

Aims:

  1. To design and deliver an effective USS training course to medical students
  2. To increase confidence and skill in the use of ultrasound
  3. To evaluate student opinion on whether USS training should be in the curriculum

 

Method

50 students signed up for the course and a further 9 students acted as healthy volunteers to be scanned. Prior to the course, all students were asked to complete: a multiple-choice questionnaire (MCQ) testing ultrasound knowledge; a questionnaire enquiring about previous experience and confidence in USS; and an online teaching module outlining some basic ultrasound principles. Students rotated around four 30-minute stations covering core uses of point-of-care ultrasound in emergency medicine: identification of abdominal aortic aneurysm; identification of intra-peritoneal free fluid; focused echocardiography and basic lung fields; and peripheral/central vascular access techniques. Each station was supervised by emergency department physicians or radiologists from Addenbrooke’s Hospital. Healthy student volunteers and vascular-access mannequins were used to enable delegates to practise USS skills effectively. After the course, the MCQ and questionnaire were repeated.

 

Results

In the pre- (n = 54) and post-course questionnaire (n = 44), the delegates reported improvements in their confidence in all areas, including the technical use of USS (1.3/5.0 to 3.4/5.0 (pre- and post-course mean scores)), and in using USS to aid diagnosis and management (1.6/5.0 to 3.5/5.0 (pre- and post-course mean scores)). In response to the questions: “How useful was the event?” and “Do you think USS should be part of undergraduate training?” the delegates scored 4.8/5 to both questions (mean scores; n = 44). In the MCQ test, delegates showed an improvement from 57% (pre-course; n = 59) to 79% (post-course; n = 45).

 

Conclusion

There was a strong desire by the student population to introduce clinical ultrasound teaching to their curriculum. Furthermore, this course demonstrated that small-group, practical ultrasound training on volunteers and vascular-access mannequins, supplemented by an online preparation course, is an effective way of improving skill and confidence in the use of ultrasound, and is a feasible way of delivering USS teaching to medical students. This course sets a strong precedent for ultrasound teaching in medical schools. The course designed here was effective and its expansion and incorporation into the curriculum of future years should be pursued.

 

Acknowledgements

Thank you to G.E. Healthcare for providing ultrasound machines to CUEMS to enable us to run this course.


Nathan HUDSON-PEACOCK (Patrixbourne, United Kingdom), Richard KENDALL, Alexander TAYLOR
11:00 - 18:00 #7117 - Polymyositis secondary to hypothyroidism unknown.
Polymyositis secondary to hypothyroidism unknown.

Polymyositis secondary to hypothyroidism unknown

MEDICAL HISTORY:

37 year old woman who comes to the emergency department with pain, oppression and feeling knots in upper and lower limbs that vary in intensity throughout the day from one week ago. Also refers yellowish vaginal discharge and pain since last night urination. 

Medical history: allergy to acetylsalicylic acid,

No disease of interest, no regular medication

Browse:

Hemodynamically stable throughout.

Conscious, oriented and collaborative; well hydrated and perfused, normo-colored, eupneic.

Head, neck, thorax, abdomen and upper and lower limbs without alterations in exploration.

Complementary tests:

Chest radiography without significant alterations

Analytical Urine leucocituria

Analytical blood: blood count, coagulation, blood gas and chemistry, except for creatine phosphokinase 1643 U / L (normal range: 20-300 U / L), with no alterations.

Evolution ansd trealtment:

We proceed to discharge home with a diagnosis of urinary tract infection after urinalysis with evidence of leukocytes with home treatment.

Besides usual analgesic treatment regimen myopathy after conducting blood tests showing only creatine values of 1643 U / L (normal range: 20-300 U / L) and is derived Rheumatology preferentially to continue study.

In patient monitoring performed by Rheumatology, additional tests are made more and analytical values of TSH were observed: 204 mIU / L (Normal: 0.2 to 4.2 mIU / L) and free T4: 0.28 ng / dL ( Normal values: 0.7 to 1.55 ng / dL) with anti-TPO anticuerpos-: 1300. She was diagnosed with Hypothyroidism autoinmuine and secondary polymyositis; establishing Levotiroxina.125 mcg treatment.

 Clinical Trial: Hypothyroidism autoimmune etiology. Polymyositis.


María Teresa VALLE GIL, María Eugenia REYES GARCÍA (Málaga, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7954 - Positive or negative? that is the question.
Positive or negative? that is the question.

The Allen test was described in 1929 by Dr. Allen, whose original description was used in the diagnosis of thromboangiitis obliterans. With the advent of radial artery cannulation and other techniques, physicians are reevaluating their method of assessing an adequate radial flow and although it has limitations (inadequate patient cooperation-unconsciousness-overextension of the wrist). It is a simple and non-invasive test, and recommended by many authors before arterial cannulation.  Evaluating the patency of collateral arteries in the hand via the ulnopalmar arches is of the utmost importance before contemplating invasive transradial approaches or radial artery harvesting. 87 years after Allen´s description of the test, it continues to be one of the most common tests performed.

Many tests in medicine are reported as either positive or negative, and generally, positive indicates abnormal. Curiously, in his original description, Dr. Allen shows how to perform the test but does define a positive or negative result nor did he give a time frame for the appearance of maximal blushing.

A search is performed with the term "Allen's test " and 169 items are obtained, of which 22 are clinical trial and Review. In this, Allen´s test appear as positive or negative to describe the normality or abnormality interchangeably, which generates confusion.  Reviewing different articles and documents dating back to 1929 we find that a positive test means normal or abnormal in other regardless of the time. In this same period we also find items that simply describe it as normal or abnormal in a similar proportion to previous, regardless of the time. In 1980, a letter was published by Peters KR and Chapin JW in Anesthesiology, where they denounce the confusion created by describing if the test is pathological or not in that way.

However, 36 years after, we continue with the same situation. In recent years, with the use of the radial artery as an alternative to the femoral artery catheterization, many studies have been published using the Allen test to assess the safety of the radial artery use in which positive and negative means normal or abnormal indistinctly.  In 2014, the RADAR trial, compared the best medical treatment versus best medical treatment plus renal artery stenting, and they used the negative Allen test to rule out, and in which a negative test result is abnormal is questioned. In this study, a negative Allen’s test indicates abnormality.

As we continue without unification of criteria, considered more appropriate to describe the test as normal or abnormal allen to avoid confusion as it has been done with other tests, such as Babinsky increasingly more often described as flexor or extensor.


Carmen RODRIGUEZ, Karina VALDEZ (Palma de Mallorca, Spain)
11:00 - 18:00 #8258 - Post partum infective endocarditis: a case report.
Post partum infective endocarditis: a case report.

INTRODUCTION: Infective endocarditis (IE) is uncommon (30 cases/ 1 million). The outcome depends on clinical presentation of the desease. Due to unfrequent symptoms, it may be discovered at late stages with life-threatening complications. Urgent treatment is the only key to improve survival.

CASE REPORT : We report the case of a 28 year old woman, with no medical history, taken back by her husband, one month after postpartum (vaginal delivery), for fever and confusion. The patient had fever and no other neurological symptoms but a glascow coma scale of 14/15. Biological exams showed high white blood cells count (22000 elements /ml) . Cerebral venous thrombosis was suspected and confirmed by a cerebral CT scan. An anticoagulant therapy was started with a neurological improvement. A magnetic resonance imaging showed no evidence of cerebral thrombosis and showed meningeal hemorrhage. Two days later, some Janeway lesions appeared and systolic murmur in mitral. A trans-thoracic echocardiography was performed : infective endocarditis with an oscillating mass on mitral valve. A second CT scan showed a parietal mycotic aneurysm. An antibiotherapy was given with a favorable clinical and biological outcome. She underwent a valvular replacement surgery. At a follow up 6 month later, the patient was fine. No risk factor was found for this patient although an exhaustive physical exam. As far as we know, 30 cases of peri-partum IE were reported.

CONCLUSION : Although it is a rare event in peri-partum, the IE must be suspected due to its bad outcome if discovered lately. By multiplying physical examinations through the day and looking for those small symptoms leading us to IE, an early treatment could make the difference


Sana LAHMAR, Asma ALOUI (Chartres), Sirine JAOUANI, Imen MEKKI, Nour El Houda NOUIRA, Maamoun BEN CHEIKH
11:00 - 18:00 #8075 - POST TRAUMATIC EPILEPSY 34 YEARS AFTER A BULLET IN THE HEAD.
POST TRAUMATIC EPILEPSY 34 YEARS AFTER A BULLET IN THE HEAD.

Introduction: Post traumatic epilepsy (PTE) is defined by the occurrence of one or more seizures beyond the first week following head trauma and has been linked to region, type, and severity of injury. We report a case of a patient who experienced seizures 34 years after a penetrating brain injury. 

Observation: A 60 years-old diabetic patient came to the emergency department after a household accident causing mild head trauma without loss of consciousness.On first examination, the patient had a Glasgow coma scale of 15/15, scratch on the forehead, his blood pressure was 150/80 mmHg, his pulse was 100 bpm and the temperature was 38 °C.Half an hour after his arrival, the patient experienced a left hemibody convulsion that have secondarily generalized with an altered state of consciousness. Concomitant capillary blood glucose was greater than 5 g/l. Seizure stopped after the administration of 1mg intravenous clonazepam and the patient recovered consciousness rapidly.On the second examination, there was no meningeal syndrome, a left post-critical hemiparesis with a left positive babinski signs. The skin examination found several scars on the right lower limb related to projectiles inlets. Patient interview revealed that he is a veteran of the 1982 Lebanon war. Laboratory tests and arterial blood gases were normal.Brain CT-scan showed, a bullet-shaped metallic foreign body lodged in the left hippocampus with no signs of recent hemorrhage. CT also showed the projectile entry point as a complex fracture of the left midparietal bone. The bullet path consisted of a sequellar left temporal hypodensity and no exit wound.The lumbar puncture showed no relevant abnormalities. No source of infection has been retraced. The patient was put under carbamazepine. He kept persistent temporal epilepsy characterized by loss of awareness of surroundings. He has been admitted to the neurology department.

Conclusion: this case illustrate that penetrating head injuries, largely gunshot wounds, increases the likelihood of developing PTE for more than 30 years after the injury. Military population and veterans in particular may require long-term neurologic follow-up.


Majed KAMEL, Kilani MOHAMED (Tunis, Tunisia), Zaouche KHEDIJA, Kallel MOHAMED AMINE, Mghirbi ABDELWAHEB, Boubaker RADHIA, Maghraoui HAMIDA, Bouali CHAKIB, Hamouda CHOKRI, Borsali Falfoul NEBIHA
11:00 - 18:00 #8228 - POST-TRAUMATIC RENAL ARTERY AND VEIN THROMBOSIS.
POST-TRAUMATIC RENAL ARTERY AND VEIN THROMBOSIS.

POST-TRAUMATIC RENAL ARTERY AND VEIN THROMBOSIS

Karaca, A KayaG, Celebi, V

Renovascular injury occured post abdominal trauma is classified as avulsion, occlusion and laceration. While the pathophisyology of post-traumatic renal artery oclusion that is a rare condition has not been clarified entirely, there is no report of cases as post-traumatic renal artery and vein occlusion.

39 years old female patient was presented to emergency service with the complaint of right side pain. When the history was deepen, it is noticed that the pain was started one hour after car accident. The general condition of the patient and her vital signs were stabil. There was no any problems on past medical history and her blood samples. According to report of abdominal USG;  there was 5 mm free fluid on perinephritic area nearby the inferior of right kidney and then  in order to investigate the  origin of free fluid,  contrast enhanced abdominal CT was requested.  Abdominal CT was evaluated by radiologist as there was hypodens appearance over hepatic subcapsular area (hemathoma), right renal artery was not observed after 1 cm proximal segment  (total laceration or rupture), right renal parenchym could not contrasted, there was free fluid on pelvic area and fractures were found out at right transvers proccess of L3-L4-L5 vertebras. The patient was consulted by Urology, Cardiovascular surgery, general surgery and interventional radiology department. Renal artery and vein angiography was planned by interventional radiology and total occlusion of right renal artery and vein was observed on angiography. Although revascularization attempt at the same session could not be successful. Trombolitic treatment and surgical revascularization were not recommende due to the patient was evaluated as multitrauma.  It is not observed that decrease of hemoglobin or increas of BUN/creatinin during emergency service follows. The patient was hospitalized and followed by Urology service.

Despite of renal artery trombosis is well known, the combination of the renal artery and vein thrombosis is a rare complication of abdominal trauma. In the treatment, observation, thrombolytic therapy, nephrectomy, surgical thrombolectomy, or more commonly used PTA are taken part.

 


Adeviye KARACA, Ferkant Gökhan KAYA (antalya, Turkey), Volkan CELEBI
11:00 - 18:00 #7653 - Post-traumatic stress disorder in mild traumatic brain injury.
Post-traumatic stress disorder in mild traumatic brain injury.

Introduction :

 Post-traumatic stress disorder (PTSD) is an important psychopathology that persists for a period of time after a mild traumatic brain injury (MTBI) has occurred. This period of time can range from weeks to months. Symptoms of PTSD are often vague and non-specific.

Purpose:

To examine the frequency of PTSD symptoms in MTBI patients admitted in emergency department (ED).

Participant and methods:

A prospective observational study that was conducted over seven months [December 2014 - June 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). PTSD is characterized by persistent re-experiencing, avoidance/numbing, and hyperarousal symptoms. After six months patients were contacted via standardized telephone interview to ascertain the symptoms of PTSD.

Results:

Three hundred eighty- seven patients were enrolled. Mean age = 41 ± 18 years, 77% were male. Mechanisms of injury were (%): traffic accident (77), falls (14), assault (15) and work accident (5). The way of the patient’s arrival at the emergency department was provided by (%): own means (35), pre-hospital care system (55). Clinical findings showed were (%): GCS =15 (89), loss of consciousness suspected or confirmed (58), Repeated vomiting (≥ 2 episodes) (11), clinical signs of depressed or basal skull fracture (14) and physical evidence of trauma above the clavicles (40). ninety – four percent of our population had a brain computed tomography (CT) which demonstrated intracranial hemorrhage in 75 cases. PTSD:  re-experiencing = 17%, avoidance/numbing = 19%, hyperarousal symptoms= 40%.         

Conclusion:

Not all people who suffer mild traumatic head injury experience PTSD. Early recognition and correction of these problems may limit the secondary effects of TBI and improve patient outcome.

References:

[1] Lebigot F.  Ann Med Psychol 2015; 173:819-27.

 


Hana HEDHLI, Salwa AMRI (villeneuve saint germain), Feten AMIRA, Bassem CHATBRI, Syrine JOUANI, Béchir BOUHAJJA
11:00 - 18:00 #8229 - POSTPARTUM CAVERNOUS SINUS THROMBOSIS.
POSTPARTUM CAVERNOUS SINUS THROMBOSIS.

POSTPARTUM CAVERNOUS SINUS THROMBOSIS

Karaca, A KayaG, Celebi, V

Cerebral venous thrombosis is an interesting and elusive disorder. It could be seen at any age. The most frequently affected sinuses, sinus superiorsagittal (70-80%), transverse and sigmoid sinuses (70%) are ranked as the cavernous sinus and sinus rectus.

33 years old female patient was admitted with complaints of numbness on the left side of the body to ED. The complaints  began one day ago had increased and along with headache and the fatigue. She had made cesarean birth four  days ago. There had been no abnormalities during pregnancy. Arrival vital stable.  Neurological examination revealed no pathological reflexes,  no loss of muscle strength, normal cranial nerve examination. Cranial CT taken to the patient who complaint about the  loss of feeling sense  in the left arm and leg  evaluated  as normal. The patient was taken on cranial MRI revealed a cavernous sinus thrombosis. The patient was admitted to the neurology service to start thrombolytic and anticoagulation therapy.

The most common cause of cerebral venous thrombosis in women; pregnancy, puerperium and periods of hormonal changes into the use of OKS. Besides the some reasons of etiology are inflammatory diseases, cancer, anemia and some hypercoagulable state . The cause can not be detected in approximately 30% of cases. Most incidence information is based on autopsy studies and cerebrovascular 12500 autopsy rates ranging from 0.1% to 9% of the deaths due to the disease have been reported. CVT compared to ischemic stroke due to arterial occlusive disease occurs rarely. Clinical spectrum ranges with papillary edema, headache, fokaldefisit, seizures and coma. The most common symptom is headache. While non-contrast CT is the first choice imaging method, the most reliable method in the diagnosis and follow-up is MRI and MR-Venogram. Cranial CT may be normal in 20% of cases. The treatment of Serebral venous thrombosis is tripod as etiological factors, symptomatically and antithrombotic therapy. Symptomatic treatment includes antiepileptic treatment in the presence of epileptic seizures, lumbar puncture precedure, acetazolamide and corticosteroid to reduce the increased intracranial pressure, antibiotic therapy  in the presence of infection.

Cavernous sinus thrombosis patients may present with different neurological complaints and it should be kept in mind that very common in women with especially during pregnancy and the postpartum period.


Adeviye KARACA, Volkan CELEBI, Ferkant Gökhan KAYA (antalya, Turkey)
11:00 - 18:00 #8224 - POSTPARTUM RENAL INFARCTS.
POSTPARTUM RENAL INFARCTS.

POSTPARTUM RENAL INFARCTS

Karaca, A KayaG, Celebi, V

Acute renovascular obstruction is a elusive and clinical condition that can be detected by investigation with  only a high rate of clinical suspicion. As acute renal infarction can be asymptomatic, the patient may also be presented with sudden, severe abdominal or lumbar pain, nausea, vomiting.

22 years old female patient was presented to our clinic with sudden right flank pain. It is learned that the patient had made cesarean birt three days ago and no similar pain on her history. On physical examination; there was only costovertebral tenderness at right. The patient was admited as renal colic and whole blood and urine samples were taken. There was 25 lococyte and 6 eritrocyte on urine test., WBC: 13.500. after analgesic. the symptoms of the patient was still exist so that renal USG was planned. parancyme of right kidney was seen heterogen and hiperecoic areas. Therefore, doppler renal usg was taken and there was hyperecogenite at superior and inferior side of right kidney and compare to left, vascularity of kidney was decreased. these findings support renal infarct. The patient was consulted by interventional radiology and urology departments and under renal artery angiography, stent had been performed. The patient was hospitalised to urology service.

The second reason mentioned for acute renal artery occlusion: thrombosis and thromboembolism. Acute thrombosis is the obstruction of trombus caused by the renovascular system.Consequently varying hormonal status during pregnancy and these cases is itself a risk factor for thrombus formation. In addition, depending on the cesarean immobilization, right renovascular posed by the growth of the uterus during pregnancy is located in the etiology of the bass made structures. Early invasive angioplasty is the treatment option less risky.

 


Ferkant Gökhan KAYA (antalya, Turkey), Volkan CELEBI, Adeviye KARACA
11:00 - 18:00 #7565 - Potential improvement of acute respiratory infection surveillance through usage of emergency department data.
Potential improvement of acute respiratory infection surveillance through usage of emergency department data.

Background:

Acute respiratory infections (ARI) may lead to increased hospitalization and excess mortality during the annual flu epidemic. Besides laboratory surveillance of influenza [1], syndromic surveillance of ARI in Germany is based on reports of primary care physicians (e.g. ICD-10-GM coded diagnoses) [2]. Hospitalization rate is likely to be underestimated as severe cases may consult an emergency department (ED) directly. The joint research project for establishing a German emergency department data registry (AKTIN) is evaluating a decentralized approach to access data routinely recorded and stored in EDs. We investigate if the flu season 2014/2015 can be shown on the basis of ICD-coded data from one of our project hospital's ED.

 

Participants and methods:

We included all patients in our analysis that were hospitalized after attending the emergency department of Wolfsburg hospital between calendar week (CW) 27/2014 and CW 26/2015. An ARI was defined if the following ICD-10-Codes were recorded as admission diagnosis J00 to J22 (including subgroups), J44.0 and B34.9. Reference data were retrieved from public health databases on a regional (laboratory surveillance) and national (ICD-coded data from primary care physicians) level. We calculated absolute and relative frequencies and compared epidemic curves, age distribution and distribution of ICD-10-codes.

 

Results:

14,106 patients were hospitalized during the observed period. 535 cases of these (3.8%) were diagnosed with an ARI, on average 10 admissions per week due to an ARI respectively. The number of cases was rising at the beginning of 2015 and reached its peak in CW 10/2015, when 25 patients (9.5%) were hospitalized. Compared with reference data there was a graphical correlation of the epidemic curves. Mean age of ARI-cases was 71.7 years (SD ± 16.2; median 76). Most common diagnoses were J18 (pneumonia, 61.1%), J15 (bacterial pneumonia, 13.5%), J44.0 (COPD with acute lower respiratory infection, 12.3%) and J20 (acute bronchitis, 7.9%). Patients in our sample were older and distribution of diagnoses differed from reference data.

 

Discussion:

Our analysis shows that the course of the flu season 2014/2015 can also be depicted on the basis of ICD-10-Codes recorded in an emergency department. The current and well-established ARI surveillance is based on data from laboratories and primary care physicians. So far hospital data is not included in syndromic surveillance, even though data from EDs may provide additional information about the epidemiological situation of ARI regarding more severe cases. Part of the AKTIN-Project is the evaluation of routinely collected ED data for public health surveillance. This includes the investigation of presenting complaint und ICD-10-diagnoses as a steady information stream to public health authorities.

 

References:

1. Niedersächsisches Landesgesundheitsamt (Hrsg.) (2015). Surveillance für Influenza und andere akute respiratorische Erkrankungen in Niedersachsen (Jahresbericht Saison 2014 / 2015). Hannover.

2. Robert Koch-Institut (Hrsg.) (2015). Bericht zur Epidemiologie der Influenza in Deutschland Saison 2014/15. Berlin.

 

Acknowledgements: AKTIN, funded by Federal Ministry of Education and Research: 01KX1319A


Felix GREINER, Armin BAILLOT, Dominik BRAMMEN, Felix WALCHER, Bernadett ERDMANN (Wolfsburg, Germany)
11:00 - 18:00 #7707 - Potentially inappropriate medication in emergency.
Potentially inappropriate medication in emergency.

Background: Beers criteria have been widely used to identify potentially inappropriate medication (PIM). In Chile, these criteria are not used routinely.

Objective: The purpose of this study was to assess PIM frequency in emergency room visits at the Clinical Hospital of the Universidad de Chile.

Methods: Clinical Pharmacists carried out a prospective follow-up study in emergency room visit between January 2015 and January 2016. Selection criteria were ages 65 years or older and a medication prescribing. Inappropriate drug prescription was defined by Beers Criteria. Outcomes of the study were PIM frequency and type of PIM used.

Results: Preliminary results of a total of 1000 patients met selection criteria. The mean age of patients was 70.7±7.7 years and 65% were women. A 44.7% of patients received at least 1 PIM. The most common inappropriate drugs were NSAIDs and Cardiovascular drugs.

Conclusion: PIM remains a health problem in emergency care. Future analyses must be performed to determine potential adverse outcomes and their consequences in geriatric patients.


Marcela JIRON (SANTIAGO, Chile), Luis HERRADA, Matias MARTINEZ, Tamara SANDOVAL, Elena VEGA, Carolina LOBOS
11:00 - 18:00 #7299 - Pott's Puffy Tumour.
Pott's Puffy Tumour.

We report the case of a 26year old male who presented  to our emergency department complaining of  forehead swelling for the past six months which is increasing in size and  associated with pressure sensation, on and off headache and blocked nose. No history of fever/chills/seizure. He also did not respond  to multiple course of oral antibiotics prescribed by GP in this past six months. Patient has underlying chronic sinusitis.

Investigation:

Plain X-ray revealed soft tissue swelling against the frontal bone and deviated nasal septum. A  CT brain was therefore performed, which demonstrated  expansile lesion originating from frontal sinus, most likely to be a frontal sinus mucocele or abscess. The lesion was in direct contact with the underlying meninges.

Management:

He was then referred to Beaumont Hospital (Dublin), where he underwent bifrontal craniotomy and excision of frontal sinus abscess. The specimen grew MSSA and Streptococcus Intermedius. He is being treated with IV Flucloxacillin, IV Benzylpenicillin,IV Metronidazole for six weeks.

Discussion:

POTT’S PUFFY TUMOUR

Was first described by Percivall Pott in 1760, its a non-neoplastic complication of sinusitis characterized by subperiosteal abscess and osteomyelitis. It can be associated with extension intracranially with epidural abscess, subdural empyema, meningitis, cerebral abscess, and dural sinus thrombosis. Frontal sinus disease has reduced significantly since the arrival of antibiotics, but it may still occur.  Pott’s puffy tumour can be caused by Sinusitis(chronic and acute), Trauma, Post-surgery (frontal sinus reconstruction), intranasal substance abuse.

 

 


Sarmila SUBRAMANIAM, Sarmila SUBRAMANIAM (GALWAY, Ireland)
11:00 - 18:00 #7272 - Practical guidelines and conservation of succinylcholine in unconventional situation.
Practical guidelines and conservation of succinylcholine in unconventional situation.

Introduction: in 2012, The French National Pharmaceuticals Agency (ANSM) recalled the need to store succinylcholine +2 to +8°C until administration, assuming otherwise an increased risk of allergy. If this risk has not been formally demonstrated, a conservation algorithm is yet to be established in unconventional situation.

Material and methods: Review of the literature on stability of succinylcholine studies in different storage requirements and allergic risk depending on the expiry date.

Results: since 2012, SAMU has evolved greatly their conservation modalities of succinylcholine (Lefort, ANNFAR 2014), a key drug in pre-hospital medicine. The recommendations are poorly adapted to resuscitation in exceptional environment. Literature helped providing arguments for the responsible use and security while reducing operational and logistical constraints. Conservation should be done between 2 and 8°C as much as possible. Depending on the undertaking time (

Conclusion: succinylcholine is a first-line curare for rapid sequence intubation. Our practical recommendations and the proposed algorithm consider a reasonable alternative to conservation standards/guidelines based on scientific evidence. The use of rocuronium is to be considered a reliable alternative.


Hugues LEFORT, Alexandre ALLONNEAU (Paris), Alexandre MENDIBIL, Franck PEDUZZI, Michel BIGNAND, René BIHANNIC, Karim TAZAROURTE, Jean-Pierre TOURTIER
11:00 - 18:00 #7351 - Pre hospital care of elderly patients: gender differences.
Pre hospital care of elderly patients: gender differences.

Introduction: The aim of this study was to identify gender differences of elderly patients who received care by the mobile emergency care unit (MECU).

Methods: This was a prospective, observational study over 2 months (July and August 2015), using the MECU-database for all out of hospital elderly patients care, included patients age greater than or equal to 65 years. The Ki2 test was used to compare differences in relation to gender (significance level=0.05).

Results: During the period of study, 100 elderly patients were management by the MECU teams. There were 52 males and 48 females. Significant differences between genders were observed regarding medical history of diabetes (46% versus 48%; P=0.045), initial autonomy (6.6 +ou- 2.2 versus 6.2 +ou- 1.4; P=0.04) and in hospitalization rate (24.5% versus 50%; P=0.005). We didn't show gender related differences in overall mortality (25% versus 31%; P=0,7).

Conclusion: During prehospital care, mortality among elderly patients was not influenced by gender. Despite a higher frequency of women hospitalization and a higher initial autonomy of men.


Dorra CHTOUROU (Tunis, Tunisia), Saida ZELFANI, Rafika BEN CHIHAOUI, Afef CHAKROUN, Samir ABDELMOUMEN, Chedly GHANEM, Mounir DAGHFOUS
11:00 - 18:00 #7773 - Pre-hospital evolution in acute myocardial infarction cases.
Pre-hospital evolution in acute myocardial infarction cases.

Background: Acute myocardial infarction require elaborated actions, fast diagnosis and  proper management. The aim of this study is to evaluate the evolution of patients with acute myocardial infarction in pre-hospital  ICU.

Methods: Retrospective medical study based on statistical analysis of SMURD Sibiu database on a period of 2 years.

Results:  From the total number of cases diagnosed as AMI (acute myocardial infarction), 25% of them are better, 65% are stationary, 3% are worse and 7% are deceaded.

Reducing the delay from symptom onset to first medical contact and targeted treatment started in the early out-of-hospital phase increase to have a good chance for patients.


Canciu ALIN, Smarandoiu MARIUS, Ciora CLAUDIA (Sibiu, Romania), Loloiu DIANA
11:00 - 18:00 #7385 - Pre-hospital hypoglycemia: the safety of not transporting treated patients.
Pre-hospital hypoglycemia: the safety of not transporting treated patients.

Introduction: Mobile emergency care unit (MECU) teams were frequently encounter patients who are not transported after being treated for an hypoglycemic episode. The outcome of these patients are unknown.

The purpose of this study was to determine the outcomes of patients treated for hypoglycemia and not transported and to identify the safety of this attitude

Methods: This was a prospective, observational study involving all adults (aged more than 15 years) hypoglycemic insulin dependent patients (blood glucose less than 4 mmol/ L by glucometer) attended to by the MECU teams three month interval.

Results: There were 36 calls for adult patients with hypoglycemia. for the 9 patients transported, there were 2 further hypoglemic episodes requiring a repeated call for an ambulance (22.2%). for the 28 patients treated and not transported, 9 further episodes of hypoglycemia (32.7%) were reported. These differences were not staticallly significant (p=0.58). There was also no statically significant difference in the intervals between hypoglycemic episodes for patients transported (2 days +ou- 1.5) compared with patients not transported for their previous hypoglycemic episode (3.2 days + ou - 2.6) (p=0.5).

Conclusion: Repeat episodes of hypoglycemia are common; however, there were on difference in the incidence of repeat episodes of hypoglucemia between transported and not transported  insulin dependent patients. 


Dorra CHTOUROU (Tunis, Tunisia), Saida ZELFANI, Yosra MANAI, Amina JEBALI, Wafa LIMAM, Slim JDIDI, Mounir DAGHFOUS
11:00 - 18:00 #7360 - Pre-hospital management of severe trauma patients: are we respecting the golden hour?
Pre-hospital management of severe trauma patients: are we respecting the golden hour?

Introduction: Time is considered as an essential determinant in the initial care of trauma patients. 

Our purpose was to evaluate the delays in out of hospital management of severe trauma patients by the mobile emergency care unit (MECU) and their adhésion to recommandations.

Methods: This was a prospective, observational study over one year (from January to December 2015), using the MECU-database. We analysed prehospital time intervals for trauma patients according to their lavels.

Results: There were 87 severely trauma patients management by MECU teams. Of these patients, 30 were evaluated level 1, 26 were evaluated level 2 and 31 were evaluated level 3. The mean time from injury occurence to arrival in the emergency department (ED) was 50 min. Only 24 (27.6%) patients reached the ED within 30 min. Delays were different according to patient's level: it was exceed 30 min to 30% of patients level 1; 19,5% of patients level 2 and 27.6% of patients level 3.

Conclusion: The median time to care for severe trauma patients was similar to recommandations. However, more than half of patients were beyond this period. The most serious patients were those for which periods were longer. Focus should not be on the type of prehospital care delivered only, but also on rapid transport.


Dorra CHTOUROU (Tunis, Tunisia), Saida ZELFANI, Amina JEBALI, Yosra MANAI, Samia ARFAOUI, Sana DRIDI, Mounir DAGHFOUS
11:00 - 18:00 #7224 - Pre-hospital transcutaneous pacing. A case of post cardiac arrest origin idioventricular escape rhythm pacing.
Pre-hospital transcutaneous pacing. A case of post cardiac arrest origin idioventricular escape rhythm pacing.

Introduction: This is a case of successful acute management of a rare condition of idioventricular escape rhythm followed by cardiac arrest, PEA, asystole in a polymorbid patient, managed by transcutaneous pacing (TCP).

Case description: Emergency Service Paramedics were sent by Dispatchers for 63-year old female patient, who was found suddenly unresposive by her relatives. Uppon arrival, the paramedics found the patient lying on the floor of the living room. The patient was unresponsive, and her daughter was present and indicated that she has just collapsed.

The patient was protecting her own airway, had no radial pulse, but the carotid pulse was felt slow and week. Her GCS was 7, and within few minutes the patient went into cardiac arrest. The paramedics called for the medical team and started CPR. The medical team arrived four minutes later, and the CPR was ongoing, but the patient was still unconscious, breathless, the pupils were equal, 5 mm in diameter, with no reaction to light. There was no palpable carotid pulse, with PEA on LP 15 monitor, and her blood sugar was 21,2 mmol/l.

We started ACLS and a brief history was taken. The patient had multiple comorbidities with a history of IHD, arterial hypertension, DM type 1 on insulin. She was feeling unwell before becoming unresponsive. ETI, ALV with 100% oxygen, chest compression, i.v. line inserted and Adrenaline was given 1 mg i.v. every 3 min. The PEA rhythm changed to asystole than again to PEA. Within 18 minutes after ACLS start, the carotid pulse started to be palpable with a rate 23/min, and her BP was 86/40 mmHg. On LP monitor there was a picture of idioventricular escape rhythm, regular, 23/min, with wide QRS and no P waves.

The medical team started prepearing for TCP, while giving 1 mg Atropin i.v., until a total dose of 3 mg, and Dopamine 10mcg/kg/min. Pacing started with a frequency 60/min, 150 mA. Immediately, a picture of successful mechanical and electrical capture was obtained, and her BP became 103/53 mm/Hg. The patient was transported to the ICU depatment, where within 30 minutes sinus rhythm reappeared. The patient survived without any neurological deficit. The reason of the cardiac arrest was diagnosed as NSTEMI, and PCI was performed.

Discussion: The presented case is interesting due to the rare appearence of an idioventricular escape rhythm after CPR with asystole and PEA. The author (and the head of the resuscitation team in presented case) did not find in literature such case description. The idioventricular escape rhythm is always mentioned as a terminal event just before ventricular standstill in patients with underlying cardiac disease. The management of the presented case was done according to the ERC guidelines for ACLS, and TCP was a life saving method of treatment for the patient.


Iryna DOMORATSKA (Trencin, Slovakia)
11:00 - 18:00 #7885 - Pre-hospital ultrasound, what benefit for pre-hospital care ?
Pre-hospital ultrasound, what benefit for pre-hospital care ?

Introduction : The pre-hospital ultrasound (PHU) has shown interest to diagnose and refer severe trauma patients. Few studies have reported its usefulness in medical condition. First, we aimed to assess PHU’s contribution in pre-hospital medical decisions, in dispatching severely injured patients and those who suffer from a medical condition in hospitals. Secondly we assessed the diagnostic agreement between PHU and hospital ultrasound (HU).

Material and methods : This was an observational prospective study. The collected datas concerned the epidemiological characteristics (age, gender, medical history..), ultrasound (type of sonography done and diagnostic contribution), and therapeutic guidelines  (what evacuation vector, what hospital destination). We included any patient who benefited from PHU by our mobile intensive care unit (MICU). After an univariate description of the patients’ characteristics, we tested the statistical association between PHU and: -specific treatment decision,  -transportation by MICU , - admission to a specific hospital department. At the end we compared the diagnostic agreement between PHU and HU.  We used Student and Fisher exact test, according to the type of variable.

Results and discussion : From 25 May to 31 December 2015, 2153 patients were treated by our MICU. In total 5.9% (n=127) benefited from PHU. Their mean age was 44.3 + 23 years and 68,5% (n=87) were men. The most frequent antecedent was cardiac related (20,5%, n=26). A PHU was performed for 25,2% (n=74/294) of severe trauma, 6,8% (n=3/44) pregnancy, 4,4% (n=11/247) of cardiac arrest, 2,6% (n=17/641) of chest pain and 2,4% (n=22/927) of other diagnoses.

Concerning the PHU procedures: 54,3% (n=69) physicians focused on abdominal sonography for trauma (FAST), 27,6% (n=35) on the chest, 14,2% (n=18) on the abdomen, 1,6% (n=4) on the 4 points DVT (Deep Vein Thrombosis) compression examination, and 3,1% on guiding for inserting venous catheter (n=2) or perform femoral nerve block (n=4) ; 9,4% (n=12) of the PHU were difficult to conclude properly. 

Among the PHU procedures performed, only the abnormal FAST seemed to be associated with prehospital treatment establishment (p=0,09), with medical transportation (p=0,051) and with the choice of a specific  hospital department (p=0,004).

Among the 55 patients who benefited from HU, there was a substantial matching between the diagnostic agreement of PHU and HU for 82% of the patients. For 41,7% of the patients, the diagnostic doubt was shared by pre-hospital and hospital sonographer as well.

Only FAST seemed to bring added value in terms of treatment decisions and dispatching in hospitals. Others PHU, more specific to medical condition, did not show interest in this cohort, probably because of too low effective and less control of gesture.

Conclusion : This work was the first to measure the diagnostic agreement between PHU and HU. Only FAST seemed to bring added value.


Jonathan GONZVA, Jimmy ROBERT, Alexandre ALLONNEAU (Paris), Clément DERKENNE, Nicolas HERVAULT, Vincent GELE, Frédéric DELAY, Daniel JOST, Jean-Pierre TOURTIER
11:00 - 18:00 #6404 - Predicting the 28-day mortality rate in elderly patients with community-acquired pneumonia: Evaluation of 11 risk prediction scores.
Predicting the 28-day mortality rate in elderly patients with community-acquired pneumonia: Evaluation of 11 risk prediction scores.

Abstract

Objective: This study aimed to evaluate the performance of existing risk scores for predicting the 28-day mortality rate in patients presenting with community-acquiring pneumonia (CAP) in an emergency department.

Methods: We conducted a cross-sectional study at the Celal Bayar University Hospital in Manisa, Turkey. The records of consecutive elderly patients with CAP were reviewed for this retrospective study. All patients were followed-up to assess their outcome within 28 days of the admission. The discriminative performance of the 11 risk prediction scores for patients with CAP was assessed using the area under the receiver operating characteristic curve (AUC). 

Results: A total of 151 elderly patients [mean age, 76.6 ± 7.8 years (range, 65-94 years); 65.6% men] with CAP were evaluated. There were 30 deaths by 28-day, an all-cause mortality rate of 19.9%. The CURB-age had the best performance with an AUC of 0.836. Three other scores that performed well were SCAP, IDSA-ATS, and CURXO-80 (AUC 0.833, 0.822, 0.805, respectively).

Conclusion: Four of the existing scores had good discriminatory power (AUC > 0.800) to predict the 28-day mortality rate. The best discrimination was demonstrated by CURB-age, a score designed for the elderly patients with CAP.  Only one score was under the level that is considered to indicate fair discriminative power (AUC < 0.700). Additional research is needed to determine the best risk score for predicting early mortality rates of elderly patients following CAP. 

Keywords: elderly, CAP, severity


Huseyin ELBI (manisa, Turkey), Adnan BILGE, Murat OZSARAC, Burcu GOLCUK, Halil Ibrahim DAYANGAC, Onur DIKMEN, Yalcin GOLCUK
11:00 - 18:00 #7664 - Predictive factors related with poor outcome in patients presenting to the emergency department with Seizures.
Predictive factors related with poor outcome in patients presenting to the emergency department with Seizures.

Introduction: Seizures are a common pattern for seeking care in the Emergency Department (ED). Several studies have identified prognostic factors that allow early identification of patients with poor outcome.

Early identification of patients whose seizures are likely to have poor outcome may help the emergency physicians to provide better management.

The objective: to identify factors associated with poor outcome in patients presenting to the ED with seizures

Design and Methods:

A prospective observational study, conducted over two years. Were included all patients who presented to the ED with seizures. The epidemiological, clinical, biological, therapeutic, and evolution criteria were collected. Patients who were at risk of poor prognosis were: patients with status epilepticus (SE), those who underwent intubation, patients admitted to the intensive care unit (ICU) and the non surviving patients. Multivariate analysis by multiple logistic regression was performed.

Results:

272 patients were enrolled. Mean age 45 + -19 years. Sex Ratio: 1.69. Comorbidities: history of epilepsy N = 117 (43%), diabetes N = 40 (15%), history of systemic disease N = 9 (3.3%), history of neonatal pain N = 3 (1%). Patients with SE N=116(42%), Intubated patients N=15(6%), admission to the ICU N=14(5%), non-surviving N=19(7%).  Patients with bad outcome N=129 (47%).

In univariate analysis, factors associated with bad outcome were: alcohol intoxication (p = 0.178), bad adherence to treatment (p=0,104), generalized tonic-clonic seizure (p = 0.007), recurrence of seizure (p = 0.002), meningeal syndrome (p = 0.141), post critical coma (p = 0.002),  respiratory rate> 28 (p = 0.103), Glasgow coma scale <13 ( p <0.001), length of post critical coma> 42 min (p = 0.026), lactate levels> 8,7 (p = 0.014).

Multivariable logistic regression analysis identified the recurrence of seizure as a bad-outcome related factor with an Odds ratio (OR) at 4,69 and confidence interval (CI) 95% [1.477 – 14,899] p=0,009.

Conclusion:

Recurrence of seizure can lead to poor prognosis in patients with seizures presenting to the ED. 


Rania JEBRI (Lyon), Anware YAHMADI, Aymen ZOUBLI, Hanane GHAZALI, Mouna GAMMOUDI, Farah RIAHI, Sawsen CHIBOUB, Sami SOUISSI
11:00 - 18:00 #7959 - Predictive value of somatosensory and visual evoked potentials in cardiac arrest patients treated with hypothermia.
Predictive value of somatosensory and visual evoked potentials in cardiac arrest patients treated with hypothermia.

Purposes: It is not certain if somatosensory (SEPs) and visual evoked potentials (VEPs) can predict neurological outcome of cardiac arrest (CA) patients treated with hypothermia. The aim of this study was to investigate the prognostic value of SEPs and VEPs and whether VEPs would increase the predictive power of SEPs for the patients treated with hypothermia.      

Methods: This retrospective cohort study included comatose patients resuscitated from CA and treated with hypothermia between March 2007 and July 2015. SEPs and VEPs were recorded during hypothermia and after rewarming in these patients. Neurological outcome was assessed at the time of discharge by the Cerebral Performance Category (CPC) Scale.

Results: One hundred fifteen patients were included. A total of 175 SEPs and 150 VEPs were performed. Five SEPs during hypothermia and nine SEPs after rewarming were excluded from outcome prediction by SEPs due to N20 indeterminable with technical error. Using 80 SEPs and 85 VEPs during hypothermia, absent SEPs yielded a sensitivity of 58% and a specificity of 100% for poor outcome (CPC 3-5) and absent VEPs predicted poor outcome with a sensitivity of 44% and a specificity of 96%. Combining SEPs and VEPs had a higher predictive power than either alone (an accuracy of 72% for SEPs and 61% for VEPs vs. 80% for combination). After rewarming, absent SEPs and absent VEPs predicted poor neurological outcome with a specificity of 100%. When SEPs and VEPs were combined, VEPs increased the predictive power of SEPs alone slightly. Although one patient with absent VEP during hypothermia had a good neurological outcome, none of the patients with good neurological outcome had an absent VEP in the normothermic period.

Conclusion: Absent SEPs and absent VEPs predicted poor neurological outcome with high specificity during hypothermia as well as in normothermia. VEPs could increase the predictive power of SEPs during both periods for the patients treated with hypothermia.  


Seung Pill CHOI (Seoul, Korea), Jung Hee WEE, Jeong Ho PARK, Chun Song YOUN, Kyu Nam PARK
11:00 - 18:00 #8069 - Predictive value of the neutrophil to lymphocyte ratio of patients with non ST elevated myocardial infarction.
Predictive value of the neutrophil to lymphocyte ratio of patients with non ST elevated myocardial infarction.

INTRODUCTION

The inflammation is well known in the initiation and propagation of acute coronary syndrome. Subtypes of white blood cells are indicators of inflammation in this specific population. The study aim was to evaluate the neutrophil to lymphocyte ratio (NLR) in prediction in hospital mortality of patients with non-elevated ST myocardial infarction.

METHODS

It was an observational prospective study conducted in an emergency department. We excluded patients who had a ST elevated myocardial infarction. We included patients who met criteria of NSTEMI who consulted the emergency department in January 2016.

RESULTS:

We enrolled 85 patients. The mean age was 67 years ± 11 years. Fifty patients were males. 53% of patients were smokers, 57% had hypertension, 37% diabetes, 21% coronary disease and 15% had heart failure. A depressed ST segment was found in 58.8 % of cases, inversed T wave in 47.1%, left bundle bloc in 13%, right bundle bloc in 11% and atrial fibrillation in 9%. The mortality was 13%. The mean NLR of dead patients was significantly higher than NLR of survivors with 11.6 ± 14. 5 vs 5.5 ± 5,2 (p=0,009)

CONCLUSION:

NLR can be used as in independent factor to predict mortality of patient with NSTEMI in emergency department.


Kamel MAJED, Baccouche RAMLA (BEN AROUS, Tunisia), Khedija ZAOUCHE, Boubaker RADHIA, Kallel MOHAMED AMINE, Abdelwaheb MGHIRBI, Hamida MAGHRAOUI, Mohamed MODHAFFER, Chokri HAMOUDA, Nebiha BORSALI FALFOUL
11:00 - 18:00 #7496 - Predictive value of the NEWS-L for mortality and the need for critical care among general emergency department patients.
Predictive value of the NEWS-L for mortality and the need for critical care among general emergency department patients.

Study objectives

What is the predictive value of the NEWS-L for mortality and the need for critical care in general emergency department (ED) patients?

Methods

In this retrospective cohort study, we enrolled all adult patients who visited the ED of an urban academic tertiary-care university hospital in South Korea over two consecutive months. The primary outcome was 2-day mortality. The secondary outcomes were the need for critical care (advanced airway use, vasopressor or inotropic agent use, intensive care unit (ICU) admission) during an ED stay; 2-day composite outcome (2-day mortality and the need for critical care); 7-day mortality; and in-hospital mortality.

Results

During the study period, 4,624 adult patients visited the ED. Of these, 87 (1.9%) died within 2 days. A total of 481 patients (10.4%) required critical care during their ED stay. The 2-day composite outcome, 7-day mortality and in-hospital mortality were 10.9% (503/4624), 2.5% (116/4624) and 3.9% (182/4624), respectively. The NEWS-L demonstrated excellent predictive value for 2-day mortality with an AUROC of 0.96 (95% confidence interval (CI) 0.94-0.98); this value was better than that of the NEWS alone (AUROC 0.94 (95% CI 0.91-0.96), p < 0.001). The AUROC of the NEWS-L for the need for critical care was 0.84 (95% CI 0.82-0.86); for the 2-day composite outcome, it was 0.85 (95% CI 0.83-0.86); for 7-day mortality, it was 0.94 (95% CI 0.92-0.96); and for in-hospital mortality, it was 0.88 (95% CI 0.85-0.91). Logistic regression results confirmed that the ratio of the NEWS to the initial lactate level was 1:1. Similar results were shown in the subgroup analyses (disease-infection, disease-vascular and heart, disease-others, and non-disease). The high-risk NEWS-L group (NEWS-L ≥ 7) had an adjusted odds ratio of 28.67 (12.66-64.92) for 2-day mortality in the logistic regression model adjusted for basic characteristics.

Conclusion

The NEWS-L can provide excellent discriminant value for predicting 2-day mortality in general ED patients, and it also has the best discriminant value for the need for critical care and composite outcomes. The NEWS-L may be helpful in the early identification of at-risk general ED patients.


Jo SION (Jeonju-si, Korea), Yoon JAECHOL, Lee JAE BAEK, Jin YOUNGHO, Jeong TAEOH
11:00 - 18:00 #7218 - Predictors of 30-day mortality in patients admitted to emergency departments for acute heart failure.
Predictors of 30-day mortality in patients admitted to emergency departments for acute heart failure.

Introduction: Acute heart failure (AHF) is a leading cause of admission in emergency departments (ED). It is also associated with significant in-hospital mortality, suggesting that there is room for improvement of care. Our aims was to investigate clinical patterns, biological characteristics and determinants of in-hospital mortality.

Methods: We conducted a monocentric, retrospective review of patients admitted to ED for AHF in a large academic center over a 12-months period. Data collected included demographics, clinical, biological and outcomes data. Epidemiologic data were collected at baseline, and patients were followed up during a 30-days period. The log-rank test, odd-ratios (OR) with 95% confidence intervals (CI) and ROC analysis were used to determine the prognostic value of clinical and biological patterns on 30-days mortality.

Results: There were a total of 322 patients. Mean age was 83 +/- 9 years, and 53% of the patients were women. During the 12-months of the study period, 53 patients (18.3%) died within 30 days of admission to the ED. The following three characteristics were independently associated with increased mortality: age >85 years, OR=1.5[95%CI:0.8-2.7]; creatinine clearance <30 mL/min, OR=2.6[95%CI:1.4-5] and NT-proBNP >5000 pg/mL, OR=2.2[95%CI:1.2-4]. Based on the ROC curve, the best NT-proBNP cut-off value to predict first day mortality was 9000 pg/mL (area under the curve (AUC) of 0,790). For 7-days mortality, it was 7900 pg/mL (AUC of 0,698) and for 30-days mortality, 5000 pg/mL (AUC of 0,667).

Conclusion: The admission NT-proBNP level, age and creatinine clearance are predictive of in-hospital mortality in elderly patients admitted to ED for AHF.


Antoine BENEDETTI, Matthieu MARCHETTI (Bayonne), Jean-Yves LARDEUR, Nicolas MARJANOVIC, Olivier MIMOZ
11:00 - 18:00 #7637 - Predictors of stroke outcome in the emergency department.
Predictors of stroke outcome in the emergency department.

BACKGROUND AND PURPOSE: Stroke is a public health priority with a high mortality and disability. The purpose of this study was to elucidate the factors that correlate with unfavorable outcomes and to develop a simple validated model for assessing its risk in patients with cerebrovascular events. 

METHODS: Prospective, monocentric, observational study conducted over 3 years. The study included a community-based cohort of acute stroke patients (age≥18 years). We examined the clinical data and scanner criteria of patients who admitted for acute stroke. Stroke severity was evaluated with the National Institutes of Health Stroke Scale (NIHSS).Unfavorable outcome was defined as modified Rankin Scale (mRS) >3 considered as severe disability) or death (mRS=6) at 90 days. Multivariate regression analysis was performed to identify factors predictive of unfavorable outcome.

RESULTS: Inclusion of 187 patients. Mean age was 67 ±13 years. Sex ratio = 1, 49. The risk factors for stroke were dominated by n (%): hypertension 118 (63), diabetes 62 (33), history of valvular heart disease 16 (9) and previous stroke 53 (28). Ischemic stroke accounted for 79%. Unfavorable outcome was found in 84 patients (45%) The mortality rate was 30%, a mRS>3 were found in 15% of patients.

In adjusted multiple regression models, age >70 years (adjusted OR = 2, 95% CI [1.25- 2,92]), pre-existing disability (adjusted OR = 3,64, 95% CI [1.51-8,78]), haemorrhagic stroke (adjusted OR= 1,79, 95% CI [1.82-4.28]), NIHSS≥ 13 (adjusted OR= 4,28, 95% CI[2,36-7,76]), and  Glascow coma scale(GCS ) ≤11   (adjusted OR= 1,96, 95% CI[ 1,2- 3,19]) were independently associated with unfavorable outcome  .

CONCLUSION: In this study, onset stroke severity, pre-existing disability, hemorrhagic lesion and old age were predictors for poor prognosis after stroke. These factors should be taken into consideration when planning treatment and rehabilitation after stroke.


Wifek BEN HMIDA, Hanen GHAZALI (Ben Arous, Tunisia), Syrine KESKES, Anware YAHMADI, Manel BAYAR, Mouna GAMMOUDI, Sawsen CHIBOUB, Sami SOUISSI
11:00 - 18:00 #8088 - Prehospital sepsis screening protocol installation and management.
Prehospital sepsis screening protocol installation and management.

Early recognition of sepsis is difficult in prehospital setting without protocol based screening. Patients with sepsis are prioritized in order to lower treatment cost and start early care initiation. Better survival rates occur from early diagnosis and treatment of sepsis. Accurate recognition of sepsis is important to initiate care in ambulance and to inform Emergency department before delivering a patient.  

Methods. Identification of sepsis was made using a quick sofa (sepsis related organ failure assessment) criteria presented in 2016 and blood lactate test in prehospital emergency medical service. Quick sofa criteria were declared by the Third International Consensus Definitions for Sepsis and Septic shock (Sepsis-3). The prehospital protocol team installed quick sofa criteria and blood lactate test question to touch pads used in everyday ambulance practice. The comparison is made between prehospital sepsis screening protocol and independent clinical judgement. The outcomes are based on diagnosed sepsis cases in hospital. Results. Prehospital sepsis screening protocol can potentially improve recognition of sepsis and early treatment initiation also impacting the outcomes. Further research is needed for a full evaluation of prehospital sepsis screening protocol impact on outcomes of early sepsis identification.


Egle ZELBIENE (Kaunas, Lithuania), Nedas JASINSKAS
11:00 - 18:00 #7942 - Prehospital transfusion of red cell concentrates in a paramedic staffed helicopter emergency medical system.
Prehospital transfusion of red cell concentrates in a paramedic staffed helicopter emergency medical system.

Background

Prehospital use of red cell concentrates (RCCs) has shown promising results. However, the administration of blood products is limited to physicians in many jurisdictions. We sought to describe the characteristics of RCC transfusions in a paramedic staffed helicopter emergency medical system in Victoria, Australia.

Methods

We performed a retrospective analysis of all cases where paramedics consulted the responsible physician for approval of RCC transfusion between April 2011 and June 2014 in Victoria, Australia. Ambulance data was retrieved from electronic patient care records and hospital and outcome data was retrieved from a statewide trauma registry.

Results

A total of 120 primary missions were identified where paramedics requested approval for transfusion of RCCs during the study period. A total of 98 patients received prehospital RCCs, of which 94 suffered trauma. The majority of these patients was male (63.8%) and was involved in a car accident (56.4%). Only two patients (2.1%) had an Injury Severity Score <12. The median heart rate of the trauma patients remained stable but median systolic blood pressure (80mmHg vs. 90mmHg, p=0.011) and shock index (1.49 vs. 1.30, p=0.002) improved from time of consultation to arrival at hospital. Overall, mortality for trauma patients was 29.8%. There were no transfusion related complications identified.

Conclusions

Prehospital transfusion of RCC by paramedics is feasible and safe. The majority of patients receiving RCC in the field are major trauma patients and the transfusion of blood helped stabilising the patients´ vital functions. 

References

Holcomb JB, Donathan DP, Cotton B a, et al. Prehospital Transfusion of Plasma and Red Blood Cells in Trauma Patients. Prehosp Emerg Care 2014;19:1-9


Stefan HESCHL (Graz, Austria), Anthony DE WIT, Emily ANDREW, Stephen BERNARD, Karen SMITH
11:00 - 18:00 #7723 - Prehospital traumatic injuries: Are they unintentional or self-inflicted?
Prehospital traumatic injuries: Are they unintentional or self-inflicted?

Background

  Injuries are the leading cause of death among individuals aged 1 to 30 years and the fourth leading cause of death overall. Beside road crashes, accidental trauma and self inflicted injuries started to grow in the last 3 years. The way that traumatic injuries are produced is important for the management and further evolution.

 Our purpose was to study how injury rates vary by age, sex, rural-urban areas, and also an important goal was classification of  injury mechanism and notice the severity of damages.

Methods and Participants

We used retrospective medical study based on the statistical data applied on SMURD Sibiu’s database.

We analyzed 490 cases that were supposed to contain traumatic injuries,  dispatched to SMURD-TIM Sibiu (Mobile Emergency Service for Resuscitation and Extraction - Mobile Intensive Care Unit) during the period between 01.01.2013-31.12.2015.

For processing the database and obtaining the final data Microsoft Excel has been used.

Results

Out of 490 cases, 303 were traumas out of which 73,60% was accidental trauma and 26,40% were self inflicted injuries.

We observe that both - accidental traumatic injuries and self inflicted injuries occur more frequently at males, age group 1-30 years is the most affected and rural populations exhibit high injury rates.

Falls from the same level, falls from heights and being struck by were the leading mechanism of injuries in unintentional trauma. Falls from the same level affect young children and adults over 60 years of age. Falls from heights and being struck by prevail in adults between 20-45 years old. Contusions and superficial injuries, open wounds, sprains and strains, and fractures are the leading first-listed diagnoses from Smurd requests.

Out of intentional self-harm injuries, prevail hanging followed by ingestion of drugs overdose. More often were affected males and the group age under 30 years was predominant.

Discussions

- In a substantial number of cases the abuse of alcohol lead to traumatic injuries, either by falling or occupational accidents, either in suicide purpose in association with drugs overdose or other suicide attempts.

- Rural population is more affected by traumatic injuries because of tough work and also the inadequate access to emergency medical services in that area rise the number of SMURD requests.

- Knowledge the mechanism and nature of injuries can be used in designing protective equipment, developing interventions for prevention of injury, and planning for rehabilitation when a specific event occurs.

- We usually find the patient in lateral safety position or not moved at all by relatives,  so that no other damages will be done. 


Diana-Paraschiva LOLOIU (Sibiu, Romania), Alin-Nicolae CANCIU, Claudia CIORA, Daniela MD TARAN, Angela-Teodora SCROB
11:00 - 18:00 #7730 - Preoperative airway assessment-predictor for difficult intubation.
Preoperative airway assessment-predictor for difficult intubation.

 

 

OBJECTIVES

The objective of this study was to explore the preoperative airway assessment in order to quantify it as a predictor for difficult airway or difficult intubation in  the perioperative period.

METHODS

We conducted a prospective study with data collected for 95 patients for one month in November 2015 in Anaesthesia in our hospital.

RESULTS

65.26% was reviewed by the same doctor that anaesthetized the patients, 33.68% was assessed by 2 doctors and 1.05% patients was assessed by 3 doctors.

66.32% patients had  adequate documentation of preoperative airway assessment, 32.63% patients had  incomplete documentation and 1.05% patients had no documentation.

5.26% patients had difficult ventilation, 2.11% patients had difficult intubation, 1.05% patients had failed intubation.

24.21% patients were overweight and 20% patients were obese.

15.79% patients were edentulous, 1.05%  had history of snoring, a beard and  Obstructive Sleep apnoea.

The inter-incisor gap was small in 1.05 patients, medium  in 9.47% patients and normal in 56.84% patients.

The atlanto-occipital distance was normal in 62.11% patients.

Mallampati score was: one for 37.89% patients, two for  42.1% patients, three for 5.26% patients, four in 1.05% patients.

The number of patients predicted for difficult ventilation and intubation who actually had difficult ventilation and intubation was the same- 3.16% patients and 1.05% patients respectively.

1.05% patients had failed intubation.

No patient sustained “can’t intubate , can’t ventilate” scenario.

CONCLUSION

The proposed standard for the best practice for this audit was 100% of patients to be assessed and anaesthetized by the same doctor,  of which we achieved 65.26%; 100% of airway to be assessed pre-operatively of which we achieved 98.95%; 100% to  have adequate documentation for preoperative airway assessment, of which we achieved 66.32%.

Difficult ventilation and patients needing to be intubated  were predicted by the pre-operative assessment.

The proposed standard for failed intubation was <0.1%,  in our study  1.05% had difficult intubation, which will need improvement in the future.

There is  room for improvement in  the documentation for preoperative airway assessment, for which we will make suggestions for changes in the assessment chart; we will follow this with  another audit after the implementation of the new chart.

Dr Nicoleta Cretu, ACCS  ST1 Emergency Medicine trainee

Dr Florence Apaloo, Consultant in Anaesthesia

Dr Ben Teasdale, Consultant in Emergency Medicine

Leicester Royal Infirmary Hospital, Leicester,UK.

 

 

 


Dr Nicoleta CRETU (Leicester, United Kingdom), Florence APALOO, Ben TEASDALE
11:00 - 18:00 #4772 - Preparing Emergency Medical Services organizations to be health literate health care organizations.
Preparing Emergency Medical Services organizations to be health literate health care organizations.

Title: Preparing Emergency Medical Services organizations to be Health Literate Health Care organizations

Background/Objectives: 

The action plan to improve health literacy in an organization is a set of health literacy priorities to be addressed by the Dubai Corporation of Ambulance Services (DCAS) to the Emergency Medical Services (EMS) organizations based on the two (2) of the Ten (10) attributes of health literate health care organizations; (#2) Integrate health literacy into planning, evaluation measures, patient safety, and quality improvement and (#3) prepare the work force to be health literate and monitors progress.

Methods:

As an integral part of the health care system, EMS providers and organizations must recognize the need of health care literacy training to all of its personnel from all levels of the organization though health literacy training is more focused to the clinicians or medical personnel on direct contact with clients or the sick and injured and their families.

Result:

High level of health literacy of the EMS organizations personnel will cause a high level of influence of patient care and safety that will result to a high standard quality of patient care services and consumer satisfactions.

Conclusions:

Unless we, as an Emergency Medical Service organizations, an integral part of the overall Public Health Care System are prepared to focus attention and resources on health literacy issues, our organizations will likely continue producing personnel, Paramedics/medics who lack skills and are ill-prepared to deal with the demands of the community and work place in terms of quality of patient care and safety and rapport building with the public, the community, and other organizations as well.


Maria Shila Clarion CARAAN (Dubai, United Arab Emirates)
11:00 - 18:00 #7412 - Presence and prognostic value of elevated high-sensitivity cardiac troponin in patients with acute ischemic stroke - a retrospective analysis.
Presence and prognostic value of elevated high-sensitivity cardiac troponin in patients with acute ischemic stroke - a retrospective analysis.

Introduction

Cerebrovascular and cardiovascular diseases are major causes of death and disability worldwide. Because of the close association between stroke and cardiac disease, current American Heart Association/American Stroke Association (AHA/ASA) guidelines for the early management of patients with acute ischemic stroke recommend assessment of cardiac biomarkers (preferably cardiac troponin [cTn]) in all patients presenting with acute ischemic stroke. In Tartu University Hospital at the time of this study cardiac troponin was not routinely assessed in these patients.

The aim of our study was to evaluate the presence of elevated high-sensitivity cTn on admission and its impact to neurological improvement and short term survival in patients with acute ischemic stroke.

Methods

This is a retrospective study of all patients admitted to the Tartu University Hospital emergency medicine department with signs and symptoms of acute ischemic stroke in a one year period (January 2014 to December 2014). In our hospital criteria for stroke „alarm“ is any stoke warning sign or symptom regardless of the severity of neurological deficits within 4,5 hours. In this analysis we included only these patients who received thrombolytic therapy. Patients were divided into two groups according to their cTnT value, less than 14ng/L versus ≥14ng/L. We use highly sensitive assay in our hospital. National Institutes of Health Stroke Scale (NIHSS) dynamics from admission to 7th day score was used to evaluate the neurological improvement. As for short term survival, patients who left the hospital alive formed one group and the ones who died within the current stroke case formed the second group.

Results

Altogether we had 263 stroke „alarm“ patients, 165 of them were diagnosed with acute stroke and 143 patients received thrombolytic therapy. From those, cTn-hs was measured in 55% (n=79) of cases on admission to the emergency department.  cTnT-hs was elevated (≥14ng/L) in 54% of these patients (n=43). Statistical linear model showed that patients, whose cTn-hs was below 14ng/L had better neurological improvement compared with patients whose cTnT-hs was above 14ng/L  (NIHSS dynamics 5.75 in cTnT-hs less than 14ng/L group versus NIHSS dynamics 0.93 in cTnT-hs ≥14ng/L group,  p= 0.0082).

We found no correlation between elevated troponin and short term survival (p=0.38).

Conclusions

According to our study elevated cTnT-hs corresponds with worse neurological improvement in patients who are diagnosed with acute stroke and treated with thrombolytic drug. No relationship was revealed with elevated cTnT-hs and short time survival, but since our cohort was very small this is inconclusive.

Elevated cTnT has a potential prognostic value in acute stroke patients and should be routinely measured in patients hospitalized to the emergency department as acute stroke patients.

Key words
Acute ischemic stroke, prognostic value of high-sensitivity cardiac troponin.


Keskpaik TRIINU, Kuido NÕMM (Ülenurme, Estonia), Sirli SAAR, Ingel TÄRK
11:00 - 18:00 #7487 - Present situation of emergency of the elderly in our hospital.
Present situation of emergency of the elderly in our hospital.

Background

Japan has one of the longest life expectancies in the world, and there is an increasing number of emergency of aged persons. In our hospital, we also accept many aged patients of emergency. Our hospital is the 15th emergency and critical care center in Osaka prefecture accredited in 2012. It covers the medical region which consist of about million people. Increasing a demand of the emergency of aged persons, especially from facilities for the elderly, becomes an issue in our hospital. In this time, we investigated the present situation of emergency of the elderly in our hospital.

Objective:

We researched patients transported by ambulance since January 2013 to December 2015 and factors as follows : emergency carrying number, number of admission of emergency department, length of hospital stay, and changing hospital number.

Outcome:

Emergency carrying number was 26,280 and number of aged persons was 12,853(48.9%). Number of admission of emergency department was 2,368 and number of aged persons was 1,546(65.3%). Length of hospital stay was 1 to 228 days. The average of length of hospital stay was 11.67 days in all patients. Aged patients stayed in hospital for 13.42 days on average and the others stayed for 8.37 days in the mean. Changing hospital number was 416 in all patients. Aged patients accounted for 78.1%, and the mean duration taken to changing hospital was 21.88 days.

Discussion:

This research showed that the hospitalization of aged patients tended to become prolonged and that they needed more time to change hospital. Because of prolonged hospitalization, beds inclined to be occupied and we sometimes had to refuse emergency patients. Japan has one of the longest life expectancies in the world and emergency medical care is required more than ever. However, in many cases, medical care of elderly people is not able to conclude only by treatment for an acute phase, and many of elderly patients cannot be discharged to home or facilities for the elderly and need to transfer to chronic care hospitals. Reasons they are not able to be discharged are as follows : disability of oral intake caused by aging or wasting, refusal by families or facilities, and so on. In this manner, the duration of treatment of elderly patients tend to be prolonged and this fact stagnate an emergency medical care. This is a problem and a present situation of elderly emergency in our hospital and in Japan.


Keitarou SUZUKI (Osaka, Japan), Hiromasa YAKUSHIJI, Arito KAJI, Motohiro YAMADA, Masahiro SHINOZAKI, Wataru SHIRASAKA, Asuka SUNADA
11:00 - 18:00 #7118 - Presentation of a case of an intraocular straign material.
Presentation of a case of an intraocular straign material.

MEDICAL HISTORY:

Patient of 28 years without drug allergies and relevant medical history presented to the emergency by pain and redness of the left eye after having the feeling jump on something as he fixed a picture on the wall. The patient has no alteration in vision as regards

Assessment requested by Ophthalmology at the sight of foreign body deep after fluorescein staining associated with corneal erosion.

Browse:

Visual acuity preserved, isochoric and normoreactivas pupils. Preserved eye movements.

Erosion superior linear full-thickness corneal but sealed spontaneously.

Fundus with some bleeding rounded supratemporal area with small whitish rounded picture size adjacent suspected intraocular straign materialforeign vitreous.

After the physical examination by the specialist, CT is performed orbital

 Complementary tests:

Blood tests unaltered

Electrocardiogram showed sinus rhythm at 80 bpm.

TAC orbital: Straign material in superior temporal level rounded

Clinical Trial: Intraocular straign material

Evolution and Treatment: After Ophthalmology valuation and realization of orbital TAC is reached definitive diagnosis of intraocular foreign body. Preoperative evaluation is performed, is entered in Observation for home intravenous antibiotic treatment and surgery is performed subsequently.


Manuel AGUILAR CASAS, María Eugenia REYES GARCÍA (Málaga, Spain), David NÚÑEZ CASTILLO
11:00 - 18:00 #7252 - Presentations of Tuberculosis in the Emergency Department of United Kingdom.
Presentations of Tuberculosis in the Emergency Department of United Kingdom.

Introduction

Over nine million cases of tuberculosis (TB) and nearly two million deaths from TB occur in the World every year. TB is the leading cause of death among curable infectious diseases. The World Health Organisation declared TB a global emergency in 1993. A total of 7892 cases of TB were notified in United Kingdom in 2013 with an incidence of 12.3/100000. The overall number of TB patients in the UK has declined by 11.6% in the past two years. 75% of cases occurred among people born outside the UK although only 15% were recent immigrants.

Objective 

We conducted a retrospective study to assess various presentations of TB in the Emergency Department at City Hospital, Birmingham and George Eliot Hospital, Nuneaton, UK.

Methods

This study was carried out in the Accident and Emergency department of City Hospital, Birmingham, United Kingdom and the Emergency Department of George Eliot Hospital, Nuneaton, United Kingdom. A list of patients diagnosed to have TB was obtained from the medical records department. Hospital notes of all these patients were reviewed to collect the following data; age, sex, ethnicity and presentation in the Emergency Department.

Results

A total number of 52 patients were included in the study. These were patients diagnosed in the Emergency Department during the time of the study. 14 were Female and 38 were Male. The age group of these patients was 18 to 86, 16 patients were under the age of 30 years. Only 7 patients were born in the United Kingdom and the rest of the patients were from an immigrant population. In the patients with Pulmonary TB only 12 patients had cough and other chest symptoms. 3 patients had weight loss, fever and night sweats. 14 patients presented with back pain and lumbar swelling of varying degrees and one of these presented with neurological deficit consistent with cauda equine syndrome. One patient presented with appendicitis diagnosed to have abdominal TB and another patient with abdominal TB presented with weight loss and night sweats.

Discussion

Our study results show there is a significant number of patients that attend the Emergency Department with atypical presentations of TB. The majority of patients are from the immigrant population. Our study is consistent with a report from the Health Protection Agency (HPA) of the United Kingdom regarding the presentation in the immigrant population. HPA figures show a higher percentage of pulmonary (42%) compared to extra-pulmonary TB. In our study we saw more (58%) extra-pulmonary TB. The main reason for this observation is better community management of pulmonary TB. Most often patients with pulmonary symptoms are detected in the community, seen by General Practitioners and treated as out-patients. But extra-pulmonary tuberculosis is difficult to diagnose in the community and they make their way to Emergency Departments as a last resort.


Mohammad ANSARI (Birmingham, United Kingdom), Ahmad ISMAIL, Inayat REHMAN
11:00 - 18:00 #7159 - Press Ganey scores do not improve for emergency medicine residents as they proceed through training.
Press Ganey scores do not improve for emergency medicine residents as they proceed through training.

Press Ganey scores are often used as an administration marker for bonuses and job security.  Certainly this application has its drawbacks, but nonetheless this evaluation tool has become an important instrument for accessing physician capabilities and patient satisfaction.  Residents at our facility are actively trained with regards to patient contentment and ways to improve this metric.

 

We sought to determine if Press Ganey scores would improve during emergency medicine residency training.   

 

This was a retrospective cohort study of emergency medicine residents.   Population: Only those resident with three years of Press Ganey scores were utilized.  Only those scores known to be associated with a specific resident were tabulated and the “doctors score” component of Press Ganey evaluation was employed.  Scores were separated for analysis into two time segments, first 1.5 years of residency and second 1.5 years of training.  Statistics: A paired student T-test with a significant P value of 0.05 was utilized.  In cases of blank data for any specific resident the average score for that time period was calculated and used for that data point.  This study was approved by our IRB. RESULTS: Three-hundred and sixty-two individual Press Ganey scores were available for analysis for ten different residents fitting inclusion criteria.  Eighty percent (N=8) were male residents.  Mean overall Press Ganey doctor’s score was 88.4 and overall Press Ganey score was 87.3.  The average score for the first half of residency was 88.3 while the second half was 86.9.  Mean difference was 1.3 (95% CI -2.4 to 5.3) P=0.48.  The highest mean score occurred in third year and lowest score was in year two (p=0.29).  Regarding gender, female residents mean Press Ganey was 88.3 and compared to the males 88.4 (p=NS) score.  

 

Though overall Press Ganey scores were very good, no significant improvement occurred during resident training.


Fred FIESSELER, Paul SZUCS, Dave SALO, Renee RIGGS (New Brunswick, USA)
11:00 - 18:00 #7226 - Prevalence and characteristics of patients with undiagnosed hiv infection in an urban Emergency Department.
Prevalence and characteristics of patients with undiagnosed hiv infection in an urban Emergency Department.

Background:

Cost-effectiveness analyses support HIV screening in health care settings including emergency departments (EDs) when local undiagnosed HIV infection prevalence exceeds 0.1%. In Spain routine HIV testing is not incorporate in the EDs. To evaluate the potential for the implementation of routine screening we determined the prevalence of unknown HIV infection among patients seeking care in the fast track area of the ED and described the factors associated with the diagnosis.

Participans and methods:

The study was conducted at a single urban academic ED:  La Princesa Hospital in Madrid.  Patients aged 15-75 presenting to the fast-track area of the ED and who was getting a blood draw for other reasons was tested for HIV regardless of risks or symptoms. Stream pretest written information was given to patients notifying that the test was going to be normally performed unless the patient opted out. Patients were excluded if they had known HIV diagnosis, had an acute psychiatric or unstable medical illness or if a language barrier existed. Plasma samples were sent to the hospital microbiology laboratory and screened for HIV with traditional 4th generation EIA test. Patients with positive results were referred to infectious diseases department for confirmatory testing and treatment. The prevalence of unknown HIV infection and 95% confidence intervals (CIs) were determined by standard methods. Odds ratios were calculated for all factors potentially associated with unknown HIV infection. Analyses were performed with SPSS v18.0 and STATA v12.

Results:

A total of 1,722 patients had blood drawn. Of these, 21 patients (1.2%) opted out from the screening and 19 (1.1%) of the blood samples weren’t eventually analyzed. The prevalence of undiagnosed HIV infection in the ED among 1,682 patients tested was 0.6% [95%CI: 0.23-0.96]. It was, statiscally non-significant, higher among foreing-born individuals 0.97% [95%CI:0.3-2.2], and middle-aged individuals 36-50 1.46% [95%CI:0.4-2.5].  Being male (OR 5,78 95%CI 1,0-31,4),  chief complaint suggesting infection (OR 8,14 95%CI 1,6-41,4) and history of hepatitis (OR 5,53 95%CI 1,1-27,7), were  associated with unknown HIV infection.

 Conclusion:

There was a high prevalence  (0.6%) of undiagnosed HIV infection among patients seeking care in this Emergency Department. Universal routine Opt- out HIV testing was highly accepted. These results advise EDs and hospitals to implement different strategies like routing screening or indicator condition guided HIV testing to avoid as many missed HIV diagnoses as possible.


Alberto PIZARRO PORTILLO, Alberto PIZARRO PORTILLO (Madrid, Spain), Monica NEGRO, Ana DEL REY, Carmen DEL ARCO, Ignacio SANTOS GIL, Francisco RODRGIUEZ
11:00 - 18:00 #7945 - Prevalence and outcomes of endotracheal intubation in the pediatric emergency department.
Prevalence and outcomes of endotracheal intubation in the pediatric emergency department.

Background and Objectives

 Intubation is a core airway skill in Pediatric Emergency Departments. There are limited data on pediatric endotracheal intubation in the emergency department especially in developing countries. This study was designed to describe the frequency, clinical features and outcomes of pediatric intubation in a large children’s hospital.

 

Methods:

We performed a retrospective analysis of emergency department medical records between January 2014 and December 2015 that involved attempted intubation of children younger than 18 years.  Medical records were reviewed to describe the intubation   process, demographics, clinical features and outcomes.

Results:

A total of 115,000 patients visited our emergency department during the study period. Eighty-six of them (1/1300) were intubated. The mean age was 3.4 years, (F/M: 1) and 23 patient was younger than 12 months.  Cardiopulmonary arrest was the most common indication for intubation (36%), followed by status epilepticus, sepsis-shock and respiratory failure respectively (27%, 20% and 17%).  Cardiopulmonary resuscitation was administered for 20 patients more than 10 minute, and they all died. While poor outcome was associated with sepsis-shock, better outcome was associated with status epilepticus with a p value of 0.03 and 0.001 respectively.

 

Most intubations were successful with 1–2 laryngoscopy attempts, while 13(15 %) were diffi-cult. A majority of tracheal intubations involved use of an intravenous anesthetic induction agent and/or a sedative 55 (64%] a benzodiazepine, 46 (53%) fentanyl, and 10 (12%) ketamine.  Rocuronium bromide as a neuromuscular blockade agent was administered in 15 (21%) of endotracheal intubations.  While infants had the highest mortality rate with a 48%, fifty-four percent of all patients were discharged from the hospital.

 

Conclusions

The most common lifesaving intervention in our pediatric emergency department was endotracheal intubation. A significant rate of intubation was successful.  Favorable outcome has been related to duration of CPR (less than 10 minute), age (>1 year) and primary clinical features (status epilepticus). 

 


Ali YURTSEVEN, Eylem Ulaş SAZ (Izmir, Turkey)
11:00 - 18:00 #7957 - Prevalence of Ambulatory Care Sensitive Conditions in the Emergency Department.
Prevalence of Ambulatory Care Sensitive Conditions in the Emergency Department.

Background
Crowding is a challenge for Emergency Departments (ED´s) caused by increasing case numbers. One approach to explore this tendency is the concept of Ambulatory Care Sensitive Conditions (ACSC´s). This means that hospitalizations related to ACSC´s (e.g. chronic diseases) could be prevented by an effective and early treatment in primary care.

Objective
The objective was to examine the prevalence of ACSC´s in the ED.

Methods
We analyzed routine data from the hospital information system of 34,444 patients in two ED´s at the Charité - Universitätsmedizin Berlin for the period between February 2009 and February 2010. We included hospitalized patients, who received one of 19 hospital main diagnoses according to the International Classification of Diseases (ICD-10). The ICD-Codes are used by the National Health Service to describe ACSC´s. In addition we analyzed the hospital main diagnoses of hospitalized patients with the first diagnoses of patients in the ED.

Results
In total 2,962 of 13,536 (21.9%) hospitalized patients were identified with ACSC´s in their main hospital diagnoses (median age 68 years, IQR 57-76; female 43%). The five most common ACSC´s were angina pectoris (6.6%), convulsions and epilepsy (3.4%), influenza and pneumonia (3.0%), congestive heart failure (2.8%) and hypertension (2.1%). The cumulative frequency of these five diagnoses among hospitalized patients with ACSC´s (n=2,962) was 81%.
The in-hospital mortality for all patients with ACSC´s was lower in comparison to all inpatients (3% vs. 4.7%), but in detail the mortality rates varied among ACSC related diagnoses (e.g. angina pectoris 0.3%; influenza and pneumonia 9.2%). Comparable results could be found in the utilization of intensive care beds, which happened less often in patients with ACSC´s in comparison to all inpatients (14.8% vs. 18.2%). In similarity to inpatients 4,266 of 20,797 (20.5%) outpatients were identified with ACSC´s (median age 50 years, IQR 34-69; female 53.3%). The five most common ACSC´s were hypertension (4.1%), dehydration and gastroenteritis (3.5%), ear, nose and throat infections (2.8%), angina pectoris (2.7%), convulsions and epilepsy (2.0%). The cumulative frequency of these five diagnoses among outpatients with ACSC´s (n=4,266) was 74.4%.
Among patients with ACSC´s in their first ED diagnoses (n=7,090), the main causes of hospitalization (n=2,824) were angina pectoris (21.3%), epilepsy (10.2%) and congestive heart failure (6.4%).

Conclusion
Every fifth hospitalized patient received a hospital main diagnoses, which was related to ACSC´s. Most of them consisted of five ACSC´s. Although not every hospitalization can be prevented, the results suggest that a more effective primary care could reduce the case number in ED´s. In similarity to inpatients 20% of the treated outpatients received ICD-codes related to ACSC´s. Outpatients deviate from inpatients in diagnoses, age and gender. Improving primary care could disburden ED´s. 


Johann FRICK (Berlin, Germany), Anna SLAGMAN, Julia SEARLE, Pr Martin MÖCKEL
11:00 - 18:00 #7441 - Primary P.C.I in Winter's E.C.G pattern: A new sign of L.A.D occlusion/subocclusion.
Primary P.C.I in Winter's E.C.G pattern: A new sign of L.A.D occlusion/subocclusion.

Winter pattern is a rare, novel and little-known electrocardiographic pattern, without elevation of ST segment, of vital importance as a standard of primary revascularization in patients without contraindication and typical chest pain. First described in 2008 by Dr. Winters and published in New England, it describes an occlusion / subocclusion of the proximal left anterior descending coronary artery (LAD), being a primary criteria for revascularization as soon as possible. Only 2% of proximal LAD occlusions have this pattern, so most of them are not diagnosed in time.

In Winter's pattern, instead of the signature ST-segment elevation, the ST segment shows a 1- to 3-mm upsloping ST-segment depression at the J point in leads V1 to V6 that continued into tall, positive symmetrical T waves.

The last experience with this syndrome  in Albacete's Emergency Service was with a 71 years old patient, ex-smoker for more than 20 years, currently on statin for dyslipidemia and operated of right herniorrhaphy. Patient referrers, from 1 hour ago, left chest pain that radiates to the back and is accompanied by vegetative symptoms. On examination, the patient was diaphoretic with low blood pressure (BP 90/60). The electrocardiogram (ECG) shows ST segment depression in precordial with peaked T and slight rise of ST <1 mm in aVR without ST elevation in V7-V9. NSTEMI (Non–ST-Segment Elevation Myocardial Infarction) initially suspected, we treated with analgesia and did troponin's serialization with slight elevation of it (Tn 18, CK 189). After a while, the chest pain and the ECG changes persist. After a second serialization with persistent troponins rise without ECG changes, it was discussed with cardiology expert who recognized the Winter's pattern and found  in the catheterization a substantially complete proximal occlusion of LAD, proceeding to primary revascularization and implanting a stent in it.

In ischemic heart diseases the myocardial damage is subjected to the time of revascularization. It is important to learn and recognize the ECG's patterns that are equivalent to ST-segment elevation, showing a false NSTEMI image.


Francisco Javier LUCAS GALÁN (Albacete, Spain), Fernando Constantino BRIONES MONTEAGUDO, María Asunción GALÁN TRABA, Nuria SÁNCHEZ GARRIDO-LESTACHE, María OLMOS ALEMÁN
11:00 - 18:00 #7722 - Priority LIFE. First emergency maneuvers on head trauma.
Priority LIFE. First emergency maneuvers on head trauma.

BACKGROUND

Today, world is characterized by new activities that put people at great trauma risk like driving, sports etc. Most head trauma involves injuries that are minor and don't require medical specialized attention.

However, even minor injuries may cause persistent chronic symptoms, such as headache or difficulty concentrating, and you may need to take some time away from many normal activities to get enough rest to ensure complete recovery. Recognizing the symptoms of these injuries is important, because the condition of someone with this injury can deteriorate without warning.

Careful observation and quick action can help identify head injuries that could evolve to an undesired state. The aim of this study is to evaluate the clinical profile of visual complications in patients hospitalized and managed for head injury in Sibiu.

METHODS

Source data for this retrospective study is Sibiu Emergency Hospital database, for a period of 2 years.  A selection of all head injuries cases is done to analyze the complications and the first important maneuvers to asses this injury.

RESULTS

Facial, neurological and visual complications occurred in most of the cases  with  a greater degree in incidence in males comparing with females. Main causes of complicated trauma cases  are  met in road accidents, work accidents, fights and other types of trauma. In road accidents pedestrians are more affected than drivers with more complications.

CONCLUSIONS:

Head injuries remain one of the most common cause of complex impairment on different systems, a life-long disability. An important number of them can be prevented or reduced implementing a prioritized trauma guide for all head injury patients in the first stages of advanced medical care. Our study highlights the need of such a protocol to be designed and implemented in Sibiu to reduce these unfortunate situations.


Marius SMARANDOIU (Sibiu, Romania), Adriana STANILA, Alin CANCIU, Dan Mircea STANILA, Daniela TARAN
11:00 - 18:00 #7393 - Problematic patients with acute alcoholic intoxication in Emergency Room.
Problematic patients with acute alcoholic intoxication in Emergency Room.

In Japan, patients with acute alcoholic poisoning often occupy beds in Emergency Room(ER) and impede medical care for other patients.
Jikei medical university hospital is located near the downtown in Tokyo and we receive almost 300-500 patients with acute alcoholic poisoning a year.
Statistical analysis showed patient age and staying time in ER had a positive correlation.Also, male patients tended to call ambulances more often than female patients,but there was no significant difference in staying time in ER between male and female patients.
Patients visiting to ER by ambulances tended to stay in ER longer than walk-in patients. The mean time was 165.1 min and 124.9 min,respectively.
Mean staying time in all patients was 159.5 min and maximum staying time was 810 min.
We also analyzed data from alcoholic concentration and Γ-GTP in serum ,the presence of head injury and the number of cases which failed to respond to a demand of emergency transportation because of all-beds occupied.
Patients with acute alcoholic intoxication in ER are problematic not only in that they occupy ER beds long time but also they occupy beds for severe patients and sometimes we have to decline emergency transportation.


Wataru YAJIMA (Tokyo, Japan)
11:00 - 18:00 #4778 - Profound opiate toxicity in gastroparesis following therapeutic dose.
Profound opiate toxicity in gastroparesis following therapeutic dose.

Profound opiate toxicity in gastroparesis following therapeutic dose

Introduction:

Gastroparesis is defined by the presence of delayed gastric emptying without mechanical obstruction. Symptoms of which include abdominal pain and vomiting, nausea, bloating, fullness and early-satiety. The prevalence is estimated to be at 24 per 100,000 and women more commonly affected than men1. It is associated with a number of conditions including diabetes, Parkinson’s disease, multiple sclerosis, previous abdominal surgeries and connective tissue disorders such as scleroderma and Ehlers-Dalos syndrome.

 

Case: 

A 20-year old female was admitted to the emergency department with sudden onset central abdominal pain and vomiting at 19:30. Background – Ehlers-Danlos type 3, gastroparesis - extremely delayed gastric emptying as confirmed by C-13 breath test motility studies (transit time >150mins) and awaiting a gastric pacemaker procedure. She had a long-term nasojejunal-feed in situ for management of her condition and had multiple previous admissions with severe abdominal pain relating to her condition.

The patient received 2.5mg IV morphine at 22:10 in the emergency department, and later at 02:20 received 20mg Oramorph (administered orally, not via NJ-tube) on the surgical ward.

An arrest call was put out at 07:40. Observations: RR 0, 19% saturation on air, HR 100, BP 168/111, bilateral pinpoint pupils. Initial blood gas – pH 6.85, pO2 8.9, pCO2 16, HCO3- 21, base excess -12, lactate 4.7. She was given a bolus of IV naloxone with instant effect. The patient was transferred to the intensive care unit for further supportive management. She went on to make a full recovery and a few months later underwent a gastric pacing procedure.

 

Discussion:

The patient was not known to be opiate-sensitive and had previously taken similar doses and preparations of opiates without ill effect. It is further notable that the initial 2.5mg intravenous dose did not produce significant cardio-respiratory compromise. However, when taken in the oral preparation some hours later the effects of opiate toxicity were profound. The degree of hypercarbia and acidosis on the arterial blood gas also demonstrate that the patient had experienced a prolonged period of respiratory depression by that time.

Gastroparesis can be a severely debilitating and painful condition. The majority of pharmacological therapy for gastroparesis include a variety of prokinetic agents such as metoclopramide, cisapride, domperidone and erythromycin. Drugs that are known to prolong gastric transit time such as opiates are relatively contraindicated and have been shown to exacerbate symptoms2. 

Conclusion:

Gastroparesis is a poorly understood, chronic condition that can be debilitating. Patients may present in extreme pain the symptoms of which can mimic an acute abdomen. Use of opiate medications may further exacerbate the symptoms and should be avoided where possible.

References

  1. Lacy BE. Neuroenteric stimulation for gastroparesis. Curr Treat Options Gastroenterol. 2015 Dec;13(4)409-17.
  2. Hasler WL, et al. Factors relating to abdominal pain in gastroparesis: contrast to patients with predominant nausea and vomiting. Neurogastroenterology and motility. 2013 May; 25(5)427-38.

Craven HENRY (London, United Kingdom)
11:00 - 18:00 #7241 - Prognostic contribution of MR-proADM in patients with acute exacerbations of COPD presenting to the emergency department.
Prognostic contribution of MR-proADM in patients with acute exacerbations of COPD presenting to the emergency department.

Background: It is essential to risk-stratify patients with acute exacerbation of COPD (AECOPD) presenting to the emergency department (ED), to adapt their management. MR-proADM has been shown to predict 2-year survival in AECOPD. CURB-65 score is associated with short-term mortality AECOPD. The aim of our study is to examine the prognostic performance of MR-proADM alone and in combination with CURB-65 score to predict short-term mortality in AECOPD in the ED.                                                                                                                                                                                       

Methods: A prospective cohort of 117 patients presenting to the ED with dyspnea with a diagnosis of  AECOPD were included in this analysis. MR-proADM assays were performed at arrival to the ED. Patients were classified into 3 risk groups using CURB-65 score:  low (LR), intermediate (IR) and high risk of mortality (HR). A score of CURB-65 of 0 or 1 corresponding to a LR, a score of 2 corresponding to an IR and a score between 3-5 corresponding to a HR group.

Results: The 30-day mortality rate was 7.1% (n = 8). High levels of PaCo2, NIV therapy or mechanical ventilation within 6 hours of ED arrival were predictive of 30-day mortality. Elevated level of MR-proADM at admission was a significant predictor of 30-day mortality (MR-proADM = 0.92 nmol/L [0.7-1.3] in survivors vs MR-proADM = 1.98 nmol/L [1.45 to 2.4] among patients who died at 30 days with p = 0.002). Level of MR-proADM changed significantly depending on the orientation of patient, with higher level in patients hospitalized in intensive care unit. The MR-proADM increased with the CURB-65 score with a significant difference between risk groups (LR: MR-proADM = 0.86 nmol/L [0.66 to 1.01]; IR: MR-proADM = 1.02 nmol/L [0.79 to 1.53]; HR: MR-proADM = 1.29 nmol/L [0.93 to 2.28] with p <0.001).

Conclusion: MR-proADM predicts 30-day mortality in patients presenting to the ED in AECOPD. The levels of MR-proADM are correlated to the CURB-65 score suggesting that MR-proADM in association with the CURB-65 score could help emergency physicians in assessing AECOPD patients severity in the ED.


Erwin HANSCONRAD, Erwin HANSCONRAD (Vincennes), Alexandre MEBAZAA, Patrick PLAISANCE, Said LARIBI
11:00 - 18:00 #7638 - Prognostic value of plasma lactate levels in normotensive patients with pulmonary embolism.
Prognostic value of plasma lactate levels in normotensive patients with pulmonary embolism.

Pulmonary embolism (PE) is a common disease with high mortality and morbidity rates. The evaluation of the prognosis is a hallmark in such situation and some tools were developed in this context (1). Plasma lactate has shown it’s superiority as a prognostic biomarker in many life-threatening diseases but might also increase in PE before overt haemodynamic impairment (2). The aim of this study was to assess the prognostic value of arterial lactate in normotensive patients with PE.

Patients and methods :

This was a prospective study over 3 years (January 2013- December 2015). Inclusion of normotensive patients with documented PE. The arterial lactate level was determined on arterial blood gas samples immediately after admission to the emergency ward. A lactate level >=2 mmol/l was considered to be abnormal.

Results:

Forty patients were enrolled. Mean age = 63 +/- 14 years. Sex-ratio= 1,85. Medical history n (%) : Atrial fibrillation: 1(2,5); Deep venous thromboembolism 5 (12,5). Severity markers of PE n(%): Troponin-I > 0,5 ng/ml : 6(15);  Right ventricular diameter/ Left ventricular diameter ratio >1 ( Chest computed tomography): 11 (27,5). Arterial lactate >=2mmol/l : 12(30). The 30-Day mortality rate = 32,5%. Median baseline arterial lactate level was significantly higher in nonsurvivors than in survivors: median; IQ(25,75) (mmol/l): Nonsurvivors =2,5 ( 1,6-3,75) vs survivors= 1,2 (1-2,5) : p-value = 0,027.Abnormal lactate level as defined below was associated to respective odds ratio in Univariate and multivariate analysis (Odds ratio [confidence interval 95%]) = 4,57 [1,11-18,7]; p 0,029 ;  and 2,1 [1,05-4,32]; p 0,035. Characteristics of Curve Roc of lactate >=2 : Area under the curve: 0,718; p= 0,027; Sensitivity: 62% ; Specificty : 74% ; positive predictive value: 54 % : negative predictive value : 80%.

 

Conclusion :

Arterial Lactate level at admission should be proposed as a prognostic biomarker in normotensive patients with diagnosed PE.

1-      S.Vanni et al. Thorax 2015;0:1-6.

2-      S.vanni et al. Ann Emerg Med 2013Mar ;61(3) :330-8.


Chtourou DORRA (Tunis, Tunisia), Hamed RYM, Bellili SARRA, Bahria WIDED, Maaref AMEL, Jebali AMINA, Bouhajja BÉCHIR
11:00 - 18:00 #8155 - Prolonged resuscitation in Traumatic cardiac arrest indicates probability of poor survival.
Prolonged resuscitation in Traumatic cardiac arrest indicates probability of poor survival.

Background:

Several studies recommend limiting the duration of resuscitation in traumatic cardiac arrest patients. There is no standardized approach in managing these patients. This study is aimed to analyze the survival of the traumatic cardiac arrest patients after prolonged resuscitation (>10 minutes).

 

HYPOTHESIS:

Prolonged resuscitation in traumatic cardiac arrest patients is futile.

 

DESIGN:

Retrospective data analysis of all traumatic cardiac arrest patients presented to our ED.

 

SETTING:

University hospital, level I trauma center.

 

PATIENTS:

Traumatic cardiac arrest patients, who had cardiopulmonary resuscitation at the scene, en route, or in the emergency department from March 2013 to March 2015 were included.

 

MAIN OUTCOME MEASURE:

Survival after prolonged resuscitation (> 10 minutes).

 

RESULTS:

Fifteen hundred and four patients were admitted. The study cohort comprised 22 victims of traumatic cardiopulmonary arrest. Only 15 were included due to lack of required information in 7 patients. Fifty percent patients were over 65years and 50% were under that age group. More than 60% patients were involved in RTC and rest of them had falls, burns and head injuries. 87% patients were had blunt trauma and 13% had penetrating injuries. The total downtime documented in the notes was 0-5 minutes with the mean time of 2.43 minutes. All patients had IV access and 87% patients had received PRCs and rest had crystalloids.

100% of the patients received CPR and 80% received adrenaline either in pre-hospitaly or in hospital. The time taken to resuscitate ranged from 19 minutes to 143 minutes with the mean of 44 minutes. None of the patients were taken to theater. The commonest rhythm was asystole 46% then PEA 33% and VF 0.6%. Out of 22 patients there was not a s ingle survivor.

 

 CONCLUSION:

Trauma victims irrespective of the rhythm, amount of blood, CPR or no CPR, prolonged resuscitation own its own means poor survival probability. As most of the current guidelines suggest resuscitation for up to 10 minutes and if no change then resuscitation should be called off. 


M Azam MAJEED (Birmingham, United Kingdom), Neil-Shastri HURST
11:00 - 18:00 #7524 - Promoting medical students' self-awareness and self-management in emergency situations.
Promoting medical students' self-awareness and self-management in emergency situations.

Quick decision-making and determined action-taking are both essential to clinical crisis situations and especially in the realm of emergency medicine. The knowledge and awareness about one’s self-image as a doctor in relation to relevant aspects of the personality represent an important foundation for adequate self-management during highly complex and emotionally demanding crisis situations. Feelings of helplessness and overpowering can quickly arise and impede professional action taking.

The University Medical Center Freiburg (Germany) has been repeatedly organising a training day for medical students interested in emergency medicine. It offers an opportunity for the students to practice their skills in a number of different high-fidelity simulations of common scenarios in the emergency context. With the presence of other occupational groups of the emergency field - such as local fire-brigades - the multidisciplinary working environment represents a unique feature of the event. All students who enrolled for the elective course “emergency medicine” had the privilege to participate in it.

Through a co-operation between the department of anaesthesiology – responsible for the conceptualisation and organisation of the training day – and the department for psychosomatic medicine, an additional elective workshop was offered to the students, to confront them with the above mentioned important factors of self-awareness and self-management. Students were not only invited to learn from experienced experts about helpful coping strategies but were also encouraged to openly discuss insecurities and fears with fellow students, which was thought to promote a climate of self-reflection and mutual support among the students. For that workshop, a special focus was set on psychiatric emergency situations and professional handling of agitated (and/or suicidal) patients. This was not only due to the experience with the topic of one of the involved departments, but also because it was believed that the interaction with a patient of that kind poses a special challenge for emergency doctors.

In line with this focus of the preceding workshop, the psychiatric emergency scenario of the training day seemed particularly suitable for a pilot study trying to investigate students’ self-awareness in highly stressful and emotionally overwhelming situations. The ability to adequately self-monitor one’s stress-level serves as a basis for subsequent self-regulation. To investigate that ability, students’ heart rate during the training scenario was compared to their perceived stress-level (before, during and after the scenario took place).

Preliminary analyses of the obtained data provide hints for a discrepancy between measured and perceived stress-level of the students. Similarly, there are indications, that students who participated in the workshop were better in self-monitoring their stress-levels and applying self-regulatory strategies.                                                            


Zoltán HÖHLING (Freiburg, Germany), Sarah-Lu OBERSCHELP, Axel SCHMUTZ, Thomas AHNE, Mareike BERGMANN, Michael WIRSCHING, Andrea KUHNERT
11:00 - 18:00 #7428 - Prospective assessment of transfusion practice among emergency room nurses.
Prospective assessment of transfusion practice among emergency room nurses.

Introduction: transfusion, even in difficult emergency conditions, nevertheless requires rigorous implementation by following to the letter the rules of "good transfusion practices" to ensure optimal blood transfusion safety. This requires adequate blood safety basic knowledge, a continuous and repeated training so that the transfusion act is set in the rules of art. No studies have evaluated the knowledge and skills of paramedics in our emergency department.

Population and Methods: Our study was prospective, descriptive, mono centric conducted during a period a period 11 weeks. The tool used was a questionnaire containing 21 items in the form of multiple choice questions which were distributed in connection with the three stages of the transfusion (pre-transfusion, per-transfusion and post-transfusion). The collection of information was carried out by two senior technician in emergency medicine, volunteering and respecting anonymity. All paramedics working in our emergency department outside the administrative were included. Outcome measures were adherence to transfusion good practice include taking the correct answers.

Results : thirty nine (93%) nurses have participated to study. Only 31 % have appropriate knowledge and practice with no negative consequences for the patient safety. In our sample, poor knowledge and practice concerned mainly pre-transfusion compatibility check whenreceiving blood units (62%); delay in preservation of blood unit in the ward (65%); and recognition of abnormal reactions after transfusion (46%). These results showed on which topics the teaching program should emphasize so as to improve the quality of blood transfusion in themedical centers according to legal obligations.

Conclusion: These results showed on which topics the teaching program should emphasize so as to improve the quality of blood transfusion in the medical centers according to legal obligations.

 


Nesrine IBN HASSINE, Chawki JEBALI (Kairouan, Tunisia), Nawfel CHBILI, Achref HAJ ALI, Mejdi OMRI, Hajer KRAIEM, Mohamed Nejib KAROUI
11:00 - 18:00 #7538 - PSYCHOMOTOR AGITATION BY SEVERE HYPONATREMIA.
PSYCHOMOTOR AGITATION BY SEVERE HYPONATREMIA.

Medical history:
71 year old woman with a history of hypertension, dyslipidemia and depressive syndrome, treated with Enalapril, Rivotril and Deprax. Since 4 days ago Hidrocliorotiazida is added to treatment due to a poorly controlled
hypertension. She come to emergency department for loss of consciousness without prodromal symptoms and spontaneous recovery, with subsequent post-traumatic headache. On examination; bradipsiquica, oriented in time and space, with no apparent neurological deficit. Normalauscultation. The clinical analysis objectifies plasma sodium 124meq / l, ECG and Rx compatible with standard chest. The patient is transferred emergency room observation unit where presented episode of disorientation, agitation and subsequent muteness. Glasgow 6-4-0, complete aphasia. Control analysis; sodium 117 meq / l. Due to worsening clinical, a cranial CT scan is performed which gave normal results and then we proceed to correct cranial hyponatremia. Due to persistentsymptoms andworsening in agitation, which Midazolam IV needs to be administered, it is performed lumbar puncture giving normal results and normal thyroid hormones, and ruling out encephalitis and subarachnoid haemorrhage and myxedema coma. Begun sodium correction slowly following formulaand administration ofhypertonic saline3%, she is transferred to intensive care unit with suspected secondary brainedema (although not objectifies by cranial CT) and severe hyponatremia and thiazides. Thepatient evolves positively after that is moved toplant and discharged with normal sodium levels.
Conclusion:
Hyponatremiais the most commondisorderhydroelectric inside and outside hospitals so knowingyourdiagnosis and treatmentis very necessary. For thisis sufficientfirstdeterminingplasma sodiumvaluesbelow135 mmol\l(meq\l). Once confirmedhyponatremia,in mostcasesbe enough withan accurate medical historyto reach theetiological causetrigger. It is alsoimportant to know andcalculate theextracellular volumeto discern betweennormovolemic or hypovolemic hyponatremia, since theetiologiccause andtreatment may vary. Suchtreatment should be aimed atcorrecting themain causeand the establishment,in each case, of the correctfluid therapy. Onlyseverehyponatremiaare associated withneurological symptomsand should be treatedurgentlybythe risk ofcerebraledemaandencephalopathy.

María Teresa FERNANDO GROS (ZARAGOZA, Spain), Patricia BONED BLAS, María Pilar POVEDA SERRANO, Alicia BAGUENA GARCÍA, Rocío ESCRICHE ROS
11:00 - 18:00 #7220 - Pulmonary Embolism:Abdominal Pain a clinical dilemma.
Pulmonary Embolism:Abdominal Pain a clinical dilemma.

Pulmonary Embolism: Abdominal Pain a clinical dilemma

Authors:

  • Dr Dalip Kumar, MBBS (ED Consultant-Southend University Hospital)
  • Matthew Osborne, RN, DipHe, BSc, PGCert, PGDip  (ED Charge Nurse- Southend University Hospital & Lecturer  School of Health and Human Scientists, University of Essex)
  • Dr Mohammad Abu Watfa, Mu Dr (ED Consultant-Southend University Hospital)
  • Dr Caroline Howard, MBBS, MRCP, FCEM ( Clinical Director and Consultant ED-Southend University Hospital)
  • Dr Claire Willis, MBBS, MRCS {A&E Ed}, FCEM (ED Consultant-Southend University Hospital)
  • Dr Dilshad Al-Sheikh, MBCHB, Dip.Med  (U.K.), MRCEM ( Locum ED Consultant-Southend University Hospital)

Key Words:

                Abdominal pain, CT, FAST scan, pulmonary embolism, thrombolysis, haemodynamic instability, obstructive shock

 

Abstract (Case Report):

The treatment and disposition of patients with pulmonary embolus (PE) is commonplace in the emergency department (ED), but atypical presentations can prove to be especially challenging. Abdominal pain is an uncommon presenting symptom for pulmonary embolism (PE).We report a case of an 83-year-old man presented to the ED via ambulance with a history of central abdominal pain and nausea for less than 24 hours; his past medical history included Parkinson’s disease. The paramedic crew initially found the patient to have tachypnoea and peripheral cyanosis but was in sinus rhythm and normotensive; he also had an altered level of consciousness, although this had since resolved. With the history of collapse, evidence of shock and abdominal pain, primary consideration was for a rupturing abdominal aortic aneurysm; as such he was managed using an ABCDE approach in the ED’s resuscitation area.

Assessment revealed he was alert and his airway patent, the respiratory rate remained tachypnoeic and shallow despite high flow oxygen therapy while respiratory auscultation was unremarkable. The patient remained in sinus rhythm and had hypotension which did not responded to resuscitative fluid challenge, he was afebrile. He additionally had significant difference in left and right blood pressure readings and displayed a prolonged capillary refill time and raised JVP. Abdominal assessment revealed no palpable or pulsatile masses, only tenderness in the epigastrium. FAST Scan revealed an aorta of 2.7cm but incidentally showed a dilated inferior vena cava and a dilated right ventricle.

The surgical team was called in to support the ED team to assist in ruling out abdominal pathology, and a CT scan of chest and abdomen was done. The findings of the CT revealed bilateral pulmonary emboli at which point the medical team were consulted for additional input.

Typical presentation of PE is tachycardia, haemoptysis, syncope, hypotension, crepitations and cough or fever[1,2] ,a combination of them are present in 95% of patients with PE[3,2]; Referred abdominal pain may be seen in less than 7% of cases[4,5] .PE can be classified according to size[6] as massive (manifesting as haemodynamic instability), sub-massive (haemodynamically stable on presentation but with the potential for instability predictable by signs of right-ventricular strain) and non-massive (haemodynamically stable and no signs of right ventricular strain). A decision was made to thrombolyse with Alteplase as the patient remained clinically unstable in an obstructive shock with a massive PE[7].This patient was admitted under the ongoing care of the medical team.

The consequences of missing a PE can be catastrophic, with around 1% of all hospital deaths due to PE alone[8] and  mortality of untreated PE’s at 15%[9].Therefore, rapid diagnosis and treatment is essential, especially in the haemodynamically unstable patient in the ED. This is facilitated by access to diagnostic imaging such as the FAST scan and CT scan, the distinguishing of hypovolemic shock compared to obstructive shock, escalation and involvement of speciality care and the use of thrombolysis in haemodynamically unstable patients.

This abstract demonstrates that patients presenting with abdominal pain should be considered for PE as their differential diagnosis.

References

  1. West, J., Goodacre, S. and Sampson, F. (2007) The value of clinical features in the diagnosis of acute pulmonary embolism: systematic review and meta-analysis. QJM. 100(12), 763-769
  2. National Institute of Clinical Excellence, 2015. Clinical Knowledge Summaries: Pulmonary Embolism http://cks.nice.org.uk/pulmonary-embolism#!diagnosissub [accessed April 2016)
  3. Stein P, Beemath A, Matta F, Weg JG, Yusen R, Hales CA, Hull R, Leeper K, Sostman H, Tapson V, Buckley J, Gottschalk A, Goodman L, Wakefied T, Woodard P. (2007) Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. American Journal of Medicine. 120(10), 871-879.
  4. Sethuraman U, Siadat M, Lepak-Hitch C and Haritos D, 2009. Pulmonary embolism presenting as acute abdomen in a child and adult. Am J Emerg Med. 27: 514
  5. Amesquita M, Cocchi M and Donnino M, 2012. Pulmonary embolism presenting as flank pain: a case series. J Emerg Med. 2012;42:e97–100.
  6. Jaff M, McMurty S, Archer S, Cushman M, Goldenberg N, Goldhaber S, Jenkins S, Kline J, Michaels A, Thistlethwaite P, Vedantham S, White J, Zierler B, 2011. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis and Chronix Thromboembolic Pulmonary Hyptertension; a scientific statement from the American Heart Association. 123: 1788-1830.
  7. National Institute of Clinical Excellence, 2012 (updated 2015). Venous Thromboembolic disease: diagnosis, management and thrombophilia testing; NICE Guidance CG144 https://www.nice.org.uk/Guidance/CG144 [accessed April 2016].
  8. Kopcke D, Harryman O, Benbow E, Hay C and Chalmers N, 2011. Mortality from pulmonary embolism is decreasing in hospital patients. JRSM. 104(8): 327-331.
  9. Scottish Intercollegiate Guidelines Network, 2015. Prevention and management of venous thromboembolism: a national clinical guideline (122). Health Improvement Scotland.

 

 

 

Abstract Word Count: 498

 


Dr Dalip KUMAR, Mohammad WATFA (London, United Kingdom), Matthew OSBORNE, Caroline HOWARD, Claire WILLIS, Dilshad AL-SHEIKH
11:00 - 18:00 #7766 - QRS amplitude for predicting recent or chronic atrial fibrillation in emergency practice.
QRS amplitude for predicting recent or chronic atrial fibrillation in emergency practice.

 Atrial fibrillation is the arrhythmia most commonly encountered in emergency practice. Serious complications can include congestive heart failure, myocardial infarction, and thromboembolism. Initial treatment is directed at controlling the ventricular rate. Medical or electrical cardioversion can be necessary in some cases especially when the diagnosis of recent atrial fibrillation is certainly established. Clinical history and electrocardiographic characteristics can help to diagnosis. It is admitted that variation of QRS morphology is an indirect sign of chronic atrial fibrillation. In Our study we analysed ECG of patients consulting for atrial fibrillation and tried to objective a relationship between variable aspect and amplitude of ventricular depolarization and chronicity of atrial fibrillation.

We performed an analytic prospective study within a period of one year  and a half. We  used our local atrial fibrillation registry. We collected specific informations about the FA.  We analyzed the ECGs aspects of 2 groups of patients: newly and previously diagnosed FA. We calculated Rmax (the maximal R wave amplitude in the ECG derivations), Rmin( the minimal R wave in the same derivation), deltaR( Rmax- Rmin)and the ratio deltaR/ Rmax.

We enrolled 100 patients who had an ED visit for atrial fibrillation. The sex ratio was 0,49. The  middle age was around 65 years (from 29 to 92 years).

In the first group with previously diagnosed FA, we included 60 patients and only 40 patients in the group of newly diagnosed FA. The study showed that the deltaR/Rmax  is very various and ranged between 0,062 and 0,610. For a ratio deltaR/Rmax between 0,062 and 0,203 ; 3 patients with chronic FA  and 22 recently diagnosed FA. For a ratio deltaR/Rmax between 0,204  and 0,300 ; 9 patients  with chronic FA  and 14 recently diagnosed FA. For a ratio deltaR/Rmax upper than 0,301 ; 48 patients chronic FA  and 4 recently diagnosed FA.

From those results we can note that more the ratio deltaR/Rmax grows more the FA is likely to be chronic, with a sensitivity of 86% and a specificity of 90% for values of ratio deltaR/Rmax upper than 0,300.

 The diagnosis of recent atrial fibrillation in the current practice is essential for its management. In the light of our results we can conclude that the ratio deltaR/Rmax can be a predictif criteria of  a previously diagnosed FA for a value upper than 0,300.

 

 

 

 

 


Houda BEN SALAH, Rim YOUSSEF, Mounir NAIJA, Asma ZORGATI (Sousse, Tunisia), Naouefel CHEBILI, Riadh BOUKEF
11:00 - 18:00 #8150 - QT interval prolongation due to domperidone: a case report.
QT interval prolongation due to domperidone: a case report.

Domperidon is a well-known drug to treat nausea and vomiting. Although it is known to cause QT interval prolongation, and due to this ventricular arrhythmias and sudden cardiac death, it is still widely prescribed.

A 26-year old healthy woman presented at our emergency deparment (ED) with complaints of vomiting and diarrhoea since two weeks. One week prior to presentation she started using domperidone 10mg twice a day. After five days it was raised to 10mg four times a day. Since the start she had complaints of palpitations. The day before presentation she also experienced chestpain lasting 30 minutes. Physical examination didn’t show any abnormalities. Blood results showed normal infection parameters and a slightly decreased potassium level of 3.3 mmol/L. Her ECG showed a sinusrhythm of 70 beats per minute with a QT interval of 502ms and a corrected QT interval of 538ms. Rhythm monitoring showed premature ventricular contractions, sometimes as bigeminies. She was admitted to the cardiac care unit and treated with intravenous potassium suppletion 3 gram per 24 hours. Domperidone was stopped immediately. At discharge the ECG was normalised.

Domperidone is blocking the human Ether-a-go-go-Related Gene (hERG) potassium channels leading to prolonging of the ventricular action potential  and thereby prolongation of the QT interval causing a variety of cardiac arrhythmias and even sudden cardiac death. There is an increased risk with the simultaneous usage of other QT prolonging medication or cytochrome P-450 3A4 inhibitors. Electrolyte disturbances and a higher domperidone dose (more than 30mg a day) will increase the risk of QT interval prolongation.

Caution is needed when prescribing domperidone, especially when there are other risk factors for QT interval prolongation, but also in young and healthy people.


Jannette VAN SOEST (Utrecht, The Netherlands), Alet PFAFF
11:00 - 18:00 #7300 - Qualitative Data Analysis of a Web-Based Decision Support Tool for the Emergency Department.
Qualitative Data Analysis of a Web-Based Decision Support Tool for the Emergency Department.

Background:

www.medstandards.ch, developed at the University Hospital of Basel, is a web-based decision support tool consisting of several hundred algorithms covering common emergencies. As part of a quality management project we conducted a qualitative data analysis of 50 emergency algorithms. The aim of the study was to analyse the structure of the medical algorithms in order to define a so-called “Master-Algorithm” enabling us to use a systematic approach for future creations of new algorithms and revisions of existing algorithms.

 

Methods:

For data analysis, an adapted version of qualitative content analysis (Mayring 2000) was used, a method that allows reduction and structuring of text for analysis. Step one: the structure of the algorithms was analysed by an expert team defining categories according to medical practice (deductive approach), stating “anchor-examples” for each category and rules to enable the appropriate allocation (e.g. Triage, Red Flags, Monitoring). Step two: 40 algorithms were analysed using mindmup.com* allowing us to allocate text passages into the predefined categories in a three step reviewing process including a medical student, a junior doctor and a senior physician. Text passages, that were similar, were paraphrased (e.g. “Durchblutung, Motorik, Sensibilität, intakt?” and “pDMS testen” were subsumed to “pDMS intakt?”) and subsumed to categories. After each run the “Master-Algorithm” was adjusted by adapting or creating new categories. Step three: a team of 10 senior emergency physicians analysed another 10 algorithms making final adjustments to the “Master-Algorithm”.  We are currently in the process of re-analysing all algorithms according to the current “Master-Algorithm”.

 

Results:

A “Master-Algorithm” was defined containing main categories, sub categories, sub-sub categories and so forth. The structure of the categories resembles sections of a book with a hierarchy in different levels. We are currently in the process of validating the “Master-Algorithm” (qualitative and quantitative data will be presented).

 

Conclusion:

By using the adapted Mayring Analysis we defined our “Master-Algorithm” with a complex hierarchy of categories. Using the so established framework, we will now revise all existing standards in order to ensure systematically complete algorithms.

 

Reference:

Mayring, P. (2000) Qualitative Content Analysis [28 paragraphs]. Qualitative Sozialforschung / Forum: Qualitative Social Research [On-line Journal]

*(a free software mind mapping application)


Christiane ROSIN (Basel, Switzerland), Alexandra MALINOVSKA, Cyrill SCHWAB, Ceylan EKEN, Christian H. NICKEL, Roland BINGISSER
11:00 - 18:00 #7600 - Quality of Danish CPR courses.
Quality of Danish CPR courses.

Quality of Danish CPR courses for laypersons

 

Background

Bystander cardiopulmonary resuscitation (CPR) is important for survival from out-of-hospital cardiac arrest. Increase in bystander CPR is associated with increased survival (1). The quality of bystander CPR is likely affected by the quality of Basic Life Support (BLS) courses(2, 3). The purpose of this study was to investigate the quality and adherence to international guidelines in Danish BLS courses.

 

Method

Based on previous models and elements important for survival, a course evaluation sheet was developed. It included 23 elements on a five point Likert scale incorporating theoretical, technical- and non-technical skills. Six experienced BLS instructors from various organizations where trained in the use of the evaluation sheet.

 

Results

A total of 59 course observations where conducted with the ten of the largest national BLS providers. The results of the observations showed variation between courses in most elements. All examined courses had an announced length of three to four hours. Of the observed courses 36% had less than one hour of practical training. Most noticeable were the variation within recoil, agonal breathing, check for consciousness, telephone assisted CPR, and AED use. The preliminary results indicate an association between variation in course elements and number of participants per instructor and the length of practical training.

 

Conclusion

Preliminary variation in adherence to international guidelines, content, and quality has been documented in Danish BLS courses and can be used to improve future BLS courses. 

 

1.         Wissenberg M, Lippert FK, Folke F, Weeke P, Hansen CM, Christensen EF, et al. Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest. Jama. 2013;310(13):1377-84.

2.         Wagner P, Lingemann C, Arntz HR, Breckwoldt J. Official lay basic life support courses in Germany: is delivered content up to date with the guidelines? An observational study. Emergency medicine journal : EMJ. 2014.

3.         Parnell MM, Larsen PD. Poor quality teaching in lay person CPR courses. Resuscitation. 2007;73(2):271-8.


Thea Palsgaard MØLLER, Søren VIERICK, Thomas EGESBORG PEDERSEN, Fredrik FOLKE, Freddy LIPPERT, Jens Flenstd LASSEN, Theo Walther JENSEN (Copenhagen, Denmark), Doris ØSTERGAARD
11:00 - 18:00 #7776 - Quantifying expert versus novice skill to intubate with McGrath video laryngoscope in prehospital setting.
Quantifying expert versus novice skill to intubate with McGrath video laryngoscope in prehospital setting.

Introduction:

Several controlled clinical trials showed McGrathâ video laryngoscope (McG) utility in operating room, but this has not been evaluated in pre-hospital setting. Tracheal intubation in pre-hospital setting is considered as more complicated than in-hospital one, due to operating conditions (cervical spine immobilization, trapped victims, poor patient positioning...), non-fasting patients and operator’s isolation. One other factor is the few number of tracheal intubations (4.5% of patients in our area), less than once a month per operator. The objective of this study was to compare expert (certified registered nurse anesthetists and physicians with more than 2 years of experience in prehospital setting) versus novice operators’ skills to intubate with the McG.

Material and Methods:

A group of 22 expert and 7 novice operators were recruited; they each performed one direct laryngoscopy (DL) with a Macintosh blade followed by a series of 5 McG in two different scenarios with an adult manikin model: easy airway and difficult airway (immobilized cervical spine) management and one scenario with a pediatric manikin.

Collected data were socio-demographic data and mean intubation time (IT) per procedure. Data were described as means and percentages, Wilcoxon test was used to compare the training effect for each group, with a threshold for statistical significance of 5%.

Results:

Novices were younger (mean age 31 years old versus 44 for experts (p<10-3) and more often women (85% versus 41% (p=0.05).

In adult easy airway management scenario, when using DL, mean IT was twice longer with novices (35.28 sec) compared with experts (17.77 sec), p=0.01. Novices could perform intubation faster than experts at first McG attempt, but IT was similar for both groups at 5th attempt.

In adult difficult airway management scenario, experts intubated faster than novices with DL (41.27 sec versus 68.14 sec), as well as with McG: at first attempt (64.23sec versus 82.14 sec), with a significant difference at 4th attempt (p=0.025).

Use of McG delayed intubation time for experts compared with DL in both airway management scenarios and only in the difficult scenario for novices. There was a reduced time delay of 5 sec in the easy airway management scenario for novice.

In pediatric manikin scenario, there was no difference between the two groups whether with LD or with McG. Use of McG allowed a gain of more than 1 minute for both groups.

 

Conclusion :

Experts intubated faster than novices and the results showed no time gain with McG when performed on adult manikins. However, in pediatric manikin scenario there is a real time gain for all operators, this might be due to the low number of pediatric interventions in this prehospital department.


Margot CASSUTO (Garches), Armelle SEVERIN, Anna OZGULER, Michel BAER, Thomas LOEB
11:00 - 18:00 #8096 - Rapid sequence intubation (RSI): reality in two urban universitary hospitals in Santiago de Chile.
Rapid sequence intubation (RSI): reality in two urban universitary hospitals in Santiago de Chile.

Objectives

1)   To describe the prefered premedication drugs, sedatives, neuromuscular blockages and their doses for RSI in different clinal scenarios.

2)   To assess the association between any selected RSI drug protocol and their effectiveness in terms of laringoscopy’s attempts and use of bougie.

Methods

We conducted a propective observational study in two urban university hospitals in Chile. Both centers receive 55.000 and 146.000 Emergency Department (ED) visits per year. A convience sample of consecutive adult patients requiring RSI in the ED during one year were included. Data regarding the estimated patient weight, selected sedatives, neuromuscular blockers, use of premedication, their doses, number of attempted laringoscopies and the use of bougie were collected. All data was collected prospectively in an electronic database. 

Results

Hundred and seventy six patients were included. The mean age was 59 years old. The reasons for intubation were need for airway protection (44,8%), respiratory failure (27,8%), rapid clinical deterioration (18,1%) and need for emergency procedure (9%).

Sixty three percent of the patients received succinilcholine as paralitic agent and a 35,8% received rocuronium.

A 33,5% were suspected to have an ongoing neurological emergency. Of these patients, the 64,4% received fentanyl as a premedication drug as compared to a 20,5% of patients without a neurological emergency (p<0,001) and a 2% received lidocaine. The most frequently used sedatives in neurological emergencies were etomidate (59,3%) and propofol (39%). Most neurological patients were paralized with succinilcholine (71,2%) and rocuronium (28,8%).

Emergency physicians identified 29,5% of patients with shock. All of them received volumen and 53,8% also received pressors pre-intubation. Half of these patients were sedated with etomidate, while a 48,1% received ketamine. As compared to patients without shock, were 86% received etomidate and 10,4% received ketamine (P<0.05). Fifty seven percent of patients received succinilcholine and the remainder 42,3% received rocuronium.

The dose of succinilcholine used in patients that were determined to be hemodinamically unstable was significantly higher than the dose used in those patients without hemodinamical instability (1,7 mg/Kg v/s 1,54 mg/Kg; p0,02). No other dose differences were found  to be statistically significant for etomidate, ketamine, propofol or rocuronium.

In the whole cohort, a mean of 1,3 laringoscopy attemps were necesary for succesfull intubation [1-6]. There was no difference  in laryngoscopy attemps between the use of succinolcholine or rocuronium. The use of bougie was neccesary in 27,6% of the succinilcholine intubations and in 30% of rocuronium intubations (p>0.05).

Conclusions

Even though both hospitals have a great variety of sedatives and paralitics available in the ED, the most frequently used drugs were etomidate and succinilcholine regardless of the clinical scenario. Interestingly, we found a tendency to use higher doses of paralitics and lower doses of sedatives in patients with hemodinamic instability as sugested by international guidelines.


Ludwig VON PLESSING (Santiago, Chile), Barbara LARA, Carlos BASAURE VERDEJO
11:00 - 18:00 #8104 - Rare case of Brucellosis In A 3 months Old Infant Transmitted By Breast Milk.
Rare case of Brucellosis In A 3 months Old Infant Transmitted By Breast Milk.

Introduction:

 

Brucellosis is the most common zoonotic disease worldwide. Infection can be transmitted to humans through direct contact with infected animals or their secretions or products of conception, and through consumption of potentially infected milk, milk products, or infected meat1.

Human-to-human transmission is rare & due to blood transfusion, tissue transplantation. It has been reported in pregnant women and may lead to spontaneous abortion, intrauterine fetal death or delivery of infected neonates. Neonatal infection can be acquired trans-placentally,during delivery and rarely through breast milk.2

 

Methods:

 

We present a case of a 3 months old infant who was diagnosed with Brucellosis, probably transmitted through breast feeding.

 

Case:

 

3 months old infant, previously healthy, presented to Pediatric Emergency at Hamad General Hospital with fever for two weeks and vomiting for three days. She was full term, delivered via normal vaginal delivery & on breast feeding. No cough/ URTI symptoms/ diarrhea.

On examination, she was febrile temperature 38C, mildly dehydrated, tachypnic respiratory rate 40/min, BP: 90/60, HRP122/minute, oxygen saturation 98% on room air. Normal throat exam. Chest was clear, cardiovascular examination with normal S1S2. Abdomen was soft, lax, no organomegaly.No skin rashes.No meningeal signs. Initial assessment was Pyrexia of Unknown Origin.

Laboratory findings: WBC 8.1X 103(neutrophils 44.2%) Hg 12.3g/dL, Renal function Test, serum electrolytes & urine analysis were normal.Patient was admitted to hospital, septic workup sent & started on empirical antibiotic (IV Ceftriaxone) and IV fluids.Later Blood culture was positive for gram negative cocco-bacilli (Brucella species).

Her mother had history of ingestion of unpasteurized camel milk, 9 months ago in Mauritania,and was asymptomatic. Serum agglutination test done to the patient was positive for Brucella Melitensis, titers (1:1280).

Accordingly,intravenous Rifampicin and Trimethoprim–Sulphamethoxazol (Bactrim) were started for five days then shifted to oral Bactrim and Rifampicin for two weeks.She responded well to treatment and was discharged home in good condition after couple of days.

Her mother was consulted & educated. Serology done to her which was positive & was treated accordingly.

 

Discussion & Conclusion:

 

The patient has most probably acquired Brucellosis through breast milk. Emergency physicians should be alerted to the disease in endemic areas and to this rare route of transmission. Detailed history & physical examination is mandatory.Symptoms, signs, and first-line laboratory findings are often non specific.2

Accordingly, Blood culture & serum agglutination tests should be performed in any child with prolonged fever, especially in endemic areas. The serum agglutination test remains the most popular diagnostic tool for brucellosis. Titers greater than 1:160 are considered diagnostic in conjunction with a characteristic clinical presentation.

Treatment is effective, but disease prevention is crucial. We emphasize that the eradication of Brucellosis can be achieved by aggressive preventive measurements,including elimination of the vector & infected animals,vaccination of newborn animals,education of families, and enforcement of control measures.1

 

Acknowledgment:

 

The authors declare no conflict of interest

References

1.Ruben, B., Band, J.D., Wong, P., Colville, J. Person-to-person transmission of Brucella melitensis.Lancet. 1991;337:14–15.

2.Lubani, M., Sharda, D., Helin, I. Probable transmission of brucellosis from breast milk to a newborn.Trop Geogr Med. 1988;40:151–152.

 


Soumaya BENSLIMAN (Doha, Qatar), Lubna Ghali Amin ANDRAOUS
11:00 - 18:00 #7228 - Rare cause of chest pain.
Rare cause of chest pain.

Introduction: Chest pain is a common symptom in patients who visit Emergency Departments. The main work is to exclude the life-threatening diseases: acute coronary syndrome, pulmonary embolization and dissection of the thoracic aorta. The diagnostic algorithms target to confirm or to reject the possibility of these illnesses but to keep in mind that many less common but dangerous diseases may cause chest pain.

Case report: An 80- year old man with dyspnea and intense chest pain for seven hours was admitted to our emergency department. The patient had no other symptoms. In his past medical history there are suspected prostatic cancer, hypertonia and cataract. Physical examination did not reveal any abnormalities however the blood pressure of the patient was 190/100 Hgmm. 12- lead ECG showed Right Tawara bundle bunch block (RBBB) with secunder ST-T alterations. Chest X-ray showed only minor alterations and the cardiac necroenzymes were insignificant. The patient had impaired renal function (eGFR: 46 ml/min/1.73 m2) and elevated D-Dimer (2.7 µg/ml) level. Pulmonary embolization and aortic dissection were mainly suspected. We performed a chest computer tomography (CT) scan and interestingly we found that the patient’s stomach was placed in the mediastinum. The patient had an urgent Nissen laparoscopic funduplication and he was emitted home.

Discussion: The cause of chest pain was hiatus hernia in this case. Chest pain is a serious problem as cardiovascular diseases are on the top of mortality statistics but sometimes less common causes should be considered.  


Bodócsi BEÁTA (Szeged, Hungary), Koncz ISTVÁN, Hum ZSIGMOND, Serfőző ORSOLYA, Pap-Szekeres JÓZSEF, Szabó ISTVÁN
11:00 - 18:00 #7112 - Rash as a manifestation of secondary LUES.
Rash as a manifestation of secondary LUES.

Case Report

22 year old male drinker weekend, stable partner.He came to the emergency box generalized rash for 4 days with musculoskeletal pain, fatigue, feeling feverish not have measurable and some vomiting at night; concerned that your partner has similar symptoms

Browse:

Upon arrival to the emergency department presents a blood pressure 110/63. Heart rate 76 beats per minute (bpm) and temperature 37.5 ° C.

The skin presents small lesions, large raised without vesicles, erythematous, pruritic spread widely, striking vasculitic lesions on palms and soles.

Investigations:

Chest x-ray: No pictures of pneumonic infiltrates are seen.

Blood test: 13.92 leukocytes with 75% neutrophils, creatinine 0.79, normal liver profile and PCR 56

Evolution:

The case was discussed with the attending physician for review at outpatient clinics of infectious diseases, analytical control is requested with liver maracadores and HIV and Syphilis serology and subject to revision in consultation and treatment Rickttsia empirically with doxycycline dose is established 100 mg every 12 hours

In this analytical 1/64 RPR positive, total antibody positive Syphilis, Syphilis Elisa IgM positive, negative rest appear.

Definitive treatment is started with Benzathine Penicillin 2.4 mill units a week for three weeks.

Conclusions:

Think of sexually transmitted infections in febrile rash in susceptible people risk sex


Manuel AGUILAR CASAS, María Victoria ALARCÓN MORALES (BCN, Spain), José Ignacio VALERO ROLDÁN
11:00 - 18:00 #7178 - Re-audit: are dipstick positive urinary tract infections managed appropriately in the Emergency Department?
Re-audit: are dipstick positive urinary tract infections managed appropriately in the Emergency Department?

A urinary tract infection (UTI) is defined as the presence of symptoms and significant bacteriuria (105 colony-forming units per millilitre) along the urinary tract.  It accounts for 1-3% of UK consultations in the Emergency Department (ED).  An initial audit of the management of UTIs in the ED of Ealing Hospital, London UK, was undertaken in September 2015.  It revealed that 94% of UTIs were diagnosed correctly; 56% of UTIs were managed according to National Institute for Health and Care Excellence (NICE) guidelines on antimicrobial prescribing; while all catheterised patients were managed incorrectly in terms of urine dipstick, culture and sensitivity.  A re-audit was undertaken 6 months later in March 2016 after presenting findings and holding departmental educational sessions.

The aims were as follows: (I) To ensure antimicrobial prescribing for UTI’s in the ED complies with national guidelines.  (II) If deviating from the guideline, ensure there is adequate documentation explaining the rationale for choosing an alternative antimicrobial.  (III) Ensure adequate knowledge of diagnosing and managing UTIs in catheterised patients.

50 symptomatic patients with dipstick positive urine were retrospectively re-audited.  The Symphony patient database was searched.  Standards were adapted from the Royal College of Pathologists Medical Microbiology audit template and divided into five standards: (I) management of UTIs follows national guidelines on antimicrobial and treatment duration; (II) valid explanation provided if clinician deviated from guidelines by choosing an alternative antimicrobial; (III) use of Nitrofurantoin in renal impairment (eGFR <45); (IV) correct utilisation of urine culture and sensitivity; (V) management of catheterised patients – dipstick testing not indicated and urine cultured only when clinically septic.  The audit target was >95%.

Results are presented below with the first cycle audit findings in parentheses.  Symptomatic bacteriuria with positive dipstick treated with an antimicrobial compliant with national guidelines: 72% (56%).  Valid justification for deviating from guidelines: 55% (27%).  Nitrofurantoin prescribed when eGFR>45: 98% (98%).  Urine culture sent only when clinically indicated: 100% (94%).  If catheterised; not given antimicrobial prophylaxis: 100% (83%); urine not dipsticked: 25% (0%); urine not cultured unless septic: 63% (0%).

In conclusion, educational sessions have vastly improved outcomes; decreasing risk to patients by improving alignment with established standards of care.  The greatest improvement is documenting the rationale for choosing an antimicrobial when deviating from guidelines; co-infection (chest and urosepsis) is the sole reason for this.  All culture samples were sent correctly when clinically indicated, highlighting another improvement following educational sessions with the multidisciplinary team.  Similarly, staff are now sending urine for culture in catheterised patients only when septic (an improvement of 63%).  However, some pertinent errors from the initial audit remain; pertaining to managing UTIs in the catheterised patient.  Only 25% of catheterised patients correctly did not have their urine dipsticked as staff members often manage the patient as they would manage non-catheterised patients.  Furthermore, 37% of catheterised patients had urine cultured when aseptic.  Further multidisciplinary education and the production of a UTI management pathway for the ED are in progress in order to further improve outcomes, particularly in the catheterised patient group.


Kabir SANDHU (London, United Kingdom), Fiona WISNIACKI
11:00 - 18:00 #8055 - Really Big Data - developing and implementing a common data set to understand Urgent and Emergency Care in the UK.
Really Big Data - developing and implementing a common data set to understand Urgent and Emergency Care in the UK.

In the UK there are approximately 25 million episodes of urgent and emergency patient care each year delivered in institutions, together with nearly 10 million ambulance calls.

The ‘Accident and Emergency Commissioning Data Set’ currently used in various forms in England, Scotland, Wales and Northern Ireland was designed in the 1970s. While appropriate for its time, this data set has not evolved to keep pace with practice in Emergency Medicine. This has resulted in an information gap between perception and practice, as well as poor communication regarding patient care. For example, there is a meaningful ‘reason for attendance’ for less than 5% of attendances, and a meaningful diagnosis for less than 40% of all patients.

The decision to to develop a new data set to inform patient care, policy and commissioning of services was lead by the Royal College of Emergency Medicine (RCEM) and has resulted in a broad coalition between politicians, the NHS, informatics professionals and IT providers.

After much development work and consultation, a data set has evolved that will cover not just Emergency Department use but (with some customisation) also minor injuries units, walk-in centre and urgent care centres, and ambulatory care. Work is being undertaken to harmonise the data set with ambulance data so that the patient journey and outcomes may be better understood.

The Emergency Care Data Set project started in February 2015, is being piloted in 2016 with a full implementation from 2017.

The development and some of the challenges encountered will be described.

The project has incorporated European standards e.g. for injury data collection and it is hoped that this project will help establish the foundations for a European data standard for emergency care.


Thomas HUGHES (Oxford, United Kingdom), Aaron HAILE, Gordon MILES, Clifford MANN, Jonathan BENGER
11:00 - 18:00 #7761 - Reapprasal of the tourniquet in severe trauma patients.
Reapprasal of the tourniquet in severe trauma patients.

In the civil setting, the use of tourniquets is currently not endorsed by European practice guidelines for the initial management of trauma victims with severed or severely injured limbs. In an military setting however, its use is considered standard of care. By simply applying a constricting or compressing device, specifically a bandage, temporary control of severe venous and arterial bleeding can be achieved in a timely and simple manner. The main reason of its reluctant use in the civil context is the fear of eventual nerve lesions, pain, etc. Furthermore, alternative methods to control major bleedings like haemostatic bandages further make its use less frequent. The terrorist attacks in Brussels airport on March 22nd 2016 demonstrated in a very painful way the potential benefits of tourniquets. By mere chance, due to the presence of soldiers on site, Combat Application Tourniquets® (CATs) were applied to injured casualties with extensive limb injury. We hypothesize that the use of tourniquets can mitigate the detrimental outcome in trauma victims suffering from catastrophic bleeding. To evaluate this, we propose a retrospective analysis by means of a questionnaire of the severely injured of Brussels airport.


Tom VAN WAELEM, Wim RAEYMAEKERS (Brussels, Belgium), Nick VERMEERSCH
11:00 - 18:00 #7684 - Reasons for attending emergency departments - a survey of 2.010 walk-in patients.
Reasons for attending emergency departments - a survey of 2.010 walk-in patients.

Background: Internationally, the number of patients in emergency departments (EDs) is steadily increasing. In Germany the reasons for walk-in patients to seek medical aid in EDs are not well examined and predominantly based on assumptions so far. Focussing on the patient´s view, we here present data of a survey among walk-in patients of two high level EDs in Berlin, Germany.

Methods: In 2015 during a period of four weeks, 2.010 walk-in patients were anonymously surveyed in two high level EDs (each approx. 60.000 ED visits p.a.) located in different catchment areas of Berlin. A standardized questionnaire and descriptive statistics for data analysis were used.   

Results: More than 90% of patients assessed themselves as an emergency. They classified their subjective feeling of “urgency” and thus, the need to be seen by an ED physician as follows: Immediately (25%), emergent (27%, “as quick as possible”), urgent (38%, “must be seen today”), less-urgent (9%, e.g. “someone else sent me”), non-urgent (1%). Three quarter of patients indicated pain. The level of pain correlated significantly to the patients subjective view of urgency. The majority of patients (57%) who attended during regular working hours tried to contact statutory health insurance (SHI) office- based physicians in advance. 59 % of patients would make use of ambulatory emergency facilities if they were available and well established. However, 55% of patients had been unaware of the (mobile) emergency service of the association of SHI physicians. 

Conclusion: The results indicate that (1) more than 90% of walk-in patients visiting the two EDs classified themselves to be an “emergency” and (2) centralized ambulatory emergency facilities should be available 24/7 closely related to hospitals with EDs. Therefore, the future planning of emergency services should integrate providers of the ambulatory and inpatient sector. International experience suggests that different instruments aiming at better coordination of care, such as integrated call centres, extended ambulatory services and facilities for less urgent cases within or nearby hospitals should also be implemented in Germany.

 

All authors contributed equally


Rajan SOMASUNDARAM (Berlin, Germany), Alexander GEISSLER, Bernd A. LEIDEL, Christian WREDE
11:00 - 18:00 #7700 - Recognition and initial treatment of intracranial hypertension by pediatricians in Spain. An advanced simulation observational study.
Recognition and initial treatment of intracranial hypertension by pediatricians in Spain. An advanced simulation observational study.

Background and objectives: Primary Care Pediatricians (PCP) use to be familiar with a wide range of children’s health-related problems, but rarely face emergency situations. Little is known about the PCP’s actual skills to adequately manage acute critical events; some evidences obtained in simulated scenarios indicate that they have diagnostic abilities but lack some practical skills. Acute intracranial hypertension (ICH) is not frequently seen in the out-of-hospital environment. However, a variety of diseases like brain tumors, brain trauma, non-traumatic intra cerebral hemorrhage, ischemic stroke, hydrocephalus and idiopathic ICH may cause acute ICH, a fact that emphasizes the need for adequate recognition and management of such events by Pediatricians.

Material and Methods: We systematically reviewed ICH simulated scenarios during advanced simulation courses designed for pediatricians in Spain. The assessment was based on a previously defined sequence of tasks (technical and non-technical), from diagnosis to initial treatment, stabilization and preparation for transport.

Results: A total of 27 scenarios from 21 courses, with the participation of 95 pediatricians were assessed. Suspicion of acute ICH was correctly done in 85% of scenarios after a median time of 7.5 minutes. Osmolar therapy was started in 78% and bag-mask hyperventilation was done in 63%. The patient’s head was elevated in 41% and sedatives were administered in 11%. Median time to ask for a brain imaging was 8.5 minutes and to contact neurosurgery was 12 minutes. The evaluation of non-technical skills showed that in 12 of 27 scenarios this aspect was poor.

Conclusions: Primary care pediatricians are able to identify an acute ICH, but need to improve their treatment skills. Systematic analysis of professional’s performance during a simulated scenario permits to detect both strengths and weakness; these evidences should be used to improve training programs. Our study has some limitations that should be considered to contextualize the results and designing future studies. The study was retrospective and analyzed sample was limited to PCP, a specific group of pediatricians working out-of-hospital; therefore, the results cannot be extrapolated to other hospital pediatricians that should be more familiarized with this kind of neurologic complication.


Luis SANCHEZ SANTOS (Santiago de Compostela (A Coruña), Spain), Antonio RODRIGUEZ NUÑEZ, Manuel FERNANDEZ SANMARTIN, Ignacio OULEGO ERROZ, Antonio IGLESIAS VAZQUEZ
11:00 - 18:00 #7749 - Recurrent headache, it is not always a trivial cause for Emergencies.
Recurrent headache, it is not always a trivial cause for Emergencies.

Young patient being treated at the Health Care center becasuse of a headache 15 days of evolution, the patient went three times by same cause with no apparent reason that justified it.

 

Clinic History:

Patient 21 years of age born in Argentina, with a history of hemolytic uremic syndrome when he was 7 years old. No other background information significant. He Has 15 days of whole head intense headache, that does not yield to analgesics. On the last visit he went to the emergency room with headache, dizzying. We decided to make a blodd analyse and we can see hemoglobin 5g / dl with platelets 25 x10e9 and other normal figures.

With these findings and with this clinical neurological findings TAC is done and it observe an extensive bleeding right temporo occipital with no evidence of aneurysm or venous malformation.

We consult with neurosurgery rejecting intervention and subsequently cause microangiopathic was discarded in the emergency department.

He was valued for neurology to study him and stabilization of the current situation. After 2 days the patient is diagnosed of Paroxysmal Nocturnal Hemoglobinuria (PNH), responsible of the pancytopenia and the hemorrhagic / thrombotic causes.

 

CONCLUSIONS:

Patients who come to the Health Care Center and the Emergency room with severe headaches require a total physical examination with a complete history. This patient with extreme pancytopenia and neurological clinic raises the differential diagnosis with hemorrhagic / thrombotic causes. PNH present complications as thrombotic in atypical location, and the possibility of hemorragia, caused of the aplasias that PNH can develop.


Veronica PARENT MATHIAS (MALAGA, Spain), Maria Del Mar BECERRA MAYOR, Lorea DE UNAMUNO LUMBRERAS, Juan Manuel GARCIA LOPEZ
11:00 - 18:00 #6481 - Reduced Admission Process Times by Direct Admission of Cardiology Patients at the Emergency Department.
Reduced Admission Process Times by Direct Admission of Cardiology Patients at the Emergency Department.

Introduction:

Prolonged waiting times are common in Emergency Departments (ED) worldwide. Traditionally, patients presenting with cardiac complaints to ED at Singapore General Hospital (SGH) were seen by ED physician and then wait for review by on-call cardiologist before admission. The objective was to improve the admission process and evaluate the effect of a new direct admission pathway on ED admission process times.

Methods:

A joint ED-Cardiology workgroup proposed and implemented a direct admissions pathway. ED specialists were empowered to decide direct admission for stable cases of angina pectoris, heart failure and arrhythmias. But for cases needing a High Dependency or ICU bed, the ED doctor would consult cardiologist on-call to get a bed. Data before implementation (Indirect Admission) was collected from 16 Aug 2014 to 14 Sept 2014 (29 days) and after implementation (Direct Admission) from 15 Sept2014 to 16 Oct 2014 (32 days).

Results:

There were 302 cases in Indirect and 303 cases Direct Admission period. The median ED arrival to disposition time decreased significantly from 221 mins (interquartile range [IQR] = 147–308mins) in the Indirect Admission period to 132 mins (IQR = 78–187mins) in the Direct Admission period (p < 0.001). Also, the median time to duration of stay in DEM decreased significantly from 365 mins (IQR = 244–478minutes) to 262 mins (IQR = 186–337; p = 0.001).

 Conclusion:

There was significant reduction in ED arrival to disposition times as well as reduced ED length of stay after implementation of Direct Admission to cardiology in tertiary teaching hospital. It also led to reduce the problem of overcrowding of the patients in the ED to a significant extent and thus reduce the number of adverse events of ED patients due to prolonged waiting times.


Sohil POTHIAWALA (Singapore, Singapore), Swee Han LIM, Paul LIM, Aaron WONG, Evelyn WONG, Marcus ONG
11:00 - 18:00 #7363 - Reduction in Emergency Department Visits after Implementing a Care Plan in Patients with Drug Seeking Behavior: Five Year Analysis.
Reduction in Emergency Department Visits after Implementing a Care Plan in Patients with Drug Seeking Behavior: Five Year Analysis.

Study objectives: Patients with drug seeking behavior can be both labor and resource intensive to the emergency department.  We determined the change in number of Emergency Department (ED) visits for five consecutive years following a care plan initiation for individuals who displayed drug seeking behavior.

 

Methods: A retrospective, cohort observational study.  Location: a suburban teaching hospital with an annual census of 85,000 patients.  A care plan was initiated for patients flagged by ED staff as concerning for drug seeking behavior.  An ED administrator then collaborated with the patient’s primary doctor regarding their concerns.  If the primary doctor concurred, a plan of care was initiated, which typically restricted narcotic administration.  Patients subsequently received a certified letter regarding their plan.  Copies of the letters were placed alphabetically by name in binders residing in the ED, and charts were flagged when patients presented to the ED.  The first 20 patients in each of 3 binders were included in the study population (N=60).  The numbers of ED Visits were determined one year prior, and for the five subsequent years following care plan, based on letter posting date.  Exclusion criteria: unclaimed letter, incomplete data, or non-drug seeking care plan. Statistics: Two-tailed Wilcoxon signed-rank test with significance of p<0.05.  This study was approved by our IRB.

 

Results:  Sixty patients were analyzed.  Exclusion criteria: incomplete data (N=3), did not receive letter (N=2), and non-drug seeking care plan (N=3).  This left 52 patients for analysis. Mean age was 38 years, (IQR-27-46 yrs).  Male gender comprised 48% of sample population.  Overall, there were 425 visits for study patients the first year and 26 during the fifth year. Mean yearly ED visits prior to care plan initiation were 8.2 (95% CI 6.7-9.7).  Mean visits following implementation of care plan were: one year, 2.5 (95% CI 1.6-3.3); two years, 1.5 (95% CI 0.9-2.2); three years, 1.1 (95 % CI 0.2-2.0); four years, 0.8 (95% CI 0.4-1.3); five years, 0.5 (95% CI 0.2-0.8) (p=<0.0001).  The mean reduction of visits 1 year following implementation was 5.3 (p=<0.0001).  The five year reduction in visits was by 7.7 (p=<0.0001).   A significant reduction in visits occurred between one year and two years following implementation with a mean reduction of 0.9 (p=0.01) and between two years and three years with a mean reduction of 0.4 (p=0.02).  There was no significant reduction in number of visits from three to four years with a mean reduction of 0.3 (p=0.88), or four to five years with a mean reduction of 0.3 (p=0.14).

 

Conclusion:  Care plans are effective as a long-term means of reducing ED visits in patients with drug seeking behavior.  ED visits were significantly decreased up to three years following care plan initiation. 


Fred FIESSELER, Renee RIGGS (New Brunswick, USA), Dave SALO, Brian WALSH, Paul SZUCS, Kj RAPP
11:00 - 18:00 #7612 - Rehospitalization decrease with intravenous isosorbide dinitrate in acute decompensated heart failure.
Rehospitalization decrease with intravenous isosorbide dinitrate in acute decompensated heart failure.

Rehospitalization decrease with intravenous isosorbide dinitrate in acute decompensated heart failure

 

Background and aims:

According to new recommendations on management of acute decompensated heart failure (ADHF) in 2015, intravenous vasodilator therapy might be given as an early therapy when systolic blood pressure is normal to high (≥110 mmHg). It was reported that only 29% of patients with ADHF are treated with vasodilators without medical contraindication. In our hospital, the only intravenous vasodilator used is the isosorbide dinitrate (IDN). Study data were analyzed to investigate the effects of IDN on 180-day hospital readmission for ADHF or acute coronary syndrome (ACS), in-hospital mortality, length of stay, intensive care unit (ICU) admission, and ICU length of stay.


Methods:
This is an observational study. CHOV (Centre Hospitalier de l'Ouest vosgien, Lorraine, France) registry data-base was analyzed for this study. All AHF episodes with hospitalization in cardiology or ICU between 01/11/2013 and 01/12/2015 were included. Patients with both ADHF and ACS (troponin I > 0.05 µg/L), low systolic blood pressure (<110mmHg) or patient without admission in emergency department were excluded. Finally, 199 hospitalizations were included in this analysis. Eligible patients were categorized into 2 groups depending on the administration of IDN: IDN group and Without IDN group. Clinical characteristics, medications, and outcomes were obtained from patient-records.

Results:
37 patients were included in the IDN group (18.6%) and 162 patients in the Without IDN group (81.4%). In the IDN group, median time to IDN initiation was 2.1 hours. The IDN group was associated with higher systolic blood pressure (P: 0,0004) and higher proportion of acute pulmonary edema (P<0.0001). There were no statistically significant difference between the both groups for medications. 180-day hospital readmission was lower for patients who were receiving IDN (8.1% vs 22.8%, p: 0,04). Patients who received IDN required more ICU admission than the other patients (54.1% vs 33.3%, p: 0,02). There were no statistically significant difference between both groups for mortality, length of stay and ICU length of stay.

Conclusions:
The administration of IDN was associated with fewer 180-day readmission events for ADHF or ACS. These observational data could be explained by subendomyocardial ischemia caused by elevated ventricular filling pressure and increased systemic vascular resistance. IDN may minimize or prevent the consequences of altered hemodynamics.
Higher ICU admission rate for IDN group could be related to institutional policies requiring vasodilator-treated patients to be admitted to the ICU.
Low guidelines adherence reported and lower rehospitalization rate with DNI observed in this study, call for a change in our current practice.


Jérémy CHAMBORD (La Queue Lez Yvelines), David ATTIVI, Véronique THUUS, Claire ZEGHMOULI, Stéphane GIBAUD
11:00 - 18:00 #7953 - Relationship between professional background and prescription behavior of low molecular weight heparin's.
Relationship between professional background and prescription behavior of low molecular weight heparin's.

INTRODUCTION

Not prescribing LMWH for patients with lower leg immobilization (LLI) and at risk for venous thromboembolic events (VTE) can be life-threatening. The basic speciality of the prescriber influences his or her behaviour when prescribing medication. For crucial medication as VTE profylaxis it is necessary to know the level of this influence. The actual incidence of VTE in patients with LLI is estimated between 5 - 39%.

METHODS

Physicians working in EDs in Belgium were asked about their prescribing behavior and the influence of their professional background on this behavior. The data was gathered using an online questionnaire. Approval was obtained from the ethical committee.

 

RESULTS

75 questionnaires were completed. These physicians, 32% residents and 65.3% attendings, had different backgrounds: surgery (21,3%), internal medecine (8%), anesthesiology (9,3%), emergency medecine (54,7%).  Information of 32 hospitals was collected from which 2 were university teaching hospitals (UH). The most (65) of the inclusions came from hospitals (86,7%) where Dutch was the common language. 76% of the response originated from non-university hospitals (NUH), in which 21% of the responders were residents. In the UH the percentage of residents was 72%, from which 78% came from the emergency medecine program. For the NUH the number of residents from the emergency medicine program was 47%. Of the total number of attendings, 52% were emergency medecine physicians and working in general in NUH (93%).

 

44% would always prescribe LMWH in patients with LLI. This would varies among specialties: surgeons 75%, emergency physicians 29,2%, internal medecine 16,7%, anesthesiologists 71,4%.

96% agree that treatment with LMWH should end with removal of LLI  and 38% are prescribing LMWH for the entire duration of treatment.

 

CONCLUSION

 

The difference seen between surgeons, anesthesiologists and internal medicine  physicians in prescribing behavior was expected but the low prescription rate for the emergency physicians identifies a clear point of focus for education and training. We noticed a higher concentration of attendings in NUH and in those centers guidelines were more commonly available. This difference is possibly created by the young status of the emergency medicine program in Belgium and the fact that there is a selection bias. Only 2 hospitals were university teaching hospitals.

Based on these results, we can conclude that a lot of respondents aren’t familiar with the use of LMWH in the ED even if guidelines are available.

Further research is planned based on these results and an international multi-center study is planned to follow this national enquiry.


Tom SCHMITZ (Humbeek, Belgium), Lien MESTDAGH, Annelies VANDEWEGE, Ives HUBLOUE
11:00 - 18:00 #7965 - Reliability of the FRENCH triage scale.
Reliability of the FRENCH triage scale.

Background: In situations where the demand is notably higher than the available resources, the question of rationing quickly arises. Such conditions imply that not all needs will be satisfied immediately. In an emergency department setting the scarceness of resources can have some tragic consequences for patients. We therefore need to be able to allocate health care resources to those who need to be treated immediately, and delay the treatment of those who can safely wait. Initial subjective evaluation by a fosterling nurse, without a triage tool, have low sensititvy and specificity. No universal triage scale is available to assess for patients acuteness. It is therefore important to develop triage systems that are tailored for their users environment, and then properly evaluate them.

Objective: The aim of our study was to measure the inter-rater and intra-rater reliability of the SFMU (French Society of Emergency Medicine) triage scale, better know as the third version of the FRench Emergency Nurses Classification in Hospital scale (FRENCH v3).

 

Methods: A sample of 16 nurses, working in different emergency settings, from different French cities, were assembled on January 15th 2016. They all received educational material beforehand and attended a 3-hour standardized training session. The FRENCH v3 is a 6 levels triage scale, with a hundred symptoms and modifiers usefull for the triage of pediatric and adult patients. All nurses had to independently assess the same 60 case-scenarios randomly selected among 150 scenarios developed by a panel of experts, based on real-life patients. Inter-rater reliability was evaluated on these 60 case-scenarios. Intra-rater reliability was evaluated by a single nurse, picked at random amoung the original sample two weeks after initial evaluation, and reassessing the same 60 case-scenarios. Inter and intra-rater reliability was measured using a weighted kappa. The numbers of nurses and cases were calculated on the basis of previous versions of FRENCH evaluations. Participants did not receive financial incentives to participate. According to French law, no ethical approval was necessary, but all the participants signed a waiver of consent.

 

Results: Datas from 15 nurses were usable. One third (n=5) graduated from nursing school in the last 10 years, one third (n=5) between 10 and 20 years the last third more than 20 years ago. The majority of the nurses (73%, n=11) received previous training on triage. All of them (100%, n=15) work in their EDs resuscitation room, and 47% (n=7) work also in pre-hospital emergency medicine. The majority (60%, n=9) only received adult patients, as opposed to adult and pediatric. Inter-rater reliability was substantial [K=0.78 (95% CI: 0.71-0.83)]. Intra-rater reliability was almost perfect [K=0.88 (95% CI: 0.80-0.94)]. When comparing the nurses triage to the experts triage, 47 to 56 cases (78%-93%) were correctly triaged. Agreement did not significantly differ with respect to the nurses experience, previous training or work environment.

Conclusion: Our findings demonstrate that FRENCH v3 is a reliable tool to assess triage case-scenarios, developed based on emergency department patients. This new scale should now be evaluated in a real life setting.


Youri YORDANOV (Paris), Guillaume RANCHON, Antoine DUCLOS, Eleonore HERQUELOT, Ceq Group SFMU, Pierre TABOULET, Carlos EL KHOURY
11:00 - 18:00 #7331 - Reliance on Self-reporting of Fever in Emergency Patients Might Miss Severe Illness.
Reliance on Self-reporting of Fever in Emergency Patients Might Miss Severe Illness.

Introduction:

The patients’ medical history, physical examination and vital signs are essential components in the evaluation of emergency patients. However, subjective feeling and self-assessment of patients might differ from the actual health condition. One important example is self-report of fever. Some patients might be feeling feverish, but their temperature is not altered. Conversely, patients not complaining about fever can have an altered temperature.

Studies showed a good accuracy of the subjective feeling towards the actual health condition. Yet, the study population was consisting of young adults with a low rate of comorbidities. Therefore, we set out to determine the accuracy of fever history in an all-comers emergency department (ED) population. Further, we compared outcome of patients who complained about fever with and without altered temperature and patients who denied having fever with and without altered temperature.  

 

Methods:

We acquired data for this prospective consecutive study during 6 weeks at the ED of the University Hospital Basel. All patients were interviewed by medical students, who received training in obtaining systematic histories by the staff physicians of the ED. Students filled in a comprehensive questionnaire regarding the patients’ symptoms and vital sign measurements upon arrival. Altered ear temperature was defined as greater than 38.3°C or lower than 36.0°C according to SIRS criteria. Information on age and outcomes were obtained from the hospital's database.

 

Results:

During 6 weeks, 5634 patients presented to the ED, 4654 patients were enrolled in the study, and in 2348 cases patient’s questionnaire and temperature measurement was fully recorded. 342 of patients reported suffering from fever. In 140 of these patients an altered temperature was detected. Patients reporting fever with an altered temperature were older than patients reporting fever without altered temperature (median age of 54 years vs. 45.8 years respectively). The sensitivity of self-reported fever was 43.6% (95% Confidence Intervall (CI): 38.1% – 49.2%). In the group of patients (2006) not reporting fever, altered temperature could be detected in 181 patients. These patients had a median age of 68 years. In 1825 patients, who “truly” denied fever, median age was 55 years. The negative predictive value was 90.9% (95%CI: 89.6%-92.2%). Patients not reporting fever while having an altered temperature had the highest rate of intensive care unit transfers and in-hospital mortality.

 

Conclusion:

We found a surprisingly low sensitivity of detecting altered temperature in self-reported fever in our cohort. Despite the good negative predictive value, the patient´s denial could lead to missing severe illness.


Alexandra MALINOVSKA (Basel, Switzerland), Christian H. NICKEL, Roland BINGISSER
11:00 - 18:00 #7961 - Relivopan for procedural pain management in children.
Relivopan for procedural pain management in children.

Aim:

The purpose of this study is to assess the efficiency of Relivopan for procedural pain relief in children (3-17y) in the emergency department.

 

Introduction:

Children are a vulnerable segment of the patient population because they are less able to rationalize pain, for this it can be difficult to cope with pain. Adequate pain relief and prevention is important. 1

Relivopan can be used for anxiety and short-term pain relief during a range of procedures. It is an equimolar mixture of nitrous oxide and oxygen (50/50%).2

 

Methods:

Forty-three children were included between July 24th 2015 and April 23th 2016.* Pain scores were obtained using the Wong-Baker faces rating scale or the NRS before and after the procedure. The FLACC scale was used during procedures.

 

Results:

Forty-four children with a mean age of 9y and 6 months received Relivopan for short procedures e.g. facture reduction (n=24), suturing wounds (n=6), joint reposition (n=8) and other procedures (n=6). 66% of the children received pain medication a priori; paracetamol (n=10), paracetamol+NSAID (n=10), paracetamol+opioid (n=3), opioid (n=4), paracetamol+NSAID+opioid (n=2).

In 93% the introduction of Relivopan was successful. In total 86% of the procedures succeeded in the emergency department.  40% of the children experienced no to mild pain (FLACC 1-3) and 40% moderate pain (FLACC 4-6). Severe pain (FLACC 7-10) was reported in 2 cases. In 6 cases (15%) the FLACC score was not reported, but the experience of the child was written down by the nurse after the procedure. Total amnesia for the procedure occurred in 54%. Mild side effects like bad dreams occurred in 3 cases and resolved  rapidly without intervention. 

 

Conclusion:                                                                               

Relivopan seems very helpful and safe in the emergency department for procedural anxiety reduction and mild analgesia without heavy sedation or major side effects. The majority of children experienced no or little pain. Possibly a combination of Relivopan and short term analgesia such as intranasal fentanyl can diminish pain even more.

 

        *      More patients will be included in the following months.

(1)    Manegement of pain in childhood. J. Emily Harrop. Arch Dis Educ Pract Ed 2007.

(2)    Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department. T. Kurien et al.

 


Emily CILIACUS (Eindhoven, The Netherlands), Stacey MANS, Lisette MIGNOT
11:00 - 18:00 #8180 - Renal colic versus appendicitis.
Renal colic versus appendicitis.

Introduction: A patient presented with right sided colicky pain in the flank This case report include a brief review of the literature about appendicolith.

Case report:

Patient female, 23 years-old, cane with 20 hours of colicky pain in the right iliac fossa and right lower lumbar region. The pain was worse on walking. She was apyrexial not There was associated vomiting.

Initial test show Leucocyte count of 11000. Urine has ketones ++++ and blood +++. Though renal colic was the primary differential diagnosis, in the face of findings on physical examination being suggestive of appendicitis a simple abdominal radiography was performed and it two appendicoliths .

Surgeon reports the discovery of two appendicoliths > 1 cm in diameter, which were causing pressure on the right ureter. This was possibly causing blood in urine.

References:

1. Puebla-Maestu et al. Microhematuria secundaria a mucocele y cistoadenoma apendicular. Gastroenterol Hepatol. 2006;29(1):25-8.

2. Aranda-Narváez et al. Empleo, eficacia y repercusión clínica del apoyo radiológico al diagnóstico de la apendicitis aguda. CIR ESP. 2013;91(9):574– 578

3. Hernigoua,B. Condatb, A. Giaouib, A. Charlier. Resolution of appendiceal colic following migration of an appendicolith. Journal of Visceral Surgery (2014) 151, 323—325.


Lupe Del Rocio CORONEL CHUMBI (MURCIA, Spain), Juan Antonio HIDALGO RAMOS, Ashid KODUMAYIL, Juan Orlando LOPEZ OJEDA, Kissy Marlene RUIZ RIVERO, Elisa MENDAZA GOMEZ, Maria Fernanda FALCON REIBAN, Paul ESPINOZA MOSQUERA
11:00 - 18:00 #7696 - Repeated episodes of low back pain in the emergency room, Ewing sarcoma.
Repeated episodes of low back pain in the emergency room, Ewing sarcoma.

23 year old patient with no personal history doctors who came to the emergency for the fourth time within 5 days box pain severe lumbar region radiating to the left thigh of 1 month of evolution that does not improve with morphic, accompanied in the last hours constipation, oligoanuria and loss of feeling in perineum.

Additional tests on admission

Blood tests: 9.4 hemoglobin, hematocrit 29.3, platelets 337,000, 20,300 leukocytes (84% neutrophils), prothrombin time 69% glucose 103 mg / DCL, Urea 41, Creatinine 1.32 mg / DCL, Na 140 mEq / L, K 4,40mEq / L, creatine kinase 68 U / L, lactate dehydrogenase 995 U / L CRP 192 mg / L, Procalcitonin <0.05 ng / mL.

Radiography lumbar and sacral without pathological findings.

Evolution

During admission under observation for pain the patient is evaluated by traumatology, neurology, gynecology and internal medicine with income in the latter. Given the persistence of uncontrolled pain with morphine is performed CT pelvis and thighs objectifying lytic bone lesions in multiple in right and left pubis sacral wing, as well as a great mass of soft tissue in the left quadriceps with poorly defined boundaries, peripheral vascular anarchic with large pockets hypoechoic not FDG uptake by necrosis. Later pathology confirmed Ewing sarcoma left quadriceps with multiple metastatic bone lesions is performed.

The patient began treatment with radiotherapy and chemotherapy with grade 4 hematologic toxicity, being derived to inclusion in palliative care.

 

Conclusion: repeated episodes of low back pain and sciatica in emergencies unrelieved with pain medication should be cause for study.

 

 

 


Rafael INFANTES RAMOS, Maria Eugenia REYES GARCIA (Málaga, Spain), Cristina FERNANDEZ- FIGARES MONTES, Maria Victoria ALARCON MORALES, Ivan VILLAR MENA, Jose Ignacio VALERO ROLDAN
11:00 - 18:00 #7709 - Response of Treatment in Primary Headaches Patients with Arterial Hypertension, a Prospective Observational Pilot Study.
Response of Treatment in Primary Headaches Patients with Arterial Hypertension, a Prospective Observational Pilot Study.

Background: There is a hesitation on the topic that about how can we treat patients which have headache and accompanying complaints of arterial hypertension that admit to emergency services. In which conditions we must decrease arterial hypertension or treat headache primarily? The purpose of this study is to contribute to selecting primary treatment method in patients with primary headaches accompanying arterial hypertension. In our study, we compared if there is any relationship between changes of mean arterial pressure and headache severity after treatment of headache.

Methods: This prospective observational study was carried out with 101 patients that admitted to Kartal Yavuz Selim State Hospital emergency service having had primary headaches accompanying complaints of arterial hypertension between 1 March and 31 May of 2013. All of 101 patients were analyzed that changes of the headache severity, mean arterial pressure and percent reduction in mean arterial pressure after medical treatment of primary headaches. All statistical analysis was recorded in SPSS 19.0 software (SPSS Inc, Chicago, IL, USA) and frequency and descriptive statistics were calculated. The relationship between the reduction of primary headache severity and changes in mean arterial pressure were analyzed via Wilcoxin signed rank test.

Results: On admission, 40 (39,6 %) patients had unbearable, 42 (41,6 %) patients had very miserable and 19 (18,8 %) patients had moderate headache. 44  (43,6 %) of them patients had intravenous metoclopramide, 35 (34,7 %)of them had intravenous nonsteroidal anti-inflammatory drugs and 22 of them (21,8 %) had intramuscular anti-inflammatory drugs treatment methods for primary headaches. After treatment, 25 (24,8 %) of patients headache severity decreased in three levels, 43 (42,6 %) of them decreased in two levels and 23 (22,8 %) of them decreased in one lower level. While at the beginning patients had 118,58 ± 12,65 average of mean arterial pressure after 30 minutes of treatment the average of mean arterial pressure dropped to 98,41 ± 13,43. There is no statistical significance between the patients which have same level or one lower one in their decrease of headaches severity after symptomatic treatment and mean arterial pressure changes (p > 0.05). We found statistical significance between changes of mean arterial pressure and headaches severity in patient which lowered their headaches severity two or three levels (p < 0.001).

Conclusion: This study showed that arterial hypertension accompanied primary headaches should be treated firstly instead of secondary causes treatment of arterial hypertension.  After treatment of primary headaches arterial hypertension is going to decrease with resolving of headache severity.


Abdullah Cüneyt HOCAGİL, Hilal HOCAGİL, Volkan ÜLKER (ISTANBUL, Turkey)
11:00 - 18:00 #8000 - Resuscitation after smoke inhalation with cyanide intoxication: Influence of early administration of hydroxycobalamin on oxygen uptake.
Resuscitation after smoke inhalation with cyanide intoxication: Influence of early administration of hydroxycobalamin on oxygen uptake.

Objective

Toxic smoke inhalation is often combined with intoxication due to both carbonmonoxide (CO) and hydrogen cyanide (HCN) [1]. Resuscitation of fire victims in cardiac arrest may be facilitated by specific antidote treatment [2,3]. We investigated the influence of resuscitation with the antidote hydroxycobalamin on oxygen uptake in cardiac arrest following toxic smoke inhalation an animal model.

Materials and methods

After approval by local authorities and in accordance with German animal protection law an intoxication model for pigs (25-35kg) with anaesthesia, intubation and instrumentation including a pulmonary arterial catheter was used. Smoke intoxication was simulated by controlled ventilation in a closed circuit with: Air with CO=1500ppm (parts per million) over 5 minutes, followed by air with CO=750ppm and HCN=500ppm over 5minutes, followed by air with HCN=1000ppm until cardiac arrest occurred. 5g hydroxycobalamin or placebo were infused and resuscitation was started with 100%oxygen and chest compressions over 10 minutes, followed by standard Advanced Life Support including defibrillation and epinephrine iv. Oxygen uptake (VO2) was calculated before intoxication (baseline) and after antidote-infusion (t=3min and t=9min). Primary endpoint was the change in oxygen uptake compared to baseline within each group (Wilcoxon-test), secondary endpoint was the oxygen uptake at t=3min and t=9min compared between both groups (U-test). Results as median (25/75%percentiles).

Results

Fourteen pigs were included. Hydroxycobalamin (n=7):  VO2 baseline 126(111/152)ml/min; t=3min 182(161/343)ml/min, p=0.016 vs. Baseline; t=9min 174(152/237)ml/min, p=0.016 vs. baseline. Placebo (n=7): VO2 baseline 146(115/221)ml/min, t=3min 132(66/152)ml/min, p=0.07 vs baseline; t=9min 138(59/157)ml/min, p=0.16 vs baseline. VO2 hydroxycobalamin vs. placebo: Baseline p=0.62; t=3min p=0.027; t=9min p=0.073 .

Return of spontaneous circulation was achieved in 12/14 pigs (5 hydroxycobalamin, 5 placebo)

Conclusions

Early administration of hydroxycobalamin during resuscitation improved oxygen uptake in this smoke inhalation model. We assume that this is a direct sign of recovery of cellular respiration from HCN intoxication.  Further investigations are needed to investigate the effects on tissue damage by this treatment.

References

[1]Postgrad Med. 1987;82(1):63-8; [2]Eur J Emerg Med 2013;20(1):2-9; [3]Fire Technology 1972;8(2):120-30


Jost BEELITZ, Wolfgang DERSCH, Clemens KILL (Essen, Germany), Nina VOGT, Florian VEIT, Hinnerk WULF, Carsten FELDMANN
11:00 - 18:00 #6313 - Return of spontaneous circulation (ROSC) from release of auto-PEEP.
Return of spontaneous circulation (ROSC) from release of auto-PEEP.

The Lazarus phenomenon is defined as the delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR). Because factors such as auto-PEEP play a role and cause of death is usually found postmortem, it is difficult to make an exact diagnosis at the time of arrest. A simple, non-invasive method such as discontinuing manual ventilation can correct hypotension or electromechanical dissociation (EMD) associated with hyperinflation of lungs from discrepancy between exhalation and inspiration. We report a 77 year old woman who suffered from cardiac arrest suspected of auto-PEEP (positive end expiratory pressure) from improper manual ventilation during transfer from the ICU to the OR but was resuscitated when ventilation was ceased by releasing intrathoracic pressure. Education for understanding the physiology of this phenomenon and recognizing it when it occurs is needed.


Ann YOUN (Daejon, Korea)
11:00 - 18:00 #7996 - Revalidation in the UK 4 years down the line.Lessons learned?
Revalidation in the UK 4 years down the line.Lessons learned?

Revalidation of doctors started in the UK in 2012 after it became legislation and thereby mandatory for all doctors to engage in. We presented some data and interesting discussion point in 2014 when the process was 2 years old and in its infancy. At that juncture the process was still in its infancy and maturing. Currently 4 years down the line we will aim to discuss how this process has matured and how it has led to better governance of the medical profession in the UK. We will also discuss some of the innovative ways appraisals are evolving and how it pertains to UK trained and registered doctors practicing medicine overseas.


Omar GHAZANFAR (Abu Dhabi, United Arab Emirates)
11:00 - 18:00 #6212 - Reversible Cerebral Vasoconstriction Syndrome at Emergency Department.
Reversible Cerebral Vasoconstriction Syndrome at Emergency Department.

Object: Reversible cerebral vasospasm syndrome (RCVS) remains an underrated cause of thunderclap headache which shares similar history of the ‘worst-ever’ headache with subarachnoid hemorrhage (SAH) to the emergency physicians. This study evaluated the clinical manifestations, radiological features, and outcomes of patients with RCVS so that the physicians could raise the high index of suspicion to detect RCVS in more patients with thunderclap headache before having life-threatening complications.

Methods: The electric medical records of 18 patients with diagnostic criteria of RCVS at the emergency department (ED) between January 2013 and December 2014 were retrospective reviewed.

Results: The mean age was 50.7 years, and 80% were women. Patients with RCVS visit an average of 4.7 physicians before receiving an accurate diagnosis and mean duration of symptom until diagnosis is 9.3 days. All patients except one experienced severe headache, from 8 to 10 pain intensity on a numerical rating scale (NRS). 44% of patients had nausea as an associated symptom, 66% of patients experienced worsening of headache while gagging, leaning forward, defecating, urinating or having sex. The most frequently affected vessels are middle cerebral arteries demonstrating the characteristic diffuse “string of beads” appearance. 4 patients had SAH as a complication.

Conclusion: Patients with RCVS have a unique set of clinical and imaging features. Emergency physicians should raise the high index of suspicion to detect RCVS in more patients with thunderclap headache before life-threatening complications


Kim TAERIM (Seoul, Korea)
11:00 - 18:00 #7655 - Reversible left bundle-branch block due to carbon monoxide poisoning: a case report.
Reversible left bundle-branch block due to carbon monoxide poisoning: a case report.

Carbon monoxide (CO) is known as a potent poisonous gas. The clinical features of CO poisoning are not specific. Cardiac disorders due to changes in cellular and subcellular levels, cardiomyopathy, angina pectoris, acute myocardial infarction, arrhythmias, heart failure, pulmonary edema, cardiogenic shock, and sudden death may occur. Myocardial damage has been determined as an indicator of increased mortality in patient with CO poisoning in the long term. The electrocardiographic (ECG) changes that may be detected in carbon monoxide intoxication are repolarization disorders, flattening and inversion of T waves, ischemic changes, QT-interval prolongation, P-wave elevation, QRS widening, and new-onset bundle-branch block in 2 consecutive derivations.

With this case, we aimed to present the development of a transient left bundle-branch block due to CO intoxication. The case had no known prior cardiac disorder, and subsequently performed percutaneous transluminal coronary angioplasty revealed normal results.

 A 48-year-old female patient was admitted to our emergency service with complaints of headache, nausea, and somnolence. Her medical history revealed exposure to coal gas of the stove at home for approximately 3 hours. The patient was cooperative and well oriented during her physical examination. Her Glasgow Coma Scale score was 15. Her vital signs were normal. In ECG, which was obtained for assessment of cardiac involvement, left bundle-branch block was present. In workup for blood gases, which was performed with preliminary diagnosis of CO poisoning, carboxyhemoglobin was 14.8% (normal value, 1%-5%); her biochemical laboratory test results revealed troponin I as 0.05 (normal value, < 0.04). Other laboratory test results were within normal limits. She was consulted with the Cardiology Department. In ECG obtained during consultation with Cardiology, normal sinus rhythm was identified The patient whose coronary angiography findings were interpreted as normal and who had no additional complaint during follow-up was discharged from the hospital.

Consequently, our case is the first and only case in whom transient left bundle-branch block had developed due to CO poisoning and this left bundle-branch block was proven to be CO-induced by normal coronary angiography

(This case report is accepted in American Journal of Emergency Medicine with doi number as:10.1016/j.ajem.2015.06.034)

 


Atif BAYRAMOGLU (Erzurum, Turkey), Abdullah Osman KOCAK, Ilker AKBAS, Alpaslan UNLU
11:00 - 18:00 #8125 - Review of cases of patients attended with attempted suicide in the Emergency Service of Barbastro Hospital.
Review of cases of patients attended with attempted suicide in the Emergency Service of Barbastro Hospital.

INTRODUCTION:

Suicide attempts are a diverse pathology in his presentation and potentially serious,1 it is important early medical valuation and stabilization,2 without forgetting the essential psychiatric medical evaluation.3 In peripheral hospitals who do not have medical psychiatrists is essential referral to hospitals with psychiatric services for valuation.

TARGET

Describe the characteristics of patients with suicide attempts, valued at an emergency department of a peripheral hospital that does not have psychiatrist on call.

MATERIALS AND METHOD

It is a Descriptive transversal study of patients with suicide attempts who consulted the emergency department for a period of twelve months (01/01/2015 - 31/12/2015).

After having obtained a sample of 35 patients, it was proceed to a statistics analysis obtained with SPSS.

RESULTS

The average age was 44,9 years, being 66,6% of them woman.

80% of patients who made a suicide attempt was treated with a level of triage III, 46% of patients was treated at the start by a resident in the emergency department, 100% of the attention was supervised by a medical specialist.

53% of patients were transferred to a hospital that had service psychiatry. 27% were referred to Domicile and 20% requested voluntary discharge

CONCLUSION

When making the first assistance to these patients, it is noteworthy that most have a low level of triage (III) and also are valued by medical residents at first, but stresses that 100% are supervised by medical specialists.

The availability of short-stay units (units of 24 hours of observation) with capacity to serve psychiatric patients who have had suicide attempts in peripheral hospitals or have call psychiatrist could help reduce the high number of transfers to other hospitals.

BIBLIOGRAPHY:

  1. Estrategia en salud mental Sistema Nacional de Salud 2009-2013. Madrid: Ministerio de Sanidad, Política Social e Igualdad; 2011.
  2. Chinchilla A, Correas J, Vega M. Manual de urgencias psiquiátricas. Barcelona: Masson; 2003.
  3. American Psychiatric Association. Practice guideline for the Assessment and Treatment of Patients with Suicidal Behaviors: American Pychiatric Association; 2003.

Juan José EITO CUELLO, Ana Graciela MORENO MEJIA (Huesca, Spain), Juan Alberto MAGALLÓN PUY, Francisco FRANCIA FRANCO, Isabel TORRES PEÑA, Beatriz TORIBIO VELAMAZÁN, César GARGALLO BERNAD, Jean Elie MARCELIN
11:00 - 18:00 #7793 - Review of ectopic pregnancies diagnosed by emergency department point-of-care ultrasound.
Review of ectopic pregnancies diagnosed by emergency department point-of-care ultrasound.

Background

Ectopic pregnancy is a high-risk condition that occurs in only 1.9 % of reported pregnancies. However, as high as 20% of pregnant patients presenting to the emergency department with abdominal pain will have ectopic pregnancy (1). Both clinician performed point of care ultrasound (POCUS) performed by emergency physicians or consultative ultrasound by the radiology department (RADUS) has been used in the diagnosis of ectopic pregnancy.

Objective

To assess whether POCUS reduces time to ED disposition (ED LOS), time to operating room (OR), and hospital length of stay (LOS) in ectopic pregnancies.

Method

A retrospective chart review was performed on patients presenting to the ED from January 1, 2014 to August 1, 2015 with a diagnoses of ectopic pregnancy. Patient charts that utilized RADUS were compared to patient charts that used POCUS. The time to disposition, OR, and hospital LOS were reviewed.

Results

From 2014-2015 there were 133 patients diagnosed with ectopic pregnancy. 41% of patients received POCUS, 68% received RADUS, and 12 patients (9%) received both. 92% were admitted and 63 (47%) went to OR. Of the OR patients, 29 had POCUS alone and 5 (8%) had both POCUS and RADUS. On average, ED LOS for POCUS was 300 minutes vs 360 minutes for RADUS (p=0.11); Time to OR for POCUS was 519 minutes vs 545 minutes for RADUS (p=0.78). Hospital LOS was 1.02 days for patients that received POCUS vs 1.13 days for patients that had RADUS (p=0.53). During RADUS hours of operation, 32% had POCUS compared to 74% RADUS. When RADUS was unavailable, 100% had POCUS, but 31% also had RADUS conducted by an on-call technician. Time to OR was 431 minutes when RADUS was unavailable and diagnoses was made by POCUS alone vs 543 minutes in other cases (p=0.48).

Conclusion

POCUS is often used in suspected ectopic pregnancies. Temporal outcomes for diagnosed ectopic pregnancies with POCUS are not inferior to that of RADUS. POCUS may allow for faster decision making and earlier implementation of treatment in patients diagnosed with ectopic pregnancies. 


Gerardo CHIRICOLO, Christopher RAIO (Dix Hills, USA)
11:00 - 18:00 #7492 - REVIEW OF TWO AND A HALF YEARS OF EXPERIENCE IN BEDSIDE ULTRASOUND OF A COLOMBIAN EMERGENCY DEPARTMENT.
REVIEW OF TWO AND A HALF YEARS OF EXPERIENCE IN BEDSIDE ULTRASOUND OF A COLOMBIAN EMERGENCY DEPARTMENT.

BACKGROUND: 

Point-of-care ultrasound (US) has improved the quality and safety of patient care by helping both clinical decision-making and procedural techniques. The Bedside Ultrasound Group of the Emergency Department of Fundacion Cardioinfantil began its activity on October 2013 after an intensive training and certification. We aimed to describe the results of the first 2,5 years of implementation of this technology to our ED.

 

OBJECTIVE: 

To describe the performance of the Bedside Ultrasound Group of the Emergency Department of Fundación Cardioinfantil – Instituto de Cardiología, Bogotá – Colombia after 30 months of activities in terms of number and type of procedures, timing, and success rate in the ultrasound guided procedures and complications.

 

METHODOLOGY: 

We performed a retrospective analytic study of all the ultrasound studies and ultrasound guided procedures performed at the Emergency Department of Fundacion Cardioinfantil Instituto de Cardiologia from October 2013 to March 2016. The reports of the cultrasound assessments done to patients admitted in the ED were reviewed. All the data was extracted from the Bussiness Intelligence Module of AGFA RIS-PACS and the clinical correlation and outcomes from our Electronic Clinical Records System (Servinte Clinical Suite – Carvajal S.A.). All the studies were done with the same ultrasound machine (Sonosite EDGE from Sonosite Inc.)

 

RESULTS: 

A total of 2112 exams were reviewed. In our study we describe the number by type of procedure, the time between the order and when the exam was done, the rate of success in ultrasound guided procedures, and the type and rate of complications.

CONCLUSIONS: 

Among these 30 months the use of point of care ultrasound  has confirmed to be a fundamental tool in the management of our patients, especially in those that require a rapid and correct diagnosis at the time of admission in the Emergency Department, and to safely guide invasive procedures with almost no complications. 

 


Carlos-Hernan CAMARGO-MILA (BOGOTA, Colombia), Gerardo LINARES-MENDOZA, Luis-Arcadio CORTES-PUENTES
11:00 - 18:00 #7431 - Rhabdomyolysis and hematuria associated with the use of simvastatin.
Rhabdomyolysis and hematuria associated with the use of simvastatin.

Male patient of 42 years old with a history of right nephrectomy 16 years ago after congenital anomaly detected by chance after traffic accident, ischemia of left renal artery in 2011 by what was being followed by hypertensive nephropathy of grade IV during 2 years. After all, the hypertension has been well controlled, there is a mild renal impairment , an dyslipidemia and an anxious syndrome with psychiatric treatment. Basal chronic treatment with Omeprazole 20mg, Torasemide 5mg, 10mg Manidipine, Alprazolam 0.25mg, 1mg Trifluoperazine and a combination of Simvastatin and Ezetimibe 20mg to 10mg. Consultation in the emergency room for sudden hematuria without urinary symptoms associated or fever. The only antecedent of interest is the resumption of moderate physical activity in the previous 24 hours. There have been no changes in their usual treatment. There has been no drug use. Up study conducted Cr 1.26mg / dl, urea 36mg / dl, Na 141mEq / L, K 4.4mEq / L and CK 91527. There is a frank hematuria without infectious signs urinals. Blood count and coagulation unchanged. Abdominal ultrasound performed without alterations.Given low probability episode of rhabdomyolysis secondary to exercise described (of mild or very moderate intensity), the study is extended in emergency room for suspected side effects to statins, confirming alteration of transaminases GOT 517 IU / L, GPT 108UI / L, high myoglobinaemia> 1340 ng / mL and confirmation myoglobinuria in urinary sediment. At first the patient experiences a torpid evolution, with low urine output despite fluid infusion and maintenance of high levels of CK during the first 72 hours. After suspension of lipid-lowering therapy and adequacy of fluid therapy is objectively progressive clinical improvement with gradual normalization of biochemical parameters during hospitalization. Conclusion: In daily clinical practice is very common the use of lipid-lowering drugs for secondary prevention of ischemic heart disease. It is known the relationship of statins with the onset of liver damage being widespread monitoring of transaminases and can spend more unnoticed association with myopathies that could condition a myoglobinaemia and myoglobinuria with even fatal renal failure, which should be considered in patients susceptible to renal involvement.


Rocio ESCRICHE, Alicia BAGUENA, Patricia BONED, Teresa DE FERNANDO (ZARAGOZA, Spain), Teresa PARDO, Pilar MIRANDA
11:00 - 18:00 #8060 - RHOMBOENCEPHALITIS: THE IMPORTANCE OF EARLY SUSPICION AND TREATMENT IN EMERGENCY DEPARTMENT.
RHOMBOENCEPHALITIS: THE IMPORTANCE OF EARLY SUSPICION AND TREATMENT IN EMERGENCY DEPARTMENT.

Introduction:

Rhombencephalitis (RE) refers to inflammatory diseases affecting the hindbrain (brainstem and cerebellum) and has a wide range of possible aetiologies: infections, autoimmune diseases and paraneoplastyic syndromes. Signs and symptoms are irritability, myoclonus, ataxia, and cranial nerve involvement. Listeria is the most common cause of infectious RE. An infection by a virus (Enterovirus 71 and herpes simplex virus) is the second most common and important cause of encephalitis, but in 30-50% of them diagnostic is not available. An accurate imaging differential diagnosis is crucial in the management of these patients. MRIs are abnormal in 100% Listeria cases but in the viral causes MRIs are abnormal only in 70% to 75% of patients.

We present two cases of clinical RE probably caused by virus, however an accurate aetiological diagnostic was not possible.

CASE 1:

A 30 years’ woman presenting occipital headache for five days with fever the last 3 days. She experienced from 24 hours’ ataxia and diplopia. Social history revealed she works in paediatric emergency department as epidemiological antecedent. Physical examination reveals diplopia and ataxia. Cerebrospinal fluid (CSF) analysis revealed lymphocytic pleocytosis, negative PCR for Enterovirus, Herpes virus, varicella zoster, virus Epstein-Barr, Listeria monocygotenes and Mycobacterium tuberculosis. CT and brain MRI were unremarkable. Blood and CSF cultures were negative. Initially the patient was treated with ceftriaxone and acyclovir, with full recovery. Final diagnostic of Rhomboencefalitis caused by virus was made at discharge.

 CASE 2:

A 16 years old patient presenting with fever, oral vesicles and odynophagia. One month ago a hand, foot and mouth syndrome was diagnosed in 15 months’ year old brother He had seen his general practitioner (GP), who prescribed amoxycilin-clavulamic for amygdalitis. This failed to relieve his symptoms and in the last 48 hours fell asleep and lethargy with nausea and vomiting.

On examination the patient was comfortable at rest with 37,6ºC. Neurological examination reveals spontaneous and irregular movement of eyes and supranuclear facial paresia. No other alterations were found.

CSF analysis was normal. negative PCR for Enterovirus, Herpes virus, varicela zoster, virus Epstein-Barr, enterovirus, Listeria monocygotenes, Mycobacterium tuberculosis. CT was normal. Brain MRI shows poster-medial lesion over cerebellums pedunculum.

Initial treatment with Ceftriaxone, Acyclovir, Ampicillin and immunoglobulins. Full recovery with   final diagnostic of Rhomboencephalitis caused by virus.

CONCLUSION:

Rhomboencephalitis must be suspected early in the emergency department. MRI findings are in most cases not conclusive for a final diagnosis and may be normal for 49% of patients. Nevertheless, lack of changes on brain MRI, along with possible false-negative CSF viral PCR, could still represent a viral rhomboencephalitis. An accurate clinical examination should allow to detect signs and symptoms of RE. If suspected, we recommend empiric therapy with ampicillin and acyclovir for all cases after samples have been obtained from CSF and blood for cultures and the polymerase chain reaction (PCR). A proper diagnosis is mandatory in order to avoid potentially severe and life threatening complications.


Doina SOLTOIANU (TARRAGONA, Spain), Albert MORENO DESTRUELS, Jesús GÁLVEZ MORA, Gilmar PUGNET, Domingo RIBAS SEGUI, Alexis GUZMAN
11:00 - 18:00 #8086 - Rickettsial Infection : A case report.
Rickettsial Infection : A case report.

Introduction :

 

Rickettsiae are zoonotic infections caused by obligate intracellular bacteria of the genera Rickettsia and Orientia, belonging to the family Rickettsiaceae and transmitted to humans by the bites of arthropods, the number of Rickettsia  species  pathogenic  has increased considerably. In recent years the incidence has increased globally. The clinical presentation is little specific as is the case described below.

 

Case report:

 

A 42-year-old man with no past medical history presented to our emergency department with icterus febrile since one week. The patient also complained of odynophagia, dysphagia, epigastric pain and recurrent episodes of vomiting. On physical examination the patient was conscious, temperature 39.3 °C, mucocutaneous icterus, non extensive non necrotic purpura, conjunctival hyperemia and Sore throat. Abdominal examination revealed mild tenderness over the epigastric region and moderate hepatosplenomegaly. The rest

of physical examination was unremarkable,

 

Laboratory investigation revealed hepatic cytolysis (4 times above normal ), cholestasis, thrombocytopenia 43000 elm/mm3, inflammatory biological syndrome with CRP 114, leukocytosis 18840elm/mm3. Serology for CMV; hepatitis A, B and C; with HIV were negative. An immunological test was negative.

An abdominal ultrasound completed by an abdominal CT showed a homogeneous moderate hepatosplenomegaly.

Ophthalmologic examination showed decrease visual acuity with non granulomatous bilateral panuveitis with retinal vasculitis and retinal necrosis of the posterior pole in favor of rickettsies and leptospirosis.

He was treated with Ampicilline during 10 days then with Levofloxacine during 7days.

 

 

The evolution was marked by the persistence of fever, also to the worsening of cholestasis and cytolysis. 10 day the thrombocytopenia began regress.

 

Serology for rickettsial finally came back positive. The patient was discharged home on hospital day 17, only requiring ocular and paraclinical followup.

 

 

Conclusion:

 

Rickettsies remain little known. They have no pathognomonic signs, although there are signs and symptoms that are highly suggestive, such as the presence of fever, rash, lymphadenopathy, and an eschar (tache noire). Unfortunately not always and not all rickettsies present typical signs and symptoms. In most cases clinical suspicion together with a positive serology is sufficient to make the diagnosis of rickettsiosis. Doxycycline is the drug of choice for all of the known rickettsies.

At present there is no vaccine and the best prevention is using repellents.


Ons ANDOLSI, Mohamed Ali CHERIF, Houcem OUNI (tunis, Tunisia), Khaled SAIDI, Youssef Zied EL HECHMI, Malek HSOUNA, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7048 - Risk management in the Accident and Emergency Department: shall we play?
Risk management in the Accident and Emergency Department: shall we play?

Introduction

How to teach behavioural skills? Even the best presentation is not an effective tool to change our behavior. Talking about behavior can be very difficult in a one-to-one interview and the presence of an observer automatically generates a different behavior.

As a link between defects of communication skills and risks, for professionals and patients, has been proved, couldn’t we find a new way to approach this topic? How could we increase our perception of our own risk generation?

Methods

In group work, we used a module focused on management of aggressiveness, which is a part of a serious game initially designed to teach behaviour and soft skills to reception agents in the hospital. The same questionnaires were submitted to each learner before and after the one-hour session. They included a common part, with analogic scales about risk perception, importance of behavior and importance of induced stress. The means before the session and after the session were compared by using paired sample T-test.

Results

28 medical students were enrolled. 26 completed fully the both questionnaires. We observed a significant increase in levels of risk perception (75.9 vs 70.8/100, p<0.05). A decrease was observed in levels of induced stress and an increase in levels of opinion on impact of the behaviour on the risk. 88% of the participants declared that they will communicate differently after this activity.

Discussion

Serious games have shown their capability to induce behavioural changes and to generate an intrinsic motivation from participants. In fact, the tool used for this activity is more a sort of game-based learning, without a real gameplay. But it acts as a mediator in a reflective activity and helps to generate engagement on this sensitive topic. It can be an interesting perspective when students consider as moderate the capacity of their practical training to prepare them to manage risks.


Sophie MONTAGNON (New York), Ghanima AL DANDACHI, Colombine BONIER, Patrick PLAISANCE
11:00 - 18:00 #7636 - Road Traffic Accident related Fatalities in Addis Ababa City, Addis Ababa, Ethiopia: A one year Analysis of Police Report.
Road Traffic Accident related Fatalities in Addis Ababa City, Addis Ababa, Ethiopia: A one year Analysis of Police Report.

Abstract   

Introduction: Road transportation provides benefits both to nations and to individuals by facilitating the movement of goods and people. It enables increased access for daily living and programs on the country at large. But these increased in access and number of transportation pose a great challenge in the individuals daily activity ranging from minor injury to death and the nation also suffers from lose of productive citizens and economic shift to preventable health activities

Objectives The general objective of the study is to assess the magnitude of and factors contributing to the Mortality related to Road Traffic Accidents in `Addis Ababa, Ethiopia from September 2013 to August 2014.

Methodology Data from the Addis Ababa Police Commission,Traffic Police Department was collected from the checklist used to collect information by the police officer at the scene and the logbook and entered to SPSS version 16.00 and description was performed.

Result Overall, there were 2372 recorded road traffic accidents (excluding accidents with only property damage) in Addis Ababa during 2013/14. Of these, 382(16.1%) were fatal. Among all fatalities majority were male 279(73.03%), Male/Female- 3:1 and pedestrians 321(84.0%). Fatal accidents were more prevalent on isled roads 262(60.7%) and involved especially commercial cars. More than half of fatalities 205(53.8%) occurred due to failure to give a way for pedestrians.

 

Conclusion Majority of affected were vulnerable road users among which pedestrians were predominant and affected while crossing the road outside the zebra cross and responsible parties were driving commercial cars and vast majority of victims died at the scene instantaneously which needs policy on pedestrian safety and education on behavioral change. These findings can serve as a basis for health care professionals and policymakers to create preventive measures for traffic accidents.

Key words:  Road traffic Accident, Mortality, Addis Ababa, Ethiopia


Anteneh KEBEDE, Aklilu AZAZH (Addis Ababa, Ethiopia), Aklilu AZAZH, Haimanot GEREMEW
11:00 - 18:00 #7999 - Safety and Effectiveness of Ultrasound Guided Supraclavicular Nerve Block for Upper Extremity Trauma.
Safety and Effectiveness of Ultrasound Guided Supraclavicular Nerve Block for Upper Extremity Trauma.

Background: Analgesia in acute trauma is notoriously undertreated, as evaluation and resuscitation often take immediate priority. Furthermore, opioid analgesia, although effective, has many detrimental effects including sedation, respiratory depression, tolerance, and potential for addiction. Regional anesthesia offers an effective adjunct for analgesia that has been shown to improve analgesia scores, improve patient comfort, decrease the need for opioids and opioid complications, decrease staffing needs, and decreasing the length of stay. There have been a handful of case reports documenting Emergency Physicians performing Ultrasound-guided nerve blocks safely; however, it is still not a common practice. Further studies would be necessary to determine practice standardization in community or rural hospital settings. Objective: We described a case of Ultrasound guided Supraclavicular brachial plexus nerve block successfully performed by an Emergency physician for pain control for acute upper extremity trauma. Case Report: A 30-year-old female presented to the Emergency Department after accidentally placing her hand in an accelerating meat grinder. She sustained severe injuries to her hand, including complete amputation of her index finger, open displaced fractures of the long finger, and significant soft tissue deformities. The emergency physician performed an ultrasound guided supraclavicular brachial plexus block, using a Sonosite Edge Ultrasound machine and a high frequency linear transducer. The skin was prepped with chloraprep and a sterile tegaderm cover was applied to the ultrasound probe. The supraclavicular artery and 1st rib were identified. The brachial plexus was visualized just posterior to the artery, and injection occurred under dynamic needle advancement. Approximately 5 mL of 0.25% bupivacaine was injected and is seen on Ultrasound as a hypoechoic fluid surrounding the plexus and the perineural sheath. Color Doppler captured surrounding vessels which increased accuracy and safety. In addition, the EM physician was able to directly characterize the pleural lining under ultrasound, and aligned the 1st rib underneath the target, minimizing complications. The patient’s pain and distress significantly improved minutes after the procedure, and she reported feeling comfortable while awaiting operative management of her injuries. Discussion: The increasing experience of emergency physicians with ultrasound-guided procedures has made formerly highly specialized procedures, such as the supraclavicular brachial plexus block, more accessible to patients. With training, emergency physicians as well as other specialists should be able to apply these techniques, increasing options for analgesia, decreasing resource utilization in select acute traumatic injuries, and improving patient care. Implementation of these techniques should impact rural communities the most but more studies are needed to determine the effect size.


Kristine ROBINSON (Morgantown, USA), Yusef SAYEED, Erik OLNESS, Gregory BORAH, Aaron MONSEAU, Jeremy ROWELL, Joseph MINARDI
11:00 - 18:00 #8257 - Safety of adult procedural sedation and analgesia in the emergency department in the Netherlands.
Safety of adult procedural sedation and analgesia in the emergency department in the Netherlands.

Introduction: several studies conducted in the world have shown that procedural sedation and analgesia (PSA) is safe. However, data from the Netherlands have thus far not been investigated. This retrospective study has been conducted to investigate how often PSA is carried out by emergency medicine doctors (EMD) on emergency departments (ED) and if this is carried out in accordance with the guidelines of the Netherlands Society of Emergency Physicians (NVSHA). The results of this study will be used to conduct a prospective study examining the safety of PSA.

Methods: the ED’s of two community hospitals and a university hospital were approached. Through a general survey, general data were collected on the organization of the ED and PSA. Using the registration system of each hospital, key data were collected and analyzed regarding the occurrence of incidents, complications, calculated risk, near misses and adverse events. Percentages morbidity and mortality were calculated. At last we looked at the degree every hospital followed the guidelines of the NVSHA and the degree of taking care in complete registration.

Results: we found that PSA is carried out more in community hospitals compared to the university hospital. Of all procedures there were very low numbers of incidents, complications, near misses and adverse events. The number of calculated risk without any complication was higher. We found no morbidity or mortality following a PSA procedure. Every procedure was carried out following the guidelines of the NVSHA and registration was complete.

Conclusion: although we found very positive numbers of incidents, complications, near misses, adverse events, morbidity and mortality, we can’t make any conclusions based on the retrospective character and the number of inclusions. Procedures were carried out strictly according to the guideline of the NVSHA and registration was complete. However, a prospective study is required to establish results on the safety of PSA by EMD’s within the emergency departments in the Netherlands.

 

References:

  • Richtlijn sedatie en/of analgesie (PSA) op locaties buiten de operatiekamer. Kwaliteitsinstituut voor de Gezondheidszorg CBO. September 2009
  • Handreiking Procedurele Sedatie en Analgesie door SEH-artsen op de Spoed Eisende Hulp. NVSHA, sectie PSA. Maart 2012 (http://www.nvsha.nl/images/secties/psa/handreiking_psa_door_seh-artsen.pdf)
  • Voor een goed begrip: bevordering patiëntveiligheid vraagt om heldere definities. Wagner et al. Medisch Contact: 2005, 60(47), 1888-1891
  • Emergency department procedural sedation: the London experience. Elkhodair et al. Eur J Emerg Med. 2014 Sept 12
  • Procedural sedation and analgesia for adults in the emergency department. Prof Atkinson et al. BMJ 2014;348:g2965
  • Clinical policy: procedural sedation and analgesia in the emergency department. Godwin et al. Ann Emerg Med. 2014 Feb;63(2):247-58.e18
  • Procedural sedation and analgesia in rural and regional emergency departments. Pinto et al. Can J Rural Med. 2013 Fall;18(4):130-6

 

Acknowledgements:

No source of funding has been used.


Matthijs ARENS (Berg en Dal, The Netherlands), Ties EIKENDAL
11:00 - 18:00 #7569 - Salivary α-Amylase levels in vertigo: can it be an autonomic dysfunction?
Salivary α-Amylase levels in vertigo: can it be an autonomic dysfunction?

Salivary α-Amylase levels in vertigo: can it be an autonomic dysfunction?

Salivary α-Amylase levels in vertigo

ABSTRACT

OBJECTIVES: This study aims to demonstrate a possible autonomic dysfunction based on salivary alpha amylase measurements during and after the vertigo attacks of Meniere’s Disease and Benign Paroxysmal Positional Vertigo.

Study Design: Cross-sectional controlled clinical study

MATERIALS and METHODS: Patients admitted to emergency room with a diagnosis of vertigo attacks of either Meniere’s Disease (n=15) or Benign Paroxysmal Positional Vertigo (n=9) constituted the study groups. The control group (n=10) consisted of volunteer patients admitted to emergencies with minor soft tissue trauma.Following the diagnosis of vertigo, saliva samples were obtained  immediately during the attacks from the patients. The second and third samples were obtained on the third and fifteenth days of the attack, respectively. For the control, the first sample was obtained following admission to the hospital, with the second sample on the third day. The control group consisted ofvolunteer, healthy subjects with normal hearing (n=43). Main outcome measures:Following an audiometric evaluation, a venous blood samp. The control group consisted ofvolunteer, healthy subjects with normal hearing (n=43). Main outcome measures:Following an audiometric evaluation, a venous blood samp.

RESULTS: The difference between sAA levels of the two diseaseswas insignificant. Amylase value measured early after the Benign Paroxysmal Positional Vertigo attack was significantly lower than the control (p=0.008) Though not significant, an undulation was observed concerning both disaeses.

CONCLUSION: An autonomic imbalance could be partly demonstrated with salivary alpha amylase early after the attack in Benign Paroxysmal Positional Vertigo. This study is the first one in using amylase in vertigo.


Tanzer KORKMAZ (IZMİR, Turkey), Serap KOYBASI SANAL, Yusuf Ozgur BICER, Erdinc SERIN, Sinan SEYHAN
11:00 - 18:00 #7763 - Saved by the rash? An unusual case of a myocardial infarction.
Saved by the rash? An unusual case of a myocardial infarction.

Myocardial infarction can assume a plethora of atypical presentations. Posterior infarcts are notoriously difficult to diagnose. We present the unusual case of a patient who visited the emergency department for an acute neck pain, believed to be of muscular origin. After an intravenous analgesic was given, she was promptly discharged, only to return one hour later with an exuberant rash and hemodynamic instability, suggestive of anaphylactic shock. Furthermore, an EKG, not previously performed, documented a postero-inferior myocardial infarction, retrospectively believed to be the cause of the cervical pain. After hemodynamic stabilisation, the patient underwent PTCA and recovered uneventfully. We discuss some considerations related to the management of anaphylaxis and the pitfalls inherent to the diagnosis of postero-inferior myocardial infarction.


Sergio CARDOSO (Sint-Niklaas, Belgium), Demeyer IGNACE, Pedro SEMEDO
11:00 - 18:00 #7455 - Secondary aortoenteric fistula: A case report.
Secondary aortoenteric fistula: A case report.

CASE REPORT: G.B. is a 81yo gentleman with a past hystory of hypertension and abdominal aortic aneurysm rupture with emergent placement of endovascular synthetic graft two years before. He is otherwise healty excluding known colic diverticulosis.He was brought to our ED by EMS for pre syncope. He also reported epigastric pain and a single emission of black stool some hours before presentation. He was evaluated for abdominal pain and bloody stools 12 days before and was diagnosed with suspected diverticulitis.
On initial evaluation the patient was tachycardic with a HR of 120bpm, his BP was normal but he had a mottled skin and appeared confused, intensely shivering despite thermal blanket. Examination revealed moderate pain to the central region of abdomen with moderate local tenderness. Rectal examination showed melena in the rectal ampulla. An ABG showed acute metaboli lactic acidosis with efficient respiratory compensation and moderate anemia (Ph 7,42, pCO2 19mmHg, Lac 11,9mmol/l, Hb 8g/dl).Omeprazole 80mg EV was administered stat and fluid resuscitation with NS was started. A FAST scan was immediately performed: no free fluid was visible in peritoneum but a liquid layer encompassed the excluded aneurysm. In the meanwhile a CBC performed just 10 minutes after the initial ABG revealed an Hb of 6g/dl, so the patient started tranfusion of 2 units of PRBC. In few minutes the situation deteriorated and several hypotensive episodes occured but despite this the patient was taken to the CT to perform an aortic scan with contrast medium. The CT showed massive quantity of air inside the aneurysmatic sac, likely due to aortoenteric fystula since the absence of a clear cleavage plain between aneurysm and duodenum. The patient needed emergent laparotomy and endotracheal intubation was performed in the ED using ketamine 1mg/kg and midazolam 5mg. Just few seconds after glottic visualization was obtained and the ET passed trough the cords, a massive hematemesis occured, accompanied by a new hypotensive epysode. The patient underwent surgical exclusion of the aneurysm as a bridge therapy for secondary endovascular repair.
At the time of this abstract, 8 days before the event, the patient is alive and is waiting for second surgery.

DISCUSSION:Aortoenteric Fistula (AEF) is defined as a communication between the aorta and the GI tract and is classified as primary if the communication i between the native aorta and GI tract or secondary if the aorta has been reconstructed (for either aneurysmal or occlusive disease). Secondary AEF are the most common. When left untreated, AEF it is almost universally fatal and is notoriously difficult to diagnose. As such an high index of suspicion is required when approaching a patient with GI bleeding and hystory of aortic disease. The classical triad of GI bleeding, Abdominal pain and pulsatile mass is present in only 11% of cases in recent rewiews. A classical clinical feature is the "herald bleeding", a self limited minor bleed that, if left untreated, will be followed by exsanguinating bleeding within hours to months. Our patient's prior episode of "diverticulitis" could have been an herald bleeding.


Francesco BORRELLI (Venezia, Italy), Danilo BENEDETTO, Marina BUDA, Giada ZECCHI
11:00 - 18:00 #7807 - Seizures during air travel.
Seizures during air travel.

History:

Male 70 years from the airport brought by present three tonic-clonic seizures sphincters relaxation during airplane flight, which have been administered intramuscular 30mg Diazepam.

AP: unknown.

Physical exploration:

Regular state general. Stuporous. Well hydrated and perfused. TA 120 / 66mmHg, Fc 105lpm. Sat O2 99%. Afebrile. arreactivas mydriatic pupils. ACP: rhythmic and audible tones. No murmurs. MVC.

Investigations:

Blood count: Leukocyte 7200. Hb 13,5. Platelets 339000. Biochemistry: Glucose 101. Creatinine 0'8. Urea 52. Na 135. K 3'7. CK 486. LDH 276. PCR 5. Normal venous blood gases.  Negative toxic. Urine Sediment: Normal.

TAC skull: multiple air bubbles in subarachnoid space scattered throughout the left brain (pneumoencephalus), associating discrete diffuse cytotoxic edema resulting loss of cortico-subcortical differentiation in the convexity.

Evolution:

The origin of pneumoencephalus can be varied, in this case may be due to air embolism secondary to barotrauma given the history of air travel.

The patient became comatose with repeated seizures, passing away a few hours.

Final diagnosis:

Air embolism secondary to barotrauma by air travel.

 

Conclusions:

The gas embolism with cerebral ischemic lesions corresponding to it and symptomatic seizures, usually poor prognosis.

Although no antecedents had to make assumptions about what it was physiopathogenesis, although the flight and in itself is a risk factor (or snorkeled have been subjected to pressure opposing changes prior to your flight?).

In such cases, the hyperbaric chamber is the therapeutic option.


Valentina MORELL, Enrique CARO (MALAGA, Spain), Maria Angela CANAS BARRANCO, Juan Antonio RIVERO, Eduardo ROSELL, Francisco TEMBOURY
11:00 - 18:00 #7536 - Seizures management in emergency department.
Seizures management in emergency department.

Introduction: seizures are quite common grounds for emergency consultation, knowledge of their causes and their prognostic factors could improve their support. The objective of our study is to describe the aspects of epidemio-clinical, etiological, therapeutic and prognostic seizures admitted to emergency.

 

Methods: Retrospective study including all patients hospitalized in the ED  who consult for a seizure between January and December 2015

 

Results: 111 topics have been collected with a median age of 63 and a sex-ratio to 1.71

 30.6% of our patients had a neurological history type of ischemic stroke.

The crisis was accompanied in 88.3% cases with seizures generalized in 60 patients the diagnosis of poorly convulsive was retained in 28 patients.

All patients received a clinical examination, a biological assessment, an electrocardiogram and a brain imaging was made in 95% of cases. An electroencephalogram has been practiced in 13 cases and the lumbar puncture in 10 cases. Vascular pathology remains the most common etiology in 38.7% followed by epilepsy in 10.8%.

Initial coma was found in 34 patients as well as a post deficit critical in 22.5%. Main associated failure was respiratory order associated especially with pneumonia of inhalation with use of intubation in 10 patients.

The mortality rate was 18% and antiepileptic treatment in the long course at base of phenobarbital was introduced in 52% of the patients.

Conclusion: a seizure requires a rapid and adequate support guided by a pre-established therapeutic protocol that should not neglect the etiological treatment associated with the symptomatic in support.


Walid MHAJBA, Mohamed Ali CHERIF, Farah RIAHI (Belfort), Mohamed MEZGHENI, Rim BEN KADDOUR, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7642 - Sepsis and its impact on outcome in elderly patients in emergency department.
Sepsis and its impact on outcome in elderly patients in emergency department.

Introduction:

Sepsis remain a major cause of mortality and morbidity especially in the elderly over than 65 years.

Objective:

To determine the epidemiological, clinical, therapeutic and outcome features in elderly presenting to the emergency department.

Methods:

Prospective study conducted over six months. Inclusion: patients (Age ≥ 65 years) with suspected infection associated with two or more criteria of the systemic inflammatory response syndrome (temperature ≥38 ° C  or ≤ 36 ° C , heart rate > 90 bpm / min , respiratory rate > 20 / min or PaCO2 < 32 mm Hg, WBC > 12,000 cel / mm3 or < 4,000 / mm3) . The presence of organ dysfunction defined severe sepsis. Persistent hypotension (systolic blood pressure < 90 mmHg) or signs of hypoperfusion (lactate ≥ 4 mmol / l, oliguria) despite adequate fluid resuscitation during severe sepsis, defined septic shock.Clinicals, epidemiologicals, biologicals, bacteriologicals, therapeutic characteristics and APACHE 2 score were noted. Evaluation of inhospital and 7 day mortality. 

Results:

Inclusion of 66 patients. Sepsis : n = 38 , 57%. Severe sepsis: n = 17, 26%. Septic Shock: n = 11, 16 %. Mean age = 75 ± 10 years. Sex ratio = 1.35.Comorbidities n (%): hypertension 41 (62), Diabetes 34 (51), chronic pulmonary Obstructive disease 8 (12), chronic renal failure 3 (4). Clinical manifestations n (%): Fever 48 (72), impaired general condition 36 (54), respiratory signs 14 (21), digestive signs 12 (18), and neurological signs 8 (12). Source of sepsis n (%): pulmonary 30 (45), urinary 13 (20), skin 12 (18) and digestive 8 (12). APACHE average =14 ± 13. Organ failures n (%): Renal 25 (38), pulmonary 9 (14), hemodynamic 6 (9), hepatic 4 (6) and hematologic 5 (8). Vasoactive drugs used in 11 patients (16%). Hospitalization in intensive care unit in two patients. Inhospital mortality: 3% and 7-day mortality: 0%.


Conclusion: This study shows that despite several comorbidities that present the elderly, early mortality is relatively low. The sepsis resuscitation and management bundles should be started early and have been shown to improve survival of the elderly in emergency department without a transfer to intensive care unit.


Wided BOUSSELMI, Hanen GHAZALI, Aymen ZOUBLI, Anware YAHMADI, Rania JEBRI (Lyon), Farah RIAHI, Najla EL HENI, Sami SOUISSI
11:00 - 18:00 #7502 - Serum biomarker levels and scene time interval are associated with outcome in out-of-hospital cardiac arrest (OHCA) patients.
Serum biomarker levels and scene time interval are associated with outcome in out-of-hospital cardiac arrest (OHCA) patients.

Objective. Predicting the outcome of out-of-hospital cardiac arrest (OHCA) patients is difficult. Thus, the objective of this study was to determine whether serum biomarker levels and the scene time interval differ between OHCA patients with favorable or unfavorable outcomes to identify potential predictors. Methods. Data from 233 OHCA patients between January and December 2014 at Taoyuan Chang Gung Memorial Hospital (Taiwan, R.O.C.) were analyzed in this study. Serum sugar, creatinine, AST, Na, K, CKMB, Trop-I, pH, and pCO2 were determined in the emergency room while performing cardiopulmonary resuscitation (CPR). The response time, scene time interval (STI) and the STI plus CPR time were also recorded. Results. OHCA patients who were discharged with good neurologic responses had normal serum pH values and normal levels of creatinine and Trop-I. Moreover, patients with STIs of less than 20 min, or STI plus CPR times less than 36 min, had better neurological outcomes. Conclusions. Our data suggest that serum biomarkers may predict outcome in OHCA patients and hospital CPR times of less than 36 min are associated with a better chance of discharge.


Po Cheng CHEN (Taoyuan, Taiwan), Cheng Yu CHIEN
11:00 - 18:00 #7629 - Serum lactate level and 7-day mortality in patients in the emergency department: a prospective observational cohort study.
Serum lactate level and 7-day mortality in patients in the emergency department: a prospective observational cohort study.

Introduction:

Lactate measurements are routinely carried out in emergency departments and are associated with increased mortality in septic and traumatic patients.  Until now, no definitive research has been carried out into whether lactate measurements can be used as a prognostic marker in a clinically unwell population in the emergency department (ED).

Objective: The aim of this study was to describe the relation between initial serum lactate level and 7-day mortality in patients presenting in the ED with different etiology.

Methods:

We carried out a prospective observational cohort study in consecutive patients whose arterial lactate concentration was measured in the ED and was above 2 mmol/L over six months. The initial arterial lactate level was categorized as intermediate (2-3.9 mmol/L), or high (> or = 4 mmo/L). The main outcome measure was 7-day mortality. The categorization of suspected etiology was based on discharge diagnoses.

Results:

Inclusion of 110 patients. Mean age was 59 +/- 20 years. Sex ratio = 1, 82. Median serum lactate was 3, 45 mmol/L.  Sixty six patients (60%) had intermediate lactate and 44 patients (40%) had high lactate. Seven-day mortality was 21%.                                                                                                                                                      Intermediate (odds ratio [OR] = 1, 76, p = 0.014) and high serum lactate levels (OR = 2, 95, p = 0.02) were associated with mortality. The association between lactate level and mortality varied across different diagnostic groups. Based on Area Under the Curve in receiver operating characteristic analysis, lactate level showed to be useful in patients with infection (0.74, 95% CI 0,31 to 0,58), cardiac diseases (0,67, 95% CI 0,45 to 0,70), respiratory diseases (0.64, 95% CI 0,41 to 0,67) and gastrointestinal diseases (0,61, 95% CI 0,38 to 0,64).  Lactate level was not useful in neurological (0, 48, 95% CI 0, 35 to 0, 62) and endocrine disease (0,43, 95% CI 0,29 to 0,57).

Conclusion: Increased lactate level is a mortality prognosis factor in most patient’s categories. However, this association differs from diagnoses to another.


Wided BAHRIA (tunisie, Tunisia), Hanen GHAZALI, Imen BOUKHALFA, Anware YAHMADI, Ahmed SOUYAH, Mohamed MGUIDICH, Ahlem AZOUZI, Sami SOUISSI
11:00 - 18:00 #8052 - Severe cutaneous drug reactions in emergency about two cases.
Severe cutaneous drug reactions in emergency about two cases.

Introduction :

 

The term cutaneous drug reaction is used for dermatoses with involvement of the skin, mucosas, and/or skin appendages, caused by the effect of a substance, usually a drug, which comes into contact with the organism by a range of pathways. These reactions may range from mildly discomforting to those that are life-threatening.

 

 

Material and Methods :

 

We report two cases of severe cutaneous drug reactions in emergency.

 

Case1

An 48-year-old woman with allergic asthma and epilepsy. She presented to the emergency department with progressive pruritic macular erythematous rash and fever 12 days after commencing carbamazepine therapy. The rash started

on her face and over 2 days spread in a caudal direction to involve

her entire body. Skin examination showed severe generalized macular erythematous skin rashes with multiple flaccid bullaes predominant in the trunk and both of upper limbs and detachment of epidermis (positive Nikolsky). Forty-two percent body surface involvements were estimated by the rule of nines Skin biopsy showed epidermal necrosis. The diagnosis of toxic epidermal necrolysis (TEN) was retained. The initial management consisted of local therapy (wound care and dressing) and rehydration. The outcome was favorable.

 

Case2

An 49-year-old woman with epilepsy treated with phenobarbital and clonazepam for 1 month. She presented to the emergency department with macular erythematous rash over her body since 5 days. The rash initially started on her trunk then quickly generalized throughout the body. Skin examination showed severe generalized  macular erythematous skin rashes with multiple bullaes on macular erythematous areas, detachment of epidermis (positive Nikolsky) predominant in the trunk and crusted lesions in the mucous ophthalmic, nasal and vaginal. Fifty percent body surface involvement was estimated by the rule of nines The diagnosis of toxic epidermal necrolysis (TEN) was retained. Initial treatment consists of local care and rehydration. The evolution was marked by the occurrence of a state of refractory septic shock and death of the patient.

 

Conclusion :

TEN is one of severe cutaneous drug reaction, with anticonvulsants such as phenytoin, carbamazepine, and phenobarbital, most commonly implicated. In addition, allopurinol antibiotics, have also been found to have a role. En typically begins 1–3 weeks after the initiation of

Therapy.

The appropriate and quick action should be taken as soon as TEN is detected  due to its high morbidity and mortality rates.


Ons ANDOLSI, Mohamed Ali CHERIF, Houcem OUNI (tunis, Tunisia), Khaled SAIDI, Youssef Zied EL HECHMI, Najeh HAJJEM, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #7659 - Severe metabolic alkalosis: a case report.
Severe metabolic alkalosis: a case report.

Introduction:

 Metabolic alkalosis is common; accounting for half of all acid- base disorders amongst patients presenting in the emergency department (ED) [1].  It can threaten life by causing tetany, leading to seizures and death. We report a patient with severe metabolic alkalosis.

 

Case report:

 

A 61-year-old woman was admitted with nausea vomiting and abdominal pain lasting for two weeks. On arrival, the physical exam found that she was confused: Glasgow Coma Scale (GCS) = 14 without any sign of focalization or lateralization. Her vital signs showed a blood pressure of 120/70 mmHg, heart rate of 62 beats per minute, respiratory rate of 30 per minute. Chvostek’s sign was positive associated with obstetrician’s hand. Neurological examination revealed marked myoclonus predominantly of the upper limbs. Blood biochemistry results were as follows: hypokalemia of 2.2 mmol /l, with severe metabolic alkalosis (PH ˃ 7.80, PaCO2 = 22 mmHg, PaO2 = 87 mmHg, HCO3 uncalculable, SaO2= 98%), lactate= 4 mmol/l, the ionized calcium was 0.4 mmol/l, urea = 27 mmol/l, creatinine = 177μmol/l. The marked metabolic alkalosis was thought to be due to loss of hydrogen ions and the response of the kidney leads to decrease in   bicarbonate excretion. The myoclonus was considered to be due to marked alkalosis and reduced ionized serum calcium. She was treated with intravenous physiological saline rehydration, intravenous administration of large amount of potassium chloride (10 mmol/l per hour), and rebreathing. Serum electrolyte levels returned to normal on this therapy:  potassium = 3.7 mmol/l, bicarbonate = 28 mmol/l, creatinine = 72 µmol/l, ionized calcium = 0.9mmol/l. The myoclonus disappeared from the face and she was discharged approximately 72 hours later. Endoscopy showed gastric outlet obstruction secondary to infiltrating process.

 

Conclusion:

The combination and degree of metabolic derangement in this case is unusual. Treatment is aimed at reversing the underlying cause. The importance of conservative management of carbon dioxide retention was emphasized.

 

References:

[1] Jennifer T et al.  Emerg Med Clin  North Am 2014.


Hana HEDHLI, Salwa AMRI (villeneuve saint germain), Sarra JOUINI, Imen MEKKI, Wided DEROUICH, Béchir BOUHAJJA
11:00 - 18:00 #7663 - Sex-based Differences in Clinical Features, Management, and Prognosis of Acute Myocardial Infarction: insights from ReSCUS Registry.
Sex-based Differences in Clinical Features, Management, and Prognosis of Acute Myocardial Infarction: insights from ReSCUS Registry.

Introduction: We sought to investigate sex-related differences among patients with ST-elevated myocardial infarction in order to identify gender-related factors associated with outcomes, and to analyze sex-based differences in clinical characteristics, diagnosis, management, and prognosis after a myocardial infarction.

Methods: Between February 2014 and December 2015, one hundred and fifty-two ST-elevated myocardial infarction(STEMI) were consecutively registered in our emergency department. We exploited ReSCUS registry data. Clinical characteristics, management, mortality (at 30-day and at 90-day) and major adverse cardiac events (MACE) were prospectively recorded.

Results: The registry included 35 women and 117 men with STEMI. Compared with men, women were older (70.9 vs. 59.8, p < 0.001), had a higher prevalence of hypertension (56% vs 29%, p = 0.004) smoking and dyslipidemia  (24 % vs 11 %, p = 0. 002 ). There was no difference in the prevalence of diabetes (p= 0.09). Women were more likely to have a history of previous myocardial infarction (18% vs. 16%, p < 0.01).  The thrombolysis rate was 14.1% (n = 20) with a success rate of 62%, the angioplasty rate was 85.9% overall. No differences were observed in use of invasive procedures. Women were less likely than men to receive care within the benchmark time for reperfusion therapy (time to treatment from symptom onset <12 hours: 68.4% vs 72.46%, p <0.001). There were no significant differences in door-to-needle (median; 79 min vs 76 min) and door-to-balloon times (median: 85 min vs 87 min). The angiographic success defined as a re-permeabilization of the artery with TIMI 2 or 3 and a residual stenosis of less than 20 % was obtained in 82.1% of cases for men and 87,9% for women (p = 0.78). Case-fatality at 1 month was similar in women and men (6.89% vs 6.46%; p = 0.24). MACE were also similar: n=9 for men vs n=2 for women at 1 month (p = 0.47). Case-fatality at 90-day was worse for men than women (8.42% vs 6.76%; p=0.02).

Conclusion: There are demographic and clinical differences between men and women STEMI. The short-term prognosis of a first myocardial infarction in this stady is similar in both sexes. However, the long-term vital prognosis after a first myocardial infarction is worse in men than in women. Delays in both women and men in STEMI remain unacceptably long and should be improved.


Achref HAJ ALI, Chawki JEBALI (Kairouan, Tunisia), Ali OUSGI, Lotfi BOUKADIDA, Asma ZORGATI, Asma JERBI, Riadh BOUKEF
11:00 - 18:00 #7305 - She is exhausted. She needs psychological assistance!
She is exhausted. She needs psychological assistance!

A 51 year-old woman was brought to the emergency ward by two of her friends. According to her relatives, she was exhausted and had to see a psychiatrist.

She worked as an employee in the administration, lived alone and had always had a lot of energy. But since the hospitalization of her mother for severe depression a few weeks earlier, the patient had stayed the whole day in her bed, lacked energy and didn`t speak anymore. Her friends said: "she is not recognizable anymore and needs urgently psychological assistance".

In regard to her medical past, we noted only a few migraine episodes and one flebitis of the right leg, 3 years before. She took no medication except the pil and paracetamol tablets occasionally.

She complained about having had a headache a week before and therefore her GP had come twice for injection of NSAIDS.

Because of her aggravating symptoms of lethargy, mutisme en bradypsychia she was referred to the ED on a Friday night.

On admission her parameters were stable: a blood pressure of 12/8 mm Hg, a pulse of 60 Bpm,  a temperature of 36.5 °C  and a Sp02 of 99%.  The clinical examination revealed only an altered neurological examination: she was conscious and well-oriented in time and space, her pupils were reflected and isocore. She presented no sign of lateralisation, had symmetrical reflexes and no meningeal signs but she was somnolent, bradypsychique and showed a difficulty with coordination. Laboratory evaluation revealed normale glycemia, normale electrolytes, normale creatinine, normale TSH and T4, crp : 19 mg/L, DD : 6114 ng/ml, GOT 32u/L, GPT 50 u/l, ethanol 0 g/dl.The urinary toxicology analyses showed only the presence of paracetamol in a therapeutical dose.

The head CT was preformed  one hour after admission and was negative. The rx-thorax was normal. She was admitted for observation in neurology. On the following days other exams were performed, the EEG was normal, the dupplex of lower limbs was normal, the CT-Angio of the thorax was normal, the head CT scan with contrast showed an empty delta-sign pathognomonic of a veneuse thrombose.A head MRI was performed in emergency and revealed multiple foci of recent ischaemia in the white matter bilaterally and a central venous sinus thrombosis superior sagittal, sigmoideus, rectus and interna cerebri. The treatment was immediately started with low molecular weight heparins at the therapeutic dose of 1mg/kg twice a day before a relay per os and the pil was stopped at live.

In a second time an extended bilan (in gynecology, cardiology , dermatology, ..) was performed and allowed to exclude any malignity. This diagnose had an important impact on her social and professional life. In conclusion, instead of referring the patient too early to the psychiatric ward, a possible diagnosis of an acute central venous thrombosis should always be considered by the emergency physician in case of headache or altered neurological examination with elevated d-dimer.

 


Elke THIJS (Bellem, Belgium), Adeline HIGUET, Saartje THIJS
11:00 - 18:00 #7644 - Shock index as a prognosticator in patients with non ST segment elevation myocardial infraction (NSTEMI).
Shock index as a prognosticator in patients with non ST segment elevation myocardial infraction (NSTEMI).

Introduction:

Several risk scoring models have been shown to identify patients at increased risks for adverse outcomes in ACS populations [1]. Recently, shock index (SI) a ratio of heart rate/systolic blood pressure, has been reported to predict increased mortality in patients with NSTEMI [2].

Objective:

To evaluate whether the shock index (SI) is useful for predicting cardiovascular outcomes in patients with NSTEMI admitted to the emergency department (ED).

Methods:

 

A prospective observational study that was conducted over three months [January- March 2016].  We enrolled patients aged more than 18 years, presenting to the hospital alive with presumptive diagnosis of ACS. Were excluded those with ventricular tachycardia, supraventricular tachycardia, implantable cardioverter defibrillator shock, and blood pressure on presentation more than 230/130 mmHg.Patients were divided into those with SI<0.7 and those with SI≧0.7.  The prognosis was evaluated based on the occurrence of myocardial infarction (MI) or death at 30 days.

Results:

A total of ninety-two patients were analyzed: fifty- eight patients (63%) had SI < 0.7, thirty-four (37%) had SI ≧ 0.7. The average of age was 62 ± 11 years, sex-ratio= 1.48. No statistically significant difference was observed in baseline characteristics between the two groups.Systolic and diastolic blood pressures were lower in patients with SI ≧0.7 than those with SI < 0.7. Heart ratewas significantly higher in patientswith SI≧0.7.MI rates was 12% in patients with SI ≧  0.7and 5%  in patients with SI <0.7 (p=0.41); 30 days mortality was 11,5% in patients with SI  ≧0.7 and 7% in patients with SI 0.7< (p=0.46)

Conclusion:

Shock index is a simple parameter that we can have on admission; it isa useful risk-stratification module to identify high-risk in-hospital mortalitypatients in a NSTEMI population. However itis not a powerful prognosticator to predict adverse cardiovascular outcomes.

 

References:

[1] Granger CBet al. Arch Intern Med 2003; 163:2345-53

[2] Kobayashi A et al. Cardiovasc Revasc Med 2016


Hana HEDHLI, Rim HAMMAMI (Tunis, Tunisia), Feten AMIRA, Zied GUERMAZI, Wided DEROUICH, Béchir BOUHAJJA
11:00 - 18:00 #7573 - Shock index predict mortality in geriatric trauma patients.
Shock index predict mortality in geriatric trauma patients.

Back ground:

Shock index (SI) (heart rate/systolic blood pressure) is a simple marker of worse outcomes after injury.  Assessment of injury severity and hemodynamic instability in geriatric trauma patients is often difficult owing to their altered response to injury (1).

Purpose: The aim of this study was to assess the utility of SI in predicting mortality in geriatric trauma patients.

Participants and Methods:

We performed a prospective analysis on traumatic patients presented to the Emergency Department from March 2014 to December 2015. Patients 65 years or older were included.Transferred patients, patients dead on arrival, missing vitals on presentation, and patients with burns were excluded.A cut-off value of SI greater than or equal to 1 was used to define hemodynamic instability.

Results:

A total of 45 geriatric patients were included. The mean age was 74 ± 6 years,71% were males, median Glasgow Coma Scale (GCS) score was 11 (range, 3-15), median Injury Severity Score (ISS) was 25 (range, 4-75), and mean  SI was 0.78 ± 0.4. The initial value of SI greater than or equal to 1 was noted in 10 geriatric trauma patients (22%).  Mortality at one month was significantly elevated in patients with SI≥1 [70% (n=7) vs 37% (n=13)].

Conclusion:

SI is an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. It allows accurate assessment of these patients and is an effective tool that can be implemented in a prehospital setting for the triage of geriatric trauma patients.

  1. Viraj Pandit and al. J Trauma Acute Care Surg. 2014;76(4):1111-15

 


Amina JEBALI (Beja, Tunisia), Sarra JOUINI, Amel MAAREF, Houssem AOUNI, Dorra CHTOUROU, Ines CHERMITI, Bechir BOUHAJJA
11:00 - 18:00 #7641 - Should we now change our policy of tetanus prophylaxis thanks to a bedside immunochromatographic test for the detection of anti-tetanus antibodies?
Should we now change our policy of tetanus prophylaxis thanks to a bedside immunochromatographic test for the detection of anti-tetanus antibodies?

Introduction

The prevention of tetanus performed in the Emergency Department (ED) is not reliable when it is based on clinical history. Indeed, many patients don’t know their immune status and could receive an unnecessary booster, while other patients wrongly think themselves to be vaccinated   and could not receive any prevention.

In 2005, a rapid bedside semi-quantitative   immunochromatographic test (TQS) became available, allowing the evaluation of tetanus antibody levels in 10 minutes.  The validity studies demonstrated that the accuracy of  TQS is much better than the  accuracy of  clinical history.

The sensitivity and specificity of TQS were respectively 93% and 94%, while the sensitivity and specificity of clinical history were respectively 41% and 85%.

 Therefore, TQS has been used for tetanus prevention in our ED.

 

Objectives

To evaluate  within the frame of a cost-benefit study whether the systematic use of TQS is conceivable

 

Methods

       In this prospective monocentric study, 2032 patients with a wound were included. TQS was performed to the patients who had not a written track-record of their immunity.1995 TQS were realized. Whenever TQS was positive the patient consequently received no tetanus prevention. If TQS was negative or doubtful the patients received tetanus prevention using WHO algorithm. We then compared the cost of tetanus prevention employing TQS against the cost of prevention using classical prevention. To obtain the costs for the anti-tetanus vaccination with the help of the TQS, we added the costs of the TQS   with the costs to vaccinate the patients with a negative TQS.

 

Results

            1431 TQS were positive and 564 TQS were negative. Among the patients with a negative TQS, 294 had a tetanus prone wound. To realize the tetanus prevention of this cohort  with TQS, 564 boosters and 294 tetanus immunoglobulin(anti-TT) were administrated.

The cost of the prevention with TQS was €22313.

Without TQS, 1874 vaccinations and 930 tetanus immunoglobulin would  have been  €37235

 

Conclusions

Systematic use of TQS is cost effective and   avoids unnecessary and expensive treatments. The test could systematically be included in the tetanus prevention algorithm.

 


Jean-Christophe CAVENAILE (BRUXELLES, Belgium), Judith HERRERO GARCIA, Jean DUCHATEAU
11:00 - 18:00 #7648 - Should we now change our policy of tetanus prophylaxis thanks to a bedside immunochromatographic test for the detection of anti-tetanus antibodies?
Should we now change our policy of tetanus prophylaxis thanks to a bedside immunochromatographic test for the detection of anti-tetanus antibodies?

Introduction

The prevention of tetanus performed in the Emergency Department (ED) is not reliable when it is based on clinical history. Indeed, many patients don’t know their immune status and could receive an unnecessary booster, while other patients wrongly think themselves to be vaccinated   and could not receive any prevention.

In 2005, a rapid bedside semi-quantitative   immunochromatographic test (TQS) became available, allowing the evaluation of tetanus antibody levels in 10 minutes.  The validity studies demonstrated that the accuracy of  TQS is much better than the  accuracy of  clinical history.

The sensitivity and specificity of TQS were respectively 93% and 94%, while the sensitivity and specificity of clinical history were respectively 41% and 85%.

 Therefore, TQS has been used for tetanus prevention in our ED.

 

Objectives

To evaluate  within the frame of a cost-benefit study whether the systematic use of TQS is conceivable

 

Methods

       In this prospective monocentric study, 2032 patients with a wound were included. TQS was performed to the patients who had not a written track-record of their immunity.1995 TQS were realized. Whenever TQS was positive the patient consequently received no tetanus prevention. If TQS was negative or doubtful the patients received tetanus prevention using WHO algorithm. We then compared the cost of tetanus prevention employing TQS against the cost of prevention using classical prevention. To obtain the costs for the anti-tetanus vaccination with the help of the TQS, we added the costs of the TQS   with the costs to vaccinate the patients with a negative TQS.

 

Results

            1431 TQS were positive and 564 TQS were negative. Among the patients with a negative TQS, 294 had a tetanus prone wound. To realize the tetanus prevention of this cohort  with TQS 564 boosters and 294 tetanus immunoglobulin(anti-TT) were administrated.

The cost of the prevention with TQS was €22313.

Without TQS, 1874 vaccinations and 930 tetanus immunoglobulin would  have been  €37235

 

Conclusions

Systematic use of TQS is cost effective and   avoids unnecessary and expensive treatments. The test could systematically be included in the tetanus prevention algorithm.


Jean-Christophe CAVENAILE (BRUXELLES, Belgium), Judith HERRERO GARCIA, Jean DUCHATEAU
11:00 - 18:00 #7589 - Should We Be Treating Hypotensive Pulmonary Embolism Patients With Fluids? – A Review Of The Literature.
Should We Be Treating Hypotensive Pulmonary Embolism Patients With Fluids? – A Review Of The Literature.

Background

5-8% of patients presenting with Pulmonary Embolus (PE) meet the criteria for acute massive pulmonary embolism (AMPE), defined as PE causing hypotension (SBP<90mmHg) or with clinical evidence of shock. AMPE carries a considerable 90 day mortality of 52.4%.

Intravenous fluids are common practice in the Emergency Department (ED) to treat hypotension and shock. Published guidelines, however, offer little guidance on the best strategies for supportive treatment prior to definitive medical or surgical therapy. It is unclear whether liberal use of IV fluids is beneficial in this population.

Aims

To evaluate published literature for evidence of efficacy of intravenous fluids in improving cardiac output and/or mortality in acute massive pulmonary embolism, and summarise therapeutic physiological rationale.

Methods

A systematic review was conducted using multiple databases and search tools with keywords: Pulmonary embolism, massive pulmonary embolism, haemodynamic, shock, fluid.  and excluding children and chronic pulmonary embolism. Citation searches were also performed from authoritative text books.

Results

Two reviewers selected 2 case reports, 3 crossover animal studies and 1 prospective crossover study from 433 results.

Discussion

There is good experimental data. Three separate studies in the 80s Molloy ’84 Ghignoue ‘84 and Belenkie ’89, demonstrated marked worsening in right ventricular dysfunction and/or death in hypotensive dogs with AMPE following treatment with volume and strongly recommended noradrenaline as the ‘drug of choice for acute resuscitation.’

However, in 1979 Hauser and Shoemaker demonstrated improvements in cardiac index and Qs/Qt shunt of a AMPE patient following 500ml boluses of colloid, hypothesising that IV fluid worked by redistribution of blood flow to underperfused lung. Similarly in crossover trial of 13 intensive care patients Mercat et al. 1999 observed an increase in cardiac index with volume loading but the patients were hypotensive or in the acute phase of the disease so difficult to apply to the acutely decompensating patient in the ED. Within the examined literature, the physiological rationale for treating acute right heart failure with IV fluids is inconsistent and difficult to apply or test within the ED without invasive cardiovascular monitoring.

One of the most recent reviews on management (Matthews and McLaughlin 2008) IV fluids are not advised at all in initial supportive measures, preferring that patients “should immediately receive vasopressor support.” Other reviews are more cautious reinforcing the view that these patients are preload dependent so intravascular volume should be optimised in conjunction with vasopressors. Hypotension in AMPE is clearly not due to hypovolaemia so liberal use of IV fluids is not recommended.

Conclusion

While published literature provides us with no good human RCTs to justify the use of fluid boluses in AMPE, there is similarly no good evidence for harm. This notwithstanding, the haemodynamic rationale for limited and restricted use of fluids based on experimental data is extremely compelling. A rationale based on clinical judgement of the patient’s volume status, followed by very early consideration of vasopressors and/or inotropes can be recommended.


Laura ASHTON (London, United Kingdom), Matt EDWARDS
11:00 - 18:00 #7157 - Should we recommend the implementation of emergency department short-stay units to alleviate emergency department overcrowding?
Should we recommend the implementation of emergency department short-stay units to alleviate emergency department overcrowding?

Aim:

To describe the general characteristics and evaluate the activity of Emergency Department short-stay units (EDSSUs) in Spanish hospitals.

Methods:

This is a cross-sectional study based on a subanalysis of the REGICE database (Spanish abbreviation for Short-stay Unit Registry) focussing specifically on short-stay units functionally depending on the Emergency Department (ED). A questionnaire was sent to coordinators responsible for the EDSSUs identified among all Spanish hospitals appearing on the Ministry of Health web page. Data regarding structure, caseloads and clinical management practices were collected. Observation units for ED patients staying less than 24 hours and specialized units designated to treat one specific condition were excluded from the analysis.

Results:

A total of 591 hospitals appearing on the web page of the Spanish Ministry of Health were contacted and 35 EDSSUs (5.9%) were identified. Of these, 23 participated in the study reporting the 12-month activity registered in 17 EDSSUs and between 5 and 10.5 months in the remaining 6 through 2011. On average, the EDSSUs had 14 beds (range 5-30) and a mean physician/bed ratio of 1:6 (range 1:2-1:10). A total of 25,568 patients with a mean age of 67.2 ± 9.8 years were admitted during the study period. Seven EDSSUs (30.4%) admitted between 1000 and 2000 patients each and four EDSSUs (17.4%) more than 2000 patients each. In the latter group, patients admitted to the EDSSU accounted for 12% to 16.3% of all admissions from the ED. The most frequent diagnoses were acute heart failure, chronic obstructive pulmonary disease exacerbation, urinary tract infection and respiratory tract infection (DRG codes 127, 088, 321 and 541). On average, the LOS was 2.6 ± 1.1 days (range 1.2-5.3) varying between 2.2 and 3.54 days for the 10 most frequent DRG considered separately, the 30-day readmission rate after discharge from the EDSSU was 6.7% (range 0-14.6%) and in-hospital mortality was 0.59% (range 0-2.68%).  

Conclusions:

  1. To date, only a few Spanish hospitals have implemented EDSSU.
  2. Prevalent infections and exacerbation of chronic conditions are the most frequent causes for admission.
  3. Considering the results in terms of LOS, and the mortality and readmission rates after discharge, EDSSU appear to be safe and effective.
  4. Specific indicators should be developed in the near future to monitor and assess activity, patient outcome, quality of care, costs and resource use of EDSSUs.
  5. Given the important number of admissions, both absolute and relative, EDSSUs may be a useful tool to alleviate ED overcrowding although studies to assess the specific impact of such units are lacking.

Carles FERRE (Barcelona, Spain), Ferran LLOPIS, Antoni JUAN, Francisco Javier MARTIN-SANCHEZ, Gonzalo SEMPERE, Pere LLORENS, Carmen NAVARRO, Mikel MARTINEZ
11:00 - 18:00 #7246 - Should we redefine criteria for extracorporeal cardiopulmonary resuscitation in prolonged cardiac arrest?
Should we redefine criteria for extracorporeal cardiopulmonary resuscitation in prolonged cardiac arrest?

Introduction

Most protocols for extracorporeal cardiopulmonary resuscitation (E-CPR) normally exclude patients in prolonged cardiac arrest, as good neurological outcome and survival decrease significantly with longer CPR times. We present an out-of-hospital cardiac arrest (OHCA) case, who received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) after 150 minutes of advanced life support. The patient was eventually discharged following successful cardiac transplantation with complete neurological recovery. 

Case report

A 21-year old female suffered a witnessed OHCA while shopping and basic life support was started immediately (T0). Emergency medical services arrived within 10 minutes (T10). The initial rhythm was ventricular fibrillation and advanced life support was initiated according to European Resuscitation Council guidelines and continued until arrival at the Emergency Department. The patient remained in refractory ventricular fibrillation with an end-tidal CO2 (ETCO2) above 25 mmHg during prehospital resuscitation. On arrival at the ED (T40) the patient had pulseless electrical activity. Bedside cardiac ultrasound did not demonstrate tamponade or right ventricular distension but severe left ventricular dysfunction was noted.

Venous blood gas at T45 showed a pH of 7.091 and lactate of 7.8 mmol/L. At T70 there was return of spontaneous circulation, but this was non-sustained, and at T80 she reverted back to ventricular fibrillation, and chest compressions were restarted. The cardiothoracic team was consulted and she was accepted for VA-ECMO. Due to logistic reasons, she was only transported to theatre at T130. Femoral VA-ECMO was successfully initiated at T150. Postoperative echocardiography in the Intensive Care Unit (ICU) demonstrated severe dilated cardiomyopathy. At day 2, she was moving all four limbs and a decision to implant a biventricular assist device as a transplant bridge was made. She had a successful cardiac transplantation on day 13 and was discharged from ICU at day 58, with complete neurological recovery. Histopathology demonstrated non-specified cardiomyopathy. The patient had a sister who died in similar circumstances at young age.

Discussion

Despite prolonged OHCA and delayed initiation of VA-ECMO, outside recommended guidelines, there was a successful outcome with complete neurological recovery. This patient matched several inclusion criteria for E-CPR: witnessed OHCA, minimal no-flow time, rapid decision to transport, and good ETCO2 during resuscitation. Most studies recommend VA-ECMO initation within 60 minutes post-arrest as neurological outcome and chances of survival significantly decrease in prolonged OHCA. Even in case of survival, neurological outcome is often poor. Maintaining efficient tissue perfusion with adequate chest compressions is probably more important than the absolute time from onset of cardiac arrest. This is also suggested by the French national recommendations on this subject.

Conclusion

We report a case of E-CPR after prolonged OHCA, with full neurological recovery following cardiac transplantation. Contrary to current literature, we suggest that rather than base the decision to initiate VA-ECMO primarily on time from cardiac arrest, other factors should be considered. This is particularly so when the out-of-hospital cardiac chain of survival is preserved, and this case demonstrates that the envelope can be extended beyond 60 minutes in some circumstances.


Philip VERDONCK (Kontich, Belgium), David YEO, Koenraad MONSIEURS
11:00 - 18:00 #7056 - Simple questionnaire to enable nurse-led emergency department referral direct to mental health.
Simple questionnaire to enable nurse-led emergency department referral direct to mental health.

Introduction

7913 patients attended 183 British emergency departments (EDs) for mental health issues in 2014-20151. The Royal College of Emergency Medicine (RCEM) 2014 “Mental Health in the ED” report1 was critical of risk assessment documentation and time to be seen by a mental health practitioner (MHP), as nationally standards were not met. The Emergency Department Adult Mental Health Triage Tool (the tool) allows the triage nurse to refer patients directly to the psychiatry liaison service (PLS) without the need for repeated assessments and potentially unnecessary waiting time. The aims are to reduce the time to PLS referral, total time in department, the number of patients who abscond, prevent the stress and cost of unnecessary repeated consultations and perform a standardised risk assessment. 

 

Methods

The records of 50 consecutive patients presenting with mental health complaints before and after the introduction of the tool were reviewed and relevant timings recorded anonymously. Patients were only included if they were medically fit adults (no intoxication, self-poisoning or self-harm requiring medical/surgical assessment) and referred directly to psychiatry by the attending doctor/triage nurse. The tool consists of a standard risk assessment, demographic data collection and triage discriminators (5 questions).

 

Results 

Average time-to-referral was significantly reduced (1 hour 43 minutes to 21 minutes) and patients rarely saw two healthcare teams after triage (6% rather than 92%). 4-hour target breaches were halved (20 to 10) after the introduction of the tool. Average time in department was slightly reduced (4:05:54 to 3:28:22). No significant reduction in absconding but PLS was aware of these patients after the introduction of the tool. Admissions rose from 12% to 20% but it is unclear whether these could have been avoided with ED doctor intervention. Documentation improved globally.

 

Discussion

This vulnerable group of patients has received improved care since the introduction of this tool, as demonstrated by the parameters above. Patients have not unnecessarily given the same history to two healthcare teams and fewer have breached which has improved the patient experience. ED doctors are released to see other patients. Faster, standardised referrals mean PLS are advised of the need to assess a patient as soon as is possible. The department is not a “Place of Safety”, so all efforts to reduce the risks to patients and others and ensure a management plan is created quickly and efficiently will best serve to protect these individuals. A description is recorded for patients who abscond. The limitations of this tool include; triage nurses receiving no additional mental health training, and no effect on time from referral to PLS assessment. This simple tool has the potential to reduce distress, overall time and cost for every medically fit mental health ED patient. 

 

No associated conflicts of interest or funding. 

 

References

1 RCEM Mental Health in the ED National Report 2014-2015


Liam KEVERN, Charlotte LINDENBAUM (Ilfracombe, United Kingdom), Ffion BARHAM
11:00 - 18:00 #7985 - Simultaneous neck and back pain.
Simultaneous neck and back pain.

41 years old male patient with a history of chronic neck and back pain, who was intervened on both knees due to ligaments and meniscal pathology. He is not under treatment. Active life with daily bodybuilding exercise. Recent contact, few weeks ago, with a friend diagnosed with pulmonary tuberculosis.Attended the Emergency Service due to five days suffering from paresthesias in all four extremities with distal predominant hypoesthesia, especially in the left side. In addition, associated weakness in all four extremities, especially in the lower ones so he could not keep standing. He also referred weakness in his left hand.On neurological examination, the patient is conscious, oriented with normal speech and language, with negative meningeal signs, weakness in proximal lower extremities 4+/ 5 in right lower extremity; 4-/5 in the left lower extremity, left foot dorsiflexion 3/5, 4/5 right foot , plantar flexion of both 4/5 , 4/5 weakness in his left hand for abduction/adduction of fingers, arreflexia in lower limbs. ¼ tendon reflexes in upper extremities. Distal sensory loss in both lower extremities with paresthesia of all four limbs. Tenderness in the abdomen, normal chest and facial.Lumbar puncture is done to discard albuminocytological dissociation and he is entered in the Neurology Department with suspected Guillain Barre syndrome.Cerebrospinal fluid is reported as xanthochromic, with marked protein concentration and pleocytosis. Urgent cranial CT with normal results.Treatment was initiated with immunoglobulins, intravenous ampicillin and ceftriaxone. He suffered urinary retention in the early days, requiring placement of bladder size for urology, due to impossibility of doing a bladder catheterization related to an urethral stenosis. He presented a rapid deterioration during the first days, becoming quadriplegic with respiratory failure and severe dysphagia, D6 bilateral sensitive level and he was allocated in the Intensive Care Unit. After 24 hours , he required intubation for respiratory failure.Electroneurogram, indicating an acute demyelinating sensorimotor polyneuropathy was performed.



In the MRI with gadolinium, a meningeal thickening with cervical pseudonodular uptake in the C5-C6 levels in the lumbar spinal and root cone, suggestive of inflammatory-infectious disease was observed .Lumbar puncture was repeated, objectifying worsening of the parameters, and empirically TB treatment was added. PCR positivity of Mycobacterium tuberculosis in cerebrospinal fluid was subsequently confirmed. Corticosteroid treatment was associated during the first weeks of treatment.

He was finally diagnosed with tuberculous meningitis and cranial multineuritis mielorradicultis.

He was derived to the spinal cord injury unit of his reference hospital .




Ana Belén MARÍN FLORÍA, Elisa RUIZ OLIVARES, Sonia BALLESTÍN SOROLLA, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Silvia GANGUTIA HERNÁNDEZ, Pilar SARASA CLAVER, Carola MEDINA SAINZ
11:00 - 18:00 #8042 - Small intestine ischaemia related malrotation anomaly in one adolescent.
Small intestine ischaemia related malrotation anomaly in one adolescent.

Introduction: Midgut volvulus is a rarely seen malrotation developed with the rotation of the mesenteric root around the superior mesenteric artery. Although it is seen in infants more frequently, it can also be seen in adults. In this case, we aimed to exhibit the intestinal malrotation anomaly in 19-year-old male patients having chronic abdominal pain and small intestine ischaemia related to this.

Case report: the 19-year-old patient is having a complaint of abdominal pain interval, started to have severe abdominal pain, nausea and puffiness last one day and applied to our clinic with these complaints. In physical examination, there was prevalent tenderness on the abdomen and dull distension. In a laboratory investigation, there was no feature except elevated white blood cell count 15400/mm 3. There were no features on the ambulant abdominal radiograph.  270-degree dextrogyrate torsion on mesenteric root on the contrast enhanced abdominal tomography is reported. The operation is planned for the patient. On laparotomy, 80 cm from the ileocecal valve all small intestines from proximal were covered by periton leaf. Opening this periton, small intestines are monitored.  Among these small intestine segments, there were congenital (Ladd's) bands. Also dudeno jejunal was settled on the right of kollumna vertebralis. It was seen that, 100-cm small intestine segment's meso rotated by turning around a band, and ischaemia developed related to this. By opening the bands, rotation on the small intestine meso is fixed. After implementation of heat for a while, colour and peristaltism of the intestine returned to normal. Patient with no problem is discharged with suggestions on his second postoperative day.

Result: Intestinal malrotation is a quite rare anomaly but in terms of complications which it can cause, it is an important anomaly.  Intestinal malrotation must be located at definitive diagnosis rather than patients with small bowel obstruction findings and acute abdominal.


Erdem KARADENIZ, Sukru ARSLAN, Bünyami OZOGUL (Erzurum, Turkey), Sabri Selcuk ATAMANALP
11:00 - 18:00 #7338 - Social network analysis of international collaboration in emergency medicine researches.
Social network analysis of international collaboration in emergency medicine researches.

Background:
Diversity and collaboration facilitate the development of human society. The effects of national diversity and international collaboration on the impact of emergency medicine (EM) researches are not studied.

Objectives:
This study aims to evaluate the effect of international collaboration on EM researches impact and determine the hub countries of international collaboration by social network analysis (SNA).

Methods:
Design: This study was an observational study.
Setting: All of the data were collected from SciVerse Scopus database.
Type of participants: All of the articles published in journals of EM category (2013 Journal Citation Reports) before 2015 were enrolled.
Data Collection: A computerized literature search was conducted in March, 2015. We collected data on publications including publication year, author’s affiliated country, document type, and cited times for further analyze. The publication’s origination was classified according to the first author’s nationality. The international collaborative research was defined as the authors were affiliated with two or more countries.
Data Analysis: The demographic data were analyzed by descriptive statistics. Linear regression was used for trend analysis. The cited times difference between single nation and international collaborative publications were analyzed by Wilcoxon rank-sum test. NodeXL were used to calculate SNA metrics of international collaborative publications (In-degree: co-author numbers; Out-degree: leading author numbers; Betweenness centrality: connectivity of hub country; Eigenvector centrality: ranking of linkage to influential hub countries) and create visualization graphs.

Results:
A total of 94925 publications were enrolled and 4480 (4.72%) were international collaborative publications. The number of international collaborative publications increase from 0 in 1961 to 511 (8.92%) out of 5734 in 2014. The trends of international collaborative publications and ratio of international collaborative publications to all EM publications from 1961 to 2014 were 7.04, and 0.002, respectively (all p<0.001). The average cited times of single nation and international collaborative publications were 9.61 and 12.42 (p<0.001). The United States, United Kingdom, Canada, Germany, and Australia were leading five countries in international collaboration. The social network metrics of leading ten countries in international collaboration were in Table.

Conclusions:
International collaboration in EM researches was increasing and the impact of international collaborative researches was greater than single nation researches from the perspective of cited times. The leading countries were the hubs of international collaborative EM researches which were in North America and Europe. From the perspectives of EM journal editors, accepting more international collaborative publications may enhance the academic influence of journals. From the perspectives of international EM, implement strategies that strengthening international collaboration in EM researches may enhance global academic excellence in EM, especially countries outside the hubs. Further analysis of the characteristic of international collaborative publications such as funding support, leading authors’ past academic contribution could identify factors that enhance researches’ impact and facilitate EM specialty development.


Ching-Hsing LEE (Taipei, Taiwan)
11:00 - 18:00 #7456 - Social network analysis of international collaborative publications in European Journal of Emergency Medicine.
Social network analysis of international collaborative publications in European Journal of Emergency Medicine.

Background:
European Journal of Emergency Medicine (EJEM) is one of the leading journals in emergency medicine (EM) with increasing publications from the all over the world. The effects of international collaboration on the impact of publications in EJEM and the hub countries of international collaboration were not studied.

Objectives:
This study aims to evaluate the effect of international collaboration on the impact of publications in EJEM and social network analysis (SNA) of international collaboration.

Methods:
Design: This study was an observational study.
Setting: All of the data were collected from SciVerse Scopus database.
Type of participants: All of the articles published in EJEM before 2015 were enrolled.
Data Collection: A computerized literature search was conducted in March, 2015. We collected data on publications including publication year, author’s affiliated country, document type, and cited times for further analyze. The publication’s origination was classified according to the first author’s nationality. The international collaborative research was defined as the authors were affiliated with two or more countries.
Data Analysis: The demographic data were analyzed by descriptive statistics. Linear regression was used for trend analysis. The cited times difference between single nation and international collaborative publications were analyzed by Wilcoxon rank-sum test. NodeXL were used to calculate SNA metrics of international collaborative publications (Out-degree: leading author numbers; In-degree: co-author numbers; Betweenness centrality: connectivity of hub country; Eigenvector centrality: ranking of linkage to influential hub countries).

Results:
A total of 1701 publications were enrolled and 84 (4.9%) were international collaborative publications. There was no international collaborative publication between 1994 and 2005. The number increased from 6 (5.9% of 102) in 2006 to 25 (9.2% of 153) in 2014. The trends of international collaborative publications and ratio of international collaborative publications to all EJEM publications from 1994 to 2014 were 0.747, and 0.007, respectively (all p<0.001). The average cited times of single nation and international collaborative publications were 13.5 and 19.4 (p<0.001). The difference remained significant when we limited the publication type to articles (6.389 and 4.120, p=0.186, respectively). The United States, Spain, United Kingdom, Belgium, Italy, Germany, France, Canada, Australia, Netherlands were leading ten countries in international collaboration publication. The social network metrics of these countries were in Table.

Conclusions:
EJEM is a globalized journal with publications from more than 20 countries every year and international collaborative publications were increasing in the past ten years. From the perspective of cited times, there was no statistic difference between the impact of international collaborative and single nation publications. The leading countries of high out-degree or in-degree were the hubs of international collaborative researches. Implement strategies that strengthening international collaboration in EM researches may enhance global academic excellence in EM, especially countries outside the hubs.


Ching-Hsing LEE, Pei-Chen JUAN (Taoyuan, Taiwan)
11:00 - 18:00 #7622 - SOFA score trend in septic patients: which is the most appropriate time interval to improve prognostic stratification?
SOFA score trend in septic patients: which is the most appropriate time interval to improve prognostic stratification?

Introduction: New criteria for diagnosis of sepsis and septic shock give a crucial role to Sequential Organ Failure Assessment (SOFA) score evaluation at the moment of presentation, but it is well known that sepsis is a rapidly evolving disease. The aim of this study was to compare the prognostic value of SOFA score trend at 6 and at 24 hours after admission, in order to identify the most appropriate timing to evaluate score’s evolution.

Methods: This is a preliminary analysis of patients enrolled in a prospective research aiming to find reliable biomarkers for an early sepsis diagnosis. We performed an interim analysis on 191 patients admitted from November 2011 to December 2015 to the Emergency Department High-Dependency Unit (ED-HDU) of the University Hospital of Careggi with a diagnosis of severe sepsis or septic shock. At ED-admission (T0), after 6 hours (T6) and 24 hours (T24) from the initial diagnosis, we evaluated SOFA score; score differences over 6-hour (ΔSOFA-6H) and 24-hour time interval (ΔSOFA-24H)were calculated. The primary end-point was in-hospital mortality.

Results: Main comorbidities among our study population (60% male gender, mean age 74±15 years) were hypertension (59%), diabetes mellitus (32%), chronic obstructive pulmonary disease (23%), coronary artery disease (21%). An hematologic malignancy was present in 16 patients (9%) and a solid tumors in 26 (14%). The source of infection was the respiratory tract in 81 (44%) patients, abdomen in 25 (14%), the urinary tract in 29 (16%), while it remained unknown in 31 (17%) patients. Seventy-nine patients developed a septic shock (41%). In-hospital mortality rate was 27%.

T0 SOFA score was comparable between survivors and non-survivors (4.9±2.7 vs 5.8±2.9, p =NS), while it became significantly higher in non-survivors compared with survivors at T6 (8±3.3 vs 6.2±2.9, p =0.003) and at T24 (8.4±3.9 vs 5.2±2.4, p <0.001). Discriminative analysis by ROC curves confirmed a poor prognostic stratification ability for T0 SOFA (area under curve, AUC, 0.605, 95%CI 0.497-0.712, p=0.060), a fair performance for T6 SOFA (AUC 0.665, 95%CI 0.559-0.770, p=0.005) and a moderate discriminating ability for T24 SOFA (AUC 0.767, 95%CI 0.670-0.865, p<0.001). ΔSOFA-T6 only tended to be higher in non-survivors than in survivors (2.1± 2.5 vs 1.2± 2.0, p=0.05), while ΔSOFA-24H was significantly higher in non-survivors (2.3±3.4 vs 0.3±1.6, p=0.006). Repeated measures analysis of variance showed a significant score increase within subjects (p=0.001) and a significant higher increase in non-survivors compared with survivors (p=0.006).

Conclusions: Prognostic value of SOFA score was poor at the moment of sepsis diagnosis; at a 6-hour interval, discrimination ability was persistently fair. Both the absolute value after 24 hours and the trend in the first 24-hour period showed a moderate prognostic ability. A six-hour interval, although appealing for an Emergency Medicine setting, appears a too short time interval to improve prognostic stratification of septic patients.


Chiara DONNINI (SESTO FIORENTINO-FIRENZE, ), Simona GUALTIERI, Camilla TOZZI, Federico MEO, Francesca INNOCENTI, Riccardo PINI
11:00 - 18:00 #8183 - Something has bitten me.
Something has bitten me.

INTRODUCTION:Tick bite is a public health concern because ticks are among nature’s efficient transmitters of infectious bacteria, with a variety of clinical presentations and a complicated clinical course without taking early actions.It is important to remove a tick as soon as you find it.Removing the tick's body helps you avoid diseases the tick may pass on during feeding.Prevention is the best means of dealing with ticks and the diseases they can transmit to humans. 

PERSONAL HISTORY:No known allergies.Hypercholesterol no treatment.Surgical Ant. Varices in 2007.

PRESENT ILLNESS:58 years old man who comes to the emergency room for pain in inner side of right calf. Indicates that a month ago had bug bite, that was treated with antibiotics by their primary care physician, but since then he has presented asthenia.Today again presents a bug bite in the internal base of the right thigh.He removed the insect and go to the emergency room presenting leg pain. No fever, no other associated symptoms.

EXPLORACION GENERAL:Hemodynamically stable, roams in antalgic position.Presents induration on the medial malleolus and indurated way up to the knee.At the level of the base of the thigh, objectifies wound insect bite, because it is possible to see traces of feet into the wound.Analytical studies: Leu 8620 (N59%, L27%, M11%).VENOUS DOPPLER: Dilated venous pathway in the territory of the saphenous vein with echogenic occupation and loss of flow in the Doppler suggestive of thrombosis, to the proximal segment. Borre. Burgdorferi IgG negative.

 

Clinical judgment, differential diagnosis, problem identification:Patient who initially presented pain in the right lower extremity, linear venous path induration, differential diagnosis arises: 1.phlebitis, 2.cellulitis, 3.lymphangitis; having made an exhaustive physical exam and valuing his personal/social context, it was determined that the patient has a thromboembolic complication secondary to a tick bite.

 DIAGNOSIS:Deep vein thrombosis as a complication of tick bite

Treatment, action plans:Insect debris removal, antibiotic, enoxaparin and NSAIDs. Followed by Surgery, Dermatology and Family Physician to assess progress and check the correct intake of medication.

Discussion and Conclusions:There is a few bibliographic information about this new disease.  The first time describe was in July 2009 a 77-year-old man from western Sweden. This patient was the first human to be infected with Candidatus Neoehrlichia mikurensis, which was first isolated in rats from Mikura Island, Japan in 2004. However, the bacteria have never before been detected in Sweden: not in ticks, rats, or humans. The bacteria have infected eleven patients thus far; three in Sweden, and the rest scattered throughout Germany, Switzerland and the Czech Republic. Its widespread range across Europe suggests that it could be an emerging pathogen and it is associated with thromboembolic complications. The importance of publishing this case is to show this new disease. "You can´t look for, which is not known", because of that it was not possible to isolate another causal agent since only Lyme serology was performed. Fortunately for the patient, Doxycycline was prescribed, medication described as effective in the treatment of this disease. A new disease, a new challenge.


Cyntia Anabella SESAM MÉNDEZ, Martha URDAZ HERNÁNDEZ, Maria Pilar POVEDA SERRANO (Zaragoza, Spain), Felicidad YAÑEZ RODRIGUEZ, Carmen TORRA CUIXART, Eduardo ROMANO MAQUEDA, Karen CONTRERAS DELGADO, Vanesa GIRÓN ESTRADA
11:00 - 18:00 #7293 - Spiked Helmet Sign – A mimic of ST-segment elevation myocardial infarction.
Spiked Helmet Sign – A mimic of ST-segment elevation myocardial infarction.

Introduction: Electrocardiogram (ECG) is an important diagnostic tool for the prompt recognition of myocardial infarction. There are some ECG findings of non-cardiac disease in critically ill patients presenting as ST-segment elevation, which might be mimicking as ST-segment elevation myocardial infarction. The spiked helmet sign is a rare and notorious ECG marker because of a high risk of impending death.1 However, the current prevalence and mechanism remain uncertain. It might be leading into catastrophic result if it is unrecognized and treated in a different clinical management.2 We presented a rare case with the spiked helmet sign presented with epigastric pain.

Case report: This 38-year-old man has the medical history of alcohol dependence. He presented to our emergency department because of progressive epigastric pain for three days. On physical examination, there were severe tenderness on the epigastrium with obvious rebounding pain. The initial ECG showed a dome and spiked ST-T segment changes T wave on II, III, aVF and atypical V1 to V4 ST-T segment elevation. However, serial ECG which was performed five minutes later showed sinus tachycardia alone without any ST-T segment change after the prescription of intramuscular 5-mg Morphine. The laboratory data showed that there was neither hyperkalemia(3.58 mmol/L) nor troponin-I (<0.01 ng/mL) elevation. The remarkable laboratory abnormality was the elevated lipase level (4124 IU/L). Subsequently, abdominal computed tomography (CT) was arranged and showed swollen pancreas with fat stranding sign, which is referred to the impression of acute pancreatitis. He was discharged without any sequelae after a seven-day hospitalization.

Discussion: Spiked helmet sign, reported by Littmann and Monroe, was linked to a spiked German military helmet. Based on the recent articles, the pseudo-ST segment elevation may imply critical-ill disease and higher mortality.1 The mechanism of this phenomenon remain uncertain and there are some hypotheses. Certain pathological conditions can rarely cause repetitive contraction of the diaphragm that is simultaneous with the cardiac cycle.3 The definite mechanism of this pseudo-ST-segment elevation is unknown, however, in the case of inferior ST-segment elevation, the postulated mechanism was diaphragmatic motion or an acute rise in intra-abdominal pressure.2 In our case, an acute rise in intra-abdominal pressure due to acute pancreatitis may be the reason of the pseudo-ST-segment elevation. Based on our knowledge, this is the first case of spiked helmet sign caused by acute pancreatitis. Furthermore, to settle whether the spiked helmet sign will alter clinical management or just remain an electric curiosity require further researches.

Reference:

  1. Littmann L. et al. The “spiked helmet” sign: a new electrocardiographic marker of critical illness and high risk of death. Mayo Clin Proc. 2011;86(12):1245–1246
  2. Tomcsányi J et al. ST elevation anterior “spiked helmet” sign. Mayo Clin Proc.2012;87:309.
  3. Agarwal A, et al. Spiked helmet sign: An under-recognized electrocardiogram finding in critically ill patients. Indian J Crit Care Med. 2014 Apr; 18(4): 238–240.

Po-Liang CHENG (Tainan City, Taiwan), Ting-An DUNG
11:00 - 18:00 #7484 - Spinal cord compresssion from a spontaneus hematoma: a diagnosis challenge in emergency room patients.
Spinal cord compresssion from a spontaneus hematoma: a diagnosis challenge in emergency room patients.

SPINAL CORD COMPRESSION FROM A SPONTANEUS HEMATOMA:

A DIAGNOSIS CHALLENGE IN EMERGENCY ROOM PATIENTS

Spinal cord compression from a hematoma is a rare clinical entity which causes a quick and severe neurological damage that turns irreversible without an early diagnosis and surgical treatment.

It is presented usually as sudden acute pain followed by neurological symptons due to spinal cord compression. The most important prognostic factors are the degree of neurological afectation as well as the time interval between the diagnosis and the surgical drainage, and here lies the true importance of role of the Emergency Rooms.

We present 6 cases serie attended in the Emergency Room during last 3 years wich present acute pain associated to neurological symptoms with a confirmed diagnosis of spinal cord hematoma.

All 6 cases were spontaneus hematomas and no common risk factors were identified.

It involves males and females equally weighted, 50 %. An average age of 66,6 years, being the younger patient 41 years old and 85 the older. Extradural hematoma was found in 2 cases and epidural in the other 4.Only 2 patients were under anticoagulant therapy.

The main symptom was acute spinal pain followed by neurological progresive affectation. This neurological involment varies depending on the affected spinal area and hematoma magnitud.

Cervical spine hematomas were founded in 2 cases with upper limbs neurological symptoms.

Lower limbs neurological symptomatology was presented in 4 cases, 2 related with dorsal spine hematoma and 2 with lumbar affectation.

The surgical successfully drainage was made in four patients and the other two developed favourably with nonsurgical treatment provided. After 6 months, 5 out of 6 patients achieved fully recover. In all 6 patients, so far, they are free from recurences.

Spontaneus hematoma phisiopathology is a controversy and production mechanism are unknown. The spinal cord compression from spontaneus hematoma are uncommon and presented in a wide range of possibilities depending on their location and with the acute spinal pain as an overarching characteristic for all. Neurological symptoms that derive from compression can appear over time.

Medical diagnosis skills, above all in Emergency Room, can be crucials in identifying this clinical entity in order to immediatly provide and not delay a surgical treatment.


Álvaro MARTÍN PÉREZ (Badajoz, Spain), Concepcion DE VERA GUILLÉN, Juan María FERNANDEZ NUÑEZ, Rosario PEINADO CLEMENS, Miguel Angel RUIZ SANZ
11:00 - 18:00 #7597 - Spontaneous intramural small-bowel hematoma due to anticoagulants use: a case report.
Spontaneous intramural small-bowel hematoma due to anticoagulants use: a case report.

Background: Spontaneous intramural hematoma of the small intestine is a rare clinical condition that must be considered in the differential diagnosis of acute abdomen in patients taking oral anticoagulants.

Case report: We report a spontaneous intramural jejunal hematoma presenting with abdominal pain, distension, vomiting and radiological signs of small bowel obstruction. At the beginning no peritoneal irritation was detected. CT performed without contrast demonstrated intramural wall thickening involving the jejunum. Surgical intervention was later required due to the onset of signs of peritonitis and active bleeding.

Conclusion: The history of anticoagulant use in patients presenting with abdominal pain should alert the ED physician.  Small bowel obstruction may be the onset, signs of peritoneal irritation may appaear due to wall ischemic necrosis and hemoperitoneum. Non-contrast CT scan is the first-line diagnostic tool, ultrasounds can be an alternative in experts hands. Early diagnosis, prompt medical treatment and close monitoring should be undertaken in the early stages in order to avoid unnecessary surgicals interventions otherwise allows to detect cases in which surgery comes to represent the therapeutic measure.


Brugioni LUCIO, Maurizio TOGNETTI, Valentino SANTORI (Offagna (AN), Italy), Lucia AMIDEI, Francesca MORI, Gabriele CALDERONE, Sabrina LUPACCIOLU
11:00 - 18:00 #7581 - Spontaneous Pneumomediastinum: Differentiation Diagnosis and Management.
Spontaneous Pneumomediastinum: Differentiation Diagnosis and Management.

Background & Objectives:

The primary spontaneous pneumomediastinum is not frequent. In other studies this disease usually has one benign course and conservative treatment could be enough. The follow up procedure can be performed in outpatient service. On the other hand secondary spontaneous pneumomediastinum should need further management including some invasive procedure to find out the induced sources and make appropriate treatment. How can we make an appropriate differentiation diagnosis between primary and secondary spontaneous pneumomediastinum. We review our cases and try to find the key point of differentiated diagnosis and set up an appropriate management strategy.

Participants and Methods: We take a retrospective review of all spontaneous pneumomediastinum(SPM) cases between May 2011 and March 2016. 17 cases are included. We separate these patients into two groups. One is primary SPM and the other is secondary SPM. The clinical outcomes are recorded including past history, mechanism, present symptoms and signs, complications and demands for investigation studies or admission. The radiologic films are reexamined by the radiologic doctor.  

Results

In this study the primary SPM group has 6 cases and secondary SPM group are 11 cases. The all patients have at least one symptom of Meckler’s triad. There are 76.5 % of cases complaining of chest pain and are the most common symptom complained. 33 % cases of primary SPM and 27.3 % cases of secondary SPM have sore throat or hoarseness. The Mackline effect is noted on 29.4% of all SPM cases. Most patients of primary SPM belong to young age and there usually is one individual matter induced such as heavy physical straining. In the secondary SPM the disease sources are more complex such as cough induced by asthma or chronic lung disease, dental or auditory tract wound infection, trauma by fishbone or blunt contusion and mediastinitis. Unfortunately the blood examination can’t be used for differentiation diagnosis.  

Discussion and Conclusion: In this study we find primary SPM is combined with heavy physical straining and usually has one benign course. The organ injury rarely occurs but secondary SPM should take further managements. Additional investigation with esophagography or other invasive procedures should be performed to exclude the infection, trauma or organ perforation. The chest computer tomography (CT) can be used for diagnosis but the air leak site is usually not found on CT. When there are clinical conditions such as asthma, chronic lung disease, s/p head or neck operation, foreign body miss-wallowing or blunt trauma with any symptoms of Meckler’s triad found, the secondary SPM should be highly suspected. The further treatments and managements will be necessary.   

Reference:

  1. Paulette I. A., Adesola C. A.,Michelle L. P., Mark V. M. Spontaneous pneumomediastinum in the pediatric patient The American Journal of Surgery 210, 1031-1036, 2015


Chia-Hsi CHEN (Chiayi, Taiwan, Taiwan), Yueh-Feng TSAI, Tak-Yee WONG, Yi-Chun SU, Jui-Fang HUANG
11:00 - 18:00 #7731 - Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury.
Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury.

Intussusception is common in early childhood. Intussusception due to blunt injury is rare and not predominant in the pediatric population but there are only a few adult cases

A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. He had no chronic illness and no drug or substance abuse. His vital signs were within reference range. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass, and surrounding gas appearances were visible. Whole-body CT showed normal head and thorax findings, but there was a target sign in the axial view consistent with intussusception. In addition, coronal views demonstrated pseudokidney or the sandwich sign. The patient was taken to our trauma room; meticulous tertiary examinations were done. Two liters of normal saline was administered. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control CT showed that the findings of intussusception disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality.

The telescoping of the proximal intestinal segment into the adjacent distal intestinal segment is described as intussusception. Although it is the most common cause of intestinal obstruction and the second most common cause of acute abdomen in pediatric age group, intussusception constitutes 1% to 5% of all intestinal obstructions of adulthood. In adults, 80% of the cases have an underlying etiology, being different from children. Tumors, polyps, edema and fibrosis of the intestinal wall due to surgical interventions, Meckel diverticulum, inflammation, postoperative adhesions, and intestinal sutures are the most frequently described causes in adults.Intussusception related to abdominal trauma is met very rarely. In published studies, abdominal trauma was found as the etiological factor in only 0.7% to 1.96% of all adult patients having intussusceptionThe risk of intussusception is higher in penetrating trauma when compared to the blunt injury. Intussusception is generally seen after trauma associated with high-energy and multiple injuries. However, in our case, it was observed as an isolated event, without any coexisting high-energy trauma or organ pathology.

In conclusion, we suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. CT is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in CT, no further treatment is required.

 (This case report is accepted in American Journal of Emergency Medicine with doi number as: doi:10.1016/j.ajem.2015.07.053)


Mucahit EMET (Erzurum, Turkey), Abdullah Osman KOCAK, Ilker AKBAS, Adem KARAMAN, Sukru ARSLAN
11:00 - 18:00 #7601 - Staff perceptions of paediatric resuscitation decisions following out-of-hospital cardiac arrest.
Staff perceptions of paediatric resuscitation decisions following out-of-hospital cardiac arrest.

Resuscitation is unsuccessful in 70-98% of cases and survival in children is worse than in adults. A review of patients presenting to the emergency department at a tertiary paediatric hospital in Western Sydney over a 13 year period found that 100% of children died following out of hospital cardiac arrest when CPR was ongoing at time of presentation to the emergency department. Despite such poor outcomes, paediatric resuscitation attempts tend to continue for longer than in adults due, at least in part, to emotional reasons. However, there is no single predictor for when to cease efforts in the case of an unsuccessful resuscitation.

In adult practice there exists a prospectively validated set of rules for the termination of cardio-pulmonary resuscitation (CPR) in the pre-hospital setting following out-of-hospital cardiac arrest (OHCA). Currently, no rules exist for the paediatric population.

Our emergency department seeks to develop a decision-making tool which will support and guide clinical staff in reaching the decision of when to stop resuscitation in patients who present to the emergency department following OHCA who are receiving CPR on arrival. Understanding staff perceptions in relation to current practice and involving staff in the development of the decision-making tool will help ensure local staff engagement, which in turn will aid in its successful implementation.

Our survey aims to gather the perceptions of staff in relation to our current practice when deciding to cease resuscitation efforts. It also aims to describe their views on the decision process for ceasing resuscitation attempts and identify their opinion on the need for a decision-making tool within our department.

We conducted a web-based, qualitative staff survey in the emergency department of The Children’s Hospital at Westmead, a tertiary paediatric hospital and paediatric trauma centre in Western Sydney. The two-part survey assessed staff views and perceptions of paediatric resuscitation following cardio-respiratory arrest in relation to the last case in which they were involved as well as their general views and perceptions. The survey also assessed staff opinion on the usefulness of a tool to guide and support decision making in relation to ceasing resuscitation efforts.

The results of the survey will help inform the development of our decision-making tool to address the needs of clinical staff and identify potential barriers to the implementation of the tool within the paediatric emergency department.


Michael MCCARRON (Glasgow, United Kingdom), Rachael FRIERY, Jason HORT
11:00 - 18:00 #7164 - Staphylococcal community-acquired urinary tract infection in the emergency department: a sign for acute infective endocarditis?
Staphylococcal community-acquired urinary tract infection in the emergency department: a sign for acute infective endocarditis?

Introduction: Urinary tract infection is a frequent cause of admission at the Emergency Department (ED). Most prevalent bacteria are usually gram-negative bacilli and Staphylococcus aureus (Sa) is rarely evidenced (2.5%) except in hospital-acquired infections due to urinary catheter (Ekkelenkamp, Clin Infect Dis Off Publ Infect Dis Soc Am 2007;44(11):1457–9). Bacteriuria can be observed in Sa infective endocarditis (IE) because of the metastatic properties of Sa. We hypothesized that presence of Sa in the urine could be related to Staphylococcal bacteremia associated with unsuspected IE and not only the expression of a "usual" urinary tract infection.

Methods: This is a descriptive single-center study conducted over a 10-year period in the Teaching Hospital of Limoges. All patients admitted to the ED with Sa (both MSSA and MRSA) isolated from their urine cultures were retrospectively analyzed. Data were collected from the database of the microbiology department and the patient medical charts. We secondarily searched if a Sa IE had been documented in patients with Sa isolated from their blood cultures in order to establish a link between IE and presence of Sa in the urine. We used modified Dukes criteria as diagnostic criteria of IE (Li, Clin Infect Dis Off Publ Infect Dis Soc Am 2000;30(4):633–8).

Results: Between 2005 and 2015, 420 000 patients were admitted in the ED. Out of the 204 records analyzed, 174 patients whose urine culture grew Sa were excluded because they had a urinary catheter (n=75) or sterile blood cultures (n=99). Finally, 30 patients were studied (17 men; median age: 73 years; diabetes: n=7; mitral valvular disease: n=2, aortic valvular disease: n=2). Reasons for admission were markedly heterogeneous and fever accounted for 14 cases. Echocardiography was performed in 25 patients with a median delay of 6.5 days (range: 0-23 days) and IE was confirmed in 21 of them. Only three cases of IE have been diagnosed in the ED because of a fever and valvular murmur (n=2) but no patient was admitted to the ED for IE suspicion. Other initially suspected diagnoses were prostatitis, pneumonia or appendicitis and not related to any type of infection in 26% of the cases. The origin of Sa bacteremia was cutaneous in 67% of the cases. During the hospital stay, 70% of the patients presented secondary sites of Sa infection in addition to the urinary tract (arthritis, splenic abcess, cerebral hematoma). Among 21 patients presenting with an IE, 8 died within 7 days, and total hospital mortality reached 50 %.

Conclusion: This case series suggests that IE should be ruled out when Sa bacteriuria is evidenced, irrespective of the clinical presentation. This could question the reality of isolated community-acquired urinary tract infections due to Sa.


Thomas LAFON (Limoges), Philippe VIGNON, Thomas DAIX, Lucie LAVAUD, Alexandra APPERT, Vincent BIGRAT, Vincent LEGARÇON, Olivier BARRAUD, Bruno FRANÇOIS
11:00 - 18:00 #7584 - STAR: STrengthening high Altitude Research – reaching consensus using the Delphi technique.
STAR: STrengthening high Altitude Research – reaching consensus using the Delphi technique.

Background: The number of clinical and basic research studies in high altitude medicine has increased in the last decade. Studies are heterogeneous and have limited impact on clinical practice. The aim of the STAR (Strengthening high Altitude Research) project is to use the approach of standard reporting systems like the Utstein style to create a list of parameters essential for clinical research in high altitude medicine.

Method: The project uses the Delphi process to collect expert input on essential parameters and definitions for high altitude research and will derive a final checklist via consensus of an expert group, renowned for their expertise in high altitude research.

Results: As per today, more than 30 renowned experts from all over the world accepted to participate in this Delphi process which will last from May until the end of 2016. In February 2017, the list of essential parameter for clinical research in high altitude will be presented at the Hypoxia Conference.

Discussion: The aim of the presentation is to show an ongoing process aiming for transparency and consensus finding for clinical research in high altitude.


Dr Monika BRODMANN MAEDER (Bern, Switzerland), Giacomo STRAPAZZON, Matiram PUN, Hermann BRUGGER
11:00 - 18:00 #6325 - Sternal fracture- rare but possible in children.
Sternal fracture- rare but possible in children.

A nine year old boy presented to a district general emergency department after he toppled off a swing and landed onto his anterior chest wall.

He was initially managed as a chest wall contusion and was discharged home with oral analgesia. Despite adequate oral analgesia, his pain persisted and he re-attended the emergency department a week later.

On examination his cardio-respiratory status was stable. There was tenderness and a step over the sternal area with no associated injuries.

On clinical suspicion plain radiographs of the chest and a lateral view of the sternum were done which showed a fracture of the body of the sternum with posterior displacement.

He was then transferred to our hospital for further management. In our emergency department his clinical examination did not change from previously described. A 12 lead electrocardiogram and a bedside echocardiogram did not reveal any abnormality.

He was admitted under cardiothoracic surgeons for overnight observation. He subsequently developed neck pain without neurological deficit. Plain films and MRI of the thoracic spine were normal.

The sternal fracture was managed conservatively and he was followed up appropriately.

On reviewing the literature chest wall injuries causing fractures are uncommon in children. The increased pliability and elasticity of the child’s chest wall reduces the susceptibility to fracture. Though rare, sternal fracture does occur with direct injury (blunt trauma) to the chest wall and indirect injury following flexion-compression to the upper thorax. Hence careful examination of the thoracic spine in the presence of a sternal injury and vice-versa is emphasized for indirect injuries. The associated intra-thoracic injuries is high in children as a result of severe blunt trauma like motor vehicle crashes. A lateral x-ray of the chest is the easily available investigation but a bed side ultrasound has higher sensitivity and specificity in diagnosing sternal fractures. Ultrasound expertise in emergency department is highly variable.

Sternal fractures in children are generally managed conservatively. In adults who are otherwise fit and well and have normal electrocardiogram & chest x-ray on presentation can be safely discharged from the emergency department with oral analgesics. However the point at which we can safely discharge children with sternal fracture from the emergency department is not clear.

There are no set guidelines regarding managing sternal fractures in children, but each presentation is managed based on the clinical situation. This case report highlights the need for further studies to make and validate decision rules regarding managing sternal fractures in children.


Bimal MEHTA, Sarah FISSLER, Balakrishna VALLURU (Southport, United Kingdom)
11:00 - 18:00 #7904 - Still a challenge: pain evaluation and management.
Still a challenge: pain evaluation and management.

Background and objectives

Pain associated with both acute and chronic medical conditions is one of the main causes patients seek medical care. However the problem of inadequate analgesia in prehospital emergency setting and emergency departments (ED) still remains. Inability to assess pain could be an important barrier to the provision of analgesia. The need for analgesia is often unrecognized, patient evaluation of pain is underrated. The aim of our study was to evaluate pain management skills, knowledge of pain assessment among prehospital emergency caregivers and emergency department triage nurses.

Methods

A questionnaire regarding pain assessment habits was completed by emergency medical service (EMS) personnel and ED nurses in tertiary care university affiliated hospital. Also prehospital and ED records of patients with conditions that potentially causes pain reviewed. Data collected included demographic information, localisation/cause of pain, pain evaluation scores, treatment choices, reassessment. Records of patients under eighteen years and patients with altered state of consciousness were excluded.

Results

The knowledge and application of standardised pain assessment tools is not satisfactory in prehospital and ED setting of investigated area. Disparities exist among both EMS providers‘ and ED nurses‘ knowledge and usage of pain evaluation techniques. There are differences between pain scores of the same patients evaluated by EMS personel after arrival to the ED and ED triage nurse. Lack of documenting pain scores and reassessment of pain after treatment are seen in many cases.

Conclusion

Existing disparities in pain assessment among emergency care providers, lack of knowledge of standardised techniques can lead to oligoanalgesia. A focus on strategies to improve pain management is necessary. Quality control programme is needed including audit on pain management, training of pain management in prehospital and ED setting. It would be the next step of this study. Further evaluation and research is needed after introduction of quality improvement programme.


Dr Ieva PALIOKAITE (Kaunas, Lithuania), Kestutis STASAITIS
11:00 - 18:00 #8092 - Stridulous sisters: a background of functional illness leading to diagnostic uncertainty.
Stridulous sisters: a background of functional illness leading to diagnostic uncertainty.

Stridulous sisters: a background of functional illness leading to diagnostic uncertainty

The differential diagnosis of stridor in children is broad and includes a number of infective and non-infective causes.  We present the unusual case of two sisters, aged 10 and 15 years (patient 1 and patient 2), who presented to the emergency department together with acute onset stridor.  Both complained of identical symptoms, notably general malaise, sore throat, chest pain, intermittent fever and difficulty in breathing.  Both sisters described worsening inspiratory stridor in the hours prior to admission.  Cough was not a prominent feature and voice quality appeared to be normal in both cases.  Both sisters were known to have a background of functional illness.  Patient 1 did not respond to initial therapy (nebulised adrenaline and dexamethasone) and stridor was noted to be intermittent during admission, with symptoms settling during sleep and when medical staff were not present.  Patient 2's stridor settled following nebulised adrenaline and dexamethasone and did not recur.  Patient 1 was diagnosed with bacterial tracheitis with characteristic appearances on flexible laryngoscopy.  Patient 2 was diagnosed with a viral upper respiratory tract infection.  Functional overlay was suspected in both cases.  Bacterial tracheitis is a rare but life threatening cause of airway obstruction that must be considered in all patients presenting with stridor.  A background of functional illness can cause diagnostic uncertainty, as in this case.  As clinicians we must remain unbiased and ensure that appropriate management is instituted for all patients.  Functional stridor is a diagnosis of exclusion.


Craig SWINBURNE (Glasgow, United Kingdom)
11:00 - 18:00 #7372 - Stroke code in emergency department between 2009 and 2015: can we do it better?
Stroke code in emergency department between 2009 and 2015: can we do it better?

INTRODUCTION:

Intravenous thrombolytic therapy after ischaemic stroke significantly reduces mortality and morbidity. Reperfusion therapy is time-dependent and is by itself a main exclusion criteria. Evaluate the state of the art about thrombolysis rates and door to needle times in our hospital are critical and allows to design  future strategies in order to shorten times.

METHODS:

Descriptive cross-sectional study by systematic search for all patients admitted in emergency department as stroke

 code activation in Hospital Universitari Joan XXIII, Catalonia, Spain. From 2009 to 2015 data concerning age,

neurological status evolution (National Institute of Health Stroke Scale (NIHSS) at arrival, 24 h and 3 months),

 onset-to-door times, door-to-neurologist examination times, and door to needle times (DTN) were collect. All

statistical analyses were performed by using IBM SPSS statistics.

 

RESULTS:

A total of 263 patients with acute ischaemic stroke treated with reperfusion therapies were evaluated. The mean age was 67,28 years (STD 12,89). Onset-to-door at emergency department was 40,75 minutes (STD36,41) and neurological examination were perform in 8,46 minutes (STD 22,53). The median door to needle time was 60,55 minutes ( STD 21,47).  DTN times decreases by years: from 70 minutes (STD 25,2) in 2009 and 60minutes (STD 18,6) in 2010 to 53,5 minutes (23,3 STD) in 2014 and 58 minutes (STD 2,8) in 2015. Neurological status calculated by NIHSS scale at arrival to emergency department was 14 (5,79 STD, RANGE  3-31). NIHSS score at 24h after thrombolysis was 7 (6,60 STD, RANGE 0-24) and after 3 months NISHSS score were 1 (STD 3,34, RANGE 0-9) with Rankin score of 2 (STD 1,942).

CONCLUSION:

Thrombolysis should be given as son as possible. Our door-to-needle times are around 60 minutes, as international and national standards. Over the years, probably due to staff experience, times decreases but improve delays in thrombolysis need to be done. Analazing our present situation  should allow us to design new procedures to shorten times once the patient arrives at hospital. Emergency physicians have an essential role to improve results as we are  responsible for the first  evaluation of patients with activated stroke code.

REFERENCES:

Heikkilä, I., Kuusisto, H., Stolberg, A., & Palomäki, A. (2016). Stroke thrombolysis given by emergency physicians cuts in-hospital delays significantly immediately after implementing a new treatment protocol. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 24(1), 1.

 

 

 


Domingo RIBAS SEGUI (LA SELVA DEL CAMP, Spain), Jesús GÁLVEZ MORA, Ana PELLISÉ GUIJOAN, Albert MORENO DESTRUELS, Doina SOLTOIANU, Gilmar PUGNET
11:00 - 18:00 #7531 - Study of different nonspecific neurological symptoms.
Study of different nonspecific neurological symptoms.

Medical history: Chronic venous insufficiency, insomnia. Treatment: lormetazepam 2mg, flunarizine 5mg and trimetazidine 20mg.

 

Anamnesis: 54 year old woman consults for presenting a year ago about holocraneal occipital headache oppressive dominance, memory loss, feelings of loss of strength. A few months ago she had an episode of dysarthria. She has also had several episodes of dysphagia. Dysphonia of nasal voice that worsens throughout the day. Rotary several episodes of dizziness, one of them is accompanied by self-limiting diplopia.

 

Exploration: normal language. Isochoric and normol reactive pupils, no nystagmus, no diplopia, visual acuity preserved. Normal cranial nerves, preserved gag reflex. Strength and sensitivity preserved. Something exalted tendon reflexes in all four limbs. Cutaneous plantar flexor left, right indiferente. No dismetria, negative romberg.

 

Additional tests: Blood test with normal biochemical blood count, normal vitamin B12, negative serology for syphilis and HIV. NMR skull: Voluminous extra-axial tumor suggestive of meningioma probably related to the right tentorium which occupies the back of the right side of the posterior fossa causing significant mass effect on the right cerebellar hemisphere, collapsing the fourth ventricle, displacing the brainstem in anteroposterior direction left side and also causing herniation of cerebellar tonsils.

 

Clinical Trial: Meningioma with mass effect.

 

Differential Diagnosis: The cerebral meningioma can be slow growing, so it may be years before they begin to manifest the more obvious symptoms, sometimes not even give any.

When a person begins to show some symptoms, usually an NMR is performed in order to detect tumor. Sometimes a biopsy of tumor tissue for greater certainty in diagnosis is necessary.

 

Treatment: The patient underwent surgery.

 

Evolution: Good performance, although the patient has clinical depression adaptive process.

 

Conclusions: The major difficulty in the diagnosis of these tumors is different symptoms that may occur, depending on size and location. In this case it was first thought of the existence of a demyelinating disease. In addition she had gone to consult over months on different symptoms until the sum of all these symptoms alerted.

 


Lorea DE UNAMUNO LUMBRERAS, Verónica PARENT MATHIAS (MALAGA, Spain), Irina YEZERSKA SUSHKO, Pablo DE UNAMUNO LUMBRERAS, Vanessa CARRASCO ALMAGRO, Cristina PÉREZ OLIVARES
11:00 - 18:00 #4517 - Study on Epidemiological Situation of HIV / AIDS in Albania.
Study on Epidemiological Situation of HIV / AIDS in Albania.

Background: HIV continues to be a major global issue of public health that has received more than 34 million lives so far. Only in 2014, about 1.2 million people have died globally from causes related to HIV. Globally, by the end of 2014, the number of people living with HIV was 36.9 million, with 2 million new cases in 2014 alone. HIV infection is diagnosed through rapid diagnostic tests that detect the presence or absence of antibodies to HIV. These tests provide rapid results; essential for early diagnosis and treatment.

Aim: The evaluation of the epidemiological situation of HIV / AIDS in Albania.

Materials and methods: Data of this study were collected by the Institute of Public Health, Tirana as far as the spread of the virus in the population.

Results: From 1993 to November 2015 by registered 870 cases, of which 40 are children. Most of them are men, who make up 70 percent of those affected."In terms of distribution by gender HIV positive cases, 613 of them are male and 257 are female. Meanwhile, in 2015 they reported 63 men and 24 women diagnosed with HIV / AIDS ". Sexual way of transmission of the virus continues to dominate in our country, which is found in 94 percent of cases. Meanwhile, other ways are at low rates from mother to child transmission, as well as through blood transfusions. Of the 40 children affected, 31 of them have contracted the virus from the mother during pregnancy.

Conclusion: "The distribution by age group shows that in our country predominates 35-44 age group, followed by the age group of 25-34, which is a sexually active age group," further stated in the report of IPH. The first cases of those affected by what is known as the disease of the century in our country, appeared in 1993.During these years there were those who failed in the face of battle. Throughout this year they have killed 9 people, while by 1993 the number has gone to 161.


Glodiana SINANAJ, Arjan HARXHI (Tirane, Albania), Mikel NAKUCI, Majlinda ZAHAJ, Brunilda MIFTARI, Brunilda SUBASHI, Denada SELFO, Rozeta LUCI
11:00 - 18:00 #7330 - Successful Medical Treatment of May-Thurner Syndrome.
Successful Medical Treatment of May-Thurner Syndrome.

May-Thurner Syndrome is a rare but prevalent condition in post-mortem examinations. It is characterized by an anatomical variable condition resulting in compression of the left common iliac vein by the right common iliac artery and underlying spine, which lead to the development of left deep vein thrombosis (DVT). The acute manifestation of DVT included swelling and pain over the affected limb. It has been associated with prolonged immobilization, dehydration, contractive therapy, surgical procedure for abdominal, gynecological, or spinal pathology, multiple pregnancy, and post-partum period.
Pharmacological treatment, endovascular intervention, and surgical management had all been proposed as treatment, but haven’t had consensus at the current time. Also, definitive treatment should be tailored in each patient as their condition varies.

Here we described a 45-year old lady, presented to our emergency department with the chief complaint of swelling and pain of left calf for 2 days. She had a huge uterine myoma with hypermenorrhea for couple of years, and been given Diane (an oral contraceptive, Cyproterone) by gynecologist in recent 16 days. She denied previous medical disease, recent trauma, recent abdominal operation, nor long term immobilization. A physical examination revealed swollen and painful left calf. A blood test revealed normal cell count and coagulation profile, but significantly elevated D-dimer (>10000). Following left lower limb untrasonography revealed left femoral-popliteal DVT with non-compressible vein, which then confirmed by contrast-enhanced computed-tomography(CT) venography. The CT scan also revealed compression of left common iliac vein by the huge uterine myoma and right common iliac artery. A variant of May-Thurner syndrome was impressed. After admitted, thrombolytic therapy with urokinase and anticoagulant were initiated. Her condition improved rapidly and was discharged uneventfully 3 days later. She was refered to a gynecologist for surgical evaluation of the huge uterine myoma, because the recurrence of DVT may happen if the anatomical lesion was not fixed.


Physician should be familiar with the May-Thurner syndrome as an etiology of unilateral DVT. The recurrence of thrombosis, pulmonary embolism, and postthrombotic syndrome may happen in this disease which may lead to significant morbidity and mortality. The key to successful treatment in May-Thurner syndrome related DVT is to fix the anatomical lesion along with removal of the clot and use of anticoagulation.


Hsu CHI-FENG (Chia-Yi City, Taiwan), Tsai MING-JEN
11:00 - 18:00 #8091 - Successful treatment using ECMO for a case of massive pulmonary thromboembolism with hemodynamic collapse.
Successful treatment using ECMO for a case of massive pulmonary thromboembolism with hemodynamic collapse.

INTRODUCTION: Pulmonary thromboembolism (PTE) is a common clinical condition related to increased mortality. Furthermore, patients with PTE presenting with hemodynamic instability or right heart thrombus show higher mortality due to rapid hemodynamic deterioration. Various treatment methods of massive PTE have been developed and therapeutic approaches discussed.

CASE DESCRIPTION: A 59-year-old man was admitted to Vilnius University Hospital Santariskiu Klinikos emergency room complaining of severe dyspnea, pain in the lower part of the chest and subfebrile fever. Further investigation findings in CT angiography showed massive PTE with thrombus in the right heart and deep vein thrombosis (DVT). Standard anticoagulation and thrombolytic therapies were initiated. The patient developed a hemodynamic collapse. Consequently mechanical ventilation and veno-arterial-venous extracorporeal membrane oxygenation (ECMO) at the flow rate of 3.4 L/min were introduced. ECMO was successful for blood oxygenation and stabilization of the cardiopulmonary function. Later the patient developed a bleeding from arterial cannula and upper respiratory tract; heparin was discontinued and blood cells transfusions were initiated. A catheter-directed embolectomy was performed with no effect. Hemodynamics was stabilized and ECMO was changed from veno-arterio-venous to a veno-venous. A CT angiography showed no thrombus in the main pulmonary arteries and heart chambers, ultrasonography of the lower limbs revealed no signs of DVT. Once the bleeding from the upper respiratory tract stopped oral anticoagulants were introduced together with the low molecular weight heparin. The patient was successfully weaned of ECMO after 45 days once the blood oxygen saturation was stabilized. ECMO system was changed three times during the treatment. The patient was weaned of mechanical ventilation after 48 days. The patient stayed for 81 days in a critical care unit.

CONSLUSIONS: We suggest that extracorporeal membrane oxygenation may be an effective treatment option for patients who have massive pulmonary thromboembolism with circulatory collapse even when hrombolysis and thrombectomy have failed and conventional anticoagulant therapy is contraindicated due to active bleeding.


Aurelija NAVICKAITE, Akvile SAULYTE (Vilnius, Lithuania), Robertas SAMALAVICIUS, Rokas SERPYTIS, Giedrius NAVICKAS, Rasa PALSAUSKAITE, Pranas SERPYTIS
11:00 - 18:00 #7717 - Suicide and suicidal behaviour at adults in a Romanian ED.
Suicide and suicidal behaviour at adults in a Romanian ED.

Introduction:

Suicide is a complex public health problem of global importance. Suicidal behaviour differs from sex, age group, geographic region, and socio-political settings, and variably associates with different risk factors, suggesting aetiological heterogeneity.

Objective:

The study was performed to analyze the profile and to identify the frequency, nature, and contributing factors of suicides .

Method:

This study  included all pacients who wanted to commit suicide and were admitted in the ED of Saint Spiridon Hospital Iasi, Romania, in 2015. Patients who died in pre-hospital were not included in our study. The patients  were analyzed according to their sex, age, residence, suicid method, associated pathology, potential risk factors and interventions.

Results:

Data from 368  patients with suicidal behaviour were included in the final analyses.

Sex distribution was approximately equal (52.44% female and 47.56% male) . According to our statistics most of the suicidal attempts were associated with rural residence and the most frequent age was between 18 and 30 years old.

72.82% of the patients were brought to the  hospital by ambulance, from their home (81.79%) in stable hemodynamic condition (95.65%).  Most emergencies were recorded during holiday, in winter, around Christmas and Valentine’s Day (38,5%).

63.58% were admitted in ED for drug ingestion, 14.13% for ingestion of organophosphorus, raticides, herbicide and corrosive substances and 21.13% were represented by other suicidal methods. The most frecvently suicidal method used was drug ingestion with benzodiazepines (20,10%) folowed by autolytic cut wounds (13,85%) and corrosive substances ingestion (6,52%). It seems that women are more theatrical and prefer drug ingestion (42,11%) while male prefered autolytic cut wounds (14,94%) and corrosive substances ingestion(8,42%).

At the admission in ED, 31,52% of patients were under current psychiatric treatment and 65,48% were at the first suicidal attempt, 5,97% at the second and 7,60% were with multiple autolytic attempts. For 16,57%, the trigger was a family conflict.

The majority of patients were admitted in ED, on average, 4 hours after attempted suicide and the clinical picture was dominated by sleepiness, heartburn, dysphagia and nausea. On ecg we detected with a high frequency respiratory arrhytmias and sinus tachycardia. 

All the patients received treatment- i.v. fluids, oxygen, gastric lavage (if time from ingestion was less than two hours), charcoal, antidotes ( after toxicity has been identified), maintenance of respiratory and circulatory functions, blood glucose correction, symptomatic treatment.

The time spend in ED was between 2 - 10 h, the admission rate was 57%. The mortality rate was 0.27%. All the patients with voluntary suicidal behavior were orientated to psychological counseling.
  Conclusions:

Psychotherapeutic, pharmacological, or neuromodulatory treatments of mental disorders can often prevent suicidal behaviour; additionally, regular follow-up of people who attempt suicide by mental health services is key to prevent future suicidal behaviour.


Tiulica GABRIELA, Mihaela CORLADE, Diana CIMPOESU (IASI, Romania)
11:00 - 18:00 #7378 - Suicides masked in a scene of motor vehicle accidents.
Suicides masked in a scene of motor vehicle accidents.

Background

Compared with suicide, death by accident is much easier to be accepted by both family and society, often for religious reasons. Prehospital emergency teams could be misled by suicides masked by the scene of a motor vehicle accident. Dynamics of production circumstances of deaths due to violence, followed over a period of time at a population level, a geographic area shows interesting trends.

Material and method

Retrospective observational study is based on a total of 1610 autopsies performed at the Forensic Clinical Service Sibiu County, between 01.01.2011 - 31.12.2015.

 Results

Of all autopsies performed in the study period, 1031 were of violent deaths.Motor vehicle accidents deaths were 199, representing 19.3 % of violent deaths.Deaths by suicide were 243, representing 23.56 % of all the violent deaths.The distribution by years of death by motor vehicle accidents is: 2011-47 (23.61 %); 2012-38 (19.095 %); 2013-34 (17.08 %); 2014-48 (24.12 %) and 2015-32 (16.08 %).The distribution by years of suicide is: 2011-59 (27.24 %; 2012-53 (21.81 %); 2013-51 (20.98 %); 2014-37 (15.22 %) and 2015-43 (17.69 %).

Conclusions

Dynamic motor vehicle accidents show a steady decline in their number from 47 (23.61 %) in 2011, to 43 (17.69 %) in 2015. Year 2014 is an exception, with the highest number of deaths from motor vehicle accidents: 48 (24.12 %).Suicide dynamics indicate a steady decline slowly, over the study period, from 59 (27.24 %) in 2011, to 43 (17.69 %) in 2015 with a sharp decline, accentuated at 37 (15.22 %) in 2014.During the study, dynamic of motor vehicle accidents deaths and the dynamic suicides show in 2014 variations, with a decrease of 10 to 14 cases of suicides which increase of the deaths caused by motor vehicle accidents. This may be because of the difficulty of identifying, in certain circumstances, a suicide masked in a scene of a motor vehicle accident.The effort to decrease mortality by accident has been effectively demonstrated by the constant decrease during the study of road accident deaths.


Virgiliu Cezar BOLOGA (SIBIU, Romania), Alexandra BOTA CRISU
11:00 - 18:00 #7686 - Superior mesenteric artery syndrome: a rare cause of intestinal obstruction.
Superior mesenteric artery syndrome: a rare cause of intestinal obstruction.

Background: Superior mesenteric artery syndrome is a rare but potentially life threatening gastrointestinal condition. This syndrome is a clinical phenomenon caused by the compression of the third part of the duodenum between the superior mesenteric artery and the aorta, leading to obstruction.

Case report: A 36 years-old patient with a medical history of appendectomy presented to the emergency room with acute abdominal pain and vomiting. The patient reported similar episodes resolved spontaneously with episodes of not explored intermittent hematuria. Clinical examination noted abdominal distension and tenderness in the left iliac fossa. Laboratory investigation showed only an anemia. Abdominal radiograph revealed gastric dilation. Ultrasonography was normal. Abdominal Computerizing Tomography scan showed a distended colon and a compression of the left renal vein between the mesenteric artery and the aorta. The Magnetic Resonance Imaging enterography showed a duodenal distension upstream its compression by an acute angulation of the superior mesenteric artery. The diagnosis of Wilkie’s syndrome associated with the nutcracker syndrome was therefore established. Then, the patient was proposed to surgery.

Conclusion: The superior mesenteric artery and the nutcracker syndromes are rare conditions. The diagnosis is based on clinical symptoms and radiologic evidence of obstruction.


Amel AMAMOU, Taieb JOMNI, Dorsaf BELLASFAR (Rennes), Saloua HOUIMLI, Mouna TITEY, Fatma BEN SALEM, Ghania Fetiha AOUADI, Jihen AOUEM, Ben Romdhane ABDELMAJID
11:00 - 18:00 #7650 - Survival of patients with high voltage electrical injuries. Case reports.
Survival of patients with high voltage electrical injuries. Case reports.

Introduction. Electrocution is an injury of low incidence but with high mortality. In years 2013 – 2015 in Slovakia emergency medical service (EMS) providers completed at average 140 calls per year (2.58 calls per 100, 000 people) for patients with electrical injuries whereas 3.33 % of the patients died right on the scene. Yet, there were reported cases of the patients´ successful resuscitation with good neurological outcomes even after high voltage electrical injuries. Authors present three such cases associated with different high voltage injuries (a lightning strike, direct current and alternating current) from year 2015.

Case 1. During a Holy Mass the lightning hit a tree under which people prayed. Nine people were injured and were moved inside a church. Six were unconscious but breathing, one had cardiac arrest and a lay rescuer CPR was started. After the first EMS unit arrival this patient was triaged black because of a massive bleeding from lungs and the CPR efforts were stopped. Meanwhile another unconscious patient developed cardiac arrest. Actual resources were evaluated and ALS was started immediately. ROSC occurred after 25 minutes and the patient was transported to the hospital. In 3 days he was discharged home with CPC1. Though CPR is seldom started in MCIs the organization of medical care on the scene during this MCI allowed enough facilities to start CPR. This is in line with the ERC 2015 Guidelines as rescuers should give the highest priority to patients in respiratory or cardiac arrest after the lightning injury. This decision proved to be a benefit to the mentioned patient as he developed the ROSC, nowadays suffering only from mild consequences as myalgia and chronic fatigue.

Case 2. A 20 – year old boy was hit by direct current of 1,500 V from overhead power lines when jumping on the roof of a wagon and went into cardiac arrest. His girlfriend called 112 and immediately started CPR. The EMS team continued the CPR on the wagon roof whilst it was still under traction mains. To protect themselves from the possible electrical injury the paramedics worked only on kneeling positions to keep the distance of 1.5 m from the overhead lines. After delivering two shocks of 200 J and 300 J ROSC was achieved and the patient was shifted down to the ambulance. He was discharged from the hospital without any neurological deficit after 3 days.

Case 3. A 19 – year old boy jumped into a river near a working high voltage industrial water pump. He developed seizures and went into cardiac arrest. Lay rescuers started CPR. The EMS team came after 10 min and immediately delivered the 200 J shock. The ROSC was achieved and after 16 days of treatment the patient was discharged home without any neurological deficit.

Conclusion. Authors emphasized the fact that immediate resuscitation of young victims even from high voltage electrical injury can result in long term survival with good neurological outcome. EMS providers should also pay strict attention to safety measures when performing CPR to such patients.

 

 

 

 


Volodymyr KIZYMA (Kosice, Slovakia), Oleksandr OPANASENKO, Miroslav HUMAJ
11:00 - 18:00 #7533 - Sweet syndrome. A case report.
Sweet syndrome. A case report.

Medical history: dyslipidemia, hepatic steatosis, lumbartrosis, depression, insomnia. Regular treatment: venlafaxine, mirtazapine, midazolam.

 

History: A 61 years woman consults for two days appearance of painful skin lesions that are spreading and increasing in size. She refers not taking medication differently than usual in previous days.

 

Exploration: She presents different scattered lesions, papules, pustules, vesicles clustered with pale center, some lesions with erythematous halo and thickening of subcutaneous tissue. In inner corner of left eye presents a hyperemic injury and upper eyelid edema.

 

She starts antibiotic treatment with amoxicillin-clavulanic on suspicion of bullous impetigo. The next day she suffers worsening of injuries, chest pain and fever of 38 ° C so she is derived to emergency to expand study.

 

Additional tests: Blood count: hb 14.9,leukocytes 12.290,platelet count 275,000,elevated erythrocyte sedimentation rate, normal hemostasis, normal biochemistry. Chest radiography without pathological findings.

 

Diagnosis: Sweet's Syndrome

 

Differential diagnosis: Stevens-Johnson Syndrome, toxicoderma, erysipelas, skin lesions of Behcet's disease, other neutrophilic dermatosis (atypical gangrenous pyoderma, neutrophilic hidradenitis, the bypass intestinal syndrome), vasculitis (erythema elevatum diutinum) and erythema nodosum may pose problems of differential diagnosis, both clinically and histopathology.

 

Treatment: 50 mg prednisone downward pattern.

 

Evolution: Initially she was treated with antibiotics and then with antiviral (brivudine) because of suspected impetigo and herpes lesions. This made she had poor outcome with worse injuries. Later she was valued by dermatology with diagnosis of Sweet syndrome and after initiation of corticosteroid therapy the lesions were regressing to the total disappearance.

 

Conclusions: The pathogenesis of Sweet's syndrome is unknown. The importance of this syndrome lies in its associated diseases or triggers and which is classified into five groups: idiopathic, para inflammatory, paraneoplastic, drugs related and associated with pregnancy. The extracutaneous clinical sometimes presents complicated practical assessment of it because it is not easy to differentiate if the affected organ is the cause or part of it. The clinical response to oral glucocorticoids is so fast that is a clinical judgment. Other treatments are potassium iodide and colchicine. Although the response is quick, recurrences are common. It is also important research and treatment of possible underlying process.


Lorea DE UNAMUNO LUMBRERAS, Verónica PARENT MATHIAS (MALAGA, Spain), Vanessa CARRASCO ALMAGRO, Pablo DE UNAMUNO LUMBRERAS, Irina YEZERSKA SUSHKO, Cristina PÉREZ OLIVARES
11:00 - 18:00 #7890 - Symptomatic hypocalcemia and hypoparathyroidism associated with Dioscorea tokoro toxicity.
Symptomatic hypocalcemia and hypoparathyroidism associated with Dioscorea tokoro toxicity.

Dioscorea species, commonly known as yam, are widely used as a staple dietary component in Africa and Asia. In Korea, it had been used for treatment of rheumatism, urinary tract infection, and sequela of stroke. Detoxification of yam is necessary before eating. Poisoning may result from the ingestion of partially detoxified tubers that can lead to acute kidney injury (AKI) and toxic encephalopathy. Herein, we report of a case of symptomatic hypocalcemia and hypoparathyroidism developed after drinking boiled water with raw tubers of Dioscorea tokoro. A 53-yearold male who had consumed raw tuber of D. tokoro boiled in water and drank the mix was presented with numbness and spasm of both hands and feet. Laboratory results showed hypocalcemia and hypoparathyroidism. During the hospital stay, colitis, acute kidney injury, and toxic encephalopathy developed. He was treated with calcium gluconate intravenous infusion and oral calcium carbonate with alfacalcidol. His symptoms improved gradually but hypocalcemia persisted despite the calcium supplementation. Our case shows that ingestion of insufficiently detoxified Dioscorea species can be harmful with effects including gastrointestinal complications, AKI with toxic encephalopathy, and hypocalcemia with hypoparathyroidism. It should be noted that certain herbs used in traditional medicine can cause serious health effects if taken inappropriately and that doctors and family physicians should educate their clients on the proper use of certain herbs and plant medicines.


Youngho JIN (Jeonju, Korea), Jaechol YOON, Taeoh JEONG, Jaebaek LEE
11:00 - 18:00 #7778 - Syncope and right-ventricular dysfunction in pulmonary embolism.
Syncope and right-ventricular dysfunction in pulmonary embolism.

BACKGROUND: Clinical presentation of pulmonary embolism (PE) comprises a wide range of clinical presentations, from asymptomatic incidental findings to typical symptons like dyspnea, chest pain, and syncope. We aimed to investigate theassociation between syncope as presentation of pulmonary embolism and right-ventricular dysfunction.

METHODS: This is a retrospective study of consecutive PE patients who were admitted at Emergency Service in a third-level hospital. Patients with or without syncope were compared. Regression models for associations between syncope and blood pressure, heart rate, high-sensitive troponine T at admission, and presence of increase of right-ventricle were calculated.

RESULTS: One hundred forty-one confirmed-PE patients (56% male, mean age 65,92 ± 12,41 years) were included in this study. Thirty-one patients (22%) showed syncope. Eight patients (3%) died in-hospital. Logistic regression models revealed association between syncope and in-hospital death (p = 0,06), and syncope and right-ventricular dysfunction (p = 0,073).

CONCLUSION: In our series, syncope was associated to in-hospital death and right ventricule dysfunction.


Dr Wojciech ROJEWSKI-ROJAS (Reus, Spain), Alicia ALVAREZ-GALARRAGA
11:00 - 18:00 #7163 - Syncope teenage footballer.
Syncope teenage footballer.

Syncope teenage footballer

 

An 16 years old man  without medical or family history that while playing a football game sincope suffers cardiac massage maneuvers starting by spectators of the party, until the arrival of emergency equipment .After 18 minutes beginning 2 monitoring ventricular fibrillation defibrillation and initiating endotracheal intubation was recovering from cardiac arrest after 15 minutes of resuscitation sinus heart rate and electrocardiogram ST elevation in inferior territory .During transfer to our hospital magnesium sulfate, amiodarone, administered and induction sedation began to cardiorespiratory postparada hypothermia.

On arrival TA 107/58 normotensive 100% saturation assisted breathing. Neurological, under the influence of sedation, symmetric and reactive pupils prone spontaneously mobilizing mydriasis and upper extremities. Net cardiac auscultation tones without audible murmurs, without pathological respiratory sounds. depressible soft abdomen and no palpable masses and symmetrical central pulses are palpated ..

Analytical Htc 44.4% 77.6% N leukocytes Platelets 18,500 286,000 66% dimer D TP 2.182 Creat 1.39 K ions, Mg normal, troponin 0.288 at 3 o'clock curve positive cardiac biomarkers CK-MB Troponin 2.46 12.30.

Rx thorax without findings.

EKG: RS 85 pm with ST elevation significantly lower territory.

Differential diagnosis:

1. arrhythmogenic heart disease where the heart is structurally normal but has electrical faults as Brugada syndrome and long QT syndrome.

2. possible structural heart disease such as hypertrophic cardiomyopathy, dilated cardiomyopathy or arrhythmogenic right ventricular to make this screening laptop Echocardiography was requested.

3. With the analytical data and electrocardiographic myocardial possible at the expense of right coronary infarction.

4. screening of pulmonary embolism

After completion of portable mass Echocardiography finding suggestive of left atrial myxoma.

Within 24 hours of admission persisted with elevated biomarkers CK-MB 675 peak maximum. cataterismo heart was dismissed due to the impossibility of revascularization or aspirating embolic material may myxomatous origin and at all times the overall ventricular contractility was preserved.

They intervened opening left atrium and reliable mass resection and anchored in foramen ovale compatible with myxoma appearance.

Excellent postoperative evolution. It was extubated 10 hours after surgery and was discharged from the service of cardiovascular surgery at 12 days of cardiac arrest.

Discussion:

Primary cardiac tumors represent 5% of all tumors and cardiac myxoma is the most common type of primary cardiac tumor in adults. Its most common presentation is in the left atrium. They may clinically present with various forms: asymptomatic incidental finding on echocardiographic examination, auscultation can clearly reveal one mitral murmur, with neurological symptoms and cardioembolígenos pictures because of the embolic potential presented with detachments small portions emboli in small vessels.

In conclusion reflect useful in emergency areas availability portable echocardiography.


Maria Isabel CORREA (MALAGA, Spain), Justino PACHECO
11:00 - 18:00 #7434 - SYPHILITIC AORTITIS: WHEN CHEST PAIN BECOMES THE WORST NIGHTMARE OF THE EMERGENCY PHYSICIAN.
SYPHILITIC AORTITIS: WHEN CHEST PAIN BECOMES THE WORST NIGHTMARE OF THE EMERGENCY PHYSICIAN.

Introduction

Tertiary Syphilis is usually slowly progressive and any organ may be involved, in particular heart.  Cardiovascular syphilis involves the ascending aorta and the arch and can cause aortic aneurysm, aortic regurgitation and coronary ostial stenosis due to aortitis, thus miming all emergent causes of chest pain.

Case Report

A 31 years old woman presented in the ED with history of episodic stress-related chest pain associated with dyspnea and tachycardia for the past 2 months. Her past history was mute and she had no cardiovascular factory risks at all.

Physical examination, vital parameters, Chest X-Ray and blood texts, including markers of cardiac ischemia and D-dimer, were normal. The ECG in course of pain showed a transient diffuse ST depression (2 mm) more evident in the inferior and lateral leads. The bedside echocardiogram showed no abnormalities. Patient was given a dose of Aspirin (250 mg chewed tablet) and recovered in the Emergency Medicine Department for further investigations.

The days after, she presented two other episodes of chest pain, associated with tachycardia and dyspnea. Seriated ECGs -during pain- showed not only the same ST deviation presented in the ED but also ST segment elevation in the anterior and septal leads, and transient T-wave inversion in the inferior and lateral ones after the pain decreased.  The last episode of chest pain was associated with respiratory distress due to pulmonary edema, being necessary a C-PAP mask to correct hypoxemia. CT Thorax Angiography, showed just a subsegmentary pulmonary embolism whereas urgent Coronary Catheterization showed the presence of an “ab estrinseco” stenosis of the coronaries’ ostia , thus leading to immediate surgery in the hypothesis of aortic dissection.  

During the surgery, which consisted on: substitution of aortic valve and arch and CABG (LIMA on AD) because of the damage of sinus-tubular junction and coronaries’ ostia, it was made the hypothesis of either inflammatory or infectious disease causing aortitis instead of hematoma, which was not present at all. Later, serology for syphilis resulted positive, and histology confirmed the suspect.

The patient was than admitted to the Infectious Disease Department and then fully recovered.

Discussion

Chest Pain is sometimes a challenge for the ED Physician, because of the difficulties in the differential diagnosis. ACLS stresses the importance of identifying some of these “ACS miming” that are severe and life threatening, above all: aortic dissection, pulmonary embolism, acute tamponade, tension pneumothorax.

This patient had presented several episodes of chest pain with ECGs suggestive for ischemia, thus leading to think, at first instance, to Printzmetal’s Angina. Further investigations identified pulmonary embolism and also led the suspect of aortic dissection. How is that possible that three of the main, most frightening chest pain causes are present in the same patient at the same time? The answer is syphilitic aortitis, because of the “ab estrinceco” compression of the coronaries’ ostia which in fact mimes an ACS.  In the antibiotic era, when syphilis is becoming uncommon, tertiary syphilis is rare and no one thinks about it as  cause of chest pain. 

 


Martina BATTISTIOLI (Treviso, Italy), Eleonora RELLA, Oscar TOTIS, Alessandro DE LEO, Mauro MASAT, Elvio POLESEL, Zoran OLIVARI, Pier Giorgio SCOTTON, Maurizio SACHER
11:00 - 18:00 #7261 - SYSTEMATIC ASSESSMENT OF THE RESULTS OF SCHOOL ALERT PROGRAM.
SYSTEMATIC ASSESSMENT OF THE RESULTS OF SCHOOL ALERT PROGRAM.

INTRODUCTION AND OBJECTIVES

The “ALERT SCHOOL” program was developed to anticipate the treatment of emergencies in children, related with chronic illnesses diagnosed previously. It includes administrative actions , training actions addressed to the teachers in charge of those children (including how to recognize a critically ill children, how to activate effectively the emergency system, and how to preserve and identify adequately the medication needed), and legal actions (once the 061 is activated, the doctors of the CEC make themselves responsible of the treatment). 

The illnesses included in the program are: epilepsy and unspecified convulsions, severe allergy in relation with potential anaphylactic shock, diabetes mellitus and severe hypoglycaemia, and loss of consciousness.

The aim of the present study was to evaluate the results obtained with the Program “School Alert” including its effectiveness both to detect children with the illnesses included in the program, as well as to distribute adequately the sanitary resources to provide the treatment to the emergencies related.

 METHODS

 A retrospective analysis since the beginning of the Program, including the total of  patients classified by pathology, the number of emergency calls received regard with the Program, and the resource required to solve the situation, was performed. The possible solutions were: solve by phone (with or without direct intervention of the teachers), mobilization of sanitary resources (including healthcare team and ambulance) and solved in situ, and admission to an Urgency Room (UR) of a Hospital Centre. 

 RESULTS

 Between January of 2007 and December of 2012, 1874 patients were included in the Program. 861 (46,02%) in relation with severe allergy, 390 (20,84%) epilepsy or febrile convulsions, 274 (14,64%) diabetes mellitus (hypoglycaemia), and the rest (346, 18,49%) included different illnesses with the common risk to present a loss of consciousness.

 In the 6-year period in the CEC were received 398 emergency calls related to those children, in 281 cases (70,60%) the call was solvedby phone in situ. In the other 117 cases (29,40%), in 40 a direct clinical assistance was needed including ambulance and solved by treatment in situ, and in the last 77 patients (19,35%), the child was admitted to the UR of a Hospital Centre.

 DISCUSSION

 The first (bystanders) link of the care chain, is the weakest. To strengthen it, it's essential to provide to bystanders both the ability to recognize precociously the emergency, as well as the ability to activate effectively the emergency system, and finally once is activated, the ability to provide the  adequate treatment guided by the doctors of the CEC. To facilitate the whole process, the assumption of legal responsibility by the doctors of the EMS is essential. 

The program was effective to detect and include children with the illnesses related (1874). In addition, if we consider that up to 70,4% of the emergencies were solved in situ, and the real emergencies (19,35%) were identified and stabilised in situ before admitting them to the UR of a Hospital Centre, we conclude that it was also effective to distribute adequately the sanitary resources.


Emilia PEREZ MEIRIÑO, Carlos MIRAS BELLO, Corsina PRADO PICO, Manuel BERNARDEZ OTERO, Luis SANCHEZ SANTOS (Santiago de Compostela (A Coruña), Spain), Antonio IGLESIAS VAZQUEZ
11:00 - 18:00 #7783 - Systemic inflammatory response syndrome (SIRS) in infected elderly patients in emergencies department.
Systemic inflammatory response syndrome (SIRS) in infected elderly patients in emergencies department.

Objective

The study aim was to assess the diagnostic and prognostic value of systemic inflammatory response syndrome (SIRS) in infected elderly patients in emergencies.

Patients and methods:

Descriptive retrospective study including patients aged more than 65 years, who were admitted to the emergency department for a proven infection during two months (December 2014 and July 2015). 

Results:

61 patients were included. The average age was 77 ± 8 years with 37 patients were males. 52% of patients had diabetes, 31% stroke, 18% chronic pulmonary disease, 13% active cancer and 8% chronic renal failure. The initial presentation was consistent with severe sepsis in 77% of cases and septic shock in 15%.  83.6% of patients had SIRS on admission (2 criteria in 42.6% and 3 criteria in 26.2% of cases). The average length of stay was 3 days. The mortality rate was 39.2% in patients with SIRS at admission versus 20% in patients without SIRS (p <0.01).

Conclusion

The presence of SIRS at admission may be considered as a significant prognostic factor in infected elderly patients presenting to the emergency department.


Kamel MAJED, Boubaker RADHIA (tunis, Tunisia), Abdelwaheb MGHIRBI, Baccouche RAMLA, Kilani MOHAMED, Khedija ZAOUCHE, Hamida MAGHRAOUI, Mohamed MODHAFFER, Chokri HAMOUDA, Nebiha BORSALI FALFOUL
11:00 - 18:00 #7458 - Systemic Inflammatory Response Syndrome Predicts in Acute Coronary Syndrome without Congestive Heart Failure.
Systemic Inflammatory Response Syndrome Predicts in Acute Coronary Syndrome without Congestive Heart Failure.

Introduction :

High levels of inflammatory biochemical markers are associated with an increased risk among patients with acute coronary syndrome (ACS). The objective of the current study was to evaluate the prognostic significance of the systemic inflammatory response syndrome (SIRS) among ACS patients with no clinical or radiological evidence of congestive heart failure (CHF).

Methods :

Consecutive patients with ACS and no clinical or radiological evidence of CHF, presented at our emergency department (ED) between January the 1st and December the 31, 2015,were included in the study. We have shared our patients into two groups : group1 (SIRS+) and group2 (SIRS-).

Physical examination, troponins and referring patients were studied.

Results :

The study included 89 patients ( 60years, male 75%). 67% were smoking, 47% were hypertensive, 29% were diabetic and 24% were coronary. 47 patients (53%) had SIRS on admission to the ED. SIRS was a predictor of hospital morbidity (p=0.004).

Conclusion :

SIRS was a marker of increased risk of hospital morbidity among patients with ACS and no clinical or radiological evidence of CHF. It can facilitate the initial management of patients in ED.


Amri SALOUA, Mohamed Ali CHERIF, Farah RIAHI (Belfort), Mohamed MEZGHENI, Asma BEN ALI, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #8267 - Systems triage. Are effective?
Systems triage. Are effective?

Introduction

 

Hospital triage systems are designed for prioritization of patient care, being a fundamental tool in the Emergency Services due to the overcrowding of these. The triage system implemented in Valencia is the Manchester triage system, which provides for prioritizing the patient in five categories

Not all vital signs are taken into account in this system, when assessing the patient. Blood pressure, is recorded only when the patient is pregnant.

Objective

Assess whether blood pressure can change the priorities of patients and should be taken into account in all Classification Systems.

 

Material and methods

It is an observational, descriptive and prospective study conducted in the emergency department of the University Hospital of the Ribera, which is a Department of Health of Valencia in Spain which covers over 240,000 patients. The study period is from 1 March to 31 May 2015. Patients older than 14 years attending the service are included, calculated a sample with a confidence level of 95% and 5% error, they were 41155 wich 381 stories analyzed.

 

 

Results

Most patients were male with an average age slightly higher at 62 ± 20.79.The reason for consultation / more representative complaint was abdominal pain (61%); the diagnostic label was mostly used "Adult poor general condition" (23.8%) followed by abdominal (18.7%) pain, being the discriminator "recent problem" described most often (32.80%). A high percentage of patients were assigned a priority "P4" (68.7%).

15% of patients had altered blood pressure values. 56.9% were susceptible to change the assigned priority. In all these patients a change to a higher priority less time required care was performed. The reason for consultation most representative of this group was abdominal pain (24.2%). The most commonly used diagnostic label in the second sample of patients was "Adult poor general condition" (33.3%) being the most commonly used discriminator most frequent (54.5%) "recent problem”.

Conclusions

 

The Blood pressure itself would change the priority in the case to be taken into account in the Manchester triage system for any type of discriminator, not only in pregnant women.


Pedro GARCIA BERMEJO, Luisa TARRASO GOMEZ, Maria Jose CORTES GOMEZ (Alzira, Spain), Vicente RIBES GADEA, Maria CUENCA TORRES, Jose Luis RUIZ LOPEZ
11:00 - 18:00 #7775 - Takotsubo syndrome. Chest pain in absence on cardiovascular risk factors but emotional stressor . A Case Report.
Takotsubo syndrome. Chest pain in absence on cardiovascular risk factors but emotional stressor . A Case Report.

Stress induced cardiomyopathy also known as Takotsubo syndrome  was first described in 1990 in Japan. Since Then increasingly diagnosed around the world. Conservative treatment and resolution of the physical or emotional stress result in a radpid  resolution of symptoms although some patients develop acute complications such as heart failure and  shock.

A  case of  24 years old male is reoprted. Abrupt onset of opressive chest pain started  1 hour  before  arriving in Emergency Department ( ED). He was driving a kart during his single  party,so had to marry  next week. Non smoker, non alcohol abuse,  no personal nor family risk factors for cardiovascular disease.

At  the moment  of  admitance  in ED  pain  was heavy opressive , elevated  heart rate, cold sweating but  with no signs  of  shock. Electrocardiogram revealed  tachycardia and  ST segment elevation in  V1  to V3. Pain relieved  after   oral  Nitroglicerine  amb intravenous morfine. Elevated  cardiac biomarkers  ( I Troponine  and CPK )  wew  found elevated at  6  to  12 hours  from  pain onset.

Patient were  moved  to local  Intensive Care Unit  where  further studies  were done,those included. Ecocardiography  with regional apical left Ventricular ( LV ) diskinesis, cardiaca catheterization  where no significant coronary disease was  found  and  Cardiovascular Magnetic Resonance ( CMR)  where myocardial edena corresponded  to areas of wall motion abnormailty  was found.

Other medical  conditions as Pheochromocitoma were   finally  asseses. Brain  natriuretic Peptide( BNP )  was not available.

Takotsubo syndrome   diagnosis was  done  following Mayo Clinic diagnostic criteria: Transient Left ventricular systolic disfunction, absence of obstructive coronary disease, new electrocardiographic abnornalities, absence of  pheochromoitoma or myocarditis

The signos of myocarditis in CMR are commonly seen in stress  cardiomyopathy , these  signos  corresponded to areas  of wall motion abnormality, Different  pattern is  seen in myocardial infarction ( MI ) and Myocarditis .

Among 1759  patients  in  the International Takotsubo Registry study 26 % had a  physical trigger ( such as acute respiratory failure, central nervous System condition or infection ) 27,7% reported a emotional trigger ( such as  grief, loss panic, fear, anxiety, frustration, financial or employment problem )

Physical as  stress conditions  may also cause heart disease  as  conventional  cardiovascular risk  factors . Heart conditions  in young people   without  those conventional  risk factorns  may be infradiagnosed ,ST  segment  in   routine  ECG  may guide us  to Takotsubo syndrome.


Josep MONTESINOS COTS (EL VENDRELL, Spain), Madalina Gabriela GRECU, Carles GREOLES ROYO, Claudia ROMERO RAMÍREZ, Ana ESTEBAN VILLACAMPA, Maria ARENAS PRAT, Salvador SARRÀ MORETÓ
11:00 - 18:00 #7892 - TARN - BEYOND SUBMITTING DATA TO NATIONAL DATABASES.
TARN - BEYOND SUBMITTING DATA TO NATIONAL DATABASES.

Objectives and Aims: We looked at how we are using the data we submitted to TARN for improving the local management of trauma patients.

Background: Submitting data to national databases is a difficult task. It involves resources, time, training and engagement of different members of the team. It is so difficult to keep up a good pace in submitting data and to ensure the quality of the data that implementing the changes required after analysing this data is sometimes forgotten. After a concerted effort of the network and our local trauma management team, we now have a sufficiently large data input and we can start looking at how we use this information for improving the management of the trauma patients in our trauma unit.

Material and method: Data analysis and initiation of local audits based on TARN, with specific action plans and deadlines. We present two local audits we conducted with the aim of improving our patient management and, subsequently, our compliance.

We conducted an audit on head injury patients, looking in particular at the times to CT and times to CT reporting. The audit showed that only 70% of our head injury patients had the CT done within one hour. We conducted an analysis of the subgroup of patients with delays, we identified the areas of improvement and we now have an action plan with specific deadlines.

The second audit we present looked at the TARN eligible trauma patients seen by an ST3+. We were not fully compliant, so we wanted to see if this is only because of the incomplete data submission or it was real. And, if it was real, what was the subgroup of patients involved and how we can improve their management.

Conclusions: Having a robust data set submitted on national databases has a significant importance only when it reflects back into the activity and the data is used for improving the pathways or for developing new pathways.


Laura BALICA, Andrei CARPIUC (London, ), Richard SMITH
11:00 - 18:00 #4591 - Termination of idiopathic sustained monomorphic ventricular tachycardia by synchronized electrical cardioversion during pregnancy.
Termination of idiopathic sustained monomorphic ventricular tachycardia by synchronized electrical cardioversion during pregnancy.

Termination of idiopathic sustained monomorphic ventricular tachycardia by synchronized electrical cardioversion during pregnancy

  Sung Min Lee, MD,  Hyungchang Kim MD,  Kyoung Hwan Song, MD.

 

Arrhythmia is one of the most common cardiac complications encountered during pregnancy. However, idiopathic sustained monomorphic ventricular tachycardia (VT) during pregnancy is rare. A-31-year-old pregnant woman at 20 weeks of gestation presented progressive with palpitations and episodes of agitation. An initial 12-lead electrocardiogram (ECG) showed normal sinus rhythm. However, 30 min after emergency room (ER) presentation, she complained of complain chest pain. The following ECG showed wide complexs monomorphic VT. We attempted administration of an antiarrhythmic drug. However, she refused any medication because of the concern regarding any adverse effect on the fetus. Therefore, we conducted synchronized electrical cardioversion 8 times. After the eighth synchronized cardioversion at 200 J, the ECG showed sinus tachycardia. The fetal condition was monitored by ultrasonography, and no adverse events were observed. We present the case of successful synchronized electrical cardioversion performed in a woman at 20 weeks of gestation because of sustained symptomatic VT.

 


Lee SUNGMIN (Gwangju, Korea), Kim HYUNCHANG, Song KYOUNG HWAN
11:00 - 18:00 #7313 - Testicular Fracture: A Tough Nut to Crack Made Easier with PoCUS.
Testicular Fracture: A Tough Nut to Crack Made Easier with PoCUS.

Background:  Injuries involving the scrotum and testicles are common in the emergency department.  History and physical examination are inadequate to differentiate between surgical and non-surgical testicular emergencies.  Early and accurate diagnosis is critical to preserve the structure and function of the testes, and timely ultrasound is essential for rapid, definitive diagnosis.  Objective:  To report a case of testicular fracture diagnosed by an emergency physician using Point-of-Care-Ultrasound.  Case Report:  An 18-year-old male presented to the emergency department with left testicular pain and swelling following an injury where he was accidentally struck in the groin by his opponent during a lacrosse match.  Physical exam revealed a tense and swollen left testicle when compared to the right.  Due to the nature of his presentation, ultrasonography was immediately performed by the emergency physician, leading to a rapid diagnosis of testicular fracture.  For the ultrasound examination, a high-resolution linear transducer (6-15MHz) with Color Doppler was employed.  Sonographic findings included heterogeneous echogenic parenchyma in the lower pole, discontinuity of the tunica albuginea, and complex hypoechoic fluid collection within the left hemiscrotum with preserved testicular blood flow including the fractured segment by Color Doppler.  Urology was consulted.  After their evaluation, the patient was promptly taken to the operating room for scrotal exploration, partial orchiectomy, and debridement of the left testis.  Discussion:  A previous study has shown that emergency physicians can accurately diagnose acute testicular pathologies by utilizing bedside ultrasound. As demonstrated by this case, use of routine bedside ultrasonography for injuries involving the scrotum and testicles by emergency physicians may help expedite diagnosis and can be used to stratify patients on the need for emergent urologic consultation and surgical intervention to improve patient outcomes. 


Tyler HOLLIDAY (Morgantown, West Virginia, USA), Kristine ROBINSON, Nicole DORINZI, Andrew VUCELIK, Erin SETZER, Debra WILLIAMS, Joseph MINARDI
11:00 - 18:00 #7587 - Testing the performance of the modified confusion assessment method for the ED (mCAM-ED).
Testing the performance of the modified confusion assessment method for the ED (mCAM-ED).

Background

Delirium is highly prevalent in older Emergency Department (ED) patients and is associated with unfavorable outcomes. If not detected in the ED, delirium is likely to be missed during the entire hospital stay. However, detection of delirium in the ED is challenging. When using an unstructured approach, 50-70% of the cases are missed. Therefore, we developed the mCAM-ED, an adaption of the original Confusion Assessment Method (Inouye SK, et al. 1990). The mCAM-ED is designed for use by ED clinicians (nurses, physicians) and meets the demands of the busy ED environment. Its feasibility was confirmed at the ED bedside in a previous study.

In this prospective study we aimed to test performance criteria of the mCAM-ED against a gold standard.

 

Method

In order to avoid selection bias, all ED patients aged ≥ 65 were included consecutively during a 10 day period. A mCAM-ED assessment was performed by trained nurses. Thereafter a geriatrician, blinded to the mCAM-ED results, assessed the patients using DSM criteria. Performance criteria were calculated.

 

Preliminary results

In total 401 patients were eligible (aged 65 or older), of which 298 patients were included into the analysis. Main reasons for exclusion were: decline to participate (27), immediate discharge (23), communication problems (19), treatment in the resuscitation room (13), other (21). Raw data are currently being processed. If accepted, final results will be presented at EUSEM 2016.

 

Discussion

Subject to the final analysis we hope to show - in addition to its already proven feasibility - that the mCAM-ED is a valid tool for use in older ED patients.


Florian GROSSMANN (BASEL, Switzerland), Wolfgang HASEMANN, Christian NICKEL
11:00 - 18:00 #8205 - tetraparesia express.
tetraparesia express.

59 year old woman without history of interest  when getting to the bathroom at night presents sudden loss of strength in the 4 limbs, keeping the sensitivity and awareness. She´s carried to bed and remained for 10 hours before transfer to hospital. No fever or infection data.

On arrival at  emergency department presents:  NIBP: 140/70 mm Hg, BF: 22 breaths / min. Sat O2: 100% (FiO2 21%) HR: 120 beats / min. Tª 35,2ºC.She  presents  strength loss  inl 4 limbs (0-1 / 6).She collaborates although  tends to sleep. No language deficit neither cranial nerves.

General examination:  only highlight dry skin and mucous membranes, loss of strength in limbs and large mass in lower abdomen.

Lab tests: severe acidosis (pH 6.1, HCO3 6.920 mmol / L), creatinine 5.32 mg / dL (previously normal), urea 287 mg / dL, Ca 6,2 mg / dL, Mg 1.4 mg / dL, P 12 , 6 mg / dL, K 1.6 mEq / L. 27000 leukocytes (Metamyelocytes 1%, 4%  bands,  87% segmented hockey sticks). Toxic urine: negative. Lactate 5 mg / dL, PCT 0.51 ng / mL CRP 7.2 mg / dL.

CXR: Normal . Urine culture: negative.

Abdominal CT: Absence of cortico-medullary differentiation in both kidneys with cortical thickening and  great multiblobulated mass  with multiple calcifications occupying pelvis and lower abdomen compatible with large fibroid uterus (16 cm diameter)

RMN cervical: no masses in vertebral bodies.

After correction of acidosis through hemodialysis and intravenous electrolyte replacement patient recovers muscle strength. Remains admitted to study with normal tumor markers , suspecting glomerulonephritis / interstitial nephritis or acute tubular necrosis, but without  improvement  renal function yet. Potassium deficit is attributed to use of laxatives patient in recent weeks by constipation.

Conclusions:

Potassium, cation essential, facilitates nerve conduction and contraction of smooth and skeletal muscle. It also facilitates the  cell membrane performance and various enzyme systems. Low levels of potassium can cause, among others, neuromuscular symptoms: weakness, fatigue, paralysis and even respiratory arrest hiporreflexia by affecting the respiratory muscles, rhabdomyolysis with acute renal failure (severe hypokalemia) and muscle atrophy (chronic hypokalemia) .Although there are  several causes of acute tetraparesia: trauma, multiple sclerosis, transverse myelitis, tumors ... the initial examination in our patient with the mass in the abdomen oriented, in  absence of other causes, metastatic or paraneoplastic origin, and were the analytical data that helped the early diagnostic.


Francisco Manuel MATEOS CHAPARRO (SANTANDER (CANTABRIA), Spain), Maria GONZÁLEZ RUIZ, Luis PRIETO LASTRA, María ANDRÉS GÓMEZ, Enrique PERAITA FERNÁNDEZ, Hector ALONSO VALLE, Luis Gerardo GARCÍA-CASTRILLO RIESGO
11:00 - 18:00 #7661 - The pesticide poisoning (PP) : Epidemiological study.
The pesticide poisoning (PP) : Epidemiological study.

Introduction:The Pesticide poisoning (PP) represents a major clinical concern responsible of persistent elevated mortality in the developing countries and resulting in frequent emergent hospital admission. In our country, the OP poisoning accounts for 11% of all acute poisoning emergency. The objective of this study was to investigate the epidemiological, clinical, and prognostic of acute pesticide poisoning in the emergency department.

Matherials and methods: It was a  retrospective study based on analysis of 73 consecutive patients In an emergency department, for 4 years .The epidemiological data, the nature of the offending product, timely care, clinical and laboratory signs, treatment and evolution were studied.

Results:N= 73 patients. Mean age was 27 ± 9 years, sex ratio=0,25. Women psychiatric history were noted in 8% of patients. The causes of poisoning were with suicidal intent in 92% of cases related mainly with parental conflict (34%) and marital conflicts (28.7%), and were accidental in 8% of cases. Chloralose was the most frequently implicated in 52.1% cases monitoring of organophosphates in 45.2% of cases. Most patients (57.5%) consults, in the first hour. Muscarinic syndrome was present in 82% of patients and nicotonic  syndrome was present in 60%. Gastric lavage was done in 54 patients (74%). Atropine was administered in 26 patients. The ventilatory support was performed in 28 patients (38%). 53% of patients were transferred to an intensive unit care. Thirty-three patients (38 %) returned home. Average duration of stay in the emergency department was 3h±2.8 hours.  Only 6 deaths were noted.

Conclusion: The PP is frequent in ED and  is associated with  high mortality. It requires  many preventive measures and standardization of care to improve the prognosis.

 

 

 


Wided BAHRIA (tunisie, Tunisia), Anware YAHMADI, Wided BOUSSLIMI, Hanane GHAZALI, Ahmed SOUYEH, Cyrine KESKES, Ahlem AZOUZI, Sami SOUISSI
11:00 - 18:00 #7398 - The biggest found.
The biggest found.

The biggest found

52-year-old woman with history of treated depressive syndrome.

Came to the Emergency Room because of dysuria, urinary frequency and urgency without fever, with slight lower abdominal pain associated in the last hours. 

As a past medical history the patient reported a previous cystitis episode treated with Norfloxacin.

On physical examination the patient was calm and alert, blood pressure 105/80 mmHg with a heart rate of 117 bpm, temperature 34.8Cº (96.64 Fº) and eupneic with basal O2 Saturation in 99%.

Initial laboratory evaluation revealed Creatinine 5.61 mg / dl, potassium 7.6 meq / liter, PCR 13.27 mg / dl, 17500 leukocytes  with 14300 PMNn, prothrombin activity 72%. Venous blood gases: pH 6.89 and HCO2 8. Normal values for the rest of the hemogram and  biochemistry.

Urinalysis revealed urine sediment with more than 300 leukocytes per field and over 300 red cells per field.

We diagnosed the patient an urological sepsis with acute renal failure, metabolic acidosis and secondary severe hyperkalemia with no electrocardiographic changes.  

We proceeded to bladder catheterization with adequate diuresis and purulent urine output.

Treatment was initiated with fluid therapy, Dextrose and insulin, bicarbonate and intravenous Ceftriaxone, with improved renal function analytical control as well as ionic disorders and acid-base balance.

Abdominal X ray was requested where we objectified a 9 centimeters diameter lithiasic image in hypogastrium. We ordered an abdominal CT, in which expansion of both renal excretory systems was seen. We also saw some adjacent fat change suggestive of inflammatory changes with giant intravesical lithiasis.

- Clinical diagnosis: 

Severe sepsis with mixed urological renal failure in relation to giant bladder stones. 

Urology was consulted and decided urgent surgery to perform a litopalaxia and a double bilateral J catheter placement. The patient evolved favorably during the income and was discharged after 8 days of hospitalization. Urology revisions were scheduled.

- Conclusions: 

The giant bladder stone is a very rare disease requiring diagnostic imaging. It is manifested by repetition sepsis, urinary frequency and stranguria.

Ultrasound and plain radiographs are sufficient for diagnosis. Continuous calculation extraction is the treatment of choice.


Isabel FERNÁNDEZ-MARÍN (Madrid, Spain), Víctor SÁNCHEZ ALEMANY, María CUADRADO FERNÁNDEZ, Carlos RUBIO CHACON, Luis PÉREZ ORDOÑO, Susana BORRUEL NACENTA, Ana Belén CARLAVILLA MARTINEZ
11:00 - 18:00 #7453 - The burden of trauma presenting to the tertiary referral hospital in Freetown, Sierra Leone.
The burden of trauma presenting to the tertiary referral hospital in Freetown, Sierra Leone.

Introduction

Injury accounts for 8% of the mortality in Sierra Leone and contributes to significant morbidity and disability1.  Connaught Hospital is the main government referral hospital in Freetown, the capital of Sierra Leone.  Its emergency department (ED) receives trauma victims that attend directly from within the city but also takes referrals from across the country.  Currently, the country is recovering from a recent Ebola epidemic, there is no formal trauma system in place and a trauma registry is lacking.  The burden of cases has not previously been measured.  The aim of this study was to assess the volume and acuity of trauma cases presenting to the ED so that services can be designed accordingly.

  

Methods

We collected data retrospectively over a 3-month period from 1st January to 31st March 2016 from the attendance register in the ED triage area.  Basic demographic data including age and sex were obtained as well as time of presentation, mechanism of injury and triage colour category as a marker of severity of illness.

 

Results

During the study period, 2928 patients were assessed by the triage staff, of which 340 (11.6%) presented following injury.  Sixty-six percent were male and the mean age of victims was 28 years old.  Road traffic collision (RTC) accounted for 55% of presentations and was the most common cause of injury, followed by falls from height (17%), assault (14%) and burns (5%).  Of the assaults, penetrating trauma was more common than blunt injury.

Although the early shift is the busiest in terms of overall attendances, the majority of trauma attendances occur during the late (40%) and night (22%) shifts.  In terms of triage category, 14% were red (emergency) cases and 27% were orange (very urgent), yellow comprised 35% and the remainder were green.   

 

Conclusion

Injury accounts for 11.6% of the cases seen in triage at the main government hospital in Freetown.  The majority of cases are due to RTC and present later in the day or overnight.  Forty-one percent of cases are high acuity, being category red or orange.  Subsequent to this study, we aim to establish a trauma service that will be able to respond appropriately to the needs of these patients and establish pathways and training that will facilitate urgent care to improve their outcomes, focusing on basic life-saving interventions such as oxygen delivery and shock management.  A formal trauma registry is also seen as an important method of monitoring and improving care.  

Reference

1)  Sierra Leone:  WHO statistical profile.  World Health Organisation, 2015.  Available from: http://www.afro.who.int/en/sierra-leone/country-health-profile.html 


Richard LOWSBY (Liverpool, United Kingdom), Ibrahim BUNDU, Hooi-Ling HARRISON, Tenema M'BAYO
11:00 - 18:00 #8254 - The burned child: assessment of first aid given by a medical regulation assistant to a witness.
The burned child: assessment of first aid given by a medical regulation assistant to a witness.

Introduction: Cooling the burn in children does not seem to be properly done by the witnesses. How do medical regulation assistants (MRA) guide witnesses on the phone when facing burns in children? Materials and methods: a retrospective observational study over one year of treatment by MRA with a call regarding burned child with referral to 15 or 112 medical dispatching center (SAMU). Listing of 4 items in direct calls to medical intensive care unit (MICU): advice given, cooling methods, duration of cooling, water temperature. Listing of these 4 items for calls transferred by the control room (CTA) of the Fire Brigade in addition to the control by the MRA advice given by CTA. Results: 25 SMUR records in 2014, evaluated 21 calls. Results: 25 MICU files in 2014, 21 assessed calls. Nine direct calls: no advice given (n=3), first aid information to be detailed (n=4), accurate and appropriate advice (n=2). Twelve transferred calls by CTA: accurate and appropriate advice by operatpr CTA (n=2), message given by CTA to be detailed (n=2), no information on advice given by CTA (n=8). No control on advice given by CTA nor given by MRA (n=8). Advice to be detailed on first aid measures (n=2). MRA mislead the witness (n=1).  Control of CTA advice and appropriate MRA advice (n=1). witness in a panic (n=9). Cause: situation (n=8), language barrier (n=1). Discussion: telephone consultations are seldom brief and nearly inexistent. The possible causes are the flood of calls, the wish to rapidly transfer the call to the regulating doctor, the lack of proper training, deliberate omission thinking the other is more competent. There is a need to verify if the witness practices first aid, that he has received and understood the advices.  The message given must be clear and accurate, reformulated, and proper integration must be confirmed. The absence of integration of advices is due to stress, to a sense of guilt or to a comprehension issue. Sometimes, in the absence of advise, the witnesses are the ones who asks, because they feel the need to feel comforted, to be active and control the situation. A poor message delays the management and increases stress. Conclusion: every element in the first aid chain is strategic. An adapted training on first aid measures and management of their position must be given to MRA to ensure an optimal prompt response to complainants. It is also necessary to valuate them without forgoing their competences.


Delphine HUGENSCHMITT, Bagou GILLES, Alexandre ALLONNEAU (Paris), Hugues LEFORT, Pierre-Yves GUEUGNIAUD
11:00 - 18:00 #7788 - The catastrophic complication of an old lady infected by swH1N1--acute disseminated encephalomyelitis(ADEM).
The catastrophic complication of an old lady infected by swH1N1--acute disseminated encephalomyelitis(ADEM).

Introduction:Flu virus attacks patients of all generations. But post-flu infection has different presentations-through minor to lethal. It depends according to the host immunity and uncontrolled post-infection cytokine storm. High amount of patient-care in emergency department (ED) always happens during the Chinese Lunar New Year with long vacation and failure to service with the regular outpatient clinic follow-up. Meanwhile heavy burden of patient care happened in our ED, no matter flu infection or other medical and trauma emergency cases. We present a case with swH1N1 infection complicated with ADEM at our ED.

Material and Methods:A 61-year-old female was robust in the past. Unconscious with hypoglycemia developed after 3 days of URI s/s. She was sent to our ED for help where stable vital sign with E3V2M2. Then a series of exams deployed and carbon dioxide retention with metabolic acidosis was noted. Influenza A infection was also confirmed through rapid test. At our ED, endotracheal tube insertion for airway secure and control of lower lung pneumonia was performed. Brain images included computed tomography and MRI were arranged and the disposition of poor conscious patient was  the intensive care unit. After detailed neurological and labratory exams, pleocytosis from central nerve system was detected through the procedure of lumbar puncture. Acute disseminated encephalomyelitis (ADEM) was highly suspected after the survey of brain images, lumbar puncture, autoimmune markers. Unfortunately, central failure with deep coma developed in the following days and she was expired about 3 weeks later. The genetic virus identification of PCR test with sputum specimen showed swine H1N1 virus.

Discussion and Conclusion:H1N1 flu is a new virus that has been detected throughout the world since 2009 April. After World Health Organization (WHO) confirmed the pandemic of swine H1N1, several sporadic neurological complications, including speculated as a precedential event in diseases such as Reye’s syndrome, Guillain-Barré syndrome (GBS), Kleine-Levine syndrome, and post-encephalitic Parkinsonism. But our case is the third case of the fulminant and fatal neurological complication after swine flu infection through reviewing published literatures. We emphasize the early warning, necessary rapid test, liberality usage of advanced images about altered mental status patients post URI s/s in ED.   

 


Hou-Wen CHEN (Taoyuan City, Taiwan), Shu-Ping TUNG
11:00 - 18:00 #8029 - The Comparison of the Effectiveness of Silibinin and Resveratrol in Preventing Alpha-Amanitin Induced Hepatotoxicity.
The Comparison of the Effectiveness of Silibinin and Resveratrol in Preventing Alpha-Amanitin Induced Hepatotoxicity.

Introduction: The alpha-amanitin (α-AMA) contained in mushrooms of the species Amanita phalloides lead to intoxications resulting in hepatotoxicity and death. Although silibinin is used in the treatment of α-AMA intoxication, morbidity and mortality associated with liver failure are high. The aim of our study was to investigate the effectiveness of resveratrol (R), a known antioxidant and hepatoprotective agent, in the treatment of α-AMA intoxication and to compare it with Sil.

 Method: The acute hepatotoxic dose of α-AMA elevating liver function tests (AST and ALT) and causing liver damage in Balb/c mices was determined at 1.4 mg/kg (intraperitoneal, i.p.). Our experimental groups were 1: Control: α-AMA (n=12), 2: α-AMA+dimethylsulfoxide (DMSO, Solvent of R and Sil, n=8), 3: α-AMA+SR (α-AMA and simultaneous  30 mg/kg R i.p. n=8), 4: α-AMA+12R (30 mg/kg  R 12 h after administration of α-AMA, n=10), 5: α-AMA+24R (30 mg/kg R 24 h after administration of α-AMA, n=10) and 6: α-AMA+Sil (α-AMA and simultaneous 5 mg/kg Sil, n=10). R was administered at 12-h intervals and Sil at 6-h intervals over 48 h in the experimental groups. Following 48-h observation, mices were sacrificed under ether anesthesia. Liver function tests and liver damage scores were evaluated. ANOVA, and the Tukey-Kramer multiple comparison test was used for the statistical analysis. P<0.05 was regarded as significant.

Results: AST values were significantly lower in the SR (2191.0 ±281.2 U/L) and 12R (2403.0 ±726.1 U/L) groups compared to the control group (7947.0 ±1335.0 U/L) (p<0.01 and p<0.01). ALT values were also lower in the SR (1335.0 ±570.4 U/L) and 12R (1542.0 ±537.3 U/L) groups compared to the control group (6454.0 ±1604.0 U/L) (p<0.05).  Histopathological liver damage scores decreased significantly in the SR (1.4 ±0.2), 12R (1.3 ±0.2), and 24R (1.4 ±0.2) groups compared to the control group (2.6 ±0.2), (p<0.01, p<0.001, and p<0.001 respectively). Histopathological damage score in the Sil group was 1.8 ±0.2. There were no statistically significant difference between the R and Sil groups in terms of AST and ALT values or histopathological damage score (p>0.05).

Conclusion: Resveratrol was effective for reversing hepatotoxicity when used simultaneously or early after the α-AMA intoxication. Silibinin, used as a traditional antidote, but it was not successful in reversing hepatotoxicity. Resveratrol is a promising potential antidote in the prevention and treatment of α-AMA-induced hepatotoxicity.

This study was supported by the Scientific and Technological Research Council of Turkey (114S927). 


Aynur SAHIN (Istanbul, Turkey), Oktay KESICI, Yesim TUNCOK, Sule KALKAN, Bekir Ugur ERGUR, Ilkay AKSU, Mualla Aylin ARICI
11:00 - 18:00 #8166 - The demographic data and risk factors for st-segment elevation myocardial infarction in romanian patients.
The demographic data and risk factors for st-segment elevation myocardial infarction in romanian patients.

Background.

Cardiovascular disease (CVD) includes: coronary heart disease and acute myocardial infarction (AMI), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital heart disease and heart failure. According to the World Health Organization (WHO), CVD is the main cause of death for women in all countries of Europe for which we have mortality data and it is the main cause of death for men in all but 6 of these countries (exceptions are France, Israel, the Netherlands, SanMarino, Slovenia and Spain). Also, CVD causes more than 50% of deaths in women in 29 countries, mostly in Central and Eastern Europe. In nine countries CVD causes more than 50% of deaths in men: Azerbaijan, Belarus, Bulgaria, Georgia, Montenegro, Romania, FYR Macedonia, Romania, Ukraine and Uzbekistan. The incidence of hospital admissions for AMI with ST-segment elevations (STEMI) varies among countries that belong to the European Society of Cardiology. For Romania between 1997 and 2009 the Romanian Registry for ST segment elevation myocardial infarction (RO-STEMI) included 19510 patients.

Aim of our study was to investigate the demographic data and risk factors for ST-segment elevation myocardial infarction in Romanian patients.

Participants and methods.

We included in this study, 100 patients presented to Emergency Clinic Hospital between January 2015 – January 2016, and we collected the demographic data (e.g. age, gender, region, etc.) and risk factors (e.g. hypertension, obesity, diabetes, etc.). The data were statistically processed by SPSS ver. 20.

Results.

From patient population pyramid can be seen preponderance of men for all age groups up to 75 years, male / women being much higher than one to 65 years. The average age of women included in this study was maintained around 68 years and for males around the age of 60 years. The most frequent risk factors were smoking, hypertension, dyslipidemia and diabetes.

Conclusion.

For our study we observed a trend increase in patients with hypertension, diabetes or dyslipidaemia. Also, the age of onset is  decreasing year by year which should become an important signal for new prevention programs and studies.

References.

  1. WHO - Cardiovascular diseases (CVDs). Fact sheet N°317, Updated March 2013 (http://www.who.int/mediacentre/factsheets/fs317/en/index.html)
  2. Global atlas on cardiovascular disease prevention and control. Geneva, World Health Organization, 2011
  3. EUROCISS Working Group. Coronary and cerebrovascular population-based registers in Europe: are morbidity indicators comparable? Results from the EUROCISS Project. Eur J Public Health. 2003; 13(3 Suppl):55-60.
  4. Tatu Chitoiu G, Arsenescu-Georgescu C, Babeș K et al. Raportul Registrului Român pentru infarctul miocardic acut cu supradenivelare de segment ST (RO-STEMI) (1997-2008). Revista Română de Cardiologie. 2009; XXIV(3):182-206.
  5. http://www.world-heart-federation.org/press/fact-sheets/cardiovascular-disease-risk-factors/

Acknowledgements.

No potential conflict of interest relevant to this study. 


Oana Andrada ALEXIU (BUCHAREST, Romania), Luisa Corina SIMION, Bogdan Mihai OPRITA, Paula Maria NECHITA, Amal Antonia ARNAOUTE, Alina Cristina STOIAN
11:00 - 18:00 #8036 - The development of the European Trauma Course in Austria – data on 30 courses.
The development of the European Trauma Course in Austria – data on 30 courses.

Introduction

Worldwide, trauma claims more productive life years than any other disease. The World Health Organization estimates that the mortality of major trauma in Europe could be decreased up to 30% by improving the chain of care for major trauma patients. In recent years different trauma teaching programmes have been established in working towards decreasing the burden of death and disability of traumatized patients. European Trauma Course (ETC) goal is to teach a simplified and standardised approach to trauma patient management. ETC was designed in collaboration with the ERC, EuSEM, ESTES and ESA. Austrian group of experts in trauma patient management and the Austrian societies joined ETC initiative from the early beginning, being the first group providing in-house courses, prehospital and inhospital scenarios, interactive presentations for instructors and pushing the topics of human factors in the courses.

Material and methods

Database search of the records of ETC Austria from 2008 until April 2015

Results

30 courses were completed, with 669 participants (199 females, 470 males). More than two thirds of participants were doctors (627), followed by nursing staff (22) and ambulance personnel (20). The majority of participants were anaesthesiologists (323), alongside with trauma surgeons (232), emergency medicine specialists (82) and others (33). Of 30 courses 20 were open ones with individual registration and 10 were closed in-house courses for single institution trauma teams training.

Conclusion

In the past six years ETC has become the standard trauma course in Austria. Every year more and more medical personnel from nursing and ambulances join our courses, building the whole concept closer towards ETC goal of multi-specialty and multi-professional trauma team approach.


Michael HÜPFL (Vienna, Austria), Florian TRUMMER, Adi DEIXLER, Katja KALAN USTAR, Christian SCHREIBER, Ileana LULIC
11:00 - 18:00 #7572 - The diagnostic value of presepsin in sepsis and the prognostic value of the comparison with SOFA, APACHE II scores.
The diagnostic value of presepsin in sepsis and the prognostic value of the comparison with SOFA, APACHE II scores.

Objective: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Presepsin is released during infectious diseases and can be detected in the blood. Presepsin has shown promising results as sepsis marker. We examined the diagnostic and prognostic validity of presepsin in patients suspicious of sepsis on admission in the emergency department.

Methods: Prospective study was conducted in the Meram Medical Faculty of Necmettin Erbakan University between June 2014 – June 2015. Eighty two patients with signs of sepsis, severe sepsis and septic shock and sixty six control patient individuals were enrolled. The value of presepsin was determined on admission and presepsin levels compared with APACHE II and SOFA scores.

Results: In the presepsin patient and control groups, there was a significant difference between the groups in terms of admission presepsin levels (p=0.006). While the mean presepsin level was 3.16±4.64 in the patient group, it was 1.92±1.95 in the control group. C-reactive protein (CRP), SOFA, lactate and APACHE II scores were significantly different between the patient and control groups (for all, p<0.001). In this study presepsin can be used as an appropriate biomarker in the prognosis of sepsis.

Conclusions: As a result presepsin is a suitable diagnostic test in the diagnosis of sepsis. At the same time lactate and CRP levels can be used as biomarkers in the prognosis of sepsis. However, more studies are required to confirm these findings.


Hasan BABADOSTU, Basar CANDER (, Turkey), Mümüne BABADOSTU, Abdullah Sadik GIRISGIN, Zerrin Defne DUNDAR
11:00 - 18:00 #7383 - The dynamics of stroke patients in emergency department.
The dynamics of stroke patients in emergency department.

The dynamics of stroke patients in emergency department

 

Virgiliu Cezar Bologa(1); Francesca Iulia Paius(1);Lucian Calutiu(1);

1. Emergency Department, UPU-SMURD, Sibiu, Romania

Speaker: Francesca Iulia Paius

Keywords: emergency room, cerebrovascular accident, hemorrhagic, ischemic, neurological disorders

 

BACKGROUND

In Romania there are approximately 300 cerebrovascular accident(CVA) registered per 100.000 inhabitants per year, compared to a European average of 200 CVA/ 100.000 inhabitants. At the moment in Romania there are approximately 800.000 patients who have suffered from CVA.

The present study focuses on the dynamics of the number of cases of CVA emerged at the Emergency Department-SMURD SIBIU between 01.01.2013 – 31.12.2015, as well as on their hospitalization within the departments of Sibiu County Clinical Emergency Hospital.

 

MATERIALS AND METHODS

The study was performed through a retrospective observational method on a number of 190268 cases emerged at the Emergency Department of Sibiu County Clinical Emergency Hospital between 01.01.2013 – 31.12.2015, out of which 2864 were diagnosed with CVA.

 

RESULTS

Out of a total number of hospitalizations within the Emergency Department-SMURD SIBIU between 01.01.2013 – 31.12.2015, the number of cases of CVA was of 2864, which stands for 1,5 % out of the total number of cases.

Out of the total number of 2864 cases of CVA emerged at the Emergency Department, the evolution throughout the 3 years was as follows: 35.71% in 2013, 34.77% in 2014, 29.50% in 2015.

Out of the total number of cases, 2628 (91.75%) were ischemic and 236 (8.24%) were hemorrhagic.

The hourly distribution of strokes throughout the 3 years was as follows: : 8:00 – 14:00 : 40.60% ; 14:00 – 20:00 : 34.11% ; 20:00 – 2:00 : 18.71% ;  2:00 – 8:00 : 6.56% .

The monthly distribution was as follows: January - 8.72%, February - 8.41%, March - 9.25%, April - 9.67%, May - 9.07%, June - 7.92%, July - 7.57%, August - 8.31%, September - 6.66%, October - 8.17%, November - 7.61%, December - 8.58%.

The distribution of CVA patients’ hospitalizations according to the hospital’s departments was the following: Neurology - 7.39%; Neurosurgery - 3.98%; transferred to regional hospitals - 1.25%; discharged upon request - 7.26%; deceased in the Emergency Department - 0,1% .

 

CONCLUSIONS

Throughout the studied period, the percent of patients hospitalized at the Emergency Department with the diagnose CVA, decreased from 35.71% in 2013 to 34.77% in 2014, and to 29.50% in 2015.

The CVA prevalence according to the monthly intervals was maintained throughout the three years by the spring months - March (9.25%), April (9.67%) unlike the autumn months - September (6.66%).

According to the time intervals, the highest number of CVA cases is within 8:00-14:00, followed by those occurring within the second part of the day, the lower number of CVA cases being registered in the interval 2:00 - 8:00.

Out of the total number of 2864 patients diagnosed with CVA, transferred according to departments, 87.39% were hospitalized at Neurology, 3.98% at Neurosurgery and 1.25% transferred to Regional Neurosurgery for the operation of broken aneurisms, and 7.26% were discharged.


Virgiliu Cezar BOLOGA, Dr Francesca Iulia PAIUS (BUCHAREST, Romania), Lucian CALUTIU
11:00 - 18:00 #7738 - The educational program for rescuers on medical emergency care in the mass casualty incidents involving children.
The educational program for rescuers on medical emergency care in the mass casualty incidents involving children.

Study/ objective:


The aim of this study was to develop an educational program for rescue workers, who can assist during mass casualty incidents and disasters. Development of the training is based on factors that are difficult for officers of the emergency services.

Methods:

In the project were involved two groups of rescuers. The first group of rescuers were without work experience or with a small (up to 5 years), the other rescuers were worked much over 5 years. The first stage of this work was to create a list of the biggest problems that lifeguards have during saving pediatric's patients at mass events and disasters. Based on this list the theoretical part of the educational program were created.
Another part of the program was a simulation of mass casualty incident involving children. The third part of the educational program was debriefing. Then the rescuers who had participated in the simulation were watching a recording of rescue operations and were asked to make a list of pros and cons of their actions. Later jointly discussed and analyzed the most important issues and questions. After all stages there was a test of knowledge and self-esteem for rescuers who were trained. Currently, this training model is still improved.

Results:

During theoretical classes, participants of the educational program learned differences between pediatric and adults's triage, which are related to the physiology and anatomy of children. They learned pediatric triage algorithm and information that are most important in the transport of pediatric patients from the scene of mass casualty incident to the hospitals. After this section, test results were at a medium level. Another part was a simulation of mass events involving children where rescuers were trained pediatric triage and how to providing medical emergency care to children. Later on they viewed the recording and discussed it. After this part, verification test results were better.
Analysis of 3 tests showed that the biggest problem for the rescuers in the mass event which involves children is: the lack of knowledge of anatomy and physiology of children, ignorance of pediatric triage algorithm, psychological stress and emotions of lifeguards, access to special training on the topic of helping children in disasters.

Conclusion:

It is necessary to introduce a broad education for paramedics, who provides medical emergency care in the mass casualty incidents. Such training should includes topics to help pediatric patients during disasters. The classes should includes knowledge of both anatomy and physiology of children, pediatric triage, medical skills, transport of children as well as stress management.


Katarzyna DLUGOSZ (Kraków, Poland), Arkadiusz TRZOS, Karol LYZINSKI
11:00 - 18:00 #7303 - The effect of Caffeic acid phenethyl ester (CAPE) on acute renal failure in crush syndrome model.
The effect of Caffeic acid phenethyl ester (CAPE) on acute renal failure in crush syndrome model.

Introduction

Crush syndrome is a severe clinical condition caused by rhabdomyolysis which is seen after massive crush injuries like earthquake injuries.  this syndrome causes a number of systemic and metabolic disorders including  myoglobinuric acute renal failure (MARF). CAPE has strong antioxidant and anti-inflammatory properties. The purpose of the present study was to evaluate the protective effect of CAPE against MARF in crush syndrome on an experimental animal model.

Material and Methods

Four groups were created with 40 well-matched healthy Sprargue-Dawley rats. In group 1 10 mL/kg intramuscular (IM) gliserol was administered to each rat to create the crush syndrome model. Consequently 10 micromole/kg CAPE was administered intramuscularly. The same CAPE dose was repeated at 24th hour of first dose. In group 2 10 mL/kg IM gliserol was administered and a crush syndrome model was created. In group 3 a single dose of 10 micromole/kg CAPE was administered intramuscularly without creating a crush syndrome model. The group 4 was the control group.   At the 48th hour of the first CAPE administration of group one cardiac blood samples were obtained and bilateral nephrectomy was carried out and the samples were prepared for histopathological and biochemical evaluations in all 4 groups. Serum urea, creatinine, IL-1β, TNF-α, IL-10 and IL-1Ra were studied on the blood samples.  The kidneys were evaluated histopathologicly to investigate any changes related to MARF.  To evaluate the oxidative damage malondialdehyde (MDA) nitric oxide (NO) levels and superoxide dismutase (SOD) and catalase(CAT) activities were studies on the renal tissue samples. 

 Results

Serum urea, creatinine, IL-1β, TNF-alpha, and IL-10 levels were significantly higher in group 2 compared to controls while these values were significantly low in group 1 compared to group 2.  Serum IL-1Ra levels were significantly lower in group 1 compared to control group. MD and NO levels of renal tissue samples were higher in group 1 compared to group 2 and control group. SOD and CAT activities were significantly lower in group 2 compared to controls while there was a significant increase of these activities in group one compared to group 2. The changes related to oxidative stress and myoglobinuria were observed in histopathological evaluation of group 1 and group 2. The renal tissue changes were apparently milder in group 1 in contrast to group 2. 

 Conclusion

Our results reveal that CAPE administration has a diminishing effect on the renal function deterioration and renal tissue changes observed in crush syndrome. We hope that our study lead innovations in the development of new protection or management of renal failure caused by crush syndrome.


Bunyamin Cuneyt TURAN, Hatice Gul SARIKAYA, Filiz TURAN, İbrahim GELINCIK, Omer KURT, Mehmet Fatih EROL (Tekirdag, Turkey), Ahsen YILMAZ, Ahmet GÜREL
11:00 - 18:00 #7798 - The Effect of Cholecystitis Diagnosed by Emergency Department Point of Care Ultrasound on Throughput Metrics.
The Effect of Cholecystitis Diagnosed by Emergency Department Point of Care Ultrasound on Throughput Metrics.

Background

 

The American College of Radiology (ACR) recommends ultrasound as the imaging modality of choice for patients with right upper quadrant pain and suspected gallbladder disease. Ultrasound is 90-95 percent sensitive for cholecystitis and is 78-80 percent specific. Either clinician-performed point of care ultrasound (POCUS) or comprehensive consultative ultrasonography (CCUS) can be used to diagnose cholecystitis. Studies indicate that emergency clinicians require minimal training to effectively use right upper quadrant ultrasonography in their practice.

 

Objectives

 

To show that POCUS reduces time to emergency department disposition (ED-LOS), time to OR (TOR) and hospital length of stay (H-LOS) in patients diagnosed with cholecystitis.

 

Methods

 

A retrospective chart review was done of all patients who presented to the emergency department between January 1, 2013 and June 1, 2015 for abdominal pain and had cholecystitis as discharge diagnosis. The POCUS use was compared to CCUS for ED-LOS, TOR, and H-LOS using unpaired t-tests with alpha set at 0.10.

 

Results

Table

 

 

ED-LOS

p value

T2OR

p value

H-LOS

p value

POCUS [P] 

N=37

4.75

 

36.81

 

67.59

 

CCUS  [C]   

N=4

7.08

0.17

71.50

0.08

102

0.09

BOTH  [B] 

N=68

5.67

0.07

59.01

0.02

93.74

0.02

CLOSED     

N=65

5.03

 

45.42

 

76.60

 

OPEN          

N=45

5.97

0.06

61.57

0.07

97.82

0.05

Closed [P vs B]

 

 

0.10

 

0.10

 

0.06

 

 

POCUS was associated with decreased TOR and H-LOS when compared to CCUS or both. POCUS had lower ED-LOS, TOR, and H-LOS when CCUS services were closed vs open. When closed, ED-LOS, TOR, & H-LOS were lower with POCUS than with CCUS or both. When CCUS was open all patients received both exams.

 

Conclusion

POCUS can diagnose and treat acute cholecystitis while helping to decrease the patient’s time to disposition, time to OR, ED and hospital length of stay when compared with traditional approach with CCUS in patients with suspected acute cholecystitis.  Routinely following POCUS with CCUS may delay care and constitute an unnecessary utilization of valuable resources.


Chiricolo GERARDO (Holmdel, USA), Christopher RAIO, Carlos CALAF
11:00 - 18:00 #8237 - The effect of complete blood count parameters and ultrasound in the management of acute cholecystitis and surgery decision.
The effect of complete blood count parameters and ultrasound in the management of acute cholecystitis and surgery decision.

Introduction: We aimed to determine the effect of complete blood count (CBC) parameters and ultrasound (USG) in the management of acute cholecystitis (AC) and surgery decision.

Methods: In a two-year period, adult patients (>18 years) in both gender who admitted to emergency department (ED) and diagnosed as AC with ultrasound (USG) were investigated from the hospital records and ED patient files retrospectively. The results of ultrasound performed in ED, complete blood count parameters, surgical or medical treatment decision and pathology reports were reviewed. Those who were under 18 years, whose study data could not be reached were excluded. Patients were divided into 2 groups according to surgical or medical treatment decisions and their data were compared statistically.

Results: Total 236 patients were included. Of the patients, 153 (64.8%) were female, mean age was 54.62±18.76 years. All patients’ gallbladder wall thickness were increased, 226 (95.8%) had stones in the gallbladder and 176 of these were multiple, 61 (25.8%) had biliary sludge and 3 (1.3%) had polyp according to USG reports. Patients were evaluated by general surgeons, and 156 (66.1%) patients with AC had surgical treatment decision and surgery was performed. Of these, 112 (71.8%) had laparoscopic cholecystectomy. Mean hospitalisation time was 3.27±2.28 days. Due to pathology reports, 3 patients had gangrenous cholecystitis, 2 had malignancy, 2 had ulceration and perforation. All patients were discharged. When surgical patient group (G1) was compared to medical treatment group (G2), there were statistically significant differences between the two groups in terms of age (G1=49.67±14.38, G2=54.69±18.65, p=0.023), the neutrophil-to-lymphocyte ratio (NLR) (G1= 3.32±3.6, G2=4.75±4.39, p=0.008), RBC (G1=4.68±0.50, G2=4.50±0.65, p=0.022), HGB (G1=13.44±1.66, G2=12.68±2.09, p=0.003), LYM (G1=2.28±0.90, G2=1.94±0.76, p=0.005) and EOS (G1=0.16±0.13, G2=0.22±0.28, p=0.003). The ratio of gender, the presence of stones in the gallbladder, stone size, WBC, MCV, MCH, RDW, PLT, MPV, MONO, NEU, BAS were not different between the two groups.

Conclusions: NLR, RBC, LYM and EOS was significantly associated with surgical treatment decision. After a good physical examination, ultrasound is useful for diagnosis of acute cholecystitis. But contrary to popular belief, ultrasound and WBC are not associated with surgical treatment decision according to our findings.


Mehmet Oguzhan AY (CORUM, Turkey), Alper CELIKDEMIR
11:00 - 18:00 #7384 - The effect of using high sensitivity troponins on emergency department admissions.
The effect of using high sensitivity troponins on emergency department admissions.

In October 2015 an Emergency Department in the West of Scotland implemented a new chest pain protocol in response to a study (Shah et al.) that showed by using high sensitivity troponin (hsTnI) levels, patients who had suffered chest pain could be safely discharged earlier. The new protocol uses hsTnI to assess the likelihood of a cardiac cause of chest pain and allows safe discharge of patients with a negative hsTnI as soon as 2 hours after onset of pain. The previous protocol required patients to be admitted for a 12 hour troponin.

This study compared the safety and efficacy of the new protocol against the former protocol. Data was retrospectively analysed from 600 patients (300 from each protocol) using patient records. Patients were included in the study if they had presented with chest pain and had a hsTnI measurement taken. The main factors considered were admission, discharge and re-admission rates. Additional data was gathered to check compliance with the protocol, including chest x-ray and time to ECG. Recommendations from the study are intended to be used to refine the protocol and increase compliance.

The new protocol resulted in a statistically significant decrease in admissions, from 62.3% to 35.7%, to the acute receiving unit (this equates to approximately 1000 admissions per annum). Patients self-discharging from the ED fell from 11 to 2. Re-attendance within one week with chest pain increased from 6 patients to 10. Mean time to first ECG was 39 minutes. The protocol suggests an ECG should be completed within 15 minutes, only 19% of patients met this target. The protocol was followed in 56% of cases, with non-compliance being mainly due to a lack of completion of a repeat hsTnI (despite clinical indications that it was appropriate) or chest x-ray.

In summary this study showed that there was a statistically significant reduction in admissions with chest pain, although it would possible to improve this even further by completing all repeat troponins in the ED to prevent unnecessary admissions. Time to first ECG could also be improved by performing ECGs immediately on presentation.


Isobel BROOKES, Jason LONG (Glasgow, United Kingdom)
11:00 - 18:00 #6292 - The effects of blood transfusion and crystallid infusion on outcome of endovascular aortic repair performed for ruptured abdominal aortic aneurysm. The evaluation of the amount and composition of blood transfusion.
The effects of blood transfusion and crystallid infusion on outcome of endovascular aortic repair performed for ruptured abdominal aortic aneurysm. The evaluation of the amount and composition of blood transfusion.

Endovascular aortic repair (EVAR) is reported to be an effective treatment for ruptured abdominal aortic aneurysm (rAAA). However, the mortality associated with rAAA remains high. The factors that might affect survival in patients with rAAA who undergo EVAR are not well known. In studies about patients with trauma, blood transfusion and crystalloid infusion is reported to be associated with survival. The aim of this study was to evaluate the effects of blood transfusion and crystalloid infusion on survival in patients with rAAA following emergency EVAR.

 In this retrospective study, we reviewed patients who were admitted to our hospital with enhanced computed tomography (CT)-confirmed rAAA between October 2013 and December 2015. Patients with symptomatic abdominal aneurysm without evidence of hemorrhage in CT images were excluded. In our facility, EVAR is considered as the first-line surgical treatment for rAAA. However, if EVAR was contraindicated, open repair was performed. We assessed blood transfusion and crystalloid infusion performed in the period between admission to the emergency room and admission to ICU after surgery.

 Twenty-five patients who underwent EVAR were enrolled. (No patients died in the ER, 1 was considered not fit for surgery and 46 went to theatre. Of 46 cases, 25 underwent EVAR.) The mean patient age was 76.4 ± 9.92 years. The male:female ratio was 18:7. Eighteen patients experienced preoperative shock. The mean operation time was 115 ± 32.5 minutes. Blood transfusion: red cell concentrates, 10.0 ± 5.70 units; fresh-frozen plasma, 4.4 ± 3.3 units; and platelet concentrate, 5.5 ± 13 units. Three patients died of abdominal compartment syndrome within 24 postsurgical hours. An additional 2 patients died between 24 hours and 30 days postsurgically; 1 patient died due to respiratory failure  and 1 due to cancer. Twenty patients (80%) survived.

RCC/FFP ratio were significantly larger in both the 24-hour (survived:non-survived=1.3+/-0.6: 1.6+/-0.8, p=0.014) and 30-day(survived:non-survived=1.1+/-0.6: 1.8+/-0.8, p=0.001) non-survival groups compared with the respective survival groups. Patients with RCC/FFP ratios greater than 1.5 were observed significantly more in non-survival groups in both 24-hour(survived:non-survived=2(9%): 3(100%), p=0.018) and 30-days(survived:non-survived=1(5%): 4(70%), p=0.030). Larger amounts of crystalloids were used in the both the 24-hour (survived:non-survived=2386+/-912:5083+/-803, p=0.028)and 30-day(survived:non-survived=2341+/-9.6: 4550+/-1252, p=0.012) non-survival groups compared with the respective survival groups. Patients who were given crystalloid more than 1.5L were observed significantly more in non-survival group both in 24-hour(survived:non-survived=5(23%): 3(100%), p=0.037) and 30-days(survived:non-survived=5(25%):4(80%), p=0.010).

In a study of trauma patients, large amounts of crystalloids has adverse effects on survival and those who infused large amounts of crystalloids needed larger blood transfusions. A retrospective investigation of RCC/FFP ratio in trauma patients reported a link between a 1:1 RCC/FFP ratio and positive prognosis. The PROPPR randomized clinical trial divided trauma patients by blood transfusion type into an RCC:FFP:PC=1:1:1 group and an RCC:FFP:PC=2:1:1 group. Better prognoses were observed in the former. We suggest that also in rAAA patients treated with EVAR, early FFP trans fusion and limitation of crystalloids can improve prognosis of the patients.


Yohei KAWATANI (Matsudo, Japan), Kurobe HIROTSUGU, Hayashi YUJIRO, Taneichi TETSUYOSHI, Ito YUJIRO, Nakamura YOSHITSUGU, Suda YUJI, Tetsuya KITAGAWA, Hori TAKAKI
11:00 - 18:00 #4535 - The effects of preoperative and postoperative coagulation profile on outcome of endovascular aortic repair performed for ruptured abdominal aortic aneurysm.
The effects of preoperative and postoperative coagulation profile on outcome of endovascular aortic repair performed for ruptured abdominal aortic aneurysm.

[Introduction] Presently, endovascular aortic repair (EVAR) is reported to be an effective treatment for ruptured abdominal aortic aneurysm (rAAA). However, the mortality associated with rAAA remains high. Previous reports indicated that a major cause of death in patients with rAAA is hemorrhage due to coagulopathy following open repair for rAAA. The factors that might affect survival in patients with rAAA who undergo EVAR are not well known. The aim of this study was to evaluate the effects of perioperative and postoperative coagulation status on survival in patients with rAAA following emergency EVAR.

 

[Methods] In this retrospective study, we reviewed patients who were admitted to our hospital with enhanced computed tomography (CT)-confirmed rAAA between October 2013 and December 2015. Patients with symptomatic abdominal aneurysm without evidence of hemorrhage in CT images were excluded. In our facility, EVAR is considered as the first-line surgical treatment for rAAA. However, if EVAR was contraindicated, open repair was performed. Blood tests were performed at the time of admission to the emergency department (preoperative status), at the time of admission to the intensive care unit (ICU) postoperatively. Major coagulopathy was defined as an international normalized ratio or activated partial thromboplastin time (APTT) ratio of ≥1.5.

[Resurts] Twenty-five patients who underwent EVAR were enrolled. (No patients died in the ER, 1 was considered not fit for surgery and 46 went to theatre. Of 46 cases, 25 underwent EVAR.) The mean patient age was 76.4±9.92 years. The male:female ratio was 18:7. Eighteen patients experienced postoperative shock. The mean operation time was 115±32.5 minutes. Blood transfusion: red cell concentrates, 10.0±5.70 units; fresh-frozen plasma, 4.4±3.3 units; and platelet concentrate, 5.5±13 units. Three patients died of abdominal compartment syndrome within 24 postsurgical hours. An additional 2 patients died between 24 hours and 30 days postsurgically; 1 patient died due to respiratory failure  and 1 due to cancer. Twenty patients (80%) survived. None of the patients had a major coagulopathy preoperatively, whereas 9 (36.0%) presented with major coagulopathy postoperatively. Although preoperative prothrombin time (PT), APTT, and major coagulopathy were not observed, postoperative APTT and major coagulopathy were associated with 24-hour survival [Survived : Non-survived 38.9±8.7:108.7±63.4 P=0.006(APTT), 6:3 P=0.037(major coagulopathy)] and 30-day survival [Survived : Non-survived 38.1±7.9: 95.7±57.9 P=0.002 (APTT), 5:4 P=0.010 (major coagulopathy)]. APTT was significantly greater in patients who died compared with those who survived at both 24 hours [Survived : Non-survived 11.9±9.2: 75.0±58.9 P=0.006] and 30 days [Survived : Non-survived 11.3±8.9: 62.7±54.1 P=0.002]. Hemoglobin, hematocrit, and platelet counts were not significantly different between those who survived and those that died.

 

[Discussion] Preoperative APTT, PT, and major coagulopathy were not observed. However, APTT on admission to ICU was significantly longer in patients who did not survive. Additionally, postoperative major coagulopathy was more frequently observed in patients that did not survive. Moreover, the differences between preoperative and postoperative APTT or major coagulopathy were significantly higher in non-survivors suggesting that progressive coagulopathy might have strong adverse effects on survival.

[Conclusion] Postoperative APTT and major coagulopathy were asocciated with mortality.


Yohei KAWATANI (Matsudo, Japan), Kurobe HIROTSUGU, Hayashi YUJIRO, Taneichi TETSUYOSHI, Ito YUJIRO, Nakamura YOSHITSUGU, Suda YUJI, Tetsuya KITAGAWA, Hori TAKAKI
11:00 - 18:00 #7769 - The emergency dispatch system- order versus chaos.
The emergency dispatch system- order versus chaos.

The emergency dispatch system- order versus chaos.

Polexa Alexandra Stefania (1),  Podariu Sorina Madalina(1),  Radu Ioana(1),  Taran Ana-Daniela(2),  Fisca Vlad-Alexandru(2)

1. Emergency department, SMURD Sibiu, Sibiu, Romania

2. Emergency department, UPU-SMURD Sibiu, Sibiu, Romania

Key words: dispatcher, optimize, triage

Background

Calls to 112, the emergency telephone number, allows European citizens in distress to contact the emergency services. These are transferred to a  dispatcher or a dispatching software able to allocate appropriate human resources and equipment to anyone who urgently asks for medical help. Furthermore, EMD also includes the provision of accurate instructions to the caller  (for example, CPR) or in case of disaster the necessary coordination. The aim of this study is to analyze and acknowledge the performance of the emergency dispatch system, to highlight the flaws and to provide proper solutions and alternatives.

 

Methods

We conducted a retrospective study based on the last three years SMURD (Mobile Emergency Service for Resuscitation and Extrication) database.  In order to exemplify our standpoint, we included 774 calls given as cases of unconsciousness. Out of this, 327 turned out to be in cardiac arrest, whereas 447 of this total of emergency cases proved to be of other etiologies. Our study focuses on the complex classification of these 447 cases by final diagnosis, gender, conscious state, etc.

 

Results

Therefore, we have included a great variety of cases:  hypoglycemia(10 cases), lipothymia(52 cases), inebriated(56 cases), epileptic seizures(101 cases), cranio- cerebral injury(54 cases), neoplasm(27 cases), heart rhythm disorders(26 cases) , hypertension(34 cases), ischemic transient attacks( 21 cases), cerebral vascular accidents(77 cases), combined drug intoxication(25 cases), death by hanging( 9 cases), coronary heart disease, pulmonary oedema( 7 cases), aggression(2 cases), angina pectoris(9 cases), respiratory distress(29 cases) which proved to be the real etiology for the cases given by the dispatcher. Besides final diagnosis classification criteria we also classified the cases in groups by GCS(Glasgow Coma Score), gender, age groups, pre-hospital parameters.

 

 

Conclusions

We are trying to magnify the importance of a well-trained dispatching system. While some of the cases observed required a type c ambulance and the assistance of a doctor, some of them could be conducted by first aid team, thus allowing type c ambulance to intervene in trully life threathenig situations. It is well known what couple of minutes or a very well trained team can do for a life, so we have to take into consideration all the variables before dispatching a unit or other. The true aim of this study is to emphasize the true necessity of a good dispatching system and to really advocate for a better training for dispatchers all around the world.

 

 

 


Alexandra-Stefania POLEXA (Dacia, Romania), Sorina Madalina PODARIU, Ioana RADU, Vlad-Alexandru FISCA, Ana-Daniela TARAN
11:00 - 18:00 #7284 - The Emerging Method of Suicide by the Fatal Exposure to Electronic Cigarette Liquid : Case Reports.
The Emerging Method of Suicide by the Fatal Exposure to Electronic Cigarette Liquid : Case Reports.

Electronic nicotine delivery system or electronic cigarette (EC) is a device that aerosolized liquid nicotine by heating a solution of nicotine, glycerol and flavoring agents. The awareness and the usage of EC has been increased in many countries. Due to the online sales and the absence of regulations of EC, the prevalence of EC usage is especially high in adolescents and young adults. Due to the large amount and the high nicotine concentration of EC liquid, the ingestion for suicide easily can lead to cardiac death. We had two patients of 27-year old male who ingested about 23 mg/kg as nicotine and 17-year old female who ingested about 30 mg/kg as nicotine. Both patients had cardiac arrest followed by cardiopulmonary resuscitation and post cardiac arrest care, who discharged as CPC 2 and 4 respectively.


Eun Jung PARK, Eun Jung PARK (Suwon, Korea), Younggi MIN
11:00 - 18:00 #8167 - The etiology of toxic encephalopathy in romanian patients in emergency department.
The etiology of toxic encephalopathy in romanian patients in emergency department.

Background.

Brain dysfunction caused by toxic exposure may be included in the term “toxic encephalopathy”, characterized by a spectrum of symptomatology ranging from subclinical deficits to overt clinical disorders. The clinical manifestations of toxic encephalopathy are related to the affected brain regions and cell types. The major clinical syndromes of toxic encephalopathy include diffuse acute or chronic toxic encephalopathy, cerebellar syndrome, Parkinsonism, and vascular encephalopathy. These relatively specific neurological syndromes may be determined by various neurotoxins, including heavy metals, organic solvents and other chemicals. Aim of our study was to investigate the etiology of toxic encephalopathy in Romanian patients in Floreasca Hospital Emergency Department.

Participants and methods.

We included in this study, 100 patients presented with toxic encephalopathy to Floreasca Hospital between March 2015 – March 2016, and we collected the demographic data (e.g. age, gender, region, etc.), risk factors (e.g. pathological personal history etc.), symptomatology at presentation and type of toxic. The data were statistically processed by SPSS ver.20.

Results.

We observed that the most frequent causes of toxic encephalopathy are alcohol consumption, medications, illicit drugs, or toxic chemicals. In the last years, the acute mental status alteration due to alcohol consumption and illicit drugs is increased.

Conclusion.

The symptoms and signs of toxic encephalopathy may be mimicked by many psychiatric, metabolic, inflammatory, neoplastic and degenerative diseases of the nervous system. A good collaboration between neurologists and occupational physicians are needed to determine whether neurological disorders are neurotoxin-related.

References.

  1. World Health Organization (WHO) Neurotoxicity risk assessment for human health: Principles and approaches; Environmental health criteria 223. Geneva (Switzerland): WHO; 2001.
  2. Dobbs MR. Clinical neurotoxicology: Syndromes, substances, environments. 1st ed. Philadelphia (PA): Saunders; 2009. pp. 3–6.
  3. So YT. Neurotoxicology. In: Ladou J, editor. Current occupational and environmental medicine. 2nd ed. New York (NY): McGraw Hill; 2007. pp. 373–383.
  4. Dobbs MR. Toxic encephalopathy. Semin Neurol. 2011;31:184–193. 
  5. Yangho KIM, Jae Woo KIM. Toxic Encephalopathy. Saf Health Work 2012;3:243-56

 

Acknowledgements.

No potential conflict of interest relevant to this study.


Paula-Maria NECHITA (Bucuresti, Romania), Bogdan Mihai OPRITA, Luisa Corina SIMION, Oana Andrada ALEXIU, Amal Antonia ARNAOUTE, Alina Cristina STOIAN
11:00 - 18:00 #8038 - The European Trauma Course development from 2006-2015.
The European Trauma Course development from 2006-2015.

Introduction

The European trauma course was developed in the pilot phase between 2006 and 2008. A group of experts from all Europe designed it as it was necessary to create a flexible course on trauma management that can be used in all the different systems in Europe. Additionally working in a team has not been reflected in the traditional courses that were available. The goal was to create a course that this focused on a team approach and flexible to adaptation to local protocols. Based on up-to-date adult learning models 85% is practical simulation based team training.

Material and methods

A database search of the ERC course data base (courses.erc.edu). Data were displayed according to country and month of the course.

Results

The courses started in 2006 with an inaugural course in Malta followed by 3 pilot courses. After that there were courses in 2008 (3), 2009 (11), 2010 (17), 2011 (18), 2012 (34), 2013 (41) and 2014 (62) in 3 (2008), 8 (2009), 10 (2010, 2011), 11 (2012)13(2013), 17(2014) and 19 countries in 2015. The most courses were done in Germany (51), followed by Austria(37) and UK (236), Egypt (28), Italy(21), Croatia (11), Malta (10), Poland (8), Slovenia (7), Portugal(6), Belgium, Finnland, Denmark (5), Hungary(4), Saudia Arabia, Sudan, Sweden, Switzerland and Romania (3), Jordan (2) and Norway, Netherland, Ireland and Greece(1).

Conclusion

The project “European Trauma Course” was piloted with four courses and started in 2008.The courses are already available in 24 countries made a quick development from 2008 to 2015.

References

The European Trauma Course: trauma teaching goes European. Thies KC et al., EurJAnaesthesiol. 2014


Michael HÜPFL (Vienna, Austria), Adi DEIXLER, Katja KALAN USTAR, Ileana LULIC, Christian SCHREIBER, Markus BRUCKE, Victor TREGUBOV, Birgit RÖSSNER, Florian TRUMMER
11:00 - 18:00 #8238 - The Evaluation Of Antimicrobial Therapy In Patients With Cholecystitis.
The Evaluation Of Antimicrobial Therapy In Patients With Cholecystitis.

Introduction 95% of cholecystitis cases are caused by gallstones which are formed by cholesterol and bilirubin (pigment) in bile, also referred to as biliary sludge. The other cases are generally caused by trauma, treatment in hospital, or treatment for illnesses related to bile or the liver. Gallstones blocking the CBD are the leading cause of cholecystitis. This blockage causes bile to build up in the gallbladder, and that buildup causes the gallbladder to become inflamed. This is a serious condition. The gallbladder could rupture if it’s not treated properly, and this is considered a medical emergency. Treatment usually involves antibiotics, pain medications, and removal of the gallbladder.

Aim To evaluate the antimicrobial  therapy in patients with cholecystitis in the Emergency and Intensive Care Unit of Vlora Regional Hospital in  August-December 2015.

Meterials and methods This is a descriptive study. We took a total of 39 individuals in the study, patients which were diagnosed with cholecystitis in the Emergency Unit, of Vlora Regional Hospital during August-December 2015. Data collection was conducted by taking information from medical records of hospitalized patients in this ward. Information was taken for gender, the conditions patients came to the hospital and the use of antimicrobial drugs.

Results There were 39 patients diagnosed  with  cholecystitis, 22 females and 17 males. 33% of the patients  were found with acute cholecystitis and 67% had chronic one.  In 7 patients  with acute pain and symtoms  were found gallbladder stones as the main cause of acute cholecystitis, in 2 patients  acute nonchalculous cholecystitis was developed after  an abdominal trauma.

The recommended treatment was with wide-spectrum antibiotics for moderate to severe acute cholecystitis. The patient with chronic cholecystitis were found with gallbladder stones as the main reason of the development of the infection and they were treated with intravenous fluids, analgesics, anti-microbial drugs such as intra venous ampicillin-sulbactam before the surgical intervention.

In 2 patients the dose of antimicrobial agents was reduced because of the reduced renal function.  Piperacillin, ampicillin and an aminoglycoside were also used in 11patients.

Conclusions Antibiotics are included in the treatment regimen. Infection is treated with broad spectrum antibiotics such as piperacillin-tazobactam, ampicillin-sulbactam, ticarcillin-clavulanate or cephalosporin. It is recommended that those who are prone to allergies to take aztreonam or clindamycin. Make sure that when patient is undergoing an antibiotic therapy, strict compliance is to avoid drug resistance. Acute cholecystitis consists of various morbid conditions, ranging from mild cases that are relieved by the oral administration of antimicrobial drugs or that resolve even without antimicrobials to severe cases complicated by biliary peritonitis. 


Majlinda ZAHAJ, Rozeta LUCI (Vlore, Albania), Brunilda SUBASHI, Glodiana SINANAJ, Denada SELFO, Erilda RUCI
11:00 - 18:00 #7592 - The experience at Rajavithi Hospital on August 17, 2015: Preparedness, response, and lessons learned.
The experience at Rajavithi Hospital on August 17, 2015: Preparedness, response, and lessons learned.

Background:There was a 10fold increase in terrorist bombing around the world between 1968and 1980, with 5075 events document.Conventional explosive devices are typically categorized into broad categories:"ordinary explosives"and"high explosives".Trinitrotoluene(TNT) are high explosives designed to detonate very rapidly,typical with only a few microseconds.The magnitude of the shock wave at the blast front, know as positive phase impulse,is animportant factor determining the severity of blast-related injury.Overpressure is the major force generating primary blastinjury(PBI), under pressure force are the principlemechanism involved in producing secondary and tertiary blast injury.The distance fromRachaprasong intersection to Rajavithi hospital were 4 kilometers.RajavithiHospital has 1,200 bed hospital located on VictoryMonoment,Rachatheve district,Bangkok.There are totallyof 42 intensive care unit beds,4 Burn unit beds,120 ventilator equipments.We have pre-hospital resources teams compose of onedispatch center,3 ambulances(ALS level team). OnAugust17,2015,within minutes of the major terrorist event.This explosion involved the detonationof ammonium-nitrate material(300 kilograms TNT-equivalent) inside the Erawan Shrine at the Rajprasong intersection in Pathumwan district at 6.55PM.The event involved 19 hospitals in Bangkok for 163 injuried patients,20 death, coverd about40 square meter.

Objectives:To study the effective clinical response to patients from a bombing event will require coordination and cooperation amoung multiple medical specialties.

               To identify available hospital beds, discharging patients,caring for patients,and providing addition support during the response.

Methodes:Rajavithi hospital received totally 8 patients factual information from events on August 17, 2015, were collectd from public media.Also materials for the hospital preparedness plan were derived from the hospital's emergency department(ED), plan for disaster, drafted by the Rajavithi administration.The data on August 17,2015, was collected retrospectively from departmental logbook individual chart review andRajavithi trauma registry Database.

Results:The ED saw the 6 patients(75%)arrived at Rajavithi Hospital with in first hour after explosion.The5 patients(62.5%)of patients triaged in EDwho required hospital admission.The5 patients(62.5%) transport to hospital by ambulances 1 ALS;3BLSand 1FR but only 3 patients(37.5%) could you discharge. Length Of Stay(LOS) 4-62 days(median6).Their median age of ED patients assessed was 18-38(median25) years old. All of them were female(100%).TheGlasgow Coma Scale(GCS)ranged from 11-15(median15).The 2 patients(25%) presented to the ED had an injury Severrity Score (ISS)>15. No death detected in Rajavithi Hospital.

Conclusion:The information should help emergency physician,specialist surgery doctor,nurses,ICU directors and disaster committee plan for mobilization of resources in response to Terrrorist Mass Casualty Event caused by explosives.


Dr Nopmanee TANTIVESRUANGDET (Bangkok, Thailand), Nirutchara KOKULDILOK, Lek KANJANAKOMUT, Teerachai UKRITMANOROAT
11:00 - 18:00 #7449 - The explosive return of dnp (2,4-dinitrophenol).
The explosive return of dnp (2,4-dinitrophenol).

2,4-dinitrophenol, an industrial organic compound, has been increasing in recreational use, thanks in part to widespread availability over the internet. Used originally in industry as an explosive precursor, it was used originally as a medication in 1933 for its profound weight loss effects. Severe toxicity led to its withdrawal as a medication, but it has found new popularity amongst body builders as an agent to increase basal metabolic rate (BMR) and enhance fat loss. We present the case of an intentional overdose of DNP and the lessons learnt from this dangerous drug.

A 32-year-old male with a history of depression took an intentional overdose of DNP before calling an ambulance. On arrival to the resuscitation room he looked extremely unwell, with profound sweating, yellow sweat and confusion. Staff commented on the unusual smell from his sweat. On initial assessment, his airway was patent, SaO2 95% in room air, heart rate 140 bpm, BP 168/86 mmHg and GCS 14 (E4V4M6), temperature was 39.5oC. Electrocardiogram showed narrow complex tachycardia. Oxygen was given by a high-flow non-rebreather mask and IV access gained. 1L Hartmann’s fluid was given stat. A venous blood gas (VBG) showed a pH of 7.36 and Lactate 8.3 mmol/L. Within five minutes of arrival his heart rate rose rapidly to over 200 bpm and within a few seconds his entire body became rigid, breathing slowed before loss of cardiac output and commencement of Cardiopulmonary resuscitation (CPR). Intubation was difficult due to extreme generalised rigidity. Administration of rocuronium and midazolam failed to improve this rigidity. A repeat VBG during CPR showed a potassium of 8 mmol/L. He was given 10mls of 10% calcium gluconate, an insulin/dextrose infusion and further IV fluid. During CPR he was given an intralipid bolus and a bolus of 8.4% sodium bicarbonate. He died after one hour of CPR with asystole throughout. His final lactate was 18 mmol/L, with an unrecordable potassium and a pH of 6.8. During CPR, advice was sought from the National Poisons information service (NPIS) who advise on severe poisoning cases in the UK.

Learning points:

DNP acts to uncouple oxidative phosphorylation and as such greatly increases the BMR leading to extreme rises in body temperature. Extreme rigidity due to release of calcium has been reported to occur immediately prior to death as well as quickly after. Yellow colouration of sweat has been reported as pathognomic of DNP overdose.

These patient should be cooled rapidly. Intubation with paralysis and sedation should be considered immediately. Dantrolene has been suggested as an early treatment for the severe hyperthermia.

Skin exposure to DNP is possible and staff should wear protective clothing whilst examining the patient.

Street names for DNP currently include Dinosan, Solfo Black, Nitrophen, Aldifen, Chemox, Mical, Caswell 392, Nitro klenup.

Easy internet availability will make overdose far more common. Emergency physicians should be aware of this compound and be mindful of how rapidly these patients can deteriorate. Very early aggressive resuscitation with cooling may allow recovery.


Dr David SHACKLETON (London, United Kingdom), Alicia REFSON
11:00 - 18:00 #4548 - The First Use Of Pralidoxime In a Child With Rivastigmine Poisoning.
The First Use Of Pralidoxime In a Child With Rivastigmine Poisoning.

The aim of this report is to describe the successful use of pralidoxime in pediatric patient who accidentally ingested 12 mg of rivastigmine and presented to the emergency department (ED) with weakness, drowsiness, hyporeactivity to environmental stimuli and full cholinergic syndrome. Case report The patient presented to the Emergency Department (ED) two hours after a suspected ingestion of rivastigmine. He was sleepy but oriented and cooperative, hypotonic, hyporeflexic and a Glasgow Coma Score of 13 (E3M6V4). Laboratory tests showed a low plasma cholinesterase levels of 2141U/L(normal range 5300-12.900 U/L), hyperglycemia (251 mg/dL), and leucocytosis with neutrophilia (21,900/mL, 75.2% neutrophils). Only two pediatric cases of rivastigmine poisoning have been reported in the literature and there are no prior reports of using pralidoxime in the management of this poisoning. In the present case intravenous pralidoxime (30mg/kg) was administered twice at the 5th and 6th hour of ingestion for nicotinic and central effects. There is reasonable theoretical science to suggest pralidoxime in case of acetylcholinesterase inhibitör toxicity . We conclude that observed clinical improvement in weakness temporally associated with pralidoxime administration. Increased plasma cholinesterase activity following pralidoxime administration also make it useful in these poisoning.

 

 

 

 

      


Eylem Ulaş SAZ (Izmir, Turkey), Ali YURTSEVEN, Mehmet Arda KILINÇ, Ferhat SARI, Hasan AĞIN
11:00 - 18:00 #7701 - The HEART score for early rule out of acute coronary syndrome in the emergency department: a meta-analysis.
The HEART score for early rule out of acute coronary syndrome in the emergency department: a meta-analysis.

Background

Patients presenting with undifferentiated chest pain account for 5-10% of emergency department (ED) attendances. This puts enormous strain on healthcare services but, as less than 25% of those investigated have an acute coronary syndrome, there is great potential to reduce unnecessary hospital admissions by improving diagnostic technology. Several studies have suggested that the HEART score, based on patient information and a single blood test on arrival, could help to achieve that. In this systematic review and meta-analysis we aimed to summarise the available evidence on the diagnostic accuracy of the HEART score for predicting major adverse cardiac events (MACE).

Methods

Two investigators independently searched the Medline, Embase and Cochrane databases between 2008 and May 2016 identifying eligible studies providing diagnostic accuracy data on the HEART score for predicting MACE as primary outcome.  Titles and abstracts were screened, including full-text review when necessary to decide about final inclusion. Study characteristics and diagnostic accuracy measures were systematically extracted and study quality was assessed with the QUADAS-2 tool before consideration in the final meta-analysis. Pooled estimates of sensitivity and specificity were calculated using a generalized linear mixed model approach with random effects assumption (Stata 13.1).

Results

We identified 12 studies meeting the inclusion criteria for this systematic review. After quality assessment, 9 studies including data from 11,217 patients were combined in a meta-analysis. In total 15.4% patients (range 7.3 – 29.1%) developed MACE after a mean of 6.0 weeks of follow-up. Among patients categorised as ‘low risk’ and suitable for early discharge (HEART score 0-3), the pooled incidence of ‘missed’ MACE was 1.6%. The pooled sensitivity and specificity of the HEART score for predicting MACE were found to be 96.7% (95% CI 94.0 to 98.2%) and 45.0% (95% CI 40.5 to 53.5%), respectively.

Conclusions

Patients with a HEART score of 0 to 3 are at low risk of incident MACE. As 3.3% of patients with MACE are ‘missed’ by the HEART score, clinicians must ask whether this risk is acceptably low for clinical implementation. Future work should focus on robust comparison with alternative strategies and integration with shared decision making.


Patricia VAN DEN BERG (Manchester, United Kingdom), Richard BODY
11:00 - 18:00 #8162 - The Immportance Of Blood Transfusion In Trauma Patients.
The Immportance Of Blood Transfusion In Trauma Patients.

Introduction While injuries are best prevented by education and by social and engineering controls, secondary prevention of injury-related death and disability through the provision of emergency medical care and physical and occupational rehabilitation is also cost-effective. Blood products play a major role in this secondary prevention of death and disability as an adjunct to surgical care.

Aim To evaluate the immportance of blood transfussion in trauma patients in the Emergency and Intensive Care Therapy of Vlora Regional Hospital in 2015.

Meterials and methods This is a descriptive study. We took a total of 810 individuals in the study, patients admitted to the Emergency ward and the Intensive Care Therapy, of Vlora Regional Hospital during 2015. Data collection was conducted by taking information from the medical records of hospitalized patients in this ward. Information was taken for gender, the conditions the patiens came to the hospital and the use of blood products.

Results Almost 82% of patients admitted directly from the scene of injury to the hospital do not require any blood products. Of 917 such patients admitted to the ICT in the calendar year 2015, 102 received a blood product. Other 33 were mostly elderly individuals who fell, sustaining head injuries with intracranial bleeding, and received plasma. Of the entire direct-admission group, 12% received blood, 3.5% received plasma.

The survival rate for these patients was 97%. For patients with fatal injuries, severe neurologic injury was the most frequent cause of death; uncontrolled hemorrhage was the second most frequent cause; and multiple organ failure was the third. 

In more severely injured patients, 7% of them with profound shock and ongoing hemorrhage, the most important intervention was the rapid transfer to the operating room. These patients had multiple injuries, including lacerations of major vessels, fractures of solid organs or disruption of a major venous plexus. With blood were treated 13% of patients with liver and pelvic injuries, while 27% of the patient treated with blood products had multiple traumas with bone fractures and internal organs injuries.

Conclusions Patients with uncontrolled hemorrhage requiring immediate transfusion as part of their initial care are the major test of a trauma center transfusion service. Patients present can die within minutes. To survive, the most critically injured need red cells and plasma within a very short time and in adequate quantities. 


Rozeta LUCI, Engjell LAZAJ, Brunilda SUBASHI (Vlore , Albania), Llambi SUBASHI, Fatmir LUCI, Xhoana GJOHILAJ, Gazment KOCI
11:00 - 18:00 #8269 - The impact of flight physicians on patient survival rates: should more air ambulance crews include medical personnel?
The impact of flight physicians on patient survival rates: should more air ambulance crews include medical personnel?

Background: Paramedics staff most air ambulances in the UK. The Air Ambulance Association has announced its intention to deploy physicians on more of its helicopters. However, there is scarce literature examining the impact of flight physicians upon patient outcomes. This paper is a literature review of studies that evaluated the impact of physician- versus paramedic-staffed air ambulances upon patient survival rates.

Methods: Studies from 1990 to 2014 were identified through MEDLINE, EMBASE, and CINAHL. Original studies comparing the pre-hospital treatment provided by physician-staffed helicopter emergency medical services (HEMS) with either a) non-physician-staffed HEMS or b) non-physician-staffed ground emergency medical services (GEMS) were included.

Results: A total of ninety studies were identified of which twenty-five met our inclusion criteria. Physicians increased the survival rate in two of the six studies that compared physician-staffed versus non-physician-staffed HEMS. Physicians increased survival rate in eight of the nineteen studies comparing physician-staffed HEMS to non-physician-staffed GEMS. The remaining studies showed that the addition of a physician to the HEMS crew made no difference to survival rates. No study identified a lower survival rate in patients receiving physician treatment. Two of the three studies including exclusively trauma patients found an improved survival rate with the addition of a physician. Six of the eight studies that included a highly experienced or Consultant physician in the HEMS team had an improved survival outcome compared to the control group.

 Conclusion: The deployment of HEMS physicians would be most beneficial for patients who have sustained a traumatic injury and an experienced anaesthetist, preferably of Consultant level, is most likely to increase patient survival rates. However, the studies display a wide variability in findings and most contain methodological weaknesses. Further research should identify which patients benefit most from pre-hospital treatment by physicians.


Gary JEVONS (Manchester, United Kingdom), Samuel GOODALL
11:00 - 18:00 #7516 - The impact of rapid pregnancy test on the medical care of emergency patients: a prospective monocentric study.
The impact of rapid pregnancy test on the medical care of emergency patients: a prospective monocentric study.

The impact of rapid pregnancy test on the medical care of emergency patients: a prospective monocentric study.

Background: Human chorionic gonadotropin (hCG) is a glycoprotein secreted by viable placenta tissue during pregnancy. In normal pregnancy, hCG can be detected in whole blood as early as 7 to 10 days after conception. hCG levels continue to rise very rapidly, frequently exceeding 100 mIU/mL make it an excellent marker for confirming pregnancy. The NG-Test hCG WB is a rapid visual immunoassay for the qualitative presumptive detection of human chorionic gonadotropin in human whole blood to aid in the early detection of pregnancy. In fact, the NG-Test hCG WB has a sensitivity of 10mIU/ml. The aim of this study was to evaluate the NG-Test hcg WB in the management of women presenting in the emergency department (ED).

 

Methods: We conduct a monocentric study in the Emergency Department, from June 2015 to January 2016. We included women who needed medical application of Beta hCG (suspected pregnancy, abdominal pain, bleeding) and woman suspected of being pregnant before radiography, drug administration, emergency surgery. The semi quantitative results were in intensity to the naked eye (+ to ++++) and confirmed by the values obtained in the laboratory on venous sampling. The outcomes were practicability test, the implementation of speed, ease of sampling and test reading, satisfaction, and patient comfort. This was evaluated by a standardized questionnaire designed by consensus among authors.



Results: We included 182 patients: 126 (69%) had a negative test and 55 (31%) tested positive. Eight (14.5%) patients had ectopic pregnancy. 

 

Conclusion: The NG Biotech bHCG Test enabled rapid orientation and safety orientation for patients coming through Emergency Department. Laboratory blood test confirmations were consistent (concordance rate of 100%). The satisfaction of this test was evaluated as very good by Nurses and Physicians and patients in ED, especially due to the optimized waiting time into ED. It would be now relevant to confirm these tests by a larger study in ED to show medical and economic outcomes in addition to more efficient and effective medical care.


Chauvin ANTHONY (Paris), Calvo ALAIN, Enrique CASALINO, Patrick PLAISANCE, Afdjei ALI
11:00 - 18:00 #7995 - The important role of Family Medicine in the UAE to establish and manage Urgent Care Services.
The important role of Family Medicine in the UAE to establish and manage Urgent Care Services.

Various hospitals throughout the Western Healthcare have now incorporated Urgent Care Centers within the Emergency Department. These are routinely run by Family Medicine Consultants and/or nurse practioners on an average of 10-14 hrs. per day. The aim is to reduce workload on the main Emergency Department. The UAE is still a maturing health care system and Family Medicine is not as well established across the seven emirates. This leads to more ER attendances with clinical pathologies which could have been seen in an Urgent Care Centre managed by a credentialed Family Medicine Consultant. We will aim to elaborate on the role and remit of an Urgent Care Center, especially in a maturing environment and talk about its importance in reducing work load for the Emergency Physicians. We will also compare some recent data from the United Kingdom from a successfully running Urgent Care Centre, co-habited within the Emergency Department.


Rahat GHAZANFAR (Abu Dhabi, United Arab Emirates)
11:00 - 18:00 #8093 - The Initial Lactate Level, Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio As Predictors of Severity of Carbon Monoxide Poisoning.
The Initial Lactate Level, Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio As Predictors of Severity of Carbon Monoxide Poisoning.

Introduction: The aim of this study was to investigate the initial lactate levels in patients with CO poisoning, and to compare these results with carboxyhemoglobin (COHb) levels, neutrophil to lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR).

Methods: A retrospective cross-sectional study was carried out among patients with CO poisoning, who were admitted to the ED between December 2014 and January 2015. The study data were extracted from a hospital database system using International Classification of Diseases-10 diagnosis codes. The patients were divided into two groups according to their initial lactate levels (Group 1: lactate value <1.85 mmol/L and Group 2: lactate value >1.85 mmol/L).

Results: A total of 94 patients with CO poisoning were enrolled in this study (37 patient in Group 1 and 57 patient in Group 2). Baseline characteristics of the study population are shown in Table 1. COHb levels of Group 2 (17.51 ± 11.62) were found to be statistically significant when compared with those of Group 1 (10.97 ± 7.69) (p=0.003). NLR of Group 1 (3.54 ± 2.35) were higher when compared with those of Group 2 (2.33 ± 1.75) and the difference found to be statistically significant (p=0.005). PLR of Group 1 (147.46 ± 79.65)  were higher when compared with those of Group 2 (108.33 ± 53.41) and the difference found to be statistically significant (p=0.005). A positive correlation found between lactate and COHb (r=0.419, p < 0.001), negative correlations found between lactate and NLR (r=-0.086, p= 0.411) and lactate and PLR (r=-0.279, p=0.006) 

Conclusion: In evaluating patients with CO poisoning, initial lactate level may be taken into consideration as an adjunctive parameter of severity, together with  the laboratory markers, such as the NLR, PLR and levels of COHb.


Halil Ibrahim CIKRIKLAR, Murat YUCEL (ISTANBUL, Turkey), Ihsan Hakki CIFTCI, Yusuf YURUMEZ
11:00 - 18:00 #7827 - The lack of consensus about the role for LP in SAH leads to wide variation in practice.
The lack of consensus about the role for LP in SAH leads to wide variation in practice.

Title

The lack of consensus about the role for LP in SAH leads to wide variation in practice.

Background

Subarachnoid haemorrhages (SAH) carry a significant mortality risk (Day 1 25-30%11). In patients with a high suspicion for SAH, a CT head is the first line investigation. If negative, a lumbar puncture (LP) has traditionally been thought to increase diagnostic yield2. However, there is controversy in the literature about the utility of performing LP following a negative CT.

Aim

To investigate current practice relating to use of LPs in diagnosis of SAH at University College Hospital (UCH) and review the guidelines and evidence base surrounding them.

Methods

Retrospective cohort study of 46 emergency patients investigated for SAH at UCH, over a period of 11 weeks.

Results

100% of patients (n=46) had a CT head, whom 9% (n=4) CT demonstrated SAH. Of those with normal CTs (n=42) 38% had an LP (n=16). 100% of LPs were negative for xanthochromia. Analysis of pre-test features of SAH showed that only 53% (n=9) of patients who had an LP presented with a thunderclap headache.

Discussion

It is clear that any patient being investigated for an SAH should have a CT head. The sensitivity of a CT in the first 6 hours is near 100% 3. Confusion lies in the utility of LP as a second line investigation.

Our data shows that a LP did not help diagnose any of the patients presenting over 11 weeks to UCH with a suspected SAH. The 4 patients who presented with a SAH were diagnosed on CT. 16 LPs were therefore performed that did not provide any additional diagnostic information.

There is a need for the development of evidence-based guidelines for the role of LPs in the diagnostic pathway of patients with a suspected SAH.

The diagnostic pathway should incorporate a scoring system to help identify pre-test probability for SAH. This should be based on a validated tool for high-risk clinical characteristics, such as witnessed loss of consciousness and neck pain or stiffness5. Clinicians would be able to make use of the guidelines to risk-stratify patients presenting with a headache and investigate to an appropriate level. 

Conclusion

There is a lack of guidance to suggest when a non-diagnostic CT head necessitates an LP in the investigation of SAH. Clearer guidelines are needed to standardise practice in order to allow clinicians to appropriately investigate SAH, whilst avoiding unnecessary invasive procedures.

References

  1. European stroke organization guidelines 2013
  2. ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. In: Stroke; 2012.
  3. Dubosh N. et al. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage. Stroke, 2016.
  4. Cortnum S et al. Determining the Sensitivity of CT scanning in Early Detection of Subarachnoid Haemorrhage. Neurosurgery, 2010
  5. Perry J et al. High risk clinical characteristics for subarachnoid haemorrhage in patients with acute headache: prospective cohort study. BMJ 2010

 

No conflict of interest


Christiana STAVROU (london, United Kingdom), Parisah SEYED-SAFI, Frances BENNETT
11:00 - 18:00 #7499 - The meaning of neutrality and impartiality in humanitarian assistance in Complex Emergencies.
The meaning of neutrality and impartiality in humanitarian assistance in Complex Emergencies.

Introduction

Medical personnel, often on mission with small humanitarian Non-Governmental Organizations (NGOs), are increasingly not only required to have skills in Emergency and Tropical Medicine but also knowledge about the humanitarian principles of neutrality and impartiality.  Intra state armed conflicts as frequent destination of their missions are additionally fuelled by natural disasters as earthquakes, floods and droughts as in the case study about Haiti in march 2010. In this Failed State United Nation blue helmet troops could contain the excess of violence since the late 2000s but the earthquake destabilized the fragile order by causing casualties among the blue helmets and infrastructure destruction.  The humanitarian organisations put into this complex scenario had to decide either to position themselves according to political neutrality and impartial aid towards all parties of the conflict or to subordinate themselves under the coordination of the Haitian government and the United Nation bodies. Beyond this question the case study focuses on the consequences for the security of humanitarian personnel and their access to victims. Beside Non-Governmental Organisations (NGOs) the International Committee of the Red Cross (ICRC) and the World Food Programme of the United Nations (WFP) will be looked at.

 

Methods

Interviewing and observing humanitarian and military actors with following qualitative analysis.

Interpreting news and publications of political science and conflict research.

 

Results

Both humanitarian organisations of the United Nations as the WFP and numerous NGOs interpreted the Complex Emergency primarily as a natural disaster and ignoring the still existing dimension of an armed conflict. As a consequence, they subordinated design and location of their aid operations under the coordination of the Haitian government and the United Nations. By doing so, they got only limited or no access at all to those parts of the population living under the control of government hostile armed groups. In those territories almost only well-established humanitarian organisations as the ICRC or Doctors Without Borders who strictly followed the principles of neutrality and impartiality were accepted by the non-governmental armed groups and thus could perform aid projects.

 

Discussion

To be able to position themselves independently from political influences according to the principles of neutrality and impartiality humanitarian actors need comprehensive knowledge about the conflict history and conflict parties. Additionally, it is a paramount to perform the aid projects independently from blue helmet troops as they are often not neutral in complex conflict scenarios as in Haiti but conflict party involved in fighting against rebel groups or gangs. Those NGOs cooperating tightly with non-neutral United Nation troops should be clear about increasing their risk of getting under armed attack and loosing access to victims living in territory controlled by non-governmental armed groups.


Bernward AUF DEM KAMPE (Marburg, Germany)
11:00 - 18:00 #7173 - The multifaceted impact of dying in the emergency department.
The multifaceted impact of dying in the emergency department.

BACKGROUND

Within a project named “Soft Emergency – not only to cure but also to care”, one of the main phases concerned “Bad news communication”.

To create a specific educational program about communicating bad news in the emergency setting we thought to be necessary to evaluate, both form a quantitative and a qualitative point of view, the impact of dying on our Emergency Department.

 

 

METHODS

We retrospectively reviewed every case of death occurred during the year 2015 within the Emergency Department of a University teaching Hospital.

We then analyzed each single case about its peculiar characteristics.

 

 

RESULTS

66312 cases were evaluated (media 182 / day);

we recorded 140 deaths in the Emergency Room (11 already dead);

in the different areas of the Ward (brief observation and regular ward; high-dependency medical unit) we documented , 61/10291 (31 in the first 12 hours) and 65/1257 cases (34 in the earlier 12 hours), respectively.

Every single case was unique: from the already dead, to sudden death; from cases with useless long lasting cardio-pulmonary resuscitation efforts, to those with careful palliative measures; from cases with an unexplained cause, to those clearly predictable; from cases in which time made possible to debate and share decisions with both the patient and the family, to those in which family members were neither attending nor aware of the occurring events.

 

 

CONCLUSIONS

In the year 2015 266 people died inside our Emergency Department.

Each case represented a peculiar medical management, welfare and olistic committment, and emotional involvement; it is not possible to share any standard recommendation, mainly about times and ways of resuscitation for the patient, and of communications for the family.

Death, and its communication in the emergency setting, are primarily important, both in frequency and significance, on the every-day life of the Emergency Department: the burden of these dramatic issues weigh on Emergency Physicians and Emergency Nurses in the worst moments and conditions, just after useless long-lasting resuscitation efforts, and often with neither a specific education, nor logistics support, nor the chance of an immediate debriefing.


Dr Rodolfo FERRARI (Bologna, Italy), Chiara LANZARINI, Annamaria LONGANESI, Rossella RAPAGNANI, Donatella ROTONDO, Mario CAVAZZA
11:00 - 18:00 #8161 - The predictive value of blood gas pH at admission to the emergency department, a cross-sectional retrospective study.
The predictive value of blood gas pH at admission to the emergency department, a cross-sectional retrospective study.

Introduction: In patients with acute illness there is a need for quick and reliable diagnostics. Commonly used is a point-of-care blood gas analysis. A low pH has been associated with poor outcome in studies with a specific type of underlying cause. The relation between all-cause mortality and pH at admission to the emergency department has only been studied in two previous studies.

Aims: to investigate the prognostic value of pH using blood gas analysis performed at admission to the emergency department in patients with highest acuity, with outcome defined as mortality. Material and Methods: All 2776 admissions arriving by ambulance or helicopter to the emergency department of Karolinska University Hospital, Solna, Sweden, during 2015 were analysed. 1342 (48%) admissions were excluded, mainly due to missing blood gas results. Data gathered consisted of point-of-care blood gas laboratory values, vital signs and general admittance information. Primary outcome was mortality within 24 hours, 7 or 30 days. Odds ratios for each outcome were obtained using logistic regression.

Results: There were significant differences between included and excluded admissions, mainly in chief complaint and in age, as the included admissions were older. Admissions with pH <7.00 had significantly increased risk of mortality in all outcomes. A significant correlation, independent of other variables, between pH and death was demonstrated. Age and lactate also independently correlated to mortality. Odds ratios for mortality and pH below 7.00 were 11.40 (245 – 52.96, p=0.002) in 24 hours, 20.30 (5.69 – 72.44, p<0.001) in 7 days, and 9.55 (3.02 – 30.28, p<0.001) in 30 days.

Conclusions: blood gas pH <7.00 at admission to the ED is independent and highly significant in predicting mortality within 30 days. There were differences between included and excluded admissions, and the results can not be applied to all patients admitted to the emergency department. The limitations stem from the study design. Future prospective studies are needed to confirm the clinical relevance of the results.


Elde HOVLAND (STOCKHOLM, Sweden), Per LINDMARKER
11:00 - 18:00 #7551 - The predictive value of triage early warning score on mortality of trauma patients presenting to the emergency department.
The predictive value of triage early warning score on mortality of trauma patients presenting to the emergency department.

Introduction:

Trauma is the most comman cause of emergency admissions.In our country  %3-20 of all emergency visits are trauma patients.(1-3). American College of Surgeons recommended to use four step activating rules due to advanced trauma life support guidelines (ATLS)  for trauma evaluation.(4) Triage early warning score that contains mobility,level of conciousness and vital signs usually helpfull in classification of patients with mortal patologies. In South africa society MEWS adapted with adding trauma as an another criteria and named again as TEWS. (5-8) In the current study, we aimed detecting the predictive accuracy of the triage early warning score (TEWS) in the prognosis and emergency treatment for trauma patients admitted to the emergency department (ED) whose triage were made by ATLS protocols.

Materials and methods

A total of 381 trauma patients admitted to Uludag University Faculty of Medicine Emergency Department in three monts period were evaluated. All patients meets criteria of ATLS protocol.After initial treatment anda diagnostic tests  emergency  emergency phisians evaluate TEWS score and all datas collected in study form. Patient demographics, Glaskow Coma Scale, AVPU score, vital signs,mobility, trauma mechanism, injured part, emergency treatment and status after evaluation were recorded. After 4 week period patients were followed by telephone or by their follow charts if admission happens and their mortality and morbidity parameters recorded. Patients 4 week mortality rates calculated.

Results

In our study population in abnormal vital signs evaluation in %5,5’ (n=21) advanced airway management  were needed, in %6 (n:23) GCS

The most comman trauma cause were collisions %32.7 (n:125). Age >55 was the comman comorbidity value of patients  in %17.5 (n:67)

The TEWS value evaluated in major trauma patients due to ATLS parmeters; among 65 patients with abnormal vital signs in 43 (66.1) patients TEWS was >7 and in anatomic part, injury mechanism, comorbidity rates were n:22 (16.5%) , n:26(6.8%) and n:3 ünde (4.4%) respectively.

4 week eksitus rates were %2 (n:8) and n:2 patients eksitus in emergency servise while their initial treatment were going on.

The AUCROC of TEWS in predicting the emergency responses for entubation [0,979 (0,962-0,996)], for tube thoracostomy [0,924 (0,887-0,962)], for blood product replacement [0,964 (0,939-0,989)] and for emergency operation was [0,919 (0,881-0,956)] respectively.

 In predicting mortality rates during 4 weeks, the cut-point was greater than 5, the areas under the receiver operating characteristic curves (AUCROC) was 0,973 (0,944-1).

Conclusion:

Emergency scoring siystems  need for predicting major  patologies and faster and effective treatment. Our study shoes that TEWS is effective in trauma victims. Triage early warning score can help anticipation of trauma and determine the importance. Triage early warning score should use with ATLS criteria for more significant results.


Gökhan TORUN, Suna ERAYBAR, Serhat ATMACA (bursa, Turkey), Okan AYDIN, Nuran SANDAL, Yasemin NENNICIOGLU, Erol ARMAGAN
11:00 - 18:00 #7392 - The rate of road traffic accidents emerged in the emergency department.
The rate of road traffic accidents emerged in the emergency department.

The rate of road traffic accidents emerged in the emergency department

Virgiliu Cezar Bologa(1); Andreea-Liliana Bocai(1);  Ioan Lucian Marian(1); Lucian Calutiu(1); Francesca Iulia Paius(1);

1. Emergency Department, UPU-SMURD Sibiu, Sibiu, Romania

 

Keywords: road traffic accidents, poly-trauma, head injuries, emergency room

 

Speaker :  Andreea-Liliana Bocai

 

BACKGROUND

Trauma ranks as the 4th most common cause of death after cardiovascular diseases, cancer and respiratory diseases.

The present study focuses on the distribution of traumatic cases caused by road traffic accidents emerged at the Emergency Department of Sibiu County Clinical Emergency Hospital as well as their gravity in the above mentioned period.

 

MATERIALS AND METHODS

The study was performed through a retrospective observational method on a number of 190268 cases emerged in the Emergency Department of Sibiu County Clinical Emergency Hospital between 01.01.2013 – 31.12.2015, out of which 1645 were road traffic accidents.

 

RESULTS

 Out of a total of 190268 arrivals at the Emergency Department of SMURD Sibiu, the number of traumas caused by road traffic accidents was 1645, which represents 0, 86%, distributed as follows: 522 patients (31.73%) in 2013, 568 patients (34.52%) in 2014 and 555 patients (33.73%) in 2015.

A number of 1068 out of these patients were not required hospitalization, which represent 64.92% and 568 patients were hospitalized, which represent 34.52%.

The distribution of hospitalizations for the severely traumatized patients by road traffic accidents was the following: Orthopedics - 236 (41.55%), Surgery - 137 (24.12%), Neurosurgery - 128 (22.54%) and the rest for other departments.

Throughout the studied period a total of 114 patients were deceased because of road traffic accidents, distributed as follows: 34 patients (29.82%) in 2013, 48 patients (42.1%) in 2014, and 32 patients (28.07%) in 2015.

The distribution per months of the patients traumatized because of road traffic accidents was increased throughout the period of July, August and December, representing 33.58%.

According to the localization of the traumatism, the majority were:  771 cranial traumas, 716 member traumas, 518 thoracic traumas, 421 injuries, 312 spinal cord traumas, 120 pelvic traumas and 114 abdominal traumas.

 

CONCLUSIONS

The number of victims caused by road traffic accidents was relatively constant, maintaining the same curve both in the case of severe accidents and in the case of deaths caused by road traffic accidents as well.

The majority of hospitalizations determined by road traffic accidents were in Orthopedics, followed by Surgery and Neurosurgery.

The cranial trauma was most frequently associated with the rest of conditions.

The highest frequency of road traffic accidents was throughout the months of July, August and December.

The severe accidents and deaths have a constant frequency according to the number of cases.

 


Ioan Lucian MARIAN, Virgiliu Cezar BOLOGA, Andreea Liliana BOCAI (Sibiu, Romania), Lucian CALUTIU, Dr Francesca Iulia PAIUS
11:00 - 18:00 #6067 - The recovery of serum pseudocholinesterase and clinical characteristics of patients by organophosphate poisoning route.
The recovery of serum pseudocholinesterase and clinical characteristics of patients by organophosphate poisoning route.

Background and objectives: Organophosphates are commonly used pesticides that are associated with a high risk of poisoning. A serum pseudocholinesterase level s used for diagnosis of organophosphate poisoning and estimation of severity. This study was performed to compare serial change of serum pseudocholinesterase level and severity in the setting of organophosphate poisoning.


Methods: We compared and analyzed serum pseudocholinesterase level change and clinical characteristics with oral route poisoned group and non-oral route poisoned group in patients who visited the emergency department due to organophosphorus intoxication from January 2009 to May 2015.


Results: A total 199 patients were enrolled that 168 were oral route poisoned group and 31 were non-oral route poisoned group. A serum pseudocholinesterase level was lower in oral route poisoned group than non-oral route poisoned group at the early stage within 5 days after poisoning. A hundred and twelve patients in oral route group and 11 patients in non-oral group suffered from respiratory distress (P = 0.001). In oral route poisoning group, 128 patients required mechanical ventilation with endotracheal intubation and 61 patients developped aspiration pneumonia. On the other hand, 12 patients needed a mechanical ventilation with endotracheal intubation and 5 patients developped aspiration pneumonia in the non-oral route poisoning group. The rate of admission and intensive care in oral route poisoned group was higher than non-oral route poisoned group.


Conclusions: Serum pseudocholinesterase level in the oral route group was lower than non-oral route group at the early stage. A frequency of respiratory complications rate was higher in oral route poisoned group than non-oral route poisoned group.


Jin Su JU (Busan, Korea), Tae Hoon KIM, Kyung Hoon SUN
11:00 - 18:00 #7741 - the relation between mortality and bnp levels and pulmomary ct right-left ventricle diameter ratio in acute pulmonary embolism patients.
the relation between mortality and bnp levels and pulmomary ct right-left ventricle diameter ratio in acute pulmonary embolism patients.

Purpose: In this study, we aimed to prospectively assess the relations between mortality, right-left ventricle diameter ratio on computed tomography pulmonary angiography (CTPA), serum brain natriuretic peptide (BNP) levels and demographic data in patients with definitive diagnosis of acute pulmonary embolism in emergency service.

 

Method: We included patients from Necmettin Erbakan University Meram Medical Faculty Emergency service between 01/2015-06/2015 that were over 18 years old adults, non-pregnant, with no congestive heart failure and definitively diagnosed as pulmonary embolism with pulmonary CT angiography.

A total of 80 patients were included to this study. 45 of whom were without congestive heart failure and had pulmonary embolism. The remaining 35 were the control group patients without congestive heart failure and did not have pulmonary embolism.

Computed tomography pulmonary angiography (CTPA) right-left ventricle diameter ratio measurements were done by the same radiologist with same measurement techniques on ENLIL-HIS version 3.0 hospital information management system (HIMS) PACS images.

Serum BNP (brain natriuretic peptide) levels were measured on the leftover serum (from routine investigations such as hemogram, glucose, urea, creatinin, alt, ast, sodium, potassium, blood gas, troponin, ck-mb, pt, ptt)  diagnosed or not diagnosed as acute pulmonary embolism. Blood serum samples were centrifuged with Hettich Rotina 46R (Hettich Zentrifugen, Tuttlingen, Germany) cooling centrifuge device at 4000 rpm for 10 minutes to separate the serum and the serum samples were stored at -80 °C until they were used. Human BNP parameters were studied with ELISA method on serum samples. Blood samples were studied in Necmettin Erbakan University Meram Medical Faculty Biochemistry Laboratory by biochemistry specialists.

Findings: Mean BNP level of pulmonary embolism patients was observed as 14,2714,90 ng/L and this parameter was 10,713,78 ng/L for the control group patients. According to Mann-Whitney U test results; no statistically significant differences were found between BNP levels of pulmonary embolism patient group and control group ( p=0,446>.

Mean right-left ventricle diameter ratio was 1,320,36 for pulmonary embolism patients and 0,840,18 for the control group. A statistical significance was found between right-left ventricle diameter ratios of pulmonary embolism patient group and control group. 

Results: BNP plasma concentrations could be increased in patients with myocardial infarcts, dilated cardiomyopathy, valvular heart diseases, pre-dialysis kidney failure and almost all of the patients applied with dialysis and all of the patients with diseases causing cardiac dysfunction. When the pulmonary embolism patient group and control group was compared; no statistical significance were detected regarding to BNP levels. Therefore we established that BNP is not a specific hormone for acute pulmonary embolism.

In our study, we also detected a statistical significance between right-left ventricle diameter ratio parameters of control group and pulmonary embolism patient group. 


Aliye Nur GÖKALP, Basar CANDER, Nazlı KARAKUŞ KENAN, Zerrin Defne DUNDAR (Konya, Turkey), Mehmet GÜL, Sedat KOCAK
11:00 - 18:00 #7790 - The relationship between systolic blood pressure at admission and LVEF in acute heart failure syndromes in the emergency department.
The relationship between systolic blood pressure at admission and LVEF in acute heart failure syndromes in the emergency department.

Introduction:  Acute heart failure syndrome (AHFS)  are a common pattern in the emergency department (ED). It has been reported that patients with a reduced left ventricular ejection fraction (LVEF) tend to be normotensive or hypotensive, while those with preserved LVEF were more likely to be hypertensive. However, it is unclear if the systolic blood pressure (SBP) is associated with LVEF in SICA.

Objective: To study the relationship between SBP at admission and LVEF in patients hospitalized in the ED with AHFS.

Design and methods: A prospective descriptive study conducted over seven months. Were included all patients who presented to the ED with dyspnea and in whom the diagnosis of acute heart failure was made. All patients underwent echocardiography by the same operator within 24 hours. Were noted the demographics, clinical, biological, and evolutionary criteria. The patients were divided according to the  systolic blood pressure (≤90mmhg between 90 and 140 mmHg, and ≥140mmhg), and the LVEF was compared between the different sub groups. ROC curves were created to establish the values of optimal cut-off and multiple logistic regression was performed.

Results: One hundred and seven patients were enrolled. The mean age was 65 ± 12 years. The sex ratio was 2.34. For the group of patients who had SBP at admission ≥ 140 mmHg, 16% had a reduced LVEF and 22% a preserved LVEF, the difference was statistically significant. For the group of patients who had a SBP between 90 and 140 mmHg, 46% had a reduced LVEF and only 8% had preserved LVEF, the difference was also statistically significant. For the group of patients who had a SBP <90mmHg, 7% had a low LVEF, and no patient had a preserved LVEF.

The ROC curve has shown a cut-off to 122mmhg to differentiate between the reduced and LVEF preserved, with an area under the curve 0.59. The sensitivity was 85%, specificity of 67% and an LR + 2.57.

Conclusion: There is a relationship between SBP at admission and LVEF in patients hospitalized for an emergency SICA.


Rania JEBRI, Rania JEBRI (Lyon), Olfa DJEBBI, Houaida MAHFOUDHI, Mounir HAGGUI, Mehdi BEN LASSOUED, Khaled LAMINE
11:00 - 18:00 #8084 - The resuscitation trolley: An overview of the situation at la Rabta Hospital in Tunisia.
The resuscitation trolley: An overview of the situation at la Rabta Hospital in Tunisia.

INTRODUCTION

The emergency trolley allows physicians to have rapidly access to emergency equipment and drugs in cases of life-threatening emergencies.

The aim of our study was to investigate if there is an emergency trolley in all the wards of la Rabta teaching hospital in Tunisia and to propose practical recommendations to improve eventual insufficiency.

 

METHODS

This was a cross-sectional descriptive study conducted at la Rabta teaching hospital in Tunisia during April 2015.

A survey was conducted in all the wards related to the existence, the composition and the maintenance of an emergency trolley.

We analyzed the composition and the arrangement of the components.

 

RESULTS

Only 36% of participant wards had already an emergency trolley, in those wards the management, the composition and the maintenance was done by a dedicated nurse without a physician contribution. Only one third of those trolley contained resuscitation drugs and a quarter contained a cardiac monitor with defibrillator.

Those trolleys were used in all situations even those witch not urgent and the components were not regularly verified.

 

Conclusion

Our data showed a lack of emergency trolleys disponibility in our hospital probably due to lack of the information regarding the usefulness utility.  


Kamel MAJED, Khedija ZAOUCHE (Tunis, Tunisia), Abdelwaheb MGHIRBI, Achouri ABDERRAHIM, Kallel MOHAMED AMINE, Mohamed MODHAFFER, Hamida MAGHRAOUI, Chokri HAMOUDA, Nebiha BORSALI FALFOUL
11:00 - 18:00 #7925 - The Role of feedback during evaluation: Does it matter in promotion of emergency medicine residents’ competencies ?
The Role of feedback during evaluation: Does it matter in promotion of emergency medicine residents’ competencies ?

Background:Student evaluation is one of the most important educational interventions in promotion effectiveness of clinical education.This study was performed to determine the role feedback during residents' evaluation on promotion their competencies in chest sonography (CS) among trauma patients.

Methods: This was a switching replications design, quasi-experimental study.The study population included 30 second-year emergency  medicine residents (EMR) from two university affliated hospitals.Before the study ,background knowledge of the EMR regarding CS was measured by a standard MCQ.EMR were assigned into two groups: A related to first and B related to second hospital.A standard check list (SC) was designed to evaluate EMR's competencies regarding CS in trauma patients.Validity of SC was approved by the expert panel and it's reliability was confirmed by the test- retest exams in a pilot study.Resident evaluation in each hospital had three phases, with 4 months apart between the first and last phases.In group A, at the first phase, SC was used with feedback to the EMR and at the second phase, SC was used without feedback.In group B, at the first phase, SC was used without feedback to the EMR and at the second phase, SC was used with feedback.Final phase of evaluation conducted simultaneously in both hospitals, two months later the second phase of evaluation by using SC without feedback. Also at the final phase of study, EMR were requested to comment to this phrase according to the 5 scale likert questionaire: ''Giving feedback to EMR during evaluation ,could promote EMR's competencies regarding CS.'' The performance score(PS) of the EMR  were calculated in each phase of study according to direct observation by one of the attending of emergency medicine department  while the EMR showed their skill about CS in a trauma patient.Min and Max of the PS were respectively 0 and 20 based on the SC.During the study the EMR were blinded to the time of evaluation and the type of competency which was supposed to be evaluated.

Results: There were 15 participants in each group of study.There was no statistically significant difference between two groups regarding demographic variables and background knowledge of the EMR about CS in trauma patients.( p value= 0.565) The PS of the EMR in each group showed statistically significant improvement in the phase in which the previous phase of evaluation was performed by using SC with feedback to the EMR. ( P value< 0.001) Twenty three percents of EMR were agree with and 73% of EMR were strongly agree with Phrase.

Conclusion: According to the study , using feedback to the EMR during evaluation, had an essential role in promotion of EMR's competencies regarding CS in trauma patients.Though giving feedback to the targeted medical students is embeded in "Direct Observed Procedural Skills" (DOPS) as a tool of evaluation, it seems that it could be used to promote EMR's competencies regarding procedural skills. 


Mostafa ALAVI MOGHADDAM (Teheran, Islamic Republic of Iran), Ali VAFAEI
11:00 - 18:00 #7613 - The role of immigrant background on presenting complaints, patient outcomes and resources in the emergency department.
The role of immigrant background on presenting complaints, patient outcomes and resources in the emergency department.

Background/Objective:

The influence of immigrant background on presenting complaints and the health care setting in Emergency Departments (ED) has not been investigated so far in Switzerland. It is known from other countries that immigrants present to ED more frequently and with more irrelevant presenting complaints than the host-population. Furthermore, there is evidence of inequitable treatments during the ED process depending on immigrant background regarding longer waiting times, lower triage levels and less access to opioids. This study focused on the disparities of the outcomes, which to our knowledge has not been described yet.

Methods:

Prospective observational study performed at a tertiary hospital, including all patients who presented to the emergency department over a period of 6 weeks. The questionnaire included demographics, measurements of presenting complaints and diagnostic resources. Outcomes were categorised in terms of serious-outcome, hospitalisation, ICU-use and in-hospital-mortality. Serious-outcome was defined as an acute morbidity requiring early intervention (e.g. use of antibiotics) to avoid deterioration of health status, disability or death. Patients were counted as host-population (HP) if the country of origin was Middle or North Europe (e.g. Switzerland, Germany, Austria etc.). Patients were categorized as immigrants (I) if the country of origin was not part of Middle or North Europe (e.g. Mediterranean countries, South Eastern Europe, East Europe, Turkey, Africa, Asia, North America/Australia or South America). Patients were triaged by the Emergency Severity Index (ESI).

Results:

A total of 5634 patients presented to the ED, of which 4654 were included to the study and 4638 patients giving full information about their country of origin. Among the latter, 67.8% were inhabitants of Middle or North-Europe (HP) and 32.3% were categorized as Immigrants (IM). Immigrants presented at younger age (IM = median 39 years (range 14–97); HP = median 60 years (range 15-106)), were more often male (IM = 54.8% male, HP = 50% male) and were assigned a lower triage level (ESI-score). IM and HP matched in 4 of the 5 most commonly presented complaints (accident, stomach ache, wounds and chest pain) but differed in oral and maxillofacial surgery and otolaryngology ENT/OMS problems (IM) and fall (HP). IM were less likely to have a serious-outcome, to get hospitalized, to need intensive care or to die in hospital. Both groups were given equal diagnostic resources according to their level of triage (ESI-score).   

 

Conclusion:

Immigrants presenting to a Swiss tertiary hospital Emergency Department were at younger age and more often male. Immigrants and Host-population presented with comparable symptom distribution but differed in the level of triage. Immigrants were less likely to develop severe outcomes.  


Leandra Kim SCHULTZE (Basel, Switzerland), Christian NICKEL, Roland BINGISSER
11:00 - 18:00 #7671 - The role of simulation unit in CPR training of health professionals: target audience focused CPR training programs.
The role of simulation unit in CPR training of health professionals: target audience focused CPR training programs.

Objective: The emphasis on cardiopulmonary resuscitation (CPR) training with skill trainers and high-fidelity manikins for health professionals has increased in recent basic and advanced cardiac life support (BLS and ACLS) guidelines. Simulation training supported with high-fidelity manikins has additional advantages due to interactive scenarios. Team leadership, distribution of tasks during CPR, team communication and time management skills can be improved in addition to improvement of chest compression and ventilation skills. Here, we aimed to present target audience focused CPR simulation training program models planned by Necmettin Erbakan University Simulation and Modeling Research and Application Unit (NEUSRU).

Methods: NEUSRU has been established in 2014 to carry out graduate and postgraduate training programs. NEUSRU has started postgraduate educational programs in April 2015. Two different CPR training programs were conducted between April 2015 and March 2016. In the first one-step program, CPR Simulation Training was provided with ACLS scenarios using high-fidelity manikin and standard debriefings for residents and nurses who performed CPR as a part of their professional activities routinely. The second program had two steps for health professionals trained with standard theoretical and practical CPR training once during their graduate degree but who did not perform CPR routinely. In the first step of second program, CPR Skill Training Module was provided with theoretical lectures and trainings with skill trainers, including airway, chest compression, and defibrillation. In the second step, Audience Focused CPR Simulation Training was provided with target audience focused BLS and ACLS scenarios by using high-fidelity manikin and/or standard patients. The scenarios were planned according to the professional requirements of trainees, e.g. only BLS scenarios for dentists. All CPR training programs and modules were evaluated by trainees with 5 point scale satisfaction questionnaire, 5 point was excellent and 1 point was failed.

Results: In one-year activity period of NEUSRU, 58 residents and 63 nurses attended to CPR Simulation Training program. 39% of trainees rated the equipment used in the training as excellent and 42% of them rated as good. 78% of trainees rated the training skills of trainers as excellent and 21% of them rated as good. At the same activity period, 168 health professionals from different disciplines attended to CPR Skill Training Module. 52% of trainees rated the equipment used in the training as excellent and 43% of them rated as good. 72% of trainees rated the training skills of trainers as excellent and 23% of them rated as good. 41 volunteers of those 168 trainees attended to Audience Focused CPR Simulation Training. 47% of trainees rated the equipment used in the training as excellent and 51% of them rated as good. 91% of trainees rated the training skills of trainers as excellent and 9% of them rated as good

Conclusion: We conclude that CPR training programs for health professionals with skill trainers and high-fidelity manikin supported simulation increase trainee satisfaction and trainer interactivity. Also, we suggest that CPR training programs may be planned unique for every target audience to increase the effectivity of skill and process training.


Zerrin Defne DUNDAR (Konya, Turkey), Sema SOYSAL, Alpay ARIBAS
11:00 - 18:00 #7553 - The side effect of the treatment of ectopic pregnancy.
The side effect of the treatment of ectopic pregnancy.

Introduction

Ectopic pregnancy is a common  gynecologic problem (1). Treatment of unruptured ectopic pregnancy occurs  differrent procedure of therapy used for conservative, medical and  surgically (2).  Methotrexate, is  one of the drug for medical management of ectopic pregnancy. That is prevents with DNA synthesis, repair, and cellular replication and  causing cell death (1). The side effects of this drug have to recognised and taking a desicion carefully to given for because it is life-threatening adverse events (2).

Case

Twenty five years old woman was admitted to the emergency department with nausea, dyspnea, bruises that occur in the body and lesions on her mouth. She denies any past medication or disease history. But she was treated a week ago from an ectopic pregnancy.  Vital signs are in physiological limits. In her physical examination diffuse, petechia, abdominal tenderness and oral mucositis occur. Her lung sounds were normal. The differential diagnosis are septicemia, disseminate intravascular coagulation (DIC), idiopathic thrombotic purpura (ITP), methotrexate intoxication. On her laboratory findings neutropenia was detected. Thrombocyte and INR values are normally.  Septicemias, DIC, ITP were excluded. Leucoverin treatment started and she hospitalized in ICU.

Discussion

Methotrexate (MTX) is a folic acid antimetabolite. The drug use in the treatment of cancer, autoimmune disease and ectopic pregnancies (3). Methotrexate apply many intercellular pathways and inhibiting the synthesis of RNA and DNA with antagonize folate (2,4). the target cell of this is supress on rapidly growing and dividing cells such as malignant cells, myeloid cells and oral and gastrointestinal mucosa (2,4). Adverse events related with  the dose and the duration of therapy. In less than 10% of the cases most common side effects were observed (2). Common  adverse effects occurs, leukopaenia, nausea, vomiting, ulcerative stomatitis, abdominal distress and liver and lung toxicity (2,3) The most seen  toxicity of methotrexate is bone marrow suppression (1). The specific antidote calcium folinate (LeucovorinR), a form of folic acid, can antogonize effects of MTX.  Leucoverin does not affected by dihydrofolate reductase and  this mechanism prevent the drug from inhibiton of MTX (5).  In our case leucoverin started immediatly and her symptoms get better.

Conclusion

Clinicians should be recognise that a low dose of MTX treatment for the termination of ectopic pregnancy can cause  severe side effects.


Ozge CAN, Funda KARBEK AKARCA (Izmir, Turkey), Sadiye MIDIK, Sercan YALCINLI
11:00 - 18:00 #7543 - The Stage Role of Electroencephalography in Diagnosis of Emergency Department Patients.
The Stage Role of Electroencephalography in Diagnosis of Emergency Department Patients.

Background: Electroencephalography (EEG) has been using for the differential diagnose of patients with consciousness problems in neurology practice. Our aim was to evaluate the role of EEG records which were applied to emergency department patients with seizure (first or frequent) and/or changes in consciousness in last three years.  

Material and Method: The EEG reports of emergency department patients with seizure (first or frequent) and/or changes in consciousness in last three years included to study and evaluated retrospectively.

Results: We included 284 patients who had EEG reports. There were 70(24.6%) patients diagnosed as epileptic abnormal patterns and 8 (0.2%) were nonconvulsive status epilepticus. Totally of 284 patients, 67 (23.5) of them hospitalized to neurology ward.

Conclusion: EGG can be a pathfinder as a useful method for the differential diagnose and the medication of emergency patients with first seizure.


Funda KARBEK AKARCA (Izmir, Turkey), Ayse GULER, Tanzer KORKMAZ, Yusuf Ali ALTUNCI, Gulsum SARUHAN, Ayçin YILDIZ TABAKOGLU, Ibrahim AYDOGDU
11:00 - 18:00 #7745 - The Tako-Tsubo Syndrome.
The Tako-Tsubo Syndrome.

Background & Aim

 

68 years old woman attend our emergency department in the Health Care center referring strong family discussion and after a central chest pain getting to the left shoulder, accompanied by important vegetative symptoms.

 

Method

 

Physical examination revealed dyspnea, pale and sweaty skin. Blood pressure 100/65 mm Hg, hearth rate 107. The electrocardiograma showed sinus rhythm with ST-segment elevation 2 mm in V2-V5 that supports anterolateral infarct.

 

Results

 

In the area of observation of the Emergency department in our Regional Hospital fibrinolytic therapy regimen and she was refered to Intensive Care Unit.

Two hours later she was moved to the Hemodynamics Unit for urgent treatment PTCA that shows no lesions.

In the blood analyse troponin I 4.8 ng / ml is obtained and creatine-MB fraction (CPKMB) of 19 ng / ml.

The subsequent clinical course was favorable, all alterations spontaneously resolved without sequelae.

The Tako-Tsubo syndrome (TKS), or transient ventricular dysfunction is a condition characterized by clinical that is indistinguishable from acute coronary syndrome with elevated enzymes and extensive anterior akinesia, but without significant alterations in the coronary arteries.

A transient left ventricular apical dysfunction or ballooning accompanied by electrocardiographic (ECG) T wave inversions. This abnormality is associated with high levels of cathecolamines, either administered or endogenously secreted from a tumor or during extreme stress.

 

CONCLUSIONS

But most importantly differentiated from ischemic heart disease, which is essential to make an early cardiac catheterization, to avoid the risk of fibrinolytic therapy.

Overall, and although the TKS carries a good prognosis in general, and usually, heart failure is a complication (30%). This situation is more common in patients with more comorbidities and worst previous functional class associated with more adverse events.


Veronica PARENT MATHIAS (MALAGA, Spain), Lorea DE UNAMUNO LUMBRERAS, Juan Manuel GARCIA LOPEZ
11:00 - 18:00 #7718 - The time, place and ambulance characteristics of medical transportations by 112 Emergency Health Services of Çanakkale from islands of Gökçeada and Bozcaada.
The time, place and ambulance characteristics of medical transportations by 112 Emergency Health Services of Çanakkale from islands of Gökçeada and Bozcaada.

Objective: The study was carried out in order to evaluate the time, place and ambulance characteristics of medical transportations by 112 Emergency Health Services (EHS) of Çanakkale from islands of Gökçeada and Bozcaada from 2009 to 2013.

Materials and Methods: The study is a descriptive-cross sectional epidemiological study. The universe of the study was consisted of all of the patient registration forms which were completed for the patients transferred in ambulances from Bozcaada and Gökçeada islands between the dates of 01.01.2009 and 31.12.2013. A total of 1,144 forms were analyzed. The data of the study were obtained from the electronic database of Çanakkale EHS which was based on these registration forms. SPSS 15.0 program was used to compute the descriptive statistics, one-way ANOVA and chi-square statistics. The variables were time (year, season, month, hour, ambulance times), place (ambulance station/region) and ambulance type. Official permissions were obtained from the relevant institutions to conduct the study.

Results: Of the medical transportations (patient transfers), 28.1% were in the year of 2012; 39.5% were in summer; 16.6% were in July; 37.1% were in between 12:00-17:59 p.m.; and 61.5% were transfers from Gökçeada island. In regard to the ambulance type in the transfers from these two islands, ground ambulances (via ferries) were the most preferred one. The findings indicated that while the ground ambulances were dispatched more for the transfers from Bozcaada island, the sea and air ambulances were dispatched more for the transfers from Gökçeada island. The use of the air ambulance service had an inverse impact on the use of the sea and ground ambulances. In regard to the ambulance types used during the transfers, a maximum of three-ambulance types (ground-sea-ground and ground-air-ground ambulances) were dispatched. The time of transfers from Bozcaada island was found to be shorter (The average of total transfer time is 57 minutes [S=26, min-max. 28-140 minutes] and the median is 45 minutes). The harbor most commonly used as an intermediate transfer hub was the harbor of Çanakkale during the transfers carried out by sea ambulances from both islands. It was concluded that there were more transfers from Bozcaada island than Gökçeada island in between 00.00-05.59 a.m. (p<0,001) and more transfers by ground ambulances than any other ambulance type in between 6 p.m.-05.59 a.m. (p<0,001). The air ambulance use in the transfers from the islands of Çanakkale was more in the year of 2010 than the other years (p<0,001). Among the transfer routes from the islands, the transfer route involving the types of Ground-Air-Ground ambulances was found to be used more than other types [F(4-768) =77,488; p<0,001].

Conclusion: The ground ambulances were mostly dispatched from Bozcaada island, whereas the sea and air ambulances were mostly dispatched from Gökçeada island. While the use of air ambulances increased, the use of sea and ground ambulances decreased. The ambulance times other than helicopter ambulances made us think that many of the transfers were not emergency cases.


Cüneyt CALISKAN (Çanakkale, Turkey), Hakan ALTINTAŞ
11:00 - 18:00 #7485 - The tip of the iceberg: Neutropenic Enterocolitis.
The tip of the iceberg: Neutropenic Enterocolitis.

Neutropenic Enterocolitis (NEC) is a pathological entity which prevalence is around 5-7 %, asocciated with haematological malignancy, oftenly as a complication of chemotherapy. Given the frequent underdiagnosis of this life threatening process, it requires a team effort to reach an early and accurate diagnosis in the Emergency Hospitalary Room (EHR). NEC represents an important clinical challenge in order to improve healthcare quality in these patients. We present a NEC confirmed case report on a patient with not known haematological disease nor active chemotherapy as early presentation of an undiagnosed haematological malignancy process.

A 71 years old male with aortic valve replacement due to rheumatic disease as unique antecedent attending in the EHR with 38,5ºC fever, abdominal pain localized in the right iliac fossa and hipogastrium and loose stools with no patholycal products of 48 hours of evolution. No other symptoms, except asthenia The phycical examination showed peritoneal irritation and intense sharp pain upon hipogastrium superficial palpation and the rest was regular. Requested complete analytical determination was made. In complete blood count, pancytopenia with severe neutropenia with cell populations suggesting haematological malignancy process: Haemoglobin 4,1 mg/dl, hematocrit 11,4%, 70.000 platelets. At this time, other diagnosis could not been excluded initially, as acute appendicitis or even pseudomembranous diarrhea. With these results, an Emergency Computerized Axial Tomogrography was made and a 12 milimeters concentric oedematous wall thickening affecting cecum and ascendent colon was found, including adjacent fat affectation and also a transverse colon trabeculation, mesenteric adenopathies and normal appendix. Based on these clinical and radiological findings, the classic Gorchluter triad (fever, abdominal pain and intestinal wall thickening bigger than 4 milimeters) suggested NEC diagnosis. The patient entered to Intensive Care Unit in order to avoid complications and it run successfully with conservative management The NEC is a clinical syndrom associated with haematological malignancy process, specially in those with active chemotherapy treatment, but not in this cases. It's the result of an alteration of colonic mucous and endotoxin producer bacterial growth. The early recognition of this syndrome suposed a challenge because the atipical presentation


Álvaro MARTÍN PÉREZ (Badajoz, Spain), Concepcion DE VERA GUILLÉN
11:00 - 18:00 #6999 - THE USE OF HIGH SENSITIVE CARDIAC TROPONIN T AS AN INDEPENDENT PREDICTOR OF IN-HOSPITAL MORTALITY IN EMERGENCY DEPARTMENT PATIENTS HOSPITALIZED WITH SUSPECTED INFECTION.
THE USE OF HIGH SENSITIVE CARDIAC TROPONIN T AS AN INDEPENDENT PREDICTOR OF IN-HOSPITAL MORTALITY IN EMERGENCY DEPARTMENT PATIENTS HOSPITALIZED WITH SUSPECTED INFECTION.

Study objective

The aim of this study was to investigate if high sensitive cardiac troponin T (hs-cTnT) is an independent predictor of in-hospital mortality, and improves risk stratification by the Predisposition, Infection, Response, and Organ failure (PIRO) score of emergency department (ED) patients hospitalized with a suspected infection.

Methods

This was a prospective observational cohort study including 1169 patients. The prognostic performance of hs-cTnT (in 3 categories – low:

Results

The hs-cTnT level (median (IQR)) was 36 (17-76) ng/L in non-survivors, significantly higher (p < 0.001) than the 12 (4-34) ng/L in survivors. Hs-cTnT was an independent predictor of in-hospital mortality: Corrected odds ratios (OR (95% confidence intervals)) were 2.8 (1.2-6.3) for hs-cTnT in the intermediate, and 2.4 (1.0-6.0) for the highest category, compared to the lowest category. For intermediate PIRO scores (5 through 19 points), a rise in hs-cTnT category is correlated with higher in-hospital mortality. For the lowest (0 to 4 points) and the highest (> 19 points) scores, hs-cTnT does not improve mortality prediction by the PIRO score.

Conclusion

In ED patients hospitalized with suspected infection, the routinely used biomarker hs-cTnT is an independent predictor of in-hospital mortality, and improves risk stratification of patients with intermediate illness severity as measured with the PIRO score.


Bas DE GROOT (AMSTERDAM, The Netherlands), Gordon CHU, Mo ABBAS, Marisya VAN GEMERT, Gurpreeth SINGH, Sophie TER HAAR, Thom RIJKEN
11:00 - 18:00 #7732 - The use of ultrasound in Dutch Emergency Departments. Where are we now?
The use of ultrasound in Dutch Emergency Departments. Where are we now?

Abstract

Background
Emergency medicine point-of-care ultrasonography has proven it’s success in improving patient care and is now widely used internationally. Since 2011 a section has been active within the Dutch Society of Emergency Physicians to enhance the development of emergency ultrasound. Point-of-care ultrasonography officially has become one of the competencies in the training program for Emergency Physicians in the Netherlands since 2014. An internship ultrasonography  has been developed in three community emergency departments and one academic. However, at this point ultrasound experiences outside these 4 ED’s are unknown and there is little consensus about the key terms of ultrasonography for residents.
Objective: the aim of this study was to evaluate the use of point-of-care ultrasonography in Dutch ED’s and it’s barriers.

Methods
We conducted an online questionnaire which was sent by email to all Emergency Physicians and Emergency Medicine Residents in the Netherlands. Data was collected from April till June 2016. We used descriptive statistics, paired student T test and multivariate regression models to analyze our data.

Results
At this moment the survey is still running and data is being collected.
Based on similar international literature we expect a response rate of 80%. Since ultrasonography is one of the competencies in the training program for Emergency Physicians we hope to see that every training clinic has an Ultrasound Machine available. We expect to see a difference in use of ultrasonography between academic, large community and small community hospitals. We also expect to see a difference in use between training clinic’s and non-training clinics (difference in availability, difference in indications of usage). We assume that the use of ultrasonography is person dependent and that the year of residency is of less influence. Furthermore we expect to identify several barriers in the use of ultrasound, mainly for those working in small clinics where they are the only Emergency Physician available. We think there is a need to expand education and skills in order to further expand the use of Emergency medicine point-of-care ultrasonography.

Conclusion
Follows as soon as we have our data and results.


Anneloes NIESINK (Gaanderen, The Netherlands), Ties EIKENDAL
11:00 - 18:00 #7301 - The Use of Venous Lactate Levels in the Prehospital Setting.
The Use of Venous Lactate Levels in the Prehospital Setting.

Background and Objective:  The aggressive treatment of sepsis has been shown to decrease mortality.  Sepsis protocols have been developed in Emergency Departments (EDs) to identify and treat patients quickly and efficiently.  It follows that identification of septic patients in the prehospital setting would provide additional benefit.  To this end, we recently began obtaining venous lactate levels in the prehospitally.  We sought to describe our initial experience and to determine the utility of its use prehospitally.

Methods:  Setting: A suburban, hospital-based, two-tiered EMS system in which the Advanced Life Support (ALS) providers treat about 15,000 patients annually.  Subjects: Consecutive patients in whom a venous lactate level was obtained prehospitally.  Protocol: Beginning in March, 2016, paramedics in our system were able to draw venous lactate on patients prehospitally.  Paramedics were instructed by EMS administration to assess lactate levels on patients with “sepsis, shock, suspected infection, or when it might be helpful” -- there are no specific guidelines for its use.  We calculated average contact and transport times, vital signs, amount of IV fluids ordered prehospitally, and whether the lactate drawn was “useful.”   95% confidence intervals (CI) were also calculated for each variable.  For the purpose of this study, we defined a ‘useful” prehospital lactate as one drawn in a patient with a suspected infection and one of the following SIRS criteria: “hot” skin on exam / fever, elevated respiratory rate >20, or tachycardia >90.

Results:  In the first two months of the program, 23 patients had lactate levels drawn.  The average age was 74 and 30% were male.  10 calls were dispatched as “Respiratory,” four as “Altered Mental Status,” and two calls each for “Fall,” “Cardiac,” “Medical NOS.”  The average total contact time with the patient was 32 minutes (CI: 28, 36) while the average transport time was 12 minutes (CI: 10, 14).  Of the patients with lactates drawn, the average SBP was 143 (CI: 128, 159), average  was 82 (CI: 74, 90) , average heart rate was 97 (CI: 85, 108), and the average respiratory rate was 21 (CI: 18, 24).  83% (CI 64, 97) of the lactates drawn were considered “useful” under our criteria.  Of those with elevated lactate levels, the average amount of IV fluid given was 286 ml (C: 72, 501), and those with normal lactate levels were given an average of 125 ml (-40, 290)  (Difference: 161, (CI: -110, 432)).

Conclusion:  Although the protocol is new and sample size is small, it appears prehospital lactate levels are being drawn in patients in which it will be useful to ED providers.  The results of this testing have not translated into additional treatment prehospitally, and it is unclear if the results will have an effect on treatment in the ED or patient outcomes.


Brian WALSH (Morristown NJ, USA), Danielle BIGGS, David FELDMAN, Lisa CLAYTON, Kristen WALSH
11:00 - 18:00 #7755 - The wolf is coming!
The wolf is coming!

54-year-old patient presenting a history of chronic pain in the extremities, having been evaluated in 2011 with vascular surgery, traumatology and rheumatology, and with a diagnosis of lumbar spondylosis associated to fibromyalgia and degenerative discopathy.

During a period of two months the patient had visited several hospitals in the area, reporting cramp-like shooting pains in both the lower and upper extremities, mainly in the hands and feet, with paresthesia in said areas. A physical examination was normal, with no neurological focus, and no evidence of deficit at a motor or sensitive level. Osteotendinous reflexes were normal; pulses were palpable and symmetric; there were no skin alterations and no changes in colour or distal cyanosis.

A number of analytics were performed including an ionogram, CPK and glucose test, all of them casting normal results. A full spine X-ray showed no alteration.

The patient had been persistently diagnosed with neuropathic pain and the treatment prescribed had included different anti-inflammatory drugs and pain-killers such as amitriptyline and gabapentin, with no improvement being observed. Thus, the patient was referred for external consultations in neurology.

Finally, the patient was admitted to the emergency room presenting hypotension, hallucinations, intermittent incoherent speech, persistent constipation and acute urine retention. The examination at the emergency room showed normal results. Radiological tests (cranial CAT-scan and X-ray of the thorax and abdomen) showed no acute pathology. The patient was admitted to the department of internal medicine where a lumbar puncture was performed as well as a cranial magnetic resonance and an electromyogram, all casting normal results. Upon performance of a CAT-scan of the abdominal thorax a tumour was observed in the left lobule area. The analysis was completed with an examination resulting in a final diagnosis of small cells carcinoma with no extension, associated to the appearance of paraneoplastic syndrome presenting as sensitive autonomic polyneuropathy. During the patient’s hospitalisation symptoms progressed to include unstable walking, hypoesthesia and global hyporeflexia that improved with corticotherapy. The patient is currently being treated with chemotherapy and radiotherapy.

Conclusions

Paraneoplastic syndrome affects between 1% to 6% of patients with cancer. Nevertheless, this rarely comes to mind at the emergency room. In our case the patient presented all the typical clinical characteristics for this syndrome and had we suspected it earlier, oncological treatment could have been administered at an early stage.

Each time a patient comes to the emergency room they must be evaluated exhaustively and as if it was the first time said patient is examined, paying no regard to labels such as chronic pain, fibromyalgia, depression, repeat user… etc. Failure to do so may result in the wolf finally coming.


Ana ESTEBAN VILLACAMPA, Jorge ALCALA ANIENTO (EL VENDRELL, Spain), Gabriela Madalina GRECU, Carles GREOLES ROYO, Claudia ROMERO RAMIREZ, Josep MONTESINOS COTS, Salvador SARRA MORETO
11:00 - 18:00 #7743 - Those emergency room doctors are always asking for X-rays!
Those emergency room doctors are always asking for X-rays!

24-year-old patient with no relevant medical history. The patient reported pain in the right quadriceps at distal third level, of a month’s duration and having started while going up the stairs, with no previous trauma.

Upon physical exploration, no apparent muscle tears were uncovered. There were no skin lesions observed and no signs of inflammation. The joint at the knee was observed to be normal with no crepitus, stable and with no limitations to the scope of movement.

When an X-ray of the knee was requested, the radiologist expressed concerns and called into question the need to irradiate the patient. The X-ray showed an intramedullary lytic bone lesion, with a secondary lesion close to the right femur’s diaphysis that presented a case of associated periosteal reaction.

No relevant alterations were shown in the blood tests.

A consultation was made to the traumatology department, resulting in an urgent ambulatory nuclear magnetic resonance. At this point possible diagnoses of osteomyelitis or malignant neoplasm were considered and, on the same day, the analysis was completed with a gammagraphy with labeled leukocytes and a bone tomogammagraphy with technetium.  The results indicated a possible osteomyelitis.

The patient was referenced to the hospital for a lumbar puncture biopsy guided by CAT scan. The recovered bone tissue along with pus-infected blood liquid confirmed the suspected diagnosis.

The patient was admitted for treatment with intravenous antibiotics with vancomycin and gentamicin, with said treatment being changed after the antibiogram showed a positive result for staphylococcus aureus.

During his hospitalisation, the patient showed feverish peaks and lab results were obtained indicating a negative result for malignant cells. The patient was finally transferred to the referencing hospital’s infection unit for surgical treatment.

 

Conclusions

-          An X-ray should be requested as a differential diagnosis tool in cases where the patient reports a long-evolving pain in the extremities.

-          Indication for radiography should not be questioned if a clinical reasoning belies the request by the assisting doctor.

-          Diagnostic circuits that are coordinated and supervise can help in avoiding unnecessary hospitalisations. This has socio-economic implications: a greater comfort for the patient and a correct management and allocation of resources. These circuits can also accelerate the diagnosis and treatment in cases where a grave pathology exists.


Ana ESTEBAN VILLACAMPA, Carles GREOLES ROYO, Jorge ALCALA ANIENTO (EL VENDRELL, Spain), Gabriela Madalina GRECU, Josep MONTESINOS COTS, Claudia ROMERO RAMIREZ, Salvador SARRA MORETO
11:00 - 18:00 #7071 - Three meters of bowel gangrene caused by strangulated Petersen’s hernia 9 years after open total gastrectomy.
Three meters of bowel gangrene caused by strangulated Petersen’s hernia 9 years after open total gastrectomy.

BACKGROUND: Petersen’s hernia is one of the internal hernias develops after gastrectomy with Roux-en-Y (R-Y) reconstruction. Petersen’s hernia is a specific type of hernia that the small bowel moves into a mesenteric defect of the transverse mesocolon. Although internal hernia is well-known complication of R-Y gastric bypass, there are few reports of bowel necrosis caused by Petersen’s hernia. We experienced the case of bowel gangrene as long as 3 meters due to Petersen’s herniation 9 years after open total gastrectomy. Internal hernia might present with ambiguous physical examination findings, initial almost normal laboratory, and nonspecific radiographic results, making early diagnosis and treatment difficult, while there is a case resulting in massive bowel necrosis.

OBJECTIVE: This is a rare case of massive bowel gangrene occurred after open gastrectomy. The purpose of the report is to heighten awareness of Petersen’s hernia among physicians of all specialties who have relevance to the patients after gastrectomy and all emergency physicians who deal with acute abdomen. Increased suspicion against internal hernia, physicians can obtain prompt surgical consultation in gastric bypass patients with unspecific abdominal symptoms.

CASE REPORT: 82-year-old man, who had undergone open total gastrectomy with R-Y reconstruction for gastric cancer 9 years earlier, was transported to our emergency department by ambulance because of his altered mental status. Abdominal examination was distended, and revealed diffuse abdominal tenderness and peritoneal irritation. Abdominal computed tomography showed dilation of small intestine and the whirl sign of superior mesenteric artery. Almost all of small intestine had no enhancement despite the use of contrast agent. Based on these findings, he was diagnosed as having internal jejunal hernia and possible massive bowel necrosis. During an emergent operation, he was found to have a strangulated Petersen's hernia with colour change that suggests bowel necrosis, and necessitated 3 meters of extensive small bowel resection. Pathological findings showed that there was a short time until forming the bowel obstruction and necrosis by the contents of resected intestine.

DISCUSSION and CONCLUSIONS: The reports of Petersen's hernias are increasing recently, and the incidence of the hernia is described as higher in laparoscopy than in laparotomy. Therefore, there are some cases of bowel gangrene caused by Petersen’s hernia after laparoscopic surgery, but rarely met after open gastrectomy. Petersen’s hernia can occur within days or several years after gastric bypass. Furthermore, patients with internal hernia may present with vague complaints such as intermittent abdominal pain, nausea, or vomiting and initial unremarkable laboratory and x-ray findings. Thus it can lead to the delay of physician’s diagnosis, heighten suspicion and careful evaluations are needed when seeing the patient after gastric bypass. Such our case, there is a case of Petersen’s hernia that develops bowel gangrene after laparotomy and that results in extensive bowel resection, it is essential to be aware of early recognition and treatment against the herniation not only after laparoscopic surgery but after open surgery.


Daisuke NISHIOKA (Nagareyama, Chiba, Japan), Yo INOKUCHI, Keitaro GOTO, Giichiro OHNO
11:00 - 18:00 #7150 - Thrombophlebitis of the facial vein: A case report.
Thrombophlebitis of the facial vein: A case report.

Introduction

Although venous thrombosis and thromboflebitis are commonly encountered in clinical practice,  thrombophlebitis of the facial vein is rarely seen in our times and there is little data in the english language literature. We found two cases dating back to 1999 and 2009 describing this condition associated with the facial area infection. This case report summarises the presentation of a 69-year-old female with signs and symptoms characteristic of facial vein thrombophlebitis.

Case presentation

Patient was presented to emegency department with swelling and tenderness of the left side of her face. Her medical  history revealed neurofibromatosis, ulcerative colitis and hypertension. Two weeks before admission to the hospital she had neurofibromatosis skin lesion excision located behind the right ear.

Physical examination showed painful induration along the course of the facial vein, multiple dermal neurofibromas, normal dental status and body temperature. Further investigation revealed normal primary laboratory findings. CT scan of the face showed enlargement of left facial vein filled with thrombus 4.5x2.9cm in diameter measured axillary. A Doppler ultrasound was performed  and showed up to 2cm expanded hypoechoic non-compressible thrombosed left facial vein, with no flow seen on color flow Doppler imaging.

Subsequent studies revealed no common predisposing factors for venous thrombosis sush as malignancies etc. The only laboratory finding was UTI and E. Coli growth in urine culture, without signs of systemic infection.

The patient was managed with anticoagulant medications with full-dose low molecular weight heparin (Enoxaparin) during hospitalisation days and continued with full-dose NOAC (Rivaroxaban) for three months. UTI was teated with sulfamethoxazole/trimethroprim antibiotics. During the first days of treatment  swelling and tenderness subsided. A repeat ultrasound was performed after five weeks and showed facial vein enlargement without thrombus findings.

Conclusion

Genesis of facial vein thrombosis remains unclear in our case. The cause may be recent procedure of facial area. There is no evidence of neurofibromatosis being risk factor for venous thrombosis. Rather agressive anticoagulant therapy was initiated considering its valveless connection with cavernos sinus. No adverse events were seen during drug therapy.


Lauri KESKPAIK (Tallinn, Estonia), Liis ILMET
11:00 - 18:00 #8053 - thyroid storm in emergency.
thyroid storm in emergency.

Introduction:

Thyrotoxic crisis is an uncommon clinical problem that is potentially life threatening. It is a severe manifestation of hyperthyroidism. The overall mortality is 10-20%. Clinical recognition, diagnosis, and early treatment are crucial to reduce the high associated morbidity and mortality.

 

Case report:

A 38-year-old man with no past medical history was brought to the emergency department  for evaluation of shortness of breath and eodema of the lower members. Initial vital signs were pulse rate, 160 beats/mitt; blood pressure, 140/80 mm Hg; temperature, 37.7°C . The cardiopulmonary examination revealed an irregular  rhythm, and bilateral basal crackles. The electrocardiogram showed  an atrial fibrillation with a rate of 170, the chest X-ray study showed a cardiomegaly.

Laboratory Test: hepatic cytolysis (4 times above normal ), rhabdomyolysis, PT= 27%, lactic acid 6.9 mmol/L (range 0.5-2.2), arterial blood gas= metabolic acidosis with hypoxemia and hypercapnia.

The initial course of action was non-invasive ventilation, diuretic, electrical cardioversion 150J×3, amiodarone 300mg/h then 50mg/h but without effect.

The etiological investigation was completed by thyroid function tests TSH levels of 0.16 mIU/mL (normal: 0.25–5mIU/mL) and free T4 levels of 73.8 ng/dL (normal: 0.8–2ng/dL). He was given basdene but the evolution was marked by death of patient in few hours.

 

Conclusion:

Clinical manifestations of Thyrotoxic crisis include fever, confusion, seizure, coma, tachycardia out of proportion to fever, diaphoresis, nausea, vomiting, diarrhea, and cardiac dysfunction. It can occur in patients of any age. The underlying pathogenesis of thyroid storm has yet to be fully understood. It is a rarely encountered clinical condition, which should be part of the differential diagnosis in patients with multiple organ dysfunction of unknown etiology. There is no specific diagnostic test. Immediate hospitalization in intensive care for the involvement of symptomatic and specific treatment is indisponsable to reduce the risk of fatal outcome.


Ons ANDOLSI, Mohamed Ali CHERIF, Houcem OUNI (tunis, Tunisia), Khaled SAIDI, Malek HSOUNA, Youssef Zied EL HECHMI, Ines SEDGHYENI, Zouhaier JERBI
11:00 - 18:00 #8230 - Tissue adhesives in adult emergency : A systematic review.
Tissue adhesives in adult emergency : A systematic review.

Background :

Wound represent until 13% of the consultations to the emergency ward. To close simple laceration, tissue adhesive (TA) is an alternative to standard wound closure (suture, staples, adhesives strips). TA has been approved for use in surgery and children. It represents potential advantages includes easy-of-use, decrease in pain, time to apply and not requiring a follow-up visit for removal.

Objectives:

To summarize the available evidence for the effect of TA on the healing of traumatic laceration in adults

Search methods:

We performed systematic review based on the Cochrane Library (1979 to august 2015), the MEDLINE (1950 to august 2015) and Web-of-Science Citation Index (1975 to august 2015).The first outcome is the occurrence of complications (infection, dehiscence, delay in healing) and secondary are pain, procedure time, cosmetic and cost consequence. 

Results:

Eighteen studies were included in this review. Seven studies reported on complications. Fourteen studies compared standard wound closure to TA. Four studies compared TA to either an association between TA and standard wound closure or two different TA. No significant difference was found for occurence of complications (RR=0.86, 95% IC [0.36 ; 2.06]). Overall, studies favoured TA for procedure time, cosmesis, pain, and cost consequence.

Conclusion:

Tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations in adults. They offer the benefit of decreased procedure time and less pain, when compared to standard wound closure. They don’t increase significantly rate of complications.


Alison HORN (Paris), Richard CHOCRON, Natacha ALAVI, Anais GUINCESTRE, Thomas TAMISIER, Philippe JUVIN
11:00 - 18:00 #7866 - To evaluate whether the existence of fever is linked to a lower rate of significant coronary artery stenosis in patients with suspected acute coronary syndrome.
To evaluate whether the existence of fever is linked to a lower rate of significant coronary artery stenosis in patients with suspected acute coronary syndrome.

Background: Although a correct and prompt diagnosis of acute coronary syndrome (ACS) is important, it is not always easy to perform in an emergency room (ER) setting.

Purpose: We evaluated whether the presence of fever at ER was associated with severe coronary artery stenosis in patients undergoing emergency catheterization [coronary angiography (CAG)] for suspected ACS.

Method and Main results: This study was approved by the local ethical committee. In this retrospective study, we enrolled patients who visited ER of the Kagoshima Medical Hospital (Kagoshima, Japan) from October 1, 2013 to March 31, 2014 and underwent emergency CAG. Those patients received examination and if they complained of the symptoms and complains such as chest pains which were suspected of ACS, physicians in charge decided to perform CAG and percutaneous coronary intervention (PCI) for necessary. And in these patients, the rate of the PCI was checked in relation to the existence of fever checked at the time of ER. In total of 1873 patients visiting ER, 100 underwent emergency CAG to determine the diagnosis of suspected ACS; 70 of them were assessed for fever at ER. Sixty two patients (average age: 72.2 year, male/female: 42/20) had a temperature of <37C (N-P) and the remaining 8 (average age: 66.9, male/female:6/2) had a temperature of >37C (F-P). In the N-P group, 77% required PCI for the stenosis treatment, and in the F-P group, 50% required PCI (P = 0.08).  There was the tendency of the lower rate of PCI in F-P group than in N-P group. The existence of the fever might have the possibility to influence on the rate of PCI in patients suspected of ACS.

Conclusion: We observed a tendency toward the lower rates of PCI in the F-P group . With a larger number of patients, the association of fever at the ER with coronary artery stenosis may be clarified. More examinations are warranted.


Hiroshi DOHGOMORI (Nishihara-cho, Japan), Shozo SAHO, Junichi IMAMURA, Ichiro KUKITA
11:00 - 18:00 #7304 - To load or not to load? Aspirin loading in acute ischemic stroke: a study of clinical outcomes.
To load or not to load? Aspirin loading in acute ischemic stroke: a study of clinical outcomes.

Background and purpose:

            Aspirin is known to reduce mortality and recurrent vascular events. However, there are no reports about dose-response of loading aspirin in treating acute ischemic stroke. The objective of this study was to compare the effectiveness of different loading doses of aspirin in acute ischemic stroke presenting within 48 hours of symptom onset.

Methods:

            This was a retrospective, hospital-based cohort study. Patients were classified as high-dose (160-325 mg) or low-dose (<160 mg) based on the initial loading dose of aspirin at the emergency department. The primary outcome measure was a favorable modified Rankin scale (mRS) score of ≤1 on discharge. Secondary outcomes included in-hospital mortality, stroke progression during admission, and bleeding events. A propensity score with 1:3 matching was used to balance baseline characteristics, and stepwise multiple logistic regression was performed for variables adjustment.

Results:

            From a total of 7738 available patients, 3802 patients were included. Among them, 750 patients belonged to the high-dose group. Multiple logistic regression after matching revealed that the high-dose group was significantly associated with a favorable clinical outcome on discharge (odds ratio: 1.49, 95% confidence interval, 1.17-1.89, p<0.01), but the associations were not found with mortality and stroke progression. Nonetheless, the high-dose group also experienced more bleeding events, but was significant only in minor but not major bleeding.

Conclusions:

            A higher loading dose of aspirin (160-325 mg) can be beneficial in treating acute ischemic stroke in the emergency departments. Although there is an increased risk of bleeding, which, however, is usually minor.


Tse-Hsuan SU (Taoyuan, Taiwan), Yi-Ling CHAN, Jiann-Der LEE, Meng LEE, Leng-Chieh LIN, Yu-Wen WEN, Tsong-Hai LEE
11:00 - 18:00 #7970 - Toluene is the enemy.
Toluene is the enemy.

 

ABSTRACT  TEXT:
 Organic dissolvents are toxic. The steams that organic dissolvents emit are heavier than the air, this is the reason why the greater concentration will be near the ground. These steams go through cellular membranes, and due to its great solubility in fat, they reach high concentrations in the CNS.
 
CLINIC CASE:
 Man of 50 years brought in mobil UVI because he shows, at his home, episode of loss of conscience, recovered  and later disartric and incoherent speech; drunkenness is suspected.
In urgencies service, conscious patient, not oriented in time nor in space, somnolent with stable constants (Pressure 120/80, F.C. 72xmin, Temperature 36.5, O2 Saturation 96%), no enolic odour.  
In the neurological exploration it is shown a somnolent patient, a bit disartric with Glasgow (3+4+6) 13/15, without another focality
Complementary tests:
leucocytosis with left deviation; thorax x-ray without alterations; ECG sinusal rate 64x min without repolarization alterations
Evolution:
When the discrepancy between the physical exploration and the first clinical direction has been observed, his wife is interviewed, who confirms that he has been drinking alcohol and inform us that has been also varnishing a furniture with a product, that she is going to look for at home. The varnish is composed by TOLUENE 100:6.
 As a result of the new information he is diagnosed of acute Poisoning by Toluene and the treatment begins.
 
CONCLUSIONS:
 Clinical history is always fundamental in the Service of Urgencies.
 Always think about the poisonings by dissolvents in situations of affectation of the CNS without clear focality.
 

Sonia Sofía BALLESTIN SOROLLA, Ana Belén MARÍN FLORÍA, Elisa RUIZ OLIVARES, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Carola MEDINA SAINZ
11:00 - 18:00 #7418 - Transition of the blood insulin concentration in insulin poisoning treatment.
Transition of the blood insulin concentration in insulin poisoning treatment.

Background: While the frequency of insulin use is increasing in association with an increase in the number of diabetic patients, reports on the insulin poisoning have been increasing.

Objective: The following three points are important in treating insulin poisoning: (1) early therapeutic intervention; (2) repeated blood glucose measurements and appropriate administration of glucose; and (3) measurement of blood potassium concentration. In theory, although the metabolism of insulin is about 24 hours at longest, the treatment often takes several days. We have examined the blood insulin concentration of the treatment in insulin-poisoning cases (6 cases).

Results: Regardless of the initial blood insulin concentration, we have recognized the possibility that the blood insulin concentration decreases regularly under appropriate treatment. Under all types of insulin (from a Rapid-Acting Insulin to a Long-Acting Insulin), similar trends were observed. We presented an example, a patient who inoculated oneself with 5,400 units of insulin (intermediate-acting) in order to commit suicide. After entering the ICU, the patient received a glucose infusion and potassium supplementation, and without developing any complications, the patient was thereafter discharged from hospital on Day 8. Maximum glucose dosage during the course of treatment was 25g / h.

Discussion: First, the effect duration of the blood insulin concentration depends on insulin metabolism, the injection amount, and the absorption speed. For the reason, it is necessary to frequently measure the blood insulin concentration. In theory, intermediate-acting insulin should disappear within 24 hours but lasted for 7 days in the present case. We have recognized that the blood insulin concentration decreased linearly under the logarithm. By measuring several times the blood insulin concentration of treatment in the beginning 24-48 hours, the possibility of predicting the time to reach the normal level of the blood insulin concentration was suggested. Next, maximum glucose dosages during this research were 22g/h-35g/h.  Insulin intakes, blood insulin concentration and maximum glucose dosage did not correlate. This result was thought to be due to glucose uptake limitations of the insulin receptor.

Conclusion: Predicting the normalization of the blood insulin concentrations is useful in building a therapeutic strategy.


Hayato YOSHIOKA (TOKYO, Japan), Kazushige INOUE, Mayuko KANEKO, Tsuyoshi CHIJIWA, Nobuaki KIRIU, Hiroshi KATO
11:00 - 18:00 #7567 - Trauma simulation: creating pressure and realism.
Trauma simulation: creating pressure and realism.

Background

Simulation-based learning is becoming increasingly recognised as a valuable education method. It allows practice of both technical and non-technical skills in a safe and controlled environment. It is unclear whether high fidelity mannequins, simple mannequins, or patient actors are the most effective way of delivering this teaching. The student-led Cambridge University Emergency Medicine Society (CUEMS), in collaboration with 254 Medical Regiment and Magpas Helimedix, designed and delivered a simulation-based training course on pre-hospital and battlefield trauma scenarios to 50 UK medical students.

 

Method

The course consisted of five civilian/military trauma scenarios and used a combination of patient actors and simple mannequins, to enable performance of skills such as intubation. Doctors from civilian and/or military backgrounds facilitated the scenarios. Delegates were then asked to complete two questionnaires.

 

Results

In the general questionnaire, delegates (n=42) rated the course 9.4/10 for usefulness with 100% of the delegates saying they felt more confident dealing with a trauma patient after the course. Additionally, 98% of delegates said they felt more confident assessing any acutely unwell patient, trauma or otherwise. Those who completed the second questionnaire (n=21) felt that using a patient actor was more effective than a high-fidelity mannequin at providing realism, and for developing non-technical skills. The respondents scored an average of 4.7/5.0 when asked to what extent they agree with the statement “Using a mannequin in combination with a live patient actor is the best way to provide realism as well as time pressure in having to perform practical skills”.

 

Conclusion

Trauma simulation-based learning is an effective way of developing transferable skills and confidence in dealing with acutely unwell patients. Using patient actors with simple mannequins is an effective way of delivering scenarios that maintain realism and develop non-technical skills, whilst enabling technical skills to be practised under pressured circumstances.


Sereena ANSARI, Nathan HUDSON-PEACOCK (Patrixbourne, United Kingdom), Alexander TAYLOR, Matt ELLINGTON
11:00 - 18:00 #7564 - Trauma simulation: developing non-technical skills in medical students.
Trauma simulation: developing non-technical skills in medical students.

Background

As clinicians, it is necessary to be able to adapt to unfamiliar, high-pressure situations. Under these circumstances, effective non-technical skills such as crisis resource management (CRM) and leadership skills are crucial. However, these are poorly taught in medical schools and often have to be acquired as working doctors. In the military, there is a strong emphasis on non-technical skills development. Additionally, simulation-based learning is commonly used as a valuable education method, enabling practise of both technical and non-technical skills in a safe, controlled environment. The student-run Cambridge University Emergency Medicine Society, in collaboration with 254 Medical Regiment and Magpas Helimedix, designed and delivered a simulation-based training course on pre-hospital and battlefield trauma scenarios to 50 medical students. This course aimed to use military scenarios and expertise, and simulation, to generate enthusiasm for this area of medicine, whilst simultaneously developing effective non-technical skills.

 

Method

50 students from UK medical students attended. Delegates were sent pre-course reading on the management of a trauma patient and given a verbal briefing at the start of the course. The day consisted of five civilian/military trauma scenarios and used a combination of patient actors and skills mannequins, to provide both realism and time pressure. Doctors from civilian and/or military backgrounds facilitated the scenarios whilst delegates took turns to team lead their group of five. Data was collected by paper questionnaire using visual analogue scales.

 

Results

Delegates (n=42) rated the course 9.4/10 for usefulness with 100% of the delegates saying they felt more confident dealing with a trauma patient after the course. Additionally, 98% of delegates said they felt more confident assessing any acutely unwell patient, trauma or otherwise. When asked whether inclusion of military scenarios and personnel added positively to the course, they scored 9.1/10.

 

Conclusion

Battlefield and pre-hospital trauma simulation exposes medical students to high-pressure situations in an unfamiliar but safe environment. Students found this a highly effective method for developing skill in trauma management, as well as confidence in managing the non-traumatic patient, through acquisition of transferable, non-technical skills such as crisis resource management, leadership and teamwork ability.


Nathan HUDSON-PEACOCK (Patrixbourne, United Kingdom), Alexander TAYLOR, Matt ELLINGTON
11:00 - 18:00 #7435 - Traumatic anterior dislocation of the hip joint; case report.
Traumatic anterior dislocation of the hip joint; case report.

Introduction

 

Traumatic dislocations and fracture-dislocations of the hip are severe injuries caused mostly by high-speed motor-vehicular accidents, fall from a significant height or sport injuries. Young adult males are most commonly affected. Traumatic anterior dislocation of the hip joint is uncommon. Here we present a traumatic anterior hip dislocation due to motor vehicle accident. 

 

The Case

A 19 years old male motorcyclist who had a car accident was brought to ED by EMS. Initial stabilization was done. On primary survey no serious injury was discovered. The patient had held his right hip and thigh in flexion and abduction. Neurovascular examination was normal. On hip x ray anterior dislocation of right hip was obvious. The patient admitted by orthopedic service and close reduction was done in less than 4 hours. Bone traction was applied and the patient discharged with no complication. On follow up visits traction was removed and he was allowed to walk. No complication such as avascular necrosis of femoral head was detected.

 

Conclusion

Hip dislocation was considered to be uncommon in previous years but the increase in incidence has been attributed to traffic accidents. Traumatic dislocation of the hip is considered an orthopaedic emergency. Delay in reduction more than 6 h has been associated with a high risk of avascular necrosis of the femoral head and osteoarthritic joint degeneration. The final outcome of isolated traumatic hip dislocation which is reduced within 6 hours is believed to be excellent.  In this case reduction was done in less than 4 hours and no complication was detected on follow up visits.

 


Azadeh MAHMOUDI GHARAEE, Behrang REZVANI (Mashhad, Islamic Republic of Iran), Morteza TALEBI DOLUEE
11:00 - 18:00 #7784 - Traumatic injuries in horse cart accidents in an emergency department in North-East Romania.
Traumatic injuries in horse cart accidents in an emergency department in North-East Romania.

Purpose of the study: Horse cart accidents are characterisc at countryside where this vehicles are still
the main way of making agriculture for people. In this study we wish to illustrate the main traumatic
mechanisms and the management in the Emergency Department of this type of patients.
Materials and methods: A descripve retrospective study made in Emergency Department of Saint Spiridon Hospital in Iasi,
between 1st of June 2015 and 31st of March 2016. There were registered patients with horsecart
accidents as presenting complaint, regardless the mechanism involved: fall down from the horse cart,
impact/crush, impact with an vehicle/car. We rated general demographic data, environmental origin, the
mechanism they were produced, investigations and treatments made in emergency department. The
data obtained were processed in SPSS, version 19.
Results: There were recorded 157 patients with trauma produced by falling down from horse cart, ages
between 18-83 years. 88% (139 patients) came from country side, 73% (115 patients) were male. Most
accidents were produced in summer (31%) and autumn (41%). The main producing mechanism was falling
down  from horsecart (69%), followed by the impact with an vehicle (14%), crush (11%) or
people/pedestrians crushed by the horse cart (6%). In 13% of cases, patients presented themselves at
the hospital and in 84% of cases the patients were hemodynamic and respiratory stable. Regarding
the   presented  injuries,  prevailed  arms  or  legs  fractures  at  27  patients  (17,19%),  followed  by
cranio-cerebral injuries (10,19%) and thoracic-abdominal injuries (8,28%). There were made X-rays in
22,9% of cases, abdominal ultrasound (63,69%), CT (6,36%), only 8 patients (5,09%) required
investigations. There were performed chest drainage in case of 7 patients (4,45%) and there were reduced
scapula-humeral dislocations at 12,1% patients, most of them requiring hemodynamic stabilization and
painkillers (86,4%). After the investigations made in emergency department, 15,28% of patients were
hospitalized at orthopedics, 11,46% at general surgery, ENT 5,09%, maxillofacial 3,82% and thoracic
surgery 10,82%. The others patients were sent at the neurosurgery or discharged to their homes (51,59%).
Conclusions: The pathology of the patients determinated by falling down from the horse cart represents
a distinct part of trauma patients that presents in Emergency Room, specific for countryside. Alcohol
ingestion is a favorable factor of producing accidents. Most of injuries produced in this accidents are
minor and they did not require hospitalization but they benefited of multiple investigations inEmergency
Department (X-rays, ultrasound, CT, blood tests).

Diana CIMPOESU (IASI, Romania), Paul - Lucian NEDELEA, Andrei HINCU, Mihaela DUMEA, Giorgiana MATEI, Tudor Ovidiu POPA
11:00 - 18:00 #7837 - Traumatic internal carotid artery dissection treated with stent.
Traumatic internal carotid artery dissection treated with stent.

Introduction: Carotid artery dissection is a rare disease. The incidence of carotid artery dissection after blunt injuries is less than 1- 3%. It is usually seen in head trauma due to high-speed motor vehicle accidents.

Case: A 23-year-old male patient was transferred from scene to emergency department with extra-vehicular motor vehicle accident by 112 emergency medical services. He had no prior disease history and he did not use any medication. His Glasgow coma score was 15, arterial blood pressure was 110/75 mmHg and pulse rate was 80/min. There was ecchymosis on the anterior aspects of both femurs and deformity on right tibia. X-rays revealed bilateral femur fracture and right tibia fracture. He was admitted to emergency department intensive care unit with a diagnosis of multiple long bone fractures. At the second day of his admission, his mental status altered and he became unresponsive to verbal comments. He had diagnosed as internal carotid artery dissection after performing brain computed tomography, brain magnetic resonance imaging and cerebral angiography. Stent was implanted in internal carotid artery by interventional radiology. He had operated by orthopedists for his long bone fractures. Then he was transferred to reanimation intensive care unit.

Conslusion: Although traumatic carotid artery dissection is a very rare clinical situation, trauma patients with altered mental status should be evaluated for dissection. After diagnosis of dissection, interventional radiological procedures may be the best choice for those trauma patients. 


Zerrin Defne DUNDAR (Konya, Turkey), Fulya KOSE, Abdulaziz DOGAN, Basar CANDER
11:00 - 18:00 #7266 - Treating the trauma team.
Treating the trauma team.

Background

It`s been decades since “golden hour” has been incorporated in trauma patient management and “trauma team” became the front line soldiers of ER. Many studies has shown the benefit on patients outcome after implementation of trauma system. However the best way of maintaining and improving trauma team performance especially on non-technical skills is still not well known. It is known that continues learning, quality measurement and feedback are the foundation of keeping high standards on patients safety.

Methods

Trauma team audit has been carried out in Lithuanian major level III trauma center. We incorporated two new components in trauma audit. First one was continuous simulation learning: every morning all trauma team members had to gather up in the ER for one simulation session. The second was measurement of non-technical skills and giving feedback after simulation learning and real-life experiences. Trauma team performance has been evaluated using our developed evaluation tool. Trauma team members has not been informed about the audit.

Results

Trauma team performance on non-technical skills has been evaluated before the intervention and after using our developed performance evaluation tool.

Conclusion

We still have a far way to a well-balanced and functioning trauma team. But “time offs” at the beginning of a shift seems to be an easily accomplished performance improvement strategy. “Time offs” drills, quality measurement and feedback should become a standard everyday procedure especially in less crowded emergency rooms, were real life practice is not that common.


Aukstakalnis VYTAUTAS (Kaunas, Lithuania), Jasinskas NEDAS, Stasaitis KESTUTIS, Dobozinskas PAULIUS, Dambrauskas ZILVINAS, Vaitkaitis DINAS
11:00 - 18:00 #7813 - TREATMENT OF NON-DISPLACED RADIAL NECK FRACTURES IN THE ED literature, protocols and practice.
TREATMENT OF NON-DISPLACED RADIAL NECK FRACTURES IN THE ED literature, protocols and practice.

ts of immobilization with upper arm plaster or compression bandage. No consensus seems to exist on the most appropriate means of initial conservative treatment in the ED. Therefore the aims of this study were: 1) review of literature, 2) inventory of existing protocols and 3) consideration of initial treatment given in practice.

Methods: 

A systematic search of PubMed was performed. Also protocols fortreatment of non-dislocated radial neck fractures were collected in every Dutch ED. Finally, a retrospective 


J.j. (Anne) EVERSDIJK (Rotterdam, The Netherlands), R. (Rianne) MEIJER, R. (Rebekka) VEUGELERS, J.m. (Sjors) Van LIESHOUT, M.i. (Menno) GAAKEER
11:00 - 18:00 #7335 - Treatment of skin and soft tissue infections on a Belgian emergency department: a retrospective analysis of 159 patients.
Treatment of skin and soft tissue infections on a Belgian emergency department: a retrospective analysis of 159 patients.

BACKGROUND: Skin and soft tissue infections (SSTI) are among the most commonly seen infections on the emergency department (ED), with an increasing incidence. European and more specific Belgian treatment guidelines are not available although they could improve patient outcome and reduce cost. We performed a retrospective analysis of patients who were treated for a SSTI in a Belgian ED and developed a protocol for our emergency department based on the available literature.

SETTING: ED of an inner city teaching hospital (Bonheiden, Belgium).

METHODS: We performed a retrospective case series analysis of patients who presented at the ED from June 2013 to March 2016 with the tentative diagnosis of SSTI. We investigated if these patients indeed had a SSTI, if they were hospitalized or received outpatient treatment, which antibiotics and/or local treatment were used and if follow-up was provided either by general practitioner or on the ED. Subsequently we performed an extensive PubMed literature search. Based on the available literature we developed our protocol for the management of SSTI’s on the ED.

RESULTS: 159 patients with the tentative diagnosis of a SSTI were included (76 males, 83 females, all adults). Further examination showed that 136 patients (86%) indeed had a SSTI. Of these, 99 (73%) were hospitalized and 37 (27%) received outpatient treatment. The most frequently used antibiotic in both groups was amoxicillin/clavulanate (51% in the outpatient group and 43% in the hospitalized group). In addition, clindamycin was more commonly used in the hospitalized group opposed to moxifloxacin in the outpatient setting. In the outpatient group follow-up was provided for 18 patients (49%). The mean time to follow-up by general practitioner was 78 hours (n = 14). On the ED all patients were reevaluated within 24 hours (n = 4). Local treatment of the infection (silver-containing foam dressing, polyvidone-jodium, silver sulfadiazine or chlorhexidine) was provided for 38% of patients in the outpatient setting.

Based on the available evidence in literature we developed a protocol for the treatment of SSTI’s on the ED. Key fact in this protocol is the identification of complicating factors both patient related as well as linked to the aspect of the skin infection.

CONCLUSION: Our retrospective analysis showed major interindividual variation in treatment strategies for SSTI’s on the ED. These results confirm the need for a treatment algorithm. In our opinion the proposed protocol can improve patient outcome, lead to more rational use of antibiotics, less hospitalization and reduction of costs. The implementation and hospital specific use of this protocol can be subject of further prospective studies.


Ruben DE VOS (Zutendaal, Belgium), Marie DE LEEUW, Marc GILLIS
11:00 - 18:00 #8245 - Triage - the comparison of two systems.
Triage - the comparison of two systems.

With increasing number of patients, difficulty and complexity of medical care, emergency medicine departments have faced the problem of overload.

The system of work based on waiting in line, as it was the practice in some Croatian hospitals, has been replaced by the organized approach to emergency patients.

The triage is a formal process through which all the patients are being evaluated upon their arrival in emergency departments.

Within the Project of emergency medicine service improvement and investment planning in healthcare, in hospitals in Republic of Croatia the ED’s are being established in which triage is having an important role. For that purpose, the Australasian triage scale has been implemented.

In 2010, the Ministry of health of Republic of Slovenia has issued an ordinance according to which all incoming patients in EDs need to be triaged using the Manchester triage scale.

The Manchester triage scale is based on 52 algorithms out of which 49 of them are applicable on children. The triage category is being assigned following algorithms, measured vital parameters and duration of symptoms.

Australasian triage scale is based on main symptom which is being detected from targeted anamnesis, as well as from observance of patient’s general appearance and physiological parameters.

Triage categories have proscribed time for safe waiting for doctor’s examination.

Generally, triage scales with 5 categories has been shown more effective than those with 3 or 4 categories.

The process of triage is being carried out by highly motivated I broadly clinically educated nurses/medical technicians.

The function of triage is to provide equal care for each patient in ED where numerous people with different health problems are coming at the same time.


Furdek DAVORKA, Damir VAZANIC (ZAGREB, Croatia)
11:00 - 18:00 #7591 - Tuberculous meningitis with pulmonary miliary tuberculosis: case report.
Tuberculous meningitis with pulmonary miliary tuberculosis: case report.

Introduction: Central Nervous System (CNS) Tuberculosis (TB) is the most dangerous form of extrapulmonary TB. It occurs in approximately 1% of all patients with active tuberculosis (1). It includes meningitis, intracranial tuberculomas and abscesses. The diagnosis and treatment of tuberculosis meningitis (TBM) is still a clinical challenge. We report a case of TBM with pulmonary miliary tuberculosis.

Case report: A 30 year-old male was admitted in the emergency department with complaints of high grade fever, weight loss, decreased appetite and generalised weakness for 1 month. On admission, the patient looked ill, he was confused, disoriented. Physical examination revealed: temperature 39°C, heart rate: 110 beats/min, blood pressure: 150/60 mmHg, respiratory rate: 18 inspirations /min. He had neck stiffness, the auscultation of the lungs was normal. The Investigations show: White blood cell count: 6360 element /L, with 79% neutrophils and 6,8% lymphocytes, Hb 13 g/dl, Platelets: 290000/mm3 , C-reactive protein: 103 mg/l, Na+ :121mmol/l , glycemia:7,5 mmol/l , creat :66 µmol/l. Computed tomography scan of the brain was normal.  The cerebrospinal fluid test was clear, with    leucocyte count at 10 103/ml, the glucose level was: 0.85 mmol/l (ratio 0,15) and the protein level was: 1,98 g/l.  HIV and Hepatitis B and C serology were negative.

Chest X-Ray showed typical milliary pattern. Thus, the diagnosis of TBM was highly suspected and antituberculous chemotherapy, with isoniazid, rifampicin, ethambutol and pyrazinamide associated with dexamethasone was initiated. Clinical improvement was noted after the first week of therapy.

Conclusions: TB is still a major public health problem in the world, and there is a rising tendency of extra pulmonary TB incidences especially in immune suppressed adults. The specificity of our patient is that no predisposing or associated conditions have been documented.

1- Guy Thwaites, Martin Fisher , Cheryl Hemingway, Geoff Scott, Tom Solomon, John Innes. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. Journal of Infection :2009: 59, 167-87.


Houda NASRI, Feten AMIRA (Tunisie, Tunisia), Asma ALOUI, Salwa AMRI, Salwa MANSOURI, Alaa ZAMMITI, Bechir BOUHAJJA
11:00 - 18:00 #7464 - Ultrasonography of the Internal Jugular Vein to assess intravascular status in the ED.
Ultrasonography of the Internal Jugular Vein to assess intravascular status in the ED.

Background:

Intravascular fluid status estimation continues to be one of the greatest challenges in critically ill patients. The current gold standard technique is the measurement of CVP, which requires an invasive central venous catheter, which is time consuming and is associated with complications. Point-of-care ultrasound has been used to assess the collapsibility IVC and Subclavian vein but requires advanced US skills. We currently propose the use of ultrasound guided Internal jugular vein measurement to assess the volume status as a potentially useful noninvasive adjunct to estimate CVP.

 

Objectives:

Primary: To assess the intravascular volume status using bedside ultrasonography of the internal jugular vein in the emergency department.

Secondary: To compare the results of two different techniques (quantitative and qualitative) mentioned in the literature.

 

Method:

A prospective observational study using a convenience sample of 21 patients was performed at the emergency department of University Hospitals Birmingham. The study was performed in 2 phases. In phase-1 we scanned 15 healthy volunteers to assess the normal shape and aspect ratio of IJV and in phase-2, 21 acutely unwell adult patients. The study was performed from October to November 2015. Emergency physicians with level-1 emergency ultrasound experience were trained in IJV ultrasound. The appearance and size (aspect ratio: height/width) of the IJV was noted first at 45 degrees and than in supine position.

We used a high frequency linear probe at a depth of 3- 4 cm. US pictures (stills and M mode) were taken at the level of cricoid. The EP performing the ultrasound was blinded to the clinical information and so was the EP treating the patient from ultrasound results. The results of the ultrasound were then compared with the final clinical diagnosis of the attending Emergency Physician using all available traditional data.

Results:

 

The results using the aspect ratio technique showed a Sensitivity of 83.33% (95% CI:

35.58 to 95.58), Specificity of 73.33 (95% CI: 44.90 to 92.21), PPV of 55.56 (95% CI: 21.20

to 86.30) and NPV of 91.67 (95% CI: 61.52 to 99.79). The results using the appearance technique had a Sensitivity of 85.71% (95% CI: 42.13 to 99.64), Specificity of 88.71 (95% CI: 57.19 to 98.22), PPV of 75.0 (95% CI: 34.9 to 96.8) and NPV of 92.31 (95% CI: 63.9 to 99.81).

 

 

Conclusion:

 

The results of this pilot study demonstrated that point-of-care ultrasonography of the IJV

in the busy ED can reliably aid in the assessment of intravascular volume status. Both techniques showed good sensitivities and specificities, however appearance technique was better and simpler. We propose to extend this study in ED with larger sample size in order to validate our current results from this pilot.


Shahzad ANWER (Birmingham, United Kingdom), M Azam MAJEED, Asif NAVEED, M Saif REHMAN
11:00 - 18:00 #8114 - Ultrasound accuracy in detecting tendon tear vs local wound exploration in limb penetrating injury.
Ultrasound accuracy in detecting tendon tear vs local wound exploration in limb penetrating injury.

Abstract:

Objectives: Tendon ruptures are common musculoskeletal injuries containing 7% of all visits  by physicians in the United states and up to 50 % of all sport injuries .correct and timely diagnosis of tendon  injuries is obviously important for the correct treatment  and consequently for minimizing the community costs.MRI has become the standard of diagnosis tool but it is an expensive and overused measure. Now a day Ultrasound is being used increasingly  by radiologists and non-radiologists in the United States as a useful method in vast areas. There fore the preset study is going to validate diagnostic ability of Ultrasound in tendon injuries among penetrating extremity trauma by using clinical wound exploration as  standard measure.

Methods:

Patients with penetrating extremity trauma with suspected tendon injury based on  history and physical exam were evaluated respectively by sonography and wound exploration separately and blind. The results were analyzed  to validate sonography  as an alternative  diagnostic test

Results:

60 patients ,51 male and 9 female , 28 patients under 30 years old and 32 patients 30 and more with 11 lower extremity and 49 upper limb injury and 32 extensor zone and 28 flexure zone injury were evaluated. The overall sensitivity  and specificity were 94.4% and 100% respectively.

Conclusion:

Similar to the results of compared studies  sonography  sensitivity and specificity were near equal. Validation reveals that sonography  is a usefull  measure  for differentiating injured tendon from intact one but small size of our samples preclude  comparison between partial and  total injuries

 


Javad SEYEDHOSSEINI, Narges MOHAMADREZAEI (Tehran, Islamic Republic of Iran)
11:00 - 18:00 #7174 - Unconventional indications to non-invasive mechanical ventilation in the emergency department.
Unconventional indications to non-invasive mechanical ventilation in the emergency department.

BACKGROUND

 

In the last decades Non-Invasive Mechanical Ventilation spread out from the Intensive Care Units to the Emergency Departments, with main evidence in efficacy when treating Acute Respiratory Failure due to Acute Exacerbation of Chronic Obstructive Pulmonary Disease and Acute Cardiogenic Pulmonary Edema.

In the meantime, many different causes, considered as “unusual” indications for NIMV, showed lower levels of efficacy and strength of recommendation, but are increasing in use.

 

 

METHODS

 

We performed an observational prospective study, in the Emergency Department of a University Teaching Hospital, including every non-selected patient treated by NIMV in a 4 months time, to assess the impact and the outcome of conditions considered as unconventional for NIMV.

Failure was defined as in-hospital death or tracheal intubation.

 

 

RESULTS

 

Total: 297 Patients (media 2.43 / day);

pH: (media, median) 7.32, 7.33; P/F: 214, 209;

NIMV as a ceiling treatment: 27.4%;

failure rate: 22.7%.

 

Unconventional indications:

rate: 51.1%;

ceiling: 32.6%;

failure rate: 26.7%;

ceiling in failures: 52.8%;

failure without tracheal intubation: 80.0%.

 

 

CONCLUSIONS

 

The use of NIMV for unconventional indications is spreading in the Emergency Department: its failure rate is higher than usual cases, as already known in the literature (data usually coming from Intensive Care Units), but in this subgroup the rate of patients with no indication to invasive ventilation in case of failure (“NIMV as a ceiling treatment”) is dramatically high.

We could not find any early predictors of outcome from the lab to help risk stratification in the Emergency Department; in failure cases arterial blood gas data showed some slight abnormalities on the metabolic side (more than the respiratory one); pneumonia and inhalation showed a particularly high failure rate.


Dr Rodolfo FERRARI (Bologna, Italy), Riccardo VOZA, Daniela AGOSTINELLI, Roberto LAZZARI, Nicola BINETTI, Mario CAVAZZA
11:00 - 18:00 #7397 - Unexpected contralateral event.
Unexpected contralateral event.

Unexpected contralateral event 

87 years old male with known cardiovascular risk factors, history of cardiac arrest treated with stent implantation and right coronary permanent pacemaker for symptomatic atrial dysfunction.

The patient came to the Emergency Room with right pleuritic chest pain and associated dyspnea for four days, he states that the symptoms began after the pacemaker implantation.

On admission the physical exam was normal, hemodynamically stable, afebrile and basal oxygen saturation of 99 % without cardiopulmonary auscultation findings nor in the rest of the examination.

Blood tests without alterations, NT-proBNP 411, raised D dimer, electrocardiogram with sinus rhythm at 50 bpm without alterations and chest radiograph suggestive of right pleural effusion.

Chest X ray after the pacemaker implantation was reviewed (Left subclavian access) describing a right pneumothorax.

Assessment was completed with a Chest CT describing a right hemopneumothorax.

Thoracic Surgeons were consulted during hospitalization, who decided to place an anterior drainage which drained blood. The patient was admitted to the Thoracic Surgery Service.

- Clinical diagnosis: 

Iatrogenic right pneumothorax after pacemaker implantation.

The patient was admitted with good evolution. He was valued by the Arrhythmia Unit during the income. They considered the release of one of the active fixation system during the procedure as the most probable cause of the hemopneumothorax. There was not a perforation in auricular cable's current location.

- Conclusions:

The frequency of complications related to implant pacemaker is variable and is betweens 6% ato 9%, and there are different factors related to them.

The most common are related to an inexperienced operator and with the concurrence of heart failure prior to implant.

Pneumothorax is a rare complication, especially contralateral to the puncture point used to channel the path.


Isabel FERNÁNDEZ-MARÍN (Madrid, Spain), Víctor SÁNCHEZ ALEMANY, Ana Belén CARLAVILLA MARTINEZ, Ana SÁNCHEZ MORLA, María Lorena CASTRO ARIAS, Luis YUBERO SALGADO, María CUADRADO FERNÁNDEZ
11:00 - 18:00 #7147 - Unilateral congenital cystic adenomatoid malformation of lung in adults: case report.
Unilateral congenital cystic adenomatoid malformation of lung in adults: case report.

Congenital cystic adenomatoid malformation of the lung (CCAM) is characterized by an adenomatoid proliferation of bronchiole-like structures and cyst formation. CCAM is most commonly found in newborns and children, although it has been described in adults in rare cases. Ch’in and Tang described this disease for the first time in 1949 and Stocker made the actual classification in 2002, including five different types regarding to the size of the cysts and their histological characteristics. We present the case of a 63 years-old-women, who denied any prior history of pulmonary illness, transferred from another hospital for shortness of breath. ECG showed left bundle branch block. Haemogram and biochemical tests, including troponin T, were normal. Postero-anterior chest radiography showed multiple cavities in the left lung and contra-lateral compensatory hyperinflation. CT scan of thorax revealed mediastinal shift to the left and elevation of the left hemidiaphragm, suggestive of volume loss in the left hemithorax. Multiple thin-walled, air-filled cavities of varying sizes were seen almost completely replacing the parenchyma of both lobes of the left lung. After admission, the patient’s evolution was favorable, being subsequently transferred to a pneumology service. This is a typical presentation for an adult with undiagnosed CCAM that was asymptomatic for a long period of time and only picked up once the diases has progressed sufficiently to involve a large portion of the lungs.


Vasile GAVRILA, Gabriela FILIP (TIMIS, Romania), Rodica Daniela GAVRILA, Alexandru Nicolae CARSTEA
11:00 - 18:00 #8190 - Unpredictable outcome after peridural accidental administration of xenobiotics.
Unpredictable outcome after peridural accidental administration of xenobiotics.

Objective: Peridural or intrathecal administration of xenobiotic may be related with potentially severe adverse effects according to factors that may influence the toxic effects (e.g. dosage, osmolarity, lipophilicity, baricity). Particularly, overdose or erroneous administration of xenobiotic unintended for peridural administration may not follow predictable pharmacokinetic models (1). We describe two cases of peridural erroneous injection for which, regards this specific route of administration, data in medical literature are lacking.

Case series: Case 1: A 72-years-old female, underwent surgery hysterectomy, erroneously received via peridural catheter 100 ml of sodium chloride solution 0.9% with ketorolac 30 mg, esomeprazole 40 mg and cefotaxime 500 mg infused in 9 hours. The patient at the end of infusion experienced severe burning lumbar pain, hypertension and mild lower limb edema. Clinical manifestations resolved during the next 2 days: no specific treatment has been applied. No sequelae were reported after one months follow-up. Case 2: A 59-years-old male, underwent surgery gastrectomy, mistakenly received via peridural a parenteral nutrition mix (CLINIMIX N9®) (estimated amount: 50 ml) in 30 minutes: intravenous delivery was inadvertently connected to the peridural catheter. The patient manifested immediate abdominal pain and a liquor lavage with sodium chloride solution 0.9% at 5 ml/h for 48 hours was performed. No other clinical effects were reported until hospital discharge after two weeks.   

Conclusion: Erroneous administration of xenobiotic not registered or routinely used in peridural route (and intrathecal) may require a prompt and urgent intervention aimed to immediate withdrawal of cerebrospinal fluid. Cases with uncertain outcome and not previously described should be considered and managed as potentially fatal evolution. Only, regarding beta-lactam antibiotics neuro-excitatory features (convulsion) due to their γ-aminobutyric acid antagonist properties have been reported (1). Our data, even if single experience, describe a favorable clinical evolution of cases. Medical error is possible despite of standardization of procedures: some specialized and exclusive dispositive are available for peridural/intrathecal injection. Because of several factors influence the clinical toxicity of xenobiotic peridural administration, a multidisciplinary approach is necessary in order to correct evaluation and management of cases.

References: 1. Rama BR. Intrathecal administration of xenobiotic. In: Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR, eds. Goldfrank’s Toxicologic Emergencies. 10th ed. McGraw-Hill Education, 2015: 703-710.


Valeria Margherita PETROLINI, Davide LONATI, Azzurra SCHICCHI, Marta CREVANI, Mara GARBI, Giulia SCARAVAGGI, Eleonora BUSCAGLIA, Sarah VECCHIO, Carlo Alessandro LOCATELLI (Travacò Siccomario, Italy)
11:00 - 18:00 #7611 - Unresolved lower abdominal pain resulted from mycotic aneurysm at the distal abdominal aorta and left common iliac artery- a rare case report.
Unresolved lower abdominal pain resulted from mycotic aneurysm at the distal abdominal aorta and left common iliac artery- a rare case report.

Introduction:

Mycotic aneurysm, an infectious break in an abnormal focal arterial dilation arterial lumen, is uncommon but can affect any artery. It may be due to bacteremia or septic embolization. Timely treatment increases the likelihood of a favorable outcome, rather than leading to fulminant sepsis, spontaneous rupture, or death. We report a rare case of mycotic aneurysm at the distal abdominal aorta and left common iliac artery

Case report:

  This 76-year-old man presented to the emergency department (ED) because of lower abdominal pain for 5 days. He had the past history of vertebrobasilar artery syndrome, hypertension and severe AR s/p AVR procine valve on 2014/1/16. There was also poor intake. He has ever visited other hospital, however, there was no improvement at all. So, he was brought to our ER for help. Throughtout the whole course, there was no nausea, no diarrhea or dysuria. Physical examination revealed lower abdominal tenderness without rebound pain. Initial bedside ultrasound (US) showed an disrupted arterial calcification with indistinct irregular arterial wall, and a perianeurysmal soft-tissue mass. Laboratory profiles were as follows: white blood cell count 12510/μL (3590 to 9640/μL), neutrophilic differential 73.8% (41.2 to 74.7%) and creatinine 1.14 mg/dl (0.7 to 1.3 mg/dl). Abdominal contrasted-CT demonstrated aneurysm with maximal diameter around 30.0 mm, partial thrombosis and periaortic fat strandings at the distal abdominal aorta to left common iliac artery (Fig. 1a and 1b).  He was admitted to cardiosurgeon’s service and received antibiotics treatment. After 3 days later, the blood culture reported Salmonella group D non Typhi. 

Discussion:

 

According to the literature review, the clinical presentations of mycotic aneurysms are diverse, dependending on the involved artery. Most patients are febrile or septic. However, some may be silent. In our patient, it involved in the distal abdominal aorta and left common iliac artery, which resulted in lower abdominal pain. Without medical or surgical management, mycotic aneurysms carry a very high mortality. Emergency physicians have to keep a high index of suspicion to prevent the life threatening condition. Sonographic evaluation of the aorta could help us to make the definite diagnosis. CT is considered the gold standard for diagnosis.


Pei-Shan WU (ROC, Taiwan), Po-Liang CHENG, Yi-Kung LEE
11:00 - 18:00 #7138 - Unscheduled return visits in the emergency department within 7 days - rate and analysis of initial diagnostic error.
Unscheduled return visits in the emergency department within 7 days - rate and analysis of initial diagnostic error.

Introduction:

Unscheduled return visits in the emergency department (ED) lead to utilization of resources. Different circumstances and factors may contribute to these visits, some of them might be preventable. Studies suggest that many patients among those who revisit the ED got a wrong diagnosis at their first visit.

The aim of the study was to identify the factors that lead to unscheduled return visits within 7 days in an emergency department.

 

Methods:

Retrospectively, we analyzed all patients that visited the ED during four months in the year 2014. Those, who used the ED service twice or more within 7 days were included into the study. Our study group developed an arbitrary classification. Two consultants independently allocated the patients to the different classes. In case of different allocations, a third consultant decided which allocation suited best.

 

Results: 

239 patients revisited the ED unscheduled within 7 days of their first visit. We identified 5 different main categories for bounce back cases. a) patient related (243%), b)illness related (35,1%), c) physician related (18,4%), d) system related (5%), e) other (20,5%). Furthermore, we identified several subcategories inside the main categories, a) wrong diagnosis (15%), b) illness persistence (18%), c) no correlation (18%), d) other (49%).

Detailed subcategories will be presented.

 

Conclusion:

We speculate that nearly 25% of all unscheduled return visits could be preventable. Many patients got wrong instructions by the doctor or system failures contributed, like difficult specialist follow up. Previous studies suggest a high rate of misdiagnosis among the bounce back patients, which this study confirms. There seem to be some typical high risk symptoms and physician behavior that can be discussed.


Felix LUDWIG, Steffen HERDTLE, Christian HOHENSTEIN (BAD BERKA, Germany)
11:00 - 18:00 #7429 - Unusual and unexpected X-ray finding: a case of Ollier disease.
Unusual and unexpected X-ray finding: a case of Ollier disease.

Introduction

A small group of patients can present to the Emergency Department (ED) with limb deformity and unusual radiological findings which are attributed to underlying benign conditions.

 

Case

A 27-year-old female presented to our ED with a right shoulder injury that she sustained whilst at the gym doing one-handed press ups.

The right shoulder X-ray showed an anterior dislocation with deformed humeral head and scapula with areas of focal calcification. On further questioning, the patient admitted that she was diagnosed with Ollier disease in early childhood.

The dislocation was successfully reduced and an orthopaedics out-patient follow up was arranged. 

 

Discussion

Ollier disease, or Enchondromatosis, is a rare bone disease defined by the presence of multiple enchondromas. Prevalence is around 1 in 100,000 and is twice as common in men than women.

Enchondromas are generally benign asymptomatic tumours of hyaline cartilage and occur secondary to defect in the development of the limb bud, which causes the long bones to grow in diameter in post-foetal life. Pathology is not clearly understood but is believed to be due to heterozygous mutations in the isocitrate dehydrogenase gene and dysregulation in the Indian hedgehog signalling pathway causing anomalies in the pathway controlling the proliferation and differentiation of chondrocytes resulting in the formation of intraosseous cartilaginous foci.

Ollier disease presents as painless bony lesions, mainly confined to the appendicular skeleton, in a bilateral but asymmetric distribution, most commonly affecting the phalanges and metacarpals, and usually in the first decade of life. Lesions usually appear and grow before puberty but soon remodel into normal bone. It may also present with shortened limbs due to an abnormal epiphyseal plate adjacent to the enchondromas affecting the longitudinal growth of the bones.

Pathological fractures can occur due to thinning of the cortical bone over the growing lesions.

Various tumours are associated with Ollier such as chondrosarcoma, osteosarcoma, central nervous system, ovaries, breast and lung. The reported incidence of malignant transformation of enchondromas ranges from 5% to 50%.

The diagnosis is based on clinical and radiological findings. Plain radiographs reveal asymmetrical osteolytic lesions with well-defined, sclerotic margins and ground-glass appearance of the matrix at the metaphysis and epiphysis of long bones. Computed tomography (CT) scans are useful to assess the lesions further as well as evaluating any soft tissue component.

However, given the hypercellularity of enchondromas, histological distinction between benign and malignant tumours may be difficult. Therefore, in suspected malignant transformation, dynamic magnetic resonance imaging (MRI) scans and bone scintigraphy are useful.

The treatment is usually conservative and surgery is reserved for cases of deformity, limb-length discrepancy, pathological fracture or malignant transformation. Overall prognosis is good.

 

Conclusion

Ollier disease is a rare bone disease and doesn’t usually cause any significant functional impairment. The presence of similar radiological findings in the ED should dictate detailed medical history and records review.


Tom BARKER, Abdo SATTOUT (Liverpool, UK, United Kingdom)
11:00 - 18:00 #7712 - Unusual localization of vitamin-K antagonists overcoagulation.
Unusual localization of vitamin-K antagonists overcoagulation.

Introduction:  

The increased aging of the population and the high prevalence of cardiovascular diseases account for the high number of patients treated with oral anticoagulants by vitamin K antagonist (VKA). Several major bleeding events were associated to the use of those medications. Ureteral   hematoma were described in polytrauma, whereas  spontaneous hematoma are much more rare and can be misdiagnosed especially in the context of emergency.

Observation :

We report a case of a 72-year old men treated by vitamin K-antagonist (VKA) therapy for  a medical history of atrial fibrillation with no screening of anticoagulation panel during the two previous months. The medical history taking did not noticed any use of new medications. Furthermore there were no history of recent trauma.

The patient presented to the emergency department for abrupt spontaneous abdominal pain. On examination : Patient was conscious  with stable blood pressure = 120/70 mmhg and irregular pulse rate = 78/min. The abdominal examination showed a hypogastric tenderness. Prothrombin Time and  international Normalised ratio (INR) levels were indosable. Other biological analysis did not noticed anemia.  Abdominal Computerized tomography revealed ureteral hematoma without signs of compression nor extravasation. Conservative treatment was attempted and the patient was admitted to the emergency ward for observation analgesia and specific antagonisation by Vitamin K. Favorable evolution was noticed after clinical correction of the haemostasis disorder.

Conclusion :

Overcoagulation is the more frequent adverse-drug related events. Co-existence of multiple comorbidities and polypharmacy makes the poor prognosis of these events especially in elderly. Various bleeding complications are commonly associated with VKA use and consequences may be potentially fatal. Ureteral  sponatenous bleeding is a rare condition but needs observation and reevaluation.


Houda NASRI (CHARTRES), Hamed RYM, Sarra JOUINI, Ryef AMMAR, Asma ALOUI, Sirine JAOUANI, Bouhajja BÉCHIR
11:00 - 18:00 #8220 - Unusual presentation of Infective endocarditis.
Unusual presentation of Infective endocarditis.

Introduction:

Infective endocarditis (IE) is a challenging diagnosis for the emergency physician.  It has many presentations ranging from an indolent infection to septicemia with life-threatening systemic embolization. Herby, a case of an unsual presentation of IE.

Case report

A 86-years-old male with no past medical history presented to the ED after a sudden loss of consciousness that recovered spontaneously.  The patient had a shortness of breath for the last two weeks. On admission, patient was conscious. His temperature was 37 celsus degrees and his blood pressure was 85/40 mmhg. Heart rate was 100 Bpm, respiratory rate 38 breaths per minute and oxygen saturation 82% on room air. The serum white blood cell count was 12,000/mm3 and CRP was 172 mg/l. The diagnosis of severe sepsis was made and an infusion of serum saline was started.  Chest radiography and a computed tomographic head scan were normal. A urine stream test was negative. A transthoracic echocardiography showed large vegetation on the sigmoid valve.  An IE was the etiologic diagnosis retained and an antibiotic treatment based on gentamicin and vancomycin was delivered. After 48 hours of antibiotherapy, the patient was still febrile with poor general condition. All the patient's blood cultures were negative. Tomographic chest scan showed a proximal embolism and the transesophageal echocardiography showed mobile echodensity on the sigmoid valve with 2 thromboses in the left atrium. Heparin therapy was adjunct. The patient’s general condition improved after 7 days.  He was than referred to the cardiology department.

 

Conclusion

The latency of the cardiac symptoms for IE and close simulation of other disorders may lead to misdiagnose. Clinicians should be aware of variety of cerebral presentations in patients with IE, since these may constitute the first symptoms of the disease.

 


Wided BOUSSLIMI, Anware YAHMADI, Rania JEBRI (Lyon), Hanane GHAZALI, Cyrine KESKES, Monia NAGUECH, Mohamed MGUIDICH, Sami SOUISSI
11:00 - 18:00 #6403 - Upper Gastrointestinal Bleeding PPI guidance.
Upper Gastrointestinal Bleeding PPI guidance.

                                                                                         Management of acute upper GI bleeds in A&E and PPI guidance

 

Acute upper gastrointestinal hemorrhage is a common medical emergency and is responsible for approximately 50 000 hospital admissions every year in the UK. Despite advances in its management over the past few years, the hospital mortality rate for an acute upper GI bleed remains 10%1. Appropriate management of these patients involves prompt resuscitation with fluids and blood products, early risk stratification, appropriate use of pharmacological agents and prompt endoscopy to identify the bleeding point and apply luminal therapy.

In this retrospective study, all of the patients who presented to Northwick Park emergency department between 1st December 2015 and 31st January 2016 with an acute upper GI bleed were identified and our management of these patients was compared with the latest NICE guidelines published on this topic in 20122and our local Trust policies. In total, 50 patients met the inclusion criteria for this study with 5 patients presenting with a suspected variceal bleed and 45 patients presenting with a suspected non-variceal bleed.

Results obtained from this study have highlighted a number of areas that can be improved. Firstly, appropriate risk stratification and calculation of the Blatchford score was calculated in only 22% of cases. In addition, 16% of patients did not have a group & save or cross match performed.  Mortality is particularly high amongst those patients presenting with a variceal bleed and amongst this group of patients, 0% had a blood culture performed and only 40% of patients received broad spectrum antibiotics and terlipressin therapy. Furthermore, in accordance with NICE guidelines, acid suppression therapy should not be given to patients with a suspected non-variceal bleed before endoscopy and should only be offered after endoscopy if there is evidence of recent haemorrhage. This study showed that 25 patients received inappropriate acid suppression therapy whilst in the A&E department. Finally, low-risk patients who have a Blatchford score of 0 can be considered for early discharge and referral to ambulatory care for urgent outpatient endoscopy.

It is important that this pathway is used correctly and is not appropriate for high-risk patients, including those with a Blatchford score of 1 or more, or a history of a chronic liver disease. Over a two month period, five patients presenting with an upper GI bleed were discharged from A&E and referred to ambulatory care. However, three of these patients were inappropriately discharged home from A&E, including a gentleman who had a Blatchford score of 6 with known oesophageal varices.

The results of this audit were presented at a local clinical governance meeting with strong emphasis on education of the health care professionals who work in our Accident and Emergency Department. In addition, they were encouraged to use the upper GI pro forma that is readily available on the intranet and can act as a prompt for clinicians. 

2 Acute upper gastrointestinal haemorrhage in over 16s: management (NICE guidelines 2012)hbhshshs    nvjhbnvnvbbvbbvbffhjfhfjames.lok@nhs.net


James LOK (Welwyn, United Kingdom), Dan Lucian GHIURLUC
11:00 - 18:00 #7264 - Urban and Rural Differences in Out-of-Hospital Cardiac Arrest of Advanced Life Support for a Video Call on Smartphones.
Urban and Rural Differences in Out-of-Hospital Cardiac Arrest of Advanced Life Support for a Video Call on Smartphones.

Objective

 To compare the survival rate and neurologic outcomes from out-of-hospital cardiac arrest in rural and urban areas of advanced life support for a video call on smartphones, and to investigate the factors associated with these differences.

 

Methods

 The 119 rescue service(Korean emergency rescue system) data bases of 1,654 cardiac arrests, who were transported in 7 pilot areas by 119 rescue services from August 1, 2015 to December 31, 2015, were analyzed.

 

Results

 The median ambulance response time was shorter (P < 0.001) and the median distance from cardiac arrest location to the closest ambulance station was shorter (P < 0.001) in urban than in rural areas. Rural patients were a median distance of 4.96 km from the ambulance station, compared with 2.64 km for urban patients. We found that cardiac arrest inside the home was more frequent (P < 0.001) among the urban patients (74.7%) than among the rural patients (58.3%). But survival rates and neurologic outcomes did not differ between urban and rural cardiac arrest patients in smart advanced life support.

 

Conclusion

 As it is impractical to substantially decrease response times and distance in rural areas, advanced life support using video call on smart phones that may improve outcome after cardiac arrest.


Seong Jung KIM, Yongjin PARK (Gwangju, Korea), Soo Hyung CHO
11:00 - 18:00 #5797 - Urgent endoscopy versus early endoscopy in patients with upper gastrointestinal bleeding.
Urgent endoscopy versus early endoscopy in patients with upper gastrointestinal bleeding.

Background: Acute upper gastrointestinal bleeding (UGIB) is one of the commonest medical emergencies. The initial evaluation of patients with UGIB involves an assessment of hemodynamic stability and resuscitation if necessary. Endoscopy is the primary diagnostic investigation in patients with acute UGIB but it has not always been clear whether urgent endoscopy is cost effective as well as clinically valuable. Endoscopy aids diagnosis, predict outcome and most importantly allows treatments to be delivered that can stop bleeding and reduce the risk of re-bleeding.

Aim: To compare urgent versus early endoscopy in patients presented to the emergency department with acute upper gastrointestinal bleeding.

Methods: Retrospective study in design, with a target population of adult patients diagnosed with upper gastrointestinal bleeding, who presented to the emergency department of the Emergency Hospital "St. Spiridon " Iasi Northeast Romania, during January to December 2014. Were included patients aged over 18 years who acute UGIB manifested by haematemesis and melena. Early and urgent endoscopy was defined according to the new guidelines. Data was collected from hospital charts and statistical analyses were performed using SPSS 20.0.

Results: Of 372 patients with acute UGIB were included in the study 323 patients. Characteristics of the study group are: mean age 60,48 years ± 14,628 (95% CI 58,83 to 62,02), 124 women (38.4%), 199 men (61.6%)  with preponderance of patients in urban areas 180 (55.7%). 235 patients (72,75%) received urgent endoscopy (within 6 hours) versus 88 (27,24%) who received early endoscopy (within 24 hours). Among patients who received urgent endoscopy, 73 (31.1%) was in the first hour of presentation in emergency department and 68 (28.9%) in the first 2 hours. The main etiology was variceal bleeding 148 (46%) followed by peptic ulcer 121 (37,5%).

Conclusions: The decision to admit patients depended on the result obtained at urgent endoscopy.  The need to start treatment also depended on the outcome of endoscopy.


Mihaela DUMEA, Diana Carmen CIMPOESU (IASI, Romania), Anca HAISAN, Paul NEDELEA, Andrei CONSTANTIN, Andrei HANCU, Gabriela GRIGORASI, Claudia RASCANU, Giorgiana Loredana MATEI
11:00 - 18:00 #7753 - Use Of Bedside Ultrasound To Diagnose Appendicular Mass in Emergency Department.
Use Of Bedside Ultrasound To Diagnose Appendicular Mass in Emergency Department.

Introduction:

Appendicitis is the most common acute surgical abdominal disorder presenting to emergency departments(ED).1-2 Diagnosis is usually made by a combination of history, physical examination, laboratory tests, and imaging studies. Since this diagnostic approach often takes place in serial steps, patients suspected of Acute Appendicitis tend to be delayed and stay for prolonged periods of time in ED, requiring considerable staff and physical resources. 1-2 This delay in diagnosis may raise safety concerns, since it can increase chances of complications like Gangrenous Appendix or even perforation.

Methods

We report a case of a male patient, where an emergency ultrasound fellow, utilized Bedside abdominal ultrasound to diagnose Acute Appendicitis and to identify complicated Appendicular Mass and abscess, inspite of atypical presentation, clinical findings and labrotary results. Findings were confirmed by CT scan.

Case

62-year old male patient, known case of Type 2 Diabetes Mellitus on (Metformin 500mg Three times daily). Presented to, Emergency Department at Hamad General Hospital, with history of right loin & suprapubic pain for five days. Patient had low grade fever & dysuria for three days, nausea & anorexia for one day. Patient denied history of vomiting, change in bowel habbits or previous similar attacks. Patient visited a private clinic five days ago and was started on Diclofenac tablets 100 mg once daily. His workup diagnosis by the General physician was Right Renal Colic. His pain improved with medication.

On examination, Looked well,not in acute distress & Visual Analogue Scale for pain (VAS) of 3. He had right loin, suprapubic & right iliac fossa abdominal tenderness. (BP130/60),(HR88bpm),(Temp36.5C), (RBS12mmol/dL), (Spo2 97%). Working diagnosis was Pyelonephritis.Patient received 2 grams IV Ceftriaxone & analgesia. Investigations showed (WBC 8,200),(Hb12.1g/dL), urine microscopy 2 + WBC, 1+ RBC, Nitrite negative. Formal Ultrasound abdomen was requested.

After 4 hours, Bedside ultrasound was done by emergency physician, showed a non-compressible tubular structure in the RIF measuring 14mm in maximum transverse diameter with fat stranding & surrounding free fluid suggestive of inflamed Appendix. There is an area of mixed echogenicity at the tip of the Appendix measuring 40X35mm. Findings were suggestive of a complicated Appendicular mass & small abscess. Accordingly, departmental ultrasound was cancelled and CT abdomen was ordered. Patient  was started on IV Metronidazole 500mg and general surgeon was informed. CT abdomen confirmed the diagnosis of a Complicated Appendicular mass with small abscess. Patient was admitted for conservative treatment & discharged in good condition after 5 days.

 

Conclusion:

Bedside ultrasound by trained emergency physicians, can diagnose, in a timely manner multiple abdominal emergencies, including Acute Appendicitis, hence facilitating appropriate treatment, consultation, shorter length of stay and better patient outcome.

Aknowledgement:

The author declares no conflict of interest.

 

References:

Elikashvili I, Tay ET, Tsung JW. The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis. Acad Emerg Med. 2014;21:163-70.

van Randen A, Bipat S, Zwinderman AH, et al. Acute appendicitis: meta-analysis of  diagnostic performance of CT and graded compression US related to prevalence of disease. Radiology. 2008;249:97-106.


Lubna Ghali Amin ANDRAOUS (Doha, Qatar)
11:00 - 18:00 #7507 - Use of Bedside Ultrasound To Diagnose Type A Aortic Dissection.
Use of Bedside Ultrasound To Diagnose Type A Aortic Dissection.

Introduction:

Aortic Dissection is a relatively uncommon yet an emergent,life-threatening condition with a high morbidity and mortality rate. It remains a challenging diagnosis for emergency physicians, due to its wide range clinical manifestations and atypical presentations. Hence diagnosis is difficult, but essential, considering the time-sensitivity of initiating treatment with intravenous antihypertensive agents and operative intervention.1 Early recognition and treatment are crucial,especially when the proximal Aorta is involved. Dissections involving the Aortic Arch can lead to Myocardial Infarction, Pericardial Tamponade and Aortic valve failure resulting in death.1

Aim/Methods:

We report a case where an emergency physician utilized Bedside Transthoracic Echocardiogram & Abdominal Ultrasound to diagnose Type A Aortic Dissection in a timely manner (about 20 minutes from presentation) in spite of atypical presentation

 

Case

A 57-year old Sudanese male patient, previously healthy and non-smoker, presented to Emergency Department at Hamad General Hospital with mild localized chest discomfort that started 12 hours ago. Blood Pressure 105/60mmHg, Heart Rate 71 beats/min, Respiratory Rate 18 breaths/min, Oxygen Saturation 99% on room air and Temperature 36.7°C. No jugular venous distension. Normal heart sounds with no murmurs. Lungs were clear. Abdomen was soft, not tender. All extremity pulses were palpable with no focal neurologic deficits.

EKG showed sinus rhythm, rate of 75, no ischemic changes. Routine investigations were ordered including Complete Blood Count, Renal Function Test, Troponin T & Chest x-ray. Initial diagnosis was to rule out Acute Coronary Syndrome, however Aspirin was held, until Bedside Echocardiogram was performed. Bedside Echocardiogram showed EF55%, a dilated Aortic root measuring 4.2cm and visualized intimal flap extending from the Aortic Arch, to the Descending Thoracic and Abdominal Aorta. Mild Aortic regurgitation,no pericardial effusion.No free fluid in the abdomen was seen.

Cardio Thoracic surgeon was immediately consulted. CT Angiogram confirmed the diagnosis of extensive Type A Aortic Dissection. Patient had emergent Aortic surgical repair, extubated next day & discharged in good condition after 12 days.

Discussion:

Clinicians should have a high index of suspicion for the atypical presentation of Aortic Dissection. Aortic dissection is a catastrophic condition with significant mortality. It is fatal if not recognized early and treated with aggressive medical and/or surgical therapy. There are several benefits to use Bedside Ultrasound at the point of care to diagnose Aortic Dissection. It provides not only a rapid, noninvasive study, but also has a high specificity for detection of Aortic Dissection. Moreover, it evaluates other potential life-threatening emergencies such as concomitant Abdominal Aortic Aneurysm, intraperitoneal hemorrhage, Pericardial Effusion/Tamponade and Aortic regurgitation.2

 

Conclusion:

This case highlights the fact that, Bedside Trans-Thoracic and abdominal ultrasound by trained emergency physicians, can diagnose, in a timely manner Life-threatening Aortic Dissection and expedite proper consultations, definitive care and better outcome 2

Acknowlodgemet

The author declares that she dosn't have competing interests

References

1. Rapezzi C, Longhi S, Graziosi M, et al. Risk factors for diagnostic delay in acute aortic dissection. Am J Cardiol 2008; 102(10): 13994

2.Perkins A, Liteplo A, Noble V. Ultrasound diagnosis of type A aortic dissection. J Emerg Med 2010; 38(4): 490-3.

 


Lubna Ghali Amin ANDRAOUS (Doha, Qatar)
11:00 - 18:00 #7963 - Use of external cooling system with hazmat personal protective equipment to increase operational time of Hospital Hazmat Responders.
Use of external cooling system with hazmat personal protective equipment to increase operational time of Hospital Hazmat Responders.

It is a physiological challenge to don and work in Hazmat personal protective equipment (PPE) in an equatorial/tropical environment.  Our institution's previous hospital decontamination exercises have resulted in responders who have physical/heat exhaustion, and syncopal attacks. Our hypothesis is that having a system or device that cools and lower our core temperature may help reduce the physiological load on the responder, and possibly increase their operational efficiency and productivity.

An external cooling device, used in targeted temperature management of post cardiac arrest patients, was deployed as a tight fitting vest as a pilot trial during our monthly hospital decontamination station training.  Physiological parameters are measured and monitored pre and post donning of hazmat PPE.  Observations are made on any change in operational effectiveness or degradation for responders with and without the cooling vest.  Qualitative feedback was also obtained from those who worked with the vest on.

The result and report of this pilot study will help policy and decision makers decide on whether the expense and other issues related to use of external cooling devices will result in better operability of our hospital hazmat responders


Mark LEONG (SINGAPORE, Singapore)
11:00 - 18:00 #7095 - Use of “urgent” Electroencephalography in the ED: a retrospective study.
Use of “urgent” Electroencephalography in the ED: a retrospective study.

Introduction: Electroencephalography (EEG) has a special place in the further investigations to host emergency department (ED). Although, it has been suggested that the use "emergency" EEG was abusive and that most applications could be remotly programmed, several studies have highlighted the significant contribution diagnostic and therapeutic impact of this exam.

Methods: We present here a retrospective and monocentric study over a six month period (01-07/2014). We analyzed all the EEG realized in ED taking into account the clinical parameters but also pattern and the relevance of the request. The main objective of this work was to evaluate the use of EEG in an urban ED.

Results: We collected 343 patients for statistical analysis. The sex ratio was 1.15. The average age of patients was 63+/-12 years. 20% of patients had a history of epilepsy. Indications were varied: 23% of focal neurological signs, 22% for generalized seizures, 19% for impaired alertness or behavior, 18% and 15% for confusion or discomfort. Ultimately, 33% (95% CI: [28-38%]) EEG objectified an epileptic syndrome, 11% diffuse slowing and only 2% a status epilepticus. 54% (95% CI: [49-59%]) of the EEG performed were normal.

Discussion: The contribution of the EEG in the diagnosis of transient focal deficits or made be noted, in fact 46% were abnormal and suggestive of brain damage (vascular 65%). In confusional syndrome, EEG has its own place, in fact 35% of EEG was pathological in our series. In front of a simple first crisis, the EEG is not recommended in the ED. The French Society of Neurology recommends performing the distance of the episode. In our study, only 30% of EEG realized in the ED for a first seizure were pathological. Regarding discomfort, the contribution of the EEG (91% normal) has been assessed as very low due to the lack of specificity of objectified anomalies.

Conclusion: Although indications from the get an "emergency" EEG are clearly established in the guidelines, its use in ED remains to be clarified. Thus, more than half of the requests made by our department are considered inappropriate and could be carried out offline. Non-invasive, inexpensive and correct accessibility, the EEG still remains a valuable tool for  emergency physicians.


Hakim SLIMANI, Pierrick LE BORGNE (Strasbourg), Amish SEERUTTUN, Charles-Eric LAVOIGNET, Céline RENFER, Elena Laura LEMAITRE, Philippe KAUFFMANN, Pascal BILBAULT
11:00 - 18:00 #8252 - Usefulness of normal automated 12-lead ECG during the initial emergency department evaluation of patients with chest pain.
Usefulness of normal automated 12-lead ECG during the initial emergency department evaluation of patients with chest pain.

Background

Evaluation of chest pain accounts for millions of costly Emergency Department (ED) visits and hospital admissions annually. Of these, approximately 10–20% are myocardial infarctions (MI). Currently, the initial automated 12 lead ECG interpretation by the machine is easily accessible but underused. 

Hypothesis

Patients with chest pain whose initial electrocardiogram (ECG) is automatically interpreted as normal do not require hospital admission for evaluation and management of a possible myocardial infarction. 

Study objective:

To determine the usefulness of initial normal automated 12-lead ECG during the initial ED evaluation of patients with chest pain.

Methods

During two months, the medical records of a consecutive cohort of patients who presented to the ED of University Hospital with chest pain and initial automated ECG automatically interpreted by the machine were reviewed. The initial ECG of each patient was performed by the orientation nurse and then were evaluated for abnormalities by the emergency physician.

Results

Of the 185 patients presenting for chest pain, 82 (44.3%) have an initial 12 lead-ECG automatically interpreted as normal by the machine. Among those, 76 (92.7%) was also considered normal by the emergency physician (Kappa coefficient=0.22). Patients with normal automated ECG have less medical history of cardiac disease and  needed less cardiologist advice (p<0.001). After adjusting on confounding (age, sexe, cardiovascular risk factors, troponin, d-dimer, palpitation, dyspnea), atypical chest pain, no cardiac history, return home and initial ECG considered normal by the emergency physician are significantly associated to normal automated ECG.

Conclusions

An initial ECG automatically interpreted as normal by the machine seems to be useful to manage patients with chest pain in ED and provide better screening of these patient during the initial evaluation.


Natacha ALAVI (Paris), Richard CHOCRON, Anais GUINCESTRE, Alison HORN, Philippe JUVIN
11:00 - 18:00 #8140 - Using medical secretaries to relieve clinicians from administrative tasks at a swedish emergency department.
Using medical secretaries to relieve clinicians from administrative tasks at a swedish emergency department.

Emergency department work is permeated by a high work load and work pace and emergency department clinicians (nurse assistants, registered nurses and physicians) need to prioritize between the assignments they are conducting. Due to the strained work situation at the emergency department at Karolinska University Hospital in Stockholm, Sweden the present work routines were analyzed in order to identify if and how the work procedures could be optimized. During this inventory it was found that a lot of administrative tasks were performed by the clinicians, time that would have been better spent delivering direct patient care.

The aim with this project was to relieve the clinicians so that they could focus on their main assignment, patient care, by distributing administrative tasks to the profession best suited for conducting these assignments. Medical secretaries were identified to be the most suitable profession for handling administrative tasks since they already have the experience of working administratively.

During a limited period of time, a medical secretary was based at the hub of one medical section in the emergency department, close to both clinicians and patients. Thus, the medical secretary could assist medical staff when needed by performing several administrative assignments. Examples of such assignments were: handling incoming phone calls, documenting vital signs in the patients’ electronic medical record, handling referrals and patient charts and answering questions from both patients and their relatives. The test was evaluated after each shift and all clinicians filled in a questionnaire. On the question “How did you experience to have a medical secretary present at your medical section during your shift?” did 72% answer “excellent” and 19 % “very good”.  The clinicians expressed that they felt relieved in their work strain and the working process became more efficient which in turn contributed to a better work environment. Further, the clinicians also experienced that they had more time to deliver patient care. The intention is to implement this working routine as a permanent solution.


Michele DEMIR (Bromma, Stockholm, Sweden), Isabella DIAZ ERAZO, Lena BERG
11:00 - 18:00 #7238 - Using the Boussignac® orotracheal intubation probe in out-of hospital cardiac arrest: an observational study.
Using the Boussignac® orotracheal intubation probe in out-of hospital cardiac arrest: an observational study.

Introduction: The Boussignac intubation probe (BIP) is a device that allows the continuous insufflation of oxygen in patients in out-of-hospital cardiac arrest (OHCA). The aim of this study was to report the experience feedback of BIP use and the characteristics of patients who received it, in a rescue system using the BIP in routine care.

Material and methods: This was a retrospective observational study which included OHCA aged over 18 years who received advanced life support by a prehospital medical team (PMT) using the BIP in routine care. Collected data were the Utstein variables, the difficulty for intubation, Cormack grade, SpO2 and EtCO2, follow up (transport to hospital with a beating heart or under automated external cardiac massage device). A univariate description was conducted comparing patients who received (B+) or did not receive (B-) the BIP. A logistic regression was used to explain the “admission alive (with beating heart) at the hospital”. The covariables were: age, gender, electric shock administration for defibrillation, the location. We used a propensity score to make the B+ and B- groups comparable. The software used for statistical analysis was Stata 14.0.

Results: From January 2012 to December 2014, 9618 CAs were supported by a professional basic life support team. The mean age was 67 +/- 17 years, 61% were men. In total, 337 patients were intubated with a BIP. The B+ versus B- patients were younger, more often initially in ventricular fibrillation (VF) (B+: 15.4% vs B-: 7.7%). EtCO2 was higher during external cardiac massage (B+: 29.4 +/- 2.8 kPa vs B-: 22.8 + 1.6 kPa). The rate of difficult intubation was the same in both groups (p=0.9). In multivariate analysis, the factor to explain (transportation of beating heart patient versus deceased left on site) was not associated with the use of the BIP (OR=1.2[0.7-1.7]).

Discussion: Concerning the difficulties encountered, greater rigidity of the probe is retained as well as the risk of personal exposure in contact with biological fluids (mucus, blood in case of hemoptysis) due to the proximal end of the tube left open to atmosphere.

Conclusion: The BIP is a commonly used pre-hospital device, especially with young subjects in VF. Its use improves EtCO2, does not generate more difficult intubation, but does not allow the transportation of more beating heart patients. Complementary studies need to explore survival rates.


Olga MAURIN (Marseille), Daniel JOST, Nicolas GENOTELLE, Olivier YAVARI-SARTAKHTI, Alexandre MENDIBIL, Julie TRICHEREAU, Vincent LANOE, Clément DERKENNE, Jean Pierre TOURTIER
11:00 - 18:00 #7279 - UTILITY OF AN INTEGRAL PHYSICAL INTERVENTION IN GERIATRIC PATIENTS WITH HIGH COMORBIDITY, FRAGILITY CRITERIA AND FREQUENT ON THE EMERGENCY SERVICES.
UTILITY OF AN INTEGRAL PHYSICAL INTERVENTION IN GERIATRIC PATIENTS WITH HIGH COMORBIDITY, FRAGILITY CRITERIA AND FREQUENT ON THE EMERGENCY SERVICES.

INTRODUCTION:

For the Emergency Services Department, the fragile ancients suppose a challenge due to the wide symptoms that they present, being in some occasions very varied and unspecific.

OBJECTIVE:

Knowing the possible modification on the number of visits to Emergency of geriatric fragile patients who are frequent in the hospital Emergency Services through an integral intervention which includes physical aerobic, anaerobic activity and equilibrium.

MATERIAL AND METHODS:

Study of community interventions, prospective and quasiexperimental consisting in the application of an integral physical intervention during 5 days a week, one hour a day, leaded by personnel of the nursery for subjects older than 75 years old from a sanitary area.

RESULTS:

The sample was formed by 27 persons, a 67% women with an average age of 82.16 years who decided to participate voluntarily in the study.

The 52% of the ancients presented 3 criteria of fragility, the 37% 4 criteria and the 11% 5 criteria of fragility.

The 15% of the subjects studied were taking alpha blockers, the 19% beta-blockers, a 44% neuroleptics and a 52% benzodiazepines.

In relation to the number of visits before and after the intervention, it was observed that 8 of the 27 patients (30%) didn’t came to Emergency, 8 of them had gone one, 5 had gone twice, 4 of them 3 times ad two persons 5 and 10 times respectively.

After the second evaluation 23 of the 27 (85%) ancients included in the study didn’t come in any occasion to the Emergency Service of the Hospital. One person turned up once and two persons in two occasions.  

CONCLUSIONS:

The physical exercise produces beneficiary changes in the health of the fragile ancients, reducing the number of visits to the Emergency Services of the hospital.


Pablo LAFUENTE SANCHIS, Sergio ENGO VERGARA, Luis MANCLÚS MONTOYA (Valencia, Spain), María CUENCA TORRES, Lucia CIANCOTTI OLIVER
11:00 - 18:00 #7491 - Utility of initial shock index and modified shock index as predictors of short term outcome in patients diagnosed with ST elevation myocardial infarction in an academic emergency department of north India: a pilot study.
Utility of initial shock index and modified shock index as predictors of short term outcome in patients diagnosed with ST elevation myocardial infarction in an academic emergency department of north India: a pilot study.

Introduction: There are approximately 8 million annual visits to emergency departments (EDs) for chest pain or symptoms consistent with myocardial ischemia in India. Unlike the developed countries, 61% of Indians presenting with chest pain have ST-segment–elevation myocardial infarction (STEMI). All these patients must undergo risk stratification soon after presentation. Given the speed with which reperfusion therapy is administered in a tertiary centre, like ours, the clinical utility of existing risk scores, in the ED, is limited. Shock index (SI) and modified shock index (MSI) have established roles in outcome assessment of critically ill patients. Their role, however, in Indian STEMI patients is yet to be stated.

 

Method: Prospective data was collected from 1st November 2014 through 31st October 2015 in the ED of Max Superspecialty Hospital, Saket, New Delhi, India and was analyzed with ROC curve. Appropriate cut off values of SI and MSI were obtained which maximized the correct prognostication of 30 day all cause mortality in STEMI.

 

Result: A total of 120 patients were included in the study. The cut off value of SI is found to be 0.8 with 100% sensitivity and 68.6% specificity. The cut off value of MSI is found to be 1.02 with 100% sensitivity and 65.7% specificity. Area under curve is 82% with p < 0.01 for both.

 

Conclusion: Both SI and MSI are noteworthy ED tools for early risk stratification of Indian STEMI patients. We now intend to validate these cut off values. 


Dolly YADAV (Gurgaon, ), Vgr SHASTRY, Anupam GOEL
11:00 - 18:00 #7273 - UTILITY OF LACTATE DETERMINATION AS A DIAGNOSTIC TEST IN PATIENTS WITH SEPSIS IN THE EMERGENCY DEPARTMENT.
UTILITY OF LACTATE DETERMINATION AS A DIAGNOSTIC TEST IN PATIENTS WITH SEPSIS IN THE EMERGENCY DEPARTMENT.

INTRODUCTION

Among biomarkers that have aroused more interest in patients with sepsis, lactate has been considered one of the most important. It has been reported that increased levels of lactate in emergency (ER) patients are related with bad prognosis outcome.

OBJECTIVE

To assess the utility of lactate determination for sepsis diagnose in patients attending our ER departments and analyze whether the sex of the patients, the source of infection, ICU admission and exitus are related to their blood levels.

 

MATERIAL AND METHODS

 

Retrospective observational study conducted in the ER department of La Ribera University Hospital (Valencia-Spain). A sample of adult patients (n=62) from those attending our ER room during 2015 that were diagnosed with infection or sepsis were included in the analysis.

 

RESULTS

 

A total of 63 patients attending the ER presented high levels of lactate (2mmoll), mean age were 73.7 (SD=14.53) years who mainly attended by fever and dysnea .

Respiratory (n=XX, 44%) followed by urinary were the main sources of infection, 21% of these patients were admitted to the ICU and the exitus rate was 6%.

No association between the lactate levels and sex (p=0.735), admission to the ICU (p=0.061) nor source of infection (p=0.796) were detected.

Significantly higher levels of lactate (p<0.001 were related with exitus, with a direct relationship between the likelihood of exitus and lactate levels.

 

CONCLUSIONS

The direct relationship between mortality and lactate levels demonstrated the usefulness of its determination in patients presenting sepsis in the ER department specially depicting the likelihood of Exitus.      

 


Pablo LAFUENTE SANCHIS, Silvia DONAT SANJUAN, Maria CUENCA TORRES (VALENCIA, Spain), Luis MANCLÚS MONTOYA, Lucia CIANCOTTI OLIVER
11:00 - 18:00 #8112 - Vaccination, O2 home and bronchodilator therapy by age in COPD patients.
Vaccination, O2 home and bronchodilator therapy by age in COPD patients.

Introduction
Chronic obstructive pulmonary disease (COPD) is a health problem of great magnitude and intensification is a major cause of morbidity and mortality. Consumes many resources with increased incidence foreseeable in the immediate future.

Objective
Assess the recommendations of clinical practice guidelines (CPG), analyzing vaccination, oxygen therapy and bronchodilator therapy at discharge according to age.

Material and method
descriptive, observational and retrospective study General Hospital with population of 200,000 and 275 emergency / day. 1167 patients treated with COPD exacerbations from January 2012 to July 2015 with FEV1 <70% were included proven. vaccination, home oxygen therapy and bronchodilator therapy at discharge: the variables were collected.

Results
1167 patients who met criteria for inclusion in the study, 595 (50.98%) received vaccination, grouping by age, 1003 are ≥ 65, 51 (5.08%) they received flu vaccine, 436 (43.36%) against flu A and 37 (3.68%) pneumococcal. 196 are <65, 16 (9.46%) were vaccinated for influenza, 44 (26.03%) influenza A and 11 (6.50%) Pneumococcal.
Grouping by age, we observed that 594 (51.16%) were ≥ 75 years and 567 (48.8%) <75 years. Of ≥ 75 years receiving home oxygen therapy by 237 (39.89%) compared with 175 (30.86%) in <75 years.
Of the patients who received bronchodilator treatment at discharge 914 (78.72%), 458 (77.1%) were ≥ 75 years and 456 (49.9%) <75 years. They received no treatment 247 (21.27%), of which 136 (22.9%) ≥ 75 and 111 (19.6%) <75 years.

Conclusion
Contrary indicating the GPC on the recommendation of vaccination in COPD patients ≥ 65 years to reduce the risk of complications in our series, only 43.3% patients received vaccine against influenza A, 5.08% and 3.68% against pneumococcal flu.
Similarly and against the recommendations in our series only 77.1% of ≥ 75 years received bronchodilators, most notably objectifying this therapeutic error <75 years where they received treatment only 456 (49.9%).
O2 home use is higher in ≥ 75 years for minors.
Despite being a known disease requires training and dissemination of GPC for better management of patients in the emergency room this.


Maria Consuelo QUESADA MARTINEZ, Blanca DE LA VILLA ZAMORA, Danae FERNANDEZ-CAMACHO, Maria CORCOLES VERGARA, Nuria RODRIGUEZ GARCIA, Cesar CINESI GOMEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7229 - Vasopressin effectiveness in renal colic pain management: systematic review and meta-analysis.
Vasopressin effectiveness in renal colic pain management: systematic review and meta-analysis.

Background: This meta-analysis of trials was conducted to evaluate the effectiveness of vasopressin on renal colic pain management in comparison to more typically used medications (opioids and nonsteroidal anti-inflammatory drugs (NSAIDs)).

Methods: PubMed, EMbase, Scopus, CINHAL, and Cochrane Central Register of Controlled Trials were searched for clinical trials. Outcomes of interest were pain reduction and need for rescue treatment.

Results: Ten studies met our inclusion criteria and analyzed. Seven out of 10 studies had low quality and 3 others were high in quality assessment using Jadad scoring system. On the scale of 1-10, NSAID showed significantly more pain reduction after 30 minutes in comparison to vasopressin (3.39 with a 95% confidence interval (CI) of 4.62-2.16 (p= <0.01)) but this reduction was not significantly different between NSAID and vasopressin-NSAID combination (-0.28 with 95% CI of -0.62-0.05 (p= 0.01)). Summary of RR for the need for rescue treatment in vasopressin in comparison to NSAID was 0.31 with a 95% CI of 0.13-0.74 and a significant RR (P= <0.04) but no difference was shown in vasopressin-NSAID combination in comparison to NSAID (0.70 with a 95% CI of 0.49-1.00 (p= <0.19)). On need for rescue treatment, vasopressin in comparison to opioid showed insignificant RR (1.82 with a 95% CI of 0.36-4.34 (p= 0.72)) but for vasopressin in comparison to vasopressin-opioid combination, it was 0.75 with a 95% CI of 0.56-0.99 and a significant RR (p= 0.042).

Conclusion: The results of this systematic review showed that according to the present low quality studies, vasopressin can be used as an adjuvant therapy in renal colic management in combination with opioids but does not have any addition therapeutic effect in NSAID combination.


Mohammad JALILI, Entezari POUYA, Doosti-Irani AMIN, Masoomi RASOUL, Mirfazaelian HADI (Tehran, Islamic Republic of Iran)
11:00 - 18:00 #7742 - Ventricular fibrillation / asystole: is there hope of recovery?
Ventricular fibrillation / asystole: is there hope of recovery?

Ventricular fibrillation / asystole: is there hope of recovery?

Podariu Sorina-Madalina (1), Radu Ioana Andrada (1), Polexa Stefania (1), Fisca Vlad-Alexandru (2), Taran Ana-Daniela (2)

 1. Emergency department, SMURD Sibiu, Sibiu, Romania

 2. Emergency department, UPU-SMURD Sibiu, Sibiu, Romania

Key words: asystole, cardiac arrest, rhythm

Speaker: Podariu Sorina-Madalina

BACKGROUND

Cardiac arrest is one of the most common reasons emergency departments are contacted for. Over a period of three years, SMURD (Mobile Emergency Service for Resuscitation and Extrication) Sibiu has been called to act on numerous cases related to cardiac arrests, all initially reported as unconsciousness.  It is of utmost importance to arrive quickly, as cardiac arrest patients need to be administrated resuscitation techniques in the first few minutes after collapsing. An efficient resuscitation requires a well-trained team, the availability of adequate equipment, and dispatching an appropriate ambulance to site. During this study, we have evaluated cases of unconsciousness reported in the last 3 years and have focused on identifying areas of our protocol and techniques that can be improved upon with the aim to provide effective solutions.

 

METHODS

We have prepared a retrospective study by examining the files of 774 patients reported as unconscious to SMURD Sibiu (Mobile Emergency Service for Resuscitation and Extrication) between 2013 until 2015.

RESULTS

From a total number of 774 patients, only 327 were diagnosed with cardiac arrest. Out of these, 219 were male and 108 females.

A total of 254 were found is asystole, of which 38 were resuscitated successfully whilst in 98 cases resuscitation was ineffective. Unfortunately, the rest of 118 patients have not been attempted resuscitation on, as they were found presenting “rigor mortis”.

A number of 39 patients were found in ventricular fibrillation. In 24 cases the patients developed constant sinus rhythm, however a further 15 patients have deceased.

CONCLUSIONS

After evaluating the data we have collected, we conclude that the most cases of cardiac arrest display asystole. There have been twice as many male than female patients, and the highest risk age group is between 65 and 80 years of age.

Considering the resuscitation rate in ventricular fibrillation, we must emphasize the importance of correct assignment of emergency teams, either a type B or C ambulance, depending on case requirements. We have observed that the low recovery rate from asystole can be attributed to the fact that there are a small number of type C ambulances in the region, not enough for them to arrive while the patient is still is ventricular fibrillation.

 

 


Sorina-Madalina PODARIU (, Romania), Stefania Alexandra POLEXA, Ioana Andrada RADU, Vlad-Alexandru FISCA, Ana-Daniela TARAN
11:00 - 18:00 #8216 - Waiting for no doctor - The impact of Physician Assistants in the interdisciplinary emergency departments of the Leopoldina Hospital Schweinfurt. An economic, organisational and medical trias.
Waiting for no doctor - The impact of Physician Assistants in the interdisciplinary emergency departments of the Leopoldina Hospital Schweinfurt. An economic, organisational and medical trias.

Background

The emergency departments in Germany had to cope an increase of emergency patients between 5-9% in recent years [1]. It is assumed that annual over 20 million emergency patients get treatment in German emergency departments [2]. In addition, the demographic change, multi-morbidity and the structural underfunding of the emergency units lead to an economic, organizational and medical dilemma.

According to the German Hospital Federation, the structural underfunding of emergency departments amounts up to 1 billion euros [2]. The hospital requirement plan demands for all medical units the “specialist standard” to ensure quality of treatment [3]. In about 30% of treatment cases of emergency is no specialist available [4]. So far no uniform requirement profiles for employees in emergency departments exist in Germany [5]. The Physician Assistant is internationally established and recognized. He is now developing also in Germany and could be a good addition in emergency care.

Aim

To show the effects of physician assistants in interdisciplinary emergency departments from an economic, organisational und medical point of view.

 

Methods

Based on a structured literature research by PubMed in Medline and EMbase SOPs have been adapted for PAs and put into practice in the emergency department in Schweinfurt. This example could be the basis for a best practice model.

 

Results

First results of practical implementation has shown that the use of PAs in economic terms resulting in minimizing funding shortfalls. From a medical perspective, the use of PAs resulted in faster identification of urgent patients. Moreover, unnecessary duplicate examinations can be avoided. The assessment of patient history and physical examination by PAs has proved to be a good physician relieving structure. This leads to greater satisfaction of both the patient and the staff.

From an organizational perspective, various measures are mandatory. In addition to the expansion of the interdisciplinary team with Physician Assistants also structural changes need to be made. By optimizing room management, patient flow can be adequately organised.

 

Discussion

Positive economic effects arise not automatically. In order to achieve this investment in personnel and building infrastructure are initially required. Even if the use of PAs does not directly generate profit, he will at least contribute in minimizing deficits.

However, the different organizational and personnel structures in German hospitals require an individual adaptation of Triage-systems [6]. European guidelines serve as a basis for national guidelines [3]. Adapted Standard measures do not require repeated Delegation for specified situations [7]. The implementation of standard is usually not a problem of the system, but of responsibility [8].

Conclusion

It was possible to show that the use of PA in an emergency department allows positive economic, organizational and medical effects. Therefore organizational changes are needed, such as building changes, staff restructuring and the introduction / adaptation of a triage system with SOPs for PAs.

The bibliography are available on request from the authors.


Manuel GEUEN (Rheine, Germany), Zelihic EDIN, Michael WESSELS
11:00 - 18:00 #5390 - Ward deterioration in the first 72 hours of admission via the emergency department: a retrospective matched cohort study.
Ward deterioration in the first 72 hours of admission via the emergency department: a retrospective matched cohort study.

Introduction: Almost one-quarter of Rapid Response Team (medical emergency or cardiac arrest team) activations occur within 48 hour of hospital admission. The aims of this study were to examine: i) the relationship between physiological status in the emergency department (ED) and RRT call within 72 hours of emergency admission; and ii) whether RRT activation was associated with an increased risk of ICU admission and in-hospital mortality.  

Methods: A retrospective matched cohort study was conducted at three hospitals in Melbourne, Australia. Exposures were adults (≥18 years), admitted via the ED to non-monitored medical or surgical wards during 2012 who had an RRT activation within 72 hours of admission. There were two matched controls (no RRT activation) for each case. 

Results: Exposures were more likely to have ≥1 physiological abnormalities fulfilling their hospital’s RRT activation criteria during ED care (29.1% vs 19.3%, p<0.001). The risk-adjusted odds of RRT activation within 24 hours of admission was highest in patients with tachypnoea fulfilling RRT activation criteria during ED care (OR=2.69, 95%CI: 1.78 - 4.07, p<0.001). The risk-adjusted odds of RRT activation within 72 hours of emergency admission was highest in patients with tachypnoea (OR=1.92, 95%CI: 1.38 – 2.67, p<0.001) or hypotension (OR=1.43, 95%CI: 1.00 - 2.03, p=0.047) fulfilling RRT activation criteria during ED care. Cases had more in-hospital deaths (16.5% vs 3.6%, p<0.001), ICU admissions (11.8% vs 0.7%, p<0.001) and longer hospital length of stay (Mdn = 8 days vs 5 days, p<0.001).  The risk-adjusted odds ratio (OR) for in-hospital death was highest for exposures with an altered conscious state during their ED stay (OR, 4.633; 95% CI, 1.365–15.728; p=0.014).

Discussion: Factors associated with RRT activation on the wards are identifiable when patients are in the ED. RRT activations within 72 hours of emergency admission are associated with higher mortality and increased LOS. Further studies are required to validate these findings more widely and determine whether early identification and intervention in patients at risk of RRT activations can improve their eventual outcomes. 

Acknowledgements: This study was generously funded by the Nurses Board of Victoria Legacy Limited Mona Menzies Postdoctoral Research Grant and an Eastern Health Research Grant.

References

Considine J, Jones D, Pilcher D, Currey J. (in press). Patient physiological status during emergency care and rapid response team or cardiac arrest team activation during early hospital admission. Eur J Emerg Med. Accepted 06/01/2016. Available on line 06/02/2016 http://journals.lww.com/euro-emergencymed/toc/publishahead

Considine J, Jones D, Plicher D & Currey J (2015): Physiological status during emergency department care: relationship with inhospital death after clinical deterioration. Critical Care and Resuscitation 17, 257-262.

Considine J, Charlesworth D & Currey J (2014): Characteristics and outcomes of patients requiring rapid response system activation within 24 hours of emergency admission. Crit Care Resusc 16, 184 - 189. 


Julie CONSIDINE (Burwood, Australia), Daryl JONES, David PILCHER, Judy CURREY
11:00 - 18:00 #7917 - What are the characteristics, evolution and monitoring of patients with acute heart failure who come to our emergency department?
What are the characteristics, evolution and monitoring of patients with acute heart failure who come to our emergency department?

INTRODUCTION
Acute heart failure (AHF) is a common reason for consultation in the emergency department (ED), and the leading cause of hospitalization in the elderly. With high mortality, increasing in the tables of acute pulmonary edema. Producing a large number of queries and reconsultations that increase health spending.

Objective: To describe the characteristics, evolution and follow-up of patients who come for ICA to our emergency department.

Material and methods:

Prospective observational study without intervention in patients who come to our SU in the period from 2012-2014 choosing two randomized months per year for ICA according to the criteria of Framingham. Inclusion criteria: age 18 years with ICA and give their written consent. The study variables were: sex, comorbidities, treatment received, hospital mortality at 30 days and one year, destination.

results:

During the 2012-2014 selected 119 patients consulted by ICA of whom 57 were women (F) (47.9%) and 62 men (M) (52.1%).
115 patients (96.6) were hypertension, 94 patients previous AHF 78.9%, 65 patients (54%) atrial fibrilation, 64 patients (53.7%) Diabetes, 52 patients (43.6%) dyslipidemia, 45 patients ( 37.8%) ischemic heart disease

vasoactive drugs (dobutamine, dopamine, norepinephrine) did not say no patients, beta blockers 6.45% M, 26.31% F, diuretics 75.8% M 87.7% F, nitrates 12,9 M 7,01 F, morphine 3,22% M, 1.35% F, corticosteroids 25.8% M, 29.8% F.

The hospital mortality was 10.93% (13 patients), at 30 days was 8.4% (10 patients) and the year was 17.65% (21 patients).

By Services: 17 patients were admitted to cardiology (14.2%), in Internal Medicine 61 patients (51.2%) in Short Stay Unit 13 patients (10,92) and other services 4 patients (3.36 %) and 24 patients were discharged directly from the emergency department (20.19%).

Conclusions:

- More than 55% were admitted to Internal Medicine while only 14.2% were admitted to Cardiology.

- The main pathologies associated with heart failure high to low frequency were hypertension, atrial fibrillation episodes prior to the consultation, diabetes, dyslipidemia.

- 100% of diastolic heart failure is admitted to hospital

- The intrahospitalria mortality was 10.93%.

- The most widely used treatment in our emergency department are diuretics, followed by steroids and beta blockers.


Jose Andres SANCHEZ-NICOLAS, Patricia SUAREZ-BEKE, Paula LAZARO-ARAGUES, Irene PAGAN-GOMEZ, Antonio MARTINEZ-GARCIA, Esther TOMAS-JIMENEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7605 - What could be behind a pleural effusion?
What could be behind a pleural effusion?

CLINICAL CASE:
Male, 78, hypertension, diabetes and dyslipidemia; with peripheral arterial disease, bipolar disorder and ischemic heart disease with inferior AMI 2002 with angioplasty and stent 2; angioplasty restenosis in 2003 and 2005. In March 2015, required ICU admission, by occlusive restenosis right coronary bypass needs (FEV1 40-45% postoperative). Also, chronic anemia with colonoscopy in December 2015 without findings.
High catarrhal consultation clinic 5 days and asthenia. Afebrile. On auscultation stands hypoventilation in left base. Chest radiography where pleural effusion evidence to half left hemithorax is performed. normal laboratory tests. Reviewing his record two months earlier and had left costophrenic breast pinching, and a month before thoracic TAC which reported massive left with passive atelectasis of the left lower lobe pleural effusion was performed. This TAC had not been seen by any physician.
Before the discovery of a pleural effusion of 2 months evolution without infectious clinical heart failure or normal analytical diagnostic thoracentesis scheduled plan proposed since no hemodynamic instability, or dyspnea. Rehistoriando left posterior rib injury concerns over a month ago. new TAC is done with contrast reports and multiple rib fractures. Thoracentesis compatible with hemothorax. Radiologically drainpipe taking more than one liter of content and instills Urokinase is placed; the tube to 72h with a resolution of the spill was removed. Diagnosis: traumatic hemothorax with multiple rib fractures.
CONCLUSIONS:
According to all current clinical guidelines pleural effusion, once discarded cardiac etiology, diagnosis is suggestive of thoracentesis and sometimes part of the treatment itself as in our case. It is recommended that the ultrasound-guided technique and if there is no clinical or hemodynamic instability can be performed on the ground.
We suspect hemothorax all closed, especially in those with chest trauma rib fractures. Initially, if the spill is low it can go unnoticed, so X control the first few hours are recommended. The treatment consists of chest drainage and instillation of urokinase cleaning helps clots in the cavity.


Carmen HERNÁNDEZ MARTÍNEZ, Daniela ROSILLO CASTRO (Murcia, Spain), Rocío LÓPEZ VALCARCEL, Maria Del Mar DE LA TORRE OLIVARES, Estefanía CARREÑO AROCA, Paula RODRIGUEZ LAVADO
11:00 - 18:00 #7711 - What Is Hiding Behind “Unclear Problem” in Criteria Based Medical Dispatch?
What Is Hiding Behind “Unclear Problem” in Criteria Based Medical Dispatch?

What Is Hiding Behind “Unclear Problem” in Criteria Based Medical Dispatch?

Introduction: Institute for Emergency Medicine Split-Dalmatian County provides emergency care for 178000 inhabitants of Split. Medical Dispatch Unit (MDU) receives calls according to symptoms presented by a caller, assesses a criteria and dispatches adequate response - red, yellow, green. Croatian Index for Emergency  Call Admissions consists of symptoms  divided into36 chapters. We wanted to find out which final diagnosis was made by physician in the field ( Team 1) after he had been dispatched to the red criteria A05 - unclear problem.

Methods: retrospective quantitative and qualitative analysis of eRinels  (programme support) database of calls and medical records of Split unit in one-year period ( 2015). We counted total number of calls which resulted with EMS alert, with special consideration on A05 - unclear problem. We wanted to see what diagnosis according to International Classification of Disease, especially the share of R96 - sudden death of unknown origin as well as  diagnosis concerning acute coronary syndrome were set in the field. Only primary missions were included.

Results: There were totally 10036 calls to MDU in 2015 year with consequent EMS response, 3753 were red criteria. There were  1063 calls taken as A05 - unclear problem(28,32%). There were 17 diagnosis I21 - acute myocardial infarction (1,6%). There were 38 of R07  - pain in throat and chest (3,57%). Syncopa (R55) was established in 198 cases (18,63%). There were 59 diagnosis R96 ( sudden death of unknown origin - 5,55%) and 8 diagnosis I46 ( sudden death of cardiac origin).

 

Conclusion: Re-listening of calls in purpose of qualitative feedback   and more thorough asking additional questions should lessen the share of “unclear problems” in total criteria assessment. Special attention is needed in assessing possible out- of- hospital cardiac arrest (OHCA) that was present in 6,3%  cases of unclear problem. Regular training  through re-listening of phone calls is crucial in recognizing agonal breathing. Recognizing of possible OHCA might “ clear the problem” and provide telephone CPR instructions according to latest guidelines in strengthening the role of MDU in survival of OHCA.

 

References:

1.Sporer KA, Youngblood GM, Rodriguez RM. The ability of emergency medical

dispatch codes of medical complaints to predict ALS prehospital interventions.

Prehosp Emerg Care. 2007 Apr-Jun;11(2):192-8

2.Dami, Fabrice et al. “Prehospital Triage Accuracy in a Criteria Based Dispatch Centre.” BMC Emergency Medicine 15 (2015): 32. PMC.

 


Radmila MAJHEN UJEVIC (yes, Croatia)
11:00 - 18:00 #7714 - What is the added-value of McGrath video laryngoscope in prehospital setting?
What is the added-value of McGrath video laryngoscope in prehospital setting?

Introduction:

Several controlled clinical trials showed McGrathâ video laryngoscope (McG) utility in operating room, but this has not been evaluated in pre-hospital setting. Tracheal intubation in pre-hospital setting is considered as more complicated than in-hospital one, due to operating conditions (cervical spine immobilization, trapped victims, poor patient positioning...), non-fasting patients and operator’s isolation. The objective of this study was to evaluate whether McG may be an alternative to direct laryngoscopy (DL) in the prehospital setting.

Material and Methods:

29 physicians, residents and nurse anesthetists were recruited; they each performed one DL (Macintosh blade) followed by a series of 5 McG in two different scenarios with an adult manikin model: easy airway and difficult airway (immobilized cervical spine) management and one scenario with a pediatric manikin.

The primary endpoint was mean intubation time (IT) per procedure, and users’ learning curve. Glottis views with Comack-Lehane grade (CLG), number of intubation attempts, optimizing maneuvers and success rate (defined as lT lower or equal to 90 seconds) were considered as secondary endpoints.

Results:

Our study showed a rapid learning curve: reduced IT from 1st to 5th attempt with the 3 scenarios (mean time: 10 seconds), with few differences from 3rd to 5th attempts.

In adult manikin scenarios, McG enabled improved glottis view compared with DL: gain of 1 CLG with easy airway, and gain of 1 to 2 CLG with difficult airway scenario.

It also reduced moderately the number of intubation attempts. The success rate was not modified during the different attempts. When compared with DL intubation time, for both adult manikin scenarios there was a gain of 4 seconds in easy airway and a loss of 11 seconds in the difficult airway scenario.

In pediatric manikin scenario, McG improved IT (71 seconds) from DL to McG 5th attempt, improved glottic view (1 to 2 CLG), and allowed a lower number of intubation attempts and a higher success rate.

Conclusion:

Use of McG showed a rapid learning curve on the 3 tested scenarios. McG brought a real added value in pediatric manikin scenario for IT, number of intubation attempts and success rate.

For adult manikin scenarios, apart from an improved glottis view, there was no argument for an added-value of McG in prehospital setting.


Margot CASSUTO (Garches), Armelle SEVERIN, Anna OZGULER, Michel BAER, Thomas LOEB
11:00 - 18:00 #7986 - What it seemed pneumonia...
What it seemed pneumonia...

65 years old woman with a history of L4-L5 foraminal posterocentral herniated discs without root affectation, treatment with dexketoprofen, tramadol/paracetamol and omeprazole. She is independent for activities of daily living.



She goes to the Emergency Service with 38°C fever in the afternoons since 4-5 days ago, whithout chills or shivering. She does not concern having cough nor expectoration. No urinary nor digestive symptoms. She does not present associated constitutional syndrome.Refers neck pain and pain in the right extremity irradiated to the hand with 2 months of evolution, with no relation with any movement.



In blood analysis, hemoglobin and hematocrit in lower limit of normality was observed with c-reactive protein of 20 mg/dl. Normal CBC.In chest X-ray, a condensation in the right lower lobe was reported.The patient was hospitalized at home, where she was treated with levofloxacin 500 mg every 24 hours was referred . Given the limited improvement of the patient, an X-ray control was requested. There, a right basal condensation was observed, in evolution with obliteration of costodiaphragmatic right breast.Then, a chest CT was requested, where a mass in right posterior chest wall was visualized, which encompassed and eroded the 9th costal right arch. This mass, had dimensions of 150 by 100 by 40 mm but it was delimited with difficulty and had hypodense component areas, apparently necrotic and central . It contacted with 7th right costal arch, encompassing 8th to 10th arches. It was also described an infiltration of intercostal muscle structures and parietal pleura, with pleural effusion and pleural dissemination by nodular thickening of it.Biopsy of the mass was performed for typing the mass, reaching the diagnosis of mesothelioma.The tumor was removed by thoracic surgery and now she is in radio and chemotherapy treatment.




Ana Belén MARÍN FLORÍA, Sonia BALLESTÍN SOROLLA, Elisa RUIZ OLIVARES, Silvia GANGUTIA HERNÁNDEZ, Carola MEDINA SAINZ, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Pilar SARASA CLAVER, Javier GIL DE BERNABÉ
11:00 - 18:00 #8076 - What Makes and Effective Shop floor leader: The Senior Doctor.
What Makes and Effective Shop floor leader: The Senior Doctor.

Introduction

High quality effective leadership is associated with improved outcomes for patients and increased staff satisfaction. Previous work at UHCW had identified traits that were regarded positively in trauma team leaders. A combined team of clinicians from UHCW and HEFT felt that  during this time of particular pressure, shop floor leadership qualities, as stated by other staff, would be of use to guide behaviours

Aims

We aimed to identify the qualities staff valued in shop floor medical leadership. We also aimed to identify behaviours that were felt to be unhelpful as well as identifying Senior tier doctors (Consultant/Middle Grade) who were most felt to run a good floor.

Methods

We conducted a qualitative survey across 3 departments in the West Midlands over one month in early 2015. We used an anonymous questionnaire which first collected demographics then  responses to the following questions

  1. What characteristics do you associate with effective shop floor leadership?

  2. What characteristics do you associate with ineffective shop floor leadership

  3. Are any  staff particularly good? Please tell us why.

    The responses were assessed to spot themes and agreed upon by the authors.

    Answers were codified by a group of 4 of the authors with disputes settled by discussion.

    Results

    A total of 101 responses were received  with a broad spectrum of staff answering. All codified results were assessed and it was deemed the best way to represent the data was in the form of word clouds. Each word present in the cloud has a larger presence in relation to the frequency of it being mentioned as a response.

    Discussion

    Interestingly the attributes most highly regarded by staff were that the senior shop floor doctor was approachable and supportive. With less a of need for good communication skills or their enthusiasm at work. This would imply that staff see the senior doctor as being somebody to be able to turn to in need without fear of rebuke. This is reinforced by a high number of the negative attributes being aspects of interpersonal interactions and areas that would represent a barrier to being a supportive and approachable member of staff.

    The ability to aid decision making when turned to for advice is clearly relied upon as a key with both a lack of availability and then being unable to make decisions seen as negatives. The observation that a dichotomy of both seeing patients in the department is a positive but then not being available is a negative

    Communication is not seen as positive attribute to be good at as much as it is seen to be a negative if its done poorly.

    Conclusion

    Being approachable is viewed as a good characteristic in a leader with unavialability and bad interpersonal skills as a negative attribute.

     


Sandeep GILL (Smethwick, United Kingdom), Mark PELL, Chris TURNER, Shewli REHMAN, Hamid ILYAS
11:00 - 18:00 #7832 - What’s Going Wrong With This Postpartum Woman?
What’s Going Wrong With This Postpartum Woman?

Introduction

Peripartum cardiomyopathy (PPCMP) is a rare entity and potentially life-threating maternal disorder occured during the late pregnancy or within five months of postpartum period in the absence of obvious etiology. Herein we report a postpartum patient who presented to emergency department (ED) with dyspne that should make a physician consider the possibility of PPCMP.

Case report

A 35 year old female patient was admitted to our ED with an acute onset of dyspnea and squeezing chest pain started a couple of hours before presentation. She described a similar with a fewer intensity of dyspnea occurred 1 week ago and was prescribed amoxiciline-clavunalate and salbutamol with the diagnosis of pneumonia by a pulmonologist. She only had an history of gestational hypertension and diabetes mellitus with an uncomplicated ceasarean section of a healthy baby 3 weeks ago.

On admission she had a blood pressure of 180/110 mmHg, oxygen saturation of 78 on pulse oxymetry, a heart rate of 140 beats/min, a body temperature of 36.7˚C and respiratory rate of 22 breaths/min. Physical examination revealed bilateral lower extremity eudema existing for 2 weeks, diminished lung sounds and rhythmic and tachycardic heart sounds on auscultation.  The electrocardiogram was nonspesific with sinus tachycardia. The chest X-ray showed bilateral mild pleural effusion existing since at the time of her pulmonologist visit.  Bedside echocardiography was performed and left ventricular ejection fraction (EF) was found to be 20%. Diffuse left ventricular hypokinesia and left atrial enlargement were also the existing sonographic pathologies. Her laboratory findings were as follows; hemoglobin level: 9.8 g/dL (12-16 g/dL), heamotocrite level: 31.8% (37-47%) and brain natriuretic peptite value: 410 pg/mL (0-100 pg/mL). Other markers including troponin, d-dimer, TSH, renal function tests, liver enzymes were found normally. . Arterial blood gas analysis on oxygen supply showed a PaO2 of 99,0 mmHg (83-108 mmHg), a pH of 7.46 (7.38-7.46), a PaCO2 of 27.3 mmHg (35-48 mmHg), and HCO3 of 19,0 mmol/L (22.2-28.3 mmol/L).  

In ED IV nitroglycerine infusion with the rate 10 µg/min and IV bolus of 40 mg furosemide was initiated. She was admitted to coronary intensive care unit (CICU) with the diagnosis of PPCMP with an additional anticoagulant and metoprolol therapy. The patient was discharged after 3 days with an EF of 35% and was prescribed per oral treatment of metoprolol 100 mg/day, ivabradine 10 mg/day, perindopril 5 mg/day, spirinolactone 25 mg/day and furosemide 40 mg/day. 20 days after discharge hypokinesia was still remained but her EF was 55%. 

Conclusion

Emergency physicians should be aware of PPCMP at the differantial diagnosis of dyspne in pregnancy related emergencies and play role in early diagnosis of heart failure both in peripartum and postpartum period. 


Müge SÖNMEZ (Ankara, Turkey), İrfan KALA, Miray BABA, Uysal PINAR, Nurullah TARHAN, Nazlı KALA
11:00 - 18:00 #4706 - Which fingers should we perform two-finger chest compression technique with when performing cardiopulmonary resuscitation on an infant in cardiac arrest?
Which fingers should we perform two-finger chest compression technique with when performing cardiopulmonary resuscitation on an infant in cardiac arrest?

This study compared the effectiveness two-finger chest compression technique (TFCC) performed using the right vs. left hand and the index-middle vs. middle-ring fingers.

Four different finger/hand combinations were tested randomly in 30 healthcare providers performing TFCC (Test 1: the right index-middle fingers; Test 2: the left index-middle fingers; Test 3: the right middle-ring fingers; Test 4: the left middle-ring fingers) using two cross-over trials. The “patient” was a 3-month-old-infant-sized manikin. Each experiment consisted of cardiopulmonary resuscitation (CPR) consisting of 2 min of 30:2 compression: ventilation performed by one rescuer on a manikin lying on the floor as if in cardiac arrest. Ventilations were performed using the mouth-to-mouth method. Compression and ventilation data were collected during the tests.

The mean compression depth (MCD) was significantly greater in TFCC performed with the index-middle fingers than with the middle-ring fingers regardless of the hand (95% confidence intervals; right hand: 37.8–40.2 vs. 35.2–38.6 mm, P = 0.002; left hand: 36.9–39.2 vs. 35.5–38.1 mm, P = 0.003). A deeper MCD was achieved with the index-middle fingers of the right versus the left hand (P = 0.004). The ratio of sufficiently deep compressions showed the same patterns. There were no significant differences in the other data.

The best performance of TFCC in simulated 30:2 compression: ventilation CPR performed by one rescuer on an infant in cardiac arrest lying on the floor was obtained using the index-middle fingers of the right hand.


Je Hyeok OH (Seoul, Korea), Young Sinn KIM, Chan Woong KIM, Sung Eun KIM, Dong Hoon LEE, Jun Young HONG
11:00 - 18:00 #8004 - White male in his late 50’s found face down, obtunded, hypoglycemic, hypotensive, hypothermic. Is he drunk or intoxicated, suffering an MI, a stroke? Or is it an aortic root dissection from brain to lower pelvis?
White male in his late 50’s found face down, obtunded, hypoglycemic, hypotensive, hypothermic. Is he drunk or intoxicated, suffering an MI, a stroke? Or is it an aortic root dissection from brain to lower pelvis?

Patients with aortic dissection may present with classic red flag features to the Emergency Department (ED) but a high index of suspicion of life threatening illness but be very high on the differential diagnosis in order to save life. An obtunded, hypothermic, hypotensive and hypoglycemic patient in their 5th decade that presents with no history from prehospital teams is atypical for such a pathology and requires thorough clinical exam, clinical acumen and most importantly a systematic approach to achieve a definitive diagnosis. This case report offers an uncommon presentation of extensive aortic dissection with very few comorbidities, no convincing evidence of blunt or penetrating trauma and an absent history of present illness. Upon initial presentation to the ED, an atypical perfusion distribution and  material anomaly on eFAST exam at the level of the bifurcation of the abdominal aorta led to CT definitive diagnosis of a peculiar aortic root dissection.


In sum, this case highlights the requirement in the ED to have a high index of suspicion in the acutely unwell and obtunded patient for life threat pathologies and to follow diagnostic algorithms with clinical judgment in order to apply best practices and maximize best outcomes. The use of bedside ultrasound, aggressive CT diagnostics, clinical exam, emergency team involvement and interdisciplinary approach offers best practices for the broad patient population presenting to emergency departments across Europe and the UK.


John QUINN (Prague, Czech Republic), Andrei CARPIUC, Dan-Lucian GHIURLUC
11:00 - 18:00 #7443 - Who cares about patient flow? Understanding the issues surrounding patient flow in the Emergency Department and Hospital.
Who cares about patient flow? Understanding the issues surrounding patient flow in the Emergency Department and Hospital.

Background

 

Patient flow and how to improve it is very topical in most hospitals. The Royal College of Emergency Medicine in the United Kingdom, see this as an important issue which as a whole country needs improving. Without patient flow (PF) through out a hospital, patients ultimately get stuck in the Emergency Department (ED). Like many trusts in the United Kingdom, acute bed pressures are seeing referred patients remaining in the ED. Consequently, there is potentially delayed treatment by the accepting speciality, due to limited capacity leading to increased bed days and morbidity. We conducted an anonymous online survey to all the consultants of one National Health Service (NHS) trust to see is we as an ED could help PF issues. This trust serves a population of approximately 600,000 people. Given increasing pressures on Emergency Departments (ED) we need to try understand and improve the issues surrounding patient flow in the hospital.

 

Aims

 

Our aim was to understand the views of consultants in one NHS trust about PF issues. We anted to understand their perception of PF and PF initiatives in the hospitals. By understanding these aims we could see if any of these issue we ED based, and see if we could change them.

 

Methods

 

Using Survey Monkey™ an online survey creator, we sent a 7-question survey to all Consultants in the trust (550). It was a completely anonymous survey asking questions around PF in respective departments and engagement in hospital wide PF initiatives. A qualitative thematic analysis of all the results was conducted by one researcher, trying to draw out themes.

 

Results

 

27% (145/550) of the hospital consultants completed the survey across all sites in the hospital. The majority of responses came from the acute specialities including critical care, emergency medicine, anaesthetics and surgery. Unsurprisingly, nearly 100% of participants across all specialities said PF was important to them and their areas of practice. The specialities that didn’t included histopathology and dermatology. No consultants felt that the ED made their PF issues any worse. Key issues were needing more community beds to move patients, frustration of nothing changing quickly and low moral with long patient waits in the ED. One final issue, was a feeling that there is no hospital wide consensus or plan that is helping minimise patient waits in the the ED.

 

Conclusion

 

PF is important to all departments not only the ED. The constant pressures and daily waits for referred patients to be moved to the correct speciality is demoralising the workforce. There is a general feeling that more community placements, would help alleviate this burden. As a speciality, we as Emergency Medicine must try and assist our speciality colleagues when referring patients, especially if they remain in our department. Moving forward, we need to draw together all specialities and have a hospital wide approach to tackle these issues, not just an Emergency Medicine one. 


Sarah EDWARDS (Leicester, United Kingdom), Leesa PARKINSON
11:00 - 18:00 #7911 - WHO DIED MORE, MEN OR WOMEN WHEN THEY CONSULT IN OUR EMERGENCY DEPARTMENT WITH DIAGNOSED OF ACUTE HEART FAILURE?
WHO DIED MORE, MEN OR WOMEN WHEN THEY CONSULT IN OUR EMERGENCY DEPARTMENT WITH DIAGNOSED OF ACUTE HEART FAILURE?

Introduction
Acute heart failure (AHF) is a common reason for consultation in the emergency services and the leading cause of hospitalization in the elderly. This leads to increased mortality, use of emergency services and health spending.

objective
Describe the differences in mortality during follow-up of a year, patients who consulted for acute heart failure in our emergency department (ED).

Material and methods
Prospective observational study without intervention in patients who come to our emergency department in the period from 2012-2014 choosing two randomized months per year with a diagnosis of acute heart failure according to the Framingham criteria. Inclusion criteria: over 18 years, diagnosis of acute heart failure and give their signed consent. The study variables were: sex, hospital mortality, mortality at 30 days, one year mortality and total mortality falls within that period.

results
During the 2012-2014 selected 119 patients consulted for acute heart failure of which 57 were women (47.9%) and 62 men (52.1%).
The hospital mortality was 13 patients (29.55%), 46.15% men and 53.85% women.
At 30 days they killed 10 patients (22.73%), 80% men and 20% women.
Year mortality was 21 patients (47.72%) of which 13 were men (61.9%) and 8 women (38.1%).
Total mortality was 44 patients (36.98%), 27 men (61.36%) and 17 women (38.64%).

conclusions:
- Do not objectify a big difference in gender, of patients who come to our emergency department.
- In-hospital mortality were no major differences in sex were observed. However, in follow-up at 30 days and one year, increased mortality in men versus women was observed, sex being a likely risk factor for mortality from acute heart failure.


Patricia SUAREZ-BEKE, Paula LAZARO-ARAGUES, Jose Andres SANCHEZ-NICOLAS, Irene PAGAN-GOMEZ, Jose Luis OTERO URIBE, Rafael QUITANILLA-LOPEZ, Pascual PIÑERA SALMERÓN (montepinar, Spain)
11:00 - 18:00 #7699 - Why consult the emergency department patients with systemic autoimmune diseases?
Why consult the emergency department patients with systemic autoimmune diseases?

Background: The causes of acute decompensations of patients with systemic autoimmune diseases are not well known.  Aim: To describe the causes for consultation in an emergency room of patients with systemic autoimmune diseases. Material and Methods: Review of medical records of patients with systemic autoimmune diseases, aged over 14 years, consulting in an emergency room of a general hospital during three months. Results: In the study period, 166 patients with systemic autoimmune diseases consulted in the emergency room, of a total of 18,153 consultations (0.9%). Patients with rheumatoid arthritis were those that consulted with higher frequency (37%) followed by patients with systemic lupus erythematosus (21%). The most common causes for consultation were cardiovascular diseases in 25%, followed by digestive disorders in 15%. The most common diagnosis was chest pain with suspected ischemic heart disease in 36%. No differences in cardiovascular risk factors were observed between those patients consulting for cardiovascular diseases and those consulting for other causes. Conclusions: The most common cause of consultation in the emergency room of patients with systemic autoimmune diseases is cardiovascular.


Maria Angelica RIVERA NÚÑEZ (MADRID, Spain), Carlos MARTÍNEZ CABALLERO, Rosario TORRES SANTOS-OLMOS, Charbel MAROUN-EID
11:00 - 18:00 #7530 - Why I can walk suddenly?
Why I can walk suddenly?

Personal Background: Type 2 diabetes mellitus 4 years of evolution in treatment with metformin and insulin; chronic liver disease with portal hypertension and hypersplenism of 15 cm in currently etiology; mild thrombocytopenia.

 

History: 51 year old man, several hours after an abdominal CT performed with iodinated contrast, begin to notice difficulty with walking and sense of loss of strength in feet progresses symmetrically legs and the next day to upper limbs. As background he has had a respiratory infection about 10 days ago that improved with anti-inflammatory.

 

Exploration: BP: 125/90, HR: 65 lpm, afebrile. Predominantly distal symmetric tetraparesis. In upper limb reflexes present and symmetrical. Achilles reflex abolished. Surface sensitivity without deficit, abolished vibratory sensation in both lower limbs. Cerebellar tests nonassessable by paresis. Romberg test unstable, paretic motion that needs support.

 

Additional tests: blood count: hb 17, leukocytes 7000, platelet count 99,000; normal hemostasis; gluc 152, normal renal function, normal ions, AST 64, ALT 100, GGT 469, FA 131, TB 0.61. Cerebrospinal fluid analysis: leukocytes 1, protein 56.2, negative culture cerebrospinal fluid. Chest radiography: increased cardio-thoracic index without other findings. CT skull without significant findings. Electroneurogram and electromyogram: findings consistent with an axonal and motor polyneuropathy with signs of moderate-intensity of upper limbs and lower limbs intense demyelination.

 

Diagnosis: Likely polyneuropathy acute motor axonal neuropathy type (clinical variety of Guillain-Barre syndrome)

 

Treatment: he was admitted to the neurology and put treatment with corticosteroids and immunoglobulins.

 

Evolution: Good clinical evolution, although gradually. Recovery of strength and tendon reflexes, lower limb faster than higher.

 

Conclusions: Guillain-Barre syndrome is an autoimmune disease more common in men. In two thirds of cases there is an infectious history, predominantly of upper respiratory tract, 2 or 3 weeks before the start of the symptoms, but it has also been associated with other entities as toxic, allergic, immune, metabolic, after surgery, after childbirth or after a vaccine. It has three phases: progression, regression and stabilization, which usually completed in 3 to 6 months. 80% of patients fully recover or have small deficit, between 10 and 15% left with permanent sequelae and the rest will die despite intensive care.


Lorea DE UNAMUNO LUMBRERAS, Verónica PARENT MATHIAS (MALAGA, Spain), Cristina PÉREZ OLIVARES, Irina YEZERSKA SUSHKO, Pablo DE UNAMUNO LUMBRERAS, Vanessa CARRASCO ALMAGRO
11:00 - 18:00 #8083 - Witnessed cardiac arrest and VT/VF as initial rhythm are still a strong predictor of survival after OHCA – results from the Eastern Bohemia Region-the Czech Republic.
Witnessed cardiac arrest and VT/VF as initial rhythm are still a strong predictor of survival after OHCA – results from the Eastern Bohemia Region-the Czech Republic.

Introduction: Out-of-hospital cardiac arrest (OHCA) is a significant cause of death in developed countries. Although early treatment has been improved in several ways, the global survival rate after OHCA still does not exceed 5-10 %.

Methods: The authors present a retrospective cohort study including 519 OHCA from the Eastern Bohemia Region-the Czech Republic from January 1 to September 31, 2015. The witnessed collapse, initial rhythm VT/VF and 30-day survival rate were recorded. The primary outcome was survival to hospital admission and survival to hospital discharge with CPC 1,2.

Results: Overall survival rate to hospital admission was 38,5 % (n=200) and overall survival rate to hospital discharge was 14,6 % (n=76), resp. survival rate to hospital discharge with CPC 1,2  was 8,7% (n=45).  Witnessed collapse occurred in 45,7 % cases (n=237) and  57,4 % (n=136) patients survived to hospital admission and 16,9 % (n=40) survived to hospital discharge with CPC 1,2. Combination of the witnessed collapse and VT/VF as initial rhythm had 33,3 % (n=79) patients,  82,3 % (n=65) of them survived to hospital admission and 44,3 % (n=35) survived to hospital discharge with CPC 1,2. Patients with combination of witnessed collapse and VT/VF had considerably the best chance of both survival and good neurological outcome.

Conclusions: We proved that the witnessed collapse and VT/VF as initial rhythm are the strong predictor of survival after OHCA with good neurological outcome (CPC1,2)


Michal PLODR (Hradec Kralove, Czech Republic), Jaroslava KRENCIKOVA, Monika PRAUNOVA
11:00 - 18:00 #7764 - Wolf-Parkinson-White syndrome with paroxysmal atrial fibrillation diagnosed in emergency department.
Wolf-Parkinson-White syndrome with paroxysmal atrial fibrillation diagnosed in emergency department.

Introduction :

Wolf-parkinson-White  (WPW) Syndrome is a rare condition in population estimated between 0,1% to 3%. In 30% of cases, paroxysmal nonsustained atrial fibrillation is associated with risk of ventricular fibrillation and can be a life-threatening condition if misdiagnosed. Differential diagnosis and adequate therapeutic choice are the challenges for emergency physicians in the management of this condition.

Case report :

A 23-year-old female with no medical history presented to the emergency department complaining of palpitations with brutal onset at rest and 2 episodes of vomiting beginning 2 hours before. On examination, she was awake, presented an irregular rapid pulse with no hemodynamic instability neither respiratory distress. A 12-lead ECG showed an irregular wide polymorphic QRS complexes tachycardia of 300/min. The diagnosis of WPW with paroxysmal AF was made and a pharmacological cardioversion with intravenous amiodarone was attempted with success. The patient was transferred to a cardiologic unit for further assessment.

Discussion :

In WPW with AF, ECG shows typically irregular tachycardia with rapid ventricular response often > 200 per min and widened polymorphic QRS. Although its good prognosis when nonsustained , AF with WPW may degenere  in 1% of cases to ventricular fibrillation with risk of sudden cardiac death. Emergency physician must recongnize because of  possible critical evolution and  therapeutic implications. Treatment must be careful. Electrical cardioversion is indicated in unstable patients. When pharmacological cardioversion is indicated, drugs may not impede the AV conduction.

Conclusion:

WPW syndrome associated to paroxysmal AF is a rare but life-threatening condition. Emergency physician may be exposed to recognize and treat without any delay this pathology.


Héla MANAÏ (Tunis, Tunisia), Hamed RYM, Feten AMIRA, Maaref AMEL, Jebali AMINA, Zied GUERMAZI, Bouhajja BÉCHIR
11:00 - 18:00 #7575 - Written complaints for excessive waiting time in an emergency department 2010-2015.
Written complaints for excessive waiting time in an emergency department 2010-2015.

Introduction

 Introduction

The Spanish public health system is considered one of the most highly valued in developed countries. It is characterized by being universal,  public funding, equal access and regionally managed . In spite of its free access, time factor is especially important in Accident and Emergency  departments,  even after  triage. Patients increasingly attend  hospital emergency departments and this increase does not need technically demanding  explanations, basically because experts have a very simple reason, it is a quality service, free and available 24 hours a day, 365 days a year.

In all Western countries a gradual increase in demand for hospital emergency care and inappropriate use of this medical service has been identified. The study of complaints made by customers in  A&E  departments represents a parameter of quality of care that allows us to assess patient's satisfaction.

Objectives

Main objective

1-To analyse the user’s profile in the health system that makes a  written complain regarding waiting time in the Accident and emergency department of the hospital del Vendrell.

Secondary objectives:

2-To analyse a possible relationship between the waiting time recommended at triage  and written complaints

3-To analyse whether patients that leave the department before being seen by the medical team make a written complain as well 

Material and method.

A descriptive,retrospective study of all the wroten complaints for excessive waiting time sent to Emergency Department of  Vendrell Hospital over 5 consecutive years, .from January 1st 2010 to December 31st.The Vendrell Hospital is district general hospital in Catalonia and attends 75000 adult and pediatric emergency visits year.

Results

During the 5 years studied, the emergency department received a total of 878 written complaints, 490 were for waiting time, 55% were female, with an average age of 44 years.

The time slot, showed that higher claims were at the evening, 26% of the complaints were from pediatry. The 77% of the complaints were written by the reference population and 23% from outside the area.

The 100% of waiting time complaints were for emergency levels 4-5. 33% of users had made over 12 visits in primary care in the last year.

98 % of visits made by level 4-5 were in the recommended waiting time

Conclusion

The user profile for those who attended the emergency room service and filed a complaint is as follows:

Young patients (<45 years) who do not frequent  the hospital service often, with isolated visits to the emergency room service (<5 /year). Patients come from the bordering sanitary region and they present minor pathology levels (level 4/5). They typically attend the service in the afternoon with 20% quitting the premises and less than 10% returning within the following 24 hours.


Carles GREOLES ROYO, Josep MONTESINOS COTS (EL VENDRELL, Spain), Gabriela Madalina GRECU, Claudia ROMERO RAMIREZ, Jorge ALCALA ANIENTO, Ana ESTEBAN VILLACAMPA, Maria ARENAS PRATS
11:00 - 18:00 #8061 - WÜNDERLICH SYNDROME: SPONTANEOUS RETROPERITONEAL HEMORRHAGE DUE TO RENAL ANGIOMYOLIPOMA.
WÜNDERLICH SYNDROME: SPONTANEOUS RETROPERITONEAL HEMORRHAGE DUE TO RENAL ANGIOMYOLIPOMA.

INTRODUCTION:

Wünderlich syndrome (WS) is a rare entity characterized by spontaneous, non traumatic retroperitoneal haemorrhage. It can be fatal if not promptly recognized clinically. The most common cause is Renal Angiomyolipoma (AML), a benign mesenchymal tumour. The incidence of this tumour is 0,3-3% with a female to male gender ratio 4,5:1, it is estimated that 10million people worldwide have such lesion.

PRESENTATION OF CASE:

A 66 years old male with no history of trauma or anticoagulation was presented to the emergency department with sudden-onset of abdominal pain in left flank initiated 2 hours ago. Associated symptoms included nausea and pallor without fever, dysuria nor digestive disorders. His personal history includes renal calculus and sigmoid adenocarcinoma T3N1 that was undergone to left hemicolectomy 8 years ago. On physical examination he appeared pale, feverless with with normal vital signs:  blood pressure 123/80 and oxygen saturations 100% on room air. Abdominal examination revealed pain and peritonism in the upper left quadrant

Initially renal colic was suspected and analgesic treatment  initiated. After a few minutes the patient’s symptoms worsened and he developed haemodynamic instability with hypotension, tachycardia and syncope. On examination he presented intense abdominal pain. He was stabilized with crystalloid fluid resuscitation without additional needs. Urgent contrast SCAN showed acute retroperitoneal hematoma (with intraperitoneal spillage). A focal and heterogeneous lesion was identified in contact with left renal upper pole suggesting a renal angiomyolipoma.  The patient’s haemoglobin decreased from 16g/dL to 10g/dl so a transfusion of two packed red blood cells was performed.

The patient was clinically diagnosed as Wünderlich syndrome caused by spontaneous haemorrhage of angiomyolipoma. Given the patient's hemodynamic stability, conservative medical management is decided. He was admitted to the ICU for closed monitoring. After some days is transferred to Urology ward where he presents a correct clinical course with analytical stability, remaining hemodynamically stable and afebrile at all times, the patient is discharged. 

CONCLUSION

Wünderlich’s syndrome is one of the most feared complications of renal angiomyolipoma and can be fatal if not diagnosed promptly. WS is classically associated with acute lumbo-abdominal pain, palpable mass and general deterioration with hypovolemic shock (Lenk’s triad). Computer tomography is considered gold standard. Management is mainly expectant but in case of haemodynamic instability radical nephrectomy to even embolization may be required. Because of his low frequency of occurrence and potential severe bleeding is important to keep WS in mind in patients with flank pain and hypotension.

 

 


Doina SOLTOIANU (TARRAGONA, Spain), Gilmar PUGNET, Jesús GÁLVEZ MORA, Albert MORENO DESTRUELS, Domingo RIBAS SEGUI, Alexis GUZMAN
11:00 - 18:00 #7971 - XXI century nightmare.
XXI century nightmare.

 

40 years old patient, she is brought to the Urgencies Service by her relatives because she shows conscience diminution and respiratory difficulty. At her arrival, she is cold, trembly, and non-reactive, with respiratory difficults and Glasgow 10. She has myotic, non-reactive and without photomotor reflection pupils. Central and peripheral cyanosis. She presents a convulsion that yields with rectal Diacepam.
The auscultation cardiac is composed of 100 b.p.m. rhythmic tones without blowings and in the pulmonary auscultation she presents roncus and dispersed sibilants with bibasal crepitants. O2 saturation under 70%. In the electrocardiogram suggestive alterations of isquemia nor alterations in repolarizacion are not observed.
Collaboration is asked to her husband to make the clinical history. He refers that the patient was in one room where there was too much smoke coming from a gasoline burner and that she had also smoked heroine.
Antidotes (flumazenil and naloxone) with transitory improvement of the level of conscience are administered but without total recovery. Cooximetry is made, that shows a carboxihemoglobine level of 32% (normal: 0-1,5%). Metabolic acidosys compensated. She is entered in I.C.U.  where the treatment continued with oxygen therapy with FiO2 100%, perfusion of naloxone and bicarbonate.
Later evolution has been favorable, presenting a carboxihemoglobine level of 8.6% after an hour and 0.6% after 6 hours. After 24 hours, the patient is passed to Internal Medicine Unit to continue evolution.
To emphasize the importance of clinical history, in this case the contribution that her relatives gave us, which was the key to diagnose her.

Sonia Sofía BALLESTIN SOROLLA, Elisa RUIZ OLIVARES, Begoña GARGALLO PLANAS (ZARAGOZA, Spain), Alicia BAGUENA GARCÍA, Ana Belén MARÍN FLORÍA, Carola MEDINA SAINZ, Silvia GANGUTIA
11:00 - 18:00 #7465 - ‘Block the break’.
‘Block the break’.

Background:

Hip fracture is one of the most common orthopaedic emergencies presenting to the emergency department. Optimal pain management is crucial to improve the patient outcomes. Different ultrasound guided nerve blocks, including the fascia iliaca compartment block and the femoral nerve block, are used in reducing pain after hip fracture. Research suggests that analgesia via nerve blockade is more effective and safer than the conventional pain management with non-steroidal anti-inflammatory drugs and/or opioids. 

Objectives:

Our primary objective was to compare the analgesic efficacy and safety of ultrasound-guided fascia iliaca compartment block to the ultrasound-guided femoral nerve block in patients with neck of femur fractures.

Methods:

We designed a prospective observational study in the emergency department of University hospitals Birmingham. A convenience sample of adult patients presenting to ED with a neck of femur fracture were included from August 2015 to October 2015. A total of 28 patients were included in the study. Patients were randomly allocated to receive either a US-FICB or a US-FNB by the performing emergency physician (Consultant or Registrar grade) with level 1 ultrasound experience, who was trained to do the blocks with the Ultrasound. We used 10ml (5+5) of lignocaine 1% and bupivicaine 0.5% for FNB and 30ml (10ml n/s, 10ml lignocaine 1% and 10ml 0.5% bupivicaine). Pain scores were assessed using verbal numeric rating scale (VNRS) on a standard data collection sheet. Patients receiving the block and the nurse assessing the pain score were blinded to the type of the block.

Results:

28 patients were included in the analysis. Our study results suggest that both blocks are equally effective in providing effective pain relief for patients presenting to ED with hip fracture (drop of 7 points on VNRS). Both blocks have quick onset of action (15 minutes), the time for maximal effect was 120 minutes on average and lasted up to 240 minutes. Pain scores were equivalent between the block groups at all times during the observation period.

In this study, there are no adverse events reported. The success rates of the blocks appears identical; 88% for US-FICB and 90% for US-FNB.

Conclusions:

Our study indicates that both US-FICB and US-FNB are equivalent in providing a quick and effective analgesia for prolonged periods (up to 4-6 hours) in patients with neck of femur fracture. Both blocks are safe, easily learnt and have similar success rates (90%). Emergency physicians can have confidence in either technique to relieve pain in patients presenting with neck of femur fractures.


Naveen RACHAKATLA, M Azam MAJEED (Birmingham, United Kingdom), Asif NAVEED, M Saif REHMAN
11:00 - 18:00 #6277 - “Hygiene in the prehospital setting - A study of bacterial contamination, personnel compliance and impact of various hygiene interventions in the emergency medical service”.
“Hygiene in the prehospital setting - A study of bacterial contamination, personnel compliance and impact of various hygiene interventions in the emergency medical service”.

Introduction: Patients are at risk of contracting a healthcare associated infection (HAI) straining on society due to prolonged hospitalization, morbidity and mortality. Prior research, although limited, indicates that ambulance environment and personnel uniforms may constitute a reservoir for potential pathogenic bacteria and that hygiene compliance among ambulance personnel could be improved. Treatment in the emergency medical service under non-clinical conditions, sometimes under severe time pressure, and not always with unlimited quantities of cleaning equipment hand rubbing and examination gloves are challenging, and despite that patients receive advanced treatment during the prehospital course, hygiene have not yet received the amount of focus as seen in primary settings. This PhD project consists of five different studies, valuable to anyone in contact with the emergency medical service, both nationally and internationally. The results will allow concise hygiene efforts and thereby enhance prevention of HAIs during the prehospital course.

Method:

  1. Current hygiene guidelines appear without evidence, hence calling for a systematic review in order to evaluate existing evidence and future research requirements. The aim is to characterize environmental contamination and to illuminate hygiene interventions, compliance and challenges in a prehospital context.
  2. Deficient evidence of current extent of bacterial contamination motivates to a cross-sectional demonstration of contamination by environmental sampling, using a combined swabbing and agar imprint method: Primary outcome: total colony forming units (CFU). Secondary outcomes: Staphylococcus aureus (MRSA), Enterococcus (VRE) and Enterobacteriaceae (ESBL), time since last cleaning, area of service and total no. of patients.
  3. Hygiene compliance is crucial but appears undocumented in a prehospital context, hence incentivizing an observational study to illuminate quality and eventual challenges. 96 hours of semi-blinded observation. With focus on conventional hand rub/glove occasions, answered by YES/NO: Before touching a patient, before clean/aseptic procedure, after body fluid exposure risk, after touching a patient and after touching patient surroundings. Additional parameters: Short hair/done up, short nails and Rings/watches.
  4. The effect of cleaning is undocumented, hence motivating a controlled before and after study of bacterial reduction when cleaning environment and medical equipment. The aim is to document the effect of current cleaning interventions when using sampling methods described in sub study two. Primary outcome: total colony forming units (CFU). Secondary outcomes: Staphylococcus aureus (MRSA) and time spend on cleaning.
  5. Uniforms may constitute a reservoir for potential pathogenic bacteria. However, evidence of domestic washing is limited, hence motivating to a cross regional before and after study. The aim is to document the effect when sampling as described in sub study two and four. Primary outcome: total colony forming units (CFU). Secondary outcomes: Staphylococcus aureus (MRSA) and environmental contamination in the washing area.

Results: No results in time of writing, we expect to present them simultaneously within the following three years. 


Heidi Storm VIKKE (Kolding, Denmark), Matthias GIEBNER
11:00 - 18:00 #8016 - “Just” A Bruise?
“Just” A Bruise?

Introduction:

A large of proportion of elderly presentations to emergency departments (ED) are due to injuries sustained at home, with most injuries attributed to falls [1]. How many of these injuries have a component of elder abuse within is unknown. The prevalence of elder abuse is highly variable ranging from 3.2 to 27.5% [2]. This may be attributed in part to under-reporting of events, a low index of suspicion on the part of the physician and inaccurate histories at presentation. With the global elderly population estimated to hit 2 billion by 2050 [3], and recent census data from Singapore in 2015 on increasing number of elderly persons [4]; we need to be vigilant to these presentations to the ED. We present a case report of a patient with an apparent atraumatic sudden onset extensive of ecchymosis.

Case:

A 91 year-old lady presented to the ED for left forearm bruising that was noted on the morning of presentation by her stay-in caregiver. She reported that the extensive left forearm bruise had occurred overnight. Her son accompanying her reported that her arm was normal when he last visited her the night before. She denied any trauma or falls overnight and this was corroborated by the stay-in caregiver. She had good family support and was being cared for by the full-time stay-in caregiver.

On examination, she was alert and comfortable. The reported left forearm bruise extended from the proximal phalanx of the dorsum of the hand to the distal end of the humerus. The palmar surfaces of the hand were spared. The arm was oedematous but not tense, no obvious wounds were identified. In addition, swelling of approximately 3x3cm was noted on the dorsum of the wrist. No increased warmth was felt over the forearm. The affected areas were non-tender. Neurological examination of her left upper limb did not reveal any deficits. Sensation was intact. Flexion-extension mechanisms and power were normal and equal bilaterally. Radial pulse and capillary refill times were normal. Mild patchy bruising was also noted on the right forearm and over the big toes of both feet.

She was subsequently admitted and worked up with coagulation studies, which were normal. X-rays of the affected limb did not identify any fractures. She was later discharged well with an outpatient follow up appointment to Vascular Surgery for further evaluation of possible distal thromboembolic events.

Discussion:

We present this case to highlight the apparent lack of preceding events giving rise to a bruise of extensive proportions. The inconsistency in history and presentation should ring alarm bells and considerations of elder abuse as a cause of presentation. Whilst this case does highlight inconsistencies in history and presentation, no findings of elder abuse were elicited from either her family or caregiver. As numbers of elderly ED visits increase owing to population demographics, we need to be aware of such issues and raise them to relevant parties to ensure care for our patients is not compromised.  


Ian HONG (Singapore, Singapore), Venkataraman ANANTHARAMAN
11:00 - 18:00 #7596 - “My head feels like it’s going to Explode!”: Massive Bilateral Temple Swelling and cellulitis resulting from a Scalp Laceration.
“My head feels like it’s going to Explode!”: Massive Bilateral Temple Swelling and cellulitis resulting from a Scalp Laceration.

Case History:

On St Stephen’s Day 2015, a 46-year-old male presented with an occipital laceration resulting from a fall having consumed alcohol. Due to loss of consciousness and vomiting, a CT brain was ordered. This study was normal. Simple interrupted 4-0 nylon sutures were applied to a deep, 8cm linear occipital laceration. There was minimal initial swelling. The patient was discharged with head injury and suture care advice. He represented five days later, complaining of bilateral temporal swelling, and redness and swelling to his neck.

On examination, there was significant bilateral temporal swelling, including the periorbital region bilaterally. He had developed cellulitis of the neck. Repeat CT brain revealed an extensive cresentic subcutaneous collection, overlying the posterior calvarium and extending to both temples. He was admitted for intravenous antibiotics by the maxillofacial surgery team. His scalp swelling and neck cellulitis settled gradually and he was discharged home well after five days.     

Discussion:

Scalp lacerations are a common Emergency Department presentation. The best way to control initial haemorrhage is controversial. The bleeding mainly comes from vessels which retract into the loose areolar tissue in the connective tissue layer, and are therefore notoriously difficult to ligate. Solutions to control initial bleeding include Raney scalp clips1, and diathermy. Oftentimes, quick closure of the wound, following debridement and irrigation, can be the best way to halt bleeding from a scalp wound2. This can be combined with direct pressure with gauze and a pressure dressing wrapped around the chin.

Despite apparent initial control of haemostasis, massive subgaleal swelling after simple scalp lacerations has been described. In the rare cases when this massive swelling presents to the Emergency Department, it can be bilateral, as the haematoma does not follow suture lines. It often presents in an insidious manner, in the days after the initial presentation. If left unchecked, such a haematoma can result in acute anaemia necessitating blood transfusion3, hypovolaemic shock, and even death4. Any associated infection, such as cellulitis, must be treated aggressively, to reduce the likelihood of subdural spread. 

Learning Points:

  • Head Trauma sometimes leads to massive delayed swelling
  • Counsel patients on this
  • Prophylactically apply a pressure dressing to all deep scalp wounds

 

References:

  1. Scalp laceration: an obvious ‘occult’ cause of shock. Turnage B. South Med J 2000 Mar; 93(3): 265-6.
  2. Rosen’s Emergency Medicine. 8th Edition. Marx J. p 360 Elsevier.
  3. A missed scalp laceration causing avoidable sequelae. Basyuni S. Int J Surg Case Rep. 2016 Apr 11; 23: 61-4.
  4. Fatal massive edema of the head and neck secondary to sclap laceration: repost of case. Limongelli WA. J Oral Surg 1977 Mar; 35(3): 215-18

 


Gareth FITZPATRICK (Dublin, Ireland)
11:00 - 18:00 #7410 - “One for all, all for one” -case series for ‘Triple Lumen Dialysis Line” in Resuscitation.
“One for all, all for one” -case series for ‘Triple Lumen Dialysis Line” in Resuscitation.

 

Abstract

 Introduction

Does an ‘ideal’ central line for emergency and resuscitation use exist?  What are its essential characteristics? - A line that allows a high infusion rate of resuscitation fluids during severe bleeding and shock; the availability of multiple ports that can be used for vaso-active agents as well as simultaneous infusion of several incompatible medications; the flexibility of using the same line to initiate emergency haemo-dialysis if necessary; the availability of an ‘extra port’ to initiate vasopressor therapy in hypotensive cases during dialysis. Currently in our Emergency Department, (ED) we stock at least 4 different types of central lines based on all the traditional use mentioned above – Pulmonary artery catheter sheath introducer (for rapid fluid resuscitation), triple lumen central line (for vaso-active and  multiple medication infusion), double lumen ‘vascath’ dialysis line, and triple lumen dialysis line with ‘extra port’.  We hypothesize the use of the latter as a central line that can be used in all 4 case scenarios.  The triple lumen dialysis line (TLDL) we are using has a 11G, 12G and a 16G access ports.  The manufacturer claimed flow rates of 320mls/min, 250mls/min, and 55mls/min respectively.  We have been using TLDLs in our busy tertiary teaching hospital ED for the last 2 years.

Methods:

We are reporting 4 cases to describe the successful use of the TLDL in different clinical scenarios:  1. A 30 year old male who presented with a massive haematemesis, reduced conscious level, blood pressure (BP) of 50/30mmHg and pulse rate (PR) of 150bpm.  TLDL was inserted to accommodate rapid fluid resuscitation and multiple simultaneous blood product infusion; 2. A 45 year old female who presented with 3 day history of fever, increased urinary frequency and a BP of 70/40mmHg despite 2 liters of crystalloid resuscitation.  TLDL was used for noradrenalin and vasopressin infusion; 3. A 24 year-old male presented with 2 weeks history of diarrhea and increased lethargy. He was normotensive, but dehydrated with very high creatinine reading and a potassium level of 8mmol/L. He remained anuric despite 3 liters of fluid and conservative therapy.  TLDL was inserted to allow for urgent dialysis in the ED; 4. A 75 year old man with a background history of heart failure presented with septic shock of unknown origin. His BP remained relatively low despite judicious fluid resuscitation.  He was oliguric so TLDL was inserted in his right internal jugular vein to fine tune the management of his cardiovascular status.  A small dose of noradrenalin was started to keep a mean arterial pressure of 70mmHg. Despite this, his renal function continues to deteriorate and he was commenced on haemo-dialysis 2 days later in the Intensive Care Unit.

Results:

We discuss the pros and cons of the TLDL being the only available central line for initial use in the ED.

Conclusion:

It is quite clear from our experience that TLDL can function as the initial central line of choice for all critical care scenarios we faced in our ED.


Alhady YUSOF, Zenab ABDEL RAHMAN (Doha, Qatar)
13:00

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State of the Art
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13:00 - 13:30 Blast injuries - military lessons for civilian practice. Jason SMITH (PHYSICIAN) (Speaker, Plymouth, United Kingdom)
13:30 - 14:00 How we use tranexamic acid for major traumatic haemorrhage in 2016. John HOLCOMB (Speaker, USA)
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Oral Papers 11

Moderators: Hani HARIRI (Besançon, France), Cyril NOEL (Londres, United Kingdom)
13:00 - 13:10 #7249 - OP001 Can we differentiate hives, angioneurotic edema and anaphylaxis using serum erythropoietin levels?
Can we differentiate hives, angioneurotic edema and anaphylaxis using serum erythropoietin levels?

Background

Erythropoietin (EPO), a renal type I cytokine, plays key role in the regulation of erythropoiesis. EPO is also increased at the area of inflammation in addition to erythropoiesis and hypoxia showing an anti-inflammatory mechanism. EPO decreases releasing of proinflammatory factors such as TNFα, IL-6, IL-12/IL-23, reduce production of NO by inhibiting inducible NO synthase (iNOS), shows anti-inflammatory effect by reducing NF-κB dependent immunocytokines production, inhibits reactive oxygen species at neutrophils and changes activity of T cells indirectly by disruption of antigen presentation or affecting signal transmission of antigen presenting cells. EPO shows non-erythropoietic functions such as immunoregulatory effect in autoimmune diseases and tissue protective effect in trauma and ischemia.

Aim

We aimed that whether there is a significant difference between erythropoietin (EPO) levels in patients who were administrated to emergency department with urticaria, angioedema and anaphylaxis or not.

Method

Our study was conducted prospectively in ED during two years. Exclusion criteria: Patients who refused to participate, with previously known anemia, renal failure, liver disease, chronic obstructive pulmonary disease, asthma, any disease affecting bone marrow, and malignancies. Patients were classified as urticaria (just skin lesions), angioedema (skin and/or mucosa signs) and anaphylaxis (according to international anaphylaxis criteria). Blood levels of white blood cell (WBC), neutrophil (NEU), lymphocyte (LEN), eosynophil (EO), basophil (BAS), red blood cell (RBC), haemoglobine, haematocrit (HTC), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MHC), mean corpuscular hemoglobin concentration (MCHC), red cell distribution width (RDW), platelet, platelet distribution width (PDW), creatinine, blood urea nitrogen (BUN) were evaluated. Parameters related to erythropoietin as HTC/EPO, RDW/EPO, WBC/EPO, NEU/EPO, LEN/EPO, RBC/EPO, PLT/EPO, EO/EPO, BAS/EPO were calculated and compared.

Results

156 patients grouped as urticaria (n=62, 41.7%), angioedema (n=56, 35.9%), anaphylaxis (n=38, 24.4%) were included. Of 38 anaphylaxis patients, 65.8% had rash, 50% had itching, 13.2% had facial edema, 21.1% had periorbital edema, 34.2% had perioral edema, 18.4% had tongue edema, 84.2% had shortness of breath. There was no significant difference, in terms of erythropoietin and related parameters among urticaria (6.2±1.7 mlU/ml), angioedema (6.2±1.7 mlU/ml) and anaphylaxis (6.4±1.7 mlU/ml) patients (p=0.799). Erythropoietin levels were significantly higher in patients with uvula edema compared to patients without (6.0±1.7 vs. 6.5±1.6; p=0.027). HTC/EPO and RDW/EPO ratios were lower in patients who had rash than patients who had not (8.0±1.9 vs. 7.1±2.3; p=0.033 and 2.7±0.9 vs. 2.2±0.6, respectively; p=0.013). 

Discussion

EpoR expression in non-hematopoietic tissues is shown in previous studies. A study conducted on cutaneous mast cells of subjects with or without dermatologic diseases showed the presence of soluble EpoR in secretory granules. Other immune cells such as macrophages also can release EPO which activate mast cells in paracrine way to express EpoR. Considering the paracrine effect on mast cells, the tissue level of EPO may be high before blood levels elevated. The relationship of mast cells in different tissues and difference between tissue and blood levels of EPO need further studies.

Conclusion

Urticaria, angioedema, anaphylaxis cannot be differentiated via using levels of erythropoietin. However, uvula edema is correlated with higher erythropoietin levels.  


Fatih Mehmet SARI, Mucahit EMET (Erzurum, Turkey), Saime OZBEK SEBIN, Haticetul Kubra SARI, Abdulkadir YILDIRIM
13:10 - 13:20 #7294 - OP002 suPAR predicts readmission and mortality in patients discharged within 24 h.
suPAR predicts readmission and mortality in patients discharged within 24 h.

Background

The critical decision of whether to discharge or admit a patient to the hospital is often made at the hospital’s acute care department. More than half of the patients that present at our acute care department are discharged within 24 h and not admitted to the specialized wards of the hospital. Still, some of these patients are subsequently readmitted or may die. Therefore, improvement of the current methods to prognosticate and assess patient risk must be improved, in order to avoid discharge of high-risk patients.

In this study, we aimed to determine whether the prognostic biomarker: soluble urokinase plasminogen activator receptor (suPAR) was able to predict readmission and mortality in patients who are discharged from the acute care department within 24 h.

 

Methods

Between 18 November 2013 and 30 September 2015 20,193 patients were admitted to the acute medical department, Copenhagen University Hospital Hvidovre. Follow-up was carried out for 30 days via Danish national registries. suPAR measurements and registry data on diagnoses, vital status etc. were available for 17,262 patients. The Charlson score was calculated and used as a measure of comorbidity burden. Statistical analysis was carried out using Kruskal-Wallis test and multiple Cox regression analysis.

 

Results

A total of 9623 patients (4459 men and 5164 women) were discharged within 24 h. Median suPAR was 2.3 ng/ml (Interquartile range (IQR) 1.7-3.2) for patients discharged within 24 h, compared with 3.7 ng/ml (IQR 2.5-5.5, P<0.0001) for patients with in-hospital stays longer than 24 h. Median age for patients discharged within 24 h was 52.1 years (IQR 36.0-68.4) and 71.2 years (IQR 57.0-82.0, P<0.0001) for patients with longer admissions.

 

Among patients who were discharged within 24 h, 174 patients (1.8%) died and 1262 patients (13.1%) were readmitted during 30-day follow-up. In comparison, 685 patients (9.0%) died and 1639 (21.5%) were readmitted among patients with in-hospital stays longer than 24 h.

 

For patients discharged within 24 h, the median suPAR level among those who survived and were not readmitted during follow-up (n=8230) was 2.2 ng/ml (IQR 1.7-3.1). Patients who were readmitted had a slightly elevated suPAR level of 2.8 ng/ml (IQR 2.0-4.0, P<0.0001), and those who died had a median suPAR of 6.9 ng/ml (IQR 4.3-9.7, P<0.0001).

 

In multiple Cox regression analyses of log2-transformed suPAR values adjusted for age, sex, Charlson score, and C-reactive protein, the HRs for 30-day mortality and readmission were 2.90 (95% confidence interval (CI) 2.25-3.75) and 1.43 (95% CI 1.33-1.53), respectively, for patients discharged within 24 h. For patients with in-hospital stays longer than 24 h, the HRs were 2.06 (95% CI 1.86-2.28, P 0.0002) for 30-day mortality and 1.21 (95% CI 1.14-1.29, P 0.01) for 30-day readmission.

 

Conclusion

Patients with short admissions (<24 h) had lower suPAR levels as well as 30-day readmission and mortality rates, however, among these patients, a high suPAR level was associated with an increased risk of readmission and mortality compared with patients with in-hospital stays longer than 24 h.


Line Jee Hartmann RASMUSSEN (HVIDOVRE, Denmark), Steen LADELUND, Thomas Huneck HAUPT, Gertrude ELLEKILDE, Jørgen Hjelm POULSEN, Martin SCHULTZ, Kasper IVERSEN, Ove ANDERSEN, Jesper EUGEN-OLSEN
13:20 - 13:30 #7527 - OP003 Design: Risk stratification with suPAR in emergency medicine (Triage III).
Design: Risk stratification with suPAR in emergency medicine (Triage III).

Background: Risk stratification with systematic triage plays a pivotal role in the emergency setting, ensuring that acutely sick patients are cared for first and observed closest. Current triage algorithms serve as risk stratification tools in many emergency departments (ED) and are all based on a combination of the patients’ vital parameters and primary symptoms. Several retrospective studies have identified biomarkers that contain prognostic information, which goes beyond the current triage utilized, and these studies suggests biomarkers as supplement to triage to improve risk stratification. Identifying patients at high and low risk shortly after admission can guide clinical decision-making towards the patients in need, regarding treatment, observation, and allocation of resources. 

Whether the implementation of a prognostic biomarker in initial risk stratification of acutely admitted patients translates into better management and treatment and actually decreases mortality, morbidity, admissions or readmissions has yet to be shown.

Soluble urokinase plasminogen activator receptor (suPAR) is a biomarker with potential use in the EDs, as several studies have found it to be an independent predictor of 30-day mortality and adverse outcomes such as readmission, admission to ICU, and longer length of stay. The suPAR blood level reflects immune activation, and it is strongly associated with presence, prognosis, and severity of a broad variety of acute and chronic diseases, as well as being a predictor of disease development in the general population. Although unspecific, suPAR might be an ideal biomarker for risk stratification of unselected patients. 

Study hypothesis: The main hypothesis is that the introduction, fast measurement, and immediate reporting of the suPAR level to the attending physicians in the EDs will enhance risk stratification and be associated with an absolute risk reduction in all-cause mortality at 10 months after inclusion by 1.5%.  The suPAR level can draw attention towards patients with an unrecognized high risk, leading to improved diagnosis and treatment.

Method: The study is designed as an open cross-over cluster-randomized interventional multicenter trial. suPAR is included in the routine blood work of all eligible patients admitted acutely during the interventional period, measured within 2 hours after admission, and immediately reported to the treating physicians in the ED. Prior to the inclusion period, these physicians are educated in the prognostic capabilities of suPAR.

Results: The inclusion period began January 11th 2016 and ends June 6th 2016.  The study aims to include 10.000 patients in both the interventional and control arm. Results regarding the primary outcome are expected to be presented in 2017. 

Conclusion: The present abstract describes the design and rationale of the TRIAGE III trial. If our hypothesis is confirmed, strong considerations should be given towards standardizing prognostic biomarkers as routine blood work in relation to early risk stratification in the ED. The TRIAGE III trial has the potential to investigate the concept: Having prognostic information can change the patients prognosis. This concept is central in triage and several other clinical situations, and the study might therefore have a central impact on future clinical organizing and decision-making.


Martin SCHULTZ (Copenhagen, Denmark), Line Jee Hartmann RASMUSSEN, Jesper EUGEN-OLSEN, Andreas Højrup Sandø KRISTENSEN, Lars Simon RASMUSSEN, Lars KØBER, Erik KJØLLER, Birgitte Nybo JENSEN, Lisbet RAVN, Theis LANGE, Kasper Karmark IVERSEN
13:30 - 13:40 #7801 - OP004 Smoothing the elective surgical schedule to decrease emergency department length of stay.
Smoothing the elective surgical schedule to decrease emergency department length of stay.

Background: The demand for emergency department (ED) care and non-elective hospital admissions exhibit “natural” variability and do not vary significantly by day of the week. In contrast, the elective surgical schedule is subject to “artificial” variability and is created, in large part, for the convenience of physicians. Consequently, the majority of patients requiring elective surgical procedures are admitted on Mondays and the procedures are subsequently performed on Tuesdays, Wednesdays and Thursdays. Many of these patients occupy a hospital bed post-operatively. We examined the effect of “smoothing” or balancing the elective surgical schedule over the five weekdays on ED length of stay as a surrogate marker of ED crowding. Previous literature has demonstrated that each additional elective surgical case can prolong the mean length of stay per ED patient because of competition for in-patient beds.

 

Methods: The Division of Vascular Surgery was asked to each limit the number of elective surgical cases to no more than two per day. Based on previous experience, two cases per day for five days exceeded the number that the vascular surgeons typically performed in a week. Agreement with this new paradigm was accomplished by assuring surgeons that they would be able to perform all elective cases in timely fashion and that no case would be turned away. A similar plan was developed for the Department of Thoracic Surgery. After implementation, the need for in-patient beds for elective surgical cases was measured for both services. The number of direct nursing hours on the floors that received these post-operative patients was measured since the demand for nursing staffing was expected to become more predictable. Finally, the time from ED decision to admit to actual departure to the floor, and, total length of stay for admitted ED patients were measured.

 

Results: The interventions were successful in limiting the number of elective vascular and thoracic surgical cases requiring in-patient beds to the maximum of two cases per day per service. The number of direct nursing hours decreased by over 6% from 8.66 hours per patient day to 8.16 after “smoothing” of the surgical schedule. This resulting in a savings of several hundreds of thousands of dollars because of more predictable nursing scheduling and fewer overtime payments. The time from ED presentation to decision to admit did not change; but, the time from decision to admit to departure for the floor for admitted patients decreased by a mean of 30 minutes (19%) per patient from 162 to 132 minutes. As a result, the total ED length of stay for admitted patients decreased by a mean of 30 minutes.

 

Conclusion: “Smoothing” the elective surgical schedule can result in lowering costs for overtime pay on the nursing floors that receive these patient postoperatively. Moreover, by reducing “artificial” variability in surgical scheduling we were able to reduce the total length of stay for patients admitted from the ED by a mean of 30 minutes.


Niels RATHLEV (Wellesley, USA)
13:40 - 13:50 #7809 - OP005 ED Crowding - Key Players in Key Roles.
ED Crowding - Key Players in Key Roles.

Background: The percentage of patients who leave without being seen (LWBS) by a physician is commonly used as a surrogate marker of ED crowding. In December 2012, a new ED opened at Baystate Medical Center in Springfield, Massachusetts. The new ED had 94 licensed beds, four separate Pods and three times the area (72,000 sq. ft.) of the old facility. The demand for ED care grew quickly from a baseline of 265 patients “seen” per day (96,725 per year). The percentage of patients who LWBS quickly became a priority because of a very high daily rate of 8.2% the first month. Nursing leadership on duty was responsible for managing patient flow, but was loosely organized and determined on an ad hoc daily basis.

 Methods: With the goals of improving efficiency, reducing the percentage of patients who LWBS and increasing the number of patients “seen” per day, nursing leadership roles were assigned to selected individuals with demonstrated management skills. Physician staffing was not added. The Charge Nurse was responsible for coordinating care throughout the ED and was responsible for all four Pods. This individual managed current resources and requested additional personnel and equipment when necessary. The Charge Nurse also coordinated the transfer of admitted patients to appropriate in-patient settings and initiated a call for assistance from in-patient services when the boarding of these patients exceeded certain benchmarks. The Flow Coordinator accepted transfers from other facilities and notification of patient arrivals from primary care and specialist physicians. Reports from Emergency Medical Services regarding in-coming traffic were also accepted by the Flow Coordinator. The Pod Lead Nurse assumed the coordination of care within each Pod for every shift. “Direct bedding” of new patients into open ED bays was the became the standard while bypassing the Waiting Room altogether after triage. Measures were calculated over a 3-year period as the mean per week of daily outcomes. The number of patients actually “seen” was approximately normally distributed; therefore, simple linear regression was used for analysis. Total walkouts as a percentage of total volume was analyzed using fractional logistic regression, since the dependent variable was a proportion ranging between 0 and 1.  All analyses were conducted in Stata (version 14.0, StataCorp, Colleg Station, TX).  A critical test level of 5% was considered statistically significant.

 

 Results: The percentage of patients who LWBS declined steadily over time with a negative trend line reaching 4.5% in December 2015. This was a 45% decrease in three years. The number of patients “seen” rose steadily with a positive trend line to a mean of 316 per day (115,340 per year) in the same timeframe. This represented a 19% increase despite no increase in physicians staffing. The regression lines for both measures were significant at P< 0.001.

 Conclusion: Measures of ED efficiency include the percentage of patients who LWBS and the number of patients “seen” on a daily basis. These outcomes can be improved significantly with a dedicated nursing management structure that is clearly focused on efficiency without adding physician staffing.


Niels RATHLEV (Wellesley, USA), Joseph SCHMIDT, Paul VISINTAINER
13:50 - 14:00 #7852 - OP006 Risk stratification in acute coronary syndrome: evaluation of the GRACE and CRUSADE scores in the setting of a tertiary care centre.
Risk stratification in acute coronary syndrome: evaluation of the GRACE and CRUSADE scores in the setting of a tertiary care centre.

Background:

The management in acute coronary syndrome (ACS) is influenced by risk assessment. The Global Registry of Acute Coronary Events (GRACE) and the Can Rapid risk stratification of Unstable angina patients Suppress Adverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines (CRUSADE) scores are among the most frequently used risk assessment tools. A recently published study on 1,587 patients suggested a clear superiority of the GRACE vs. the CRUSADE score to predict in-hospital mortality and major bleeding. These results were noted controversially in the scientific community.  

Objectives:

We aimed to assess the performance of the GRACE and CRUSADE risk scores to predict in-hospital mortality and major bleeding in a contemporary ACS population at a high-volume centre.

Methods:

All patients treated for ACS from January 1, 2006 to December 31, 2015 at our tertiary care centre were prospectively included in our registry. Demographic and clinical characteristics as well as details on diagnostic findings and therapy were collected according to the Cardiology Audit and Registration Data Standards (CARDS) of the European Society of Cardiology. GRACE and CRUSADE risk scores were calculated. The discrimination capacity of both scores for in-hospital mortality and major bleeding were compared using receiver operating characteristic curves and the method suggested by DeLong et al.

Results:

In total 4,087 patients (874 (21.4%) female; age 62±14 years) were included, 2218 (54.3%) were diagnosed with ST-elevation myocardial infarction (STEMI), 2973 (72.7%) underwent acute percoutaneous coronary intervention (PCI), 92 (2.3%) received thrombolytic therapy, 113 (2.8%) died, and major bleeding occurred in 65 (1.6%).  Based on GRACE risk categories 1,031 patients (25.2%) had low risk, 1,401 patients (34.3%) had intermediate risk, and 1,655 patients (40.5%) had high risk. Risk based on CRUSADE categories was very low/low in 1,505 patients (36.8%), moderate in 924 patients (22.6%), and high/very high risk in 1,658 patients (40.6%). Discrimination capacity for in-hospital mortality of the GRACE score was superior to the CRUSADE score (area under the curve (AUC) 0.91 (95% CI 0.89 - 0.93) vs. 0.83 (95% CI 0.80-0.86); p<0.05). Performance for major bleeding was poor for both scores (AUC 0.71 (0.65-0.76) for GRACE vs. 0.61 (0.55-0.68) for CRUSADE; ns).

Conclusion:

Our findings support a superiority of the GRACE over the CRUSADE score to predict in-hospital mortality. Major bleeding is rare in the era of primary PCI and performance of both scores to predict it was poor, however there was a trend towards superiority of the GRACE score for this outcome, too.


Katharina TSCHERNY (Pottenbrunn, Austria), Raphael VAN TULDER, Harald HERKNER, Christof HAVEL, Wolfgang SCHREIBER, Dominik ROTH
14:00 - 14:10 #7994 - OP007 Additional value of copeptin and FABP to the HEART score.
Additional value of copeptin and FABP to the HEART score.

Introduction

Chest pain is a frequent complaint at the emergency department (ED). It is often difficult to differentiate between an acute coronary syndrome (ACS) and other causes of chest pain. The HEART score is a validated risk score for all patients with chest pain at the ED.

Troponin is one of the key elements of the HEART score. Currently other biomarkers are known to rise early in case of an ACS, such as copeptin and fatty acid binding protein (FABP). We investigated if the accuracy of the HEART score increases by adding copeptin and FABP to the HEART score.

 

Study design

In 586 patients with chest pain we collected all elements of the HEART score plus copeptin and FABP on arrival at the ED.

We compared the discriminative performances (c-statistic) of the original HEART score vs the HEART score plus copeptin or FABP for the occurrence of Major Adverse Cardiac Events (MACE).

 

Results

In total 164 patients (28.96 %) reached at least one MACE within six weeks (140 AMI, 88 PCI, 15 CABG, one death). The event rate in patients with a HEART score of zero to three was 0.6%. The c-statistics for MACE were: HEART 0.877, HEART+copeptin 0.877 (p=0.868), HEART+FABP 0.886 (p=0.032).

 

Conclusions

In this study the addition of copeptin does not improve the HEART score. The addition of FABP slightly improves the discriminating performance of the HEART score in chest pain patients. Adding FABP to the HEART score could improve the rule out of ACS at the ED.


Simone GOPAL (boxmeer, The Netherlands), Barbra BACKUS, Leo JACOBS, Roger HESSELS, Ron KUSTERS
14:10 - 14:20 #8203 - OP008 The prognostic value of intrahospital hemorrhagic complications for acute coronary syndrome without ST elevation patients in the Emergency Department.
The prognostic value of intrahospital hemorrhagic complications for acute coronary syndrome without ST elevation patients in the Emergency Department.

Introduction:

Hemorrhagic complications were associated with short-term mortality in patients with acute coronary syndrome without ST elevation (NSTEMI). The CRUSADE score (Circulation 2009) was used to assess the short-term mortality. But its predictive value for the midterm mortality has been poorly studied.

Objective: We propose to determine the predictive value of the 6 month mortality CRUSADE score for NSTEMI patients seen in the emergency department (ED).

Materials and methods:

A prospective observational study was conducted over two years. Patients with NSTEMI diagnosis was made. Anamnestic, clinical, electrocardiographic, biological and therapeutic criteria were collected. The CRUSADE score was calculated. The prognosis was based on the 6-month mortality. Multivariate analysis by multiple logistic regression was performed.

Results:

Three hundred and ninety patients were included. Mean age 61 + -11 years. Sex ratio to 1.34. Comorbidities N (%): HTA 235 (60), Diabetes 208 (53), dyslipidemia 112 (29), tobacco 101 (26), Coronary Artery Disease 112 (31). Overall mortality at 6 months was 5%. The mean CRUSADE score was higher in the non survivors patients comparing to the survivors: 45± 11 vs 27 ±11 respectively, P <0.001.  The CRUSADE score was predictive of 6 months mortality with a cut-off at 45 with an area under the curve at 0.82, 95% CI [0.74 to 0.90]. Sensitivity = 53%, specificity = 86%, Liklehood ratio (LR) += 3.78, LR- = 0.54.

Conclusion:

Hemorrhagic complications have a major impact on the short and midterm mortality prognosis of NSTEMI patients. Including the CRUSADE score in the management and risk stratification of NSTEMI patients could reduce the midterm mortality.


Rania JEBRI (Lyon), Hanen GHAZALI, Manel BAYAR, Anware YAHMADI, Jihen ESSID, Mahbouba CHKIR, Ahlem AZOUZI, Sami SOUISSI
14:20 - 14:30 #8214 - OP009 Benefit of NTproBNP in the etiological diagnosis of acute dyspnea in the emergency department.
Benefit of NTproBNP in the etiological diagnosis of acute dyspnea in the emergency department.

Introduction:

Dyspnea is a common pattern to seek care in the emergency department (ED). Distinguish cardiac or respiratory origin is a diagnostic challenge for the emergency physicians especially with patients with several comorbidities and intricate clinical presentation.

NT-proBNP is a specific marker of acute heart failure, however, its usefulness in the diagnostic approach of acute dyspnea remains controversial which may  lead us to resort to a echocardigraphy.

Material and methods

Descriptive prospective observational study. Were included all patients who presented to the ED with acute dyspnea and whose etiology remains unclear. Patients with renal impairment have not been included (false positives of NT-pro BNP).

The diagnosis of heart failure was excluded if the NT-proBNP rate was inferior than 300 pg per ml, made if the NT-proBNP was superior than 1800 pg per ml and doubtful if the NT-proBNP rate was between 300 and 1800pg per ml. the rate of NT-pro BNP was adjusted to the patient's age by the standards of the laboratory.

Results:

During one year, 126 patients were included. The mean age was 62 ± 20 years. The sex ratio was 2.33.

The dosage of NT proBNP has laid the diagnosis of acute heart failure in 70% of cases, revealed the respiratory origin of dyspnea in 18% of cases (negative NT-proBNP). In 12% of the remaining cases, we used the transthoracic echocardiography to seek the etiological diagnosis of acute dyspnea.

Conclusion:

The dosage of NT-proBNP has laid the etiological diagnosis of dyspnea in 88% of cases. Through this study we find that the determination of NT-proBNP for any acute dyspnea of uncertain etiology may be useful. The recourse to echocardiography occurred only in 12% of cases


Olfa DJEBBI, Rania JEBRI (Lyon), Mounir HAGGUI, Mehdi BEN LASSOUED
Room OP-SCHATZKAMMERSAAL
14:35

"Sunday 02 October"

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PH1-S1
14:35 - 14:55

Poster Highlight Session 1 - Screen 1

14:35 - 14:40 #7345 - Delays in being admitted from an emergency department to an inpatient ward increase the risk of 30-day mortality: a retrospective database analysis of two emergency departments.
Delays in being admitted from an emergency department to an inpatient ward increase the risk of 30-day mortality: a retrospective database analysis of two emergency departments.

Introduction: Emergency Department (ED) exit block, which is a manifestation of poor patient flow in hospitals, undermines patient safety, quality of care, staff morale, and ED performance. The extent to which exit block undermines patient survival in NHS hospitals is less well known.

Aim: To determine the relationship between the time patients have to wait in the ED for an inpatient bed to become available and thirty-day mortality.

Method:  Retrospective analysis of consecutive ED attendances at two EDs between 1st June 2013 and 23rd February 2015 (633 days).  The mortality of patients who were admitted to a bed was modelled using a multivariable Poisson regression model which controlled for age, gender, ambulance transportation to the ED, case-mix profile, day of week, season of attendance and ED site attended. The risk ratio per hour of ED exit delay was determined.

Results:  52 987 patients were admitted from 243 499 attendances across two EDs. The mean (SD) ED exit delay (hours) for deceased patients was 2.31 (2.04) vs 1.46 (1.67) for non-deceased patients. About half the patients experienced a median exit delay of 1+ hour and 7.7% waited for more than 4 hours. ED exit delays were associated with a 10% increase in risk of death per hour of exit delay (Risk Ratio 1.10 (95% confidence interval 1.08 to 1.12)), after controlling for seasonality, day of week, case-mix profile and hospital ED.

Discussion: ED Exit block is associated with an increased risk of death. Further work to understand how and why increased delay leads to increased risk of death is required. Strategies to reduce unnecessary delays from ED to inpatient beds in hospitals are urgently required.


Sally-Anne WILSON (LEEDS, United Kingdom), Paul JARVIS, Mohamed MOHAMMED
14:40 - 14:45 #7544 - Learning from clinical incidents that occur in English emergency departments.
Learning from clinical incidents that occur in English emergency departments.

Patient safety incidents that could have or did harm a patient receiving NHS funded care should be reported so they can be learnt from on a local and national level. All NHS trusts in England routinely share the incidents reported to them by uploading them to the National Reporting and Learning System (NRLS).  The Royal College of Emergency Medicine (RCEM) examines the reported incidents that relate to care within Emergency Departments.

In the first half of 2015, there were 61 448 incident reports coded as from Accident and Emergency.  This represents just 0.9% of all attendances at type 1 Emergency Departments in England.  The incidents resulting in severe harm or death are a small proportion of the data (0.4% and 0.2% respectively).  The average age of patients involved in an incident was 63 years.

Incidents leading to death:  The strongest theme to come out of the analysis is that of abdominal pain, especially in the elderly.  These accounted for 20% of all the deaths.  The other worrying themes were the lack of/inadequate monitoring of patients, at times specifically as a result of crowding (18% of cases).

Severe Incidents:  The most common themes were falls in the ED (18% of ED severe incidents), crowding/exit block (16%), unsafe transfers (11%), and failure to adequately monitor patients or review results (10%).  On a more clinical theme, abdominal pain cases was the cause of serious incidents in 9% of cases, stroke/TIAs in 7% of cases, and missed trauma (including neck of femur fractures and cervical spine fractures), in the elderly was the cause of severe harm in 6% of cases. 

Sharing short clinical vignettes serves to demonstrate some of the themes and highlights areas where improvement is needed.  The incident data informs the work of the RCEM safety committee, and also aids the direction of RCEM national audits and guidance documents.


Sally-Anne WILSON (LEEDS, United Kingdom), Emma REDFERN
14:45 - 14:50 #7618 - The exploitation of big data to predict patient fow: a new way to manage emergency.
The exploitation of big data to predict patient fow: a new way to manage emergency.

Introduction: Emergency department (ED) have become the patient's main point of entrance in modern hospitals causing a frequent overcrowding in the ED, in fact the “Observatoire Regionale des Urgences Champagne- Ardennes” announced that the number of visits to the emergency departments in the Champagne-Ardennes state of France has increased by 6.43% per year from 2008 to 2013, thus hospital managers are increasingly giving attention to the ED in order to provide better quality service for patients. One of the key elements for a good management strategy is demand forecasting. In this case, forecasting patients flow, which will help decision makers plan their strategic actions like expanding the locals and optimize their tactical operations like human (doctors, nurses. . . ) and material (beds, boxs. . . ) resources allocation. The main interest of this research is forecasting daily attendance at an emergency department.

Materials and Methods: We conducted a cross design study on the Emergency Department of the Hospital of Troyes city, France, in which we propose a new practical ED patients classification that consolidate the CCMU (classifies patients according to their severity) and GEMSA (classifies patients according to their affiliation after being treated in the ED) categories into one category. We collected the summary attendance to emergencies (Resumé de Passage aux Urgences: RPU) of every patient at the ED of Troyes city Hospital Center from the first January 2010 to the 31st December 2014 which counted 252 438 entry, this data was collected from the database used by the information system “ResUrgences” used by the ED's staff. Statistical tools like correspondence analysis and principal component analysis and experimental knowledge were exploited to introduce a new practical patient classification that we called EP (patient status). A time-series forecasting models based on statistical approach: adapted additive model, ARMA and signal processing approach: hybrid Fourier series were then developed and used to predict the long and short term daily attendance at the ED.

Results: The models we developed for this case study have a performance of 90.17% for the long-term forecast and 91.24% for the short-term forecast of the total patients flow. The models also show a robustness to epidemic periods with a correlation of 0.055 (resp. 0.05) between the flu (resp. acute diarrhea) patients count and the residuals of the short-term models.

Conclusion and discussions: Using the forecasting models developed to predict the daily patients flow, decision makers can plan the ED's activity in order to reduce the risk of overcrowding, this will lead to a better quality service, decrease in waiting time and a better patient experience in the ED. These models are now being used to predict daily patient’s attendance at the ED of Troyes city Hospital Center, these latter can be adapted to other similar facilities in order to predict their daily flow.


Mohamed AFILAL (Rosières Près Troyes), Farouk YALAOUI, Lionel AMODEO, Fréderic DUGARDIN, David LAPLANCHE, Stéphane SANCHEZ, Philippe BLUA
14:50 - 14:55 #7955 - Socioeconomic and demographic determinants of emergency departments inappropriate use : findings from a National Survey in France. 
.
Socioeconomic and demographic determinants of emergency departments inappropriate use : findings from a National Survey in France. 
.

INTRODUCTION. The number of emergency department (ED) visits is constantly rising. The proportion of inappropriate visits was described to be up to 10% to 30% of ED total visits. Inappropriate use causes a surge on health care costs and increase the risk of ED overcrowding. Overcrowding is known to be associated with a higher burden of work among emergency physicians and most importantly it is associated to an increased morbi-mortality and increased frequency of medical errors. The aim of this study was to explore socioeconomic and demographic determinants of emergency departments inappropriate use based on the results of a national survey in France.

METHOD. The French Emergency Survey is a nationwide cross-sectional survey with a two-levels design, aiming to portray hospital-based emergency care in France by describing ED organization and patients. Data were collected on the June 11th 2013, simultaneously in all adult or pediatric EDs in France. All patients visiting the ED on that date were included. Data collected included ED level questions, pertaining to the organization of the participating emergency department, and patients level questions allowing to collect individual’s characteristics and details of care management. In total, the French Emergency Survey included 48,711 patients questionnaires and 734 EDs questionnaires. In our study we focused on adult patients (>15 years). Appropriateness of the ED visit was assessed by the caring physician based on a Likert scale (0 being not appropriate to 10 being appropriate). We considered all visits with a score lower than 4 as being inappropriate. Descriptive statistics and logistic regression were performed to examine ED inappropriate use determinants.

RESULTS. Among the 30,675 patients of our sample, 24% (n=XX) of the visits were considered as inappropriate use. Being a woman (AOR=1.15; 95CI%=1.08-1.22), not having aprivate complementary health coverage (AOR=1.31 ; 95CI%=1.17-1.46), universal suplementary health coverage (AOR=1.16 ; 95CI%=1.05-1.29), homelessness (AOR=1.86 ; 95CI%=1.33-2.61) and symptoms being several days old (AOR=1.67 ; 95CI%=1.57-1.78) were associated with a higher likelihood of inappropriate use. On the other hand, high level of education (AOR=0.86 ; 95CI%=0.79-0.93), trauma (AOR=0.65 ; 95CI%=0.61-0.69), having a general practitioner (AOR=0.82 ; 95CI%=0.74-0.92), being addressed by a doctor (AOR=0.56 ; 95CI%=0.49-0.63) and intermediate (AOR=0.88 ; 95CI%=0.78-0.98) or high (AOR=0.91 ; 95CI%=0.86-0.96) medical densities were associated with a lower likelihood of inappropriate use.

DISCUSSION. Our results underline that inappropriate use of ED is associated with some socioeconomic and demographic characteristics. Socially vulnerable populations and areas with a low medical density had higher rates of inappropriate use. This can make us question the concept of appropriateness, as these populations seem to have few other choices than referring to the ED (lack of healthcare coverage of lack of physicians). This study could help formulate public policies to improve the use of ambulatory care, especially for the most vulnerable people, and thus reduce the inappropriate use of ED.


Diane NAOURI (Paris), Guillaume RANCHON, Ceq Group SFMU, Carlos EL KHOURY, Youri YORDANOV

"Sunday 02 October"

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PH1-S2
14:35 - 14:55

Poster Highlight Session 1 - Screen 2

14:35 - 14:40 #4645 - Diagnostic biomarkers for ischemic stroke: a meta-analysis.
Diagnostic biomarkers for ischemic stroke: a meta-analysis.

Objectives

The development of a diagnostic biomarker test would have a major impact on the care of stroke by facilitating earlier and more accurate identification of ischemic stroke patients, thus increasing the number of patients receiving thrombolytic treatment. Therefore the aim of this study is to perform a meta-analysis regarding the use of biomarkers that are able to distinguish ischemic stroke patients from healthy controls, stroke mimics and hemorrhagic stroke patients.

Design and methods

A comprehensive literature research was carried out to collect studies reporting the use of blood biomarkers for stroke in humans. Data was extracted from the studies that met the inclusion criteria of this meta-analysis. The meta-analysis was performed using the Review Manager 5.3 software. Differences in biomarker levels between the two comparison groups were expressed as P-value and for each meta-analysis the I²-value was used to estimate the potential heterogeneity among studies. Results were regarded as statistically significant if the P-value was <0.05.

Results

We identified 140 studies describing biomarkers to diagnose ischemic stroke. Data could be extracted from 40 studies that met the inclusion criteria. In total 26 biomarkers were examined in this meta-analysis, however only two (BNP and S100B) were able to significantly differentiate ischemic stroke patients from healthy controls, stroke mimics and hemorrhagic stroke patients. GFAP, a biomarker reported to have high diagnostic accuracy for differentiating HS patients from IS patients, was not able to differentiate these comparison groups in this meta-analysis.

Conclusions:

Considering the many limitations interfering with the results of this meta-analysis and the questionable additional value of a blood-based biomarker test beyond clinical assessment and neuroimaging, the widespread use of biomarkers in a diagnostic test for IS seems unlikely. However, biomarkers may still have an additional role to the current clinical modalities of clinical assessment and imaging. They may be especially useful in cases of remaining diagnostic uncertainty or when less experienced health-care personnel have to diagnose IS. In this case, the use of the protein biomarkers brain natriuretic peptide and S100 calcium-binding protein B could be recommended as a result from this meta-analysis. In order to make studies more eligible for a meta-analysis in the future, this paper also proposed a study design suitable for diagnostic biomarker studies for IS.

 


Thomas MONBAILLIU (Varsenare, Belgium), Saïd HACHIMI-IDRISSI, Joline GOOSSENS
14:40 - 14:45 #7268 - P25 peak of the somatosensory evoked potentials as a novel biomarker of neurologic outcome after cardiac arrest.
P25 peak of the somatosensory evoked potentials as a novel biomarker of neurologic outcome after cardiac arrest.

Introduction

The absence of N20 of the somatosensory evoked potentials (SEP) is recommended as a valuable predictor of poor neurologic outcome in post-cardiac arrest patients(1). However, interpretation of N20 is affected by the background noise levels. Reliable analysis of N20 is limited with high noise levels and artifacts. P25 is a positive deflection of N20 occurring at 25-30 msec. The amplitude of N20 varies widely between individuals while P25 is evident even with an ambiguous N20 in patients with good outcome. We hypothesized that the negative-positive deflection of N20-P25 components is more valuable predictor than the N20 alone.

Participants and Methods

We retrospectively investigated SEP, recorded 72 hours after cardiac arrest in 99 patients treated with hypothermic targeted temperature management. We classified N20 and P25 as normal or abnormal. Abnormal N20 was defined as the bilateral or unilateral absence of N20. Abnormal P25 was defined as the bilateral or unilateral absence of positive deflection occurred after N20 in the 25–30 msec range. A peak was considered absent if the amplitude was less than 0.1 μV. Cerebral performance category (CPC) was determined upon hospital discharge. Poor outcome was defined as CPC < 2. Diagnostic parameters of N20 and P25 were calculated.

Results

72% of the patients with poor outcome (n=67) showed abnormal N20 while 91% showed abnormal P25. None of the patients with good outcome (n=32) showed abnormal N20 or P25. Diagnostic values of N20 and P25 and their 95% confidence intervals were as follows. Sensitivity: 71.6% (59.3-82), 91% (81.5-96.6). Specificity: 100% (89.1-100), 100% (89.1-100). Negative likelihood ratio: 0.28 (0.19-0.41), 0.09 (0.04-0.19). Positive predictive value: 100% (92.6-100), 100% (94.1-100). Negative predictive value: 62.8% (48.1-75.9), 84.2% (68.8-94). Area under curve: 0.86 (0.77-0.92), 0.96 (81.52-96.64).

Discussion

This study revealed that the N20 followed by a positive deflection (P25) is more valuable as a prognostic marker than the N20 alone. According to the recent study, not only the presence of N20 but the amplitude of N20 has also predictive value (2). However, N20 amplitude is variable among patients, and a few patients with good outcome show small N20. Therefore, small N20 cannot identify poor outcome or good outcome of normal variant. No P25 occur without preceding N20, and the amplitude of P25 seems to be closely related to the outcome similar to the N20. It seems that the defective somatosensory pathway resulting small N20 also leads to small P25. However, the amplitude of P25 occurred in the normal somatosensory pathway is not strictly related to the amplitude of N20. In patients with good outcome, small N20 can be followed by a large P25, which makes P25 more reliable marker than N20. Meanwhile, three patients with poor outcome showed very high N20 and P25 amplitude (>3μV). Very high amplitude might indicate poor outcome, which is consistent with a recent study (2). The prognostic value of N20 and P25 needs to be reevaluated in larger prospective studies.

References

  1. Wijdicks EFM, et al: Neurology 2006;67:203-210.

  2. Endisch C, et al: Neurology 2015;85:1752-1760.

 

Acknowledgement

None.


Pr Joo Suk OH (Seoul, Korea), Sung Wook KIM, Kyoung Ho CHOI
14:45 - 14:50 #7675 - Amino acids predicting prognosis in patients with acute dyspnoea.
Amino acids predicting prognosis in patients with acute dyspnoea.

 

Objective

To identify amino acids that predicts risk of 90-days mortality in patients with acute dyspnea.

Introduction

Dyspnoea is one of the most common symptoms at the emergency department (ED), accounting for approximately 3-4 million visits in the emergency department every year in the US. The underlying differential diagnoses are diverse and range from conditions with high risk of mortality to virtually no risk of mortality at all. Determining risk of mortality may aid first-line physician in subsequent decision-making regarding investigation and level of care. 

Metabolic changes as part of a pathology can aid to indicate severity of disease and prognosis. Amino acids are a vital part of the metabolism, and can be altered during a catabolic state. They may therefore be of importance in determining prognosis in patients with acute dyspnoea.  

Method

Nine amino acids were analysed in plasma, in 674 adult patients admitted to the Emergency Department (ED) with acute dyspnoea, and then related to risk of 90-days mortality using Cox proportional hazard models adjusted for age, sex, oxygen saturation, respiratory rate, C-reactive protein (CRP), lactate, estimated glomerular filtration rate (eGFR) and “Medical Emergency Triage and Treatment System-Adult” - score.

Result

Eighty-four patients (12.5%) died within 90-days from admission. Two strong and independent amino acid signals were detected: The Hazard Ratio (95% confidence interval) for 90-days mortality per 1 standard deviation (SD) increment of Phenylalanine was 1.31 ( 1.02-1.68) (P=3.5x10-2) and for Valine 0.63 (0.51 – 0.79) (P = 4.9x10-5) An “Amino Acid Mortality Risk Score” (AMRS) summing standardized and weighted values of Phenylalanine and Valine, revealed that of patients belonging to quartile 1 (Q1) of the AMRS, only 4 patient died, whereas 52 patients died among those belonging to quartile 4. Each 1 SD increment of the AMRS was associated with a Hazard Ratio of 2.31  (1.76 – 3.03) (P=1.3x10-9) for 90-days mortality and the point estimate was 10 times higher in Q4 as compared to Q1 of the AMRS (Ptrend over quartiles=4.0x10-7).

Conclusion

Phenylalanine and valine are strongly and independently related to risk of 90-days mortality in unselected patients admitted to the ED because of acute dyspnea, suggesting that they may guide first-line physicians at the ED in risk assessment which in turn could lead to more accurate level of care and treatment intensity.

We speculate that high levels of phenylalanine reflects muscle breakdown and low levels of valine due to increased metabolic substrate demand as a result of acute catabolic stress in response to acute dyspnoea.  


Karolin WIKLUND (VANERSBORG, Sweden), Maria BENGTSSON-TONI, Marjaneh PEYMAN, Lena TEGNÉR, Klas GRÄNSBO, Mattias WIELOCH, Olle MELANDER
14:50 - 14:55 #8067 - The platelet to lymphocyte ratio as a predictor of mortality in non ST elevated myocardial infarction.
The platelet to lymphocyte ratio as a predictor of mortality in non ST elevated myocardial infarction.

INTRODUCTION

The platelet to lymphocyte ratio is an easily available inflammatory biomarker for coronary disease.

The study aim was to assess the ability of this ratio to predict in hospital mortality of patients with non-elevated ST myocardial infarction (NSTEMI).

METHODS

It was an observational prospective study conducted in an emergency department. We excluded patients who had a ST elevated myocardial infarction. We included patients who met criteria of NSTEMI who consulted the emergency department in January 2016.

RESULTS:

We enrolled 85 patients. The mean age was 67 years ± 11 years. Fifty patients were males. 53% of patients were smokers, 57% had hypertension, 37% diabetes, 21% coronary disease and 15% had heart failure. A depressed ST segment was found in 58.8 % of cases, inversed T wave in 47.1%, left bundle bloc in 13%, right bundle bloc in 11% and atrial fibrillation in 9%. The mortality was 13%. The mean PLR of dead patients was significantly higher than PLR of survivors with 362 ± 499 vs 198 ±  185 (p=0.04).

CONCLUSION:

PLR can be used as in independent factor to predict mortality of patient with NSTEMI in emergency department.


Kamel MAJED, Baccouche RAMLA (BEN AROUS, Tunisia), Khedija ZAOUCHE, Boubaker RADHIA, Kilani MOHAMED, Achouri ABDERRAHIM, Hamida MAGHRAOUI, Mohamed MODHAFFER, Chokri HAMOUDA, Nebiha BORSALI FALFOUL

"Sunday 02 October"

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PH1-S3
14:35 - 14:55

Poster Highlight Session 1 - Screen 3

14:35 - 14:40 #4504 - Left arm - V2 ECG lead misplacement: a largely unknown entity which can easily be misdiagnosed as a pulmonary embolism.
Left arm - V2 ECG lead misplacement: a largely unknown entity which can easily be misdiagnosed as a pulmonary embolism.

Left arm – V2 ECG lead misplacement: a largely unknown entity which can easily be misdiagnosed as a pulmonary embolism.

Introduction: Correct electrocardiographic (ECG) lead placement is essential for accurate ECG analysis. ECG lead misplacement does occur and, if unrecognized, can masquerade as pathology with the potential for erroneous diagnosis and unnecessary management. Left arm-V2 lead misplacement, for example, can easily be misdiagnosed as pulmonary embolism.

Aims: To determine if any significant changes in QRST morphology occurs in limb leads and V2 between normally placed and misplaced LA V2 leads.

Methods: Two ECGs, one normal the other with LAV2 misplacement were recorded in 75 patients. ECGs with bundle branch block, ventricular hypertrophy, axis deviation and those of poor quality were excluded (13 in total). Statistical analysis, with 2-tailed T-test and Wilcoxon signed-rank test was performed.

Results: 62 pairs of ECGs were included for analysis. There was a statistical significant difference in mean amplitude in S1 (0.75 versus 8.35; difference 7.65mm; 95%CI 6.3 to 8.9), Q3 (0.59 versus 3.39; difference 2.8; 95%CI 2.17 to 3.42) T3 (0.94 versus -1.9; difference 2.83; 95% CI 2.14 to 3.53) and R3 (5.34 versus 13.65; difference 8.3; 95%CI 6.87 to 9.73). The presence of S1Q3T3R3 (very deep S waves in lead I, deep Q, very tall R and deeply inverted T waves in lead III) was statistically significant for LAV2 misplacement. Statistically significant differences were noted throughout the limb leads.

Conclusion:

The presence of S1Q3T3R3 pattern appears to be pathognomonic for LAV2 misplacement. Healthcare professionals responsible for recording/interpreting ECGs need to be familiar with this, largely unknown entity, which can easily be misinterpreted as pulmonary embolism.

 


Salman QURESHI, Louise BALLESTY, Yarlini PONNAMBOLAN, Sam KUAN, Richard LYNCH (Mullingar, Ireland)
14:40 - 14:45 #7309 - Emergency physician accuracy in interpreting electrocardiograms with potential ST-segment elevation myocardial infarction: is it enough?
Emergency physician accuracy in interpreting electrocardiograms with potential ST-segment elevation myocardial infarction: is it enough?

Background and aims: Rapid recognition of ST-segment elevation myocardial infarction (STEMI) is of utmost importance to pursue a timely restoration of coronary blood flow. As a consequence, electrocardiogram (ECG) interpretation is now widely performed by emergency physicians. We aimed to determine the accuracy of interpretation of potential ST-segment elevation myocardial infarction (STEMI) ECGs when only a few clinical data are available and rapid recognition is necessary, by a cohort of Italian physicians working in the emergency medicine field.

Methods: Italian physicians were recruited to participate in this study during a scientific session of the European Society of Emergency Medicine (EuSEM) 2015 congress (Torino, Italy). Participants were asked to respond to a survey including a total of 36 12-lead ECGs previously resulted in putative STEMI diagnoses. To better represent an emergency situation, all participants were given 60 seconds to define each ECG using a standardized form. The survey included an introductory statement explaining that all ECGs belonged to patients with moderate risk of acute coronary syndrome and asking to focus on whether or not the ECG in question met the diagnostic criteria for a STEMI. Based on the coronary angiogram, a binary outcome of accurate versus inaccurate ECG interpretation was defined. We computed the sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), accuracy and their 95% CIs for ECG interpretation for the whole cohort. We then calculated and compared the diagnostic performance according to the reader level of training, working experience and the hospital level of care.

Results: A total of 135 participants interpreted 4603 ECGs. Sixty-seven (49.6%) respondents were fully licensed physicians (“attending”), 49 (36.3%) were emergency medicine residents, and 14 (10.3%) were medical students with an interest in emergency medicine. The majority of participants (n = 49, 36.3%) declared to work in a tertiary care emergency department (ED), 31.8% in a secondary care ED, and 5% in a primary care centre. A total of 62 participants (45.9%) had less than 5 years of working experience in an ED, 15 (11.1%) between 5 and 10 years, 19 (14.1%) more than 10 years. The overall sensitivity to identify “true” STEMI ECGs was 64.5% (95% CI: 62.8-66.3) while participants’ specificity in determining “false” ECGs was 78% (95% CI: 76-80.1). Overall accuracy among readers, namely the ability to discriminate “true” STEMI pattern from “false” STEMI ECG, was modest (69.1, 95% CI: 67.8-70.4). There was a trend toward a higher accuracy in ECG interpretation for attending physicians, participants working in tertiary care emergency departments and those having more than ten years of experience.

Conclusion: The study supports the notion that ECG interpretation for establishing a STEMI diagnosis lacks the necessary sensitivity and specificity to be considered a reliable “stand-alone” diagnostic test. We underline the relevance of early adjuvant factors (e.g. history, clinical characteristics, echocardiographic pattern) when establishing a STEMI diagnosis and support the role of targeted educational efforts towards the younger emergency medicine professionals and those working in non-referral centres.


Giacomo VERONESE (Milan, Italy), Federico GERMINI, Stella INGRASSIA, Ombretta CUTULI, Luca BONACCHINI, Maura MARCUCCI, Andrea FABBRI
14:45 - 14:50 #7508 - Catheterization laboratory or cardiology intensive care unit : destination of ST-elevation myocardial infarction.
Catheterization laboratory or cardiology intensive care unit : destination of ST-elevation myocardial infarction.

Introduction : The European Society of Cardiology recommends primary percutaneous intervention (pPCI) for ST-elevation myocardial infarction (STEMI) <2h when the delay between the first medical contact (FMC) and the balloon inflation is expected to be <90 min with a target of 60 min. The choice to send MiCU towards a cardiology intensive care unit (CICU) or a catheterization laboratory (cath-lab) depends on the medical assessment, the regulator doctor and the decision of the cardiologist. Aim : Knowing the distribution of patients, management delays and mortality.

Material and method : Data derived from a prospective register including STEMI having primary percutaneous coronary intervention (PCI), managed by 6 medical care intensive units (MCIU), from 2003 to 2014. Variables collected : chest pain onset schedule, emergency call schedule, first medical contact schedule, destination to CICU or cath-lab and mortality.

Results : 1066 STEMI were included : 88,7% (n=946) in cath-lab and 11,3% (n=120) in CICU. Chest pain – emergency call delay influences the patient's destination  55 minutes (min) [20 ; 144] for cath-lab versus 90 min [25 ; 332] for CICU (p<0,05). MICU – hospital door delay is faster for the cath-lab group : 50 min [43 ; 60] versus 55 min [47 ; 67] (p<0,05). Mortality is 3 times higher for the CICU group  : 5,9% versus 1,9%(p<0,05).

Conclusion : Chest pain – emergency call delay influences the patient's destination to cath-lab. The recommendations are not applied to some patients CICU group because they have delay compatible with cath-lab admission. Mortality is more important for CICU’s patients. An epidemiological description of these patients would optimize medical care.


Jonathan GONZVA, Alexandre ALLONNEAU (Paris), Aurélie LOYEAU, Isabelle KLEIN, Yann-Laurent VIOLIN, Catherine RIVET, Jennifer CULOMA, Amandine ABRIAT, Olivier YAVARI, Olga MAURIN, Alain COURTIOL, Hugues LEFORT
14:50 - 14:55 #7604 - Diagnostic accuracy of emergency echocardiography and venous compression ultrasonography in patients with suspected pulmonary embolism presenting with shock or cardiac arrest.
Diagnostic accuracy of emergency echocardiography and venous compression ultrasonography in patients with suspected pulmonary embolism presenting with shock or cardiac arrest.

Background. To evaluate diagnostic performance of emergency echocardiography (EEC) and of venous compression ultrasonography (CUS) in patients with suspected PE presenting with shock or cardiac arrest.

Methods. Consecutive adult patients suspected of PE, presenting with shock or cardiac arrest to four different Italian Emergency Departments, were included. All patients underwent EEC and CUS in the Emergency Department before final diagnosis. Emergency physicians expert in EEC and CUS performed the tests. PE diagnosis was established by multi-detector CT pulmonary angiography or by autopsy.

Results. We included 94 patients, with a mean age of 74±12 years. Forty (43%) patients showed RVD, 20 (21%) showed deep vein thrombosis at CUS and 35 (37%) had a final diagnosis of PE. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EEC were 86% (CI 95% 73-94), 83% (CI 95% 76-98), 75% (CI 95% 64-82) and 91% (CI 95% 82-96), respectively. CUS showed a lower sensitivity (51%, 95% CI 40-56%) and higher specificity (97%, 95% CI 90-99%) and PPV (90%, 95% CI 70-98%) than EEC (p<0.05 for all). When both EEC and CUS were positive (16 out of 94 patients, 17%) the PPV rose to 100%, whereas when both EEC and CUS were negative (50 out of 94 patients, 53%) the NPV increased to 94% (95% CI 87-98%).

Conclusion. Emergency echocardiography showed high but not optimal sensitivity and specificity for PE in patients presenting with shock or cardiac arrest. The addition of CUS significantly increased specificity, so that the diagnosis of PE can be certain only when both tests are positive.


Simone VANNI, Gabriele VIVIANI (firenze, Italy), Peiman NAZERIAN, Michele BAIONI, Chiara GIGLI, Cosimo CAVIGLIOLI, Valerio STEFANONE, Gabriele CERINI, Giuseppe PEPE, Stefano GRIFONI

"Sunday 02 October"

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PH1-S4
14:35 - 14:55

Poster Highlight Session 1 - Screen 4

14:35 - 14:40 #7559 - Validity of the Manchester Triage System in different settings.
Validity of the Manchester Triage System in different settings.

Introduction

Triage aims to sort patients according to their urgency for treatment or ability to safely wait. The Manchester Triage System (MTS) is the most widely used triage system in Europe. Several studies have been conducted to evaluate the performance of the MTS. It is known that the performance of prediction models depends on the target population in which they are evaluated. However, little is known about the performance of the MTS for children in different settings. The aim of this study was to assess the validity of the MTS for children in various settings.

Methods

First, we conducted a systematic review to assess the available evidence on the performance of the MTS. We identified 7 studies (2 adults, 3 children, 2 combination) with a median of 13,554 patients (range 872 - 45,469). We were able to compare 4 studies that used the same reference standard: hospitalisation. Second, we conducted an observational study on the validity of the MTS in children to validate these results. We included all consecutive ED visits in two large academic hospitals during the 6 to 12 month study period. Hospital 1 is a relatively high- prevalence setting (hospitalisation rate: 24.4%) and hospital 2 a relatively low- prevalence setting (hospitalisation rate: 11.2%). We used the same reference standard as the systematic review (hospitalisation) and added ICU admission and immediate lifesaving interventions as reference standards for high-urgent patients.

Results

Of the 7 included studies in the review, patient populations differed as indicated by differences in hospitalisation rate (range: 4.6-32.9%). Despite these differences, sensitivity and specificity of the MTS for hospitalisation were similar. Sensitivity ranged from 0.37 (95% CI 0.36-0.38) to 0.49 (95% CI 0.41-0.56) and specificity ranged from 0.86 (95 CI 0.86- 0.87) to 0.93 (95% CI 0.93-0.93). We included 18,598 children in our observational study, 6012 in hospital 1 and 12,586 in hospital 2. Despite the differences in  setting, sensitivity and specificity were more or less similar for the different reference standards. Hospitalisation had a sensitivity of 0.34 (95% CI 0.32-0.37) in hospital 1 and 0.45 (95% CI 0.42- 0.48) in hospital 2. Specificity was 0.93% (95% CI 0.92-0.94) and 0.88% (95% CI 0.88-0.89) respectively. For ICU admission sensitivity was 0.66% (95% CI 0.58-0.73) and 0.77 (95% CI 0.57-0.90); specificity was 0.88 (95% CI 0.87-0.88) and 0.85 (95% CI 0.84-0.85). For immediate lifesaving interventions sensitivity was 0.80% (95% CI 0.65-0.90) and 0.67% (95% CI 0.60-0.74); specificity was 0.87 (95% CI 0.86-0.88) and 0.85 (95% CI 0.85-0.86).

Conclusion

The performance of the MTS has not yet been compared in different settings. In a systematic review of studies evaluating the MTS, it seems as if sensitivity and specificity remain in the same range regardless of the variation in settings. We found the same results when we validated these findings in a high and low prevalence setting, indicating that performance of the MTS is relatively independent of the setting. Future observational studies with a larger variation in settings is needed to confirm these findings.


Joany ZACHARIASSE, Vera VAN DER HAGEN (Rotterdam, The Netherlands), Ian MACONOCHIE, Henriëtte MOLL
14:40 - 14:45 #7770 - Does the use of The Copenhagen Triage Algorithm (CTA) change the triage level of patients in the emergency department.
Does the use of The Copenhagen Triage Algorithm (CTA) change the triage level of patients in the emergency department.

Background

The goal of triage in the emergency department (ED) is to identify the sickest and most urgent patients for treatment as well as identifying patients at a low risk of mortality and adverse outcomes were treatment can be postponed without risk.

Existing systematic triage models have a well-documented problem with over-triage – overestimating the risk of low risk patients. Our goal was to see if The Copenhagen Triage Algorithm has a lower rate of patients classified as resuscitation, emergent, and urgent compared to the standard Danish Emergency Process Triage (DEPT).

Methods

The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing a newly developed triage system (CTA) to Danish Emergency Process Triage (DEPT).  All emergency department admissions of patients ≥17 years (n=45.000) at two large acute hospitals are included. Centers are randomly assigned to perform either CTA or DEPT triage until half of the sample size is included and subsequently cross-over. Both models stratify patients in 4 acuity levels: Red (resuscitation – seen by doctor immediately), orange (emergent – seen by doctor within 15 min), yellow (urgent – seen by doctor within 60 min), and green (non-urgent – seen by doctor within 180 min) (patients with minor injuries (level 5) are excluded).

Results

As of May, all patients are included and over 90 % are registered in the CTA database. Of 45379 patients, 24835 (54.7 %) were triaged using DEPT and 20544 (45.3 %) were triaged using CTA. Among the patients triaged using DEPT 7146 (28.8 %) were classified as green, 9651 (38.9 %) as yellow, 7240 (29.2 %) as orange, and 798 (3.2 %) as red. Among the patients triaged using CTA 7855 (38.2 %) were classified as green, 8309 (40.4 %) as yellow, 8319 (18.6 %) as orange, and 561 (2.7 %) as red. Patients triaged using CTA were triaged significantly lower than patients triaged using DEPT (P<0.001).

Conclusion

Patients randomized to CTA triage have a lower frequency of red and orange triage. This might reduce waiting time for the patients at highest risk and thereby potentially reduce the risk of adverse events.


Rasmus Bo HASSELBALCH (Copenhagen Ø, Denmark), Mia PRIES-HEJE, Louis LIND PLESNER, Lisbet RAVN, Morten LIND, Rasmus GREIBE, Birgitte NYBO JENSEN, Lars S. RASMUSSEN, Kasper IVERSEN
14:45 - 14:50 #7992 - Can the introduction of a "e;virtual clinic"e; in a major UK paediatric tertiary centre help to reduce the burden of follow up for minor paediatric fractures?
Can the introduction of a "e;virtual clinic"e; in a major UK paediatric tertiary centre help to reduce the burden of follow up for minor paediatric fractures?

Introduction

Fractures account for approximately 25% of all injuries during childhood in the UK (Cooper C et al; 2004). Of those the radius/ulna are most common (30%) (Landin, Lennart A; 1997) - 80% of those are buckle/torus fractures. The volume of these injuries poses considerable pressures to the emergency department (ED), whilst their subtle nature makes them difficult to identify radiologically. Furthermore, lack of homogenous guidance can lead to inconsistencies in management. Children require follow up in Fracture clinics, meaning time off school or nursery; potential time off work for parents and additional hospital visits for the family.

Given that buckle fractures require minimal intervention and follow-up, this is unfortunate. There is evidence showing that optimal treatment entails the use of a Futuro splint for three weeks (Plint et al; 2006), with safety netting and patient information. Many EDs in the UK are adopting this approach successfully.

Objectives

The aim of this quality improvement project was to introduce a new pathway for the management of torus fractures of the radius/ulna, including a “virtual” fracture clinic. We also reviewed our current management of these injuries within the ED. Finally, we compared costs of the old management plan and new protocol, including attendance, plasters and splints.

Methods

A list of children aged 0-16 years with wrist x-rays between June-Nov 2015 was obtained. Those with a buckle-torus fracture were reviewed for method of immobilization and outcome of fracture clinic follow-up.

After this review, in collaboration with our orthopaedic colleagues, a “virtual” clinic was established within the existing Fracture clinic. 

Results

24 children fulfilled the inclusion criteria; fourteen were managed in a Futuro splint; ten with a plaster of Paris (POP). All were followed up in fracture clinic. At this visit, seven children switched from a Futuro to a POP. Three switched from a POP to a Futuro, leaving nine in total with a splint. One child was discharged from fracture clinic on first attendance; 23 required ongoing follow-up with at least one additional visit to clinic. This equates to at least 57 hospital appointments in this group for inclusion to the “virtual” clinic over five months.

In this clinic, the Orthopaedic Consultant reviews the child’s case notes and images; contacts the family and decides whether a follow-up is required. The patient does not need to attend this appointment. The costs of running this clinic would be approximately 20% cheaper on our current overheads.

Conclusions

The majority of children were managed appropriately as per current guidance. Some treatment discrepancies were identified with preferential use of a POP in Fracture Clinic. We educated staff on gold standard treatment and introduced a new clinical guideline. As a result of identifying the number of children returning unnecessarily, a “virtual” fracture clinic has been established. It is hoped this will generate significant cost savings as well as providing families with continuity of care, reassurance and convenience.

We plan to reaudit whether this clinic reduces follow up hospital attendances, in view of expanding it to include other minor fractures.


Sanjoy ROY (London, ), Nicola MCDONALD, Di BACK
14:50 - 14:55 #8113 - Accuracy of 3 pre-endoscopic risk scores in patients with upper gastrointestinal bleeding at a University Hospital in Chile. A retrospective study.
Accuracy of 3 pre-endoscopic risk scores in patients with upper gastrointestinal bleeding at a University Hospital in Chile. A retrospective study.

Introduction

Upper gastrointestinal bleeding (UGB) is a frequently encountered lifethreating condition presenting to the emergency department (ED) that emergency medical clinicians must know how to adequately evaluate. To properly risk stratify these patients, the use of risk scores has been widely recommended in international guidelines as a way to predict mortality, risk of re-bleeding and need for intervention. The Glasgow-Blatchford Score (GBS), pre-endoscopic Rockall (pre-RS) and AIMS65 are 3 of the most used rules that have been externally validated in a variety of European, Australasian and Northamerican populations. However, no studies have validated their accuracy in our country.

The aim of our study was to measure mortality in patients with UGB and explore the performance of these three pre-endoscopic risk scores in predicting need for intervention (endoscopic, surgical or radiological).

Participants and Methods 

We conducted a retrospective, observational study in patients aged 15 years and older that consulted to the emergency department of a university hospital in Santiago, Chile. Based on our electronic health record (EHR) we selected patients who were diagnosed in the ED with Hematemesis (K92.0), Melena (K92.1) or Unspecified Gastrointestinal Hemorrhage (K92.2) according to ICD-10 between April 2013 and July 2015. We excluded all patients with do not resuscitate order, those with incomplete laboratory or endoscopic studies and those in whom UGB was ruled out during in-hospital evaluation. All independent variables required for GBS, AIMS65 and pre-RS were collected from the EHR. In-hospital mortality, need for intervention (endoscopic, surgical or radiological) and blood transfusion were collected from EHR. Death at 30 days for those that were alive at hospital discharge was determined based on the national registry database. The epidemiological profile of included patients was reported as descriptive statistics. We assessed the accuracy of these scales using area under the receiver operating characteristic curve (AUROC).

 

Results:

Five hundred and forty nine patients fulfilled inclusion criteria. After excluding those that met exclusion criteria, 290 patients were reviewed. The median age was 63 years [range, 17-97] and 52.7% were male. In-hospital mortality occurred in 15 patients (5.1%), 122 (42.0%) required intervention and 139 (47.9%) received blood transfusion.

Accuracy of risk scores to predict in-hospital mortality was: AIMS65 (AUROC = 0.82, 95% CI, 0.70-0.93) and pre-RS (AUROC = 0.81, 95% CI, 0.72-0.89). Those two scores tended to be more accurate than GBS (AUROC = 0.68, 95% CI, 0.55-0.82) in predicting mortality (P=0.08). GBS predicted any adverse outcome (mortality, intervention or transfusion) (AUROC = 0.82, 95% CI, 0.77-0.87) significantly better than pre-RS (AUROC = 0.74, 95% CI, 0.68-0.8) and AIMS65 (AUROC = 0.68, 95% CI, 0.62-0.74) (P<0.0001).

 

Conclusion:
All three risk scores adequately predicted outcomes. AIMS65 and pre-RS showed a particularly good accuracy for inpatient mortality and GBS was significantly better in predicting any outcome. These findings support the role of pre-endoscopic scales in the emergency department in our setting.

Acknowledgements:

No conflict of interest.

 


Nicolás MENA (Santiago, Chile), Flavio AYALA, Barbara LARA, Rosario DIAZ, Cristóbal KRIPPER, Bernardita ELICER, Francisca DONOSO

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PH1-S5
14:35 - 14:55

Poster Highlight Session 1 - Screen 5

14:35 - 14:40 #6479 - Randomized Controlled Trial of Internal and External Targeted Temperature Management methods in post-cardiac arrest patients.
Randomized Controlled Trial of Internal and External Targeted Temperature Management methods in post-cardiac arrest patients.

Introduction

Targeted temperature management (TTM) post-cardiac arrest is currently implemented using various methods, broadly categorized as internal and external, each with their advantages and disadvantages. Objective of the study is to evaluate survival-to-hospital discharge and neurological outcomes (Glasgow Pittsbugh Score) of post-cardiac arrest patients undergoing internal cooling verses external cooling. The secondary objective was to compare survival outcomes for TTM (either method) and normothermia (historical controls).

Methodology

A randomized controlled trial of post-resuscitation cardiac arrest patients was conducted from October 2008 – September 2014. Patients were randomized to either internal or external cooling methods. Historical controls were selected matched by age and gender. Analysis using SPSS version 21.0 presented descriptive statistics and frequencies while univariate logistic regression was done using R 3.1.3.

Results

23 patients were randomized to internal cooling and 22 patients to external cooling and 42 matched controls were selected. No significant difference was seen between internal and external cooling in terms of survival, neurological outcomes and complications. However in the internal cooling arm, there was lower risk of developing overcooling (OR=0.25, 95% CI=(0.06, 0.90)) or undercooling during maintenance phase (OR=0.12, 95% CI=(0.02, 0.52)). Compared to normothermia, internal cooling had higher survival (OR=3.361, 95% CI=(1.130, 10.412), and lower risk of developing cardiac arrhythmias (OR=0.182, 95% CI=(0.039, 0.632)). Subgroup analysis showed those with cardiac cause of arrest (OR=4.29, 95% CI=(1.26, 15.80)) and sustained ROSC (OR=5.50, 95% CI=(1.64, 20.39)) had better survival with internal cooling compared to normothermia. Cooling curves showed tighter temperature control for internal compared to external cooling

Conclusion

Internal cooling showed tighter temperature control compared to external cooling. Internal cooling can potentially provide better survival-to-hospital discharge outcomes and reduce cardiac arrhythmia complications in carefully selected patients as compared to normothermia.  


Sohil POTHIAWALA (Singapore, Singapore), Xinqi LOOK, Kenneth TAN, Aaron WONG, Shahidah NUR, Pin Pin PEK, Juliana POH, Eric LIM, Chee Tang CHIN, Duu Wen SEWA, Marcus ONG
14:40 - 14:45 #7196 - Using a witness geolocation system adapted to first aid work to improve the management of out-of-hospital cardiac arrests in urban area.
Using a witness geolocation system adapted to first aid work to improve the management of out-of-hospital cardiac arrests in urban area.

Introduction: The time between occurrence of out-of-hospital cardiac arrest (OHCA) and initiation of chest compressions (CC) determines prognosis. To overcome the lack of witnesses trained in first aid and the difficulties in carrying out a telephone-guided ECM, the 2015 international recommendations emphasize the value of geolocating rescuers near a patient in OHCA. The purpose of this simulation study was to test geolocation and the OHCA witness alert, via the use of a smartphone application in an emergency calls reception center. This study was the precondition for large scale deployment.

Materials and methods: Three tests were performed involving simulated calls for OHCA, call response in accordance with the service procedure (address, detection of OHCA, phone-guided CC and then searching if the situation required for "Good Samaritans" (GS) located within 500 meters of the simulated victim. The GS were personnel deployed in the area but not informed of the address of the emergency. For the last 2 tests, sending an ambulance was performed in real time.

Results:  Delay (min) measured during 3 tests (T1;T2;T3) of the GS engagement by call center from simulated call time for OHCA to:

- Search time for a GS ( 3;2;1)

- GS engagement time (3;3;2)

- RVTV Departure time (not measured;4;3)

- RVTV arrival time (not measured;8;20)

- Time saved for the initiation of CC (not measured;2;15)

Distance (m) from GS at engagement and delay (min) of CC start:

- T1 (100;5) (300;7)

- T2 (100;6) (300;5)

- T3 (300;5)

RVTV = rescue vehicle to victims

The results show a benefit of using this system in terms of the CC initiation period.

Discussion: These results confirm the usefulness of this tool to integrate emergency calls reception center. The next goal will be to measure its impact on the immediate outcome of patients.


Stéphane TRAVERS (Paris), Daniel JOST, Paul DARDEL, Sabine LEMOINE, Vincent LANOE, Frédérique BRICHE, Benjamin RAJON, Michel BIGNAND, Jean Pierre TOURTIER
14:45 - 14:50 #8211 - New onset atrial fibrillation in men: epidemiology, clinical features and management.
New onset atrial fibrillation in men: epidemiology, clinical features and management.

Background

Atrial fibrillation (AF) is the most frequently arrhythmia represented in emergency department (ED).  It affects more than 2.2 million persons in the United States. AF is strongly age-dependent, affecting 4% of individuals older than 60 years and 8% of persons older than 80 years. The incidence of AF is significantly higher in men than in women in all age groups. 

Purpose:

The aim of the study was to provide an overview on the epidemiological features of new-onset atrial fibrillation at the ED in men.

Methods

A single-center, prospective, observational study was conducted in an ED during five years (January 2011 to December 2015). We enrolled men over 18 years of age with a diagnostic of a new onset AF. Collection of epidemiological and clinical parameters, classification of AF, calculation of ischemic risk (the Congestive heart failure, Hypertension, Age75 years, Diabetes mellitus, Stroke, Vascular disease, Age 65 -74 years, Sex category (CHA2DS2-VAS score)  and bleeding risk (Hypertension, Abnormal renal and liver function, Stroke, Bleeding, Labile INR, Elderly, Drugs or alcohol (HASBLED)). Therapeutic intervention and outcome were collected.

Results

During the study, 92 patients were enrolled. Mean age was 59±17 years, 39 % were aged more than 70 years. Comorbidities (%): hypertension (38), diabetes (17), heart failure (13), dyslipidemia (6) and previous stroke (4). AF classification: paroxysmal n=47, persistent n=26 and permanent n=9. The most frequent presenting symptom was palpitations (n=46, 50%) followed by dyspnea (28.3%). The median CHA2DS2VASc score (25th, 75th percentile) was 2 (0.75-3) and the median HASBLED score (25th, 75th percentile) was 1 (0-1.75).  CHA2DS2VASc score≥1 was found in 73% of cases.  Anticoagulation (VKA) was prescribed in 23% of cases. Pharmacologic cardioversion was performed in 29% of patients using amiodarone. Eleven patients (39%) were converted to sinus rhythm. Rate control was performed in   29% of patients using respectively. Diltiazem, Digoxine, and Atenolo in 10, 6 and 3%. At three months, the mortality rate was about 8%.

Conclusion :

Atrial fibrillation in men is associated with increased morbidity and mortality, in part due to the  high risk of thromboembolic events and in part due to its associated risk factors.


Farah RIAHI (Belfort), Hanen GHAZALI, Jihen ESSID, Anware YAHMADI, Ghezela CHAABENI, Mouna GAMMOUDI, Najla ELHENI, Sami SOUISSI
14:50 - 14:55 #4628 - The comparison injection lidocaeine and morphine effect in the acute pain control due to limbs fracture in patients referred to emergency of shohadaye haftom tir hospital.
The comparison injection lidocaeine and morphine effect in the acute pain control due to limbs fracture in patients referred to emergency of shohadaye haftom tir hospital.

Introduction :The first objective is to provide patient comfort and acute pain managment in the emergency department .followed to prevent the negative physiological responses so this study to comparision injection lidocain and morphine effect in the acut pain control due to limbs fracture in patent referred  to emergency department of shohday haftetir hospital

Materials and Methode :In this randomised double -blind clinical traial 'all patents 18 to 65 years old Rasoul Akram hospital in 1393 with limb fractures and without a history of kidney disease 'liver and heart (ischmic heart deasese and arrhytmias) to complet A sample of the syudy will be required .Patients withe a history of sensitivity to lidocaine and morhine; illiterate patients and  patients who can not speak (lack of awareness) and  patient who have been excluded Prnnmaynd written consent.patient are randomly divided into two groups.For a group Aydvkayyn injection (mg/kg5/1) and another group of morphine injection (mg/kg1/0) is injected as a single dose .Vital signs'pain and other injected as a single dose .Vital signs'pain and other symptoms are at 5'10'15 and 30 and data record at the checklist then data will be analyzed 'using SPSS' VERSION 21 

Resalts: The mean age of patients receiving morphine intravenously to 35/65+-12/35 years and in patients receiving intravenous lidocaeine to 35/20+- 11/77yearse Repeated Measurement test showed that differences the average severity of pain according to VAS scale significancly between the study periods respectivly in the two groups receiving morphine and lidocainseen (P=0/0001 and P=0/0001)

Conclusion:according the results can be concluded that lidocaine compared withe injection of morphine analgesic effects desirable and more efective and havr fewer side effects than morphin 'lidocaine injection .so this study suggests lidocaein as the first choice analgesia in trauma patents

Keywords: lidocaeine 'morphine ' acute pain control 'limbs fractures

 

 

 

 

 

 

 

 

 

 

 

 

 

 


Seyed Mohammad HOSSEINI KASNAVIEH (tehran, Islamic Republic of Iran), Seyed Hossein SHAKER, Sakineh BEIKI HASAN, Hossein SAIDI, Gholamreza MASOUMI, Hassan AMIRI, Saeed ABBASI, Nader TVAKOLI, Samana NABI
15:00

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A12
15:00 - 16:30

State of the Art
Pulmonary

Moderators: Basar CANDER (Turkey), Roberto COSENTINI (Head of Emergency Medicine) (BERGAMO, Italy)
15:00 - 15:30 Non-invasive ventilation in acute respiratory failure. Roberto COSENTINI (Head of Emergency Medicine) (Speaker, BERGAMO, Italy)
15:30 - 16:00 Lung ultrasound in the ED: what can be seen (and what not)? Erden Erol UNLUER (Speaker, Turkey)
16:00 - 16:30 Acute asthma exacerbation in the ED. Arschang VALIPOUR (Speaker, Austria)
Room A-FESTSAAL

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B12
15:00 - 16:30

Austria, Germany, Switzerland Invites
EuSEM hosts ÖNK - Ausbildung im Rettungsdienst

Moderators: Gerhard PRAUSE (Assoc. Prof. MD) (Graz, Austria), Mathias ZÜRCHER (Switzerland)
15:00 - 15:30 Gemeinsame Weiterbildung LNA/EL San in der Schweiz. Mathias ZÜRCHER (Speaker, Switzerland)
15:30 - 16:00 Modulare Sanitäterausbildung: neue Perspektiven für nichtärztliche Mitarbeiter. Gerhard PRAUSE (Assoc. Prof. MD) (Speaker, Graz, Austria)
16:00 - 16:30 Ausbildung von Notärzten in Österreich. Helmut TRIMMEL (Speaker, Austria)
Room B-ZEREMONIENSAAL

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C12
15:00 - 16:30

Philosophy & Controversies
P&C Trauma

Moderators: Carlo D'APUZZO (Torino, Italy), Dr Zaffer QASIM (Speaker) (Philadelphia, USA)
15:00 - 15:30 Controversies in chest trauma. Dr Zaffer QASIM (Speaker) (Speaker, Philadelphia, USA)
15:30 - 16:00 What is the optimum transfusion ratio in trauma? John HOLCOMB (Speaker, USA)
16:00 - 16:30 Minor head injury: a minor problem? Crispijn VAN DEN BRAND (PHYSICIAN) (Speaker, den haag, The Netherlands)
Room C-PRINZ EUGEN SAAL

"Sunday 02 October"

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D12
15:00 - 16:30

Administration management
Leadership

Moderators: Raed ARAFAT (Romania), Dr Barbara C HOGAN (Past President of the European Society for Emergency Medicine, EuSEM) (HAMBURG, Germany)
15:00 - 15:30 Leading IFEM: challenges and opportunities for international Emergency Medicine. Pr Jim DUCHARME (Immediate Past President) (Speaker, Mississauga, Canada)
15:30 - 16:00 EM leader and political leader. Raed ARAFAT (Speaker, Romania)
16:00 - 16:30 Gaining the EM specialty in Portugal. Vitor Manuel LOPES FERNANDES ALMEIDA (doctor) (Speaker, viseu, Portugal)
Room D-FORUM

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E12
15:00 - 16:30

Research
Education

Moderators: Iain BEARDSELL (United Kingdom), Ruth BROWN (Speaker) (London), Gregor PROSEN (EM Consultant) (MARIBOR, Slovenia), Anna SPITERI (Consultant) (Malta, Malta)
15:00 - 15:30 Beef-Up Your EM Education Program with Open-Access Scenarios and Checklists. Gregor PROSEN (EM Consultant) (Speaker, MARIBOR, Slovenia), Eric DRYVER (Consultant) (Speaker, Lund, Sweden)
15:30 - 16:00 The physician and their skills development – utilising feedback. Ruth BROWN (Speaker) (Speaker, London), Cristian BOERIU (Assoc.Professor) (Speaker, Targu Mures, Romania), Sabine LEMOYNE (Clinical Head-Operational Lead) (Speaker, Antwerp, Belgium)
16:00 - 16:30 Assessment – why and how? Nikolas SBYRAKIS (Consultant Emergency Physician) (Speaker, Heraklion, Greece), Cornelia HÄRTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (Speaker, STOCKHOLM, Sweden), Mohammad Ashraf BUTT (Consultant in Emergency Medicine) (Speaker, Cavan, Ireland)
Room E-GEHEIME RATSTUBE

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F12
15:00 - 16:30

YEMD
Humanitarian medicine

Moderators: Dean DE MEIRSMAN (Emergency medicine resident) (Geel, Belgium), Dusica JANKOVIC (Nis, Serbia)
15:00 - 15:30 Humanitarian refugee crisis in the Balkans-medical aspects. Dusica JANKOVIC (Speaker, Nis, Serbia)
15:30 - 16:00 Organising professional disaster response—the UK experience. Amy HUGHES (Speaker, Cambridge, United Kingdom)
16:00 - 16:30 Opportunities for young doctors in Humanitarian and disaster response. Luca RAGAZZONI (Scientific Coordinator) (Speaker, Novara, Italy)
Room F-RITTERSAAL

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G12
15:00 - 16:30

EuSEM Meets ICOH
Emergency Medicine at the Working Place

Moderators: Alexis DESCATHA (France), Luis GARCIA-CASTRILLO (ED director) (ORUNA, Spain)
15:00 - 15:30 The Emergency Physician point of view. Michel BAER (physician) (Speaker, GARCHES, France)
15:30 - 16:00 The academic point of view. Alexis DESCATHA (Speaker, France)
16:00 - 16:30 The occupational Physician point of view. Susanne SCHUNDER-TATZER (Speaker, Austria)
Room G-GARTENSAAL

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OP12
15:00 - 16:30

Oral Papers 12

Moderators: Hani HARIRI (Besançon, France), Karim TAZAROURTE (Chef de service) (Lyon, France)
15:00 - 15:10 #7334 - OP010 Validation of BAP-65 score for prediction of in-hospital death or use of mechanical ventilation in patients presenting to the emergency department with acute exacerbations of COPD: a retrospective multi-center study from the SIMEU study group.
Validation of BAP-65 score for prediction of in-hospital death or use of mechanical ventilation in patients presenting to the emergency department with acute exacerbations of COPD: a retrospective multi-center study from the SIMEU study group.

Background Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) require frequent hospitalization, may necessitate mechanical ventilation (MV) and are associated with a remarkable in-hospital mortality. The BAP-65 score is based on information easily available (elevated blood urea nitrogen [BUN], altered mental status, pulse > 109 beats/min, age > 65 years), and may serve clinicians as a simple risk-stratification tool. We aimed to describe the characteristics of patients attending EDs for an AECOPD, the management of events and the final outcome. We further validated the BAP-65 ability to predict in-hospital death or the need for mechanical ventilation (MV) in a large cohort of AECOPD patients admitted to the ED.

Methods We report the preliminary results of a retrospective analysis of data from 13 Italian EDs in a 12-month period (January-December 2014). Patients aged ≥ 40 years presenting to the ED with either a principal diagnosis of AECOPD or acute respiratory failure with a secondary diagnosis of AECOPD were included in the study. Information on patient demographics, clinical characteristics, including chronic COPD-related treatment, comorbidity burden according to the Charlson Comorbidity Index (CCI), presenting symptoms, BUN level, and ED management was collected. Disposition following ED admission was retrieved. In-hospital mortality or the need for MV served as composite primary outcome. Association between a BAP-65 and the occurrence of composite outcome was investigated through univariate and multivariate logistic regression. We assessed the discrimination of BAP-65 via the area under the receiver operating characteristic curve (AUROC) and the prognostic performance of a BAP-65 score ≥ 4 for the primary outcome.

Results A total of 2098 patients were included in the study; 789 (37.6%) were female, mean age was 74±15 years. Comorbidity burden was low (CCI 0) in 623 (29.7%) cases, moderate (CCI 1-2) in 909 (43.3%), and severe (CCI ≥3) in 566 (26.9%) patients. Almost half cases (n = 1100, 52.7%) required the intervention of the emergency ambulance services. Following the ED visit, 621 cases (29.6%) were sent home; 153 cases (7.3%) received a short-term observation; 1172 (55.9%) were admitted to hospital wards. In-hospital death occurred in 74 patients (3.5%), MV was deemed necessary in 27 (1.3%) cases. Five centres (680 patients) were not able to provide data on BUN and were excluded from the validation analysis. A total of 273 (19.2%) patients had a BAP-65 score ≥ 4. The multivariable analysis showed a significant association between the BAP-65 score and the primary outcome (OR 1.65, 95% CI 1.08-2.53). The AUROC for BAP-65 was 0.67 (95 % CI 0.60-0.75). The sensitivity of BAP-65 score ≥ 4 to predict the composite outcome was 92.5% (95% CI 91.1-93.8), the specificity was 21.6% (95% CI 19.5-23.8)., the positive predictive value was 4.4% (95% CI 3.3-5.4), and the negative predictive value was 98.7 (95% CI 98.1-99.3).

Conclusion: We confirmed BAP-65 score to have high sensitivity and negative predictive value for short-term mortality or use of MV in patients with AECOPD. Our findings suggest that it can be safely used as triage instrument at ED to identify low risk patients.


Federico GERMINI (Milano, Italy), Giacomo VERONESE, Giulia Maria AZIN, Massimo ZACCHINO, Maura MARCUCCI, Daniele COEN, Andrea FABBRI
15:10 - 15:20 #7608 - OP011 Troponin only Manchester Acute Coronary Syndromes (TMACS) decision aid: single biomarker re-derivation and external validation in three cohorts.
Troponin only Manchester Acute Coronary Syndromes (TMACS) decision aid: single biomarker re-derivation and external validation in three cohorts.

Background

The original Manchester Acute Coronary Syndromes decision aid (MACS) is a computer-based model that ‘rules in’ and ‘out’ acute coronary syndromes (ACS) using high sensitivity cardiac troponin T (hs-cTnT) and heart-type fatty acid binding protein (H-FABP) measured at admission. The latter is not always available. We aimed to refine and validate MACS as T-MACS, cutting down the biomarkers to just hs-cTnT. Our primary objective was therefore to return to the derivation of the original MACS model but using hs-cTnT as the only biomarker (T-MACS), and then to evaluate the model in three separate external cohort studies. A secondary objective was to compare the predictive characteristics of TMACS to MACS and to the alternative ‘LoD strategy’, by which ACS is excluded in patients with a hs-cTnT concentration below the limit of detection (LoD) of the assay and no ECG ischaemia.

Methods

We present secondary analyses from four prospective diagnostic cohort studies including patients presenting to the Emergency Department (ED) with suspected ACS. Data were collected and hs-cTnT measured on arrival. The primary outcome was ACS, defined as prevalent acute myocardial infarction (AMI) or incident death, AMI or coronary revascularization within 30 days. AMI was adjudicated based on reference standard troponin testing (12h after symptom onset or 6h after arrival) with reference to the third universal definition of myocardial infarction. T-MACS was built by logistic regression in one cohort (derivation set) and validated in three external cohorts (validation set).

Results

In the derivation set (n=703), T-MACS could ‘rule out’ 37.7% patients with 99.3% (95% CI 97.3– 99.9%) negative predictive value (NPV) and 98.7% (95.3–99.8%) sensitivity for ACS. In the validation set (n=1,459), T-MACS could ‘rule out’ 40.4% (n=590) patients with 99.3% (98.3–99.8%) NPV and 98.1% (95.2–99.5%) sensitivity. T-MACS would ‘rule in’ 10.1% and 4.7% patients in the respective sets, of which 100.0% and 91.3% had ACS. C-statistics for the original and refined rules were similar (T-MACS 0.91 vs. MACS 0.90 on validation).

In the validation set, original MACS had 100.0% sensitivity, which was not significantly different to T-MACS (absolute difference 1.6%, 95% CI -0.7 to 1.6%, p=0.25) but T-MACS had greater specificity (absolute difference 25.9%, 95% CI 35.3 - 25.9%, p<0.0001) meaning that T-MACS would avoid more hospital admissions. T-MACS had identical sensitivity to the 'LoD strategy' (absolute difference 0.0%, 95% CI -2.2 to 2.2%, p=1.00) but T-MACS had greater specificity (absolute difference 9.8%, 95% CI 6.7 to 12.7%, p<0.0001). Thus, T-MACS would have 'ruled out' ACS in 40.4% patients (n=590) compared to 32.1% (n=468) for the LoD strategy. 

Conclusions

T-MACS could ‘rule out’ ACS in 40% of patients while ‘ruling in’ 5% at highest risk using a single hscTnT measurement on arrival. It has similar sensitivity to the original MACS decision aid and the LoD strategy but greater specificity than both. As a clinical decision aid, T-MACS could therefore help to conserve healthcare resources. 


Pr Richard BODY (Manchester, ), Edward CARLTON, Matthew SPERRIN, Philip S LEWIS, Gillian BURROWS, Simon D CARLEY, Garry MCDOWELL, Iain BUCHAN, Kim GREAVES, Kevin MACKWAY-JONES
15:20 - 15:30 #7616 - OP012 Manchester Acute Coronary Syndromes (MACS) decision rule successfully reduces unnecessary hospital admissions: a pilot randomized controlled trial.
Manchester Acute Coronary Syndromes (MACS) decision rule successfully reduces unnecessary hospital admissions: a pilot randomized controlled trial.

Background

Observational research, including two external validation studies, shows that the Manchester Acute Coronary Syndromes (MACS) decision rule can effectively ‘rule out’ and ‘rule in’ acute coronary syndromes following a single blood test in the Emergency Department (ED). MACS is a computer model that uses a combination of clinical features and two biomarkers (high sensitivity cardiac troponin T and heart-type fatty acid binding protein) to estimate the probability that a patient has an acute coronary syndrome (ACS) and stratify patients into four groups. Patients in the 'very low risk' group could be immediately discharged from hospital in the appropriate clinical circumstances. 

We aimed to evaluate the impact of using the MACS rule in practice. Anticipating a modest effect size that would require a large trial, our objectives were two-fold: (a) to evaluate the feasibility of running a multi-centre randomised controlled trial (RCT) to compare use of the MACS rule to standard practice; and (b) to assess, in patients presenting to the ED with possible acute coronary syndromes, whether use of the MACS rule can increase the proportion of patients safely discharged within 4 hours, compared with contemporary clinical pathways.

Methods

In a pragmatic pilot RCT, consenting patients presenting to two EDs with suspected cardiac chest pain were randomised, stratified by trial centre and MACS risk group in a 1:1 ratio, to receive care guided by the MACS decision rule (intervention group) or standard care according to contemporary guidelines (controls). The primary efficacy outcome was successful discharge from the ED, defined as a decision to discharge within 4h of arrival providing that the patient did not have a missed AMI or develop a major adverse cardiac event (MACE: death, acute myocardial infarction or coronary revascularization) within 30 days. Feasibility outcomes included recruitment and attrition rates, patient satisfaction and acceptability of the MACS decision rule to clinicians.

Results

In total 138 patients were included across 22 weeks, of whom 131 (95%) were randomised (66 in the intervention group and 65 controls). All 131 patients completed 30-day follow up and were included in the final analysis. Seventeen (26%) patients in the intervention group were successfully discharged within 4h compared to 5 (8%) controls (odds ratio 5.5, 95% CI 1.7-17.1, p=0.004). No patients in either group who were discharged within 4h developed MACE. There were no significant differences in patient satisfaction between groups. Clinicians gave a median acceptability score of 5.1/6 indicating high overall acceptability.

Conclusions

In this pilot trial, the MACS rule led to a significant reduction in safe discharges from the ED when used in practice. We have demonstrated the feasibility of a larger trial, which would provide greater statistical power for safety outcomes.


Pr Richard BODY (Manchester, ), Charles BOACHIE, Alex MCCONNACHIE, Simon D CARLEY, Patricia VAN DEN BERG, Fiona LECKY
15:30 - 15:40 #7634 - OP013 Prognostic utility of quantifying ST-segment depression in patients with non- ST- segment elevationacute coronary syndromes (NSTEMI -ACS).
Prognostic utility of quantifying ST-segment depression in patients with non- ST- segment elevationacute coronary syndromes (NSTEMI -ACS).

Background: The presence of ST- segment depression (STD) on the admission electrocardiogram (ECG) has been well recognized to be a powerful adverse prognosticator [1].Several clinical trial investigations have further suggested that more extensive STD on admission predicts a greater risk of adverse cardiovascular events [2].

 

Purpose:The aim of this study was to examine the relationship between the magnitude of STD and adverse events: angina recurrence, myocardial infarction (MI) and death at 30 days.

 

Methods: A prospective observational study conducted in the emergency department (ED). We enrolled patients aged more than 18 years, presenting to the hospital alive with presumptive diagnosis of ACS and STD on the admission ECG.STD was considered to be present if ≥ 1leads exhibited STD ≥ 0, 05 mV. Three groups were defined according to quantitative ST depression : GP1 < 1 mm, GP2 = 1 - 2 mm , GP3 ≥ 2 mm. Patients with incomplete ECG, left bundle branch block, right bundle branch block, ventricular pacemakers were excluded from the analysis.

 

Results: Eighty one patients were included, mean age= 61± 11 years, 60%were male. Patients history (%): Smoker (47), hypertension (49), diabetes mellitus (59), hyperlipidemia(10), previous MI(35), heart failure (8%), Previous coronary intervention (18), previous coronary bypass surgery (6). The troponin I was positive in 52 patients. Among patients exhibiting STD on admission we individualized: GP1 (N=37), GP2 (N=33), GP3 (N=11).The magnitude of STD has a significant interaction for all outcomes (P-values for interaction): angina recurrence (0,012), MI (0,002), 30 days mortality (0,003).

 

Conclusion: Although the presence of STD has been incorporated as an independent dichotomous prognosticator into several trials, the magnitude of STD confers adverse prognosis in patients with NSTEMI-ACS and should be employed to assist medical decision making.

References:

[1] Kaul et al. J Am Coll Cardiol 2001; 38:64-71.

[2] Raymond Tet al. Eur Heart J 2010; 31:958-966


Hana HEDHLI, Salwa MANSOURI (Valenciennes), Sarra JOUINI, Hela MANNAI, Houssem AOUNI, Béchir BOUHAJJA, Ines CHERMITI
15:40 - 15:50 #7786 - OP014 Thrombolytic Therapy on acute coronary syndrome with ST segment elevation in emergency department : Predictors of TIMI 3 coronary flow.
OP014 Thrombolytic Therapy on acute coronary syndrome with ST segment elevation in emergency department : Predictors of TIMI 3 coronary flow.

Introduction :

Thrombolytic therapy of acute coronary syndromes with ST segment elevation (STEMI) helped ahieve better outcome especially in hospitals without cath-lab department .

Objetive :

 The purpose of this study was to identify patient characteristics that are a priori predictors of early infarct related artery patency following thrombolytic therapy in patients presenting to the emergency department (ED) with STEMI.

 

Materiel and method:

Prospective study over a period of 5 years. Were included all the patients admitted to the emergency department with STEMI within less than 12 hours, which were thrombolysed and for whom the results of coronary angiography was collected. Anamnestic, clinical features, treatment and outcome characteristic were collected. The success of lysis was defined by a TIMI III coronary flow.

Results:

During a period of 5 years, 193 patients were included, mean age  58 +/- 11 years, the sex ratio was 6.4. Comorbidities: N (%) : history of smoking 153 (79), Diabetes 63 (32), hypertension 60 (31), dyslipidemia 23 (12%), coronaropathy  8 (4%). The mean time of ED visit was 179 +/- 158 min, with a mean first-time medical thrombolysis contact 32 min +/- 22, and a mean hospital stay of 231 minutes (+/- 325).

In univariate analysis, time of visit to the ED, SBP, history of smoking, diabetes and inferior infraction were identified as predictive factors of success.

In multivariate analysis, only the inferior infraction was identified as predictor of thrombolysis success with OR 1.4, 95% CI [1.04 to 1.89], p = 0.02.

Conclusion :

STEMI in the lower territory have better outcomes after thrombolysis in the ED.


Aymen ZOUBLI, Sami SOUISSI, Rania JEBRI (Lyon), Wided BAHRIA, Anware YAHMADI, Farah RIAHI, Mohamed MGUIDICH, Hanane GHAZALI
15:50 - 16:00 #7828 - OP015 Acute coronary syndrome with ST segment elevation (STEMI): Impact of a medical intermediary to trigger the prehospital Emergency Medical Services.
Acute coronary syndrome with ST segment elevation (STEMI): Impact of a medical intermediary to trigger the prehospital Emergency Medical Services.

Introduction: The prognosis for patients with an acute coronary syndrome with ST segment elevation (STEMI) is determined by the reperfusion time period. The presence of an intermediary, such as a general practitioner (GP) or cardiologist before the call to the prehospital Emergency Medical Services could help extend these time periods.

Goal: To evaluate patient handling times and the rate of reperfusion decisions by origin of the call to theprehospital Emergency Medical Services.

Methods: Data was retrieved from a regional register of 8 prehospital Emergency Medical Services and 39 medical intensive care units (MICU). Inclusion criteria: patients with a STEMI of less than 24 hours. Exclusion criteria: secondary transfer. Judgement criteria: period between pain and patient handling by MICU and the rate of reperfusion decisions.

Results: 9,858 patients with STEMI were included from 2009 to 2014. The prehospital Emergency Medical Services were called in 6,457 (65%) of the cases by the patient, relative or friend, in 1,209 (12%) of the cases by a GP/cardiologist, in 1,810 (18%) of the cases by firefighters and in 382 (4%) of the cases by other callers. Consistent breakdown over the period was studied. The average period between pain and patient handling was significantly prolonged if the call was from a GP/cardiologist (versus a call by the patient or firefighters) (181 [79-437] minutes versus 50 [20-130] minutes; p <0.0001). By comparison, people using a medical intermediary before calling the prehospital Emergency Medical Services were significantly older (64.2 [53.8 to 76.5] against 60.2 [51.8 to 72.2]), more likely to be women (29.2% against 20.4%), were less typical syndrome (83.7% against 88.5%), had less medical history (90.3% against 92.3%) and had fewer unblocking decisions (89.2% against 95.9%). The main prognosis was not significantly different (3.9% against 4.5%; p = 0.4).

Conclusion: The delay before patient handling was significantly extended if there was an intermediary, GP or cardiologist. These patients, who were older and more often women, with less medical history and more unusual pain, encountered lower rates of reperfusion decisions.


Gaelle LE BAIL, Alain COURTIOL, Alexandre ALLONNEAU (Paris), François-Xavier LABORNE, Aurélie LOYEAU, Virginie PIRÈS, Thévy BOCHE, Jean-Michel JULIARD, François DUPAS, Yves LAMBERT, Hugues LEFORT, Frédéric LAPOSTOLLE
16:00 - 16:10 #7876 - OP016 Diagnosis, Management and Risk Profile Of Patients With Venous Thromboembolism Attended In Spanish Emergency Departments: Espheria Registry.
OP016 Diagnosis, Management and Risk Profile Of Patients With Venous Thromboembolism Attended In Spanish Emergency Departments: Espheria Registry.

Background

In most cases in which venous thromboembolism (VTE) is developed in the outpatient setting, the Emergency Departments (EDs) is where the disease is actually diagnosed. Surprisingly, however, few studies have analyzed the characteristics of patients with VTE and the disease itself from the perspective of the ED.  This is relevant for several reasons. Firstly, little is known about the epidemiology of VTE in the ED and the risk factors most frequently presented by patients diagnosed with an episode of VTE in the ED. Secondly, few studies have evaluated the most adequate management of patients with VTE by emergency physicians or whether this managment is carried out according to the recommendations of the clinical practice guidelines (CPG), and if this has any repercussion on the final outcome of the patient. Lastly, little is known about the treatment performed in the ED and how this may influence the outcome of the patient.

 

Aim. The aim of this study was to determine the clinical presentation of VTE and the main risk factors involved in patients diagnosed in Spanish EDs as well as evaluate the management of these patients and adherence to clinical practice guidelines by emergency physicians.

Methods. We performed a prospective cohort study in 53 Spanish EDs, consecutively including patients diagnosed with VTE in the ED. The following data were evaluated: demographic, comorbidities, risk factors for the development of VTE, index event, hemorrhagic risk factors, prognostic factors [pulmonary embolism (PE)] and in-hospital mortality. To evaluate health care quality we determined the percentage of patients registered with clinical probability of PE, requests for D-dimer concentrations according to clinical probability, administration of treatment prior to confirmation of diagnosis based on clinical probability and records of risk of bleeding and prognosis of the patients with VTE. 

Results. Of 549,840 ED visits made over a mean period of 40 days, 905 patients were diagnosed with VTE (impact 1.6/1000 visits). Of these, 801 patients were included in the analysis, 49.8% of whom had PE with or without deep venous trhrombosis (DVT).  The most frequent risk factors for VTE were: age (≥70 years), obesity, new immobility, previous VTE and active cancer. In the ED medical reports a scale of clinical probability, the prognosis or the risk of bleeding were only described in 7.6%, 7.5% and 1%, respectively of the cases. Of the patients with PE and high clinical probability, D-dimer was determined in 87.2%, and treatment was initiated prior to confirmation in 35.9%. Regarding risk, 31.3% of the patients with PE presented low risk, 59.1% intermediate-low risk, 6% intermediate-high risk and 3.5% high risk. Of the patients with PE, 98.7% were hospitalized while 50.2% of the VTE (without PE) were admitted. The in-hospital mortality of the patients with PE was 3.8%. 

Conclusion. VTE has an appreciable impact on Spanish EDs. Risk profile for the VTE development  in patients diagnosed in ED being similar to previous studies. Adherence to CPG recommendations needs to significantly improve.


Marta MERLO (MADRID, Spain), Pedro RUIZ-ARTACHO, Pascual PIÑERA, Coral SUERO, Albert ANTOLIN, José Ramón CASAL, Marta SÁNCHEZ-GONZÁLEZ, Pablo HERRERO, Sònia JIMENEZ
16:10 - 16:20 #8024 - OP017 Knowledge of risk factors for venous thromboembolisms and the use of low molecular weight heparin in the emergency departement.
OP017 Knowledge of risk factors for venous thromboembolisms and the use of low molecular weight heparin in the emergency departement.

INTRODUCTION

Low molecular weight heparin (LMWH) are commonly prescribed in the emergency department (ED). Not prescribing LMWH for patients with lower limb immobilization (LLI) and at risk for venous thromboembolic events (VTE) can be life-threatening. The incidence of VTE in patients with LLI is estimated between 5 - 39%. The known risk factors for VTE are easily misinterpreted we noticed in our departement. 

METHODS

Participants were asked about their prescribing behavior: the influence of risk factors for VTE, the level of evidence and the need for dose reduction in patients with renal failure.

Ethical committee was obtained and a online questionnaire was created.

 

RESULTS

75 questionnaires were filled out by physicians, both attendings (65,3%) and residents (32%), working at EDs.

89% of the respondents does not differentiate immobilization of grade III distortions from fractures when prescribing LMWH and 14,9% indicates being influenced by the type of immobilization (splint versus circular cast).

Withholding treatment in patients with known risk factors, other than the immobilization itself, was seen for known risk factors: hormonal therapy (28%), history (24%) and pregnancy (22.6%). Of the respondents 88% recognized that BMI is a risk factor.

56% wrongly indicated being influenced by the patient’s gender in their decision and 4% indicated using the age of 60 or higher as the cut-off for prescribing LMWH.

Renal insufficiency was not taken into account in 39.1% of the responders.

 

CONCLUSION

It is important to only initiate VTE-prophylaxis in patients where benefits outweigh the possible risks.

Based on the results of our multi-center survey, we can conclude that a lot of physicians aren’t familiar with the correct use of LMWH in the ED. It seems that the role of gender and age is not well known. More surprisingly, more than half of the respondents does not consider LLI itself as risk factor. In contrast, about one fourth of the physicians would not prescribe LMWH even though the patient has a proven risk factor for VTE.

Dose reduction is an important issue in patients with severe renal insufficiency and is apparently easily forgotten.

Even though there is extensive research available about the risk factors for development of VTE, a lot of physicians seem to be having difficulties identifying patients at increased risk. In addition, most research available about the subject is not applicable on the population encountered in the ED. 

The decision pathway is not difficult so flowcharts could easily be created to limit the possibility of errors in interpretation of the risk factors.

Further research is planned based on the results of this research, an international multi-center study is planned to follow this national enquiry.


Annelies VANDEWEGE (GENT, Belgium), Lien MESTDAGH, Tom SCHMITZ, Ives HUBLOUE
16:20 - 16:30 #8151 - OP018 Acute coronary syndrome with ST segment elevation admitted in emergency department. Risk factors of cardiac arrest.
OP018 Acute coronary syndrome with ST segment elevation admitted in emergency department. Risk factors of cardiac arrest.

Background: Half of cardiac arrests (CA) complicating acute coronary syndromes with ST segment elevation (STEMI) occurred during the first two hours. During this initial phase, STEMI were supported in emergency department in the absence of direct orientation to the interventional cardiology structures. Prevalence, risk factors and prognosis of CA complicating STEMI admitted to the emergency department were not well assessed.   

 

Aim of study:  To study the risk factors and prognosis of cardiac arrest occurring during the initial management of STEMI in the emergency department.

 

Methods: Prospective observational study extended over a period of 81 months (January 2009-September 2015) in the emergency department of regional hospital in Ben Arous. Inclusion of patients admitted for STEMI lasting for less than 24 hours. The demographic, clinical, electrocardiographic and therapeutic data were collected. Analysis of patients group complicated of CA in emergency department. Identification of factors related to the occurrence of CA using a logistic regression model.

 

Results: Inclusion of 694 STEMI with a mean age of 60 ± 12 years and a sex ratio of 5. The cardiovascular risk factors were dominated by active smoking (71%) followed by hypertension (35%) and diabetes (32%). The median time of consultation was 150 min (5 min to 24 h). Fibrinolysis was administered in 72% of patients with a success rate of 59%.the most dreaded complications related to the SCA were the cardiogenic shock (10%) and  the cardiac arrest (9%). Patients who experienced CA (n=62) had a mean age of 60 ± 12 years and a male predominance with a sex ratio of 6. Active smoking was the most common cardiovascular risk factor (73%). The median time of consultation was 120 min (30 min and 16 h). Analysis of the initial rhythm of CA objectified ventricular fibrillation (72%), asystole (18%) and ventricular tachycardia (10%). The STEMI was in the anterior territory in 70% of patients and in the lower area in 32% of patients. The treatment in emergency includes (n): External Defibrillation (55), intubation (28), catecholamines (22), anti-arrhythmic (16). Multivariate analysis identified three independent factors related to the occurrence of CA: cardiogenic shock (OR = 2.44 95% CI 1,31- 44,54), reaching the anterior territory (OR = 1 97 95% CI 1.12 to 3.43) and pulsed oxygen saturation less than 90% (OR = 1.05 95% CI 1.02 to 1.09). The mortality of CA in the emergency department was 29%.

Conclusion: Identifying and improving care of risk factors can prevent the occurrence of CA, reduce mortality and improve the short-term prognosis of STEMI.


Ghezala CHAABENI, Hanene GHAZALI, Aymen ZOUBLI, Anware YAHMADI, Mouna GAMMOUDI, Nejla HENI, Moez MOUGAIDA, Sami SOUISSI (Ben Arous, Tunisia)
Room OP-SCHATZKAMMERSAAL
16:40

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A13
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State of the Art
Education

Moderators: Cornelia HÄRTEL (Medical Director of the ED, Consultant in EM, Director of Medical Education in EM) (STOCKHOLM, Sweden), Roberta PETRINO (Head of department) (Italie, Italy)
16:40 - 17:10 Why education is the core of European Emergency Medicine. Gregor PROSEN (EM Consultant) (Speaker, MARIBOR, Slovenia)
17:10 - 17:40 How to integrate #FOAMed into #MedEd. Simon CARLEY (Consultant in Emergency Medicine) (Speaker, Manchester)
17:40 - 18:10 FOAM: Is all that glitters gold? Carlo D'APUZZO (Speaker, Torino, Italy)
Room A-FESTSAAL

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16:40 - 18:10

Austria, Germany, Switzerland Invites
EuSEM hosts ÖNK - Flugrettung

Moderators: Bernd LANG (Steyr, Austria), Helmut TRIMMEL (Austria)
16:40 - 17:10 Flugrettung in Deutschland. Matthias RUPPERT (Speaker, Germany)
17:10 - 17:40 Flugrettung in der Schweiz. Stephan BECKER (Speaker, Switzerland)
17:40 - 18:10 Flugrettung in Österreich. Bernd LANG (Speaker, Steyr, Austria)
Room B-ZEREMONIENSAAL

"Sunday 02 October"

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C13
16:40 - 18:10

Philosophy & Controversies
P&C Thrombosis

Moderators: Thomas BENTER (Berlin, Germany), Yonathan FREUND (PUPH) (Paris, France)
16:40 - 17:10 Do we need whole leg ultrasound or will serial above knee ultrasound suffice? Daniel HORNER (Speaker, Manchester, United Kingdom)
17:10 - 17:40 To PERC or not to PERC? Franck VERSCHUREN (MD, PhD) (Speaker, Brussels, Belgium), Yonathan FREUND (PUPH) (Speaker, Paris, France)
17:40 - 18:10 Pulmonary embolism : clinical cases with interactive discussion. Franck VERSCHUREN (MD, PhD) (Speaker, Brussels, Belgium), Yonathan FREUND (PUPH) (Speaker, Paris, France)
Room C-PRINZ EUGEN SAAL

"Sunday 02 October"

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D13
16:40 - 18:10

Administration management
General EM

Moderators: Colin GRAHAM (Director and Professor of Emergency Medicine) (Hong Kong, Hong Kong), Crispijn VAN DEN BRAND (PHYSICIAN) (den haag, The Netherlands)
16:40 - 17:10 Strategies to cope with crowding in Hong Kong EDs. Colin GRAHAM (Director and Professor of Emergency Medicine) (Speaker, Hong Kong, Hong Kong)
17:10 - 17:40 Management of acute bleeding in patients on oral anticoagulants. Michael CHRIST (Director) (Speaker, Lucerne, Switzerland)
17:40 - 18:10 The Emergency Team – Elements to get them working. Mehmet Akif KARAMERCAN (Chair of EuSEM Research Committee) (Speaker, ANKARA, Turkey)
Room D-FORUM

"Sunday 02 October"

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E13
16:40 - 18:10

Research
Trauma

Moderators: Sigrid HAHN (New York, USA), Damian MACDONALD (Canada)
16:40 - 17:10 Damage Control Resuscitation in War Trauma. Damian MACDONALD (Speaker, Canada)
17:10 - 17:40 REBOA: Lessons learned from use in the United States. Dr Zaffer QASIM (Speaker) (Speaker, Philadelphia, USA)
17:40 - 18:10 Traumatic cardiac arrest - new evidence to support management strategies. Jason SMITH (PHYSICIAN) (Speaker, Plymouth, United Kingdom)
Room E-GEHEIME RATSTUBE

"Sunday 02 October"

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F13
16:40 - 18:10

YEMD
Work life balance

Moderators: Blair GRAHAM (Research Fellow) (Plymouth, United Kingdom), Alice HUTIN (PH) (Paris, France)
16:40 - 17:10 Does work life balance affect patient outcome? Ruth BROWN (Speaker) (Speaker, London)
17:10 - 17:40 Working and parenting, whose career goes first? Alice HUTIN (PH) (Speaker, Paris, France), Blair GRAHAM (Research Fellow) (Speaker, Plymouth, United Kingdom)
17:40 - 18:10 Dealing with the new generation, the boss's point of view. Patrick PLAISANCE (Head of Department) (Speaker, Paris, France)
Room F-RITTERSAAL

"Sunday 02 October"

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OP13
16:40 - 18:10

Oral Papers 13

Moderators: Dr Thomas BEATTIE (Senior lecturer) (Edinburgh, United Kingdom), Karim TAZAROURTE (Chef de service) (Lyon, France)
16:40 - 16:50 #7060 - OP019 Refractory ventricular fibrillation treated with esmolol.
Refractory ventricular fibrillation treated with esmolol.

Aims: This study aimed to evaluate the effects of esmolol treatment for patients with refractory ventricular fibrillation (RVF) and out-of-hospital cardiac arrest (OHCA).

Methods: This single-centre retrospective pre-post study evaluated patients who were treated between January 2012 and December 2015. Some patients had received esmolol (loading dose: 500 µg/kg, infusion: 0–100 µg/kg/min) for RVF (≥3 defibrillation attempts), after obtaining consent from the patient’s guardian.

Results: Twenty-five patients did not receive esmolol (the control group), and 16 patients received esmolol. Sustained return of spontaneous circulation (ROSC) was significantly more common in the esmolol group, compared to the control group (56% vs. 16%, p = 0.007). Survival and good neurological outcomes at 30 days and at 3 months were >2-fold better in the esmolol group, compared to the control group, although these increases were not statistically significant. A multiple logistic regression model revealed that esmolol treatment provided an odds ratio of 9.24 for sustained ROSC (95% confidence interval: 1.64–52.11, p = 0.012).

Conclusions: Among patients with RVF and OHCA, treatment with esmolol was associated with higher rates of sustained ROSC and survival, and patients who received esmolol exhibited an odds ratio of 9.24 for sustained ROSC. Therefore, we suggest considering esmolol for patients with RVF and OHCA after administering standard therapy.


Seung Min PARK (Anyang, Korea), Young Hwan LEE, Hee Cheol AHN, Young Taeck OH, Ji Hun KIM, Moon Sik KIM
16:50 - 17:00 #7192 - OP020 Cardiac arrest in children outside the hospital: what is the impact of shockable rhythms?
OP020 Cardiac arrest in children outside the hospital: what is the impact of shockable rhythms?

Introduction: Out-of-hospital cardiac arrest (OHCA) in children is a situation that faced by the whole pre-hospital emergency team. The aim of this study was to describe pediatric OHCA heart rhythms recorded by semi-automated external defibrillators (AED) used by on-scene First Aid professionals.

Material and methods: This was a prospective observational study of an urban area with high population density. It included children from 0 to 18 years in OHCA who received an AED.  When used, pediatric electrodes delivered 30 joules of energy.  The collected variables showed a relation to the epidemiological data in accordance with Utstein's recommendations, as well as the electrocardiographic data from the AEDs.

Vincent Thomas, Sabine Lemoine, Daniel Jost, Vincent Lanoë, Marilyn Franchin, Benoit Frattini, Michel Bignand, Jean-Pierre Tourtier 

Results: Over a period of 4 years, 229 children were included and 191 AED plots were analyzed.  The median [Inter Quartile Range] age was 6 [5-16] years, with 129 boys (56%). Twenty-eight children (12%) had a shockable rhythm on the First Aid workers' arrival and were multi-shocked in 39% of cases. The fraction of time devoted to external chest compressions over the total time of care was 60%. The AED reported shock in 3 children and administered an excessive shock in 1 case. The rate of successful defibrillation was 95.4%.

Conclusion: Shockable rhythms in children were rare. Reducing chest compression interruptions by First Aid workers and better consideration of pediatric specifics in the analysis algorithm of AEDs can improve care. The study continues with the collection of survival and neurological outcome data at 1 year.


Vincent THOMAS (PARIS), Sabine LEMOINE, Daniel JOST, Vincent LANOE, Marilyn FRANCHIN, Benoit FRATTINI, Michel BIGNAND, Jean Pierre TOURTIER
17:00 - 17:10 #7405 - OP021 Thromboembolic Disease in Pregnancy – Acute Management.
OP021 Thromboembolic Disease in Pregnancy – Acute Management.

Background:

Venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE) remains one of the main direct causes of maternal death according to the Centre for Maternal and Child Enquiries. The risk of antenatal VTE is four to five folds higher in pregnant versus non-pregnant women. Acute VTE should be suspected in pregnant women with signs and symptoms of DVT and PE.

The subjective clinical assessment is unreliable in pregnancy and only a minority of women with suspected VTE have the diagnosis confirmed with objective testing. Failure to obtain objective diagnosis and subsequent treatment has been attributed to mortality in these patients according to the sequential reports on Confidential Enquiries into Maternal Deaths. Early recognition of VTE and widespread use of low-molecular-weight-heparin (LMWH) thromboprophylaxis until the diagnosis is reached by objective testing can prevent mortality.

Method:

A retrospective study of 46 pregnant patients referred to acute ambulatory care unit with suspected VTE (suspected PE  n=24, suspected DVT n=22) was conducted over a 1 year period.

Patient demographics (age, gestation), signs and symptoms consistent with VTE, predisposing risk factors (Wells score), thromboprophylaxis with LMWH, objective testing with investigations including bloods (d-dimer<250), Chest X-rays, ECGs, Duplex Ultrasound, Ventilation perfusion (V/Q) or CT pulmonary Angiogram (CTPA) scans were analysed.

Results:

The mean age of our pregnant patients was 31 years (18-43). The mean presentation with suspected VTE was at 27 weeks.

21(46%) out of 46 patients were given LMWH thromboprophylaxis prior to objective testing. 25(64%) patients did not receive thromboprophylaxis due to prompt access to radiological imaging, low suspicion index of VTE(negative d-dimer, low Wells score) or maternal refusal until imaging was conducted. 1(2.5%) out of these 25 patients had a positive DVT scan and was commenced on LMWH immediately.

D-dimer was raised in 21(46%) patients, negative in 7(15%) patients but proven positive in 1 patient for a DVT and not conducted in 18(39%) patients given a high index of suspicion for a VTE.

9(37%) patients suspected of having a PE had a CXR and 1(4.2%) CXR was suggestive of consolidation. ECGs were performed in all patients (100%).

Of the 46 pregnant patients with suspected VTE, 5(11%) patients had a confirmed VTE on objective testing. 25(54%) patients underwent a Duplex Ultrasound, 6(13%) underwent a CTPA, V/Q scan was not conducted in any patient. 3(14%) out of 22 patients with suspected DVT had a positive duplex ultrasound. 2(8%) out of 24 patients with suspected PE had a confirmed VTE 1(4%) positive CTPA and 1(4%) positive duplex ultrasound.

Conclusion:

Pregnancy is associated with a hypercoagulable state, increasing the risk of VTE. The subjective clinical assessment of VTE is unreliable in pregnancy and if clinically suspected, treatment with LMWH should be commenced immediately until a definitive diagnosis is reached by objective testing. D-dimer is affected due to physiological changes in pregnancy and should not be relied upon. Radiological objective testing with patient counselling should be considered in all suspected cases to confirm or exclude VTE, leading to appropriate management in these high risk patients. 


Hina IFTIKHAR (london, United Kingdom), Mahnoor LALLMAHAMOOD, Anna IQBAL, Christopher MCQUITTY, Jacqueline SIA, Neil CAMPBELL
17:10 - 17:20 #7692 - OP022 Prognostic value of the NR2 peptide in patients underwent cardiopulmonary resuscitation.
OP022 Prognostic value of the NR2 peptide in patients underwent cardiopulmonary resuscitation.

Background: It is important to know the factors affecting survival, good neurological outcome and prognosis in patients underwent cardiopulmonary resuscitation (CPR). NR2 (N-methyl-D-aspartate receptor 2) peptide is a plasma biomarkers for acute cerebral ischemia.  In literature, it has not been demonstrated any study assessing NR2 levels in patients undergoing CPR. In this study, we investigated the relationship between the NR2 peptide levels and prognosis in patients underwent CPR in our hospital emergency room.

Method: In the study, the patients with cardiopulmonary arrest (CPA) consecutively admitted to the emergency room and the patients suffer from CPA while being followed in the emergency department, were evaluated prospectively between October 2014 and June 2015. Traumatic, non-traumatic, pre-hospital and in-hospital cardiac arrest patients were included the study. Blood samples for NR2 and other biochemical analysis were  taken during resuscitation. NR2 levels in patients who can provided return of spontaneous circulation (ROSC) and not provided ROSC, and the benefits of NR2 in predicting 28-day mortality were investigated. SPSS ™ ver.16.0 was used for statistical analysis.

Results: A  hundred patients were included in the study but nine patients were excluded from the study due to errors in the blood sampling. Mean age of the patients was 63.6±17.6/year and 64.8% were male. Pre-hospital and in-hospital cardiac arrest percents were 56.0% and 44.0% respectively, and 13.2% of them were traumatic cardiac arrest patients. ROSC was achieved in 60.4% of patients. Between the patients who were achieved ROSC and those who died were detected significant differences in terms of NR2 levels (p=0.004). Although NR2 values of survivors at twenty-eight days were higher than those being exitus, there was no statistical difference (p=0,075). Also in the study,  lactate levels in patients who provided ROSC  and the patients who living 28 days were found significantly lower than those who died  (p=0.02 and p=0.01 respectively).

Conclusion: NR2 levels are increased as an indicator of the ROSC in patients who underwent CPR. This condition is thought to be associated with reperfusion. However, NR2 levels has not been shown to be superior to lactate levels in 28-day mortality prediction.


Tamer COLAK, Sedat KOCAK (KONYA, Turkey), Zerrin Defne DUNDAR, Mehmet ERGIN, Abdullah Sadik GIRISGIN, Basar CANDER, Mehmet GUL
17:20 - 17:30 #7695 - OP023 Preceding NEWS among in-hospital cardiac arrest and their impact on survival.
OP023 Preceding NEWS among in-hospital cardiac arrest and their impact on survival.

Background: In-hospital cardiac arrest (IHCA) are often preceded by abnormal vital signs. Preceding abnormal vital signs might lower the physiological reserve capacity and therefore decrease survival after an IHCA.

Aim: To assess preceding national early warning score (NEWS) and its impact on survival after IHCA.

Material and methods: All patients ≥18 years suffering IHCA at Karolinska University Hospital between 1st January 2014 and 31st December 2015 were included. Data regarding the IHCA, patient characteristics, NEWS and 30days survival were drawn from the electronic patient records. Parameters included in NEWS were assessed up to 12hrs before the IHCA.  Differences in survival were assessed with adjusted logistic regression models and presented as Odds Ratios with 95% Confidence Intervals (OR, 95% CI) between patients with NEWS of 0-4 points (low) versus those with at least 5points (moderate) and high (7 points). Adjustments included hospital site, gender, co-morbidities, first rhythm and place of IHCA.

Results: In all, 358 patients suffered IHCA, of whom 109 (30%) survived at least 30 days. The 87 patients with medium NEWS had a minor chance and those 78 with high NEWS (22%) had a minimal chance of surviving IHCA compared to those with low NEWS (Adjusted OR 0.24, 95% CI 0.12-0.50 and OR 0.08, 95% C.I. 0.03-0.22, respectively).

Conclusion: The NEWS can be a probable proxy for estimating physiological reserve capacity when discussing prognosis with patients and relatives. But even more important, it stresses the need for better preventive strategies in IHCA.


Samuel BRUCHFELD, Therese DJARV (Stockholm, Sweden)
17:30 - 17:40 #7810 - OP024 Characteristics and Survival Outcomes of Adult Non-­traumatic Out-­of-­hospital Cardiac Arrests Between Patients With and Without Extracorporeal Cardiopulmonary Resuscitation -­ A Prospective Community-­wide Evaluation.
OP024 Characteristics and Survival Outcomes of Adult Non-­traumatic Out-­of-­hospital Cardiac Arrests Between Patients With and Without Extracorporeal Cardiopulmonary Resuscitation -­ A Prospective Community-­wide Evaluation.

Objectives: 


The outcome of patients after OHCA is poor. Return to spontaneous circulation (ROSC) dramatically decreases with the duration of CPR. Extracorporeal membrane oxygenation has been proposed to assist CPR (ECPR) in OHCA. This study was to investigate the effects and characteristics of ECPR for adult non-­traumatic OHCA versus Non­ECPR on a community­wide basis.

Methods:


A prospective four­-year observational database collected from a community­wide OHCA web registry in an urban EMS (emergency medical services) was studied. The EMS ambulance teams were capable with advanced airway, intravenous (iv) fluid skills, basic and advanced life support and automated external defibrillator techniques. Outcomes included survival and cerebral performance category scale (CPC) at discharge. Adult non-traumatic OHCAs with and without ECPR were compared by regression analysis including factors of patient, pre­hospital and hospital characteristics and outcomes.


Results: 


Comparing OHCA receiving ECPR (n=79) to those without (n=959), ECPR group were younger (median age 56 vs 78, p<0.001) and had higher portion for men (89 vs 64%, p<0;001), witnessed arrest (Wit) (60.8 vs 32.5%, p<0.001), bystander CPR (BCPR) (53.2 vs 36.8%, p=0.005), initial shockable rhythms (SR) (74.6 vs 12.2%, p<0.001) and therapeutic hypothermia (TH) (22.8 vs 1.1%, p<0.001). They (EPCR vs non­ECPR) had no difference for prehospital time intervals (22.5 vs 23 min.), laryngeal mask airway treatment (55.7 vs 52.8%), EMS iv epinephrine (20.3 vs 15.5%), endotracheal intubation (6.3 vs 8.0%), prehospital ROSC (11.4 vs 6%, p=0.09), and ROSC upon hospital arrival (10.1 vs 8.5%). Outcomes were better in ECPR for discharged survival (41 vs 7%, p<0.001) and CPC 1or2 (20.8 vs 3.8%, p<0.001). After adjusting for Wit, BCPR, SR, TH, age and sex, both survival (adjusted odds ratio: 3.6 [95% CI: 2.0­-6.6]) and good CPC 1or2 (adjusted OR: 2.9 [95% CI: 1.2­-6.9]) were still significantly higher in ECPR.

Conclusions:

In current clinical practice for adult non­traumatic OHCA, ECPR tended to apply to patients of younger age, men, witnessed arrest, BCPR, and initially shockable rhythms regardless of positive ROSC upon hospital arrival, that can independently lead to higher survival and good neurological outcome compared to non­ECPR.


Patrick Chow-In KO (Taipei, Taiwan), Matthew Huei-Ming MA, Yih­-Sharng CHEN
17:40 - 17:50 #7811 - OP025 Creative Signals Analysis of Media Technology for Recognizing Cardiac Arrest.
OP025 Creative Signals Analysis of Media Technology for Recognizing Cardiac Arrest.

Purpose:

Recognition of cardiac arrest with checking carotid pulse is less than a half correct by the public. Poor recognition of cardiac arrest or patient of agonizing situation delays early bystander cardiopulmonary resuscitation (BCPR) that should be critically provided in the first five minutes before emergency ambulance arrival. Globally we still lack of effective technology to assist better recognition of cardiac arrest to facilitate early BCPR and public access defibrillation (PAD). In this study, we aim to innovate a video signals analysis tool to assist recognition of cardiac arrest.

Method:

We designed an innovative skill algorithm for transforming and analyzing the signals of the video recordings filmed with mobile smartphone for part of human body. Fast Fourier Transform (FFT) signals were evaluated in our skill algorithm. The time length for each video recording was fifteen seconds, which was filmed within the first five minutes after cardiac arrest witnessed in the intensive care unit. This signal analysis skill algorithm was applied on the video recordings of cardiac arrest patients and compared with that of normal volunteers.

Results:

We applied our skill algorithm analysis on video segments from twenty cardiac arrest patients (asystole for 18 cases, ventricular fibrillation for 2 cases) and twenty non-arrest volunteers (median heart rate 74/min, IQR: 65-88/min), matched in age and sex. We innovated a mathematic formula to calculate a value (we called it Slope Alfa) mainly from the cluster of FFT signals evaluated by the skill algorithm. The Slope Alfa value (Mean, [SD]) of cardiac arrest patients was significantly different from the value of non-arrest volunteers (0.14, [0.09] vs 1.96, [0.37], p<0.01). The results also indicated a tendency that for cardiac arrest patient the Slope Alfa would be less than 1.0.

Conclusions:

The skill algorithm we innovated for smartphone video signals analysis may successfully recognize patient after cardiac arrest. Further integration of this technology with mobile devices would provide the general public an easily accessible tool for cardiac arrest recognition and early chest compressions.


Patrick Chow-In KO, Yu-Chen LIN (Taipei, Taiwan), Yuan-Hsiang LIN
17:50 - 18:00 #7878 - OP026 Anticoagulant treatment of acute venous thromboembolism in the Spanish Emergency Services: Does it change the attitude of the specialist physician in front of emergency physicians? EDITH Study.
OP026 Anticoagulant treatment of acute venous thromboembolism in the Spanish Emergency Services: Does it change the attitude of the specialist physician in front of emergency physicians? EDITH Study.

The Emergency deparments (ED) are very important, among other things,  because are the places where the diagnosis of venous thromboembolic disease  (VTE) that develops on an outpatient basis in most cases is established. It is also where doctors often start specific treatment for VTE and management is decided.

 

AIM

The principle aim of this study was to evaluate the therapeutic management by emergency physicians of patients diagnosed with VTE in Spanish ED. On the other hand, which is the process of change that has experienced this treatment during follow-up of the patients for six months.

 

METHODS

The EDITH study is a multicenter retrospective cohort study involving 50 Spanish emergency services belonging to fifteen regions .

We included consecutive patients who were diagnosed with VTE (-PE- pulmonary embolism or deep vein thrombosis -DVT-) and were treated in emergency services between October 13 and December 14, 2014 were included in the study.

We were collected demographic variables, morbidity, risk factors for VTE in the moment of diagnosis , besides the diagnostic and therapeutic management in the emergency department and 6 months later.

 

RESULTS

A total of 775 patients with VTE were included in the study. 386 patients (49.8%) have PE, with or without DVT. The mean age of patients was 66 years. A 96.9% received anticoagulant therapy in the emergency department, of which 90.6% was LMWH. Only 30 patients in the emergency began acenocumarol and 7 patients received rivaroxaban. At hospital discharge, 65% of DVT and 33.6% of PE remained with LMWH monotherapy. At 1, 3 and 6 months after the stay in the emergency these percentages were maintained for DVT in 42.7, 30.6% and 17.8%, and for PE in 29.2%, 23.1% and 18.9%, respectively. These results are not exclusive to cancer patients but it also observed in all study population. A 73.1% of patients maintained anticoagulant therapy for at least 6 months (83.9% of PE and 61.2% of DVT).

 

CONCLUSION

A hospital management centered in the use  of  heparins and low transition to antivitamins K in patients with VTE was observed. Similarly, in the outpatient management  the introduction of oral anticoagulants was less than would be expected according to the guidelines of recommendation and a more prolonged duration of treatment it was observed.


Marta MERLO (MADRID, Spain), Pedro RUIZ-ARTACHO, Pascual PIÑERA, Coral SUERO, Albert ANTOLIN, José Ramón CASAL, Marta SÁNCHEZ-GONZÁLEZ, Pablo HERRERO, Sònia JIMENEZ
18:00 - 18:10 #8033 - OP027 Supporting isolated patients who test negative for the Ebola Virus Disease: a descriptive analysis of a novel equitable strategy for providing capped free healthcare in Sierra Leone.
OP027 Supporting isolated patients who test negative for the Ebola Virus Disease: a descriptive analysis of a novel equitable strategy for providing capped free healthcare in Sierra Leone.

Background

Due to the undifferentiated presentation of EVD during the recent outbreak in West Africa, some suspect patients were isolated who subsequently tested negative for the virus. In Sierra Leone, a country in which 69% of healthcare is funded (1) through out of pocket payments, these patients were effectively made destitute as a result of stigmatization and destruction of personal possessions. A number of factors highlighted a need to provide emergency care pathways for these patients. This paper describes the design and implementation of a novel initiative to provide a level of free healthcare to EVD negative patients at Connaught Hospital, the main government hospital in Sierra Leone.

 

Methods and Findings

Following review of existing global schemes and a consultation period, data was collected from a random sample of 50 patients requiring admission to Connaught Hospital, after presentation to the A&E, in order to estimate routine aggregate costs for investigations and medical treatment. This data was used to set a funding cap of 260,000 Leones (approx GBP £35), which was calculated to provide free investigations and treatment for 98% of cases. In total, free care was provided to ~300 eligible patients over a 6 month period. The major boundaries to implementation were absence of strong patient advocacy, and lack of hospital resources: both preventing patients receiving the full complement of prescribed services.

 

Conclusions

In resource-poor settings such as Sierra Leone, where free healthcare is provided in incremental packages alongside the existing out-of-pocket payment system, it is essential for successful implementation that new initiatives are embedded within existing systems. This paper presents a number of lessons learned in the design and implementation process of a novel capped free healthcare system and proposes an extended approach to provide on-going tertiary care to EVD survivors and other vulnerable groups in Sierra Leone. This work also proposes a generalizable mechanism to support patients and strengthen healthcare systems in the transitional phase that follows other such humanitarian crises.

 


Edward BLANDFORD, Hooi-Ling HARRISON (London, United Kingdom), Cecilia KAMARA, Samuel SEISAY, Daniel YOUKEE, Aminata ALFSATU
Room OP-SCHATZKAMMERSAAL

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G13
16:40 - 18:10

Prehospital EMS
Prehospital Research by ambulance organisations

Moderators: Joost BIERENS (Thesis Coordinator EMDM) (Brussel, Belgium), Karen SMITH (United Kingdom)
16:40 - 17:10 Creating a support structure for EMS research. Karen SMITH (Speaker, United Kingdom)
17:10 - 17:40 Doing EMS research as an EMT. Veronica LINDSTRÖM (Researcher, Lecture) (Speaker, Stockholm, Sweden)
17:40 - 18:10 Best Paramedic-led studies 2010-2015. Joost BIERENS (Thesis Coordinator EMDM) (Speaker, Brussel, Belgium)
Room G-GARTENSAAL
18:10

"Sunday 02 October"

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OPEN
18:10 - 19:00

Opening Ceremony

Moderators: Wilhelm BEHRINGER (Chair) (Vienna, Austria), Anton N. LAGGNER (Vienn, Austria)
18:10 - 18:15 Introduction. Wilhelm Behringer and Anton N. Laggner.
18:15 - 18:20 Music: the secret of Waltz. Klaus Laczika.
18:20 - 18:25 Greeting from EuSEM President. Barbara Hogan.
18:25 - 18:30 Greetings from AAEM/DGINA/SGNOR Presidents.
18:30 - 18:35 Greetings from the Health Minister. Sabine Oberhauser, Austrian Minister of Health.
18:35 - 18:40 Greetings from the City of Vienna. Sonja Wehsely, Executive City Councillor for Public Health, Social Affairs and Generations.
18:40 - 18:45 Greetings from the Austrian Physician Chamber. Thomas Szekeres, President of the Viennese Physician Chamber.
18:45 - 19:00 How to conduct the Emergency Department. Gernot Schulz.
Room A-FESTSAAL